Trauma and Death in the Emergency Department: A Time to PAUSE (Promoting Acknowledgment, Unity, and Sympathy at the End of Life).

BACKGROUND: Witnessing death can be difficult and emotionally draining for health care workers and presents a risk factor for burnout. The practice of a ritual pause at patient death to recognize the patient as a person, reflect, and acknowledge the health care team is an emerging intervention that has not been well studied in trauma. OBJECTIVE: This study aims to explore the effect of a team pause on trauma team member attitudes after emergency department patient death. METHODS: This is a pre- and postintervention study of the implementation of a Trauma PAUSE (Promoting Acknowledgment, Unity, and Sympathy at the End of Life) conducted from March 2018 to June 2020. RESULTS: A total of 466 participated in this study. Emergency department employee responses to the pre- (296 of 745 employees contacted responded) and postimplementation surveys (170 of 732 employees contacted responded) were compared. Although not statistically significant, responses to the postsurvey suggested an increased connection to patients and belief in the need for a moment of silence following a death. Employees who had participated in a PAUSE (57/170) reported improvements in internal conflict, feeling of emptiness, resilience, and ability to move on to the next task. Overall, 84.2% (48/57) of Trauma PAUSE participants were satisfied with the Trauma PAUSE. CONCLUSION: The Trauma PAUSE is a meaningful way to help trauma staff members find peace, maintain resiliency, and readily shift their focus to providing care to other patients.

Patient characteristics and diagnostic tests associated with syncopal falls: A Southwestern surgical congress multicenter study.

BACKGROUND: Patients suspected of syncope frequently undergo laboratory and imaging studies to determine the etiology of the syncope. Variability exists in these workups across institutions. The purpose of this study was to evaluate the utilization and diagnostic yield of these workups and the patient characteristics associated with syncopal falls. METHODS: A multi-institutional retrospective review was performed on adult patients admitted after a fall between 1/2017-12/2018. Syncopal falls were compared to non-syncopal falls. RESULTS: 4478 patients were included. There were 795 (18%) patients with a syncopal fall. Electrocardiogram, troponin, echocardiogram, CT angiography (CTA), and carotid ultrasound were more frequently tested in syncope patients compared to non-syncope patients. Syncope patients had higher rates of positive telemetry/Holter monitoring, CTAs, and electroencephalograms. CONCLUSION: Patients who sustain syncopal falls frequently undergo diagnostic testing without a higher yield to determine the etiology of syncope.

Epidemiology, Management, and Outcomes of Accidental Hypothermia: A Multicenter Study of Regional Care.

BACKGROUND: Hypothermia is an uncommon, potentially life-threatening condition. We hypothesized (1) advanced rewarming techniques were more frequent with increased hypothermia severity, (2) active rewarming is increasingly performed with smaller intravascular catheters and decreased cardiopulmonary bypass, and (3) mortality was associated with age, hypothermia severity, and type. METHODS: Trauma patients with temperatures <35°C at 4 ACS-verified trauma centers in Wisconsin and Minnesota from 2006 to 2016 were reviewed. Statistical analysis included chi-square and Fisher's exact tests. A P value < .05 was considered significant. RESULTS: 337 patients met inclusion criteria; primary hypothermia was identified in 127 (38%), secondary in 113 (34%), and mixed primary/secondary in 96 (28%) patients. Hypothermia was mild in 69%, moderate in 26%, and severe in 5% of patients. Intravascular rewarming catheter was the most frequent advanced modality (2%), used increasingly since 2014. Advanced techniques were used for primary (12%) vs. secondary (0%) and mixed (5%) (P = .0002); overall use increased with hypothermia severity but varied by institution. Dysrhythmia, acute kidney injury, and frostbite risk worsened with hypothermia severity (P < .0001, P = .031, and P < .0001, respectively). Mortality was greatest in patients with mixed hypothermia (39%, P = .0002) and age >65 years (33%, P = .03). Thirty-day mortality rates were similar among severe, moderate, and mild hypothermia (P = .44). CONCLUSION: Advanced rewarming techniques were used more frequently in severe and primary hypothermia but varied among institutions. Advanced rewarming was less common in mixed hypothermia; mortality was highest in this subgroup. Reliance on smaller intravascular catheters for advanced rewarming increased over time. Given inconsistencies in management, implementation of guidelines for hypothermia management appears necessary.

The role of palliative care in acute trauma: When is it appropriate?

INTRODUCTION: We hypothesized that trauma providers are reticent to consider palliative measures in acute trauma care. METHODS: An electronic survey based on four patient scenarios with identical vital signs and serious blunt injuries, but differing ages and frailty scores was sent to WTA and EAST members. RESULTS: 509 (24%) providers completed the survey. Providers supported early transition to comfort care in 85% old-frail, 53% old-fit, 77% young-frail, and 30% young-fit patients. Providers were more likely to transition frail vs. fit patients with (OR = 4.8 [3.8-6.3], p < 0.001) or without (OR = 16.7 [12.5-25.0], p < 0.001) an advanced directive (AD) and more likely to transition old vs. young patients with (OR = 2.0 [1.6-2.6], p < 0.001) or without (OR = 4.2 [2.8-5.0], p < 0.001) an AD. CONCLUSIONS: In specific clinical situations, there was wide acceptance among trauma providers for the early institution of palliative measures. Provider decision-making was primarily based on patient frailty and age. ADs were helpful for fit or young patients. Provider demographics did not impact decision-making.

Impact of Advance Directives on Outcomes and Charges in Elderly Trauma Patients.

Background: As the number of geriatric trauma patients rises, end-of-life planning is of increased importance. A community-wide initiative to increase advance care planning was undertaken in the 1990s, resulting in a high rate (85%) of completed advance directives (ADs). Objectives: To assess the impact of ADs on quality measures of care and outcomes for elderly trauma patients. To determine if the historically high rate of completed ADs in the community applied to the trauma patient population. Design: A single trauma center's registry was retrospectively reviewed. Patients with versus without an AD were compared. A case-control analysis was completed. Statistical analysis included chi-square test, Wilcoxon rank sum, and multivariate linear regression modeling. Setting: American College of Surgeons-verified level II trauma center with a 325-bed teaching hospital. Subjects: Patients ≥55 years admitted as level I or II activations from January 2007 through April 2017. Measurements: Hospital and intensive care unit (ICU) length of stay (LOS), ventilator days, and 30-day mortality. Results: Nine hundred thirty-six patients were identified; 173 (18%) had an AD and 763 (82%) did not. ADs were more common among older, female patients. The majority of patients with ADs lived within the medical center's service area (99% vs. 1%) and had a primary care provider within the health care system (72% vs. 28%). Although 30-day mortality was higher in patients with ADs versus without (21% vs. 15%; p = 0.03), this difference was not significant on case-control analysis (20% vs. 15%, p = 0.31). No difference was identified in LOS, ICU days, ventilator days, or charges. Conclusions: Presence of an AD was not associated with any difference in 30-day mortality, LOS, or hospital charges. More widespread efforts at AD education and documentation are necessary, particularly in the setting of trauma.

Delayed splenic hemorrhage: Myth or mystery? A Western Trauma Association multicenter study.

BACKGROUND: Multi-detector computed tomography imaging is now the reference standard for identifying solid organ injuries, with a high sensitivity and specificity. However, delayed splenic hemorrhage (DSH), defined as no identified injury to the spleen on the index scan but delayed bleeding from a splenic injury, has been reported. We hypothesized that the occurrence of DSH would be minimized by utilization of modern imaging techniques. METHODS: Data was retrospectively collected from 2006 to 2016 in 12 adult Level I and II trauma centers. All patients had an initial CT scan demonstrating no splenic injury but subsequently were diagnosed with splenic bleeding. Demographic, injury characteristics, imaging parameters and results, interventions and outcomes were collected. RESULTS: Of 6867 patients with splenic injuries, 32 cases (0.4%) of blunt splenic hemorrage were identified. Patients were primarily male, had blunt trauma, severely injured (ISS 32 (9-57) and with associated injuries. Injuries of all grades were identified up to 16 days following admission. Overall, half of patients required splenectomy. All index images were obtained using multi-detector CT (16-320 slice). Secondary review of imaging by two trauma radiologists judged 72% (n = 23) of scans as suboptimal. This was due to poor scan quality primary from artifact(23), single phase contrast imaging (16), and/or poor contrast bolus timing or volume (6). Notably, only 28% of scans in patients with DSH were performed with optimal scanning techniques. CONCLUSION: This is the largest reported series of DSH in the era of modern imaging. Although the incidence of DSH is low, it still occurs despite the use of multi-detector imaging and when present, is associated with a high rate of splenectomy. Most cases of DSH can be attributed to missed diagnosis from suboptimal index imaging and ultimately be avoided.

An Unusual Subcutaneous Mass in an Otherwise Healthy Patient: A Case Report of Localized Histoplasmosis Diagnosed on Excisional Biopsy.

Patients are commonly referred to general surgery clinics for evaluation of soft-tissue masses of the trunk and extremities. The primary goal of surgical referral is to confirm the presence of a mass, to assess the need for additional imaging and/or testing, and to gauge amenability to surgical biopsy, whether incisional or excisional. This is a case of a 67-year-old woman who was referred to surgery clinic for a small soft-tissue mass near her left elbow that had increased in size and pain over the past year. The mass had been present for several years. After MRI imaging revealed a nonspecific process, an excisional biopsy was performed. Following a careful review of the patient's history, risk factors, and histological results, a diagnosis of localized subcutaneous Histoplasma capsulatum var. capsulatum infection was made. Without signs or symptoms of active, systemic disease, no further treatment was recommended. The patient was provided risk factor counseling for symptoms or signs of active histoplasmosis and outpatient follow-up. Histologically, most masses will return as benign and mesenchymal in origin. However, soft-tissue masses may arise from uncommon etiologies and a broad differential is needed to ensure appropriate management and recommendations.

Contemporary management of subclavian and axillary artery injuries-A Western Trauma Association multicenter review.

BACKGROUND: Subclavian and axillary artery injuries are uncommon. In addition to many open vascular repairs, endovascular techniques are used for definitive repair or vascular control of these anatomically challenging injuries. The aim of this study was to determine the relative roles of endovascular and open techniques in the management of subclavian and axillary artery injuries comparing hospital outcomes, and long-term limb viability. METHODS: A multicenter, retrospective review of patients with subclavian or axillary artery injuries from January 1, 2004, to December 31, 2014, was completed at 11 participating Western Trauma Association institutions. Statistical analysis included χ, t-tests, and Cochran-Armitage trend tests. A p value less than 0.05 was significant. RESULTS: Two hundred twenty-three patients were included; mean age was 36 years, 84% were men. An increase in computed tomography angiography and decrease in conventional angiography was observed over time (p = 0.018). There were 120 subclavian and 119 axillary artery injuries. Procedure type was associated with injury grade (p < 0.001). Open operations were performed in 135 (61%) patients, including 93% of greater than 50% circumference lacerations and 83% of vessel transections. Endovascular repairs were performed in 38 (17%) patients; most frequently for pseudoaneurysms. Fourteen (6%) patients underwent a hybrid procedure. Use of endovascular versus open procedures did not increase over the duration of the study (p = 0.248). In-hospital mortality rate was 10%. Graft or stent thrombosis occurred in 7% and graft or stent infection occurred in 3% of patients. Mean follow-up was 1.6 ± 2.4 years (n = 150). Limb salvage was achieved in 216 (97%) patients. CONCLUSION: The management of subclavian and axillary artery injuries still requires a wide variety of open exposures and procedures, especially for the control of active hemorrhage from more than 50% vessel lacerations and transections. Endovascular repairs were used most often for pseudoaneurysms. Low early complication rates and limb salvage rates of 97% were observed after open and endovascular repairs. LEVEL OF EVIDENCE: Prognostic/epidemiologic, level IV.

Stress cardiomyopathy with an "inverse" takotsubo pattern in a patient with acute aneurysmal subarachnoid hemorrhage.

BACKGROUND: Subarachnoid hemorrhage (SAH) induced myocardial dysfunction (often labeled neurogenic stunned myocardium) encompasses a spectrum of clinical presentations ranging from an isolated elevation of cardiac enzymes to cardiogenic shock. OBJECTIVE: We describe a case of stress cardiomyopathy in a patient following acute aneurysmal subarachnoid hemorrhage that showed an "inverse" or reverse takotsubo pattern on echocardiography. CASE REPORT: The patient was a 46-year-old female who presented with acute cardiogenic shock following acute subarachnoid hemorrhage necessitating aggressive cardiorespiratory in the ICU. Her admission echo showed a depressed left ventricular ejection fraction of 25%. The basal 2/3 of the left ventricle (LV) was severely hypokinetic and the apical 1/3 of the LV was hypercontractile, i.e. the reverse or inverse takotsubo pattern of regional wall motion abnormality. With ongoing aggressive support her cardiovascular function steadily improved and on day 6 her follow up echo showed LV ejection fraction increased to 60-65% with resolution of the previous regional wall motion abnormality. The patient was discharged to a neuro-rehabilitation facility on day 16. SUMMARY: The "inverse" or "reverse" takotsubo pattern of regional wall motion abnormalities, i.e. with preserved apical LV contractility and hypokinesis of the basal walls of the LV is more common in patients following acute SAH.

Intraoperative cystoscopic stent placement in robot-assisted pyeloplasty: a novel and efficient technique.

INTRODUCTION: Robot-assisted pyeloplasty (RAP) is a minimally invasive approach for repair of ureteropelvic junction obstruction. Ureteral stent placement is a necessary step that may necessitate additional procedures and/or radiation exposure for placement and confirmation of stent location. These may prolong operative times and increase morbidity. PATIENTS AND METHODS: Unique patient positioning and draping allow access to the urethra for intraoperative cystoscopy. As the surgeon performs the posterior portion of the Anastomosis, the assistant performs simultaneous flexible cystoscopy and retrograde stent placement. Stent location is confirmed by direct vision. RESULTS: This technique has been performed in 30 consecutive patients without difficulty or complication. CONCLUSION: This novel technique is a simple and efficient method of stent placement during RAP. It is performed simultaneously without the need for additional procedures, repositioning, or radiation exposure. Application of this technique may result in decreased operative time.