Predictors for Direct to Operating Room Admission in Severe Trauma.

BACKGROUND: Protocols for expediting critical trauma patients directly from the helipad to the operating room tend to vary by center, rely heavily on physician gestalt, and lack supporting evidence. We evaluated a population of severely injured trauma patients with the aim of determining objective factors associated with the need for immediate surgical intervention. METHODS: All highest-activation trauma patients transported by air ambulance between 1/1/16 and 12/31/17 were enrolled retrospectively. Transfer, pediatric, isolated burn, and isolated head trauma patients were excluded. Patients who underwent emergency general surgery within 30 min of arrival without the aid of cross-sectional imaging were compared to the remainder of the cohort. RESULTS: Of the 863 patients who were enrolled, 85 (10%) spent less than 30 min in the emergency department (ED) before undergoing an emergency operation. The remaining 778 patients (90%) formed the comparison group. The ED ≤ 30 min group had a higher percentage of penetrating injuries, lower blood pressure, and was more likely to have a positive FAST exam. The "Direct to Operating Room" (DTOR) score is a predictive scoring system devised to identify patients most likely to benefit from bypassing the ED. The odds ratio of emergency operation within 30 min of hospital arrival increased by 2.71 (95% confidence interval 2.23-3.29; P < 0.001) for every 1-point increase in DTOR score. CONCLUSIONS: Trauma patients with profound hypotension or acidosis and positive FAST were more likely to require surgery within 30 min of hospital presentation. Use of a scoring system may allow early identification of these patients in the prehospital setting by nonphysician providers.

Whole Blood for Resuscitation in Adult Civilian Trauma in 2017: A Narrative Review.

After a hiatus of several decades, the concept of cold whole blood (WB) is being reintroduced into acute clinical trauma care in the United States. Initial implementation experience and data grew from military medical applications, followed by more recent development and data acquisition in civilian institutions. Anesthesiologists, especially those who work in acute trauma facilities, are likely to be presented with patients either receiving WB from the emergency department or may have WB as a therapeutic option in massive transfusion situations. In this focused review, we briefly discuss the historical concept of WB and describe the characteristics of WB, including storage, blood group compatibility, and theoretical hemolytic risks. We summarize relevant recent retrospective military and preliminary civilian efficacy as well as safety data related to WB transfusion, and describe our experience with the initial implementation of WB transfusion at our level 1 trauma hospital. Suggestions and collective published experience from other centers as well as ours may be useful to those investigating such a program. The role of WB as a significant therapeutic option in civilian trauma awaits further prospective validation.

Trauma-associated bleeding: management of massive transfusion.

PURPOSE OF REVIEW: Early treatment goals in the bleeding trauma patient have changed based on recent research findings. Trauma patients requiring a massive transfusion protocol have shown a decreased mortality based on a more aggressive and balanced approach to blood product resuscitation. This chapter will review the recent advances in managing the bleeding trauma patient. RECENT FINDINGS: Recent data have suggested a combined approach of early ratio-based blood product use, bedside viscoelastic hemostatic assays, hemostatic resuscitation, and finally goal-directed therapy to complete resuscitation. SUMMARY: There is now evidence to support the early use of a 1 : 1 : 1 blood product transfusion protocol to restore lost circulating volume, improve oxygen carrying capacity, replace diluted platelets, and replenish clotting factors in massively bleeding trauma patients. Further study is needed to determine whether prehospital initiation of blood products and pharmacological adjuncts will improve outcomes.

Ketamine For Acute Pain After Trauma (KAPT): A Pragmatic, Randomized Clinical Trial.

INTRODUCTION: Non-narcotic intravenous medications may be a beneficial adjunct to oral multimodal pain regimens (MMPRs) which reduce but do not eliminate opioid exposure and prescribing after trauma. We hypothesized that the addition of a sub-dissociative ketamine infusion (KI) to a standardized oral MMPR reduces inpatient opioid exposure. METHODS: Eligible adult trauma patients admitted to the intermediate or intensive care unit were randomized upon admission to our institutional MMPR per usual care (UC) or UC plus sub-dissociative KI for 24 to 72 hours after arrival. The primary outcome was morphine milligram equivalents per day (MME/d) and secondary outcomes included total MME, discharge with an opioid prescription (OP%), and rates of ketamine side effects. Bayesian posterior probabilities (pp) were calculated using neutral priors. RESULTS: A total of 300 patients were included in the final analysis with 144 randomized to KI and 156 to UC. Baseline characteristics were similar between groups. The injury severity scores for KI were 19 [14, 29] versus UC 22 [14, 29]. The KI group had a lower rate of long-bone fracture (37% versus 49%) and laparotomy (16% versus 24%). Patients receiving KI had an absolute reduction of 7 MME/day, 96 total MME, and 5% in OP%. Additionally, KI had a relative risk (RR) reduction of 19% in MME/day (RR 0.81 [0.69 - 0.95], pp = 99%), 20% in total MME (RR 0.80 [0.64, 0.99], pp = 98%), and 8% in OP% (RR 0.92 [0.76, 1.11], pp = 81%). The KI group had a higher rate of delirium (11% versus 6%); however, rates of other side effects such as arrythmias and unplanned intubations were similar between groups. CONCLUSION: Addition of a sub-dissociative ketamine infusion to an oral MMPR resulted in a decrease in opioid exposure in severely injured patients. Sub-dissociative ketamine infusions can be used as a safe adjunct to decrease opioid exposure in monitored settings. LEVEL OF EVIDENCE: I; Therapeutic/Care Management.

Ketamine for acute pain after trauma: the KAPT randomized controlled trial.

BACKGROUND: Evidence for effective pain management and opioid minimization of intravenous ketamine in elective surgery has been extrapolated to acutely injured patients, despite limited supporting evidence in this population. This trial seeks to determine the effectiveness of the addition of sub-dissociative ketamine to a pill-based, opioid-minimizing multi-modal pain regimen (MMPR) for post traumatic pain. METHODS: This is a single-center, parallel-group, randomized, controlled comparative effectiveness trial comparing a MMPR to a MMPR plus a sub-dissociative ketamine infusion. All trauma patients 16 years and older admitted following a trauma which require intermediate (IMU) or intensive care unit (ICU) level of care are eligible. Prisoners, patients who are pregnant, patients not expected to survive, and those with contraindications to ketamine are excluded from this study. The primary outcome is opioid use, measured by morphine milligram equivalents (MME) per patient per day (MME/patient/day). The secondary outcomes include total MME, pain scores, morbidity, lengths of stay, opioid prescriptions at discharge, and patient centered outcomes at discharge and 6 months. DISCUSSION: This trial will determine the effectiveness of sub-dissociative ketamine infusion as part of a MMPR in reducing in-hospital opioid exposure in adult trauma patients. Furthermore, it will inform decisions regarding acute pain strategies on patient centered outcomes. TRIAL REGISTRATION: The Ketamine for Acute Pain Management After Trauma (KAPT) with registration # NCT04129086 was registered on October 16, 2019.

The success of emergency endotracheal intubation in trauma patients: a 10-year experience at a major adult trauma referral center.

BACKGROUND: Emergency airway management is a required skill for many anesthesiologists. We studied 10 yr of experience at a Level 1 trauma center to determine the outcomes of tracheal intubation attempts within the first 24 h of admission. METHODS: We examined Trauma Registry, quality management, and billing system records from July 1996 to June 2006 to determine the number of patients requiring intubation within 1 h of hospital arrival and to estimate the number requiring intubation with the first 24 h. We reviewed the medical record of each patient in either cohort who underwent a surgical airway access procedure (tracheotomy or cricothyrotomy) to determine the presenting characteristics of the patients and the reason they could not be orally or nasally intubated. RESULTS: All intubation attempts were supervised by an anesthesiologist experienced in trauma patient care. Rapid sequence intubation with direct laryngoscopy was the standard approach throughout the study period. During the first hour after admission, 6088 patients required intubation, of whom 21 (0.3%) received a surgical airway. During the first 24 h, 10 more patients, for a total of 31, received a surgical airway, during approximately 32,000 attempts (0.1%). Unanticipated difficult upper airway anatomy was the leading reason for a surgical airway. Four of the 31 patients died of their injuries but none as the result of failed intubation. CONCLUSIONS: In the hands of experienced anesthesiologists, rapid sequence intubation followed by direct laryngoscopy is a remarkably effective approach to emergency airway management. An algorithm designed around this approach can achieve very high levels of success.

The Anesthesiologist's Response to Hurricane Natural Disaster Incidents: Hurricane Harvey.

From personal experience and available resources, such as the American Society of Anesthesiologists Committee on Trauma and Emergency Preparedness templates from the manual for department procedures, the authors describe the primarily flooding impact of Hurricane Harvey in their area of Texas. They review the necessary analysis, development, and implementation of logistics; staffing and relief models; coordination with hospital partners; and dissemination of the planned procedures. The authors emphasize the commitment of anesthesiologists to patient care and rescue efforts outside of the operating room.

Rupture of a nonaneurysmal aorta secondary to Staphylococcus aortitis.

Infectious aortitis has become increasingly uncommon and, when diagnosed, typically occurs in an immunocompromised elderly male with a history of Staphylococcus or Salmonella infection and underlying atheromatous cardiovascular disease. The authors report a case of a 74-year-old man with aortitis complicated by rupture secondary to Staphylococcus aureus infection. The patient presented with worsening abdominal pain and fever after being discharged from the emergency room 2 weeks before with back pain and leukocytosis diagnosed as urinary tract infection and bronchitis. Computed tomography (CT) imaging of the retroperitoneum on the first visit appeared normal. Repeat CT scan on the subsequent visit revealed a contained rupture of a nonaneurysmal aorta at the level of the diaphragm. The patient was taken to the operating room emergently for repair. An infected periaortic hematoma and a 1 cm perforation in the posterior aorta were found. The aorta was excised and the area debrided. Revascularization was performed using a 22 mm extruded polytetrafluoroethylene (ePTFE) interposition graft placed in situ. This case demonstrates that a high index of suspicion is required in diagnosing infectious aortitis and that the diagnosis may be delayed in many cases. Additionally, it may not be uncommon for the infected aorta to rupture without prior aneurysm formation.

Assessing trauma care provider judgement in the prediction of need for life-saving interventions.

INTRODUCTION: Human judgement on the need for life-saving interventions (LSI) in trauma is poorly studied, especially during initial casualty management. We prospectively examined early clinical judgement and compared clinical experts' predictions of LSI to their later occurrence. PATIENTS AND METHODS: Within 10-15 min of direct trauma admission, we surveyed the predictions of pre-hospital care providers (PHP, 92% paramedics), trauma centre nurses (RN), and attending or fellow trauma physicians (MD) on the need for LSI. The actual outcomes including fluid bolus, intubation, transfusion (<1h and 1-6h), and emergent surgical interventions were observed. Cohen's kappa statistic (K) and percentage agreement were used to measure agreement among provider responses. Sensitivity, specificity, negative predictive value (NPV) and positive predictive value (PPV) were calculated to compare clinical judgement to actual patient interventions. RESULTS: Among 325 eligible trauma patient admissions, 209 clinical judgement of LSIs were obtained from all three providers. Cohen's kappa statistic for agreement between pairs of provider groups demonstrated no "disagreement" (K<0) between groups, "fair" agreement for fluid bolus (K=0.12-0.19) and blood transfusion 0-6h (K=0.22-0.39), and "moderate" (K=0.45-0.49) agreement between PHP and RN regarding intubation and surgical interventions, but no "excellent" (K ≥ 0.81) agreement between any pair of provider groups for any intervention. The percentage agreement across the different clinician groups ranged from 50% to 83%. NPV was 90-99% across providers for all interventions except fluid bolus. CONCLUSIONS: Expert clinical judgement provides a benchmark for the prediction of major LSI use in unstable trauma patients. No excellent agreement exists across providers on LSI predictions. It is possible that quality improvement measures and computer modelling-based decision-support could reduce errors of LSI commission and omission found in resuscitation at major trauma centres and enhance decision-making in austere trauma settings by less well-trained providers than those surveyed.

Airway management in cardiac arrest.

Airway management has been emphasized as crucial to effective resuscitation of patients in cardiac arrest. However, recent research has shown that coronary and cerebral perfusion should be prioritized rather than airway management. Endotracheal intubation has been deemphasized. This article reviews the current state of the literature regarding airway management of the patient in cardiac arrest. Ventilatory management strategies are also discussed.

Vascular and extravascular volume expansion of dobutamine and norepinephrine in normovolemic sheep.

In low-flow states, such as circulatory shock, both fluids and catecholamines are often coadministered. We have previously found that adrenergic agents alter volume expansion after a fluid bolus. The present study tested the volume expansion properties of dobutamine and norepinephrine in sheep treated with (series 1) and without (series 2) a fluid bolus. Series 1 (n = 6 per group): no drug (control), dobutamine (10 µg x kg(-1) x min), or norepinephrine (1.0 µg x kg(-1) x min(-1)) was begun 30 min before a 24-mL x kg(-1), 20-min, 0.9% NaCl bolus. The effect of drug and fluid on plasma volume (ΔPV), urinary output (UOP), and extravascular volume (ΔEVV) was determined. Series 2: Identical protocol but no fluid bolus. Series 1: the fluid bolus resulted in a peak and sustained ΔPV expansion. Norepinephrine (7.5 ± 0.9 mL x kg(-1)) and dobutamine (9.5 ± 1.1 mL x kg(-1)) significantly increased ΔPV compared with control (3.8 ± 1.1 mL x kg(-1)). Cumulative UOP was reduced by dobutamine (3.8 ± 1.4 mL x kg) compared with norepinephrine (25.1 ± 3.9 mL x kg(-1)) and control (16.9 ± 4.0 mL x kg(-1)). Norepinephrine increased ΔPV, while reducing ΔEVV after bolus. Series 2: ΔPV was unchanged in the control group. Dobutamine and norepinephrine increased ΔPV over time, 5.1 ± 0.5 and 4.0 ± 0.5 mL x kg(-1), respectively. At study end, UOP was lowest in dobutamine. Norepinephrine resulted in loss of ΔEVV fluid. data suggest a novel role for adrenergic receptors in regulating vascular and EVV expansion. ß-Adrenergic agonists enhance vascular volume expansion, whereas α-adrenergic agonists eliminate extravascular fluid.

Effects of fenoldopam, a dopamine D-1 agonist, and clevidipine, a calcium channel antagonist, in acute renal failure in anesthetized rats.

The present studies were conducted to: a) comparatively evaluate the effects of clevidipine, a new dihydropyridine calcium antagonist, and fenoldopam, a dopamine (D-1) receptor agonist on basal renal function, and b) to determine the efficacy of these agents in protecting renal function in an experimental model of ischemia/reperfusion (I/R) induced acute renal failure in rats. Infusions of either clevidipine or fenoldopam (5.0 nmol/kg(-1) min(-1) i.v. for 60 min) produced significant increases in urine flow (UV), urinary sodium excretion (UNaV), and fractional excretion of sodium (FENa) in inactin anesthetized rats. Unlike clevidipine, fenoldopam also produced significant increases in renal blood flow (RBF) and urinary potassium excretion (UKV). In a separate series, unilateral renal failure was induced in anesthetized rats by occluding the left renal artery for 40 min followed by reperfusion. In this model, there was a 70-75% reduction in the GFR that was paradoxically associated with several fold increases in UV, UNaV, and FENa in the vehicle treated group. In two separate groups, infusions of neither clevidipine nor fenoldopam (5.0 nmol/kg(-1) min(-1)) for 60 min beginning 10 min before reperfusion, improved filtration fraction. However, clevidipine treatment markedly improved tubular function in that loss of sodium and water were significantly attenuated and UV and UNaV were restored towards basal levels. In contrast, in the fenoldopam group, tubular function was further deteriorated as evidenced by exacerbated losses of sodium and water. These observations suggest that whereas both clevidipine and fenoldopam were potent natriuretic agents, only the calcium antagonist was effective in preserving renal function in the present experimental model of ischemic renal failure.