Evaluation of the Impact of a Less-Invasive Trunk and Pelvic Trauma Protocol on Mortality in Patients with Severe Injury by Interrupted Time-Series Analysis.

Background and Objectives: Minimally invasive trauma management, including interventional radiology and non-operative approaches, has proven effective. Consequently, our hospital established a trauma IVR protocol called "Ohta Nishinouchi Hospital trauma protocol (ONH trauma protocol) in 2013, mainly for trunk trauma. However, the efficacy of the ONH trauma protocol has remained unverified. We aimed to assess the protocol's impact using interrupted time-series analysis (ITSA). Materials and Methods: This retrospective cohort study was conducted at Ohta Nishinouchi hospital, a tertiary emergency hospital, from January 2004 to December 2019. We included patients aged ≥ 18 years who presented to our institution due to severe trauma characterized by an Abbreviated Injury Scale of ≥3 in any region. The primary outcome was the incidence of in-hospital deaths per 100 transported patients with trauma. Multivariable logistic regression analysis was conducted with in-hospital mortality as the outcome, with no exposure before protocol implementation and with exposure after protocol implementation. Results: Overall, 4558 patients were included in the analysis. The ITSA showed no significant change in in-hospital deaths after protocol induction (level change -1.49, 95% confidence interval (CI) -4.82 to 1.84, p = 0.39; trend change -0.044, 95% CI -0.22 to 0.14, p = 0.63). However, the logistic regression analysis revealed a reduced mortality effect following protocol induction (odds ratio: 0.50, 95% CI: 0.37 to 0.66, p < 0.01, average marginal effects: -3.2%, 95% CI: -4.5 to -2.0, p < 0.01). Conclusions: The ITSA showed no association between the protocol and mortality. However, before-and-after testing revealed a positive impact on mortality. A comprehensive analysis, including ITSA, is recommended over before-and-after comparisons to assess the impact of the protocol.

A Novel Approach to Noncompressible Torso Hemorrhage Using a Silicone-Based Polymer Universal Combat Matrix.

INTRODUCTION: Battlefield trauma necessitates prompt hemostatic intervention to mitigate fatalities resulting from critical blood loss. Insights from Operation Enduring Freedom and Operation Iraqi Freedom emphasize the limitations of conventional methods, such as tourniquets, especially in noncompressible torso hemorrhage. Despite advancements in hemostatic agents, the evolving dynamics of multidomain operations necessitate novel, lightweight strategies for hemorrhage control. This study investigates the Silicone-Based Polymer (SBP) Universal Combat Matrix (UCM) by SiOxMed, a multimodal matrix exhibiting efficacy in lethal hemorrhage models. The study evaluates UCM's multiday hemostatic capabilities in a noncompressible torso hemorrhage model, offering pivotal insights for potential deployment in battlefield trauma. MATERIALS AND METHODS: This research was performed under Institutional Animal Care and Use Committee approval and was designed to replicate austere conditions in an off-site enclosed facility. Yorkshire Hampshire swine underwent baseline assessments and anesthesia induction (n = 3). A Grade IV liver injury was made by incising X-shaped lesions, each measuring 4 cm × 2.5 cm, into the diaphragmatic surface of the left and right middle lobes using a scalpel blade, resulting in a lesion region of approximately 3 cm × 6 cm × 3 cm, followed by 30 seconds of uncontrolled bleeding. The injuries were then treated with SBP. Intensive care unit monitoring for 1 hour ensured sustained hemostasis, followed by 48 hours of postanesthesia monitoring and then a return to the operating table to visualize sustained hemostasis. Posteuthanasia, liver tissue underwent histological assessments to evaluate the hemorrhagic interface and liver tissue reactivity. RESULTS: The average time to hemostatic control was 247.3 ± 71.3 seconds. Stable heart rate (81.3 ± 10.0) and respiratory rate (31.7 ± 16.5) were maintained during intensive care unit monitoring. All swine survived the 1-hour anesthesia monitoring period and the subsequent 48-hour monitoring (average survival time, 48.0 hours ± 0.0, n = 3). Visualization of the abdominal cavity at 48 hours revealed no hemorrhage. Histological assessment demonstrated aligned red blood cells and stratified layers of fibrin at the hemorrhagic interface. Masson's Trichrome analysis demonstrated a reactive and regenerative scenario 48 hours postinjury, with a collagen membrane demarcating uninjured and exposed liver regions, along with a comprehensive stromal response. CONCLUSIONS: In conclusion, our investigation into the SBP UCM hemostatic efficacy in a grade IV liver laceration model demonstrates its rapid and reliable action in controlling bleeding, showcasing practicality with an average mass of 4.0 ± 1.0 g. Silicone-Based Polymer sustained hemostasis without adverse physiological effects, as evidenced by stable parameters and the survival of all swine during and after anesthesia. Macroscopic examination at 48 hours revealed durable adherence with no indications of hemorrhage. Histological evaluations highlighted SBP's role in stable clot formation, fibrinogenesis, and tissue regeneration, indicating its potential as a multimodal wound dressing. Although promising, the study has limitations, emphasizing the need for future research with larger samples and controls. This work sets the stage for exploring SBP's clinical implications, particularly in scenarios where lightweight, multimodal technologies are crucial for addressing traumatic injuries and enhancing military medical capabilities.

Evaluating the association between time to skin grafting for truncal burn patients and complications: a comparative cohort study using the National Trauma Data Bank.

BACKGROUND: The split-thickness skin graft (STSG) procedure is frequently used in the reconstruction of burn-injured patients. This study assessed the impact of graft timing on associated skin complications in patients with torso burns using a comprehensive national database. METHODS: Truncal burn (2nd-degree and 3rd-degree burns covering 20-89% TBSA) patients who underwent STSG in the National Trauma Data Bank from 2011 to 2015 were studied. The outcomes examined were graft-related complications (superficial surgical site infections, deep surgical site infections, and graft failure), overall mortality and hospital length of stay (LOS). Patients were compared based on the presence or absence of grafting complications. A linear regression model was used to assess the relationship between hospital LOS and graft timing, considering other variables. RESULTS: Among the 853 studied patients, the cohort with graft complications exhibited a significantly prolonged time to STSG (413.0 h compared to 264.6 h, P<0.001) and a higher percentage of patients with pre-existing diabetes (18.5 vs. 8.0%, P=0.008). The multiple logistic regression analysis revealed that both the extended time to STSG (odds=1.001, P=0.003) and pre-existing diabetes (odds=2.790, P=0.010) significantly elevated the likelihood of complications associated with STSG. Notably, this delay did not elevate mortality risks. A positive relationship was found between grafting delay and LOS. CONCLUSION: The findings underscore that a prolonged duration to skin grafting contributes to extended hospital stays and increased graft-related complications. However, the role of grafting delay in influencing the mortality of truncal burn patients appeared inconsequential, indicating that mortality may be influenced by various factors.

Utility of Torso Imaging for Elderly Patients Sustaining Ground-Level Falls.

INTRODUCTION: Computed tomography (CT) of the torso has become increasingly common for assessment of fall patients in the emergency department. Some data suggest that older adults (≥65) may benefit from torso imaging more than younger patients. We sought to evaluate the usage and utility of CT imaging for elderly patients presenting after ground-level falls (GLFs) from 1 meter or less at our level 1 trauma center. METHODS: Patients ≥18 presenting with GLF in 2015-2019 were included. Data were obtained through chart and trauma registry review. Descriptive statistics were used to summarize the use of CT imaging for patients younger than versus older than 65 y old. Three multivariate logistic regression models with age as a continuous, binary (<65 versus ≥65), or categorical (in multiples of 5) variable were used to investigate whether age is associated with an increased identification of traumatic injury not previously suspected or known based on physical exam (PE) or plain radiograph after GLF. RESULTS: A total of 522 patients <65 and 673 patients ≥65 y old were included. Older patients were significantly more likely to receive screening chest radiograph, screening pelvic radiograph, brain CT, and neck CT (all P < 0.001), but not torso (chest, abdomen, and pelvis) CT (P = 0.144). On multivariate logistic regression, age was not significantly associated with an increased odds of identification of traumatic injury after torso CT (continuous: adjusted odds ratio [aOR] = 1.01, 95% confidence interval [CI] = 0.99-1.03, P = 0.379; binary: aOR = 0.86, 95% CI = 0.46-1.58, P = 0.619; categorical: aOR = 1.03, 95% CI = 0.94-1.14, P = 0.453). A positive PE was the only variable associated with significantly increased odds of having an abnormal torso CT scan in all models. Only two patients ≥65 y old had injuries identified on torso CT in the context of a negative PE and negative screening imaging. CONCLUSIONS: The rate of torso injury identification in patients sustaining GLF is not associated with age, but is strongly associated with positive PE findings. In the subset of elderly GLF patients without positive torso PE findings, more conservative use of CT imaging could decrease health-care utilization costs without compromising patient care.

Effectiveness of a specific trauma training on war-related truncal injury management: A pre-post study.

BACKGROUND: Non-Compressible Torso Hemorrhage (NCTH) is the leading cause of preventable death in combat casualty care. To enhance the French military surgeons' preparedness, the French Military Health Service designed the Advanced Course for Deployment Surgery (ACDS) in 2008. This study evaluates behavioral changes in war surgery practice since its implementation. METHODS: Data were extracted from the OPEX® registry, which recorded all surgical activity during deployment from 2003 to 2021. All patients treated in French Role 2 or 3 Medical Treatment Facilities (MTFs) deployed in Afghanistan, Mali, or Chad requiring emergency surgery for NCTH were included. The mechanism of injury, severity, and surgical procedures were noted. Surgical care produced before (Control group) and after the implementation of the ACDS course (ACDS group) were compared. RESULTS: We included 189 trauma patients; 99 in the ACDS group and 90 in the Control group. Most injuries were combat-related (88 % of the ACDS and 82 % of the Control group). The ACDS group had more polytrauma (42% vs. 27 %; p= 0.034) and more e-FAST detailed patients (35% vs. 21 %; p= 0.044). Basics in surgical trauma care were similar between both groups, with a tendency in the ACDS group toward less digestive diversion (n= 6 [6 %] vs. n= 12 [13 %]; p= 0.128), more temporary closure with abdominal packing (n= 17 [17 %] vs. n= 10 [11 %]; p= 0.327), and less re-operation for bleeding (n= 0 [0 %] vs. n= 5 [6 %]; p= 0.046). CONCLUSION: The French model of war trauma course succeeded in keeping specialized surgeons aware of the basics of damage control surgery. The main improvements were better use of preoperative imaging and better management of seriously injured patients.

Singular stab wounds to the trunk: Is this suicidal or homicidal?

Differentiating homicidal or suicidal deaths in presence of a singular stab wound to the anterior or lateral trunk is still a challenge in forensic practice. There are numerous criteria in the literature and in current forensic textbooks to distinguish between self-inflicted injuries and homicide. The applicability of these criteria in single stab injuries was examined by elucidating 12 suicides and 33 homicides, each with a single stab injury to the anterior or lateral trunk and were largely confirmed. An instrumentality still stuck in the corpse was always associated with a suicide in the given cohort. In summary, the final evaluation should always be based on an interpretation of the post mortem findings together with the circumstances on site of discovery as well as the results of the police investigation.

Diagnostic performance of sonography in penetrating torso trauma: a systematic review and meta-analysis.

BACKGROUND: This systematic review investigates the diagnostic value of ultrasound in the evaluation of torso injuries following a penetrating trauma. METHODS: We searched PubMed, Scopus, and WOS databases for related original articles until May 7, 2023, and extracted data related to diagnostic performance. The bivariate model and hierarchic summary receiver operating characteristic (HSROC) approach were used to calculate pooled diagnostic values. Cochrane Q test and I-squared were performed to evaluate heterogeneity. We assessed heterogeneity with meta-regression. RESULTS: Seventeen studies were included, which involved a total number of 1866 patients. According to meta-analysis, sonography demonstrated a pooled sensitivity of 56% (45-67%) and specificity of 96% (94-97%), positive likelihood ratio (LR +) of 13.66 (8.03-23.23), and negative likelihood ratio (LR-) of 0.45 (0.35-0.59) for detecting abdominal injuries. In pericardial penetrating trauma, pooled sensitivity was 100% (45-100%), pooled specificity was 99% (96-100%), LR + was 136.7 (24.8-752.3), and LR- was 0.00 (0.00-1.22). For thoracic penetrating trauma, pooled sensitivity was 99% (93-100%) and specificity was 100% (98-100%). CONCLUSIONS: Sonography demonstrated promising diagnostic value in the initial assessment of torso penetrating trauma, particularly in the thoracic and pericardial regions. However, the sensitivity of sonography is limited in abdominal penetrating trauma and a combination with other imaging modalities should be considered in these cases.

Circulation First for the Rapidly Bleeding Trauma Patient-It Is Time to Reconsider the ABCs of Trauma Care.

This Surgical Innovation describes the advantages of prioritizing circulation in patients with compressible bleeding sources and in those with noncompressible torso injuries.

Impact of time to surgery on mortality in hypotensive patients with noncompressible torso hemorrhage: An AAST multicenter, prospective study.

BACKGROUND: Death from noncompressible torso hemorrhage (NCTH) may be preventable with improved prehospital care and shorter in-hospital times to hemorrhage control. We hypothesized that shorter times to surgical intervention for hemorrhage control would decrease mortality in hypotensive patients with NCTH. METHODS: This was an AAST-sponsored multicenter, prospective analysis of hypotensive patients aged 15+ years who presented with NCTH from May 2018 to December 2020. Hypotension was defined as an initial systolic blood pressure (SBP) ≤ 90 mm Hg. Primary outcomes of interest were time to surgical intervention and in-hospital mortality. RESULTS: There were 242 hypotensive patients, of which 48 died (19.8%). Nonsurvivors had higher mean age (47.3 vs. 38.8; p = 0.02), higher mean New Injury Severity Score (38 vs. 29; p < 0.001), lower admit systolic blood pressure (68 vs. 79 mm Hg; p < 0.01), higher incidence of vascular injury (41.7% vs. 21.1%; p = 0.02), and shorter median (interquartile range, 25-75) time from injury to operating room start (74 minutes [48-98 minutes] vs. 88 minutes [61-128 minutes]; p = 0.03) than did survivors. Multivariable Cox regression showed shorter time from emergency department arrival to operating room start was not associated with improved survival (p = 0.04). CONCLUSION: Patients who died arrived to a trauma center in a similar time frame as did survivors but presented in greater physiological distress and had significantly shorter times to surgical hemorrhage intervention than did survivors. This suggests that even expediting a critically ill patient through the current trauma system is not sufficient time to save lives from NCTH. Civilian prehospital advance resuscitative care starting from the patient first contact needs special consideration. LEVEL OF EVIDENCE: Prognostic/Epidemiologic, Level III.

Moderate and Severe Injuries at Five International Olympic-Style Wrestling Tournaments during 2016-2019.

As a contact sport, wrestling may result in injuries. Based on the severity, they are classified as mild, moderate, severe and critical. All injuries occurring at international competitions are documented in a cloud-based surveillance system. The purpose of this study was to analyze the incidence and characteristics of moderate and severe (including critical) wrestling injuries that occurred during five international Olympic-style wrestling competitions in 2016-2019. Three Wrestling World Championships and two European Wrestling tournaments were organized by the Hungarian Wrestling Federation in 2016-2019. A total of 2483 wrestlers in three Olympic wrestling styles have competed in 3007 matches. Data from all injuries were recorded and analyzed to define rates, locations, types and severity, and to compare with previous reports. A total of 53 wrestlers sustained 55 injuries, which is equivalent to an overall injury incidence rate of 9.1‰ (9.1/1000 athletic exposures). Greco-Roman and Women Wrestling had the same injury incidence rate, while Freestyle had a lower one (9.5‰ versus 8.5‰). The injury proportion by regions and anatomic locations were on head and face 29.1%, spine and trunk 16.4 % and the upper-and-lower extremity injuries equally 27.3%. The most common types of injuries included ligament lesions, joint injuries, skin lacerations, and contusions. Five wrestlers (0.8‰) sustained strangulation or concussion. Wrestling injury rates during United World Wrestling competitions are not high, but when happen they can be serious. Despite relatively low incidence rate of injuries, there is a need for continuous education for medical teams, referees and coaches to avoid wrestling injuries.

A review of treatments for non-compressible torso hemorrhage (NCTH) and internal bleeding.

Non-compressible torso hemorrhage (NCTH) is associated with significant mortality in preventable deaths, both in the field and in civilian settings. Current management strategies of these injuries include fluid resuscitation, the use of foaming materials to occlude damaged vessels, and fibrin sealants. Researchers in the field have proposed multiple alternatives to these treatments, such as hemostatic sponges, self-assembling peptide materials, in situ crosslinking hydrogels, and intravenous nanoparticles, which are then challenged in a wide variety of injury models to evaluate their efficacy. This review first discusses the treatment of NCTH in the clinic and field before providing an overview of materials in literature designed for this same purpose, with the intention of summarizing the treatment options and research currently available in this field. The mechanisms of these hemostats, as well as their effectiveness in promoting hemostasis (evaluated through survival, bleeding time, and blood loss volume) are summarized side-by-side for easy comparison across various studies and animal models. Ultimately, a better understanding of existing technologies and the metrics through which they are evaluated may facilitate the development of safer, more effective therapies for non-compressible torso hemorrhage and internal bleeding.

Emergency first responder management of combat injuries to the torso in the military, remote and austere settings.

Traumatic injuries to the torso account for almost a quarter of all injuries seen in combat and are typically secondary to blast or gunshot wounds. Injuries due to road traffic collisions or violence are also relatively common during humanitarian and disaster relief efforts. There may also be multiple injured patients in these settings, and surgical care may be limited by a lack of facilities and resources in such a non-permissive environment. The first responder in these scenarios should be prepared to manage patients with severe injuries to the torso. We aim to describe the management of these injuries in the military and austere environment, within the scope of practice of a level 5 registered prehospital practitioner.

Risk factors for acute kidney injury in critically ill patients with torso injury: A retrospective observational single-center study.

ABSTRACT: Acute kidney injury (AKI) is common in trauma patients and associated with poor outcomes. Identifying AKI risk factors in trauma patients is important for risk stratification and provision of optimal intensive care unit (ICU) treatment. This study identified AKI risk factors in patients admitted to critical care after sustaining torso injuries.We performed a retrospective chart review involving 380 patients who sustained torso injuries from January 2016 to December 2019. Patients were included if they were aged >15 years, admitted to an ICU, survived for >48 hours, and had thoracic and/or abdominal injuries and no end-stage renal disease. AKI was defined according to the Kidney Disease Improving Global Outcomes definition and staging system. Clinical and laboratory variables were compared between the AKI and non-AKI groups (n = 72 and 308, respectively). AKI risk factors were assessed using multivariate logistic regression analysis.AKI occurred in 72 (18.9%) patients and was associated with higher mortality than non-AKI patients (26% vs 4%, P < .001). Multivariate logistic regression analysis identified bowel injury, cumulative fluid balance >2.5 L for 24 hours, lactate levels, and vasopressor use (adjusted odds ratio: 2.953, 2.058, 1.170, and 2.910; 95% confidence interval: 1.410-6.181, 1.017-4.164, 1.019-1.343, and 1.414-5.987; P = .004, .045, .026, and .004, respectively) as independent risk factors for AKI.AKI in patients admitted to the ICU with torso injury had a substantial mortality. Recognizing risk factors at an early stage could aid risk stratification and provision of optimal ICU care.

Incidence Rate of Musculoskeletal Injuries among Professional Tennis Players during 2019 International Tournaments in Indonesia.

Several studies have indicated that musculoskeletal injuries are common during a professional tennis competition. However, data from a tropical country like Indonesia is lacking. This study aimed to obtain the incidence rate and injury characteristics and identify risk factors of musculoskeletal injuries among professional tennis players competing in Indonesia under the International Tennis Federation (ITF). The study was a prospective cohort during professional tennis tournaments in Jakarta, Indonesia in 2019, consisting of the ITF Women's Circuit Indonesia (two weeks) and ITF Men's Future Indonesia (three weeks). All athletes were enrolled in this study. Injuries were assessed based on the ITF Consensus Statement. Incidence rate was the number of injuries per 1000 player hours (i.e., the total duration from before the match starts to completion of the match after the final point). The magnitude of risk was expressed as a relative risk (RR) and its 95% confidence interval (CI). Independent risk factors were identified using multivariate analyses. A total of 161 tennis players were enrolled; 71 (44.1%) were men. Their mean age was 22 years old. The incidence rate of musculoskeletal injuries was 30.8 injuries per 1000 player hours (95% CI: 28.2-33.5). The most common onset was acute injuries (61.1%), while the most common location and type of injury was the trunk (38.9%) and muscle strain (61.1%). Risk factors associated with musculoskeletal injury were higher body height, skill level, history of previous injury, and wet bulb globe temperature (WBGT) zone. There was no injury during the doubles matches. Previous injury was an independent risk factor (adjusted RR: 48.1 (95% CI: 11.3-155.0; p < 0.001). The incidence of musculoskeletal injuries among professional tennis player is considerably high. Factors associated with injury are body height, skill level, previous injury, and WBGT zone. Future injury prevention programmes should incorporate the management of previous injuries and take into account the effect of environmental temperature.

Sociodemographic Factors and Outcomes by Intent of Firearm Injury.

BACKGROUND AND OBJECTIVES: Firearm injuries are a leading and preventable cause of morbidity and mortality among youth. We sought to explore differences in sociodemographic factors and youth firearm injury outcomes by injury intent (unintentional, assault, and self-harm). METHODS: We conducted a repeated cross-sectional analysis of emergency department (ED) visits among youth aged 21 and younger presenting to an ED with a firearm injury between 2009 and 2016 using the Nationwide Emergency Department Sample. We performed multivariable logistic regression to measure the strength of association between (1) patient-level factors, (2) visit-level characteristics, and (3) clinical outcomes and intent of firearm injury. RESULTS: We identified 178 299 weighted visits for firearm injuries. The mean age was 17.9 (95% confidence interval 17.8-18.0) years; 89.0% of patients were male, 43.0% were publicly insured, 28.8% were admitted, and 6.0% died. Approximately one-third of the injuries were categorized as unintentional (39.4%), another third as assault (37.7%), and a small proportion as self-harm (1.7%). Unintentional firearm injuries were associated with younger age, rural hospital location, Southern region, ED discharge, and extremity injury. Self-harm firearm injuries were associated with older age, higher socioeconomic status, rural hospital location, transfer or death, and brain, back, or spinal cord injury. Firearm injuries by assault were associated with lower socioeconomic status, urban hospital location, and requiring admission. CONCLUSIONS: We identified distinct risk profiles for youth with unintentional, self-harm-, and assault-related firearm injuries. Sociodemographic factors related to intent may be useful in guiding policy and informing tailored interventions for the prevention of firearm injuries in at-risk youth.

Trunk Injuries in Athletes.

ABSTRACT: Trunk pain is a common cause of performance limitation and time away from sport in athletes. However, atraumatic trunk injuries are underrepresented in medical literature and underrecognized clinically. Delays in diagnosis and initiation of appropriate treatment can increase injury morbidity and return-to-play time. Currently, evidence-based guidelines for diagnosis and treatment of trunk pain in athletes are limited. Thus, we provide an overview of atraumatic sport-related injuries to the thoracic spine (disc herniation, scoliosis, kyphosis), ribcage (bone stress injury, costochondritis, Tietze syndrome, slipping rib syndrome, costovertebral or costotransverse joint dysfunction), and chest and abdominal wall musculature (intercostal, serratus anterior, oblique strains, regional myofascial pain), highlighting sport-specific biomechanical considerations. We aim to increase awareness of these causes of trunk pain among sports medicine providers in an effort to guide diagnostic and treatment recommendations that will ultimately improve overall musculoskeletal health in athletes.

Surviving traumatic cardiac arrest: Identification of factors associated with survival.

INTRODUCTION: The endpoint of resuscitative interventions after traumatic injury resulting in cardiopulmonary arrest varies across institutions and even among providers. The purpose of this study was to examine survival characteristics in patients suffering torso trauma with no recorded vital signs (VS) in the emergency department (ED). METHODS: The National Trauma Data Bank was analyzed from 2007 to 2015. Inclusion criteria were patients with blunt and penetrating torso trauma without VS in the ED. Patients with head injuries, transfers from other hospitals, or those with missing values were excluded. The characteristics of survivors were evaluated, and statistical analyses performed. RESULTS: A total of 24,191 torso trauma patients without VS were evaluated in the ED and 96.6% were declared dead upon arrival. There were 246 survivors (1%), and 73 (0.3%) were eventually discharged home. Of patients who responded to resuscitation (812), the survival rate was 30.3%. Injury severity score (ISS), penetrating mechanism (odds ratio [OR] 1.99), definitive chest (OR 1.59) and abdominal surgery (OR 1.49) were associated with improved survival. Discharge to home (or police custody) was associated with lower ISS (OR 0.975) and shorter ED time (OR 0.99). CONCLUSION: Over a recent nine-year period in the United States, nearly 25,000 trauma patients were treated at trauma centers despite lack of VS. Of these patients, only 73 were discharged home. A trauma center would have to attempt over one hundred resuscitations of traumatic arrests to save one patient, confirming previous reports that highlight a grave prognosis. This creates a dilemma in treatment for front line workers and physicians with resource utilization and consideration of safety of exposure, particularly in the face of COVID-19.

Free Flap Reconstruction of Posterior Trunk Soft-Tissue Defects: Single-Institution Experience and Systematic Literature Review.

BACKGROUND: The posterior trunk is a technically demanding location for microvascular free tissue transfer. In this study, the authors report their own institutional experience with soft-tissue free flap reconstruction of the posterior trunk and provide a systematic review of the literature regarding this uncommon clinical scenario. METHODS: A systematic review was performed using the PubMed database in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines. A single-institution retrospective review was also performed including all patients who received a soft-tissue free flap for a posterior trunk defect between 1990 and 2019. RESULTS: The database search yielded 15 articles, representing 61 patients; the most commonly used flap was the latissimus dorsi (45.9 percent) and the most commonly reported defect location was the lumbosacrum (42.3 percent). Retrospective review of the authors' database identified 26 patients, with the latissimus dorsi being the most common flap and the sacrum the most common defect site. The authors' institutional case series showed a 30.7 percent major complication rate and 7.7 percent total flap loss rate; 38.4 percent of flaps required vein grafting. CONCLUSIONS: In this study, the authors provided a systematic literature review and described their own long-term institutional experience with these rare and difficult reconstructions. Although the overall complication rate is high, these reconstructions are frequently necessary, and an algorithmic approach can improve outcomes. CLINICAL QUESTION/LEVEL OF EVIDENCE: Therapeutic, IV.