Weight-based enoxaparin thromboprophylaxis in young trauma patients: analysis of the CLOTT-1 registry.

Introduction: Optimal venous thromboembolism (VTE) enoxaparin prophylaxis dosing remains elusive. Weight-based (WB) dosing safely increases anti-factor Xa levels without the need for routine monitoring but it is unclear if it leads to lower VTE risk. We hypothesized that WB dosing would decrease VTE risk compared with standard fixed dosing (SFD). Methods: Patients from the prospective, observational CLOTT-1 registry receiving prophylactic enoxaparin (n=5539) were categorized as WB (0.45-0.55 mg/kg two times per day) or SFD (30 mg two times per day, 40 mg once a day). Multivariate logistic regression was used to generate a predicted probability of VTE for WB and SFD patients. Results: Of 4360 patients analyzed, 1065 (24.4%) were WB and 3295 (75.6%) were SFD. WB patients were younger, female, more severely injured, and underwent major operation or major venous repair at a higher rate than individuals in the SFD group. Obesity was more common among the SFD group. Unadjusted VTE rates were comparable (WB 3.1% vs. SFD 3.9%; p=0.221). Early prophylaxis was associated with lower VTE rate (1.4% vs. 5.0%; p=0.001) and deep vein thrombosis (0.9% vs. 4.4%; p<0.001), but not pulmonary embolism (0.7% vs. 1.4%; p=0.259). After adjustment, VTE incidence did not differ by dosing strategy (adjusted OR (aOR) 0.75, 95% CI 0.38 to 1.48); however, early administration was associated with a significant reduction in VTE (aOR 0.47, 95% CI 0.30 to 0.74). Conclusion: In young trauma patients, WB prophylaxis is not associated with reduced VTE rate when compared with SFD. The timing of the initiation of chemoprophylaxis may be more important than the dosing strategy. Further studies need to evaluate these findings across a wider age and comorbidity spectrum. Level of evidence: Level IV, therapeutic/care management.

Emergency vascular repairs in trauma: Predictors of poor prognosis and a novel scoring system.

BACKGROUND: Vascular injuries comprise 1% to 4% of all trauma patients, and there are no widely used risk-stratification tools. We sought to establish predictors of revascularization failures and compare outcomes of trauma and vascular surgeons. METHODS: We performed a single-institution, case-control study of consecutive patients with traumatic arterial injuries who underwent open repair between 2016 and 2021. Multivariable logistic regression was used to investigate covariates impacting the primary composite outcome of repair failure/revision, amputation, or in-hospital mortality. RESULTS: Among 165 patients, the median age was 34 years, 149 (90%) were male, and 99 (60%) suffered penetrating injury. Popliteal (46%) and superficial femoral (44%) arterial injuries were most common. Interposition graft/bypass was the most frequent repair (n = 107 [65%]). Revascularization failure was observed in 24 patients (15%). Compared with trauma surgeons, vascular surgeons more frequently repaired blunt injuries (66% vs. 20%, p < 0.001), anterior tibial (18% vs. 5%, p = 0.012), or tibioperoneal injuries (28% vs. 4%, p < 0.001), with a below-knee bypass (38% vs. 20%, p = 0.019). Revascularization failure occurred in 10% (9 of 93) of repairs by trauma surgeons and 21% (13 of 61) of repairs by vascular surgeons. Mangled Extremity Severity Score >8 (odds ratio, 15.6; 95% confidence interval, 4.4-55.9; p < 0.001) and concomitant laparotomy or orthopedic procedure (odds ratio, 6.7; 95% confidence interval, 1.6-28.6; p = 0.010) were independently associated with revascularization failure. A novel composite scoring system (UT Houston Score) was developed by combining Mangled Extremity Severity Score, concomitant procedure, mechanism of injury, and injury location. This score demonstrated a sensitivity of 100% with a score of 0 and a specificity of 95% with a score of >3. CONCLUSION: After traumatic arterial injury, trauma surgeons repaired less-complex injuries but with fewer revascularization failures than vascular surgeons. The UT Houston Score may be used to risk stratify patients to determine who may benefit from vascular surgery consultation. LEVEL OF EVIDENCE: Therapeutic/Care Management; Level III.

Rates and risk factors for anastomotic leak following blunt trauma-associated bucket handle intestinal injuries: a multicenter study.

Objectives: The risk factors for anastomotic leak (AL) after resection and primary anastomosis for traumatic bucket handle injury (BHI) have not been previously defined. This multicenter study was conducted to address this knowledge gap. Methods: This is a multicenter retrospective study on small intestine and colonic BHIs from blunt trauma between 2010 and 2021. Baseline patient characteristics, risk factors, presence of shock and transfusion, operative details, and clinical outcomes were compared using R. Results: Data on 395 subjects were submitted by 12 trauma centers, of whom 33 (8.1%) patients developed AL. Baseline details were similar, except for a higher proportion of patients in the AL group who had medical comorbidities such as diabetes, hypertension, and obesity (60.6% vs. 37.3%, p=0.015). AL had higher rates of surgical site infections (13.4% vs. 5.3%, p=0.004) and organ space infections (65.2% vs. 11.7%, p<0.001), along with higher readmission and reoperation rates (48.4% vs. 9.1%, p<0.001, and 39.4% vs. 11.6%, p<0.001, respectively). There was no difference in intensive care unit length of stay or mortality (p>0.05). More patients with AL were discharged with an ostomy (69.7% vs. 7.3%, p<0.001), and the mean duration until ostomy reversal was 5.85±3 months (range 2-12.4 months). The risk of AL significantly increased when the initial operation was a damage control procedure, after adjusting for age, sex, injury severity, presence of one or more comorbidities, shock, transfusion of >6 units of packed red blood cells, and site of injury (adjusted RR=2.32 (1.13, 5.17)), none of which were independent risk factors in themselves. Conclusion: Damage control surgery performed as the initial operation appears to double the risk of AL after intestinal BHI, even after controlling for other markers of injury severity. Level of evidence: III.

Anastomotic leak rates after repair of mesenteric bucket-handle injuries: A multi-center retrospective cohort study.

BACKGROUND: Primary aim was to assess the relative risk (RR) of anastomotic leak (AL) in intestinal bucket-handle (BH) compared to non-BH injury. METHODS: Multi-center study comparing AL in BH from blunt trauma 2010-2021 compared to non-BH intestinal injuries. RR was calculated for small bowel and colonic injury using R. RESULTS: AL occurred in 20/385 (5.2%) of BH vs. 4/225 (1.8%) of non-BH small intestine injury. AL was diagnosed 11.6 ± 5.6 days from index operation in small intestine BH and 9.7 ± 4.3 days in colonic BH. Adjusted RR for AL was 2.32 [0.77-6.95] for small intestinal and 4.83 [1.47-15.89] for colonic injuries. AL increased infections, ventilator days, ICU & total length of stay, reoperation, and readmission rates, although mortality was unchanged. CONCLUSION: BH carries a significantly higher risk of AL, particularly in the colon, than other blunt intestinal injuries.

Tissue plasminogen activator resistance is an early predictor of posttraumatic venous thromboembolism: A prospective study from the CLOTT research group.

BACKGROUND: Venous thromboembolism (VTE) remains a frequent postinjury complication with well established but nonmodifiable risk factors. We hypothesized that fibrinolysis shutdown (SD) as measured by thromboelastography (TEG) would be an independent risk factor for VTE in trauma patients. METHODS: A subgroup of patients enrolled in the CLOTT-2 (Consortium of Leaders in the Study of Traumatic Thromboembolism 2), multicenter prospective cohort study had kaolin TEG and tissue plasminogen activator (tPA)-TEG data at 12 and 24 hours postadmission. Patients underwent a screening duplex venous ultrasound examination during the first week unless clot was already detected on computed tomography. Injury factors associated with early fibrinolysis SD (defined as kaolin TEG Ly30 ≤0.3%) and/or tPA resistance (tPA-R) (defined as kaolin TEG with tPA 75 ng Ly30 <2.1%) were investigated as was the association of the TEG measurements with the development of VTE. RESULTS: A total of 141 patients had both TEG measurements at 24 hours, and 135 had both TEG measurements at 12 hours. Shutdown was evident at 12 hours in 71 of 135 (52.6%) patients and in 62 of 141 (44%) at 24 hours. Tissue plasminogen activator resistance was found in 61 of 135 (45.2%) at 12 hours and in 49 of 141 (34.3%) at 24 hours. Factors significantly associated with SD included receiving >4 U of FFP in the first 24 hours, the presence of a major brain injury or pelvic fracture, and the need for major surgery. In contrast, factors significantly associated with early tPA-R included >4 U of red blood cells transfused in the first 24 hours and the presence of a major chest injury or long bone fracture. Deep vein thrombosis was detected in 15 patients and pulmonary clots in 5 (overall VTE rate, 14.2%). Tissue plasminogen activator resistance at 12 hours was found to be an independent risk factor for VTE (hazard ratio, 5.57; 95% confidence interval, 1.39-22.39). CONCLUSION: Early development of a hypercoagulable state as defined by tPA-R at 12 hours after admission represents a potentially modifiable risk factor for postinjury VTE. LEVEL OF EVIDENCE: Therapeutic/Care Management; Level II.

Multi-center validation of the Bowel Injury Predictive Score (BIPS) for the early identification of need to operate in blunt bowel and mesenteric injuries.

INTRODUCTION: The Bowel Injury Prediction Score (BIPS) is a tool for identifying patients at risk for blunt bowel and mesenteric injury (BBMI) requiring surgery. BIPS is calculated by assigning one point for each of the following: (1) WBC ≥ 17,000, (2) abdominal tenderness, and (3) injury grade ≥ 4 (mesenteric contusion or hematoma with bowel wall thickening or adjacent interloop fluid collection) on CT scan. A total score ≥ 2 is associated with BBMI requiring surgery. We aimed to validate the BIPS as a predictor for patients with BBMIs requiring operative intervention in a multi-center prospective study. MATERIALS AND METHODS: Patients were prospectively enrolled at 15 U.S. trauma centers following blunt trauma with suspicion of BBMI on CT scan between July 1, 2018 and July 31, 2019. The BIPS was calculated for each patient enrolled in the study. RESULTS: Of 313 patients, 38% had BBMI requiring operative intervention. Patients were significantly more likely to require surgery in the presence of abdominal tenderness (OR, 3.6; 95% CI, 1.6-8.0) and CT grade ≥ 4 (OR, 11.7; 95% CI, 5.7-23.7). Patients with a BIPS ≥ 2 were more than ten times more likely to require laparotomy than those with a BIPS < 2 (OR, 10.1; 95% CI, 5.0-20.4). The sensitivity, specificity, positive predictive value (PPV), and negative predictive value (NPV) of a BIPS ≥ 2 for BBMI requiring surgery was 72% (CI 0.6-0.8), 78% (CI 0.7-0.8), 67% (CI 0.6-0.8), and 82% (CI 0.8-0.9), respectively. The AUROC curve for BIPS ≥ 2 was 0.75. The sensitivity, specificity, PPV, and NPV of a BIPS ≥ 2 for BBMI requiring surgery in patients with severe alteration in mental status (GCS 3-8) was 70% (CI 0.5-0.9), 92% (CI 0.8-1.0), 82% (CI 0.6-1.0), and 86% (CI 0.7-1.0), respectively. CONCLUSION: This prospective multi-center trial validates BIPS as a predictor of BBMI requiring surgery. Calculation of BIPS during the initial evaluation of trauma patients is a useful adjunct to help general surgeons taking trauma call determine operative versus non-operative management of patients with BBMI including those with severe alteration in mental status.

Challenging Traditional Paradigms in Posttraumatic Pulmonary Thromboembolism.

Importance: Pulmonary clots are seen frequently on chest computed tomography performed after trauma, but recent studies suggest that pulmonary thrombosis (PT) and pulmonary embolism (PE) after trauma are independent clinical events. Objective: To assess whether posttraumatic PT represents a distinct clinical entity associated with the nature of the injury, different from the traditional venous thromboembolic paradigm of deep venous thrombosis (DVT) and PE. Design, Setting, and Participants: This prospective, observational, multicenter cohort study was conducted by the Consortium of Leaders in the Study of Traumatic Thromboembolism (CLOTT) study group. The study was conducted at 17 US level I trauma centers during a 2-year period (January 1, 2018, to December 31, 2020). Consecutive patients 18 to 40 years of age admitted for a minimum of 48 hours with at least 1 previously defined trauma-associated venous thromboembolism (VTE) risk factor were followed up until discharge or 30 days. Exposures: Investigational imaging, prophylactic measures used, and treatment of clots. Main Outcomes and Measures: The main outcomes of interest were the presence, timing, location, and treatment of any pulmonary clots, as well as the associated injury-related risk factors. Secondary outcomes included DVT. We regarded pulmonary clots with DVT as PE and those without DVT as de novo PT. Results: A total of 7880 patients (mean [SD] age, 29.1 [6.4] years; 5859 [74.4%] male) were studied, 277 with DVT (3.5%), 40 with PE (0.5%), and 117 with PT (1.5%). Shock on admission was present in only 460 patients (6.2%) who had no DVT, PT, or PE but was documented in 11 (27.5%) of those with PE and 30 (25.6%) in those with PT. Risk factors independently associated with PT but not DVT or PE included shock on admission (systolic blood pressure <90 mm Hg) (odds ratio, 2.74; 95% CI, 1.72-4.39; P < .001) and major chest injury with Abbreviated Injury Score of 3 or higher (odds ratio, 1.72; 95% CI, 1.16-2.56; P = .007). Factors associated with the presence of PT on admission included major chest injury (14 patients [50.0%] with or without major chest injury with an Abbreviated Injury Score >3; P = .04) and major venous injury (23 [82.1%] without major venous injury and 5 [17.9%] with major venous injury; P = .02). No deaths were attributed to PT or PE. Conclusions and Relevance: To our knowledge, this CLOTT study is the largest prospective investigation in the world that focuses on posttraumatic PT. The study suggests that most pulmonary clots are not embolic but rather result from inflammation, endothelial injury, and the hypercoagulable state caused by the injury itself.

Damage control laparotomy in trauma: a pilot randomized controlled trial. The DCL trial.

BACKGROUND: Although widely used in treating severe abdominal trauma, damage control laparotomy (DCL) has not been assessed in any randomized controlled trial. We conducted a pilot trial among patients for whom our surgeons had equipoise and hypothesized that definitive laparotomy (DEF) would reduce major abdominal complications (MAC) or death within 30 days compared with DCL. METHODS: Eligible patients undergoing emergency laparotomy were randomized during surgery to DCL or DEF from July 2016 to May 2019. The primary outcome was MAC or death within 30 days. Prespecified frequentist and Bayesian analyses were performed. RESULTS: Of 489 eligible patients, 39 patients were randomized (DCL 18, DEF 21) and included. Groups were similar in demographics and mechanism of injury. The DEF group had a higher Injury Severity Score (DEF median 34 (IQR 20, 43) vs DCL 29 (IQR 22, 41)) and received more prerandomization blood products (DEF median red blood cells 8 units (IQR 6, 11) vs DCL 6 units (IQR 2, 11)). In unadjusted analyses, the DEF group had more MAC or death within 30 days (1.71, 95% CI 0.81 to 3.63, p=0.159) due to more deaths within 30 days (DEF 33% vs DCL 0%, p=0.010). Adjustment for Injury Severity Score and prerandomization blood products reduced the risk ratio for MAC or death within 30 days to 1.54 (95% CI 0.71 to 3.32, p=0.274). The Bayesian probability that DEF increased MAC or death within 30 days was 85% in unadjusted analyses and 66% in adjusted analyses. CONCLUSION: The findings of our single center pilot trial were inconclusive. Outcomes were not worse with DCL and, in fact, may have been better. A randomized clinical trial of DCL is feasible and a larger, multicenter trial is needed to compare DCL and DEF for patients with severe abdominal trauma. LEVEL OF EVIDENCE: Level II.

A multicenter trial of current trends in the diagnosis and management of high-grade pancreatic injuries.

BACKGROUND: Outcomes following pancreatic trauma have not improved significantly over the past two decades. A 2013 Western Trauma Association algorithm highlighted emerging data that might improve the diagnosis and management of high-grade pancreatic injuries (HGPIs; grades III-V). We hypothesized that the use of magnetic resonance cholangiopancreatography, pancreatic duct stenting, operative drainage versus resection, and nonoperative management of HGPIs increased over time. METHODS: Multicenter retrospective review of diagnosis, management, and outcomes of adult pancreatic injuries from 2010 to 2018 was performed. Data were analyzed by grade and time period (PRE, 2010-2013; POST, 2014-2018) using various statistical tests where appropriate. RESULTS: Thirty-two centers reported data on 515 HGPI patients. A total of 270 (53%) had penetrating trauma, and 58% went directly to the operating room without imaging. Eighty-nine (17%) died within 24 hours. Management and outcomes of 426 24-hour survivors were evaluated. Agreement between computed tomography and operating room grading was 38%. Magnetic resonance cholangiopancreatography use doubled in grade IV/V injuries over time but was still low.Overall HGPI treatment and outcomes did not change over time. Resection was performed in 78% of grade III injuries and remained stable over time, while resection of grade IV/V injuries trended downward (56% to 39%, p = 0.11). Pancreas-related complications (PRCs) occurred more frequently in grade IV/V injuries managed with drainage versus resection (61% vs. 32%, p = 0.0051), but there was no difference in PRCs for grade III injuries between resection and drainage.Pancreatectomy closure had no impact on PRCs. Pancreatic duct stenting increased over time in grade IV/V injuries, with 76% used to treat PRCs. CONCLUSION: Intraoperative and computed tomography grading are different in the majority of HGPI cases. Resection is still used for most patients with grade III injuries; however, drainage may be a noninferior alternative. Drainage trended upward for grade IV/V injuries, but the higher rate of PRCs calls for caution in this practice. LEVEL OF EVIDENCE: Retrospective diagnostic/therapeutic study, level III.

Predictors for Direct to Operating Room Admission in Severe Trauma.

BACKGROUND: Protocols for expediting critical trauma patients directly from the helipad to the operating room tend to vary by center, rely heavily on physician gestalt, and lack supporting evidence. We evaluated a population of severely injured trauma patients with the aim of determining objective factors associated with the need for immediate surgical intervention. METHODS: All highest-activation trauma patients transported by air ambulance between 1/1/16 and 12/31/17 were enrolled retrospectively. Transfer, pediatric, isolated burn, and isolated head trauma patients were excluded. Patients who underwent emergency general surgery within 30 min of arrival without the aid of cross-sectional imaging were compared to the remainder of the cohort. RESULTS: Of the 863 patients who were enrolled, 85 (10%) spent less than 30 min in the emergency department (ED) before undergoing an emergency operation. The remaining 778 patients (90%) formed the comparison group. The ED ≤ 30 min group had a higher percentage of penetrating injuries, lower blood pressure, and was more likely to have a positive FAST exam. The "Direct to Operating Room" (DTOR) score is a predictive scoring system devised to identify patients most likely to benefit from bypassing the ED. The odds ratio of emergency operation within 30 min of hospital arrival increased by 2.71 (95% confidence interval 2.23-3.29; P < 0.001) for every 1-point increase in DTOR score. CONCLUSIONS: Trauma patients with profound hypotension or acidosis and positive FAST were more likely to require surgery within 30 min of hospital presentation. Use of a scoring system may allow early identification of these patients in the prehospital setting by nonphysician providers.

Different strokes: differences in the characteristics and outcomes of BCVI and non-BCVI strokes in trauma patients.

BACKGROUND: Although strokes are rare in trauma patients, they are associated with worse functional and cognitive outcomes and decreased mobility. Blunt cerebrovascular injury (BCVI)-related strokes and mortality have decreased, likely due to refined screening and treatment algorithms in trauma literature; however, there is a paucity of research addressing non-BCVI strokes in trauma. The purpose of this study is to evaluate the incidence, etiology, and risk factors of stroke in our trauma population in order to identify preventive strategies. METHODS: This study was a retrospective review of all adult trauma patients admitted to a level 1 trauma hospital who suffered a stroke during trauma admission from 2010 to 2017. Data were collected from the prospectively maintained trauma and stroke databases. Stroke etiology was determined by a vascular neurologist. RESULTS: Of the 43 674 adult trauma patients admitted during the study period, 99 (0.2%) were diagnosed with a stroke during the index admission. Twenty-one (21%) strokes were due to BCVI. Seventy-eight (79%) strokes were due to non-BCVI etiologies. Patients with non-BCVI strokes were older, less severely injured, and had more medical comorbidities compared with patients with a BCVI stroke. While patients with a BCVI stroke were more likely to suffer multiple traumatic injuries from MVC (76% vs 28%, p<0.001), non-BCVI strokes had more isolated extremity injuries from fall mechanism (55% vs 10%, p<0.001). Over the study period, the age and incidence of stroke and BCVI (p<0.001) increased. However, the rate of BCVI strokes decreased while the rate of non-BCVI strokes increased. DISCUSSION: The incidence of stroke has increased despite aggressive screening and treatment of BCVI. This increase is primarily due to non-BCVI strokes which are associated with advanced age and medical comorbidities after low mechanism traumatic injury. Medical optimization of comorbid conditions during trauma hospitalization will become increasingly important for stroke prevention as the population ages.Level of evidence: Level III.

A Survey of Trauma Surgeon Perceptions of Resources for Patients With Psychiatric Comorbidities.

BACKGROUND: Psychiatric illness is an independent risk factor for trauma and recidivism and is often comorbid in the trauma population. There is no current standard for the delivery of mental health services in trauma care. The purpose of this study was to gauge trauma surgeon perceptions of needed and currently available resources for this patient population at level 1 trauma centers in the United States. MATERIALS AND METHODS: A 10-question survey was developed to capture the estimated volume of psychiatric patients admitted to level 1 trauma centers, their available psychiatric services, and perceived need for resources. It was sent to 27 trauma surgery colleagues at different level 1 trauma centers across the United States using a public survey tool. Descriptive analyses were performed. RESULTS: Twenty-two of 27 trauma surgeons responded (81% response rate). Ten centers (48%) estimated admitting 1-5 patients with preexisting serious mental illness weekly, whereas others admitted more. Eight (36%) reported not having acute situational support services available. Ten respondents (46%) did not know how many psychiatric consultants were available at their institution. Twelve surgeons (55%) reported no designated outpatient follow-up for psychiatric issues. Sixteen trauma surgeons (73%) stated that expanded psychiatric services are needed at their trauma center. CONCLUSIONS: Trauma patients frequently present with preexisting serious mental illness and many struggle with psychological sequelae of trauma. Over half of the surveyed surgeons reported no outpatient follow-up for these patients, and almost three quarters perceived the need for expansion of psychiatric services. In addition to a lack of resources, these findings highlight an overlooked gap in high-quality patient-centered trauma care.

Age-Dependent Association of Occult Hypoperfusion and Outcomes in Trauma.

BACKGROUND: Occult hypoperfusion (OH), or global hypoperfusion with normal vital signs, is a risk factor for poor outcomes in elderly trauma patients. We hypothesized that OH is associated with worse outcomes than shock in both young and elderly trauma patients. METHODS: We conducted a single-center cohort study of adult (16 years or older) trauma patients from 2016 to 2018 with base excess measured on arrival. Perfusion states were defined as shock if heart rate was >120 beats/min or systolic blood pressure was <90 mmHg; OH if base excess was < -2 mmol/L, heart rate was <120 beats/min, and systolic blood pressure was >90 mmHg; and normal for all others. Patients were stratified as young (younger than 55 years) or elderly (55 years or older). Bayesian regression was used to assess the relationship between arrival perfusion state and mortality or serious complication. RESULTS: Of 3,126 included patients, 808 were elderly. Rates of shock (33% and 31%) and OH (25% and 23%) were similar in young and elderly patients, respectively. OH on arrival was associated with higher odds of mortality or serious complication than normal perfusion, regardless of age group. Compared with shock, OH was associated with an odds ratio of 1.21 (95% CI, 0.97 to 1.52, posterior probability 96%) for poor outcomes in elderly patients and an odds ratio of 0.52 (95% CI, 0.42 to 0.65, posterior probability <1%) for poor outcomes in younger patients. Findings were similar on sensitivity analysis, excluding shock patients with base excess ≥ -2 mmol/L. CONCLUSIONS: In elderly but not younger patients, OH is associated with worse outcomes than shock. Although shock parameters might need to be redefined in elderly patients, more attention is necessary for the diagnosis and treatment of all hypoperfused states in this age group.

Are We Out of the Woods Yet? The Aftermath of Resuscitative Thoracotomy.

BACKGROUND: After traumatic arrest, resuscitative thoracotomy is lifesaving in appropriately selected patients, yet data are limited regarding hospital course after intensive care unit (ICU) admission. The objective of this study was to describe the natural history of resuscitative thoracotomy survivors admitted to the ICU. MATERIALS AND METHODS: We conducted a retrospective review (January 1, 2012-June 30, 2017) of all adult trauma patients who underwent resuscitative thoracotomy after traumatic arrest at two adult level 1 trauma centers. Data evaluated include demographics, injury characteristics, hospital course, and outcome. RESULTS: Over 66 mo, there were 52,624 trauma activations. Two hundred ninety-eight patients underwent resuscitative thoracotomy and 96 (32%) survived to ICU admission. At ICU admission, mean age was 35.8 ± 14.5 y, 79 (82%) were male, 36 (38%) sustained blunt trauma, and the mean injury severity score was 32.3 ± 13.7. Eight blunt and 20 penetrating patients (22% and 34% of ICU admissions, respectively) survived to discharge. 67% of deaths in the ICU occurred within the first 24 h, whereas 90% of those alive at day 21 survived to discharge. For the 28 survivors, mean ICU length of stay was 24.1 ± 17.9 d and mean hospital length of stay was 43.9 ± 32.1 d. Survivors averaged 1.9 ± 1.5 complications. Twenty-four patients (86% of hospital survivors) went home or to a rehabilitation center. CONCLUSIONS: After resuscitative thoracotomy and subsequent ICU admission, 29% of patients survived to hospital discharge. Complications and a long hospital stay should be expected, but the functional outcome for survivors is not as bleak as previously reported.

Implementation of a multi-modal pain regimen to decrease inpatient opioid exposure after injury.

INTRODUCTION: In 2013, we implemented a pill-based, multi-modal pain regimen (MMPR) in order to decrease in-hospital opioid exposure after injury at our trauma center. We hypothesized that the MMPR would decrease inpatient oral morphine milligram equivalents (MME), decrease opioid prescriptions at discharge, and result in similar Numerical Rating Scale (NRS) pain scores. METHODS: Adult patients admitted to a level-1 trauma center with ≥1 rib fracture from 2010 to 2017 were included - spanning 3 years before and 4 years after MMPR implementation. MME were summarized as medians and interquartile range (IQR) by year of admission. The effect of the MMPR on daily total MME was estimated using Bayesian generalized linear model. RESULTS: Over the 8 year study period, 6,933 patients who met study inclusion criteria were included. No significant differences between years were observed in Abbreviated Injury Scale (AIS) Chest or Injury Severity Scores (ISS). After introduction of the MMPR, there was a significant reduction in median total MME administered per patient day from 60 MME/patient day (IQR 36-91 MME/patient day) pre-MMPR implementation to 37 MME/patient day (IQR 18-61 MME/patient day) in 2017, p < 0.01. Total MME administered per patient day decreased by 31% in 2017 as compared to 2010 (rate ratio 0.69, 95% CI 0.64-0.75). Average NRS pain scores decreased by 0.8 points (95% CI -0.87, -0.81) from 2010 to 2017. CONCLUSION: The introduction of a multi-modal pain regimen resulted in significant reduction in in-patient opioid exposure after injury. The reduction in inpatient opioid use from 2010 to 2017 was equivalent to 11 mg less oxycodone or 17 mg less hydrocodone per patient per day. Additionally, use of the MMPR was associated with a reduction in NRS pain scores.

Time to stroke: A Western Trauma Association multicenter study of blunt cerebrovascular injuries.

BACKGROUND: Screening for blunt cerebrovascular injuries (BCVIs) in asymptomatic high-risk patients has become routine. To date, the length of this asymptomatic period has not been defined. Determining the time to stroke could impact therapy including earlier initiation of antithrombotics in multiply injured patients. The purpose of this study was to determine the time to stroke in patients with a BCVI-related stroke. We hypothesized that the majority of patients suffer stroke between 24 hours and 72 hours after injury. METHODS: Patients with a BCVI-related stroke from January 2007 to January 2017 from 37 trauma centers were reviewed. RESULTS: During the 10-year study, 492 patients had a BCVI-related stroke; the majority were men (61%), with a median age of 39 years and ISS of 29. Stroke was present at admission in 182 patients (37%) and occurred during an Interventional Radiology procedure in six patients. In the remaining 304 patients, stroke was identified a median of 48 hours after admission: 53 hours in the 144 patients identified by neurologic symptoms and 42 hours in the 160 patients without a neurologic examination and an incidental stroke identified on imaging. Of those patients with neurologic symptoms, 88 (61%) had a stroke within 72 hours, whereas 56 had a stroke after 72 hours; there was a sequential decline in stroke occurrence over the first week. Of the 304 patients who had a stroke after admission, 64 patients (22%) were being treated with antithrombotics when the stroke occurred. CONCLUSIONS: The majority of patients suffer BCVI-related stroke in the first 72 hours after injury. Time to stroke can help inform clinicians about initiation of treatment in the multiply injured patient. LEVEL OF EVIDENCE: Prognostic/Epidemiologic, level III.

Circulation first - the time has come to question the sequencing of care in the ABCs of trauma; an American Association for the Surgery of Trauma multicenter trial.

Background: The traditional sequence of trauma care: Airway, Breathing, Circulation (ABC) has been practiced for many years. It became the standard of care despite the lack of scientific evidence. We hypothesized that patients in hypovolemic shock would have comparable outcomes with initiation of bleeding treatment (transfusion) prior to intubation (CAB), compared to those patients treated with the traditional ABC sequence. Methods: This study was sponsored by the American Association for the Surgery of Trauma multicenter trials committee. We performed a retrospective analysis of all patients that presented to trauma centers with presumptive hypovolemic shock indicated by pre-hospital or emergency department hypotension and need for intubation from January 1, 2014 to July 1, 2016. Data collected included demographics, timing of intubation, vital signs before and after intubation, timing of the blood transfusion initiation related to intubation, and outcomes. Results: From 440 patients that met inclusion criteria, 245 (55.7%) received intravenous blood product resuscitation first (CAB), and 195 (44.3%) were intubated before any resuscitation was started (ABC). There was no difference in ISS, mechanism, or comorbidities. Those intubated prior to receiving transfusion had a lower GCS than those with transfusion initiation prior to intubation (ABC: 4, CAB:9, p = 0.005). Although mortality was high in both groups, there was no statistically significant difference (CAB 47% and ABC 50%). In multivariate analysis, initial SBP and initial GCS were the only independent predictors of death. Conclusion: The current study highlights that many trauma centers are already initiating circulation first prior to intubation when treating hypovolemic shock (CAB), even in patients with a low GCS. This practice was not associated with an increased mortality. Further prospective investigation is warranted. Trial registration: IRB approval number: HM20006627. Retrospective trial not registered.

Management of blunt cerebrovascular injury (BCVI) in the multisystem injury patient with contraindications to immediate anti-thrombotic therapy.

INTRODUCTION: Practice management guidelines for screening and treatment of patients with blunt cerebrovascular injury (BCVI) have been associated with a decreased risk of ischemic stroke. TREATMENT: of patients with BCVI and multisystem injuries that delays immediate antithrombotic therapy remains controversial. The purpose of this study was to determine the timing of BCVI treatment initiation, the incidence of stroke, and bleeding complications as a result of antithrombotic therapy in patients with isolated BCVI in comparison to those with BCVI complicated by multisystem injuries. MATERIALS AND METHODS: This study was a retrospective review of all adult blunt trauma patients admitted to a level 1 trauma center from 2009 to 2014 with a diagnosis of BCVI. RESULTS: A total of 28,305 blunt trauma patients were admitted during the study period. Of these, 323 (1.1%) had 481 BCEVIs and were separated into two groups. Isolated BCVI was reported in 111 (34.4%) patients and 212 (65.6%) patients had accompanying multisystem injuries (traumatic brain injury (TBI), solid organ injury, or spinal cord injury) that contraindicated immediate antithrombotic therapy. TREATMENT: started in patients with isolated BCVI at a median time of 30.3 (15, 52) hours after injury in contrast to 62.4 (38, 97) hours for those with multisystem injuries (p<0.001). The incidence of stroke was identical (9.9%) between groups and no bleeding complications related to antithrombotic therapy were identified. CONCLUSION: The lack of bleeding complications and equivalent stroke rates between groups suggests that the presence of TBI, solid organ injury, and spinal cord injury are not contraindications to anti-thrombotic therapy for stroke prevention in patients with BCVI.