Trauma and Acute Care Surgery

Helmet Use is Associated with Higher Injury Severity Scores in Alpine Skiers and Snowboarders Evaluated at a Level 1 Trauma Center Background There is uncertainty regarding the efficacy of ski helmets in preventing traumatic injury. We investigated the relationship between helmet use, injury types and injury severity among skiers and snowboarders. Methods The trauma registry at a Northeast ACS Level 1 trauma center was queried by ICD 9/10-code for skiing and snowboarding injury between 2010 and 2018. The primary exposure was helmet use and primary outcome was severe injury (injury severity score >15). We performed univariate and multivariable logistic regression to assess for injury types and severity associated with helmet use. Results 721 patients (65% helmeted, 35% unhelmeted) met inclusion criteria. Helmet use doubled during the study period (43% to 81%, p<0.001), but the rate of any head injury did not significantly change (49% to 43%, p=0.499). On multivariable regression, helmeted patients were significantly more likely to suffer severe injury (OR:2.01, CI:1.30-3.11), intracranial hemorrhage (OR:1.81, CI:1.10-2.96), chest injury (OR:1.66, CI:1.05-2.61), and/or lumbosacral spine injury (OR:1.84, CI:1.04-3.25) than unhelmeted patients. Helmeted patients were half as likely to suffer cervical spine injury (OR:0.51, CI:0.30-0.89) and a third as likely to sustain skull fracture and/or scalp laceration (OR:0.30, CI:0.14-0.64). More patients who hit a stationary object were helmeted compared to those who fell from standing height onto snow (70% vs. 56% respectively, p<0.001). After adjustment, hitting a stationary object was the injury mechanism most significantly associated with severe injury (OR:2.80, CI:1.79-4.38). Conclusion Helmeted skiers and snowboarders evaluated at a Level 1 trauma center were more likely to suffer severe injury, including intracranial hemorrhage, as compared to unhelmeted participants. However, they were less likely to sustain skull fractures or cervical spine injuries. Helmeted patients were also more likely to hit a stationary object. Our findings reinforce the importance of safe skiing practices and trauma evaluation after high impact injury, regardless of helmet use. Level of Evidence III, prognostic and epidemiological 49th Annual Meeting Western Trauma Association Earl G. Young Clinical Research Competition March 3rd - 8th, 2019 Aspen, CO Correspondence: Andrew O. Crockett, MD, Assistant Professor of Surgery, Division of Trauma and Acute Care Surgery, Dartmouth-Hitchcock Medical Center, 1 Medical Center Dr.Lebanon, NH 03756. T: (603)650-5000, F: (603)650-8030 Conflict of Interest Statement: The authors of this manuscript have nothing to declare. © 2019 Lippincott Williams & Wilkins, Inc.

Influence of prehospital physician presence on survival after severe trauma: Systematic review and meta-analysis Background As trauma is one of the leading causes of death worldwide, there is great potential for reducing mortality in trauma patients. However, there is continuing controversy over the benefit of deploying EMS physicians in the prehospital setting. The objective of this systematic review and meta-analysis is to assess how out-of-hospital hospital management of severely injured patients by EMS teams with and without physicians affects mortality. Methods PubMed and Google Scholar were searched for relevant articles and the search was supplemented by a hand search. Injury severity in the group of patients treated by an EMS team including a physician had to be comparable to the group treated without a physician. Primary outcome parameter was mortality. Helicopter transport as a confounder was accounted for by sub-group analyses including only the studies with comparable modes of transport. Quality of all included studies was assessed according to the Cochrane handbook. Results 2,249 publications were found, 71 full-text articles assessed and 22 studies included. Nine of these studies were matched or adjusted for injury severity. The odds ratio (OR) of mortality was significantly lower in the EMS physician-treated group of patients: 0.81; 95% confidence interval (CI): 0.71-0.92. When analysis was limited to the studies that were adjusted or matched for injury severity, the OR was 0.86 (95% CI: 0.73-1.01). Analysing only studies published after 2005 yielded an OR for mortality of 0.75 (95% CI: 0.64-0.88) in the overall analysis and 0.81 (95% CI: 0.67-0.97) in the analysis of adjusted or matched studies. The OR was 0.80 (95% CI: 0.65-1.00) in the sub-group of studies with comparable modes of transport and 0.74 (95% CI: 0.53-1.03) in the more recent studies. Conclusion Prehospital management of severely injured patients by EMS teams including a physician seems to be associated with lower mortality. After excluding the confounder of helicopter transport we have shown a non-significant trend toward lower mortality. Level of evidence level III Type of study Systematic review and meta-analysis Corresponding author: Dr. Jürgen Knapp, MD, Department of Anaesthesiology and Pain Medicine, Inselspital, Bern University Hospital, University of Bern, Freiburgstrasse, 3010 Bern, Switzerland, Phone: +41 31 632 04 96, Mobile: +49 176 20 370 299. E-mail: juergen.knapp@insel.ch Funding: None Conflicts of interest: None © 2019 Lippincott Williams & Wilkins, Inc.

KEtaminE/ProPofol Admixture vs Etomidate for Intubation in the Critically-Ill: KEEP PACE Randomized Clinical Trial Background Peri-intubation hypotension is associated with poor outcomes in the critically-ill. We aimed to determine if an admixture of ketamine and propofol for emergent endotracheal intubation in critically-ill patients was superior to etomidate. Primary endpoint was the change in mean arterial pressure from baseline to 5 minutes post-drug administration. Methods Emergent-use, stratified (shock status and unit type), multi-unit, randomized, parallel-group superiority clinical trial was conducted at a tertiary academic medical center. Adult medical/surgical and transplant/oncologic intensive care unit patients undergoing emergent intubation were assigned randomly to receive either ketamine/propofol admixture [0.5 mg/kg of ketamine and propofol each] or reduced dose etomidate [0.15 mg/kg] for emergent intubation. Results One hundred and sixty participants were randomized and 152 (79 ketamine/propofol admixture, 73 etomidate) were included in the intention-to-treat analysis. There was no statistically significant difference in mean arterial pressure change from baseline to 5 minutes post-drug administration [treatment difference (ketamine/propofol admixture – etomidate): -2.1 mmHg 95% C.I. (-6.9 mmHg, +2.7 mmHg); P=0.385]. In addition, no statistically significant difference was demonstrated in the change of mean arterial pressure from baseline at 10 and 15 minutes post-drug administration, no statistical difference in the use of new-onset vasoactive agents or difficulty of intubation between groups. More patients in the etomidate group required non-red blood cell transfusions [16 (22%) vs. 8 (10%), P=0.046]. For patients who had adrenal testing performed, more patients in the etomidate group developed immediate adrenal insufficiency [13/16 (81%) vs. 5/13 (38%), P=0.027]. Serious adverse events were rare, 2 (3%) [cardiac arrest, hypotension] in ketamine/propofol admixture and 4 (5%) [hypertension, hypotension] in etomidate (P=0.430). Conclusions In a heterogeneous critically-ill population, ketamine/propofol admixture was not superior to a reduced dose of etomidate at preserving per-intubation hemodynamics and appears to be a safe alternative induction agent in the critically-ill. Level of Evidence Level 1, Therapeutic Trial Registry ClinicalTrials.gov, # NCT02105415, Ketamine / Propofol Admixture "Ketofol" at Induction in the Critically Ill Against Etomidate: KEEP PACE Trial, IRB# 13-000506, Trial Registration: 03/31/2014 Correspondence/Reprints: Nathan J. Smischney, MD, Department of Anesthesiology, Mayo Clinic, 200 First St SW, Rochester, MN 55905. Tel: 507-255-6051/Fax: 507-255-4267. Email: smischney.nathan@mayo.edu. No reprints will be ordered. Conflict of Interest: Drs. Smischney and Nicholson have a provisional patent filed for ketamine/propofol admixture: Serial #:62/487,330; Filing Date: 04/19/17. The other authors have nothing to disclose. Meetings: 2018 Military Health System Research Symposium, August 20-23, 2018 in Kissimmee, Florida; 2018 Georgia Society of Anesthesiologists Summer Meeting, July 13-15, 2018 in Lake Oconee, Greensboro, Georgia. Financial Support: Funded by the Department of Anesthesiology and Perioperative Medicine and the Critical Care Independent Multidisciplinary Practice at Mayo Clinic Rochester. This publication was made possible by CTSA Grant Number UL1 TR002377 from the National Center for Advancing Translational Sciences (NCATS), a component of the National Institutes of Health (NIH). Its contents are solely the responsibility of the authors and do not necessarily represent the official view of NIH. © 2019 Lippincott Williams & Wilkins, Inc.

My Dad the Renaissance Man No abstract available

One Year Mortality in Geriatric Trauma Patients: Improving Upon the Geriatric Trauma Outcomes Score Utilizing the Social Security Death Index Background GTOS predicts in-patient mortality in geriatric trauma patients and has been validated in a prospective multicenter trial and expanded to predict adverse discharge (GTOS II). We hypothesized that these formulations actually underestimate the downstream sequelae of injury and sought to predict longer-term mortality in geriatric trauma patients. Methods The Parkland Memorial Hospital Trauma registry was queried for patients age ≥65 years from 2001–2013. Patients were then matched to the SSDI. The primary outcome was one-year mortality. The original GTOS formula (variables of age, ISS, 24-hour transfusion) was tested to predict 1-year mortality using receiver operator curves. Significant variables on univariate analysis were used to build an optimal multivariate model to predict 1-year mortality (GTOS III). Results There were 3,262 patients who met inclusion. Inpatient mortality was 10.0% (324) and increased each year: 15.8% one, 17.8% two, and 22.6% five years. The original GTOS equation had an area under the curve (AUC) of 0.742 for 1-year mortality. Univariate analysis showed that patients with 1-year mortality had on average increased age (75.7 vs. 79.5 years), ISS (11.1 vs. 19.1), lower GCS (14.3 vs. 10.5), more likely to require transfusion within 24 hours (11.5% vs. 31.3%), and adverse discharge (19.5% vs. 78.2%; p<0.0001 for all). Multivariate logistic regression was used to create the optimal equation to predict one-year mortality: [GTOSIII = Age + (0.806 x ISS) + 5.55 (if transfusion in first 24 hours) + 21.69 (if low GCS) + 34.36 (if adverse discharge)]; AUC of 0.878. Conclusions Traumatic injury in geriatric patients is associated with high mortality rates at 1–5 years. GTOS III has robust test characteristics to predict death at one year and can be used to guide patient centered goals discussions with objective data. Study Type Original Article Level of Evidence III Evidence Level III: Retrospective cohort study Presented at the 49th Annual Meeting of Western Trauma Association, March 4, 2019 in Snowmass, Colorado, Earl G. Young Clinical Research Competition Award Nomination Paper No funding was received for this study The authors have no conflicts of interest to report Senior Author Contact: Herbert Phelan, MD, MSCS, FACS, Associate Professor of Surgery, Division of General and Acute Care Surgery, UT Southwestern Medical Center, 5323 Harry Hines Blvd. – Mail Code 9158, Dallas, TX 75390-9158, Email: Herbert.Phelan@utsouthwestern.edu, Phone: 214-648-7548 © 2019 Lippincott Williams & Wilkins, Inc.

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.