Surgical Science and the Evolution of Critical Care Medicine.

Surgical science has driven innovation and inquiry across adult and pediatric disciplines that provide critical care regardless of location. Surgically originated but broadly applicable knowledge has been globally shared within the pages Critical Care Medicine over the last 50 years.

Prospective Observational Evaluation of the ER-REBOA Catheter at 6 U.S. Trauma Centers.

OBJECTIVE: To describe the current use of the ER-REBOA catheter and associated outcomes and complications. INTRODUCTION: Noncompressible truncal hemorrhage is the leading cause of potentially preventable death in trauma patients. Resuscitative endovascular balloon occlusion of the aorta (REBOA) is a novel strategy to obtain earlier temporary hemorrhage control, supporting cardiac, and cerebral perfusion before definitive hemostasis. METHODS: Prospective, observational study conducted at 6 Level 1 Trauma Centers over 12-months. Inclusion criteria were age >15 years of age with evidence of truncal hemorrhage below the diaphragm and decision for emergent hemorrhage control intervention within 60 minutes of arrival. REBOA details, demographics, mechanism of injury, complications, and outcomes were collected. RESULTS: A total of 8166 patients were screened for enrollment. In 75, REBOA was utilized for temporary hemorrhage control. Blunt injury occurred in 80% with a median injury severity score (ISS) 34 (21, 43). Forty-seven REBOAs were placed in Zone 1 and 28 in Zone 3. REBOA inflation increased systolic blood pressure from 67 (40, 83) mm Hg to 108 (90, 128) mm Hg 5 minutes after inflation (P = 0.02). Cardiopulmonary resuscitation was ongoing during REBOA insertion in 17 patients (26.6%) and 10 patients (58.8%) had return of spontaneous circulation after REBOA inflation. The procedural complication rate was 6.6%. Overall mortality was 52%. CONCLUSION: REBOA can be used in blunt and penetrating trauma patients, including those in arrest. Balloon inflation uniformly improved hemodynamics and was associated with a 59% rate of return of spontaneous circulation for patients in arrest. Use of the ER-REBOA catheter is technically safe with a low procedural complication rate.

How we built a hospital-based community whole blood program.

BACKGROUND: Whole blood (WB) is an attractive product for prehospital treatment of hemorrhagic shock and for initial in-hospital resuscitation of patients likely to require massive transfusion. Neither our regional blood provider nor our hospital blood bank had recent experience collecting or using WB, so we developed a stepwise process to gather experience with WB in clinical practice. METHODS: When our Transfusion Committee suggested a WB program, we worked with our regional blood provider to collect cold-stored, leukoreduced, low-titer anti-A, and anti-B group O RhD positive WB (low-titer group O WB [LTOWB]) and worked with our city Fire Department to integrate it into prehospital care. This work required planning, development of protocols, writing software for blood bank and electronic medical records, changes in paramedic scope of practice, public information, training of clinicians, and close clinical follow-up. RESULTS: Between June 2019 and December 2021, we received 2269 units of LTOWB and transfused 2220 units; 24 (1%) were wasted, two were withdrawn, and 23 were in stock at the end of that time. Most (89%) were transfused to trauma patients. Usage has grown from 48 to 120 units/month, covers all 5 Fire Districts in the county, and represents about » of all hospital trauma blood product use. CONCLUSIONS: Developing a WB program is complex but can be started slowly, including both pre-hospital and hospital elements, and expanded as resources and training progress. The investments of time, effort, and funding involved can potentially improve care, save blood bank and nursing effort, and reduce patient charges.

Nonoperative Management in Blunt Splenic Trauma: Can Shock Index Predict Failure?

INTRODUCTION: Predicting failure of nonoperative management (NOM) in splenic trauma remains elusive. Shock index (SI) is an indicator of physiologic burden in an injury but is not used as a prediction tool. The purpose of this study was to determine if elevated SI would be predictive of failure of NOM in patients with a blunt splenic injury. METHODS: Adult patients admitted to a level-1 trauma center from January 2011 to April 2017 for NOM of splenic injury were reviewed. Patients were excluded if they underwent a procedure (angiography or surgery) prior to admission. The primary outcome was requiring intervention after an initial trial of noninterventional management (NIM). An SI > 0.9 at admission was considered a high risk. Univariate and multivariate analyses were used to identify predicators of the failure of NOM. Findings were subsequently verified on a validation cohort of patients. RESULTS: Five hundred and eighty-five patients met inclusion criteria; 7.4% failed NIM. On an univariate analysis, findings of pseudoaneurysm or extra-arterial contrast on computed tomography did not differentiate successful NIM versus failure (8.1% versus 14.0%, P = 0.18). Age, the American Association for the Surgery of Trauma injury grade, and elevated SI were included in multivariate modeling. Grade of injury (OR 3.49, P = 0.001), age (OR 1.02, P = 0.009), and high SI (OR 3.49, P = 0.001) were each independently significant for NIM failure. The risk-adjusted odds of failure were significantly higher in patients with a high risk SI (OR 2.35, P < 0.001). Validation of these findings was confirmed for high SI on a subsequent 406 patients with a c-statistic of 0.71 (95% CI 0.62-0.80). CONCLUSIONS: Elevated SI is an independent risk factor for failure of NIM in those with splenic injury. SI along with age and computed tomography findings may aid in predicting the failure of NIM. Trauma providers should incorporate SI into decision-making tools for splenic injury management.

Improving Data Collection and Abstraction to Assess Health Equity in Trauma Care.

Current trauma registries suffer from inconsistent collection of data needed to assess health equity. To identify barriers/facilitators to collecting accurate equity-related data elements, we assessed perspectives of national stakeholders, Emergency Department (ED) registration, and Trauma Registry staff. We conducted a Delphi process with experts in trauma care systems and key informant interviews and focus groups with ED patient registration and trauma registry staff at a regional Level I trauma center. Topics included data collection process, barriers/facilitators for equity-related data collection, electronic health record (EHR) entry, trauma registry abstraction, and strategies to overcome technology limitations. Responses were qualitatively analyzed and triangulated with observations of ED and trauma registry staff workflow. Expert-identified barriers to consistent data collection included lack of staff investment in changes and lack of national standardization of data elements; facilitators were simplicity, quality improvement checks, and stakeholder investment in modifying existing technology to collect equity elements. ED staff reported experiences with patients reacting suspiciously to queries regarding race and ethnicity. Cultural resonance training, a script to explain equity data collection, and allowing patients to self-report sensitive items using technology were identified as potential facilitators. Trauma registry staff reported lack of discrete fields, and a preference for auto-populated and designated EHR fields. Identified barriers and facilitators of collection and abstraction of equity-related data elements from multiple stakeholders provides a framework for improving data collection. Successful implementation will require standardized definitions, staff training, use of existing technology for patient self-report, and discrete fields for added elements.

Outcomes of ß-Hemolytic Streptococcal Necrotizing Skin and Soft-tissue Infections and the Impact of Clindamycin Resistance.

BACKGROUND: ß-Hemolytic streptococci are frequently implicated in necrotizing soft-tissue infections (NSTIs). Clindamycin administration may improve outcomes in patients with serious streptococcal infections. However, clindamycin resistance is growing worldwide, and resistance patterns in NSTIs and their impact on outcomes are unknown. METHODS: Between 2015 and 2018, patients with NSTI at a quaternary referral center were followed up for the outcomes of death, limb loss, and streptococcal toxic shock syndrome. Surgical wound cultures and resistance data were obtained within 48 hours of admission as part of routine care. Risk ratios for the association between these outcomes and the presence of ß-hemolytic streptococci or clindamycin-resistant ß-hemolytic streptococci were calculated using log-binomial regression, controlling for age, transfer status, and injection drug use-related etiology. RESULTS: Of 445 NSTIs identified, 85% had surgical wound cultures within 48 hours of admission. ß-Hemolytic streptococci grew in 31%, and clindamycin resistance was observed in 31% of cultures. The presence of ß-hemolytic streptococci was associated with greater risk of amputation (risk ratio, 1.80; 95% confidence interval, 1.07-3.01), as was the presence of clindamycin resistance among ß-hemolytic streptococci infections (1.86; 1.10-3.16). CONCLUSIONS: ß-Hemolytic streptococci are highly prevalent in NSTIs, and in our population clindamycin resistance was more common than previously described. Greater risk of limb loss among patients with ß-hemolytic streptococci-particularly clindamycin-resistant strains-may portend a more locally aggressive disease process or may represent preexisting patient characteristics that predispose to both infection and limb loss. Regardless, these findings may inform antibiotic selection and surgical management to maximize the potential for limb salvage.

Long-term Outcomes of Firearm Injury Survivors in the United States: The National Trauma Research Action Plan Scoping Review.

SUMMARY BACKGROUND/OBJECTIVE: To describe the current literature regarding long-term physical, mental, and social outcomes of firearm injury survivors in the United States. METHODS: We systematically searched the PubMed/MEDLINE and Embase databases for articles published from 2013 to 2019 that involved survivors of acute physical traumatic injury aged 18 or older and reported health outcomes between 6 months and 10 years postinjury. Out of 747 articles identified, seven reported outcomes on United States-based civilian patients whose mechanism of injury involved firearms. We extended our publication date criteria from 1995 to 2020 and expanded the search strategy to include medical subject headings terms specific for firearm injury outcomes. Ultimately, ten articles met inclusion criteria. RESULTS: When studied, a significant proportion of patients surviving firearm injury screened positive for posttraumatic stress disorder (49%-60%) or were readmitted (13%-26%) within 6 months postinjury. Most studies reported worse long-term outcomes for firearm injury survivors when compared both to similarly injured motor vehicle collision survivors and to the United States general population, including increased chronic pain, new functional limitations, and reduced physical health composite scores. Studies also reported high rates of posttraumatic stress disorder, reduced mental health composite scores, lower employment and return to work rates, poor social functioning, increased alcohol, and substance abuse. CONCLUSIONS: Research on the long-term health impact of firearm injury is scant, and heterogeneity in available studies limits the ability to fully characterize the outcomes among these patients. A better understanding of the long-term health impact of firearm injury would support systematic change in policy and patient care to improve outcomes.

A Prospective US National Trauma Center Study of Firearm Injury Survivors Weapon Carriage and Posttraumatic Stress Disorder Symptoms.

OBJECTIVE: To describe the demographic, injury-related, and mental health characteristics of firearm injury patients and trace firearm weapon carriage and PTSD symptoms over the year after injury. SUMMARY AND BACKGROUND DATA: Based on the increasing incidence of firearm injury and need for novel injury prevention strategies, hospital-based violence intervention programs are being implemented in US trauma centers. There is limited data on the long-term outcomes and risk behaviors of firearm injury survivors to guide this work. METHODS: We conducted a secondary analysis of a pragmatic 25-trauma center randomized trial (N = 635). Baseline characteristics of firearm-injured patients (N = 128) were compared with other trauma patients. Mixed model regression was used to identify risk factors for postinjury firearm weapon carriage and PTSD symptoms. RESULTS: Firearm injury patients were younger and more likely to be black, male and of lower socioeconomic status, and more likely to carry a firearm in the year before injury. Relative to preinjury, there was a significant drop in firearm weapon carriage at 3- and 6-months postinjury, followed by a return to preinjury levels at 12-months. Firearm injury was significantly and independently associated with an increased risk of postinjury firearm weapon carriage [relative risk = 2.08, 95% confidence interval (1.34, 3.22), P < 0.01] and higher PTSD symptom levels [Beta = 3.82, 95% confidence interval (1.29, 6.35), P < 0.01]. CONCLUSIONS: Firearm injury survivors are at risk for firearm carriage and high PTSD symptom levels postinjury. The significant decrease in the high-risk behavior of firearm weapon carriage at 3-6 months postinjury suggests that there is an important postinjury "teachable moment" that should be targeted with preventive interventions. TRIAL REGISTRATION: ClinicalTrials.gov NCT02655354.

Evidence-Based and Clinically Relevant Outcomes for Hemorrhage Control Trauma Trials.

OBJECTIVE: To address the clinical and regulatory challenges of optimal primary endpoints for bleeding patients by developing consensus-based recommendations for primary clinical outcomes for pivotal trials in patients within 6 categories of significant bleeding, (1) traumatic injury, (2) intracranial hemorrhage, (3) cardiac surgery, (4) gastrointestinal hemorrhage, (5) inherited bleeding disorders, and (6) hypoproliferative thrombocytopenia. BACKGROUND: A standardized primary outcome in clinical trials evaluating hemostatic products and strategies for the treatment of clinically significant bleeding will facilitate the conduct, interpretation, and translation into clinical practice of hemostasis research and support alignment among funders, investigators, clinicians, and regulators. METHODS: An international panel of experts was convened by the National Heart Lung and Blood Institute and the United States Department of Defense on September 23 and 24, 2019. For patients suffering hemorrhagic shock, the 26 trauma working-group members met for almost a year, utilizing biweekly phone conferences and then an in-person meeting, evaluating the strengths and weaknesses of previous high quality studies. The selection of the recommended primary outcome was guided by goals of patient-centeredness, expected or demonstrated sensitivity to beneficial treatment effects, biologic plausibility, clinical and logistical feasibility, and broad applicability. CONCLUSIONS: For patients suffering hemorrhagic shock, and especially from truncal hemorrhage, the recommended primary outcome was 3 to 6-hour all-cause mortality, chosen to coincide with the physiology of hemorrhagic death and to avoid bias from competing risks. Particular attention was recommended to injury and treatment time, as well as robust assessments of multiple safety related outcomes.

Blood component use and injury characteristics of acute trauma patients arriving from the scene of injury or as transfers to a large, mature US Level 1 trauma center serving a large, geographically diverse region.

BACKGROUND: Advanced trauma care demands the timely availability of hemostatic blood products, posing special challenges for regional systems in geographically diverse areas. We describe acute trauma blood use by transfer status and injury characteristics at a large regional Level 1 trauma center. STUDY DESIGN AND METHODS: We reviewed Harborview Medical Center (HMC) Trauma Registry, Transfusion Service, and electronic medical records on acute trauma patients for demographics, injury patterns, blood use, and in-hospital mortality, 2011-2019. RESULTS: Among 47,471 patients (mean age 45.2 ± 23.0 years; 68.3% male; Injury Severity Score 12.6 ± 11.1), 4.7% died and 8547 (18%) received at least one blood component through HMC. Firearms injuries were the most often transfused (690/2596, 26.6%) and the most urgently (39.9% ≥3 units in <1 h; 40.6% ≥5 units in <4 h), and had the highest mortality (case-fatality, 12.2%) (all p < .001). From-scene patients were younger than transfers (42.9 ± 21.0 vs. 47.2 ± 24.4), predominated among firearms injuries (68.2% from-scene vs. 31.8% transfers), were more likely to receive blood (18.5% vs. 17.6%) more urgently (≥3 units first hour, 24.4% vs. 7.7%; ≥5 units first 4 h: 25.6% vs. 8.2%), were more likely to die of hemorrhage (15.5% vs. 4.3%) and from firearms injuries (310/1360, 22.8%) (all p < .001). DISCUSSION: Early blood use, firearms injuries, and mortality were all greater among from-scene patients, and firearms injuries had worse outcomes despite greater and more urgent blood use, but the role of survivor bias for transfer patients must be clarified. Future research must identify strategies for providing local hemostatic transfusion support, particularly for firearms injuries.

Systematic Review of Evidence-Based Guidelines for Prehospital Care.

Introduction: Multiple national organizations have identified a need to incorporate more evidence-based medicine in emergency medical services (EMS) through the creation of evidence-based guidelines (EBGs). Tools like the Appraisal of Guidelines for Research and Evaluation (AGREE) II and criteria outlined by the National Academy of Medicine (NAM) have established concrete recommendations for the development of high-quality guidelines. While many guidelines have been created that address topics within EMS medicine, neither the quantity nor quality of prehospital EBGs have been previously reported. Objectives: To perform a systematic review to identify existing EBGs related to prehospital care and evaluate the quality of these guidelines using the AGREE II tool and criteria for clinical guidelines described by the NAM. Methods: We performed a systematic search of the literature in MEDLINE, EMBASE, PubMED, Trip, and guidelines.gov, through September 2018. Guideline topics were categorized based on the 2019 Core Content of EMS Medicine. Two independent reviewers screened titles for relevance and then abstracts for essential guideline features. Included guidelines were appraised with the AGREE II tool across 6 domains by 3 independent reviewers and scores averaged. Two additional reviewers determined if each guideline reported the key elements of clinical practice guidelines recommended by the NAM via consensus. Results: We identified 71 guidelines, of which 89% addressed clinical aspects of EMS medicine. Only 9 guidelines scored >75% across AGREE II domains and most (63%) scored between 50 and 75%. Domain 4 (Clarity of Presentation) had the highest (79.7%) and domain 5 (Applicability) had the lowest average score across EMS guidelines. Only 38% of EMS guidelines included a reporting of all criteria identified by the NAM for clinical practice guidelines, with elements of a systematic review of the literature most commonly missing. Conclusions: EBGs exist addressing a variety of topics in EMS medicine. This systematic review and appraisal of EMS guidelines identified a wide range in the quality of these guidelines and variable reporting of key elements of clinical guidelines. Future guideline developers should consider established methodological and reporting recommendations to improve the quality of EMS guidelines.

A Novel Immune Modulator for Patients With Necrotizing Soft Tissue Infections (NSTI): Results of a Multicenter, Phase 3 Randomized Controlled Trial of Reltecimod (AB 103).

BACKGROUND AND OBJECTIVE: Reltecimod, a CD 28 T-lymphocyte receptor mimetic, inhibits T-cell stimulation by an array of bacterial pathogens. A previous phase 2 trial demonstrated improved resolution of organ dysfunction after NSTI. We hypothesized that early administration of reltecimod would improve outcome in severe NSTI. METHODS: Randomized, double-blind, placebo-controlled trial of single dose reltecimod (0.5 mg/kg) administered within 6 hours of NSTI diagnosis at 65 of 93 study sites. Inclusion: surgical confirmation of NSTI and organ dysfunction [modified Sequential Organ Failure Assessment Score (mSOFA) score ≥3]. Primary analysis was modified Intent-to-Treat (mITT), responder analysis using a previously validated composite endpoint, necrotizing infection clinical composite endpoint, defined as: alive at day 28, ≤3 debridements, no amputation beyond first operation, and day 14 mSOFA ≤1 with ≥3 point reduction (organ dysfunction resolution). A prespecified, per protocol (PP) analysis excluded 17 patients with major protocol violations before unblinding. RESULTS: Two hundred ninety patients were enrolled, mITT (Reltecimod 142, Placebo 148): mean age 55 ±â€Š15 years, 60% male, 42.4% diabetic, 28.6% perineal infection, screening mSOFA mean 5.5 ±â€Š2.4. Twenty-eight-day mortality was 15% in both groups. mITT necrotizing infection clinical composite endpoint success was 48.6% reltecimod versus 39.9% placebo, P = 0.135 and PP was 54.3% reltecimod versus 40.3% placebo, P = 0.021. Resolution of organ dysfunction was 65.1% reltecimod versus 52.6% placebo, P = 0.041, mITT and 70.9% versus 53.4%, P = 0.005, PP. CONCLUSION: Early administration of reltecimod in severe NSTI resulted in a significant improvement in the primary composite endpoint in the PP population but not in the mITT population. Reltecimod was associated with improved resolution of organ dysfunction and hospital discharge status.

ECMO Membrane Lung Failure due to Hypertriglyceridemia: A Case Report and Review of the Literature.

The deleterious effects of high serum lipid content on the membrane lung (ML) during extracorporeal membrane oxygenation (ECMO) are sparsely documented, and the threshold of lipemia-induced membrane failure is poorly described. We present a case of a patient on venovenous ECMO who developed ML failure after 7 days due to moderate to severe hypertriglyceridemia (700-800 mg/dL). ML failure was exhibited by impaired gas exchange and high transmembrane pressures, and there was notable lipemic layering in the circuit immediately after decannulation. This case demonstrates that in addition to patients with extreme lipemia, ML failure can also occur in patients with moderate to severe hypertriglyceridemia. Hypertriglyceridemia should be suspected in patients with high transmembrane pressures and ML failure not attributable to thrombosis, and these patients may require frequent ML changes if a prolonged ECMO run is required.

Effect of Out-of-Hospital Tranexamic Acid vs Placebo on 6-Month Functional Neurologic Outcomes in Patients With Moderate or Severe Traumatic Brain Injury.

Importance: Traumatic brain injury (TBI) is the leading cause of death and disability due to trauma. Early administration of tranexamic acid may benefit patients with TBI. Objective: To determine whether tranexamic acid treatment initiated in the out-of-hospital setting within 2 hours of injury improves neurologic outcome in patients with moderate or severe TBI. Design, Setting, and Participants: Multicenter, double-blinded, randomized clinical trial at 20 trauma centers and 39 emergency medical services agencies in the US and Canada from May 2015 to November 2017. Eligible participants (N = 1280) included out-of-hospital patients with TBI aged 15 years or older with Glasgow Coma Scale score of 12 or less and systolic blood pressure of 90 mm Hg or higher. Interventions: Three interventions were evaluated, with treatment initiated within 2 hours of TBI: out-of-hospital tranexamic acid (1 g) bolus and in-hospital tranexamic acid (1 g) 8-hour infusion (bolus maintenance group; n = 312), out-of-hospital tranexamic acid (2 g) bolus and in-hospital placebo 8-hour infusion (bolus only group; n = 345), and out-of-hospital placebo bolus and in-hospital placebo 8-hour infusion (placebo group; n = 309). Main Outcomes and Measures: The primary outcome was favorable neurologic function at 6 months (Glasgow Outcome Scale-Extended score >4 [moderate disability or good recovery]) in the combined tranexamic acid group vs the placebo group. Asymmetric significance thresholds were set at 0.1 for benefit and 0.025 for harm. There were 18 secondary end points, of which 5 are reported in this article: 28-day mortality, 6-month Disability Rating Scale score (range, 0 [no disability] to 30 [death]), progression of intracranial hemorrhage, incidence of seizures, and incidence of thromboembolic events. Results: Among 1063 participants, a study drug was not administered to 96 randomized participants and 1 participant was excluded, resulting in 966 participants in the analysis population (mean age, 42 years; 255 [74%] male participants; mean Glasgow Coma Scale score, 8). Of these participants, 819 (84.8%) were available for primary outcome analysis at 6-month follow-up. The primary outcome occurred in 65% of patients in the tranexamic acid groups vs 62% in the placebo group (difference, 3.5%; [90% 1-sided confidence limit for benefit, -0.9%]; P = .16; [97.5% 1-sided confidence limit for harm, 10.2%]; P = .84). There was no statistically significant difference in 28-day mortality between the tranexamic acid groups vs the placebo group (14% vs 17%; difference, -2.9% [95% CI, -7.9% to 2.1%]; P = .26), 6-month Disability Rating Scale score (6.8 vs 7.6; difference, -0.9 [95% CI, -2.5 to 0.7]; P = .29), or progression of intracranial hemorrhage (16% vs 20%; difference, -5.4% [95% CI, -12.8% to 2.1%]; P = .16). Conclusions and Relevance: Among patients with moderate to severe TBI, out-of-hospital tranexamic acid administration within 2 hours of injury compared with placebo did not significantly improve 6-month neurologic outcome as measured by the Glasgow Outcome Scale-Extended. Trial Registration: ClinicalTrials.gov Identifier: NCT01990768.

Association of Blood Component Ratios With 24-Hour Mortality in Injured Children Receiving Massive Transfusion.

OBJECTIVES: To determine if higher fresh frozen plasma and platelet to packed RBC ratios are associated with lower 24-hour mortality in bleeding pediatric trauma patients. DESIGN: Retrospective cohort study using the Pediatric Trauma Quality Improvement Program Database from 2014 to 2016. SETTING: Level I and II pediatric trauma centers participating in the Trauma Quality Improvement Program PATIENTS:: Injured children (≤ 14 yr old) who received massive transfusion (≥ 40 mL/kg total blood products in 24 hr). Of 123,836 patients, 590 underwent massive transfusion, of which 583 met inclusion criteria. INTERVENTIONS: None. MEASUREMENTS AND MAIN RESULTS: Ratios of fresh frozen plasma:packed RBC and platelet:packed RBC. Of the 583 patients, 60% were male and the median age was 5 years (interquartile range, 2-10 yr). Overall mortality was 19.7% (95% CI, 16.6-23.2%) at 24 hours. There was 51% (adjusted relative risk, 0.49; 95% CI, 0.27-0.87; p = 0.02) and 40% (adjusted relative risk, 0.60; 95% CI, 0.39-0.92; p = 0.02) lower risk of death at 24 hours for the high (≥ 1:1) and medium (≥ 1:2 and < 1:1) fresh frozen plasma:packed RBC ratio groups, respectively, compared with the low ratio group (< 1:2). Platelet:packed RBC ratio was not associated with mortality (adjusted relative risk, 0.94; 95% CI, 0.51-1.71; p = 0.83). CONCLUSIONS: Higher fresh frozen plasma ratios were associated with lower 24-hour mortality in massively transfused pediatric trauma patients. The platelet ratio was not associated with mortality. Although these findings represent the largest study evaluating blood product ratios in pediatric trauma patients, prospective studies are necessary to determine the optimum blood product ratios to minimize mortality in this population.

Higher LRINEC Scores and Escalation of Anesthesia Care in Necrotizing Soft Tissue Infection.

BACKGROUND: The Laboratory Risk Indicator for Necrotizing Fasciitis (LRINEC) score may distinguish necrotizing soft tissue infection (NSTI) from non-NSTI. The association of higher preoperative LRINEC scores with escalations of intraoperative anesthesia care in NSTI is unknown and may be useful in communicating illness severity during patient handoffs. MATERIALS AND METHODS: We conducted a retrospective cohort study of first operative debridement for suspected NSTI in a single referral center from 2013 to 2016. We assessed the association between LRINEC score and vasopressors, blood products, crystalloid, invasive monitoring, and minutes of operative and anesthesia care. RESULTS: We captured 332 patients undergoing their first operative debridement for suspected NSTI. For every 1-point higher LRINEC score, there was a higher risk of norepinephrine and vasopressin use (relative risk [RR] = 18%, 95% confidence interval [CI] [10%, 26%] and [10%, 27%], respectively), packed red blood cell use (RR = 28% [95% CI 13%, 45%]), and additional crystalloid (17.57 mL/h [95% CI 0.37, 34.76]). Each additional LRINEC point was associated with longer anesthesia (3.42 min, 95% CI 0.94, 5.91) and operative times (2.35 min, 95% CI 0.29, 4.40) and a higher risk of receiving invasive arterial monitoring (RR 1.11, 95% CI 1.05, 1.18). The negative predictive value for an LRINEC score < 6 was > 90% for use of vasopressors and packed red blood cells. CONCLUSIONS: Preoperative LRINEC scores were associated with escalations in intraoperative care in patients with NSTI. A low score may predict patients unlikely to require vasopressors or blood and may be useful in standardized handoff tools for patients with NSTI.

Frequency of Operative Anesthesia Care After Traumatic Injury.

BACKGROUND: Virtually all anesthesiologists care for patients who sustain traumatic injuries; however, the frequency with which operative anesthesia care is provided to this specific patient population is unclear. We sought to better understand the degree to which anesthesia providers participate in operative trauma care and how this differs by trauma center designation (levels I-V), using data from a comprehensive, regional database-the Washington State Trauma Registry (WSTR). We also sought to specifically assess operative anesthesia care frequency vis a vis the American College of Surgeons guidelines for continuous anesthesiology coverage for Level II trauma center accreditation. METHODS: We conducted a retrospective analysis measuring the frequency of operative anesthesia care among patients enrolled in the WSTR. Univariate comparisons were made between trauma patients who had surgery during their admission and those who did not (medical management only). In addition, clinical factors associated with surgical intervention were measured. We also measured the average times from hospital admission to surgery and compared these times across trauma centers, grouped level I, II, and III-V. RESULTS: From 2004 to 2014, there were approximately 176,000 encounters meeting WSTR inclusion criteria. Approximately 60% of these trauma encounters included exposure to operative anesthesia during the admission. Among all surgical procedures during the trauma admission, approximately 33% occurred within a level I trauma center, 23% occurred within a level II trauma center, and 44% occurred in a trauma center with a III, IV, or V designation. The predominant procedure category during a trauma admission was orthopedic. The presence of hypotension on admission (P < .01), increasing injury severity score (P < .01) and higher emergency department Glasgow Coma Score (P < .01) were all associated with surgical intervention during the trauma hospitalization, after adjustment for potential confounders. In level I trauma centers, for general surgical procedures, the median time to surgery was 2.5 hours; in level II trauma centers, the median time was 1.7 hours. CONCLUSIONS: This study highlights the frequent role anesthesiologists play in caring for patients who sustain traumatic injuries, in trauma centers levels I-V. In level II trauma centers, in-house anesthesiology coverage might have benefit for those patients requiring surgery within 1 hour, whereas the former American College of Surgeons requirement of 30-minute response time for out-of-hospital anesthesiology coverage is likely sufficient to provide satisfactory care to patients requiring surgery within 3 hours. Whether the increased cost of such in-house anesthesiology coverage at level II trauma centers is justified by its clinical benefit remains an unanswered question.

Quality management of a massive transfusion protocol.

BACKGROUND: Massive transfusion is a response to massive uncontrolled hemorrhage. To be effective, it must be timely and address the patient's needs for blood volume, oxygen transport, and hemostasis. STUDY DESIGN AND METHODS: A review was performed on all activations of the massive transfusion protocol (MTP) in a hospital with large emergency medicine, trauma, and vascular surgery programs. Indications, transfused amounts, and outcomes were determined for each MTP event to determine appropriateness of MTP use. Results are presented as descriptive statistics, categorical associations, and simple linear trend relationships. RESULTS: The MTP was activated 309 times in 2016. Of these episodes, 237 were for trauma, 29 for gastrointestinal bleeding, 16 for ruptured abdominal aortic aneurisms, and 25 for a variety of other causes. Trauma-related MTP activations had a mean injury severity score of 32. Blood use averaged 6.6 units of red blood cells (RBCs), 6.5 units of plasma, and 1.2 units of apheresis platelets. Fourteen activations ended without the administration of any blood products, and 45 (14%) did not meet the critical administration threshold of three components. Only 60 (19%) activations met the historic definition of massive with at least 10 units of RBCs administered. Mortality was 15% for the trauma-related activations. CONCLUSIONS: Massive transfusion protocol activations were frequent and conducted with high fidelity to the 1:1:1 unit ratio standard. Making blood components available quickly was associated with low rates of total component usage and low mortality for trauma patients and was not associated with overuse.

Alcohol-impaired driving in US counties, 2002-2012.

BACKGROUND: Excessive alcohol consumption and alcohol-impaired driving remain significant public health problems, leading to considerable morbidity and mortality, particularly among younger populations. METHODS: Using data from the Behavioral Risk Factor Surveillance System (BRFSS), we employed a small areas modeling strategy to estimate the county-level annual prevalence of alcohol-impaired driving in every United States county for the years 2002 through 2012, the latest year in which county identifiers were publicly available. RESULTS: Alcohol-impaired driving episodes declined from 157.0 million in 2002 (prevalence 3.8%: 95% uncertainty interval [UI], 3.7%-4.0%) to 129.7 million in 2012 (prevalence 3.7%: 95% UI, 3.5%-3.8%), a 17.4% decline. There is considerable variation in the prevalence of alcohol-impaired driving at the county level, ranging from 2.0% in the Sitka City Borough of Alaska to 9.3% in Nance County, Nebraska. Clusters of increased alcohol-impaired driving were observed in Northern Wisconsin (Marinette, Florence, Forest, Vilas, Oneida, Iron counties), North Dakota (Cavalier, Pembina, Walsh, Ramsey, Nelson, Benson, Eddy counties) and Montana (Sheridan, Daniels, Roosevelt, Valley, Phillips, Petroleum, Garfield counties). CONCLUSIONS: This study showed guarded progress with respect to the occurrence of alcohol-impaired driving episodes in the US from 2002 to 2012. Because these data rely on self-report, this likely represents an underestimate of the true prevalence of alcohol-impaired driving in the US. As the US continues to have several million episodes of alcohol-impaired driving each month, renewed efforts are needed to mitigate this high-risk health behavior.

Spinal Motion Restriction in the Trauma Patient - A Joint Position Statement.

The American College of Surgeons Committee on Trauma (ACS-COT), American College of Emergency Physicians (ACEP), and the National Association of EMS Physicians (NAEMSP) have previously offered varied guidance on the role of backboards and spinal immobilization in out-of-hospital situations. This updated consensus statement on spinal motion restriction in the trauma patient represents the collective positions of the ACS-COT, ACEP and NAEMSP. It has further been formally endorsed by a number of national stakeholder organizations. This updated uniform guidance is intended for use by emergency medical services (EMS) personnel, EMS medical directors, emergency physicians, trauma surgeons, and nurses as they strive to improve the care of trauma victims within their respective domains.