Prevalence and Outcomes of High versus Low Ratio Plasma to Red Blood Cell Resuscitation in a Multi-Institutional Cohort of Severely Injured Children.

BACKGROUND: The benefit of targeting high ratio fresh frozen plasma (FFP):red blood cell (RBC) transfusion in pediatric trauma resuscitation is unclear as existing studies are limited to patients who retrospectively met criteria for massive transfusion. The purpose of this study is to evaluate the use of high ratio FFP:RBC transfusion and the association with outcomes in children presenting in shock. METHODS: A post-hoc analysis of a 24-institution prospective observational study (4/2018-9/2019) of injured children <18 years with elevated age-adjusted shock index was performed. Patients transfused within 24 hours were stratified into cohorts of low (<1:2) or high (>1:2) ratio FFP:RBC. Nonparametric Kruskal-Wallis and chi-square were used to compare characteristics and mortality. Competing risks analysis was used to compare extended (≥75th percentile) ventilator, intensive care, and hospital days while accounting for early deaths. RESULTS: Of 135 children with median (IQR) age 10 (5,14) years and weight 40 (20,64) kg, 85 (63%) received low ratio transfusion and 50 (37%) high ratio despite similar activation of institutional massive transfusion protocols (MTP; low-38%, high-46%, p = .34). Most patients sustained blunt injuries (70%). Median injury severity score was greater in high ratio patients (low-25, high-33, p = .01); however, hospital mortality was similar (low-24%, high-20%, p = .65) as was the risk of extended ventilator, ICU, and hospital days (all p > .05). CONCLUSION: Despite increased injury severity, patients who received a high ratio of FFP:RBC had comparable rates of mortality. These data suggest high ratio FFP:RBC resuscitation is not associated with worst outcomes in children who present in shock. MTP activation was not associated with receipt of high ratio transfusion, suggesting variability in MTP between centers. LEVEL OF EVIDENCE: Prospective cohort study, Level II.

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.

Development and Validation of a Novel Hollow Viscus Injury Prediction Score for Abdominal Seatbelt Sign: A Pacific Coast Surgical Association Multicenter Study.

BACKGROUND: High-quality CT can exclude hollow viscus injury (HVI) in patients with abdominal seatbelt sign (SBS) but performs poorly at identifying HVI. Delay in diagnosis of HVI has significant consequences necessitating timely identification. STUDY DESIGN: This multicenter, prospective observational study conducted at 9 trauma centers between August 2020 and October 2021 included adult trauma patients with abdominal SBS who underwent abdominal CT before surgery. HVI was determined intraoperatively and physiologic, examination, laboratory, and imaging findings were collected. Least absolute shrinkage and selection operator- and probit regression-selected predictor variables and coefficients were used to assign integer points for the HVI score. Validation was performed by comparing the area under receiver operating curves (AUROC). RESULTS: Analysis included 473 in the development set and 203 in the validation set. The HVI score includes initial systolic blood pressure <110 mmHg, abdominal tenderness, guarding, and select abdominal CT findings. The derivation set has an AUROC of 0.96, and the validation set has an AUROC of 0.91. The HVI score ranges from 0 to 17 with score 0 to 5 having an HVI risk of 0.03% to 5.36%, 6 to 9 having a risk of 10.65% to 44.1%, and 10 to 17 having a risk of 58.59% to 99.72%. CONCLUSIONS: This multicenter study developed and validated a novel HVI score incorporating readily available physiologic, examination, and CT findings to risk stratify patients with an abdominal SBS. The HVI score can be used to guide decisions regarding management of a patient with an abdominal SBS and suspected HVI.

Prehospital ETCO2 is predictive of death in intubated and non-intubated patients.

BACKGROUND: Prehospital identification of shock in trauma patients lacks accurate markers. Low end tidal carbon dioxide (ETCO2) correlates with mortality in intubated patients. The predictive value of ETCO2 obtained by nasal capnography cannula (NCC) is unknown. We hypothesized that prehospital ETCO2 values obtained by NCC and in-line ventilator circuit (ILVC) would be predictive of mortality. METHODS: This was a prospective, observational, multicenter study. ETCO2 values were collected by a NCC or through ILVC. AUROCs were compared with prehospital systolic blood pressure (SBP) and shock index (SI). The Youden index defined optimal cutoffs. RESULTS: Of 550 enrolled patients, 487 (88.5%) had ETCO2 measured through an NCC. Median age was 37 (27-52) years; 76.5% were male; median ISS was 13 (5-22). Mortality was 10.4%. Minimum prehospital ETCO2 significantly predicted mortality with an AUROC of 0.76 (CI 0.69-0.84; Youden index â€‹= â€‹22 â€‹mmHg), outperforming SBP with an AUROC of 0.68; (CI 0.62-0.74, p â€‹= â€‹0.04) and shock index with an AUROC of 0.67 (CI 0.59-0.74, p â€‹= â€‹0.03). CONCLUSION: Prehospital ETCO2 measured by non-invasive NCC or ILVC may be predictive of mortality in injured patients.

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.

Early Surgical Stabilization of Rib Fractures is Feasible in Patients With Non-Urgent Operative Pelvic Injuries.

INTRODUCTION: The feasibility of prioritizing surgical stabilization of rib fractures (SSRF) in patients with other injuries is unknown. The purpose of this study was to evaluate the timing and outcomes of SSRF between patients with and without non-urgent operative pelvic injuries. PATIENTS AND METHODS: In this retrospective observational study, all patients between 2010 and 2020 who underwent SSRF (SSRF group) and those who underwent SSRF and non-urgent operative management of pelvic fractures (SSRF + P group) were included. Demographics, injury characteristics, operative details, and outcomes were compared between the 2 groups. RESULTS: Over 11 years, 154 SSRF patients were identified, with 143 patients in the SSRF group (93%) and 11 patients in the SSRF + P group (7%). Median number of rib fractures (7 vs 9, P = .04), total number of fractures (11 vs 15, P < .01), and flail segment (54% vs 91%, P = .02) were higher in SSRF + P group. Median time to SSRF was similar (0 vs 1 day, P = .20) between the 2 groups. Median time to pelvic fixation was 3 days in SSRF + P group and 8 out of 11 patients (73%) underwent SSRF prior to pelvic fixation. Median operative time (137 vs 178 mins, P = .14) and median number of ribs plated (4 vs 5, P = .05) were higher in SSRF + P group. There was no difference in SSRF-related complications, pelvic fracture-related complications from operative positioning, rates of pneumonia, or mortality between the 2 groups. CONCLUSIONS: SSRF can be performed early in patients with non-urgent operative pelvic injuries without a difference in pelvic fracture-related complications, SSRF-related complications, pneumonia, or mortality.

Prehospital and emergency department pediatric readiness for injured children: A statement from the American College of Surgeons Committee on Trauma Emergency Medical Services Committee.

ABSTRACT: Injury is the leading cause of death in children older than 1 year, and children make up 22% of the population. Pediatric readiness (PR) of the nation's emergency departments and state trauma and emergency medical services (EMS) systems is conceptually important and vital to mitigate mortality and morbidity in this population. The extension of PR to the trauma community has become a focused area for training, staffing, education, and equipment at all levels of trauma center designation, and there is evidence that a higher level of emergency department PR is independently associated with long-term survival among injured children. Although less well studied, there is an associated need for EMS PR, which is relevant to the injured child who needs assessment, treatment, triage, and transport to a trauma center. We outline a blueprint along with recommendations for incorporating PR into trauma system development in this opinion from the EMS Committee of the American College of Surgeons Committee on Trauma. These recommendations are particularly pertinent in the rural and underserved areas of the United States but are directed toward all levels of professionals who care for an injured child along the trauma continuum of care.

Crystalloid volume is associated with short-term morbidity in children with severe traumatic brain injury: An Eastern Association for the Surgery of Trauma multicenter trial post hoc analysis.

OBJECTIVE: This study examined differences in clinical and resuscitation characteristics between injured children with and without severe traumatic brain injury (sTBI) and aimed to identify resuscitation characteristics associated with improved outcomes following sTBI. METHODS: This is a post hoc analysis of a prospective observational study of injured children younger than 18 years (2018-2019) transported from the scene, with elevated shock index pediatric-adjusted on arrival and head Abbreviated Injury Scale score of ≥3. Timing and volume of resuscitation products were assessed using χ 2t test, Fisher's exact t test, Kruskal-Wallis, and multivariable logistic regression analyses. RESULTS: There were 142 patients with sTBI and 547 with non-sTBI injuries. Severe traumatic brain injury patients had lower initial hemoglobin (11.3 vs. 12.4, p < 0.001), greater initial international normalized ratio (1.4 vs. 1.1, p < 0.001), greater Injury Severity Score (25 vs. 5, p < 0.001), greater rates of ventilator (59% vs. 11%, p < 0.001) and intensive care unit (ICU) requirement (79% vs. 27%, p < 0.001), and more inpatient complications (18% vs. 3.3%, p < 0.001). Severe traumatic brain injury patients received more prehospital crystalloid (25% vs. 15%, p = 0.008), ≥1 crystalloid boluses (52% vs. 24%, p < 0.001), and blood transfusion (44% vs. 12%, p < 0.001) than non-sTBI patients. Among sTBI patients, receipt of ≥1 crystalloid bolus (n = 75) was associated with greater ICU need (92% vs. 64%, p < 0.001), longer median ICU (6 vs. 4 days, p = 0.027) and hospital stay (9 vs. 4 days, p < 0.001), and more in-hospital complications (31% vs. 7.5%, p = 0.003) than those who received <1 bolus (n = 67). These findings persisted after adjustment for Injury Severity Score (odds ratio, 3.4-4.4; all p < 0.010). CONCLUSION: Pediatric trauma patients with sTBI received more crystalloid than those without sTBI despite having a greater international normalized ratio at presentation and more frequently requiring blood products. Excessive crystalloid may be associated with worsened outcomes, including in-hospital mortality, seen among pediatric sTBI patients who received ≥1 crystalloid bolus. Further attention to a crystalloid sparing, early transfusion approach to resuscitation of children with sTBI is needed. LEVEL OF EVIDENCE: Therapeutic/Care Management; Level IV.

A proposed clinical coagulation score for research in trauma-induced coagulopathy.

BACKGROUND: Trauma-induced coagulopathy (TIC) has been the subject of intense study for greater than a century, and it is associated with high morbidity and mortality. The Trans-Agency Consortium for Trauma-Induced Coagulopathy, funded by the National Health Heart, Lung and Blood Institute, was tasked with developing a clinical TIC score, distinguishing between injury-induced bleeding from persistent bleeding due to TIC. We hypothesized that the Trans-Agency Consortium for Trauma-Induced Coagulopathy clinical TIC score would correlate with laboratory measures of coagulation, transfusion requirements, and mortality. METHODS: Trauma activation patients requiring a surgical procedure for hemostasis were scored in the operating room (OR) and in the first ICU day by the attending trauma surgeon. Conventional and viscoelastic (thrombelastography) coagulation assays, transfusion requirements, and mortality were correlated to the coagulation scores using the Cochran-Armitage trend test or linear regression for numerical variables. RESULTS: Increased OR TIC scores were significantly associated with abnormal conventional and viscoelastic measurements, including hyperfibrinolysis incidence, as well as with higher mortality and more frequent requirement for massive transfusion ( p < 0.0001 for all trends). Patients with OR TIC score greater than 3 were more than 31 times more likely to have an ICU TIC score greater than 3 (relative risk, 31.6; 95% confidence interval, 12.7-78.3; p < 0.0001). CONCLUSION: A clinically defined TIC score obtained in the OR reflected the requirement for massive transfusion and mortality in severely injured trauma patients and also correlated with abnormal coagulation assays. The OR TIC score should be validated in multicenter studies. LEVEL OF EVIDENCE: Prognostic and Epidemiological; Level IV.

An Unencumbered Acute Care Surgeon Improves Delivery of Emergent Surgical Care for Cholecystectomy Patients.

Introduction: Many patients utilize the Emergency Room (ER) for primary care, resulting in overburdened ERs, strained resources, and delays in care. To combat this, many centers have adopted a Trauma/Acute Care Surgery (TACS) service providing specialty surgeons whose primary work is the unencumbered surgical availability to emergency surgery patients. To evaluate our programs' efficacy, we investigated cholecystectomies as a common urgent procedure representative of services provided. We hypothesized that the adoption of a TACS service would result in improved access to care as evidence by decreased ER visits prior to cholecystectomy, improved time to cholecystectomy, and decreased hospital length of stay (LOS). Methods: All patients that underwent urgent cholecystectomy from January 1, 2018 to December 31, 2018 were reviewed. The unencumbered TACS surgeon was implemented on July 1, 2018. Prior ER visits involving biliary symptoms, time from admission to cholecystectomy, and hospital LOS were compared. Results: Of the 322 urgent cholecystectomies over the study period, 165 were performed prior and 157 following adoption of the TACS structure. The average number of ER visits for biliary symptoms prior to cholecystectomy decreased from 1.4 to 1.2 (p = 0.01). Time from admission to cholecystectomy was 28.3 hours and 27.3 hours respectively (p = 0.74). Average LOS decreased following the restructure (3.1 vs 2.5 days; p = 0.03). Conclusion: Implementation of an unencumbered TACS surgeon managing urgent surgical disease improves access to and delivery of surgical services for cholecystectomy patients in a safety net, level one trauma center. Further research is necessary to determine potential improvements in hospital cost and patient satisfaction.

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.

Inflate and pack! Pelvic packing combined with REBOA deployment prevents hemorrhage related deaths in unstable pelvic fractures.

INTRODUCTION: Resuscitative endovascular balloon occlusion of the aorta (REBOA) is advocated for hemorrhage control in pelvic fracture patients in shock. We evaluated REBOA in patients undergoing preperitoneal pelvic packing (PPP) for pelvic fracture-related hemorrhage. METHODS: Retrospective, single-institution study of unstable pelvic fractures (hemodynamic instability despite 2 units of red blood cells (RBCs) and fracture identified on x-ray). Management included the placement of a Zone III REBOA in the emergency department (ED) for systolic blood pressure <80 mmHg. All PPP patients were included and analyzed for injury characteristics, transfusion requirements, outcomes and complications. Additionally, patients who received REBOA (REBOA+) were compared to those that did not (REBOA-). RESULTS: During the study period (January 2015 - January 2019), 652 pelvic fracture patients were admitted; 78 consecutive patients underwent PPP. Median RBCs at PPP completion compared to 24 h post-packing were 11 versus 3 units (p<0.05). Median time to operation was 45 min. After PPP, 7 (9%) patients underwent angioembolization. Mortality was 14%. No mortalities were due to ongoing pelvic fracture hemorrhage or physiologic exhaustion; all were a withdrawal of life sustaining support, most commonly due to neurologic insults (TBI/fat emboli = 6, stroke/spinal cord injury = 3). REBOA+ patients (n = 31) had a significantly higher injury severity score (45 vs 38, p<0.01) and higher heart rate (130 vs 118 beats per minute, p = 0.04) than REBOA-. The systolic blood pressure, base deficit, and number of RBCs transfused in the ED, and time spent in the ED were similar between groups. REBOA+ had a higher median transfusion of RBCs at PPP completion (11 units vs 5 units, p<0.01) but similar RBC transfusion in the 24 h after PPP (2 vs 1 units, p = 0.27). Mortality, pelvic infection, and ICU length of stay was not different between these cohorts. CONCLUSION: PPP with REBOA was utilized in more severely injured patients with greater physiologic derangements. Although REBOA patients required greater transfusion requirements, there were no deaths due to acute pelvic hemorrhage. This suggests the combination of REBOA with PPP provides life-saving hemorrhage control in otherwise devastating injuries.

Time to Look for Another Infectious Source? White Blood Cell Trends during Ventilator-Associated Pneumonia.

Background: Ventilator-associated pneumonia (VAP) continues to plague patients in intensive care units (ICUs) throughout the world. Persistent leukocytosis despite antibiotic treatment for VAP can have many etiologies including normal inflammatory response, inadequate VAP antimicrobial therapy, and the presence of additional infectious diagnoses. Hypothesis: Surgical patients with VAP and a second infectious source have a different white blood cell count (WBC) trend than patients with VAP alone. Patients and Methods: Retrospective, single-center study of surgical ICU patients diagnosed with VAP (>104 CFU/mL on semi-quantitative culture) between January 2019 and June 2020. Chart review identified additional infections diagnosed during VAP treatment. White blood cell count values were compared between patients treated for VAP alone (VAP-alone) and those with additional infections (VAP-plus) using a Wilcoxon test. Univariable analysis compared admission type, surgeries, and steroid use between cohorts. Results: Eighty-eight VAPs were included for analysis; 61 (69%) were VAP-alone and 27 (31%) VAP-plus. Average age was 47.1 ± 16.7 years, 78% were male, and 93% were trauma admissions. Median hospital day of VAP diagnosis was six (interquartile range [IQR], 4-10). Nearly all patients (99%) were started on initial antibiotic agents to which the VAP organism was sensitive. Daily WBC was higher for VAP-plus compared with VAP-alone on days five, six, and seven of treatment. The maximum WBC was higher for VAP-plus (21.6 k/mcL vs. 16.1 k/mcL; p = 0.02). There were no differences in admission types, number of surgeries, or steroid use between groups. Conclusions: Providers should have increased suspicion for additional sources of infection when ICU patients with a VAP continue to have elevated WBC despite appropriate antibiotic therapy.

Excluding Hollow Viscus Injury for Abdominal Seat Belt Sign Using Computed Tomography.

Importance: Abdominal seat belt sign (SBS) has historically entailed admission and observation because of the diagnostic limitations of computed tomography (CT) imaging and high rates of hollow viscus injury (HVI). Recent single-institution, observational studies have questioned the utility of this practice. Objective: To evaluate whether a negative CT scan can safely predict the absence of HVI in the setting of an abdominal SBS. Design, Setting, and Participants: This prospective, observational cohort study was conducted in 9 level I trauma centers between August 2020 and October 2021 and included adult trauma patients with abdominal SBS. Exposures: Inclusion in the study required abdominal CT as part of the initial trauma evaluation and before any surgical intervention, if performed. Results of CT scans were considered positive if they revealed any of the following: abdominal wall soft tissue contusion, free fluid, bowel wall thickening, mesenteric stranding, mesenteric hematoma, bowel dilation, pneumatosis, or pneumoperitoneum. Main Outcomes and Measures: Presence of HVI diagnosed at the time of operative intervention. Results: A total of 754 patients with abdominal SBS had an HVI prevalence of 9.2% (n = 69), with only 1 patient with HVI (0.1%) having a negative CT (ie, none of the 8 a priori CT findings). On bivariate analysis comparing patients with and without HVI, there were significant associations between each of the individual CT scan findings and the presence of HVI. The strongest association was found with the presence of free fluid, with a more than 40-fold increase in the likelihood of HVI (odds ratio [OR], 42.68; 95% CI, 20.48-88.94; P < .001). The presence of free fluid also served as the most effective binary classifier for presence of HVI (area under the receiver operator characteristic curve [AUC], 0.87; 95% CI, 0.83-0.91). There was also an association between a negative CT scan and the absence of HVI (OR, 41.09; 95% CI, 9.01-727.69; P < .001; AUC, 0.68; 95% CI, 0.66-0.70). Conclusions and Relevance: The prevalence of HVI among patients with an abdominal SBS and negative findings on CT is extremely low, if not zero. The practice of admitting and observing all patients with abdominal SBS should be reconsidered when a high-quality CT scan is negative, which may lead to significant resource and cost savings.

Assessment of Discharge Analgesic Prescription Patterns for Hospitalized Patients With Rib Fractures.

INTRODUCTION: There is a paucity of data describing opioid prescribing patterns for trauma patients. We investigated pain medication regimens prescribed at discharge for patients with traumatic rib fractures, as well as potential variables predictive of opioid prescribing. METHODS: A single-center, retrospective analysis was performed of 337 adult patients presenting with ≥1 traumatic rib fractures between January and December 2019. The primary outcome was oral morphine milligram equivalents (MME) prescribed on discharge. A multivariable logistic regression analysis was performed to determine factors independently associated with above median (150) MME prescription at discharge. RESULTS: The majority of patients were male (68.8%) with a median age of 53 y. Blunt trauma accounted for 97.3% of cases with a median Injury Severity Score(ISS) of 10. Locoregional pain procedures were utilized in 16.9% of patients. Opioids were the most common analgesic prescribed at discharge, and 74.1% of patients prescribed opioids on discharge were also prescribed a non-opioid adjunct. On multivariable analysis, daily MME prescribed during hospitalization (OR 1.01, 95% CI 1.01-1.02, P < 0.01) and number of rib fractures (OR 2.26, 95% CI 1.36-3.74, P < 0.01) were predictive of high MME prescribed on discharge. CONCLUSIONS: For patients with traumatic rib fractures, daily MME during hospitalization and number of rib fractures were predictive of high MME prescribing on discharge. Further prospective studies evaluating strategies for pain management and protocolized approaches to opioid prescribing are needed to reduce unnecessary and inappropriate opioid use in this patient population.

The national trauma triage protocol: how EMS perspective can inform the guideline revision.

OBJECTIVES: The Field Triage Guidelines (FTG) support emergency medical service (EMS) decisions regarding the most appropriate transport destination for injured patients. While the components of the algorithm are largely evidenced-based, the stepwise approach was developed with limited input from EMS providers. FTG are only useful if they can easily be applied by the field practitioner. We sought to gather end-user input on the current guidelines from a broad group of EMS stakeholders to inform the next revision of the FTG. METHODS: An expert panel composed an end-user feedback tool. Data collected included: demographics, EMS agency type, geographic area of respondents, use of the current FTG, perceived utility, and importance of each step in the algorithm (1: physiologic, 2: anatomic, 3 mechanistic, 4: special populations). The American College of Surgeons Committee on Trauma (ACS COT), in partnership with several key organizations, distributed the tool to reach as many providers as possible. RESULTS: 3958 responses were received (82% paramedics/emergency medical technicians, 9% physicians, 9% other). 94% responded directly to scene emergency calls and 4% were aeromedical providers. Steps 2 and 3 were used in 95% of local protocols, steps 1 and 4 in 90%. Step 3 was used equally in protocols across all demographics; however, step 1 was used significantly more in the air medical services than ground EMS (96% vs 88%, p<0.05). Geographic variation was demonstrated in FTG use based on the distance to a trauma center, but step 3 (not step 1) drove the majority of the decisions. This point was reinforced in the qualitative data with the comment, "I see the wreck before I see the patient." CONCLUSION: The FTG are widely used by EMS in the USA. The stepwise approach is useful; however, mechanism (not physiological criteria) drives most of the decisions and is evaluated first. Revision of the FTG should consider the experience of the end-users. LEVEL OF EVIDENCE: V.

Prehospital end-tidal carbon dioxide is predictive of death and massive transfusion in injured patients: An Eastern Association for Surgery of Trauma multicenter trial.

BACKGROUND: Prehospital identification of the injured patient likely to require emergent care remains a challenge. End-tidal carbon dioxide (ETCO2) has been used in the prehospital setting to monitor respiratory physiology and confirmation of endotracheal tube placement. Low levels of ETCO2 have been demonstrated to correlate with injury severity and mortality in a number of in-hospital studies. We hypothesized that prehospital ETCO2 values would be predictive of mortality and need for massive transfusion (MT) in intubated patients. METHODS: This was a retrospective multicenter trial with 24 participating centers. Prehospital, emergency department, and hospital values were collected. Receiver operating characteristic curves were created and compared. Massive transfusion defined as >10 U of blood in 6 hours or death in 6 hours with at least 1 U of blood transfused. RESULTS: A total of 1,324 patients were enrolled. ETCO2 (area under the receiver operating characteristic curve [AUROC], 0.67; confidence interval [CI], 0.63-0.71) was better in predicting mortality than shock index (SI) (AUROC, 0.55; CI, 0.50-0.60) and systolic blood pressure (SBP) (AUROC, 0.58; CI, 0.53-0.62) (p < 0.0005). Prehospital lowest ETCO2 (AUROC, 0.69; CI, 0.64-0.75), SBP (AUROC, 0.75; CI, 0.70-0.81), and SI (AUROC, 0.74; CI, 0.68-0.79) were all predictive of MT. Analysis of patients with normotension demonstrated lowest prehospital ETCO2 (AUROC, 0.66; CI, 0.61-0.71), which was more predictive of mortality than SBP (AUROC, 0.52; CI, 0.47-0.58) or SI (AUROC, 0.56; CI, 0.50-0.62) (p < 0.001). Lowest prehospital ETCO2 (AUROC, 0.75; CI, 0.65-0.84), SBP (AUROC, 0.63; CI, 0.54-0.74), and SI (AUROC, 0.64; CI, 0.54-0.75) were predictive of MT in normotensive patients. ETCO2 cutoff for MT was 26 mm Hg. The positive predictive value was 16.1%, and negative predictive value was high at 98.1%. CONCLUSION: Prehospital ETCO2 is predictive of mortality and MT. ETCO2 outperformed traditional measures such as SBP and SI in the prediction of mortality. ETCO2 may outperform traditional measures in predicting need for transfusion in occult shock. LEVEL OF EVIDENCE: Diagnostic test, level III.

Empiric antifungals do not decrease the risk for organ space infection in patients with perforated peptic ulcer.

INTRODUCTION: Infection control in patients with perforated peptic ulcers (PPU) commonly includes empiric antifungals (AF). We investigated the variation in the use of empiric AF and explored the association between their use and the subsequent development of organ space infection (OSI). METHODS: This was a secondary analysis of a multicenter, case-control study of patients treated for PPU at nine institutions between 2011 and 2018. Microbiology and utilization of empiric AF, defined as AF administered within 24 hours from the index surgery, were recorded. Patients who received empiric AF were compared with those who did not. The primary outcome was OSI and secondary outcome was OSI with growth of Candida spp. A logistic regression was used to adjust for differences between the two cohorts. RESULTS: A total of 554 patients underwent a surgical procedure for PPU and had available timing of AF administration. The median age was 57 years and 61% were male. Laparoscopy was used in 24% and omental patch was the most common procedure performed (78%). Overall, 239 (43%) received empiric AF. There was a large variation in the use of empiric AF among participating centers, ranging from 25% to 68%. The overall incidence of OSI was 14% (77/554) and was similar for patients who did or did not receive empiric AF. The adjusted OR for development of OSI for patients who received empiric AF was 1.04 (95% CI 0.64 to 1.70), adjusted p=0.86. The overall incidence of OSI with growth of Candida spp was 5% and was similar for both groups (adjusted OR 1.29, 95% CI 0.59 to 2.84, adjusted p=0.53). CONCLUSION: For patients undergoing surgery for PPU, the use of empiric AF did not yield any significant clinical advantage in preventing OSI, even those due to Candida spp. Use of empiric AF in this setting is unnecessary. STUDY TYPE: Original article, case series. LEVEL OF EVIDENCE: III.

Strategies for successful implementation of resuscitative endovascular balloon occlusion of the aorta in an urban Level I trauma center.

BACKGROUND: The rationale for resuscitative endovascular balloon occlusion of the aorta (REBOA) is to control life-threatening subdiaphragmatic bleeding and facilitate resuscitation; however, incorporating this into the resuscitative practices of a trauma service remains challenging. The objective of this study is to describe the process of successful implementation of REBOA use in an academic urban Level I trauma center. All REBOA procedures from April 2014 through December 2019 were evaluated; REBOA was implemented after surgical faculty attended a required and internally developed Advanced Endovascular Strategies for Trauma Surgeons course. Success was defined by sustained early adoption rates. METHODS: An institutional protocol was published, and a REBOA supply cart was placed in the emergency department with posters attached to depict technical and procedural details. A focused professional practice evaluation was utilized for the first three REBOA procedures performed by each faculty member, leading to internal privileging. RESULTS: Resuscitative endovascular balloon occlusion of the aorta was performed in 97 patients by nine trauma surgeons, which is 1% of the total trauma admissions during this time. Each surgeon performed a median of 12 REBOAs (interquartile range, 5-14). Blunt (77/97, 81%) or penetrating abdominopelvic injuries (15/97, 15%) comprised the main injury mechanisms; 4% were placed for other reasons (4/97), including ruptured abdominal aortic aneurysms (n = 3) and preoperatively for a surgical oncologic resection (n = 1). Overall survival was 65% (63/97) with a steady early adoption trend that resulted in participation in a Department of Defense multicenter trial. CONCLUSION: Strategies for how departments adopt new procedures require clinical guidelines, a training program focused on competence, and a hospital education and privileging process for those acquiring new skills. LEVEL OF EVIDENCE: Therapeutic, level V.

Characteristics of survivors of civilian public mass shootings: An Eastern Association for the Surgery of Trauma multicenter study.

BACKGROUND: Firearm injury remains a public health crisis. Whereas there have been studies evaluating causes of death in victims of civilian public mass shootings (CPMSs), there are no large studies evaluating injuries sustained and treatments rendered in survivors. The purpose of this study was to describe these characteristics to inform ideal preparation for these events. METHODS: A multicenter, retrospective study of CPMS survivors who were treated at designated trauma centers from July 1, 1999 to December 31, 2017, was performed. Prehospital and hospital variables were collected. Data are reported as median (25th percentile, 75th percentile interquartile range), and statistical analyses were carried out using Mann-Whitney U, χ2, and Kruskal-Wallis tests. Patients who died before discharge from the hospital were excluded. RESULTS: Thirty-one events involving 191 patients were studied. The median number of patients seen per event was 20 (5, 106), distance to each hospital was 6 (6, 10) miles, time to arrival was 56 (37, 90) minutes, number of wounds per patient was 1 (1, 2), and Injury Severity Score was 5 (1, 17). The most common injuries were extremity fracture (37%) and lung parenchyma (14%). Twenty-nine percent of patients did not receive paramedic-level prehospital treatment. Following arrival to the hospital, 27% were discharged from the emergency department, 32% were taken directly to the operating room/interventional radiology, 16% were admitted to the intensive care unit, and 25% were admitted to the ward. Forty percent did not require advanced treatment within 12 hours. The most common operations performed within 12 hours of arrival were orthopedic (15%) and laparotomy (15%). The most common specialties consulted were orthopedics (38%) and mental health (17%). CONCLUSION: Few CPMS survivors are critically injured. There is significant delay between shooting and transport. Revised triage criteria and a focus on rapid transport of the few severely injured patients are needed. LEVEL OF EVIDENCE: Therapeutic/care management, level IV.