Trauma and Acute Care Surgery

Development of Transfusion Guidelines for Injured Children Using a Modified Delphi Consensus Process No abstract available

Is Early Chemical Thromboprophylaxis in Patients with Solid Organ Injury a Solid Decision? Background The optimal time to initiate chemical thromboprophylaxis (CTP) in patients who have undergone non-operative management (NOM) of blunt solid organ injuries remains controversial. The aim of our study was to assess the impact of early initiation of CTP in patients with blunt abdominal solid organ injuries (SOI). Methods We performed a 2-year (2013-14) retrospective analysis of ACS-TQIP. We included all adult trauma patients (Age≥18 years) with blunt SOI who underwent NOM. Patients were stratified into 3 groups based on timing of CTP (early≤48-hours of injury, late>48-hours of injury and No Prophylaxis group). Our primary outcomes were rates of failure of NOM, pRBC transfusion, and mortality. Our secondary outcomes were the rate of venous thromboembolic (VTE) events (i.e. DVT and/or PE), and length of stay. Results A total of 36,187 patients met the inclusion criteria. Mean age was 49.5±19y and 36% of patients received CTP (Early: 37% (n=4,819) vs. Late: 63% (n=8,208)). After controlling for confounders, patients receiving early CTP had lower rates of DVT (p=0.01) and PE (p=0.01) compared to the no prophylaxis and late CTP groups. There was no difference between the three groups regarding the post-prophylaxis pRBCs transfusions, failure of NOM, and mortality. Conclusions Our results suggest that in patients undergoing NOM of blunt abdominal SOI, early initiation of CTP should be considered. It is associated with decreased rates of DVT and PE, with no significant difference in post prophylaxis pRBCs transfusion, failure of non-op management, and mortality. Level of Evidence Level IV Therapeutic Oral presentation for the 49th Annual Meeting of Western Trauma Association, March 3rd – 8th, 2019, Snowmass, Colorado. There are no identifiable conflicts of interests to report. The authors have no financial or proprietary interest in the subject matter or materials discussed in the manuscript. Address for correspondence: David J Skarupa, MD, University of Florida, Department of Surgery, Division of Acute Care Surgery, Address: 655 West 8th Street, Jacksonville, FL 32209, E-mail: David.Skarupa@jax.ufl.edu Tel: 904-244-3416 © 2019 Lippincott Williams & Wilkins, Inc.

Magnetically Trackable MT-REBOA: A new non-image-guided technique for resuscitative endovascular balloon occlusion of the aorta No abstract available

Effect of Partial and Complete Aortic Balloon Occlusion on Survival and Shock in a Swine Model of Uncontrolled Splenic Hemorrhage with Delayed Resuscitation Introduction Resuscitative endovascular balloon occlusion of the aorta (REBOA) is accepted as a resuscitation adjunct and bridge to definitive hemostasis. The ischemic burden of REBOA may be mitigated by a partial REBOA (P-REBOA) strategy permitting longer occlusion times and military use for combat trauma. We evaluated REBOA and P-REBOA in a swine polytrauma model with uncontrolled solid organ hemorrhage and delayed resuscitation and surgical hemostasis. Methods Anesthetized swine (51.9±2.2 Kg) had 20mL/kg hemorrhage and closed femur fracture. Splenic transection was performed and free bleeding permitted for 10 min. Controls (n=5) were hemorrhaged but had no REBOA, REBOA (n=8) had 60 min complete Zone 1 occlusion, P-REBOA (n=8) had 15 min complete occlusion and 45 min 50% occlusion. Splenectomy was performed and plasma (15mL/kg) resuscitation initiated 5 min prior to deflation. Resuscitation goal was 80mmHg systolic with epinephrine as needed. Animals were monitored for 6 hours. Results An initial study with 120min occlusion had universal fatality in 3 REBOA (upon deflation) and 3 P-REBOA animals (after 60min inflation). With 60min occlusion, mortality was 100%, 62.5% and 12.5% in the Control, REBOA and P-REBOA groups (P <0.05). Survival time was shorter in controls (120±89 min) than REBOA and P-REBOA groups (241±139, 336±69 min). Complete REBOA hemorrhaged less during inflation (1.1±0.5mL/kg) than Control (5.6±1.5) and P-REBOA (4.3±1.4), which were similar. Lactate was higher in the REBOA group compared to the P-REBOA group after balloon deflation, remaining elevated. Potassium increased in REBOA after deflation but returned to similar levels as P-REBOA by 120 minutes. Conclusions In a military relevant model of severe uncontrolled solid organ hemorrhage one hour P-REBOA improved survival and mitigated hemodynamic and metabolic shock. Two hours of partial aortic occlusion was not survivable using this protocol due to ongoing hemorrhage during inflation. There is potential role for P-REBOA as part of an integrated minimally invasive field-expedient hemorrhage control and resuscitation strategy. Level of Evidence Preclinical animal study The authors have no financial or other conflicts of interest. Drs. Kauvar and Schechtman are co-first authors of this manuscript Correspondence: David S. Kauvar, MD, FACS, 3551 Roger Brooke Drive, JBSA Fort Sam Houston, TX 78234, David S. Kauvar, MD (david.s.kauvar.mil@mail.mil) The assertions and opinions contained herein are solely those of the authors and do not represent those of the United States Army, United States Air Force or the Department of Defense. All authors are US Government Employees. Presented in part at the 49th annual meeting of the Western Trauma Association, March 3-8, 2019 in Snowmass, CO. © 2019 Lippincott Williams & Wilkins, Inc.

Palliative Care in Trauma: Not Just for the Dying Background Palliative care (PC) is indicated in patients with functional dependency and advanced care needs in addition to those with life threatening conditions. Older trauma patients have PC needs due to increased risk of mortality and poor long-term outcomes. We hypothesized that older trauma patients discharged alive with poor outcomes are not easily identified nor receive PC interventions. Methods Prospective observational study of trauma patients >55 years. Patients with poor functional outcomes defined by discharge Glasgow Outcome Scale Extended (GOSE) 1-4 or death at 6 month follow up were analyzed for rate and timing of PC interventions including goals of care conversation (GOCC), do not resuscitate order (DNR), do not intubate order (DNI) and withdrawal of life supporting measures. Logistic regression was performed for having and timing of GOCC. Results 315 (54%) of 585 patients had poor outcomes. Of patients who died, 94% had GOCC compared to 31% of patients who were discharged with GOSE 3 or 4. In patients who died, 85% had DNR, 18% had DNI, and 56% had withdrawal of ventilator. Only 24% and 9% of patients with GOSE of 3 or 4 respectively had DNR orders. 50% patients dead at 6 month follow up had GOCC during initial hospitalization. The median time to DNR in patients that died was 2 days compared to 5 days and 1 day in GOSE 3 and 4 (p=0.046). Age, injury severity scale and pre-existing limited physiological reserve were predictive of having a GOCC. Conclusion PC utilization was very high for older trauma patients who died in hospital. In contrast, the majority of those who were discharged alive, but with poor outcomes, did not have PC. Development of triggers to identify older trauma patients who would benefit from PC, could close this gap and improve quality of care and outcomes. Level of Evidence Prognostic Study-Level II Please address all Correspondence to: Anne C. Mosenthal, 185 South Orange Avenue, Newark, NJ 07103, Tel: 973-972-5045, Fax: 973-972-6803 The Authors have no conflicts of interest to report and no funding was received for this work. This paper will be presented at 49th Annual Meeting of the Western Trauma Association Meeting, Snowmass, CO, March 2019. © 2019 Lippincott Williams & Wilkins, Inc.

RE: Organ injury scaling 2018 update: Spleen, liver, and kidney No abstract available

RESIILIENCE AND LONG-TERM OUTCOMES AFTER TRAUMA: AN OPPORTUNITY FOR EARLY INTERVENTION? Background Resilience, or the ability to cope with difficulties, influences an individual’s response to life events including unexpected injury. We sought to assess the relationship between patient self-reported resilience traits and functional and psychosocial outcomes six months after traumatic injury. Methods Adult trauma patients 18-64 years of age with moderate to severe injuries (ISS ≥9) admitted to one of three Level I Trauma Centers between 2015-2017 were contacted by phone at 6 months post-injury and asked to complete a validated Trauma Quality of Life (T-QoL) survey and PTSD screen. Patients were classified into “low” and “high” resilience categories. Long-term outcomes were compared between groups. Adjusted logistic regression models were built to determine the association between resilience and each of the long-term outcomes. Results A total of 305 patients completed the 6-month interview. 204/305 of the patients (67%) were classified as having low resilience. Mean age was 42±14 years, 65% were male, 91% suffering a blunt injury and average ISS was 15.4±7.9. Patients in the low resilience group had significantly higher odds of functional limitations in activities of daily living (OR 4.81 [2.48-9.34]). In addition, patients in the lower resilience group were less likely to have returned to work/school (OR 3.25 [1.71-6.19]), more likely to report chronic pain (OR 2.57 [1.54-4.30]) and more likely to screen positive for PTSD (OR 2.96 [1.58-5.54]). Conclusion Patients with low resilience demonstrated worse functional and psychosocial outcomes six months after injury. These data suggest that screening for resilience and developing and deploying early interventions to improve resilience-associated traits as soon as possible after injury may hold promise for improving important long-term functional outcomes. Level of evidence II Study type Original Article, Prognostic Conflict of Interest Statement: No conflicts of interest Sources of Financial Support: None Presented as an Oral Podium Presentation at the 77th Annual Meeting of the Association for the Surgery of Trauma September 26-29 2018 San Diego CA Corresponding Author: Deepika Nehra, MD, 75 Francis St. Boston, MA 02215, Fax: 617-566-9549, Phone: 617-732-7715, Email: dnehra@bwh.harvard.edu © 2019 Lippincott Williams & Wilkins, Inc.

Non-Fatal Motor Vehicle Related Injuries among Deployed US Service Members: Characteristics, Trends, and Risks for Limb Amputations. Background: Motor Vehicle-Related (MVR) incidents are important causes of morbidity among deployed US Service Members (SMs). Non-battle MVR injuries are usually similar to civilian MVR injuries, while battle MVR injuries are often unique due to the blast effects from precipitating explosive mechanisms. Our primary objective was to describe the characteristics and trends of non-fatal MVR injuries sustained by deployed US SMs. A second objective was to assess the association between mechanism of injury (i.e. explosive vs. non-explosive) and limb amputation. Methods: We conducted a retrospective cross-sectional analysis using data from the Department of Defense Trauma Registry (DoDTR) collected from October 2001- December 2018. Descriptive statistics were reported stratified by mechanism of injury (explosive vs. non-explosive). The association between mechanism of injury and limb amputation was assessed using logistic regression models. Results: There were 3119 US casualties who sustained non-fatal MVR injuries, 2380 SMs (76.3%) sustained non-explosive MVR injuries while 739 (23.7%) sustained explosive MVR injuries. Of all MVR casualties, 2085 (66.9%) were in Iraq or Syria and 1034 (33.1%) in Afghanistan. The annual prevalence of non-fatal MVR battle casualties was highest in Iraq and Syria from 2003-2009 and Afghanistan from 2009-2014, ranging overall 15-50 MVR casualties per 1000 wounded in action. There were 92 limb amputations associated with MVR incidents. Compared to non-explosive MVR mechanisms, explosive MVR mechanisms had higher association with limb amputation (OR: 2.6; CI: 1.7-3.9), even after adjusting for injury year and injury severity score (AOR: 2.1; CI: 1.4-3.4). Conclusions: MVR incidents are an important cause of injury in US military operations. Compared to non-explosive MVR incidents, explosive MVR incidents result in more severe injuries, and have a higher associated risk of limb amputation. Continued efforts to improve injury prevention through protective equipment and medical training specific to MVR injuries are needed. Level of Evidence: Level III. Study Type: Epidemiological Study. Corresponding Author: Dr. Marc A. Schweizer (ORCID: 0000-0002-3459-6477) Email: marc.a.schweizer2.ctr@mail.mil; Phone: 00 1 303 909 8083 Conflicts of Interest: The authors have no financial interest, and declare that there is no conflict of interest. Funding: None Disclaimer: The view(s) expressed herein are those of the author(s) and do not reflect the official policy or position of the US Army Medical Department, the US Army Office of the Surgeon General, the Department of the Army and Department of Defense, or the US Government. © 2019 Lippincott Williams & Wilkins, Inc.

Simulation-Based Training is Associated with Lower Risk-Adjusted Mortality in ACS Pediatric TQIP Centers Background Although use of simulation-based team training for pediatric trauma resuscitation has increased, its impact on patient outcomes has not yet been shown. The purpose of this study was to determine the association between simulation use and patient outcomes. Methods Trauma centers that participate in the American College of Surgeons (ACS) Pediatric Trauma Quality Improvement Program (TQIP) were surveyed to determine frequency of simulation use in 2014 and 2015. Center-specific clinical data for 2016 and 2017 were abstracted from the ACS TQIP registry (n=57,916 patients) and linked to survey responses. Center-specific risk-adjusted mortality was estimated using multivariable hierarchical logistic regression and compared across four levels of simulation-based training use: no training, low-volume training, high-volume training, and survey non-responders (unknown training use). Results Survey response rate was 75% (94/125 centers) with 78% of the responding centers (73/94) reporting simulation use. The average risk-adjusted odds of mortality was lower in centers with a high volume of training compared to centers not using simulation (OR 0.58, 95% CI 0.37-0.92). The times required for resuscitation processes, evaluations, and critical procedures (endotracheal intubation, head computed tomography, craniotomy, and surgery for hemorrhage control) were not different between centers based on levels of simulation use. Conclusions Risk-adjusted mortality is lower in TQIP-Pediatric centers using simulation-based training, but this improvement in mortality may not be mediated by a reduction in time to critical procedures. Further investigation into alternative mediators of improved mortality associated with simulation use is warranted, including assessment of resuscitation quality, improved communication, enhanced teamwork skills, and decreased errors. Level of Evidence Level III therapeutic / care management This work was presented as a poster at the 77th Annual Meeting of the American Association for the Surgery of Trauma, San Diego, CA, September 26, 2018. None of the authors have any conflicts of interest to disclose. This work is not under consideration for publication in any other journal. Children’s Hospital Los Angeles Institutional Review Board Exemption # CHLA-16-00341 This work was supported by grant #KFVS6290 from the National Institute for Child Health and Development (NICHD) and grant #KL2TR001854 from the National Center for Advancing Translational Science (NCATS) of the U.S. National Institutes of Health. The content is solely the responsibility of the authors and does not necessarily represent the official views of the National Institutes of Health. © 2019 Lippincott Williams & Wilkins, Inc.

AUTHOR’S RESPONSE TO LETTER TO THE EDITOR WRITTEN BY DR. MELVYN HARRIS No abstract available