Optimal Timing for Initiation of Thromboprophylaxis After Hepatic Angioembolization.

OBJECTIVE: To evaluate the optimal timing of thromboprophylaxis (TPX) initiation after hepatic angioembolization in trauma patients. SUMMARY BACKGROUND DATA: TPX after hepatic trauma is complicated by the risk of bleeding, but the relative risk after hepatic angioembolization is unknown. METHODS: Patients who underwent hepatic angioembolization within 24 hours were retrospectively identified from the 2017-19 ACS TQIP datasets. Cases with <24-hour length of stay and other serious injuries were excluded. VTE included DVT and PE. Bleeding complications included hepatic surgery, additional angioembolization, or blood transfusion after TPX initiation. Differences were tested with univariate and multivariate analyses. RESULTS: Of 1,550 patients, 1,370 had initial angioembolization. Bleeding complications were higher in those with TPX initiation within 24 hours (20.0% vs 8.9%, P<0.001) and 48 hours (13.2% vs 8.4%, P=0.013). However, VTE was higher in those with TPX initiation after 48 hours (6.3%vs 3.3%, P=0.025). In the 180 patients with hepatic surgery prior to angioembolization, bleeding complications were higher in those with TPX initiation within 24 hours (72% vs 20%, P <0.001), 48 hours (50% vs 17%, P<0.001), and 72 hours (37% vs 14%, P=0.001). Moreover, DVT was higher in those with TPX initiation after 96 hours (14.3% vs 3.1%, P =0.023). CONCLUSION: This is the first study to address timing of TPX after hepatic angioembolization in a national sample of trauma patients. For these patients, initiation of TPX at 48- 72 hours achieves the safest balance in minimizing bleeding while reducing the risk of VTE. LEVEL OF EVIDENCE: Level III - Retrospective Cohort Study.

Initial Hemorrhage Control Procedure for Splenic Injuries May Affect Risk of Venous Thromboembolism.

INTRODUCTION: Venous thromboembolism (VTE) continues to be a major cause of morbidity in trauma. It is unclear whether the type of hemorrhage control procedure (i.e., splenectomy versus angioembolization) is associated with an increased risk of VTE. We hypothesize that hemodynamically stable patients undergoing angioembolization for blunt high-grade splenic injuries have lower rates of VTE compared to those undergoing splenectomy. METHODS: The American College of Surgeons Trauma Quality Program dataset from 2017 to 2019 was queried to identify all patients with American Association for the Surgery of Trauma grade 3-5 blunt splenic injuries. Outcomes including VTE rates were compared between those who were managed with splenectomy versus angioembolization. Propensity score matching (1:1) was performed adjusting for age, sex, initial vital signs, Injury Severity Score, and splenic injury grade. RESULTS: The analysis included 4698 matched patients (splenectomy [n = 2349] and angioembolization [n = 2349]). The median (interquartile range) age was 41 (27-58) years and 69% were male. Patients were well matched between groups. Angioembolization was associated with significantly lower VTE than splenectomy (2.2% versus 3.4%, P = 0.010) despite less use of VTE chemoprophylaxis (70% versus 80%, P < 0.001), as well as a relative delay in initiation of chemoprophylaxis (44 h versus 33 h, P < 0.001). Hospital and intensive care unit length of stay and mortality were also significantly lower in the angioembolization group. CONCLUSIONS: Angioembolization is associated with a significantly lower incidence of VTE than splenectomy. Thus, angioembolization should be considered for initial management of hemodynamically stable patients with high-grade blunt splenic injuries in whom laparotomy is not otherwise indicated.

Nationwide Analysis of Firearm Injury Versus Other Penetrating Trauma: It's Not All the Same Caliber.

INTRODUCTION: Ballistic injuries cause both a temporary and permanent cavitation event, making them far more destructive and complex than other penetrating trauma. We hypothesized that global injury scoring and physiologic parameters would fail to capture the lethality of gunshot wounds (GSW) compared to other penetrating mechanisms. METHODS: The 2019 American College of Surgeons Trauma Quality Programs participant use file was queried for the mortality rate for GSW and other penetrating mechanisms. A binomial logistic regression model ascertained the effects of sex, age, hypotension, tachycardia, mechanism, Glasgow Coma Scale, ISS, and volume of blood transfusion on the likelihood of mortality. Subgroup analyses examined isolated injuries by body regions. RESULTS: Among 95,458 cases (82% male), GSW comprised 46.4% of penetrating traumas. GSW was associated with longer hospital length of stay (4 [2-9] versus 3 [2-5] days), longer intensive care unit length of stay (3 [2-6] versus 2 [2-4] days), and more ventilator days (2 [1-4] versus 2 [1-3]) compared to stab wounds, all P < 0.001. The model determined that GSW was linked to increased odds of mortality compared to stab wounds (odds ratio 4.19, 95% confidence interval 3.55-4.93). GSW was an independent risk factor for acute kidney injury, acute respiratory distress syndrome, venous thromboembolism, sepsis, and surgical site infection. CONCLUSIONS: Injury scoring systems based on anatomical or physiological derangements fail to capture the lethality of GSW compared to other mechanisms of penetrating injury. Adjustments in risk stratification and reporting are necessary to reflect the proportion of GSW seen at each trauma center. Improved classification may help providers develop quality processes of care. This information may also help shape public discourse on this highly lethal mechanism.

Survival of In-Hospital Cardiopulmonary Arrest in Trauma Patients.

INTRODUCTION: Relative to other hospitalized patients, trauma patients are younger with fewer comorbidities, but the incidence and outcomes of in-hospital cardiopulmonary arrest (IHCA) with cardiopulmonary resuscitation (CPR) in this population is unknown. Therefore, we aimed to investigate factors associated with survival in trauma patients after IHCA to test the hypothesis that compared to other hospitalized patients, trauma patients with IHCA have improved survival. METHODS: Retrospective review of the Trauma Quality Improvement Program database 2017 to 2019 for patients who had IHCA with CPR. Primary outcome was survival to hospital discharge. Secondary outcomes were in-hospital complications, hospital length of stay, intensive care unit length of stay, and ventilator days. Data were compared with univariate and multivariate analyses at P < 0.05. RESULTS: In 22,346,677 admitted trauma patients, 14,056 (0.6%) received CPR. Four thousand three hundred seventy-seven (31.1%) survived to discharge versus 26.4% in a national sample of all hospitalized patients (P < 0.001). In trauma patients, median age was 55 y, the majority were male (72.2%). Mortality was higher for females versus males (70.3% versus 68.3%, P = 0.026). Multivariate regression showed that older age 1.01 (95% confidence interval (CI) 1.01-1.02), Hispanic ethnicity 1.21 (95% CI 1.04-1.40), and penetrating trauma 1.51 (95% CI 1.32-1.72) were risk factors for mortality, while White race was a protective factor 0.36 (95% CI 0.14-0.89). CONCLUSIONS: This is the first study to show that the incidence of IHCA with CPR is approximately six in 1000 trauma admissions and 31% survive to hospital discharge, which is higher than other hospitalized patients. Age, gender, racial, and ethnic disparities also influence survival.

Advances in the Management of Coagulopathy in Trauma: The Role of Viscoelastic Hemostatic Assays across All Phases of Trauma Care.

Uncontrolled bleeding is the leading cause of preventable death following injury. Trauma-induced coagulopathy can manifest as diverse phenotypes ranging from hypocoagulability to hypercoagulability, which can change quickly during the acute phase of trauma care. The major advances in understanding coagulation over the past 25 years have resulted from the cell-based concept, emphasizing the key role of platelets and their interaction with the damaged endothelium. Consequently, conventional plasma-based coagulation testing is not accurate in predicting bleeding and does not provide an assessment of which blood products are indicated. Viscoelastic hemostatic assays (VHA), conducted in whole blood, have emerged as a superior method to guide goal-directed transfusion. The major change in resuscitation has been the shift from unbridled crystalloid loading to judicious balanced blood product administration. Furthermore, the recognition of the rapid changes from hypocoagulability to hypercoagulability has underscored the importance of ongoing surveillance beyond emergent surgery. While the benefits of VHA testing are maximized when used as early as possible, current technology limits use in the pre-hospital setting and the time to results compromises its utility in the emergency department. Thus, most of the reported experience with VHA in trauma is in the operating room and intensive care unit, where there is compelling data to support its value. This overview will address the current and potential role of VHA in the seriously injured patient, throughout the continuum of trauma management.

Incidence and Operative Factors Associated With Discretional Postoperative Mechanical Ventilation After General Surgery.

BACKGROUND: Mechanical ventilation after general surgery is associated with worse outcomes, prolonged hospital stay, and increased health care cost. Postoperatively, patients admitted to the intensive care unit (ICU) may be categorized into 1 of 3 groups: extubated patients (EXT), patients with objective medical indications to remain ventilated (MED), and patients not meeting these criteria, called "discretional postoperative mechanical ventilation" (DPMV). The objectives of this study were to determine the incidence of DPMV in general surgery patients and identify the associated operative factors. METHODS: At a large, tertiary medical center, we reviewed all surgical cases performed under general anesthesia from April 1, 2008 to February 28, 2015 and admitted to the ICU postoperatively. Patients were categorized into 1 of 3 cohorts: EXT, MED, or DPMV. Operative factors related to the American Society of Anesthesiologists Physical Status (ASA PS), duration of surgery, surgery end time, difficult airway management, intraoperative blood and fluid administration, vasopressor infusions, intraoperative arterial blood gasses, and ventilation data were collected. Additionally, anesthesia records were reviewed for notes indicating a reason or rationale for postoperative ventilation. Categorical variables were compared by χ test, and continuous variables by analysis of variance or Kruskal-Wallis H test. Categorical variables are presented as n (%), and continuous variables as mean ± standard deviation or median (interquartile range) as appropriate. Significance level was set at P≤ .05. RESULTS: Sixteen percent of the 3555 patients were categorized as DPMV and 12.2% as MED. Compared to EXT patients, those classified as DPMV had received significantly less fluid (2757 ± 2728 mL vs 3868 ± 1885 mL; P < .001), lost less blood during surgery (150 [20-625] mL vs 300 [150-600] mL; P< .001), underwent a shorter surgery (199 ± 215 minutes vs 276 ± 143 minutes; P< .001), but received more blood products, 900 (600-1800) mL vs 600 (300-900) mL. The DPMV group had more patients with high ASA PS (ASA III-V) than the EXT group: 508 (90.4%) vs 1934 (75.6%); P< .001. Emergency surgery (ASA E modifier) was more common in the DPMV group than the EXT group: 145 (25.8%) vs 306 (12%), P< .001, respectively. Surgery end after regular working hours was not significantly higher with DPMV status compared to EXT. DPMV cohort had fewer cases with difficult airway when compared to EXT or MED. When compared to MED patients, those classified as DPMV received less fluid (2757 ± 2728 mL vs 4499 ± 2830 mL; P< .001), lost less blood (150 [20-625] mL vs 500 [200-1350] mL; P < .001), but did not differ in blood products transfused or duration of surgery. CONCLUSIONS: In our tertiary medical center, patients often admitted to the ICU on mechanical ventilation without an objective medical indication. When compared to patients admitted to the ICU extubated, those mechanically ventilated but without an objective indication had a higher ASA PS class and were more likely to have an ASA E modifier. A surgery end time after regular working hours or difficult airway management was not associated with higher incidence of DPMV.

Hybrid Revascularization Combining Iliofemoral Endarterectomy and Iliac Stent Grafting for TransAtlantic Inter-Society Consensus C and D Aortoiliac Occlusive Disease.

BACKGROUND: This study examines the outcome of hybrid revascularization combining iliofemoral endarterectomy and iliac artery stenting using covered stents in TransAtlantic Inter-Society Consensus (TASC) C and D aortoiliac occlusive disease (AIOD) involving the common femoral artery (CFA). METHODS: A retrospective review was conducted in patients with TASC C and D AIOD involving the CFA and undergoing hybrid revascularization. Covered stents were used primarily. Demographics, indications for surgery, lesion classification, hospital length of stay (LOS), 30-day morbidity/mortality, hemodynamic and clinical success, and patency were assessed. RESULTS: Thirty-six male patients (41 limbs), mean age 63.9 ± 6 years, were identified (TASC C = 39%, D = 61%). Indications for surgery were claudication (27%), rest pain (44%), and tissue loss (29%). A simultaneous adjunctive procedure (5 infrainguinal bypass, 3 superficial femoral artery stents) was performed in 22%. Thirty-day outcomes included 1 mortality (2.7%) and 2 reoperation (5.5%), 1 for femoral artery pseudoaneurysm and 1 for bilateral groin seroma. LOS was 4 days (interquartile range 3-6). All patients with available data experienced 30-day clinical and hemodynamic success. Mean follow-up was 23 months (range 1-79 months) with a primary patency of 85.4%. Cumulative primary assisted and secondary patency was 92.6%. The femoral patch repair was the most frequent site of reintervention (3/3). Mortality was 34% during the study period, and it was significantly higher in patients with tissue loss (57.1% vs. 14.8%, P = 0.01). CONCLUSIONS: The hybrid approach has low morbidity, mortality, and fast recovery. The use of covered stents/stent grafts provides good mid-term patency. Close follow-up with noninvasive imaging is paramount to avoid repair failure, in particular at the femoral patch repair site.

A simplified stratification system for venous thromboembolism risk in severely injured trauma patients.

BACKGROUND: The objective of this study was to re-evaluate and simplify the Greenfield risk assessment profile (RAP) for venous thromboembolism (VTE) in trauma using information readily available at the bedside. METHODS: Retrospective review of 1233 consecutive admissions to the trauma intensive care unit from August 2011-January 2015. Univariate analyses were performed to determine which RAP risk factors were significant contributors to VTE. Multivariable logistic regression was used to develop models for risk stratification. All results were considered statistically significant at P ≤ 0.05. RESULTS: The study population was as follows: age 44 ± 19, 75% male, 72% blunt, injury severity score 21 ± 13, RAP score 9 ± 5, and 8% mortality. Groups were separated into +VTE (n = 104) and -VTE (n = 1129). They were similar in age, gender, mechanism, and mortality, but injury severity and RAP scores were higher in the +VTE group (all P < 0.0001). The +VTE group had more transfusions and longer time to prophylaxis (all P < 0.05). Receiving four or more transfusions in the first 24 h (odds ratio [OR], 2.60; 95% confidence interval [CI], 1.64-4.13), Glasgow coma score <8 for >4 h (OR, 2.13; 95% CI, 1.28-3.54), pelvic fracture (OR, 2.26; 95% CI, 1.44-3.57), age 40-59 y (OR, 1.70; 95% CI, 1.10-2.63), and >2-h operation (OR, 1.80; 95% CI, 1.14-2.85) predicted VTE with an area under the receiver operator curve of 0.729, which was comparable with 0.740 for the RAP score alone. CONCLUSIONS: VTE risk in trauma can be easily assessed using only five risk factors, which are all readily available at the bedside (transfusion, Glasgow coma scale, pelvic fracture, prolonged operation, and age). This simplified model provides similar predictive ability to the more complicated RAP score. Prospective validation of a simplified risk assessment score is warranted.

Admission hyperglycemia is associated with different outcomes after blunt versus penetrating trauma.

BACKGROUND: Stress-induced hyperglycemia is associated with worse outcomes after trauma; however, the effect of mechanism of injury has not been studied. To fill this gap, we tested the hypothesis that blunt and penetrating trauma evoke different glycemic responses which are associated with different outcomes. MATERIALS AND METHODS: A retrospective cohort study comparing adults with blunt (n = 835) or penetrating trauma (n = 858) and admission glucose levels ≥ 106 mg/dL, ≥150 mg/dL, and ≥200 mg/dL at a level 1 trauma center from 02, 2011 to 08, 2013. Primary outcomes were mortality and infectious complications. RESULTS: For all patients, mean Injury Severity Score was 14 ± 12, with 10% (n = 162) infections and 6% (n = 102) mortality. Median admission glucose was 122 mg/dL (102-154 mg/dL). Hyperglycemia was associated with infections, length of stay, and mortality (all P < 0.01). Ten percent had an admission glucose ≥200 mg/dL, which was associated with infections after blunt trauma (odds ratio [OR], 2.28; 95% CI, 1.16-4.47; P = 0.017) but not penetrating trauma. Hyperglycemia was not an independent predictor of mortality in blunt trauma. In contrast, glucose ≥150 mg/dL (OR, 2.58; 95% CI, 1.13-5.89; P = 0.025) and ≥200 mg/dL (OR, 2.98; 95% CI, 1.27-6.98; P = 0.012) both predicted mortality in penetrating trauma patients. CONCLUSIONS: This is the first study to show that hyperglycemia is associated with fundamentally different outcomes after blunt versus penetrating trauma. Patients who died were 4-8 times more likely to have hyperglycemia and penetrating, not blunt, trauma. Incorporation of hyperglycemia in injury scoring systems might improve outcome predictions after trauma.

Delayed gastric emptying after pancreaticoduodenectomy.

BACKGROUND: Delayed gastric emptying (DGE) remains an unsolved complication after pancreaticoduodenectomy (PD) with conflicting reports of its cause. We aimed to compare the effect of surgical techniques involving the stomach in PD in lowering the risk of postoperative DGE. METHODS: Online search and review of key bibliographies in PubMed, Medline, Embase, Scopus, Cochrane, and Google Scholar was performed. Studies comparing PD surgical techniques were identified. Primary outcome was postoperative DGE. Methodological quality was assessed using Strengthening the Reporting of Observational Studies in Epidemiology and Consolidated Standards of Reporting Trials. Calculated pooled relative risk and odds ratios (ORs) with the corresponding 95% confidence interval (CI) were used in the meta-analyses. RESULTS: Overall, 376 studies were reviewed, of which 22 studies were selected including a total of 5172 patients. The incidence of DGE was lower in antecolic compared with retrocolic gastrojejunostomy (risk ratio [RR], 0.260; CI, 0.157-0.431; P < 0.001; n = 1067 patients) and in subtotal stomach preserving PD compared with pylorus preserving PD (RR, 0.527; CI, 0.363-0.763; P < 0.001; n = 663 patients). There was no significant difference between classic PD versus pylorus preserving PD (OR, 0.64; CI, 0.40-1.00; P = 0.05; n = 1209 patients), pancreaticogastrostomy versus pancreaticojejunostomy (RR, 1.02; CI, 0.62-1.68; P = 0.94; n = 961 patients), Roux-en-Y versus Billroth II gastrojejunostomy (RR, 0.946; CI, 0.788-1.136; P = 0.5513; n = 470 patients), or minimally invasive PD versus open PD (OR, 0.99; CI, 0.62-1.56; P = 0.96; n = 802). CONCLUSIONS: In PD, surgical techniques using antecolic reconstruction route and subtotal stomach preserving PD seem to be associated with a lower risk of DGE. Further randomized controlled trials are necessary to evaluate these results taking other causes into consideration.

Hypercoagulability and venous thromboembolism in burn patients.

To our knowledge, this is the first comprehensive review on the subject of venous thromboembolism (VTE) and hypercoagulability in burn patients. Specific changes in coagulability are reviewed using data from thromboelastography and other techniques. Disseminated intravascular coagulation in burn patients is discussed. The incidence and risk factors associated with VTE in burn patients are then examined, followed by the use of low-molecular-weight heparin thromboprophylaxis and monitoring techniques using antifactor Xa levels. The need for large, prospective trials in burn patients is highlighted, especially in the areas of VTE incidence and safe, effective thromboprophylaxis.

Liquid plasma use during "super" massive transfusion protocol.

BACKGROUND: A massive transfusion protocol (MTP) presents a logistical challenge for most blood banks and trauma centers. We compare the ratio of packed red blood cells (PRBC) and plasma transfused over serial time points in those requiring MTP (10-30 U PRBC/24 h) to those requiring "super" MTP (S-MTP; >30 U PRBC/24 h) and test the hypothesis that changes in allocation of blood products with use of readily transfusable liquid plasma (LP) improves the ratio of PRBC and plasma during S-MTP. MATERIALS AND METHODS: All transfused trauma patients (n = 1305) from January 01, 2009-April, 03, 2015 were reviewed. PRBC:plasma ratio was compared for MTP (n = 277) and S-MTP (n = 61) patients, before and after the availability of LP at our institution. Data are reported as mean ± standard deviation or median (interquartile range). RESULTS: Age was 41 ± 19 y, 52% blunt mechanism, injury severity score 32 ± 16, and 46.3% mortality. In 24 h, requirements were 17 (14) U PRBC and 10 (11) U plasma, with a PRBC:plasma of 1.6 (0.8). Within the first hour, PRBC:plasma for S-MTP versus MTP was 2.1:1 versus 1.7:1 (P = 0.017). With LP, S-MTP patients received significantly lower PRBC:plasma at the first hour (P < 0.001). Before institutional changes, PRBC:plasma positively correlated with PRBC transfused at hour 1 (r = 0.410, R(2) = 0.168, P < 0.001); after institutional changes and the advent of LP, there was no correlation (r = 0.177, R(2) = 0.031, P = 0.219). CONCLUSIONS: Within the first hour of transfusion, units of PRBC transfused positively correlated with PRBC:plasma, and patients receiving S-MTP had higher PRBC:plasma than those receiving MTP. Changes in our institution's MTP protocol to include LP improved the early PRBC:plasma transfused in patients requiring S-MTP.

Does obesity affect outcomes of adult burn patients?

BACKGROUND: Obesity negatively affects outcomes after trauma and surgery; results after burns are more limited and controversial. The purpose of this study was to determine the effect of obesity on clinical and economic outcomes after thermal injury. METHODS: The National Inpatient Sample was queried for adults from 2005-2009 with International Classification of Diseases-9 codes for burn injury. Demographics and clinical outcomes of obese and nonobese cohorts were compared. Univariate and multivariate analysis using logistic regression models were performed. Data are expressed as median (interquartile range) or mean ± standard deviation and compared at P < 0.05. RESULTS: In 14,602 patients, 3.3% were obese (body mass index ≥30 kg/m(2)). The rate of obesity increased significantly by year (P < 0.001). Univariate analysis revealed significant differences between obese and nonobese patients in incidence of wound infection (7.2% versus 5.0%), urinary tract infection (7.2% versus 4.6%), deep vein thrombosis in total body surface area (TBSA) ≥10% (3.1% versus 1.1%), pulmonary embolism in TBSA ≥10% (2.3% versus 0.6%), length of stay [6 d (8) versus 5 d (9)], and hospital costs ($10,122.12 [$18,074.72] versus $7892.07 [$17,191.96]) (all P < 0.05). Death occurred less frequently in the obese group (1.9% versus 4%, P = 0.021). Significant predictors of grouped adverse events (urinary tract infection, wound infection, deep vein thrombosis, and pulmonary embolism) on multivariate analysis include obesity, TBSA ≥20%, age, and black race (all P ≤ 0.05). CONCLUSIONS: Obesity is an independent predictor of adverse events after burn injury; however, obesity is associated with decreased mortality. Our findings highlight the potential clinical and economic impact of the obesity epidemic on burn patients nationwide.

Prehospital care and transportation of pediatric trauma patients.

BACKGROUND: Despite advances in prehospital emergency medical services (EMS), most advocate "scoop-and-run" over "stay-and-play." However, there are almost no studies in children. We hypothesize that the transportation of mortally injured children is delayed and that the performance of prehospital interventions (PHIs) themselves delay transportation and worsen outcomes in pediatric trauma patients. MATERIALS AND METHODS: A total of 1884 admissions (≤17-y-old) transported via EMS to a level 1 trauma center from January 2000-December 2012 were reviewed. Propensity scores were assigned based on the need for a PHI (intubation and resuscitation). PHI and non-PHI cohorts were matched 1:1 to compare outcomes. Data are expressed as mean ± standard deviation or median (interquartile range). RESULTS: The population was 11 ± 6 y, 70% male, 50% black, 76% blunt injury, injury severity score 13 ± 12, length of stay 3 (7) d, and mortality 3.6%. Incident to EMS arrival was 38 (20) min, EMS on-scene time was 14 (12) min, and overall time of arrival to hospital was 27 (15) min. Patients that were mortally wounded, despite having significantly higher rates of PHI, still had similar transportation times to those who survived. Mostly every measure of injury severity was worse in those who required PHI. When these factors were corrected, EMS on-scene time was 18 (13) versus 14 (13) min (P = 0.551), EMS arrival at the hospital was 31 (16) versus 28 (12) min (P = 0.292), length of stay was 5 (15) versus 4 (12) d (P = 0.368), and mortality was 31.7% versus 28.3% (P = 0.842) for PHI and non-PHI matched cohorts. CONCLUSIONS: PHIs did not delay transportation times or worsen outcomes in pediatric trauma patients. Although mortally injured children more often required PHIs, this did not delay transportation to the trauma center.

Pediatric vascular injury: experience of a level 1 trauma center.

BACKGROUND: Our purpose was to analyze modern major vascular injury (MVI) patterns in pediatric trauma, interventions performed, and outcomes at a level 1 trauma center. MATERIALS AND METHODS: From January 2000-December 2012, all pediatric admissions (≤17 y) were reviewed. RESULTS: Of 1928 pediatric admissions, 103 (5.3%) sustained MVI. This cohort was 85% male, age 15 ± 3 y, 55% black, 58% penetrating, injury severity score of 23 ± 15, with a length of stay of 8 (5) days. Firearm-related injury (47%) was the most common mechanism. Location of injuries included the extremities (50.5%), abdomen/pelvis (29.1%), and chest/neck (20.4%). Operative procedures included repair/bypass (71.4%), ligation (12.4%), amputation (10.5%), or temporary shunt (2.9%). Only three injuries (2.9%) were treated endovascularly. MVI patients had a mortality rate of 19.4%, higher than the overall pediatric trauma population of 3.5% (P < 0.001). After logistic regression, independent risk factors of mortality were vascular injury to the neck (odds ratio [OR]: 6.5; confidence interval (CI): 1.1-39.3), abdomen/pelvis (OR: 16.3; CI: 3.13-80.2), and chest (OR: 49.0; CI: 3.0-794.5). CONCLUSIONS: MVI in children more commonly results from firearm-related injury. The mortality rate associated with MVI is profoundly higher than that of the overall pediatric trauma population. These findings underscore the major public health concern of firearm-related injury in children.

Advanced and alternative research methods for the acute care surgeon scientist.

Clinical research has evolved significantly over the last few decades to include many advanced and alternative study designs to answer unique questions. Recognizing a potential knowledge gap, the AAST Associate Member Council and Educational Development Committee created a research course at the 2022 Annual Meeting in Chicago to introduce junior researchers to these methodologies. This manuscript presents a summary of this AAST Annual Meeting session, and reviews topics including hierarchical modeling, geospatial analysis, patient-centered outcomes research, mixed methods designs, and negotiating complex issues in multicenter trials.

Management of lower extremity vascular injuries in pediatric trauma patients: 20-year experience at a level 1 trauma center.

Introduction: Pediatric lower extremity vascular injuries (LEVI) are rare but can result in significant morbidity. We aimed to describe our experience with these injuries, including associated injury patterns, diagnostic and therapeutic challenges, and outcomes. Methods: This was a retrospective review at a single level 1 trauma center from January 2000 to December 2019. Patients less than 18 years of age with LEVI were included. Demographics, injury patterns, clinical status at presentation, and intensive care unit (ICU) and hospital length of stay (LOS) were collected. Surgical data were extracted from patient charts. Results: 4,929 pediatric trauma patients presented during the 20-year period, of which 53 patients (1.1%) sustained LEVI. The mean age of patients was 15 years (range 1-17 years), the majority were Black (68%), male (96%), and most injuries were from a gunshot wound (62%). The median Glasgow Coma Scale score was 15, and the median Injury Severity Score was 12. The most commonly injured arteries were the superficial femoral artery (28%) and popliteal artery (28%). Hard signs of vascular injury were observed in 72% of patients and 87% required operative exploration. There were 36 arterial injuries, 36% of which were repaired with a reverse saphenous vein graft and 36% were repaired with polytetrafluoroethylene graft. One patient required amputation. Median ICU LOS was three days and median hospital LOS was 15 days. There were four mortalities. Conclusion: Pediatric LEVIs are rare and can result in significant morbidity. Surgical principles for pediatric vascular injuries are similar to those applied to adults, and this subset of patients can be safely managed in a tertiary specialized center. Level of evidence: Level IV, retrospective study.

When is it safe to start thromboprophylaxis after splenic angioembolization?

BACKGROUND: Thromboprophylaxis after blunt splenic trauma is complicated by the risk of bleeding, but the risk after angioembolization is unknown. We hypothesized that earlier thromboprophylaxis initiation was associated with increased bleeding complications without mitigating venous thromboembolism events. METHODS: All blunt trauma patients who underwent splenic angioembolization within 24 hours of arrival were identified from the American College of Surgeons Trauma Quality Improvement Program datasets from 2017 to 2019. Cases with <24-hour length of stay, other serious injuries, and surgery before angioembolization were excluded. Venous thromboembolism was defined as deep vein thrombosis or pulmonary embolism. Bleeding complications were defined as splenic surgery, additional embolization, or blood transfusion after thromboprophylaxis initiation. Data were compared with χ2 analysis and multivariate logistic regression at P < .05. RESULTS: In 1,102 patients, 84% had American Association for the Surgery of Trauma grade III to V splenic injuries, and 73% received thromboprophylaxis. Splenic surgery after angioembolization was more common in those with thromboprophylaxis initiation within the first 24 hours (5.7% vs 1.7%, P = .007), whereas those with the initiation of thromboprophylaxis after 72 hours were more likely to have a pulmonary embolism (2.3% vs 0.2%, P = .001). Overall, venous thromboembolism increased considerably when thromboprophylaxis was initiated after day 3. In multivariate analysis, time to thromboprophylaxis initiation was associated with bleeding (odds ratio 0.74 [95% confidence interval 0.58-0.94]) and venous thromboembolism complications (odds ratio 1.5 [95% confidence interval 1.20-1.81]). CONCLUSION: This national study evaluates bleeding and thromboembolic risk to elucidate the specific timing of thromboprophylaxis after splenic angioembolization. Initiation of thromboprophylaxis between 24 and 72 hours achieves the safest balance in minimizing bleeding and venous thromboembolism risk, with 48 hours particularly serving as the ideal time for protocolized administration.

Whole Blood Resuscitation for Injured Patients Requiring Transfusion: A Systematic Review, Meta-Analysis, and Practice Management Guideline from the Eastern Association for the Surgery of Trauma.

INTRODUCTION: Whole blood resuscitation has reemerged as a resuscitation strategy for injured patients. However, the effect of whole blood-based resuscitation on outcomes has not been established. The primary objective of this guideline was to develop evidence-based recommendations on whether whole blood should be considered in civilian trauma patients receiving blood transfusions. METHODS: An EAST working group performed a systematic review and meta-analysis utilizing the GRADE methodology. One PICO question was developed to analyze the effect of whole blood resuscitation in the acute phase on mortality, transfusion requirements, infectious complications, and ICU length of stay. English language studies including adult civilian trauma patients comparing in-hospital whole blood to component therapy were included. Medline, Embase, Cochrane CENTRAL, CINAHL Plus, and Web of Science were queried. GRADEpro was used to assess quality of evidence and risk of bias. The study was registered on PROSPERO (#CRD42023451143). RESULTS: A total of 21 studies were included. Most patients were severely injured and required blood transfusion, massive transfusion protocol activation, and/or a hemorrhage control procedure in the early phase of resuscitation. Mortality was assessed separately at the following intervals: early (i.e., ED, 3-, or 6-hour), 24-hour, late (i.e., 28- or 30-day), and in-hospital. On meta-analysis, whole blood was not associated with decreased mortality. Whole blood was associated with decreased 4-hour RBC (mean difference -1.82, 95% CI -3.12 to -0.52), 4-hour plasma (mean difference -1.47, 95% CI -2.94 to 0), and 24-hour RBC transfusions (mean difference -1.22, 95% CI -2.24 to -0.19) compared to component therapy. There were no differences in infectious complications or ICU length of stay between groups. CONCLUSION: We conditionally recommend WB resuscitation in adult civilian trauma patients receiving blood transfusions, recognizing that data are limited for certain populations, including women of childbearing age, and therefore this guideline may not apply to these populations. LEVEL OF EVIDENCE: Level III, Guidelines.

Admission to a Verified Pediatric Trauma Center is Associated With Improved Outcomes in Severely Injured Children.

BACKGROUND: Previous studies have shown improved survival for severely injured adult patients treated at American College of Surgeons verified level I/II trauma centers compared to level III and undesignated centers. However, this relationship has not been well established in pediatric trauma centers (PTCs). We hypothesize that severely injured children will have lower mortality at verified level I/II PTCs compared to centers without PTC verification. METHODS: All patients 1-15 years of age with ISS >15 in the 2017-2019 American College of Surgeons Trauma Quality Programs (ACS TQP) dataset were reviewed. Patients with pre-hospital cardiac arrest, burns, and those transferred out for ongoing inpatient care were excluded. Logistic regression models were used to assess the effects of pediatric trauma center verification on mortality. RESULTS: 16,301 patients were identified (64 % male, median ISS 21 [17-27]), and 60 % were admitted to verified PTCs. Overall mortality was 6.0 %. Mortality at centers with PTC verification was 5.1 % versus 7.3 % at centers without PTC verification (p < 0.001). After controlling for injury mechanism, sex, age, pediatric-adjusted shock index (SIPA), ISS, arrival via interhospital transfer, and adult trauma center verification, pediatric level I/II trauma center designation was independently associated with decreased mortality (OR 0.72, 95 % CI 0.61-0.85). CONCLUSIONS: Treatment at ACS-verified pediatric trauma centers is associated with improved survival in critically injured children. These findings highlight the importance of PTC verification in optimizing outcomes for severely injured pediatric patients and should influence trauma center apportionment and prehospital triage. LEVEL OF EVIDENCE: Level IV - Retrospective review of national database.