Infected chylopericardium: An unexpected cause of cardiac tamponade.

A 22-year-old immunocompetent female with a history of small pericardial effusion while infant presented with fever and hemodynamic collapse 4 days after facial trauma. She was found to have cardiac tamponade secondary to infected chylopericardium from bacterial translocation. We report this very unusual case and review of the literature on chylopericardium infections.

Development of a Standardized Data Collection Tool for Evaluation and Management of Coronavirus Disease 2019.

BACKGROUND: Severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2 ) is responsible for coronavirus disease 2019 (COVID-19), a disease that had not been previously described and for which clinicians need to rapidly adapt their daily practice. The novelty of SARS-CoV-2 produced significant gaps in harmonization of definitions, data collection, and outcome reporting to identify patients who would benefit from potential interventions. METHODS: We describe a multicenter collaboration to develop a comprehensive data collection tool for the evaluation and management of COVID-19 in hospitalized patients. The proposed tool was developed by a multidisciplinary working group of infectious disease physicians, intensivists, and infectious diseases/antimicrobial stewardship pharmacists. The working group regularly reviewed literature to select important patient characteristics, diagnostics, and outcomes for inclusion. The data collection tool consisted of spreadsheets developed to collect data from the electronic medical record and track the clinical course after treatments. RESULTS: Data collection focused on demographics and exposure epidemiology, prior medical history and medications, signs and symptoms, diagnostic test results, interventions, clinical outcomes, and complications. During the pilot validation phase, there was <10% missing data for most domains and components. Team members noted improved efficiency and decision making by using the tool during interdisciplinary rounds. CONCLUSIONS: We present the development of a COVID-19 data collection tool and propose its use to effectively assemble harmonized data of hospitalized individuals with COVID-19. This tool can be used by clinicians, researchers, and quality improvement healthcare teams. It has the potential to facilitate interdisciplinary rounds, provide comparisons across different hospitalized populations, and adapt to emerging challenges posed by the pandemic.

Development and Implementation of a COVID-19 Disease Response Protocol at a Large Academic Medical Center.

In response to the rapid spread of novel coronavirus disease 2019 (COVID-19), health-care systems should establish procedures for early recognition and management of suspected or confirmed cases. We describe the various steps taken for the development, implementation, and dissemination of the interdisciplinary COVID-19 protocol at Jackson Health System (JHS), a complex tertiary academic health system in Miami, Florida. Recognizing the dynamic nature of COVID-19, the protocol addresses the potential investigational treatment options and considerations for special populations. The protocol also includes infection prevention and control measures and routine care for suspected or proven COVID-19 patients.

Polymyxin B-induced skin hyperpigmentation.

Polymyxin B (PMB) is a potent antibiotic targeting gram-negative bacteria and is associated with serious side effects including nephrotoxicity, neurotoxicity, and hypersensitivity reactions. PMB is a therapeutic option for the management of infections caused by multi-drug-resistant (MDR) bacteria and used in combination with other antibiotics when options are limited. We describe the case of a 30-year-old female patient with a complex medical history who underwent a multi-visceral transplantation complicated by intra-abdominal infections. Subsequently, patient developed diffuse skin darkening after initiation of intravenous PMB for treatment of MDR Pseudomonas aeruginosa. Her skin hyperpigmentation was most prominent on her face and forearms. Hyperpigmentation peaked at around 2 weeks following PMB initiation and was discontinued after 3 weeks when the possibility of PMB hyperpigmentation was raised and other causes were ruled out. Skin biopsy showed hypermelanosis of the basal layer and melanin deposition in the dermis. Overall clinical picture was consistent with PMB-induced hyperpigmentation. The patient demonstrated some improvement in discoloration within 4 weeks of PMB discontinuation.

Reduction in Exposure to Selected Harmful and Potentially Harmful Constituents Approaching Those Observed Upon Smoking Abstinence in Smokers Switching to the Menthol Tobacco Heating System 2.2 for 3 Months (Part 1).

INTRODUCTION: The Tobacco Heating System (THS) is a "heat-not-burn" tobacco product designed to generate significantly lower levels of harmful and potentially harmful constituents (HPHCs) and present lower risk of harm than cigarettes. This study assessed the exposure reduction to selected HPHCs in smokers switching to menthol Tobacco Heating System (mTHS) 2.2 compared with smokers continuing smoking menthol cigarettes (mCCs) and smoking abstinence (SA) for 5 days in a confined setting, followed by an 86-day ambulatory period. METHODS: A total of 160 healthy adult US smokers participated in this randomized, three-arm parallel group, controlled clinical study. Biomarkers of exposure to 16 HPHCs were measured in blood and 24-hour urine. Safety was monitored throughout the study. Information was also gathered on product evaluation, product use, subjective effects, and clinical risk markers (co-publication Part 2). RESULTS: Nicotine uptake was comparable in both exposure groups (mTHS:mCC ratio of 96% on day 90). On day 5, biomarker of exposure levels to other HPHCs were reduced by 51%-96% in the mTHS group compared with the mCC group, and these reductions were sustained for most biomarkers of exposure over ambulatory period. After 90 days of use, the level of satisfaction with mTHS and suppression of urge to smoke were comparable to mCC. CONCLUSION: Switching from mCCs to mTHS significantly reduced the exposure to HPHCs to levels approaching those observed in subjects who abstained from smoking for the duration of the study. IMPLICATIONS: This study compared the impact of switching to mTHS on biomarkers of exposure, relative to continued smoking or SA. TRIAL REGISTRATION: NCT01989156 (ClinicalTrials.gov).

Favorable Changes in Biomarkers of Potential Harm to Reduce the Adverse Health Effects of Smoking in Smokers Switching to the Menthol Tobacco Heating System 2.2 for 3 Months (Part 2).

INTRODUCTION: Tobacco Heating System (THS) 2.2, a candidate modified-risk tobacco product, aims at offering an alternative to cigarettes for smokers while substantially reducing the exposure to harmful and potentially harmful constituents found in cigarette smoke. METHODS: One hundred and sixty healthy adult US smokers participated in this randomized, three-arm parallel group, controlled clinical study. Subjects were randomized in a 2:1:1 ratio to menthol Tobacco Heating System 2.2 (mTHS), menthol cigarette, or smoking abstinence for 5 days in confinement and 86 subsequent ambulatory days. Endpoints included biomarkers of exposure to harmful and potentially harmful constituents (reported in our co-publication, Part 1) and biomarkers of potential harm (BOPH). RESULTS: Compliance (protocol and allocated product exposure) was 51% and 18% in the mTHS and smoking abstinence arms, respectively, on day 90. Nonetheless, favorable changes in BOPHs of lipid metabolism (total cholesterol and high- and low-density cholesterol), endothelial dysfunction (soluble intercellular adhesion molecule-1), oxidative stress (8-epi-prostaglandin F2α), and cardiovascular risk factors (eg, high-sensitivity C-reactive protein) were observed in the mTHS group. Favorable effects in other BOPHs, including ones related to platelet activation (11-dehydrothromboxane B2) and metabolic syndrome (glucose), were more pronounced in normal weight subjects. CONCLUSIONS: The results suggest that the reduced exposure demonstrated when switching to mTHS is associated with overall improvements in BOPHs, which are indicative of pathomechanistic pathways underlying the development of smoking-related diseases, with some stronger effects in normal weight subjects. IMPLICATIONS: Switching to mTHS was associated with favorable changes for some BOPHs indicative of biological pathway alterations (eg, oxidative stress and endothelial dysfunction). The results suggest that switching to mTHS has the potential to reduce the adverse health effects of smoking and ultimately the risk of smoking-related diseases. Switching to mTHS for 90 days led to reductions in a number of biomarkers of exposure in smokers, relative to those who continued smoking cigarettes, which were close to those observed when stopping smoking (reported in our co-publication, Part 1). Initial findings suggest reduced levels of 8-epi-prostaglandin F2α and intercellular adhesion molecule 1, when switching to mTHS for 90 days. These changes are comparable to what is observed upon smoking cessation. In normal weight subjects, additional favorable changes were seen in 11-dehydrothromboxane B2, fibrinogen, homocysteine, hs-CRP, percentage of predicted forced expiratory volume in 1 second, systolic blood pressure, diastolic blood pressure, glucose, high-density lipoprotein, apolipoprotein A1, and triglycerides. TRIAL REGISTRATION: NCT01989156.

Household Surveys in the General Population and Web-Based Surveys in IQOS Users Registered at the Philip Morris International IQOS User Database: Protocols on the Use of Tobacco- and Nicotine-Containing Products in Germany, Italy, and the United Kingdom (Greater London), 2018-2020.

BACKGROUND: Philip Morris International (PMI) has developed a novel heat-not-burn tobacco product, Tobacco Heating System (THS), which is marketed under the brand name of IQOS with HEETS (IQOS). The aerosol generated by THS has substantially fewer toxicants than combustible cigarette smoke, although the extent of the reduction of harmful and potentially harmful constituents reported varies between studies. To evaluate the potential harm reduction associated with IQOS use, the assessment of the uptake and continued use of IQOS in the context of all other tobacco- and nicotine-containing products is crucial. In March 2018, PMI launched cross-sectional surveys in Germany, Italy, and the United Kingdom (Greater London) to estimate the prevalence and use patterns of IQOS and other tobacco- and nicotine-containing products use in these 3 markets following the commercialization of IQOS. This study describes the protocol of the surveys. OBJECTIVE: The objectives of these surveys are to estimate the prevalence of tobacco- and nicotine-containing products use; describe past and current patterns of use; and explore their associations with self-reported health, motivation to use, risk perceptions, and perceived aesthetic changes. METHODS: The overall design of the surveys is similar in all 3 countries. Repeated cross-sectional surveys are being conducted annually over 3 consecutive years (2018 to 2020) and in 2 samples: a representative sample of the general population and a sample of IQOS users. A total of 6085 adults per year will be selected from the general population for each survey through multistage stratified sampling, and participants will respond to face-to-face computer-assisted personal interviews. In addition, 1404, 1384, and 1246 IQOS users per year in Germany, Italy, and Greater London, respectively, will be randomly selected from the PMI IQOS user database and will be invited to complete the Web-based survey using computer-assisted self-interviews. The Smoking Questionnaire is used to assess the tobacco use patterns of the participants. RESULTS: The recruitment of the general population sample began in March 2018 and that of the IQOS user sample began in April 2018. The data collection is ongoing, and the results of the first year data analysis are expected to be available by June 2019. CONCLUSIONS: As the design of the 3 surveys is similar, the results will allow for cross-countries comparison of the prevalence of IQOS and other tobacco- and nicotine-containing products use as well as patterns of use and associated factors. INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID): DERR1-10.2196/12061.

Pelvic fracture pattern predicts the need for hemorrhage control intervention-Results of an AAST multi-institutional study.

BACKGROUND: Early identification of patients with pelvic fractures at risk of severe bleeding requiring intervention is critical. We performed a multi-institutional study to test our hypothesis that pelvic fracture patterns predict the need for a pelvic hemorrhage control intervention. METHODS: This prospective, observational, multicenter study enrolled patients with pelvic fracture due to blunt trauma. Inclusion criteria included shock on admission (systolic blood pressure <90 mm Hg or heart rate >120 beats/min and base deficit >5, and the ability to review pelvic imaging). Demographic data, open pelvic fracture, blood transfusion, pelvic hemorrhage control intervention (angioembolization, external fixator, pelvic packing, and/or REBOA [resuscitative balloon occlusion of the aorta]), and mortality were recorded. Pelvic fracture pattern was classified according to Young-Burgess in a blinded fashion. Predictors of pelvic hemorrhage control intervention and mortality were analyzed by univariate and multivariate regression analyses. RESULTS: A total of 163 patients presenting in shock were enrolled from 11 Level I trauma centers. The most common pelvic fracture pattern was lateral compression I, followed by lateral compression I, and vertical shear. Of the 12 patients with an anterior-posterior compression III fracture, 10 (83%) required a pelvic hemorrhage control intervention. Factors associated with the need for pelvic fracture hemorrhage control intervention on univariate analysis included vertical shear pelvic fracture pattern, increasing age, and transfusion of blood products. Anterior-posterior compression III fracture patterns and open pelvic fracture predicted the need for pelvic hemorrhage control intervention on multivariate analysis. Overall in-hospital mortality for patients admitted in shock with pelvic fracture was 30% and did not differ based on pelvic fracture pattern on multivariate analysis. CONCLUSION: Blunt trauma patients admitted in shock with anterior-posterior compression III fracture patterns or patients with open pelvic fracture are at greatest risk of bleeding requiring pelvic hemorrhage control intervention. LEVEL OF EVIDENCE: Prognostic/epidemiologic study, level III.

Biomarker of exposure level data set in smokers switching from conventional cigarettes to Tobacco Heating System 2.2, continuing smoking or abstaining from smoking for 5 days.

Levels of biomarkers of exposure to selected harmful and potentially harmful smoke constituents found in cigarette smoke, in addition to nicotine were measured in 160 smokers randomized for 5 days to continuing smoking conventional cigarettes (41 participants), switching to Tobacco Heating System 2.2 (THS 2.2) (80 participants), or abstaining from smoking (39 participants). The data reported here are descriptive statistics of the levels of each biomarker of exposure expressed as concentrations adjusted to creatinine; at baseline, and at the end of the study, and their relative change from baseline. Reductions in the levels of biomarkers of exposure when expressed as quantity excreted, are also reported. Detailed descriptions of bioanalytical assays used are also provided. The data presented here are related to the article entitled "Evaluation of the Tobacco Heating System 2.2. Part 8: 5-Day randomized reduced exposure clinical study in Poland" (Haziza et al., 2016) [1].

Clinical relevance of the routine daily chest X-Ray in the surgical intensive care unit.

INTRODUCTION: A daily Chest X-ray (CXR) is obtained in many surgical intensive care units (SICU). This study implemented a selective CXR protocol in a high volume, academic SICU and evaluated its impact on clinical outcomes. METHODS: All SICU patients admitted in 2/2010 were compared with patients admitted in 2/2012. Between the time periods, a protocol eliminating the routine daily CXRs was instituted. RESULTS: In 02/2010 and 02/2012, 107 and 90 patients were admitted to the SICU, respectively, for a total of 1384 patient days. CXRs decreased from 365 (57.1% of patient-days) in 2010 to 299 (40.9% of patient days; p < 0.001) in 2012. A greater proportion of Physician Directed CXRs (PDCXRs) had new findings (80.8%) compared to Automatic Daily CXRs (ADCXRs) (23.5%, p < 0.001). There was no difference in overall or SICU length of stay, ventilator-free days, morbidity or mortality. CONCLUSION: Eliminating ADCXRs decreased the number of CXRs performed, without affecting LOS, mechanical ventilation, morbidity or mortality. Physician-directed ordering of CXRs increased the diagnostic value of the CXR and decreased the number of clinically irrelevant CXRs performed.

Evaluation of the Tobacco Heating System 2.2. Part 8: 5-Day randomized reduced exposure clinical study in Poland.

The Tobacco Heating System (THS) 2.2, a candidate Modified Risk Tobacco Product (MRTP), is designed to heat tobacco without burning it. Tobacco is heated in order to reduce the formation of harmful and potentially harmful constituents (HPHC), and reduce the consequent exposure, compared with combustible cigarettes (CC). In this 5-day exposure, controlled, parallel-group, open-label clinical study, 160 smoking, healthy subjects were randomized to three groups and asked to: (1) switch from CCs to THS 2.2 (THS group; 80 participants); (2) continue to use their own non-menthol CC brand (CC group; 41 participants); or (3) to refrain from smoking (smoking abstinence (SA) group; 39 participants). Biomarkers of exposure, except those associated with nicotine exposure, were significantly reduced in the THS group compared with the CC group, and approached the levels observed in the SA group. Increased product consumption and total puff volume were reported in the THS group. However, exposure to nicotine was similar to CC at the end of the confinement period. Reduction in urge-to-smoke was comparable between the THS and CC groups and THS 2.2 product was well tolerated.

The Role of Radio Frequency Detection System Embedded Surgical Sponges in Preventing Retained Surgical Sponges: A Prospective Evaluation in Patients Undergoing Emergency Surgery.

OBJECTIVE: To prospectively evaluate the ability of radio frequency detection (RFD) system-embedded sponges to mitigate the incidence of retained surgical sponges (RSS) after emergency surgery. BACKGROUND: Emergency surgery patients are at high risk for retained foreign bodies. METHODS: All emergent trauma and nontrauma cavitary operations over a 5-year period (January 2010-December 2014) were prospectively enrolled. For damage-control procedures, only the definitive closure was included. RFD sponges were used exclusively throughout the study period. Before closure, the sponge and instrument count was followed by RFD scanning and x-ray evaluation for retained sponges. RSS and near-misses averted using the RFD system were analyzed. RESULTS: In all, 2051 patients [median (range)], aged 41 (1-101) years, 72.2% male, 46.8% trauma patients, underwent 2148 operations (1824 laparotomy, 100 thoracotomy, 30 sternotomy, and 97 combined). RFD detected retained sponges in 11 (0.5%) patients (81.8%laparotomy, 18.2% sternotomy) before cavitary closure. All postclosure x-rays were negative. No retained sponges were missed by the RFD system. Body mass index was 29 (23-43), estimated blood loss 1.0 L (0-23), and operating room time 160 minutes (71-869). Procedures started after 18:00 to 06:00 hours in 45.5% of the patients. The sponge count was incorrect in 36.4%, not performed due to time constraints in 45.5%, and correct in 18.2%. The additional cost of using RFD-embedded disposables was $0.17 for a 4X18 laparotomy sponge and $0.46 for a 10 pack of 12ply, 4X8. CONCLUSIONS: Emergent surgical procedures are high-risk for retained sponges, even when sponge counts are performed and found to be correct. Implementation of a RFD system was effective in preventing this complication and should be considered for emergent operations in an effort to improve patient safety.

The AAST prospective Aortic Occlusion for Resuscitation in Trauma and Acute Care Surgery (AORTA) registry: Data on contemporary utilization and outcomes of aortic occlusion and resuscitative balloon occlusion of the aorta (REBOA).

INTRODUCTION: Aortic occlusion (AO) for resuscitation in traumatic shock remains controversial. Resuscitative endovascular balloon occlusion of the aorta (REBOA) offers an emerging alternative. METHODS: The American Association for the Surgery of Trauma Aortic Occlusion for Resuscitation in Trauma and Acute Care Surgery registry prospectively identified trauma patients requiring AO from eight ACS Level 1 centers. Presentation, intervention, and outcome variables were collected and analyzed to compare REBOA and open AO. RESULTS: From November 2013 to February 2015, 114 AO patients were captured (REBOA, 46; open AO, 68); 80.7% were male, and 62.3% were blunt injured. Aortic occlusion occurred in the emergency department (73.7%) or the operating room (26.3%). Hemodynamic improvement after AO was observed in 62.3% [REBOA, 67.4%; open OA, 61.8%); 36.0% achieving stability (systolic blood pressure consistently >90 mm Hg, >5 minutes); REBOA, 22 of 46 (47.8%); open OA, 19 of 68 (27.9%); p =0.014]. Resuscitative endovascular balloon occlusion of the aorta (REBOA) access was femoral cut-down (50%); US guided (10.9%) and percutaneous without imaging (28.3%). Deployment was achieved in Zones I (78.6%), II (2.4%), and III (19.0%). A second AO attempt was required in 9.6% [REBOA, 2 of 46 (4.3%); open OA, 9 of 68 (13.2%)]. Complications of REBOA were uncommon (pseudoaneurysm, 2.1%; embolism, 4.3%; limb ischemia, 0%). There was no difference in time to successful AO between REBOA and open procedures (REBOA, 6.6 ± 5.6 minutes; open OA, 7.2 ± 15.1; p = 0.842). Overall survival was 21.1% (24 of 114), with no significant difference between REBOA and open AO with regard to mortality [REBOA, 28.2% (13 of 46); open OA, 16.1% (11 of 68); p = 0.120]. CONCLUSION: Resuscitative endovascular balloon occlusion of the aorta has emerged as a viable alternative to open AO in centers that have developed this capability. Further maturation of the American Association for the Surgery of Trauma Aortic Occlusion for Resuscitation in Trauma and Acute Care Surgery database is required to better elucidate optimal indications and outcomes. LEVEL OF EVIDENCE: Therapeutic/care management study, level IV.

A high-volume trauma intensive care unit can be successfully staffed by advanced practitioners at night.

PURPOSE: It remains unknown whether critically ill trauma patients can be successfully managed by advanced practitioners (APs). The purpose of this study was to examine the impact of night coverage by APs in a high-volume trauma intensive care unit (ICU) on patient outcomes and care processes. MATERIALS AND METHODS: During the study period, our ICU was staffed by APs during the night shift (7 pm-7 am) from Sunday to Wednesday and by resident physicians (RPs) from Thursday to Saturday. On-call trauma fellows and attending surgeons in house supervised both APs and RPs. Patient outcomes and care processes by APs was compared with those admitted by RPs. RESULTS: A total of 289 patients were identified between July 2013 and February 2014. Median lactate clearance rate within 24 hours of admission was similar between study groups (10.0% vs 9.1%; P = .39). Advanced practitioners and RPs transfused patients requiring massive transfusion with a similar blood product ratio (packed red blood cell:fresh frozen plasma) (2.1:1 vs 1.7:1; P = .32). In a multiple logistic regression analysis, AP coverage was not associated with any clinical outcome differences. CONCLUSIONS: Our data suggest that, with adequate supervision, a high-volume trauma ICU can be safely staffed by APs overnight.

Current management of hemorrhage from severe pelvic fractures: Results of an American Association for the Surgery of Trauma multi-institutional trial.

BACKGROUND: There is no consensus as to the optimal treatment paradigm for patients presenting with hemorrhage from severe pelvic fracture. This study was established to determine the methods of hemorrhage control currently being used in clinical practice. METHODS: This prospective, observational multi-center study enrolled patients with pelvic fracture from blunt trauma. Demographic data, admission vital signs, presence of shock on admission (systolic blood pressure < 90 mm Hg or heart rate > 120 beats per minute or base deficit < -5), method of hemorrhage control, transfusion requirements, and outcome were collected. RESULTS: A total of 1,339 patients with pelvic fracture were enrolled from 11 Level I trauma centers. Fifty-seven percent of the patients were male, with a mean ± SD age of 47.1 ± 21.6 years, and Injury Severity Score (ISS) of 19.2 ± 12.7. In-hospital mortality was 9.0 %. Angioembolization and external fixator placement were the most common method of hemorrhage control used. A total of 128 patients (9.6%) underwent diagnostic angiography with contrast extravasation noted in 63 patients. Therapeutic angioembolization was performed on 79 patients (5.9%). There were 178 patients (13.3%) with pelvic fracture admitted in shock with a mean ± SD ISS of 28.2 ± 14.1. In the shock group, 44 patients (24.7%) underwent angiography to diagnose a pelvic source of bleeding with contrast extravasation found in 27 patients. Thirty patients (16.9%) were treated with therapeutic angioembolization. Resuscitative endovascular balloon occlusion of the aorta was performed on five patients in shock and used by only one of the participating centers. Mortality was 32.0% for patients with pelvic fracture admitted in shock. CONCLUSION: Patients with pelvic fracture admitted in shock have high mortality. Several methods were used for hemorrhage control with significant variation across institutions. The use of resuscitative endovascular balloon occlusion of the aorta may prove to be an important adjunct in the treatment of patients with severe pelvic fracture in shock; however, it is in the early stages of evaluation and not currently used widely across trauma centers. LEVEL OF EVIDENCE: Prognostic study, level II; therapeutic study, level III.

Cadaveric comparison of the optimal site for needle decompression of tension pneumothorax by prehospital care providers.

BACKGROUND: Computed tomographic and cadaveric studies have demonstrated needle decompression of tension pneumothorax at the fifth intercostal space (ICS), anterior axillary line (AAL) has advantages over the second ICS midclavicular line (MCL). The purpose of this study was to compare the ability of prehospital care providers to accurately decompress the chest at these two locations. METHODS: Randomly selected US Navy hospital corpsmen (n = 25) underwent a standardized training session followed by timed needle decompression on unmarked fresh cadavers. A 14-gauge angiocatheter was inserted in the right and left second ICS MCL and fifth ICS AAL in a predetermined computer-generated order. Time from needle uncapping to insertion, accuracy, and ease of placement were examined. RESULTS: A total of 25 corpsmen inserted 100 needles into 25 cadavers. Mean (SD) age was 25.9 (3.7) years, 72.0% were male, with 4.2 (3.2) years of experience, and 52.0% had previously deployed. A total of 60.0% had attempted decompression previously, 93.3% in a model and 6.7% in a patient. Time to decompression did not differ between the second and fifth ICS (16.8 [10.1] seconds vs. 16.9 [12.3] seconds, p = 0.438). Accuracy however was superior at the fifth ICS, with a misplacement rate of only 22.0% versus 82.0% at the second ICS (p < 0.001). The aggregate distance from the target position was also significantly greater for the second ICS (3.1 [1.7] cm vs. 1.2 [1.5] cm, p < 0.001). Insertion at the fifth ICS was rated as being easier than the second by 76.0% of providers, the same by 12.0%, and more difficult by 12.0%. CONCLUSION: For prehospital care providers, the fifth ICS AAL can be localized and decompressed with a higher degree of accuracy than the traditional second ICS MCL. It is rated as easier to perform and can be done just as quickly. Based on these data, the fifth ICS AAL should be considered as an equivalent first-line position for needle decompression in patients with clinical evidence of a tension pneumothorax.

Emergent operation for isolated severe traumatic brain injury: Does time matter?

BACKGROUND: It remains unclear whether the timing of neurosurgical intervention impacts the outcome of patients with isolated severe traumatic brain injury (TBI). We hypothesized that a shorter time between emergency department (ED) admission to neurosurgical intervention would be associated with a significantly higher rate of patient survival. METHODS: Our institutional trauma registry was queried for patients (2003-2013) who required an emergent neurosurgical intervention (craniotomy, craniectomy) for TBI within 300 minutes after the ED admission. We included patients with altered mental status upon presentation in the ED (Glasgow Coma Scale [GCS] score < 9). Patients with associated severe injuries (Abbreviated Injury Scale [AIS] score ≥ 2) in other body regions were excluded. In-hospital mortality of patients who underwent surgery in less than 200 minutes (early group) was compared with those who underwent surgery in 200 minutes or longer (late group) using univariate and multivariate analyses. RESULTS: A total of 161 patients were identified during the study time frame. Head computed tomographic scan demonstrated subdural hematoma in 85.8%, subarachnoid hemorrhage in 55.5%, and equal numbers of epidural hematoma and intraparenchymal hemorrhage in 22.6%. Median time between ED admission and neurosurgical intervention was 133 minutes. In univariate analysis, a significantly lower in-hospital mortality rate was identified in the early group (34.5% vs. 59.1%, p = 0.03). After adjusting for clinically important covariates in a logistic regression model, early neurosurgical intervention was significantly associated with a higher odds of patient survival (odds ratio, 7.41; 95% confidence interval, 1.66-32.98; p = 0.009). CONCLUSION: Our data suggest that the survival rate of isolated severe TBI patients who required an emergent neurosurgical intervention could be time dependent. These patients might benefit from expedited process (computed tomographic scan, neurosurgical consultation, etc.) to shorten the time to surgical intervention. LEVEL OF EVIDENCE: Prognostic study, level IV.

Prospective evaluation of treatment of open fractures: effect of time to irrigation and debridement.

IMPORTANCE: The standard practice of irrigation and debridement (I&D) of open fractures within 6 hours of injury remains controversial. OBJECTIVE: To prospectively evaluate the effect of the time from injury to the initial I&D on infectious complications. DESIGN, SETTING, AND PARTICIPANTS: A total of 315 patients who were admitted to a level 1 trauma center with open extremity fractures from September 22, 2008, through June 21, 2011, were enrolled in a prospective observational study and followed up for 1 year after discharge (mean [SD] age, 33.9 [16.3] years; 79% were male; and 78.4% were due to blunt trauma). Demographics, mechanism of injury, time to I&D, operative intervention, and incidence of local infectious complications were documented. Patients were stratified into 4 groups based on the time of I&D (<6 hours, 7-12 hours, 13-18 hours, and 19-24 hours after injury). Univariate and multivariable analysis were used to determine the effect of time to I&D on outcomes. MAIN OUTCOMES AND MEASURES: Development of local infectious complications at early (<30 days) or late (>30 days and <1 year) intervals from admission. RESULTS: The most frequently injured site was the lower extremity (70.2%), and 47.9% of all injuries were Gustilo classification type III. There was no difference in fracture location, degree of contamination, or antibiotic use between groups. All patients underwent I&D within 24 hours. Overall, 14 patients (4.4%) developed early wound infections, while 10 (3.2%) developed late wound infections (after 30 days). The infection rate was not statistically different on univariate (<6 hours, 4.7%; 7-12 hours, 7.5%; 13-18 hours, 3.1%; and 19-24 hours, 3.6%; P = .65) or multivariable analysis (<6-hour group [reference], P = .65; 7- to 12-hour group adjusted odds ratio [AOR] [95% CI], 2.1 [0.4-10.2], P = .37; 13- to 18-hour group AOR [95% CI], 0.8 [0.1-4.5], P = .81; 19- to 24-hour group AOR [95% CI], 1.1 [0.2-6.2], P = .90). Time to I&D did not affect the rate of nonunion, hardware failure, length of stay, or mortality. CONCLUSIONS AND RELEVANCE: In this prospective analysis, time to I&D did not affect the development of local infectious complications provided it was performed within 24 hours of arrival.

Prospective derivation of a clinical decision rule for thoracolumbar spine evaluation after blunt trauma: An American Association for the Surgery of Trauma Multi-Institutional Trials Group Study.

BACKGROUND: Unlike the cervical spine (C-spine), where National Emergency X-Radiography Utilization Study (NEXUS) and the Canadian C-spine Rules can be used, evidence-based thoracolumbar spine (TL-spine) clearance guidelines do not exist. The aim of this study was to develop a clinical decision rule for evaluating the TL-spine after injury. METHODS: Adult (≥15 years) blunt trauma patients were prospectively enrolled at 13 US trauma centers (January 2012 to January 2014). Exclusion criteria included the following: C-spine injury with neurologic deficit, preexisting paraplegia/tetraplegia, and unevaluable examination. Remaining evaluable patients underwent TL-spine imaging and were followed up to discharge. The primary end point was a clinically significant TL-spine injury requiring TL-spine orthoses or surgical stabilization. Regression techniques were used to develop a clinical decision rule. Decision rule performance in identifying clinically significant fractures was tested. RESULTS: Of 12,479 patients screened, 3,065 (24.6%) met inclusion criteria (mean [SD] age, 43.5 [19.8] years [range, 15-103 years]; male sex, 66.3%; mean [SD] Injury Severity Score [ISS], 8.8 [7.5]). The majority underwent computed tomography (93.3%), 6.3% only plain films, and 0.2% magnetic resonance imaging exclusively. TL-spine injury was identified in 499 patients (16.3%), of which 264 (8.6%) were clinically significant (29.2% surgery, 70.8% TL-spine orthosis). The majority was AO Type A1 282 (56.5%), followed by 67 (13.4%) A3, 43 (8.6%) B2, and 32 (6.4%) A4 injuries. The predictive ability of clinical examination (pain, midline tenderness, deformity, neurologic deficit), age, and mechanism was examined; positive clinical examination finding resulted in a sensitivity of 78.4% and a specificity of 72.9%. Addition of age of 60 years or older and high-risk mechanism (fall, crush, motor vehicle crash with ejection/rollover, unenclosed vehicle crash, auto vs. pedestrian) increased sensitivity to 98.9% with specificity of 29.0% for clinically significant injuries and 100.0% sensitivity and 27.3% specificity for injuries requiring surgery. CONCLUSION: Clinical examination alone is insufficient for determining the need for imaging in evaluable patients at risk of TL-spine injury. Addition of age and high-risk mechanism results in a clinical decision-making rule with a sensitivity of 98.9% for clinically significant injuries. LEVEL OF EVIDENCE: Diagnostic test, level III.