Comparison of treatment and outcomes in blunt thoracic aortic injury based on different vascular surgery guidelines.

OBJECTIVE: Society for Vascular Surgery (SVS) recommendations for managing intimal (grade 1) blunt thoracic aortic injuries (BTAIs) include observation and medical management. University of Washington (UW) revised criteria suggest that intimal injuries with ≥1 cm flap should be upgraded to a moderate injury and treatment be considered. We sought to evaluate and compare SVS and UW criteria for BTAI and determine how discordance in grading affected treatment and outcome. METHODS: We reviewed all patients admitted with BTAI from January 1, 2011, to March 31, 2022. Data included injury grading, demographics, and concomitant traumatic injuries. Images were reviewed to categorize the injury with both grading systems. Treatment and outcomes were analyzed for concordant and discordant groups. RESULTS: Our cohort comprised 208 patients after excluding four who died upon arrival. The mean age was 45 ± 19 years, 69% were men, and the median injury severity score was 34 (interquartile range, 26-45). Strong agreement was observed between the grading systems (kappa = 0.88). All patients with concordant grade 1 injuries (n = 54) were observed. SVS grade 1/2 BTAIs were reclassified in 12 of 71 patients (16.9%). Two (28.6%) SVS grade 2 injuries were graded lower with the UW criteria; neither patient required immediate or delayed repair. Ten (15.6%) SVS grade 1 BTAIs were graded higher with UW criteria. Of these, six underwent repair (one for preoperative embolization), and four were observed without sequalae. Overall mortality was 7.7% with no difference for concordant or discordant grades (7.7% vs 8.3%; P = .99). No aneurysm-related mortalities were observed. Follow-up imaging was available for 94 survivors (49.0%) at a median of 193 days (interquartile range, 42-522 days). Two patients unrepaired at the index hospitalization (SVS grade 3/UW grade 2) underwent successful delayed repair. No patient observed for a minimal injury had BTAI progression or required treatment. CONCLUSIONS: The UW grading system may upgrade or downgrade SVS grade 1 or 2 BTAI for as many as one in six injuries. Upgraded injuries should prompt consideration of repair if there is evidence of flap progression or thromboembolic complications. Downgraded injuries suggest that treatment may not be necessary; clinical expertise is key to determine optimal management in these patients.

A Parallel Pandemic: Increased Firearm Injuries at Five Northern California Trauma Centers During the COVID-19 Pandemic: An Interrupted Time-series Analysis.

OBJECTIVE: This study aimed to characterize changes in firearm injuries at 5 level 1 trauma centers in Northern California in the 12 months following the start of the COVID-19 pandemic compared with the preceding 4 years, accounting for regional variations and seasonal trends. SUMMARY AND BACKGROUND DATA: Increased firearm injuries have been reported during the early peaks of the COVID-19 pandemic despite shelter-in-place restrictions. However, these data are overwhelmingly from singlecenter studies, during the initial phase of the pandemic prior to lifting of shelter-in-place restrictions, or do not account for seasonal trends. METHODS: An interrupted time-series analysis (ITSA) of all firearm injuries presenting to 5 adult level 1 trauma centers in Northern California was performed (January 2016to February 2021). ITSA modeled the association of the onset of the COVID-19 pandemic (March 2020) with monthly firearm injuries using the ordinary least-squares method, included month indicators to adjust for seasonality, and specified lags of up to 12 months to account for autocorrelation. RESULTS: Prior to the start of COVID-19, firearm injuries averaged (±SD) of 86 (±16) and were decreasing by 0.5/month (P < 0.01). The start of COVID- 19 (March 2020) was associated with an alarming increase of 39 firearm injuries/month (P < 0.01) followed by an ongoing rise of 3.5/mo (P < 0.01). This resulted in an average of 130 (±26) firearm injuries/month during the COVID-19 period and included 8 of the 10 highest monthly firearm injury rates in the past 5 years. CONCLUSIONS: These data highlight an alarming escalation in firearm injuries in the 12 months following the onset of the COVID-19 pandemic in Northern California. Additional studies and resources are needed to better understand and address this parallel public health crisis.

Internal and External Validation of an Alcohol Biomarker for Screening in Trauma.

OBJECTIVE: We aimed to examine biomarkers for screening unhealthy alcohol use in the trauma setting. SUMMARY AND BACKGROUND DATA: Self-report tools are the practice standard for screening unhealthy alcohol use; however, their collection suffers from recall bias and incomplete collection by staff. METHODS: We performed a multi-center prospective clinical study of 251 adult patients who arrived within 24 hours of injury with external validation in another 60 patients. The Alcohol Use Disorders Identification Test served as the reference standard. The following biomarkers were measured: (1) PEth; (2) ethyl glucuronide; (3) ethyl sulfate; (4) gamma-glutamyl-transpeptidase; (5) carbohydrate deficient transferrin; and (6) blood alcohol concentration (BAC). Candidate single biomarkers and multivariable models were compared by considering discrimination (AUROC). The optimal cutpoint for the final model was identified using a criterion for setting the minimum value for specificity at 80% and maximizing sensitivity. Decision curve analysis was applied to compare to existing screening with BAC. RESULTS: PEth alone had an AUROC of 0.93 [95% confidence interval (CI): 0.92-0.93] in internal validation with an optimal cutpoint of 25 ng/mL. A 4- variable biomarker model and the addition of any single biomarker to PEth did not improve AUROC over PEth alone ( P > 0.05). Decision curve analysis showed better performance of PEth over BAC across most predicted probability thresholds. In external validation, sensitivity and specificity were 76.0% (95% CI: 53.0%-92.0%) and 73.0% (95% CI: 56.0%-86.0%), respectively.Conclusion and Relevance: PEth alone proved to be the single best biomarker for screening of unhealthy alcohol use and performed better than existing screening systems with BAC. PEth may overcome existing screening barriers.

Emergency Department Length of Stay and Mortality in Critically Injured Patients.

OBJECTIVE: Multicenter data from 2 decades ago demonstrated that critically ill and injured patients spending more than 6 hours in the emergency department (ED) before transfer to the intensive care unit (ICU) had higher mortality rates. A contemporary analysis of ED length of stay in critically injured patients at American College of Surgeons' Trauma Quality Improvement Program (ACS-TQIP) centers was performed to test whether prolonged ED length of stay is still associated with mortality. METHODS: This was an observational cohort study of critically injured patients admitted directly to ICU from the ED in ACS-TQIP centers from 2010-2015. Spending more than 6 hours in the ED was defined as prolonged ED length of stay. Patients with prolonged ED length of stay were matched to those with non-prolonged ED length of stay and mortality was compared. MAIN RESULTS: A total of 113,097 patients were directly admitted from the ED to the ICU following injury. The median ED length of stay was 167 minutes. Prolonged ED length of stay occurred in 15,279 (13.5%) of patients. Women accounted for 29.4% of patients with prolonged ED length of stay but only 25.8% of patients with non-prolonged ED length of stay, P < 0.0001. Mortality rates were similar after matching-4.5% among patients with prolonged ED length of stay versus 4.2% among matched controls. Multivariable logistic regression of the matched cohorts demonstrated prolonged ED length of stay was not associated with mortality. However, women had higher adjusted mortality compared to men Odds Ratio = 1.41, 95% Confidence Interval 1.28 -1.61, P < 0.0001. CONCLUSION: Prolonged ED length of stay is no longer associated with mortality among critically injured patients. Women are more likely to have prolonged ED length of stay and mortality.

Development and Validation of a Deep Learning Strategy for Automated View Classification of Pediatric Focused Assessment With Sonography for Trauma.

OBJECTIVE: Pediatric focused assessment with sonography for trauma (FAST) is a sequence of ultrasound views rapidly performed by clinicians to diagnose hemorrhage. A technical limitation of FAST is the lack of expertise to consistently acquire all required views. We sought to develop an accurate deep learning view classifier using a large heterogeneous dataset of clinician-performed pediatric FAST. METHODS: We developed and conducted a retrospective cohort analysis of a deep learning view classifier on real-world FAST studies performed on injured children less than 18 years old in two pediatric emergency departments by 30 different clinicians. FAST was randomly distributed to training, validation, and test datasets, 70:20:10; each child was represented in only one dataset. The primary outcome was view classifier accuracy for video clips and still frames. RESULTS: There were 699 FAST studies, representing 4925 video clips and 1,062,612 still frames, performed by 30 different clinicians. The overall classification accuracy was 97.8% (95% confidence interval [CI]: 96.0-99.0) for video clips and 93.4% (95% CI: 93.3-93.6) for still frames. Per view still frames were classified with an accuracy: 96.0% (95% CI: 95.9-96.1) cardiac, 99.8% (95% CI: 99.8-99.8) pleural, 95.2% (95% CI: 95.0-95.3) abdominal upper quadrants, and 95.9% (95% CI: 95.8-96.0) suprapubic. CONCLUSION: A deep learning classifier can accurately predict pediatric FAST views. Accurate view classification is important for quality assurance and feasibility of a multi-stage deep learning FAST model to enhance the evaluation of injured children.

Cost-effectiveness evaluation of the PROPPR trial transfusion protocols.

BACKGROUND: There have been no prior investigations of the cost effectiveness of transfusion strategies for trauma resuscitation. The Pragmatic, Randomized, Optimal Platelet and Plasma Ratios (PROPPR) study was a Phase III multisite, randomized trial in 680 subjects comparing the efficacy of 1:1:1 transfusion ratios of plasma and platelets to red blood cells with the 1:1:2 ratio. We hypothesized that 1:1:1 transfusion results in an acceptable incremental cost-effectiveness ratio, when estimated using patients' age-specific life expectancy and cost of care during the 30-day PROPPR trial period. STUDY DESIGN AND METHODS: International Classification of Diseases, Ninth Revision codes were prospectively collected, and subjects were matched 1:2 to subjects in the Healthcare Utilization Program State Inpatient Data to estimate cost weights. We used a decision tree analysis, combined with standard costs and estimated years of expected survival to determine the cost effectiveness of the two treatments. RESULTS: The 1:1:1 group had higher overall costs for the blood products but were more likely to achieve hemostasis and decreased hemorrhagic death by 24 hours (p = 0.006). For every 100 patients treated in the 1:1:1 group, eight more achieved hemostasis than in the 1:1:2 group. At 30 days, the total hospital cost per 100 patients was $5.6 million in the 1:1:1 group compared with $5.0 million in the 1:1:2 group. For each 100 patients, the 1:1:1 group had 218.5 more years of life expectancy. This was at a cost of $2994 per year gained. CONCLUSION: The 1:1:1 transfusion ratio in severely injured hemorrhaging trauma patients is a very cost-effective strategy for increasing hemostasis and decreasing trauma deaths.

Improving Efficiency and Meeting Expectations Without Compromising Care on Trauma Surgical Rounds.

BACKGROUND: Care teams on complex surgical services face a growing list of competing expectations. Approaches to quality improvement must use minimal resources and address both system and human requirements to meet expectations without compromising care. The purpose of this study was to demonstrate that iterative prototyping, combined with a rigorous quantitative evaluation approach, can effectively improve system and stakeholder efficiency on daily trauma surgical rounds at an academic safety-net hospital and level 1 trauma center. MATERIALS AND METHODS: This study occurred between May 2017 and October 2017 at the Zuckerberg San Francisco General Hospital and Trauma Center. Care team members rounding on the trauma service included attending trauma surgeons, fellows, residents, interns, nurse practitioners, pharmacists, and medical students. We used human-centered design to develop and test solutions to improve the surgical rounding process. Each prototype was evaluated using qualitative design research methods, which informed the next iteration. Time observations of rounding activities were adopted from the Lean methodology and tracked before and after implementation. Intern work hours, on-time operative starts, and discharge order times were also tracked before and after implementation. RESULTS: Four prototypes were designed and iteratively implemented, producing care team satisfaction by the end of the implementation period. Discharge order times decreased by a median of 58 min, intern work hours were decreased by 97 min/d, and first operative case on-time starts increased from 40% to 63% (P < 0.05). The time spent on clarifications decreased by 4.7% (P < 0.05), allowing for more time to discuss care plans with the patients themselves. CONCLUSIONS: Iterative prototyping as part of a human-centered design methodology is a powerful tool to address complex systems with diverse interests and competing priorities. Rapid, in-context prototyping is feasible on a complex trauma surgical service and can result in improved workflows and efficiency for the system and its stakeholders.

The Hidden Burden of Mental Health Outcomes Following Firearm-related Injures.

OBJECTIVES: Examine the effect of different types of firearms on readmission due to acute stress disorder (ASD) and/or post-traumatic stress disorder (PTSD) in firearm-injury victims. BACKGROUND: Survivors of firearm-related injuries suffer long-term sequelae such as disability, work loss, and deterioration in the quality of life. There is a paucity of data describing the long-term mental health outcomes in these patients. METHODS: We performed a 5-year (2011-2015) analysis of the Nationwide Readmission Database. All adult patients with firearm injuries were stratified into 3 groups by firearm type: handgun, shotgun, and semiautomatic rifle. Outcome measures were the incidence and predictors of ASD/PTSD. RESULTS: A total of 100,704 victims of firearm-related injuries were identified, of which 13.3% (n = 13,393) were readmitted within 6 months of index hospitalization, 6.7% (n = 8970) of these due to ASD/PTSD. Mean age was 34 ±â€Š14 years, 88% were men. Of those readmitted due to ASD/PTSD, 24% (n = 2153) sustained a handgun-related injury on index hospitalization, 12% (n = 1076) shotgun, and 64% (n = 5741) semiautomatic gun (P = 0.039). On regression analysis, semiautomatic gun and shotgun victims had higher odds of developing ASD/PTSD upon readmission [odds ratio (OR): 2.05 (1.10-4.12) and OR: 1.41 (1.08-2.11)] compared to handgun. Female sex [OR: 1.79 (1.05-3.05)] and younger age representing those younger than 25 years [OR: 4.66 (1.12-6.74)] were also independently associated with higher odds of ASD/PTSD. CONCLUSIONS: Apart from the lives lost, survivors of semiautomatic rifle- and shotgun-related injuries suffer long-term mental health sequalae. These secondary and debilitating mental health outcomes are important considerations for capturing the overall burden of the disease.

Beyond emergency surgery: redefining acute care surgery.

BACKGROUND: Considerable debate exists regarding the definition, skill set, and training requirements for the new specialty of acute care surgery (ACS). We hypothesized that a patient subset could be identified that requires a level of care beyond general surgical training and justifies creation of this new specialty. MATERIALS AND METHODS: Reviewed patient admissions over 1-y to the only general surgical service at a level I trauma center-staffed by trauma and/or critical care trained physicians. Patients classified as follows: trauma, ACS, emergency general (EGS), or elective surgery. ACS patients are nonelective, nontrauma patients with significantly altered physiology requiring intensive care unit admission and/or specific complex operative interventions. Differences in demographics, hospital course, and outcomes were analyzed. RESULTS: In-patient service evaluated approximately 5500 patients, including 3300 trauma patients. A total of 2152 admissions include 37% trauma, 30% elective, 28% EGS, and 4% ACS. ACS and trauma patients were more likely to require multiple operations (ACS relative risk [RR] = 11.5; trauma RR = 5.7, P < 0.0001), have longer hospital and intensive care unit length of stay, and higher mortality (P < 0.0001). They were less likely to be discharged home (ACS RR = 0.75; trauma RR = 0.67, P < 0.0001) compared with that of the EGS group. EGS and elective patients were most similar to each other in multiple areas. CONCLUSIONS: ACS and EGS patients represent distinct patient cohorts, as reflected by significant differences in critical care needs, likelihood of multiple operations, and need for postdischarge rehabilitation. The skills required to care for ACS patients, including ability to rescue from complications and provide critical care, differ from those required for EGS patients and supports development of ACS training and regionalization of care.

Transfusion of plasma, platelets, and red blood cells in a 1:1:1 vs a 1:1:2 ratio and mortality in patients with severe trauma: the PROPPR randomized clinical trial.

IMPORTANCE: Severely injured patients experiencing hemorrhagic shock often require massive transfusion. Earlier transfusion with higher blood product ratios (plasma, platelets, and red blood cells), defined as damage control resuscitation, has been associated with improved outcomes; however, there have been no large multicenter clinical trials. OBJECTIVE: To determine the effectiveness and safety of transfusing patients with severe trauma and major bleeding using plasma, platelets, and red blood cells in a 1:1:1 ratio compared with a 1:1:2 ratio. DESIGN, SETTING, AND PARTICIPANTS: Pragmatic, phase 3, multisite, randomized clinical trial of 680 severely injured patients who arrived at 1 of 12 level I trauma centers in North America directly from the scene and were predicted to require massive transfusion between August 2012 and December 2013. INTERVENTIONS: Blood product ratios of 1:1:1 (338 patients) vs 1:1:2 (342 patients) during active resuscitation in addition to all local standard-of-care interventions (uncontrolled). MAIN OUTCOMES AND MEASURES: Primary outcomes were 24-hour and 30-day all-cause mortality. Prespecified ancillary outcomes included time to hemostasis, blood product volumes transfused, complications, incidence of surgical procedures, and functional status. RESULTS: No significant differences were detected in mortality at 24 hours (12.7% in 1:1:1 group vs 17.0% in 1:1:2 group; difference, -4.2% [95% CI, -9.6% to 1.1%]; P = .12) or at 30 days (22.4% vs 26.1%, respectively; difference, -3.7% [95% CI, -10.2% to 2.7%]; P = .26). Exsanguination, which was the predominant cause of death within the first 24 hours, was significantly decreased in the 1:1:1 group (9.2% vs 14.6% in 1:1:2 group; difference, -5.4% [95% CI, -10.4% to -0.5%]; P = .03). More patients in the 1:1:1 group achieved hemostasis than in the 1:1:2 group (86% vs 78%, respectively; P = .006). Despite the 1:1:1 group receiving more plasma (median of 7 U vs 5 U, P < .001) and platelets (12 U vs 6 U, P < .001) and similar amounts of red blood cells (9 U) over the first 24 hours, no differences between the 2 groups were found for the 23 prespecified complications, including acute respiratory distress syndrome, multiple organ failure, venous thromboembolism, sepsis, and transfusion-related complications. CONCLUSIONS AND RELEVANCE: Among patients with severe trauma and major bleeding, early administration of plasma, platelets, and red blood cells in a 1:1:1 ratio compared with a 1:1:2 ratio did not result in significant differences in mortality at 24 hours or at 30 days. However, more patients in the 1:1:1 group achieved hemostasis and fewer experienced death due to exsanguination by 24 hours. Even though there was an increased use of plasma and platelets transfused in the 1:1:1 group, no other safety differences were identified between the 2 groups. TRIAL REGISTRATION: clinicaltrials.gov Identifier: NCT01545232.

Do serial troponins predict the need for cardiac evaluation in trauma patients after ground-level fall?

Purpose: Troponin T levels are routinely checked in trauma patients after experiencing a ground-level fall to identify potential cardiac causes of syncope. An elevated initial troponin prompts serial testing until the level peaks. However, the high sensitivity of the test may lead to repeat testing that is of little clinical value. Here, we examine the role of serial troponins in predicting the need for further cardiac workup in trauma patients after sustaining a fall. Methods: Retrospective review of all adult trauma activations for ground-level fall from January 1, 2021 to December 31, 2021 in patients who were hemodynamically and neurologically normal at presentation. Outcomes evaluated included need for cardiology consult, admission to cardiology service, outpatient cardiology follow-up, cardiology intervention and in-hospital mortality. Results: There were 1555 trauma activations for ground-level fall in the study period. The cohort included 560 patients evaluated for a possible syncopal fall, hemodynamically stable, Glasgow Coma Scale score of 15, and with a troponin drawn at presentation. The initial median troponin was 20 ng/L (13-37). Second troponin values were drawn on 58% (median 33 ng/L (22-52)), with 42% of patients having an increase from first to second test. 29% of patients had a third troponin drawn (median 42 ng/L (26-67)). The initial troponin value was significantly associated with undergoing a subsequent echo (p=0.01), cardiology consult (p<0.01), admission for cardiac evaluation (p<0.01), cardiology follow-up (p<0.01), and in-hospital mortality (p=0.01); the initial troponin was not associated with cardiac intervention (p=0.91). An increase from the first to second troponin was not associated with any of outcomes of interest. Analysis was done with cut-off values of 30 ng/L, 50 ng/L, 70 ng/L, and 90 ng/L; a troponin T threshold of 19 ng/L was significant for cardiology consult (p=0.01) and cardiology follow-up (p=0.04). When the threshold was increased to 50 ng/L, it was also significant for admission for cardiac issue (p<0.01). When the threshold was increased to 90 ng/L, it was significant for the same three outcomes and in-hospital mortality (p=0.04). Conclusion: The initial serum troponin has clinical value in identifying underlying cardiac disease in patients who present after ground-level fall; however, that serial testing is likely of little value. Further, using a cut-off of >50 ng/L as a threshold for further clinical evaluation would improve the utility of the test and likely reduce unnecessary hospital stays and costs for otherwise healthy patients. Level of evidence: Level III.

Cell-Free Hemoglobin in the Pathophysiology of Trauma: A Scoping Review.

OBJECTIVES: Cell-free hemoglobin (CFH) is a potent mediator of endothelial dysfunction, organ injury, coagulopathy, and immunomodulation in hemolysis. These mechanisms have been demonstrated in patients with sepsis, hemoglobinopathies, and those receiving transfusions. However, less is known about the role of CFH in the pathophysiology of trauma, despite the release of equivalent levels of free hemoglobin. DATA SOURCES: Ovid MEDLINE, Embase, Web of Science Core Collection, and BIOSIS Previews were searched up to January 21, 2023, using key terms related to free hemoglobin and trauma. DATA EXTRACTION: Two independent reviewers selected studies focused on hemolysis in trauma patients, hemoglobin breakdown products, hemoglobin-mediated injury in trauma, transfusion, sepsis, or therapeutics. DATA SYNTHESIS: Data from the selected studies and their references were synthesized into a narrative review. CONCLUSIONS: Free hemoglobin likely plays a role in endothelial dysfunction, organ injury, coagulopathy, and immune dysfunction in polytrauma. This is a compelling area of investigation as multiple existing therapeutics effectively block these pathways.

Using microfluidic shear to assess transfusion requirements in trauma patients.

Background: Viscoelastic assays have widely been used for evaluating coagulopathies but lack the addition of shear stress important to in vivo clot formation. Stasys technology subjects whole blood to shear forces over factor-coated surfaces. Microclot formation is analyzed to determine clot area (CA) and platelet contractile forces (PCFs). We hypothesize the CA and PCF from this novel assay will provide information that correlates with trauma-induced coagulopathy and transfusion requirements. Methods: Blood samples were collected on adult trauma patients from a single-institution prospective cohort study of high-level activations. Patient and injury characteristics, transfusion data, and outcomes were collected. Thromboelastography, coagulation studies, and Stasys assays were run on paired samples collected at admission. Stasys CA and PCFs were quantified as area under the curve calculations and maximum values. Normal ranges for Stasys assays were determined using healthy donors. Data were compared using Kruskal-Wallis tests and simple linear regression. Results: From March 2021 to January 2023, 108 samples were obtained. Median age was 37.5 (IQR 27.5-52) years; patients were 77% male. 71% suffered blunt trauma, 26% had an Injury Severity Score of ≥25. An elevated international normalized ratio significantly correlated with decreased cumulative PCF (p=0.05), maximum PCF (p=0.05) and CA (p=0.02). Lower cumulative PCF significantly correlated with transfusion of any products at 6 and 24 hours (p=0.04 and p=0.05) as well as packed red blood cells (pRBCs) at 6 and 24 hours (p=0.04 and p=0.03). A decreased maximum PCF showed significant correlation with receiving any transfusion at 6 (p=0.04) and 24 hours (p=0.02) as well as transfusion of pRBCs, fresh frozen plasma, and platelets in the first 6 hours (p=0.03, p=0.03, p=0.03, respectively). Conclusions: Assessing coagulopathy in real time remains challenging in trauma patients. In this pilot study, we demonstrated that microfluidic approaches incorporating shear stress could predict transfusion requirements at time of admission as well as requirements in the first 24 hours. Level of evidence: Level II.

Predictors of emergency department death for patients presenting with ruptured abdominal aortic aneurysms.

OBJECTIVE: Ruptured abdominal aortic aneurysm (rAAA) is a critically time-sensitive condition with outcomes dependent on rapid diagnosis and definitive treatment. Emergency department (ED) death reflects the hemodynamic stability of the patient upon arrival and the ability to mobilize resources before hemodynamic stability is lost. The goals of this study were to determine the incidence and predictors of ED death for patients presenting to EDs with rAAAs. METHODS: Data for patients presenting with International Classification of Disease, 9th Revision, Clinical Modification codes for rAAA from 2006 to 2008 were extracted from discharge data using the Nationwide Emergency Department Sample (NEDS), Healthcare Cost and Utilization Project, and Agency for Healthcare Research and Quality. The NEDS is the largest stratified weighted sample of US hospital-based ED visits with links to inpatient files. We compared those transferred to those admitted and treated. Sample weights were applied to produce nationally representative estimates. Patient and hospital factors associated with transfer were identified using multivariate logistic regression. These factors were then analyzed for a relationship with ED deaths. RESULTS: A total of 18,363 patients were evaluated for rAAAs. Of these, 7% (1201) died in the ED, 6% (1160) were admitted and died without a procedure, 42% (7731) were admitted and died after repair, and 41% (7479) were admitted, treated, and survived. Transfers accounted for 4% (793) of all ED visits for rAAAs. ED death was more likely for patients seen in nonmetropolitan hospitals (12.7%) vs metropolitan nonteaching (7.0%) or metropolitan teaching hospitals (4.5%; P < .0001). Compared with other regions, the West had a higher ED mortality rate (9.6% vs 5.1%-6.9%; P = .0038). On multivariate analysis, ED death was associated with hospital groups exhibiting both high and low transfer rates. CONCLUSIONS: ED death remains a significant cause for mortality for rAAAs and varies by hospital type, rural/urban location, and geographic region. Both delays in ED arrival and delays in providing definitive care may contribute to increased ED death rates, suggesting that improved regional systems of care may improve survival after rAAA.

Trauma and COVID-Induced Severe Rhabdomyolysis.

The novel coronavirus COVID-19 has been implicated in a number of extra-pulmonary manifestations including rhabdomyolysis. It is hypothesized to be secondary to direct muscle damage from the virus. The usual treatment of rhabdomyolysis is resuscitation with aggressive fluid management to prevent acute renal failure. However, the combination of blunt thoracic trauma and COVID pneumonia has posed additional challenges for critical care management. A 68-year-old male presented to our institution after being found down for an unknown duration of time. He was diagnosed symptomatic COVID pneumonia. His traumatic injuries included 4 rib fractures, a rectus sheath hematoma, and rhabdomyolysis with a creatinine kinase (CK) level of 16,716 U/L. He was initially treated with steroids, prone positioning, and aggressive fluid administration. Despite treatment his CK level peaked at 146,328 U/L. Here we present the case of trauma and COVID-induced rhabdomyolysis with an extremely elevated CK level.

Growing the next generation of trauma surgeon-scientists: Reflections on 20 years of research investment.

INTRODUCTION: The Eastern Association for the Surgery of Trauma mission includes fostering research and providing career development opportunities. Eastern Association for the Surgery of Trauma has awarded for 20 years a research scholarship to a promising young investigator. The research mentorship efforts were expanded 5 years ago with the INVEST-C Hack-a-thon. INVEST-C provides an intensive, short-term engagement to propel junior faculty toward establishing research independence. This study investigates the impact of these programs on academic productivity. METHODS: Pubmed records, National Institutes of Health (NIH) Reporter data, and SCOPUS h-index were acquired for all scholarship (SCH) awardees from 2002 to 2021 (n = 20) and all INVEST-C (INV) participants (2017-2020, n = 19). Current type of practice, total number of funding awards, and timing of first award were ascertained. INVEST-C participants were also surveyed on an annual basis to track their progress. Medians (interquartile range [IQR]) are reported and compared (analysis of variance). RESULTS: Median publications (PUBs) of SCH awardees were 56 (IQR, 33-88), h-index was 16 (IQR, 12-21), and 25% of awardees have ≥1 NIH grant since their SCH. Among the last 10 awardees with a minimum of 2 years from SCH, 40% have received an NIH award compared with a mean NIH funding rate of 18.5% over the same period. For those remaining in academics (90% SCH), PUBs were higher for those >5 years (66 [IQR, 51-115]) versus <5 years from their SCH (33 [22-59]; p = 0.05), but there was no difference in h-index (16 [IQR, 14-25] vs. 15 [9-19], p = NS). Comparing the most recent 5 years of SCH to INV group, there was no difference in academic productivity as measured by total PUBs (SCH, 33 [IQR, 22-59] vs. INV, 34 [IQR, 18-44]; p = 0.7) or h-index (INV, 9 [IQR, 5-14]; p = 0.1). However, no attendee held research funding before INV, but 31.6% (6 of 19 attendees) have subsequently acquired ≥1 funding award (11 non-NIH, 1 NIH) in the short interval since participation. CONCLUSION: Investments in research activities have translated to significant extramural funding. Those in the last 5 years have been particularly fruitful with INV participants already achieving equal median academic productivity to SCH recipients. LEVEL OF EVIDENCE: Prognostic and Epidemiologic; Level III.

Postinjury platelet aggregation and venous thromboembolism.

BACKGROUND: Posttraumatic venous thromboembolism (VTE) remains prevalent in severely injured patients despite chemoprophylaxis. Importantly, although platelets are central to thrombosis, they are not routinely targeted in prevention of posttraumatic VTE. Furthermore, platelets from injured patients show ex vivo evidence of increased activation yet impaired aggregation, consistent with functional exhaustion. However, the relationship of this platelet functional phenotype with development of posttraumatic VTE is unknown. We hypothesized that, following injury, impaired ex vivo platelet aggregation (PA) is associated with the development of posttraumatic VTE. METHODS: We performed a secondary analysis of 133 severely injured patients from a prospective observational study investigating coagulation and inflammation (2011-2019). Platelet aggregation in response to stimulation with adenosine diphosphate (ADP), collagen, and thrombin was measured at presentation (preresuscitation) and 24 hours (postresuscitation). Viscoelastic clot strength and lysis were measured in parallel by thromboelastography. Multivariable regression examined relationships between PA at presentation, 24 hours, and the change (δ) in PA between presentation and 24 hours with development of VTE. RESULTS: The 133 patients were severely injured (median Injury Severity Score, 25), and 14% developed VTE (all >48 hours after admission). At presentation, platelet count and PA were not significantly different between those with and without incident VTE. However, at 24 hours, those who subsequently developed VTE had significantly lower platelet counts (126 × 10 9 /L vs. 164 × 10 9 /L, p = 0.01) and lower PA in response to ADP ( p < 0.05), collagen ( p < 0.05), and thrombin ( p = 0.06). Importantly, the magnitude of decrease in PA (δ) from presentation to 24 hours was independently associated with development of VTE (adjusted odds ratios per 10 aggregation unit decrease: δ-ADP, 1.31 [ p = 0.03]; δ-collagen, 1.36 [ p = 0.01]; δ-thrombin, 1.41 [ p < 0.01]). CONCLUSION: Severely injured patients with decreasing ex vivo measures of PA despite resuscitation have an increased risk of developing VTE. This may have implications for predicting development of VTE and for studying platelet targeted chemoprophylaxis regimens. LEVEL OF EVIDENCE: Prognostic/Epidemiological; Level III.

A comparison of management and outcomes following blunt versus penetrating pancreatic trauma: A secondary analysis from the Western Trauma Association Multicenter Trials Group on Pancreatic Injuries.

BACKGROUND: The impact of injury mechanism on outcomes of pancreatic trauma has not been well studied, and current guidelines do not differentiate recommendations for blunt and penetrating injuries. The purpose of this study was to analyze interventions and outcomes as they relate to mechanism. We hypothesized that penetrating pancreatic trauma results in greater morbidity than blunt trauma because of more frequent operative exploration without imaging and thus more aggressive surgical management. METHODS: Secondary analysis of a multicenter retrospective review of pancreatic injuries in patients 15 years and older from 2010 to 2018 was performed. Deaths within 24 hours of admission were excluded from analysis of the primary outcome, pancreas-related complications (PRCs). Data were analyzed by injury mechanism using various statistical tests where appropriate. RESULTS: Thirty-three centers reported on 1,240 patients (44% penetrating). Penetrating trauma patients were twice as likely to undergo resection (45% vs. 23%) and suffer PRCs (39% vs. 20%). However, differences varied widely based on injury grade and management. There were fewer resections and more nonoperative management in blunt grades I to III injury. Pancreas-related complications occurred in 40% of high-grade injuries with no difference between mechanisms and in 40% of patients after resection, regardless of mechanism or injury grade. High-grade pancreatic injury (odds ratio [OR], 2.39; 95% confidence interval [CI], 1.55-3.67), penetrating injury (OR, 1.99; 95% CI, 1.31-3.05), and management in a low-volume center (i.e., five or fewer cases/year) (OR, 1.65; 95% CI, 1.16-2.35) were independent predictors of PRCs. CONCLUSION: Management of grades I to III, but not grades IV/V, pancreatic injuries varies based on mechanism. Penetrating injury is an independent risk factor for PRCs, but main pancreatic duct injury and resection are associated with high rates of PRCs regardless of the injury mechanism. Resection appears to offer better outcomes for grade IV/V injuries, and grade I and II injuries should be managed nonoperatively. LEVEL OF EVIDENCE: Therapeutic/Care Management; Level III.

Importance of catecholamine signaling in the development of platelet exhaustion after traumatic injury.

BACKGROUND: Impaired ex vivo platelet aggregation is common in trauma patients. The mechanisms driving these impairments remain incompletely understood, but functional platelet exhaustion due to excessive in vivo activation is implicated. Given platelet adrenoreceptors and known catecholamine surges after injury, impaired ex vivo platelet aggregation in trauma patients may be linked to catecholamine-induced functional platelet exhaustion. OBJECTIVE: To determine the relationship of catecholamines with platelet-dependent hemostasis after injury and to model catecholamine-induced functional platelet exhaustion in healthy donor platelets. PATIENTS/METHODS: Whole blood was collected from 67 trauma patients as part of a prospective cohort study. Platelet aggregometry and rotational thromboelastometry were performed, and plasma epinephrine (EPI) and norepinephrine (NE) concentrations were measured. The effect of catecholamines on healthy donor platelets was examined in a microfluidic model, with platelet aggregometry, and by flow cytometry examining surface markers of platelet activation. RESULTS: In trauma patients, EPI and NE were associated with impaired platelet aggregation (both p < 0.05), and EPI was additionally associated with decreased viscoelastic clot strength, increased fibrinolysis, and mortality (all p < 0.05). In healthy donors, short duration incubation with EPI enhanced platelet aggregation, platelet adhesion under flow, and increased glycoprotein IIb/IIIa activation, while weaker effects were observed with NE. Compared with short incubation, longer incubation with EPI resulted in decreased platelet adhesion, platelet aggregation, and surface expression of glycoprotein IIb/IIIa. CONCLUSIONS: These findings suggest sympathoadrenal activation in trauma patients contributes to impaired ex vivo platelet aggregation, which mechanistically may be explained by a functionally exhausted platelet phenotype under prolonged exposure to high plasma catecholamine levels.

A new trauma frontier: Exploratory pilot study of platelet transcriptomics in trauma patients.

BACKGROUND: The earliest measurable changes to postinjury platelet biology may be in the platelet transcriptome, as platelets are known to carry messenger ribonucleic acids (RNAs), and there is evidence in other inflammatory and infectious disease states of differential and alternative platelet RNA splicing in response to changing physiology. Thus, the aim of this exploratory pilot study was to examine the platelet transcriptome and platelet RNA splicing signatures in trauma patients compared with healthy donors. METHODS: Preresuscitation platelets purified from trauma patients (n = 9) and healthy donors (n = 5) were assayed using deep RNA sequencing. Differential gene expression analysis, weighted gene coexpression network analysis, and differential alternative splicing analyses were performed. In parallel samples, platelet function was measured with platelet aggregometry, and clot formation was measured with thromboelastography. RESULTS: Differential gene expression analysis identified 49 platelet RNAs to have differing abundance between trauma patients and healthy donors. Weighted gene coexpression network analysis identified coexpressed platelet RNAs that correlated with platelet aggregation. Differential alternative splicing analyses revealed 1,188 splicing events across 462 platelet RNAs that were highly statistically significant (false discovery rate <0.001) in trauma patients compared with healthy donors. Unsupervised principal component analysis of these platelet RNA splicing signatures segregated trauma patients in two main clusters separate from healthy controls. CONCLUSION: Our findings provide evidence of finetuning of the platelet transcriptome through differential alternative splicing of platelet RNA in trauma patients and that this finetuning may have relevance to downstream platelet signaling. Additional investigations of the trauma platelet transcriptome should be pursued to improve our understanding of the platelet functional responses to trauma on a molecular level.