'Door-to-prophylaxis' as a novel quality improvement metric in prevention of venous thromboembolism following traumatic injury.

Objective: Venous thromboembolism (VTE) risk reduction strategies include early initiation of chemoprophylaxis, reducing missed doses, weight-based dosing and dose adjustment using anti-Xa levels. We hypothesized that time to initiation of chemoprophylaxis would be the strongest modifiable risk for VTE, even after adjusting for competing risk factors. Methods: A prospectively maintained trauma registry was queried for patients admitted July 2017-October 2021 who were 18 years and older and received emergency release blood products. Patients with deep vein thrombosis or pulmonary embolism (VTE) were compared to those without (no VTE). Door-to-prophylaxis was defined as time from hospital arrival to first dose of VTE chemoprophylaxis (hours). Univariate and multivariate analyses were then performed between the two groups. Results: 2047 patients met inclusion (106 VTE, 1941 no VTE). There were no differences in baseline or demographic data. VTE patients had higher injury severity score (29 vs 24), more evidence of shock by arrival lactate (4.6 vs 3.9) and received more post-ED transfusions (8 vs 2 units); all p<0.05. While there was no difference in need for enoxaparin dose adjustment or missed doses, door-to-prophylaxis time was longer in the VTE group (35 vs 25 hours; p=0.009). On multivariate logistic regression analysis, every hour delay from time of arrival increased likelihood of VTE by 1.5% (OR 1.015, 95% CI 1.004 to 1.023, p=0.004). Conclusion: The current retrospective study of severely injured patients with trauma who required emergency release blood products found that increased door-to-prophylaxis time was significantly associated with an increased likelihood for VTE. Chemoprophylaxis initiation is one of the few modifiable risk factors available to combat VTE, therefore early initiation is paramount. Similar to door-to-balloon time in treating myocardial infarction and door-to-tPA time in stroke, "door-to-prophylaxis time" should be considered as a hospital metric for prevention of VTE in trauma. Level of evidence: Level III, retrospective study with up to two negative criteria.

Exposure to statin therapy decreases the incidence of venous thromboembolism after trauma.

INTRODUCTION: Venous thromboembolism (VTE) is a leading cause of morbidity and mortality in trauma patients, despite chemoprophylaxis. Statins have been shown capable of acting upon the endothelium. We hypothesized that statin therapy in the pre- or in-hospital settings leads to a decreased incidence of VTE. METHODS: We conducted a retrospective cohort study of injured patients who received statin therapy pre- or in-hospital. Adult, highest-level trauma activation patients admitted January 2018 - June 2022 were included. Patients on prehospital anticoagulants, history of inherited bleeding disorder, and who died within the first 24 hours were excluded. Statin users were matched to non-users by statin use indications including age, current heart and cardiovascular conditions and history, hyperlipidemia, injury severity, and body mass index. Time to in-hospital statin initiation and occurrence of VTE and other complications within 60 days were collected. Differences between groups were determined by univariate, multivariable logistic regression, and Cox proportional hazard analyses. RESULTS: Of 3,062 eligible patients, 79 were statin users that were matched to 79 non-users. There were no differences in admissions demographics, vital signs, injury pattern, transfusion volumes, lengths of stay, or mortality between groups. The overall VTE incidence was 10.8% (17/158). Incidence of VTE in statin users was significantly lower (3%) than non-users (19%; P = 0.003). Differences between statin users and non-users were observed for rates of DVT (0% vs 9%), PE (3% vs 15%), and sepsis (0% vs 5%). Exposure to statins was associated with an 82% decreased risk of developing VTE (hazard ratio = 0.18, 95% CI 0.04 - 0.86; P = 0.033). CONCLUSIONS: Statin exposure was associated with decline in VTE and lower individual rates of DVT, PE, and sepsis. Our findings indicate that statins should be evaluated further as a possible adjunctive therapy for VTE chemoprophylaxis after traumatic injury. LEVEL OF EVIDENCE AND STUDY TYPE: Level III, Retrospective Cohort Study.

Resuscitation and Care in the Trauma Bay.

Start balanced resuscitation early (pre-hospital if possible), either in the form of whole blood or 1:1:1 ratio. Minimize resuscitation with crystalloid to minimize patient morbidity and mortality. Trauma-induced coagulopathy can be largely avoided with the use of balanced resuscitation, permissive hypotension, and minimized time to hemostasis. Using protocolized "triggers" for massive and ultramassive transfusion will assist in minimizing delays in transfusion of products, achieving balanced ratios, and avoiding trauma induced coagulopathy. Once "audible" bleeding has been addressed, further blood product resuscitation and adjunct replacement should be guided by viscoelastic testing. Early transfusion of whole blood can reduce patient morbidity, mortality, decreases donor exposure, and reduces nursing logistics during transfusions. Adjuncts to resuscitation should be guided by laboratory testing and carefully developed, institution-specific guidelines. These include empiric calcium replacement, tranexamic acid (or other anti-fibrinolytics), and fibrinogen supplementation.

When is it safe to start venous thromboembolism prophylaxis after blunt solid organ injury? A prospective American Association for the Surgery of Trauma multi-institutional trial.

BACKGROUND: The optimal time to initiate venous thromboembolism (VTE) chemoprophylaxis (VTEp) after blunt solid organ injury remains controversial, as VTE mitigation must be balanced against bleeding promulgation. Evidence from primarily small, retrospective, single-center work suggests that VTEp ≤48 hours is safe and effective. This study was undertaken to validate this clinical practice. METHODS: Blunt trauma patients presenting to 19 participating trauma centers in North America were screened over a 1-year study period beginning between August 1 and October 1, 2021. Inclusions were age older than 15 years; ≥1 liver, spleen, or kidney injury; and initial nonoperative management. Exclusions were transfers, emergency department death, pregnancy, and concomitant bleeding disorder/anticoagulation/antiplatelet medication. A priori power calculation stipulated the need for 1,158 patients. Time of VTEp initiation defined study groups: Early (≤48 hours of admission) versus Late (>48 hours). Bivariate and multivariable analyses compared outcomes. RESULTS: In total, 1,173 patients satisfied the study criteria with 571 liver (49%), 557 spleen (47%), and 277 kidney injuries (24%). The median patient age was 34 years (interquartile range, 25-49 years), and 67% (n = 780) were male. The median Injury Severity Score was 22 (interquartile range, 14-29) with Abbreviated Injury Scale Abdomen score of 3 (interquartile range, 2-3), and the median American Association for the Surgery of Trauma grade of solid organ injury was 2 (interquartile range, 2-3). Early VTEp patients (n = 838 [74%]) had significantly lower rates of VTE (n = 28 [3%] vs. n = 21 [7%], p = 0.008), comparable rates of nonoperative management failure (n = 21 [3%] vs. n = 12 [4%], p = 0.228), and lower rates of post-VTEp blood transfusion (n = 145 [17%] vs. n = 71 [23%], p = 0.024) when compared with Late VTEp patients (n = 301 [26%]). Late VTEp was independently associated with VTE (odd ratio, 2.251; p = 0.046). CONCLUSION: Early initiation of VTEp was associated with significantly reduced rates of VTE with no increase in bleeding complications. Venous thromboembolism chemoprophylaxis initiation ≤48 hours is therefore safe and effective and should be the standard of care for patients with blunt solid organ injury. LEVEL OF EVIDENCE: Therapeutic and Care Management; Level III.

Use of Low-Titer O-Positive Whole Blood in Female Trauma Patients: A Literature Review, Qualitative Multidisciplinary Analysis of Risk/Benefit, and Guidelines for Its Use as a Universal Product in Hemorrhagic Shock.

BACKGROUND: Whole blood transfusion is associated with benefits including improved survival, coagulopathy, and decreased transfusion requirements. The majority of whole blood transfusion is in the form of low-titer O-positive whole blood (LTOWB). Practice at many trauma centers withholds the use of LTOWB in women of childbearing potential due to concerns of alloimmunization. The purpose of this article is to review the evidence for LTOWB transfusion in female trauma patients and generate guidelines for its application. STUDY DESIGN: Literature and evidence for LTOWB transfusion in hemorrhagic shock are reviewed. The rates of alloimmunization and subsequent obstetrical outcomes are compared to the reported outcomes of LTOWB vs other resuscitation media. Literature regarding patient experiences and preferences in regards to the risk of alloimmunization is compared to current trauma practices. RESULTS: LTOWB has shown improved outcomes in both military and civilian settings. The overall risk of alloimmunization for Rhesus factor (Rh) - female patients in hemorrhagic shock exposed to Rh + blood is low (3% to 20%). Fetal outcomes in Rh-sensitized patients are excellent compared to historical standards, and treatment options continue to expand. The majority of female patients surveyed on the risk of alloimmunization favor receiving Rh + blood products to improve trauma outcomes. Obstetrical transfusion practices have incorporated LTOWB with excellent results. CONCLUSIONS: The use of whole blood resuscitation in trauma is associated with benefits in the resuscitation of severely injured patients. The rate at which severely injured, Rh-negative patients develop anti-D antibodies is low. Treatments for alloimmunized pregnancies have advanced, with excellent results. Fears of alloimmunization in female patients are likely overstated and may not warrant the withholding of whole blood resuscitation. The benefits of whole blood resuscitation likely outweigh the risks of alloimmunization.

Empiric Cryoprecipitate Transfusion in Patients with Severe Hemorrhage: Results from the US Experience in the International CRYOSTAT-2 Trial.

BACKGROUND: Hypofibrinogenemia has been shown to predict massive transfusion and is associated with higher mortality in severely injured patients. However, the role of empiric fibrinogen replacement in bleeding trauma patients remains controversial. We sought to determine the effect of empiric cryoprecipitate as an adjunct to a balanced transfusion strategy (1:1:1). STUDY DESIGN: This study is a subanalysis of patients treated at the single US trauma center in a multicenter randomized controlled trial. Trauma patients (more than 15 years) were eligible if they had evidence of active hemorrhage requiring emergent surgery or interventional radiology, massive transfusion protocol (MTP) activation, and received at least 1 unit of blood. Transfer patients, those with injuries incompatible with life, or those injured more than 3 hours earlier were excluded. Patients were randomized to standard MTP (STANDARD) or MTP plus 3 pools of cryoprecipitate (CRYO). Primary outcomes included all-cause mortality at 28 days. Secondary outcomes were transfusion requirements, intraoperative and postoperative coagulation laboratory values, and quality-of-life measures (Glasgow outcome score-extended). RESULTS: Forty-nine patients (23 in the CRYO group and 26 in the STANDARD group) were enrolled between May 2021 and October 2021. Time to randomization was similar between groups (14 vs 24 minutes, p = 0.676). Median time to cryoprecipitate was 41 minutes (interquartile range 37 to 48). There were no differences in demographics, arrival physiology, laboratory values, or injury severity. Intraoperative and ICU thrombelastography values, including functional fibrinogen, were similar between groups. There was no benefit to CRYO with respect to post-emergency department transfusions (intraoperative and ICU through 24 hours), complications, Glasgow outcome score, or mortality. CONCLUSIONS: In this study of severely injured, bleeding trauma patients, empiric cryoprecipitate did not improve survival or reduce transfusion requirements. Cryoprecipitate should continue as an "on-demand" addition to a balanced transfusion strategy, guided by laboratory values and should not be given empirically.

Hypofibrinogenemia following injury in 186 children and adolescents: identification of the phenotype, current outcomes, and potential for intervention.

Objectives: Recent studies evaluating fibrinogen replacement in trauma, along with newly available fibrinogen-based products, has led to an increase in debate on where products such as cryoprecipitate belong in our resuscitation strategies. We set out to define the phenotype and outcomes of those with hypofibrinogenemia and evaluate whether fibrinogen replacement should have a role in the initial administration of massive transfusion. Methods: All patients <18 years of age presenting to our trauma center 11/17-4/21 were reviewed. We then evaluated all patients who received emergency-release and massive transfusion protocol (MTP) products. Patients were defined as hypofibrinogenemic (HYPOFIB) if admission fibrinogen <150 or rapid thrombelastography (r-TEG) angle <60 degrees. Our analysis sought to define risk factors for presenting with HYPOFIB, the impact on outcomes, and whether early replacement improved mortality. Results: 4169 patients were entered into the trauma registry, with 926 level 1 trauma activations, of which 186 patients received emergency-release blood products during this time; 1%, 3%, and 10% were HYPOFIB, respectively. Of the 186 patients of interest, 18 were HYPOFIB and 168 were non-HYPOFIB. The HYPOFIB patients were significantly younger, had lower field and arrival Glasgow Coma Scale, had higher head Abbreviated Injury Scale, arrived with worse global coagulopathy, and died from brain injury. Non-HYPOFIB patients were more likely to have (+)focused assessment for the sonography of trauma on arrival, sustained severe abdominal injuries, and die from hemorrhage. 12% of patients who received early cryoprecipitate (0-2 hours) had higher mortality by univariate analysis (55% vs 31%, p=0.045), but no difference on multivariate analysis (OR 0.36, 95% CI 0.07 to 1.81, p=0.221). Those receiving early cryoprecipitate who survived after pediatric intensive care unit (PICU) admission had lower PICU fibrinogen and r-TEG alpha-angle values. Conclusion: In pediatric trauma, patients with hypofibrinogenemia on admission are most likely younger and to have sustained severe brain injury, with an associated mortality of over 80%. Given the absence of bleeding-related deaths in HYPOFIB patients, this study does not provide evidence for the empiric use of cryoprecipitate in the initial administration of a massive transfusion protocol. Level of Evidence: Level III - Therapeutic/Care Management.

The reports of my death are greatly exaggerated: An evaluation of futility cut points in massive transfusion.

BACKGROUND: Following COVID and the subsequent blood shortage, several investigators evaluated futility cut points in massive transfusion. We hypothesized that early aggressive use of damage-control resuscitation, including whole blood (WB), would demonstrate that these cut points of futility were significantly underestimating potential survival among patients receiving >50 U of blood in the first 4 hours. METHODS: Adult trauma patients admitted from November 2017 to October 2021 who received emergency-release blood products in prehospital or emergency department setting were included. Deaths within 30 minutes of arrival were excluded. Total blood products were defined as total red blood cell, plasma, and WB in the field and in the first 4 hours after arrival. Patients were first divided into those receiving ≤50 or >50 U of blood in the first 4 hours. We then evaluated patients by whether they received any WB or received only component therapy. Thirty-day survival was evaluated for all included patients. RESULTS: A total of 2,299 patients met the inclusion criteria (2,043 in ≤50 U, 256 in >50 U groups). While there were no differences in age or sex, the >50 U group was more likely to sustain penetrating injury (47% vs. 30%, p < 0.05). Patients receiving >50 U of blood had lower field and arrival blood pressure and larger prehospital and emergency department resuscitation volumes ( p < 0.05). Patients in the >50 U group had lower survival than those in the ≤50 cohort (31% vs. 79%; p < 0.05). Patients who received WB (n = 1,291) had 43% increased odds of survival compared with those who received only component therapy (n = 1,008) (1.09-1.87, p = 0.009) and higher 30-day survival at transfusion volumes >50 U. CONCLUSION: Patient survival rates in patients receiving >50 U of blood in the first 4 hours of care are as high as 50% to 60%, with survival still at 15% to 25% after 100 U. While responsible blood stewardship is critical, futility should not be declared based on high transfusion volumes alone. LEVEL OF EVIDENCE: Therapeutic/Care Management; Level III.

Mortality and outcomes by blood group in trauma patients: A systematic review and meta-analysis.

BACKGROUND AND OBJECTIVES: Blood group O contains lower levels of factor VIII and von Willebrand factor. Higher incidence of bleeding among group O is reported in multiple contexts. Results of studies vary regarding outcomes stratified by blood group in trauma. We systematically reviewed the literature for outcomes related to blood group in trauma patients. Meta-analysis of studies evaluating mortality related to blood group was performed. MATERIALS AND METHODS: The PubMed and Embase databases were searched for studies analysing relationships between blood group and outcomes in trauma patients. Preferred Reporting Items in Systematic Reviews and Meta-Analyses (PRISMA) guidelines were followed. We synthesized outcomes data related to blood group. Meta-analysis compared mortality rates between group O and non-O patients. RESULTS: Inclusion criteria were met by 13 studies. Statistically significant differences by blood group were reported in 3 of 10 (30%) studies evaluating mortality, 2 of 3 (66.7%) evaluating mortality from haemorrhage and 2 of 9 (22.2%) evaluating transfusion requirement. Meta-analysis was performed on seven studies evaluating mortality (total n = 11,835). There was significant heterogeneity among studies (I2 = 86%, p < 0.00001). No difference was found in mortality between group O and non-O patients (relative risk = 1.21, 95% confidence interval = 0.89-1.64, p = 0.23). CONCLUSION: Existing literature does not consistently demonstrate a mortality difference between trauma patients with O and non-O blood groups. High variability in the methods and results among studies limits this conclusion, and further research is needed to delineate under what circumstances blood group may influence outcomes.

Power of mentorship for civilian and military acute care surgeons: identifying and leveraging opportunities for longitudinal professional development.

Across disciplines, mentorship has been recognized as a key to success. Acute care surgeons, focused on the care of trauma surgery, emergency general surgery and surgical critical care, practice in a wide variety of settings and have unique mentorship needs across all phases of their career. Recognizing the need for robust mentorship and professional development, the American Association for the Surgery of Trauma (AAST) convened an expert panel entitled 'The Power of Mentorship' at the 81st annual meeting in September 2022 (Chicago, Illinois). This was a collaboration between the AAST Associate Member Council (consisting of surgical resident, fellow and junior faculty members), the AAST Military Liaison Committee, and the AAST Healthcare Economics Committee. Led by two moderators, the panel consisted of five real-life mentor-mentee pairs. They addressed the following realms of mentorship: clinical, research, executive leadership and career development, mentorship through professional societies, and mentorship for military-trained surgeons. Recommendations, as well as pearls and pitfalls, are summarized below.

Predicting Futility in Severely Injured Patients: Using Arrival Lab Values and Physiology to Support Evidence-Based Resource Stewardship.

BACKGROUND: The recent pandemic exposed a largely unrecognized threat to medical resources, including daily available blood products. Some of the most severely injured patients who arrive in extremis consume tremendous resources yet succumb shortly after arrival. We sought to identify cut points available early in the patient's resuscitation that predicted 100% mortality. STUDY DESIGN: Cut points were developed from a previously collected data set of all level 1 trauma patients admitted January 2010 to December 2016. Objective values available on or shortly after arrival were evaluated. Once generated, we then validated these variables against (1) a prospective data set November 2017 to October 2021 of severely injured patients and (2) a multicenter, randomized trial of hemorrhagic shock patients. Analyses were conducted using STATA 17.0 (College Station, TX), generating positive predictive value (PPV), negative predictive value, sensitivity, and specificity. RESULTS: The development data set consisted of 9,509 patients (17% mortality), with 2,137 (24%) and 680 (24%) in the two validation data sets. Several combinations of arrival vitals and labs had 100% PPV. Patients undergoing CPR in the field or on arrival (with subsequent return of spontaneous circulation) required lower fibrinolysis LY-30 (30%) than those with systolic blood pressures of ≤50 (30 to 50%), ≤70 (80 to 90%), and ≤90 mmHg (90%). Using a combination of these validated variables, the Suspension of Transfusions and Other Procedures (STOP) criteria were developed, with each element predicting 100% mortality, allowing physicians to cease further resuscitative efforts. CONCLUSIONS: The use of evidence-based STOP criteria provides cut points of futility to help guide early decisions for discontinuing aggressive treatment of severely injured patients arriving in extremis.

Is the use of nonsteroidal anti-inflammatories after bowel anastomosis in trauma safe?

BACKGROUND: With an increasing interest in multimodal and opioid-reducing pain strategies, nonsteroidal anti-inflammatory drugs (NSAIDs) have become common place in the care of injured patients. Long-standing concerns of increased anastomotic leak (AL) rate with the use of NSAIDs, however, have persisted. We hypothesized that there would be no significant risk associated with NSAID use after bowel anastomosis in trauma patients. METHODS: All patients presenting to a level 1 trauma center who required intestinal resection and anastomosis from 2011 to 2017 were reviewed. Patients receiving NSAIDs were compared with those managed without NSAIDs. Primary outcome of interest was anastomosis-related complications (AL, intra-abdominal abscess, anastomotic bleed, fascial dehiscence, fascial dehiscence, and enterocutaneous fistula). Multivariable logistic regression analyses were performed with propensity adjustment for inverse probability of NSAID treatment weights. RESULTS: A total of 295 patients met the inclusion criteria with 192 receiving NSAIDs. Patients receiving NSAIDs had lower abdominal Abbreviated Injury Scale and Injury Severity Score ( p < 0.046). Arrival systolic blood pressure, diastolic blood pressure, and Glasgow Coma Scale were higher in the NSAID group ( p < 0.013). After propensity weighting, NSAID use was not a major predictor of anastomotic complication ( p = 0.39). There was an increased risk of AL with perioperative vasopressor exposure (odds ratio [OR], 3.33; 95% confidence interval [CI], 1.17-9.05; p < 0.001). Increasing red blood cell transfusions in the first 24 hours were associated with intra-abdominal complications (OR, 1.02; 95% CI, 1.00-1.04; p = 0.05). Nonsteroidal anti-inflammatory drug exposure demonstrated a weak association with AL (OR, 1.92; 95% CI, 0.97-3.90; p = 0.06). CONCLUSION: Consistent with previous studies, perioperative vasopressor exposure and increased number of red blood cell transfusions are risk factors for ALs and intra-abdominal complications, respectively. Nonsteroidal anti-inflammatory drug use in trauma patients with multiple risk factors may be associated with an increased risk of AL and should be used with caution in the setting of other established risk factors. LEVEL OF EVIDENCE: Therapeutic/Care Management; Level III.

Transpacific Aeromedical Evacuation for a Ruptured Brain Arteriovenous Malformation During the COVID-19 Pandemic.

The COVID-19 pandemic has altered preexisting patient treatment algorithms and referral patterns, which has affected neurosurgical care worldwide. Brain arteriovenous malformations are complex vascular lesions that frequently present with intracerebral hemorrhage. Care for these patients is best performed at large medical centers by specialists with high volumes. The authors describe the care of a patient who presented in extremis to a resource-limited, community-sized military treatment facility (MTF) in Southeast Asia. In the MTF, the patient underwent emergent neurosurgical therapy. However, given newly implemented restrictions enacted to mitigate COVID-19 spread, local transfer for definitive care to a tertiary care facility was not possible. In order to attain definitive care for the patient, a transpacific aeromedical evacuation augmented with a critical care air transport team was utilized for transfer to a tertiary care, teaching hospital. This case demonstrates the safe treatment of a patient with hemorrhagic arteriovenous malformations and postoperative management under limited conditions in an MTF outside the CONUS. Given the unique circumstances and challenges the pandemic presented, the authors feel that this patient's outcome was only possible by leveraging all the capability military medicine has to offer.

Perforated Appendicitis: An Unintended Consequence During the Coronavirus-19 Pandemic.

BACKGROUND: The coronavirus disease 2019 (COVID-19) pandemic has had major clinical impact across the globe. Delayed presentation for medical emergencies has been noted by the medical community. There has been limited reporting on the impact for the care for emergent surgical conditions. We sought to describe the effect of the global pandemic on the presentation and outcomes for the most common urgent general surgery disease process, acute appendicitis. METHODS: We performed a retrospective review of patients admitted to the United States Naval Hospital Okinawa during the COVID-19 pandemic, from January 2020 to May 2020 (COVID cohort), and compared them to a historical cohort (pre-COVID cohort) over the prior 2 years. Demographics, clinical presentation data, and interventions were collected. RESULTS: Of the 80 patients with appendicitis, 20% presented perforated. Most patients were male (71%), presented with 1 day of symptoms and had a length of stay of 1 to 2 days. Comparing groups, 13% of the pre-COVID group vs. 31% of the COVID cohort presented perforated (P = .04), with a symptom duration of 1.6 vs. 2.7 days before presentation (P = .075), respectively. CONCLUSIONS: The COVID-19 pandemic and the global systematic response has impacted unrelated medical and surgical conditions. At our overseas military hospital with minimal disease burden, we observed a delay in presentation for acute appendicitis with a higher incidence of perforation. Patients should be empowered to continue to seek care for urgent and emergent medical and surgical conditions so that they are not harmed by fear of COVID-19 rather than by COVID-19 itself.

Nationwide analysis of resuscitative thoracotomy in pediatric trauma: Time to differentiate from adult guidelines?

BACKGROUND: Emergency department thoracotomy (EDT) for pediatric patients is uncommon, and practice patterns have not been evaluated. We examined the indications and outcomes for EDT by trauma center designation using a nationwide database. METHODS: Patients 16 years or younger who underwent EDT within 30 minutes of arrival from 2013 to 2016 were identified in the American College of Surgeons National Trauma Data Bank. Patient demographic information, indications for EDT, and outcomes were analyzed. Outcomes were compared between centers with and without pediatric trauma center designation. RESULTS: A total of 114 patients were identified for analysis with a mean ± SD age of 10.3 ± 4.7 years. Patients were predominantly male (69%) with a median Injury Severity Score of 26 (interquartile range, 18-42). Penetrating trauma occurred in 56%. Overall, mortality was 90% and was similar in penetrating and blunt trauma (88% vs. 94%; p = 0.34). There were no survivors among the 53 patients (46%) who arrived with no signs of life. Among the 11 patients (10%) who survived, median length of stay was 26 days (interquartile range, 6-28 days). Overall, 8% of EDT was performed at free-standing pediatric trauma centers, 45% at adult centers, and 47% at combined trauma centers. Mortality rates and indications were similar among trauma centers regardless of designation status. CONCLUSION: In a national population-based data set, the mortality after pediatric EDT is high, and many of these procedures are performed at nonpediatric trauma centers. Regardless of injury mechanism, EDT is not appropriate in children without signs of life on arrival. Pediatric guidelines are needed to increase awareness of the poor outcomes and limited indications for EDT. LEVEL OF EVIDENCE: Therapeutic, level IV.

Expeditionary Immersion Circulating Heating Device: A Promising Technique for Treating Frostbite Injuries and Warming Intravenous Fluids in a Forward Deployed Cold Weather Environment.

INTRODUCTION: Cold weather injuries require prompt warm water immersion therapy, which proves to be a difficult task in the cold austere environment. Current guidelines recommend 104 °F water immersion, but producing and maintaining large volumes of warm water is challenging in sub-freezing temperatures. We describe a novel process of utilizing a sous vide immersion circulator to maintain warm fluids for immersion therapy and efficient fluid rewarming in a cold forward-deployed setting for the treatment of cold weather injuries in an effort to bridge the gap between current medical guidelines and practices. MATERIALS AND METHODS: Large water cans were warmed to 104 °F with the immersion circulator. A thermometer was inserted into a 1-inch steak, frozen to 30 °F, and placed in a basin with only the warmed water while the internal temperature was monitored until physiologic temperature was achieved. The time to this endpoint was recorded. A 1-L bag of normal saline and a 450-mL bag of whole blood were also separately warmed by the same technique. The temperature of the normal saline was monitored at 0-, 5-, 7-, 8-, 9-, and 10 -minute intervals. The process was similarly repeated, measuring the whole blood temperature at 0-, 5-, 7-, and 10-minute intervals. RESULTS: Ambient internal tent temperatures averaged 54 °F; outdoor temperatures were consistently sub-freezing. The 5-gallon cans of water at ambient temperature heated to 104 °F in 15 minutes. The water temperature remained constant for 3 weeks with the circulator running. The frozen steak started at 30 °F and reached 98 °F in 52 minutes and 45 seconds. The bag of normal saline and whole blood, refrigerated to 39 °F, achieved temperatures of 102 °F and 94 °F respectively after 10 minutes. CONCLUSION: A heating immersion circulator device is a lightweight, flameless, and inexpensive way to consistently heat large volumes of water for treatment of cold weather injuries, hypothermia, and whole blood rewarming in a cold austere environment.

Pediatric extremity vascular trauma: It matters where it is treated.

BACKGROUND: Extremity vascular injuries in children are rare events that present unique therapeutic challenges. The absence of a pediatric-specific protocol for definitive care of these injuries risks variability in treatment practices and outcomes. Using a nationwide data set, we investigated variations in the management and outcomes of pediatric patients with peripheral vascular trauma and characterized differences based on hospital category. METHODS: Retrospective cohort study using the American College of Surgeons (ACS) National Trauma Data Bank to identify patients 16 years or younger with extremity vascular trauma admitted in calendar year 2016. Hospitals were categorized as ACS-verified pediatric trauma centers (Level I or II), ACS-verified adult trauma centers (Level I or II), or other hospitals (all other trauma centers and nondesignated hospitals). Patient data were evaluated by hospital category. RESULTS: Among 164,882 pediatric admissions, 702 patients were identified for analysis. There were 430 (61.3%) patients with upper-extremity injuries, 270 (38.5%) with lower-extremity injuries, and 2 (0.2%) had both. Mean age was 11.5 years, and 51.6% were blunt-injured. Overall, 40.2% were admitted to pediatric trauma centers, 28.9% to adult trauma centers, and 30.9% to other hospitals. Hospitals without ACS trauma center verification had a significantly higher amputation rate than any ACS-verified adult or pediatric center (p = 0.013). CONCLUSION: The incidence of pediatric extremity vascular injury is low. Hospitals with ACS trauma center verification have greater pediatric limb salvage rates than those without verification. Future study should seek to identify specific regional or resource-related factors that contribute to this disparity. LEVEL OF EVIDENCE: Epidemiological, level III.

Evaluating surgical outcomes in pediatric extremity vascular trauma.

BACKGROUND: The purpose of this study was to evaluate the epidemiology and management of pediatric vascular extremity trauma to assess injury patterns and other factors that may contribute to poor outcomes. METHODS: Using the California Office of Statewide Health Planning and Development discharge database, we identified pediatric patients with extremity arterial trauma admitted to acute-care hospitals from 2007 to 2014. Demographics, management patterns, and outcomes were collected and analyzed. RESULTS: A total of 775 patients were treated for an extremity arterial injury. Overall, 40% were admitted to pediatric trauma centers and 39% to adult trauma centers. Management was predominantly by open surgical repair. Injury to the common femoral artery was associated with mortality (Hazard Ratio 3.9; 95% CI 1.1-14.5; p < 0.05). Popliteal artery injuries (Odds Ratio [OR] 4.8; 95% CI 1.2-19.9; p < 0.05) and anterior tibial artery injuries (OR 7.1; 95% CI 1.4-37.3; p < 0.05) had an increased risk of amputation. There was no difference in amputation or mortality rates by hospital category. CONCLUSIONS: Pediatric extremity arterial injuries are rare. In California, outcomes are similar by hospital type. Common femoral artery injuries are associated with an increased risk of mortality, while popliteal and anterior tibial artery injuries are associated with an increased risk of amputation. TYPE OF STUDY: Prognosis Study. LEVEL OF EVIDENCE: Level III.

The Initial Impact of Tele-Critical Care on the Surgical Services of a Community Military Hospital.

Introduction: Mortality is reduced in hospitals staffed with intensivists, however, many smaller military hospitals lack intensivist support. Naval Hospital Camp Pendleton (NHCP) is a Military Treatment Facility (MTF) that operates a 6-bed Intensive Care Unit (ICU) north of its referral center, Naval Medical Center San Diego (NMCSD). To address a gap in NHCP on-site intensivist coverage, a comprehensive Tele-Critical Care (TCC) support system was established between NHCP and NMCSD. To examine the initial impact of telemedicine on surgical ICU patients, we compare NHCP surgical ICU admissions before and after TCC implementation. Materials and methods: Patient care by remote intensivist was achieved utilizing video teleconferencing technology, and remote access to electronic medical records. Standardization was promoted by adopting protocols and mandatory intensivist involvement in all ICU admissions. Surgical ICU admissions prior to TCC implementation (pre-TCC) were compared to those following TCC implementation (post-TCC). Results: Of 828 ICU admissions, 21% were surgical. TCC provided coverage during 35% of the intervention period. Comparing pre-TCC and post-TCC periods, there was a significant increase in the percentage of surgical ICU admissions [15.3 % vs 24.6%, p = 0.01] and the average monthly APACHE II score [4.1vs 6.5, p = 0.03]. The total number of surgical admissions per month also increased [3.9 vs 6.3, p = 0.009]. No adverse outcomes were identified. Conclusion: Implementation of TCC was associated with an increase in the scope and complexity of surgical admissions with no adverse outcomes. Surgeons were able to safely expand the surgical services offered requiring perioperative ICU care to patients who previously may have been transferred. Caring for these types of patients not only maintains the operational readiness of deployable caregivers but patient experience is also enhanced by minimizing transfers away from family. Further exploration of TCC on surgical case volume and complexity is warranted.

Risk factors for deep vein thrombosis and pulmonary embolism after traumatic injury: A competing risks analysis.

BACKGROUND: Venous thromboembolism, including deep vein thrombosis (DVT) and pulmonary embolism (PE), is typically reported as a composite measure of the quality of trauma center care. Given that recent data suggesting postinjury DVT and PE are distinct clinical processes, a better understanding may result from analyzing them as independent, competing events. Using competing risks analysis, we evaluated our hypothesis that the risk factors and timing of postinjury DVT and PE are different. METHODS: We examined all adult trauma patients admitted to our Level I trauma center from July 2006 to December 2011 who received at least one surveillance duplex ultrasound of the lower extremities and who were at high risk or greater for DVT. Outcomes included DVT and PE events, and time-to-event from admission. We used competing risks analysis to evaluate risk factors for DVT while accounting for PE as a competing event, and vice versa. RESULTS: Of 2,370 patients, 265 (11.2%) had at least one venous thromboembolism event, 235 DVT only, 19 PE only, 11 DVT and PE. Within 2 days of admission, 38% of DVT cases had occurred compared with 26% of PE. Competing risks modeling of DVT as primary event identified older age, severe injury (Injury Severity Score, ≥ 15), mechanical ventilation longer than 4 days, active cancer, history of DVT or PE, major venous repair, male sex, and prophylactic enoxaparin and prophylactic heparin as associated risk factors. Modeling of PE as the primary event showed younger age, nonsevere injury (Injury Severity Score, < 15), central line placement, and prophylactic heparin as relevant factors. CONCLUSION: The risk factors for PE and DVT after injury were different, suggesting that they are clinically distinct events that merit independent consideration. Many DVT events occurred early despite prophylaxis, bringing into question the preventability of postinjury DVT. We recommend trauma center quality reporting program measures be revised to account for DVT and PE as unique events. LEVEL OF EVIDENCE: Epidemiologic, level III.