Trauma and Acute Care Surgery

Optimizing Energy Expenditure and Oxygenation Toward Ventilator Tolerance is Associated with Lower Ventilator and ICU Days Introduction We hypothesize that if both energy expenditure and oxygenation are optimized (EEOO) towards ventilator tolerance; this would provide patients with the best condition to be liberated from the ventilator. We defined ventilator tolerance as having a RQ value between 0.7 and 1.0, while maintaining saturations above 98% with FiO2 70% or less and a normal respiratory rate without causing disturbances to the patient’s pH. Methods This is a single institution prospective cohort study of ventilator dependent patients within a closed trauma ICU. The study period was over 52 months. A total of 1,090 patients were part of the primary analysis. The test group (EEOO) was compared to a historical cohort, comparing 26 months in each study group. The primary outcome of this study was number of ventilator days. Secondary outcomes included in-hospital mortality, ICU LOS, overall hospital length of stay, tracheostomy rates, reintubation rates, and in hospital complication rates such as pneumonia and ARDS. Both descriptive and multivariable regression analysis were performed to compare the effects of the EEOO protocol to our standard protocols alone. Results The primary outcome of number of ventilator days was significantly shorter the EEOO cohort by nearly 3 days. This was significant even after adjustment for age, gender, race, comorbidities, nutrition type, and injury severity, (4.3 vs. 7.2 days, pvalue 0.0001). The EEOO cohort also had significantly lower ICU days, hospital days, and overall complications rates. Conclusions Optimizing the patient’s nutritional regimen to ventilator tolerance and optimizing oxygenation by means of targeted pulmonary mechanics and inspired FiO2 may be associated with lower ventilator and ICU days as well as overall complication rates. Level of Evidence IV, comparative study *None of the authors report any conflict of interest and this study was not funded. This was an oral presentation at the 32nd EAST Annual Scientific Assembly, January 15-19, 2019 in Austin, Texas. Correspondence: Darwin Ang @ Darwin.Ang@hcahealthcare.com or darwinang@gmail.com © 2019 Lippincott Williams & Wilkins, Inc.

Implementation of a Prehospital Air Medical Thawed Plasma Program: Is It Even Feasible? Introduction The PAMPer trial demonstrated a 30-day survival benefit among hypotensive trauma patients treated with prehospital plasma during air medical transport. We characterized resources, costs and feasibility of air medical prehospital plasma program implementation. Methods We performed a secondary analysis using data derived from the recent PAMPer trial. Intervention patients received thawed plasma (5-day shelf-life). Unused plasma units were recycled back to blood bank affiliates, when possible. Distribution method and capability of recycling varied across sites. We determined the status of plasma units deployed, utilized, wasted, and returned. We inventoried thawed plasma use and annualized costs for distribution and recovery. Results The PAMPer trial screened 7,275 patients and 5,103 plasma units were deployed across 22 air medical bases over a 42-month time period. Only 368 units (7.2%) of this total thawed plasma pool were provided to plasma randomized PAMPer patients. Of the total plasma pool, 3,716 (72.8%) units of plasma were returned to the blood bank with the potential for transfusion prior to expiration and 1,019 (20.0%) thawed plasma units were deemed wasted for this analysis. The estimated average annual cost of implementation of a thawed plasma program per air medical base at an average courier distance would be between $24,343 and $30,077 depending on the ability to recycle plasma and distance of courier delivery required. Conclusion A prehospital plasma program utilizing thawed plasma is resource intensive. Plasma waste can be minimized depending on trauma center and blood bank specific logistics. Implementation of a thawed plasma program can occur with financial cost. Products with a longer shelf-life such as liquid plasma or freeze-dried plasma may provide a more cost-effective prehospital product relative to thawed plasma. Study Type Secondary Analysis of Clinical Trial Level of evidence III This paper was presented as an oral presentation at the annual meeting of the Western Trauma Association, March 3th-9th, 2019; Snowmass, CO. This research was funded by the US Army Medical Research and Materiel Command, Fort Detrick, Maryland 21702, Grant Number W81XWH-12-2-0023. There are no conflicts of interest for the current study Correspondence and Reprints: Jason L. Sperry, MD, MPH, Division of General Surgery and Trauma, Department of Surgery, University of Pittsburgh Medical Center, 200 Lothrop Street, Pittsburgh, PA 15213, Phone: (412) 802-8270, Fax: (412) 647-1448, email: sperryjl@upmc.edu © 2019 Lippincott Williams & Wilkins, Inc.

An Inflammatory Pulmonary Insult Post-TBI Worsens Subsequent Spatial Learning and Neurological Outcomes Background Severe traumatic brain injury (TBI) patients are at high risk for early aspiration and pneumonia. How pneumonia impacts neurological recovery after TBI is not well characterized. We hypothesized that, independent of the cerebral injury, pneumonia after TBI delays and worsens neurological recovery and cognitive outcomes. Methods Fifteen CD1 male mice were randomized to sham craniotomy or severe TBI (controlled cortical impact (CCI) - velocity 6m/s, depth 1.0mm) ± intratracheal lipopolysaccharide (LPS-2mg/kg in 0.1ml saline) as a pneumonia bioeffector. Neurological functional recovery by Garcia Neurologic Testing (GNT) and body weight loss were recorded daily for 14 days. On days 6-14, animals underwent Morris Water Maze (MWM) learning and memory testing with Cued Trials (platform visible), Spatial Learning Trials (platform invisible, spatial cues present), and Probe (memory) Trials (platform removed, spatial clues present). Intergroup differences were assessed by the Kruskal-Wallis test with Bonferroni correction (p<0.05). Results Weight loss was greatest in the CCI+LPS group (maximum 24% on Day 3 vs. 8% [Sham], 7% [CCI], both on Day 1). GNT was lowest in CCI+LPS during the first week. MWM testing demonstrated greater spatial learning impairment in the CCI+LPS group vs. Sham or CCI counterparts. Cued learning and long-term memory were worse in CCI+LPS and CCI as compared to Sham. Conclusion A pneumonia bioeffector insult after TBI worsens weight loss and mortality in a rodent model. Not only is spatial learning impaired, but animals are more debilitated and have worse neurologic performance. Understanding the adverse effects of pneumonia on TBI recovery is the first step in optimizing pulmonary care for brain-injured patients. Study Type This is a basic science Original Article and does not require a Level of Evidence. Correspondence address: Jose L. Pascual, MD, PhD, FRCS(C), FACS, FCCM, Division of Traumatology, Surgical Clinical Care and Emergency Surgery, University of Pennsylvania Perelman School of Medicine, 51 N 39th Street, Medical Office Building 1st Floor Suite 120, room 108, Philadelphia, PA 19104. Tel: +1-215-614-0316. E-mail address: jose.pascual@uphs.upenn.edu Institution where work was performed: Perelman School of Medicine, University of Pennsylvania Financial Support: Departments of Surgery at both Thomas Jefferson University Hospital and the University of Pennsylvania. Funding was used to supply materials, animals, and reagents for this study. Conflicts of Interest: None This work has not been previously published in any form. This work was a podium presentation at 32nd Annual Meeting of the Eastern Association for the Surgery of Trauma, Jan 15-19, 2019 in Austin, TX. Author Contributions: Authors contributed to literature search (CLJ, SA, YS, AJP, RL, JM, MCS, JLP), study design (CLJ, SA, YS, AJP, MCS, JLP), data collection (CLJ, SA, YS, RL, JM), data analysis (CLJ, SA, YS, RL, JM, JLP), data interpretation (CLJ, SA, YS, AJP, RL, JM, MCS, LJK, DHS, DNH, CWS, JLP), writing (CLJ, SA, YS, AJP, RL, JM, MCS, LJK, DHS, DNH, CWS, JLP), and critical revision (CLJ, SA, YS, AJP, RL, JM, MCS, LJK, DHS, DNH, CWS, JLP). © 2019 Lippincott Williams & Wilkins, Inc.

ORTHOPEDIC INJURIES IN MULTI-TRAUMA PATIENTS: RESULTS OF THE 11th TRAUMA UPDATE INTERNATIONAL CONSENSUS CONFERENCE: MILAN, DECEMBER 11, 2017 Background In blunt trauma, orthopedic injuries are often associated with cerebral and torso injuries. The optimal timing for definitive care is a concern. The aim of the study was to develop evidence-based guidelines for Damage Control Orthopedic (DCO) and Early Total Care (ETC) of pelvic and long-bone fractures, closed or open, and mangled extremities in adult trauma patients with and without associated injuries. Methods The literature since 2000 to 2016 was systematically screened according to PRISMA [Preferred Reporting Items for Systematic Reviews and meta-analyses] protocol. One-hundred twenty-four articles were reviewed by a panel of experts to assign grade of recommendation (GoR) and level of evidence (LoE) using the GRADE [Grading of recommendations Assessment, Development, and Evaluation] system, and an international consensus conference, endorsed by several scientific Societies was held. Results The choice between DCO and ETC depends on the patient’s physiology as well as associated injuries. In hemodynamically unstable pelvic fracture patient, extra-peritoneal pelvic packing, angio-embolization, external fixation, C-clamp and REBOA are not mutually exclusive. Definitive reconstruction should be deferred until recovery of physiological stability. In long bone fractures, DCO is performed by external fixation, while ETC should be preferred in fully resuscitated patients because of better outcomes. In open fractures early debridement within 24 hours should be recommended and early closure of most grade I, II, IIIa performed. In mangled extremities limb salvage should be considered for non-life-threatening injuries, mostly of upper limb. Conclusion Orthopedic priorities may be: to save a life: control hemorrhage by stabilizing the pelvis and femur fractures; to save a limb: treat soft tissue and vascular injuries associated with fractures, stabilize fractures, recognize and prevent compartmental syndrome; to save functionality: treat dislocations, articular fractures, distal fractures. While DCO is the best initial treatment to reduce surgical load, ETC should be applied in stable or stabilized patients to accelerate the recovery of normal functions. Level of evidence Level II: Systematic review of predominantly level II studies No conflict of interest to be declared, no funding has been received. © 2019 Lippincott Williams & Wilkins, Inc.

“THE BUSINESS OF RESEARCH: AN EXPLORATION INTO THE EXPERIENCES GAINED FROM A CAREER IN ACADEMIA & INDUSTRY” No abstract available

Rethinking the definition of major trauma: The Need For Trauma Intervention outperforms Injury Severity Score and Revised Trauma Score in 38 adult and pediatric trauma centers Background Patients’ trauma burdens are a combination of anatomic damage, physiologic derangement, and the resultant depletion of reserve. Typically, Injury Severity Score (ISS) >15 defines major anatomic injury and Revised Trauma Score (RTS) <7.84 defines major physiologic derangement, but there is no standard definition for reserve. The Need For Trauma Intervention (NFTI) identifies severely depleted reserves (NFTI+) with emergent interventions and/or early mortality. We hypothesized NFTI would have stronger associations with outcomes and better model fit than ISS and RTS. Methods Thirty-eight adult and pediatric U.S. trauma centers submitted data for 88,488 encounters. Mixed models tested ISS >15, RTS <7.84, and NFTI’s associations with complications, survivors’ discharge to continuing care, and survivors’ length of stay (LOS). Results NFTI had stronger associations with complications and LOS than ISS and RTS (odds ratios (99.5% CI): NFTI = 9.44 (8.46, 10.53), ISS = 5.94 (5.36, 6.60), RTS = 4.79 (4.29, 5.34); LOS incidence rate ratios (99.5% CI): NFTI = 3.15 (3.08, 3.22), ISS = 2.87 (2.80, 2.94), RTS = 2.37 (2.30, 2.45)). NFTI was more strongly associated with continuing care discharge but not significantly more than ISS (relative risk (99.5% CI): NFTI = 2.59 (2.52, 2.66), ISS = 2.51 (2.44, 2.59), RTS = 2.37 (2.28, 2.46)). Cross-validation revealed that in all cases NFTI’s model provided a much better fit than ISS>15 or RTS<7.84. Conclusions In this multicenter study, NFTI had better model fit and stronger associations with the outcomes than ISS and RTS. By determining depletion of reserve via resource consumption, NFTI+ may be a better definition of major trauma than the standard definitions of ISS >15 and RTS <7.84. Using NFTI may improve retrospective triage monitoring and statistical risk adjustments. Level of Evidence III, Therapeutic Corresponding author information: Jacob W. Roden-Foreman, 3409 Worth Street, Pickens building, Ste. C2.500, Dallas, TX 75214. Jacob.RodenForeman@BSWHealth.org This manuscript was accepted for presentation at the 77th Annual Meeting of the American Association for the Surgery of Trauma, September 26-29, 2018 in San Diego, CA. Conflicts of Interest and Source of Funding: Author KWS is funded by the University of Arkansas for Medical Sciences Clinician Scientist Program. All others declare no conflicts of interest or sources of funding. © 2019 Lippincott Williams & Wilkins, Inc.

Readmission Rates and Associated Factors Following Rib Cage Injury Background There remains a lack of knowledge about readmission characteristics after sustaining rib fractures. We aimed to determine rates, characteristics, and predictive/protective factors associated with unexpected reevaluation and readmission after rib cage injury. Methods A retrospective review was performed based on trauma patients evaluated at an urban level 1 trauma center from January 2014 to December 2016. Adult patients sustaining blunt trauma with >1 rib fracture or a sternomanubrial fracture were defined as having moderate to severe rib cage injury. Exclusion criteria included penetrating injury, death during initial hospitalization, and only 1 rib fracture. Reevaluation was defined as presenting at a hospital within 90 days of discharge urgently or emergently. Demographics, injury characteristics, comorbidities, complications, imaging, and readmission data were collected. Univariate and multivariate analysis was performed with a significance of p<0.05. Results During the study period, 11,667 patients underwent trauma evaluation, of which 1,717 patients were found to have a moderate to severe rib cage injury. Within 90 days, 397 (23.1%) of patients underwent reevaluation, while 177 (10.3%) required readmission. 142 (8.3%) patients were reevaluated specifically for chest related complaints and 55 (3.2%) required readmission. On univariate analysis, Injury Severity Score >15, hospital length of stay (LOS) >7 days, intensive care unit LOS >3 days, a worsened chest x-ray at discharge, a psychiatric comorbidity, a smoking comorbidity, deep vein thrombosis, unplanned readmission to the ICU, and unplanned intubation were higher in the overall reevaluation cohort. On multivariate analysis, age 15-35, Risk Assessment Profile score >8, hypertension, psychiatric comorbidity, current smoker, and unplanned return to the ICU on index admission were predictive of reevaluation of overall reevaluation. Conclusions Moderate to severe rib cage injury is associated with high rates of reevaluation and readmission. Younger patients who smoke and required a return to the ICU are at greater risk for readmission. Level of Evidence Level IV, Retrospective Cohort, Prognostic and Epidemiologic CONFLICT OF INTEREST: The authors report no proprietary or commercial interest in any product mentioned or concept discussed in this article. No funding was received for this work Presented at the 2019 Chest Wall Injury Summit, March 28-30, Santa Fe, NM. Corresponding Author: Christopher Janowak, MD, christopher.janowak@uc.edu, Assistant Professor of Surgery, University of Cincinnati, Department of Surgery, 231 Albert Sabin Way, ML 0558, Cincinnati, OH 45267-0558 © 2019 Lippincott Williams & Wilkins, Inc.

Reply to Letter to Editor concerning “Comparison of the Efficacy of a Bougie and Stylet in Patients With Endotracheal Intubation” No abstract available

Undertriaged Trauma Patients: Who are we Missing? Introduction Trauma team activation (TTA) criteria, set by the ACS Committee on Trauma (COT), are used to identify patients prehospital who are at highest risk for severe injury and mobilize the optimal resources. Patients are undertriaged if they are severely injured (ISS ≥16) but do not meet TTA criteria. This study examined the epidemiology and injury patterns of undertriaged patients and potential clinical effects. Methods All patients presenting to our Level I trauma center (06/01/2017-05/31/18) were screened for inclusion using modified TTA criteria (mTTA), i.e. age >70 added to the standard ACS COT TTA criteria. Demographics, injury/clinical data, and outcomes of undertriaged patients were analyzed. Undertriaged patients were further subcategorized as "high risk" if they expired or required emergent intervention. Results 233 undertriaged patients were identified from 1423 routine trauma consults (16%). Mean ISS was 20 (range 16-43). Most undertriage occurred following blunt trauma (n=224, 96%), especially MVCs (n=66, 28%) and AVPs (n=57, 24%). Thirty-two patients (14%) were identified as high risk undertriaged patients: 16 (50%) required emergency surgery (mainly craniectomy; n=10, 63%), 5 (16%) required angioembolization, and 14 patients (44%) died. In this high risk group, the cause of death was almost exclusively traumatic brain injury (TBI) (n=13, 93%). Of the patients who died of TBI, the majority had a depressed GCS on presentation to the ED (<11) (n=10, 77%) despite not meeting field criteria for TTA. Conclusions Using mTTA criteria, undertriage rates are relatively low, particularly after penetrating trauma. However, there is a high risk population that is not captured, among whom mortality and need for emergent intervention are high. Most undertriage deaths are secondary to severe TBI. Despite not qualifying for highest level activation, patients with head trauma and GCS <11 on admission are at high risk for adverse outcomes and additional resource mobilization should be considered. Level of Evidence III Study Type Prognostic and Epidemiological Author Email Addresses Morgan Schellenberg, morgan.schellenberg@med.usc.edu Elizabeth Benjamin, elizabeth.benjamin@med.usc.edu James M. Bardes, james.bardes@hsc.wvu.edu Kenji Inaba, kinaba@surgery.usc.edu Demetrios Demetriades, demetrios.demetriades@med.usc.edu Address for Correspondence Morgan Schellenberg, MD MPH Division of Trauma and Surgical Critical Care LAC + USC Medical Center University of Southern California 2051 Marengo Street Inpatient Tower, C5L100 Los Angeles, CA 90033 E-mail: morgan.schellenberg@med.usc.edu Conflict of interest The authors have no conflicts of interest or disclosures of funding to declare. Presentations This study was presented at the 90th annual meeting of the pacific coast surgical association (pcsa), february 15-18, 2019 in tucson, az. © 2019 Lippincott Williams & Wilkins, Inc.

Straddle injuries to the bulbar urethra: what’s the best choice for immediate management? BACKGROUND Cystostomy, endoscopic realignment and emergency anastomosis are three methods used to treat bulbous urethral injury (BUI). The aim of the study is to determine the optimal management. METHODS A retrospective study was performed on 328 male patients with blunt straddle injury to the perineum. In total, 304 patients were included in the analysis due to strict criteria. Among these 304 patients, 197 had partial urethral disruption diagnosed, and 107 had complete urethral disruption. Group placement of the patients was based on the extent of injury. Each group was further divided into two subgroups based on the immediate management. Propensity score matching was used to correct for differences in baseline characteristics. RESULTS In the partial disruption group, the propensity score-matched subgroups set comprised of 164 patients. Of the 82 patients treated with endoscopic realignment, 34 patients (41.5%) required no urethral surgery, in contrast to 12 patients (14.6%) with cystostomy (P<0.05). No significant difference was found in the other respects (P>0.05). In the complete disruption group, the propensity score-matched subgroups set comprised of 104 patients. The success rate of emergency anastomosis was 90.4% (47 patients), and urethral stricture occurred in five patients (96%), while urethral stricture developed in all 52 patients in the cystostomy subgroup. With regard to surgical management of complications, the choice of management methods significantly differed between the two subgroups (all, P<0.05). The time to natural urination and duration of hospital stay were significantly shorter in the emergency anastomosis subgroup (29.1±5.4 days vs. 57.1±6.4 days; 7.2±3.1 days vs.12.5±2.3days, each p <0.05). CONCLUSIONS Endoscopic realignment is associated with a lower stricture rate than cystostomy as immediate management for partial disruption. Emergency anastomosis provides better clinical outcomes for patients with complete disruption. LEVEL OF EVIDENCE Therapeutic Level IV. These authors have contributed equally to this work #Corresponding author: Jihong Wang, PhD, Department of Urology Shanghai Jiao Tong University Affiliated Sixth People’s Hospital 600 Yi Shan Road, Shanghai 200233, China E-mail: wangjihongsh@aliyun.com Declaration of conflicting interest: The authors declare no conflicts of interest. Funding: The author(s) received no financial support for the research, authorship, and/or publication of this article. Xufeng Peng:pxf1991715@163.com Hailin Guo: 1176602027@qq.com Xinru Zhang:13061764323@163.com Jihong Wang: wangjihongsh@aliyun.com © 2019 Lippincott Williams & Wilkins, Inc.