Real-time attending trauma surgeon assessment of direct-to-operating room trauma resuscitations: Results from a prospective observational study.

BACKGROUND: Direct-to-operating room (DOR) resuscitation expedites interventions for trauma patients. Perceived benefit from the surgeon's perspective is not well known. This study assesses the integration of a real-time surgeon assessment tool into a DOR protocol. METHODS: Surgeon assessment tool results from a prospective study of DOR cases were analyzed. Analysis assessed patient factors and surgeon perception for appropriateness and benefit of DOR. Multivariate analysis identified independent factors associated with perceived DOR benefit. RESULTS: A total of 104 trauma patients underwent DOR resuscitation; 84% were perceived as appropriate triage, and 48% as beneficial. Patients with Injury Severity Score of >15 (50% vs. 28%), systolic blood pressure of <90 mm Hg (24% vs. 9%), and severe abdominal injury (28% vs. 9%) had higher perceived DOR benefits (all p < 0.05). Patients deemed to benefit from DOR underwent more emergent interventions or truncal surgery (44% vs. 92%, p < 0.01). No difference in benefit was seen based on age, sex, Glasgow Coma Scale score of <9, or injury mechanism. Forty-four percent had perceived benefit from DOR resuscitation despite requiring imaging after initial evaluation. Patients with perceived benefit had a higher rate of unplanned return to the operating room (16% vs. 2%, p < 0.05), but no differences in complication rates, Glasgow Outcome Score, or mortality. Injury Severity Score of >15 was the only independently associated variable with a perceived benefit on surgeon assessment tool (odds ratio, 3.5; p < 0.05). CONCLUSION: The majority of DOR resuscitations were deemed as appropriately triaged, and approximately half had a perceived benefit. Benefit was associated with higher injury severity and the need for urgent interventions but was not predicted by injury mechanism or other triage variables. LEVEL OF EVIDENCE: Prognostic and Epidemiological; Level IV.

Choosing wisely: A prospective study of direct to operating room trauma resuscitation including real-time trauma surgeon after-action review.

INTRODUCTION: Although several centers have direct to operating room (DOR) resuscitation programs, there are no published prospective studies on optimal patient selection, interventions, outcomes, or real-time surgeon assessments. METHODS: Direct to operating room cases for 1 year were prospectively enrolled. Demographics, injury types/severity, triage criteria, interventions, and outcomes including Glasgow Outcome Scale score were collected. Detailed time-to-event and sequence data on initial lifesaving interventions (LSIs) or emergent surgeries were analyzed. A structured real-time attending surgeon assessment tool for each case was collected. Direct to operating room activation criteria were grouped into categories: mechanism, physiology, injury pattern, or emergency medical services (EMS) suspicion. RESULTS: There were 104 DOR cases: male, 84%; penetrating, 80%; and severely injured (Injury Severity Score, >15), 39%. The majority (65%) required at least one LSI (median of 7 minutes from arrival), and 41% underwent immediate emergent surgery (median, 26 minutes). Blunt patients were more severely injured and more likely to undergo LSI (86% vs. 59%) but less likely to require emergent surgery (19% vs. 47%, all p < 0.05). Analysis of DOR criteria categories showed unique patterns in each group for interventions and outcomes, with EMS suspicion associated with the lowest need for DOR. Surgeon assessment tool results found that DOR was indicated in 84% and improved care in 63%, with a small subset identified (9%) where DOR had a negative impact. CONCLUSION: Direct to operating room resuscitation facilitated timely emergent interventions in penetrating truncal trauma and a select subset of critically ill blunt patients. Unique intervention/outcome profiles were identified by activation criteria groups, with little utility among activations for EMS suspicion. Real-time surgeon assessment tool identified high- and low-yield DOR groups. LEVEL OF EVIDENCE: Prospective observational study, level III.

Direct to operating room trauma resuscitation: Optimizing patient selection and time-critical outcomes when minutes count.

BACKGROUND: Although several trauma centers have developed direct to operating room (DOR) trauma resuscitation programs, there is little published data on optimal patient selection, practices, and outcomes. We sought to analyze triage criteria and interventions associated with optimal DOR outcomes and resource utilization. METHODS: Retrospective review of all adult DOR resuscitations for a 6-year period was performed. Triage criteria were analyzed individually and grouped into categories: mechanism, physiology, anatomy/injury, or other. The best univariate and multivariate predictors of requiring lifesaving interventions (LSIs) or emergent surgery (ES) were analyzed. Actual and predicted mortality were compared for all patients and for predefined time-sensitive subgroups. RESULTS: There were 628 DOR patients (5% of all admissions) identified; the majority were male (79%), penetrating mechanism (70%), severely injured (40% ISS >15), and 17% died. Half of patients required LSI and 23% required ES, with significantly greater need for ES and lower need for LSI after penetrating versus blunt injury (p < 0.01). Although injury mechanism criteria triggered most DOR cases and best predicted need for ES, the physiology and anatomy/injury criteria were associated with greater need for LSI and mortality. Observed mortality was significantly lower than predicted mortality with DOR for several key subgroups. Triage schemes for both ES and LSI could be simplified to four to six independent predictors by regression analysis. CONCLUSION: The DOR program identified severely injured trauma patients at increased risk for requiring LSI and/or ES. Different triage variable categories drive the need for ES versus LSI and could be simplified or optimized based on local needs or preferences. Direct to operating room was associated with better than expected survival among specific time-sensitive subgroups. LEVEL OF EVIDENCE: Therapeutic/Care Management, Level IV.

[Paramphistomidosis - an overview on epidemiology and clinical signs]. / Paramphistomidose ­ eine Übersicht zu Epidemiologie und klinischer Symptomatik.

Paramphistosis is a globally occurring parasitic disease in various ruminants caused by a range of rumen flukes (including Paramphistomum cervi, Calicophoron daubneyi and Paramphistomum leydeni). In Europe, local occurrences of rumen fluke infection in domestic and wild ruminants have been described for decades. There is now evidence that paramphistomidosis is gaining in importance, because high prevalence rates were reported in the United Kingdom, Ireland, France, Spain, Belgium and The Netherlands. Current prevalence data from Germany are lacking. In recent investigations in northern Germany, Hesse and Bavaria, C. daubneyi was detected, which is currently the most prevalent rumen fluke in Europe. The development of therumen fluke is linked to aquatic snails as intermediate hosts. C. daubneyi and the liver fluke Fasciola hepatica share in the course of their development the same intermediate snail host, Galba truncatula. The definitive ruminant host takes up infective metacercaria. In the small intestine, the young flukes excyst and attach to the duodenum. Subsequently, they migrate to the rumen, where, as adults, they begin to release eggs. The infection can lead to severe diarrhea during the intestinal phase and death at high infection intensity. Ruminal paramphistomidosis is subclinical in most cases. Currently, coproscopic detection by the sedimentation method is the available diagnostic tool. Because of similar morphology, there is a risk of confusion with the eggs of the liver fluke F. hepatica. Paramphistomidosis can be treated with oxyclozanide. There are conflicting results regarding the effectiveness of other drugs. Therefore, prophylaxis of this parasitosis is important. Because of the similar epidemiology, control recommendations are based on those for the prevention of fasciolosis. Whether paramphistomidosis is also an emerging infectious disease in Germany cannot be currently assessed.