Every minute matters: Improving outcomes for penetrating trauma through prehospital advanced resuscitative care.

INTRODUCTION: Prehospital resuscitation with blood products is gaining popularity for patients with traumatic hemorrhage. The MEDEVAC trial demonstrated a survival benefit exclusively among patients who received blood or plasma within 15 minutes of air medical evacuation. In fast-paced urban EMS systems with a high incidence of penetrating trauma, mortality data based on the timing to first blood administration is scarce. We hypothesize a survival benefit in patients with severe hemorrhage when blood is administered within the first 15 minutes of EMS patient contact. METHODS: This was a retrospective analysis of a prospective database of prehospital blood (PHB) administration between 2021 and 2023 in an urban EMS system facing increasing rates of gun violence. PHB patients were compared to trauma registry controls from an era before prehospital blood utilization (2016-2019). Included were patients with penetrating injury and SBP ≤ 90 mmHg at initial EMS evaluation that received at least one unit of blood product after injury. Excluded were isolated head trauma or prehospital cardiac arrest. Time to initiation of blood administration before and after PHB implementation and in-hospital mortality were the primary variables of interest. RESULTS: A total of 143 patients (PHB = 61, controls = 82) were included for analysis. Median age was 34 years with no difference in demographics. Median scene and transport intervals were longer in the PHB cohort, with a 5-minute increase in total prehospital time. Time to administration of first unit of blood was significantly lower in the PHB vs. control group (8 min vs 27 min; p < 0.01). In-hospital mortality was lower in the PHB vs. control group (7% vs 29%; p < 0.01). When controlling for patient age, NISS, tachycardia on EMS evaluation, and total prehospital time interval, multivariate regression revealed an independent increase in mortality by 11% with each minute delay to blood administration following injury (OR 1.11, 95%CI 1.04-1.19). CONCLUSION: Compared to patients with penetrating trauma and hypotension who first received blood after hospital arrival, resuscitation with blood products was started 19 minutes earlier after initiation of a PHB program despite a 5-minute increase in prehospital time. A survival for early PHB use was demonstrated, with an 11% mortality increase for each minute delay to blood administration. Interventions such as PHB may improve patient outcomes by helping capture opportunities to improve trauma resuscitation closer to the point of injury. LEVEL OF EVIDENCE: Prospective, Level IV.

Impact of Prehospital Exsanguinating Airway-Breathing-Circulation Resuscitation Sequence on Patients with Severe Hemorrhage.

BACKGROUND: At the 2023 ATLS symposium, the priority of circulation was emphasized through the "x-airway-breathing-circulation (ABC)" sequence, where "x" stands for exsanguinating hemorrhage control. With growing evidence from military and civilian studies supporting an x-ABC approach to trauma care, a prehospital advanced resuscitative care (ARC) bundle emphasizing early transfusion was developed in our emergency medical services (EMS) system. We hypothesized that prioritization of prehospital x-ABC through ARC would reduce in-hospital mortality. STUDY DESIGN: This was a single-year prospective analysis of patients with severe hemorrhage. These patients were combined with our institution's historic controls before prehospital blood implementation. Included were patients with systolic blood pressure (SBP) less than 90 mmHg. Excluded were patients with penetrating head trauma or prehospital cardiac arrest. Two-to-one propensity matching for x-ABC to ABC groups was conducted, and the primary outcome, in-hospital mortality, was compared between groups. RESULTS: A total of 93 patients (x-ABC = 62, ABC = 31) met the inclusion criteria. There was no difference in patient age, sex, initial SBP, initial Glasgow Coma Score, and initial shock index between groups. When compared with the ABC group, x-ABC patients had significant improvement in vitals at emergency department admission. Overall mortality was lower in the x-ABC group (13% vs 47%, p < 0.001). Multivariable regression revealed that prehospital circulation-first prioritization was independently associated with decreased in-hospital mortality (odds ratio 0.15, 95% CI 0.04 to 0.54, p = 0.004). CONCLUSIONS: This is the first analysis to demonstrate a prehospital survival benefit of x-ABC in this subset of patient with severe injury and hemorrhagic shock. Standardization of prehospital x-ABC management in this patient population warrants special consideration.

Risk Factors for Postoperative Infections Following Appendectomy of Complicated Appendicitis: A Meta-analysis and Retrospective Single-institutional Study.

Patients with complicated appendicitis have an increased risk for postoperative infections. Potential risk factors for postoperative infections through a meta-analysis and retrospective chart review are discussed. A meta-analysis consisting of 35 studies analyzing complicated appendicitis treated with an appendectomy noting at least 1 postoperative infection was performed. A retrospective review was then conducted in patients diagnosed with complicated appendicitis after appendectomy. Of 5326 patients in total, 15.4% developed postoperative infections. Laparoscopic surgery and perioperative hyperoxygenation were found to be protective factors for the development of infection. Retrospectively, 53.2% of patients presented with complicated appendicitis. Patients with complicated appendicitis were more likely to be older in age and have an increased length of stay. Patient demographics, operative time, and comorbid status had no effect on postoperative infection or readmission rate. Physicians should strongly consider minimally invasive techniques to treat all cases of complicated appendicitis irrespective of comorbidities, age, sex, or body mass index.

Causes and outcomes of finger ischemia in hospitalized patients in the intensive care unit.

OBJECTIVE: Vascular surgeons may be consulted to evaluate hospitalized patients with finger ischemia. We sought to characterize causes and outcomes of finger ischemia in intensive care unit (ICU) patients. METHODS: All ICU patients who underwent evaluation for finger ischemia from 2008 to 2015 were reviewed. All were evaluated with finger photoplethysmography. The patients' demographics, comorbidities, ICU care (ventilator status, arterial lines, use of vasoactive medications), finger amputations, and survival were also recorded. ICU patients were compared with concurrently evaluated non-ICU inpatients with finger ischemia. RESULTS: There were 98 ICU patients (55 male, 43 female) identified. The mean age was 57.1 ± 16.8 years. Of these patients, 42 (43%) were in the surgical ICU and 56 (57%) in the medical ICU. Seventy (72%) had abnormal findings on finger photoplethysmography, 40 (69%) unilateral and 30 (31%) bilateral. Thirty-six (37%) had ischemia associated with an arterial line. Twelve (13%) had concomitant toe ischemia. Eighty (82%) were receiving vasoactive medications at the time of diagnosis, with the most frequent being phenylephrine (55%), norepinephrine (47%), ephedrine (31%), epinephrine (26%), and vasopressin (24%). Treatment was with anticoagulation in 88 (90%; therapeutic, 48%; prophylactic, 42%) and antiplatelet agents in 59 (60%; aspirin, 51%; clopidogrel, 15%). Other frequently associated conditions included mechanical ventilation at time of diagnosis (37%), diabetes (34%), peripheral arterial disease (32%), dialysis dependence (31%), cancer (24%), and sepsis (20%). Only five patients (5%) ultimately required finger amputation. The 30-day, 1-year, and 3-year survival was 84%, 69%, and 59%. By Cox proportional hazards modeling, cancer (hazard ratio, 2.4; 95% confidence interval, 1.1-5.6; P = .035) was an independent predictor of mortality. There were 50 concurrent non-ICU patients with finger ischemia. Non-ICU patients were more likely to have connective tissue disorders (26% vs 13%; P = .05) and hyperlipidemia (42% vs 24%; P = .03) and to undergo finger amputations (16% vs 5%; P = .03). CONCLUSIONS: Finger ischemia in the ICU is frequently associated with the presence of arterial lines and the use of vasopressor medications, of which phenylephrine and norepinephrine are most frequent. Anticoagulation or antiplatelet therapy is appropriate treatment. Whereas progression to amputation is rare, patients with finger ischemia in the ICU have a high rate of mortality, particularly in the presence of cancer. Non-ICU patients hospitalized with finger ischemia more frequently require finger amputations, probably because of more frequent connective tissue disorders.