Trauma and Acute Care Surgery

EXTRA-PERITONEAL PACKING IN UNSTABLE BLUNT PELVIC TRAUMA: A SINGLE-CENTER STUDY Background Hemodynamically unstable pelvic fractures often require a multi-modal approach including both operative and endovascular management. While an important adjunct in hemorrhage control, time to angioembolization (AE) even at the most advanced trauma centers may take hours. Extra-Peritoneal Packing (EPP) is a fast and effective procedure that can immediately address pelvic hemorrhage from the retroperitoneal space in severe pelvic injuries. The aim of this study was to evaluate the efficacy of early EPP, looking at 24 hour and overall mortality, and the hemodynamic impact of EPP in unstable blunt pelvic trauma. Methods All trauma patients admitted to an urban Level I trauma center were evaluated from 2002 to 2018 in a retrospective single-center comparative study. Inclusion criteria were patients >= 14 years old who sustained blunt trauma with pelvic fractures and hemodynamic instability. Exclusion criteria were a concomitant head injury (AIS >3) and patients who underwent resuscitative thoracotomy. The patient population was divided into two groups: an EPP group and a No-EPP group. Propensity score matching (PSM) was used to adjust for differences in baseline characteristics in the two groups: a one-to-one matched analysis using nearest-neighbor matching was performed based on the estimated propensity score of each patient. Results Two-hundred forty four patients presented hemodynamically unstable, with a pelvic fracture (180 No-EPP, 64 EPP). With propensity score matching, thirty-seven patients in each group were analyzed. Survival within the first 24 hours was significantly improved in the EPP group (81.1% vs. 59.5%, p=0.042) and we registered similar results in overall survival rate (78.4% EPP group vs 56.8% No-EPP group, p=0.047). Those patients who underwent early EPP (n=64) were associated with a significant improvement in hemodynamic stability, with a pre-EPP mean arterial pressure (MAP) of 49.9 mmHg and post-EPP MAP of 70.1 mmHg (p < 0.01). Conclusion EPP is an effective procedure that can be performed immediately, even within the trauma bay, to improve hemodynamic stability and overall survival in patients who sustain severe blunt pelvic trauma. The early use of EPP can be lifesaving. Level of Evidence LOE III Corresponding Author: Osvaldo Chiara, MD, FACS University of Milan, ASST Grande Ospedale Metropolitano Niguarda, Milano, Piazza Ospedale Maggiore 3, Postal Code 20162, Milano, Italy. +39 02 6444 2541, +39 02 64445381, +39 02 64447209, Fax: +39 02 64442392 Presented as a Podium Presentation at 78th Annual Meeting of American Association for the Surgery of Trauma, September 20th, 2019 in Dallas, Texas Work conducted at the hospital ASST Niguarda, Milano, Piazza Ospedale Maggiore 3, postal code 20162, Milano, Italy in collaboration with the R. Adams Cowley Shock Trauma Center, University of Maryland, Baltimore, USA. Funding: This research did not receive any specific grant from funding agencies in the public, commercial, or not-for-profit sectors. Conflicts of interest: None. © 2020 Lippincott Williams & Wilkins, Inc.

Accelerating availability of clinically-relevant parameter estimates from Thromboelastogram point-of-care device Background Modeling approaches offer a novel way to detect and predict coagulopathy in trauma patients. A dynamic model, built and tested on thromboelastogram (TEG) data, was used to generate a virtual library of over 160,000 simulated RapidTEGs. The patient-specific parameters are the initial platelet count, platelet activation rate, thrombus growth rate, and lysis rate (P(0), k1, k2, and k3, respectively). Methods Patient data from both STAAMP (n=182 patients) and PAMPer (n=111 patients) clinical trials were collected. A total of 873 RapidTEGs were analyzed. 116 TEGs indicated maximum amplitude (MA) below normal and 466 TEGs indicated lysis percent above normal. Each patient’s TEG response was compared against the virtual library of TEGs to determine library trajectories having the least sum-of-squared error versus the patient TEG up to each specified evaluation time ∈ {3, 4, 5, 7.5, 10, 15, 20 minutes}. Using 10 nearest-neighbor trajectories, a logistic regression was performed to predict if the patient TEG indicated MA below normal (< 50 mm), lysis percent 30 minutes after MA (LY30) greater than 3%, and/or blood transfusion need using the parameters from the dynamic model. Results The algorithm predicts abnormal MA values using the initial 3 minutes of RapidTEG data with a median AUC of 0.95, and improves with more data to 0.98 by 10 minutes. Prediction of future platelet and packed red blood cell transfusion based on parameters at 4 and 5 minutes, respectively, provides equivalent predictions to the traditional TEG parameters in significantly less time. Dynamic model parameters could not predict abnormal LY30 or future fresh frozen plasma transfusion. Conclusions This analysis could be incorporated into TEG software and workflow to quickly estimate if the MA would be below or above threshold value within the initial minutes following a TEG, along with an estimate of what blood products to have on hand. Level of Evidence Therapeutic/Care Management: Level IV: Prospective/retrospective study using historical controls or having more than one negative criterion. Study Type: Diagnostic Test Funding and Conflict of Interest Statement: Financial support for this work is provided by the US Department of Education Graduate Assistance in Areas of National Need fellowship program (P200A150050) and the National Institutes of Health, National Heart, Lung, and Blood Institute (R21-HL-133891). Dr. Clermont has received support from Edwards Life Sciences and Astute Medical Inc. through the University of Pittsburgh. Dr. Clermont has received royalties from UpToDate, Inc. No other conflicts of interest are declared. Corresponding Author Information: Gilles Clermont, Scaife 602, 3550 Terrace St., Pittsburgh, PA 15213. map312@pitt.edu; rparker@pitt.edu; nealm2@upmc.edu; sperryjl@upmc.edu; cler@pitt.edu. © 2020 Lippincott Williams & Wilkins, Inc.

Inferior Vena Cava Bullet Embolization No abstract available

The Evolution of Initial-Hemostatic Resuscitation and the Void of Post-Hemostatic Resuscitation No abstract available

Natural Language Processing of Prehospital Emergency Medical Services Trauma Records Allows for Automated Characterization of Treatment Appropriateness Background Incomplete prehospital trauma care is a significant contributor to preventable deaths. Current databases lack timelines easily constructible of clinical events. Temporal associations and procedural indications are critical to characterize treatment appropriateness. Natural language processing (NLP) methods present a novel approach to bridge this gap. We sought to evaluate the efficacy of a novel and automated NLP pipeline to determine treatment appropriateness from a sample of prehospital EMS motor vehicle crash (MVC) records. Methods 142 records were utilized to extract airway procedures, intraosseous (IO)/intravenous (IV) access, packed red blood cell (PRBC) transfusion, crystalloid bolus, chest compression system, tranexamic acid (TXA) bolus, and needle decompression. Reports were processed using four clinical NLP systems and augmented via a word2phrase method leveraging a large integrated health system clinical note repository to identify terms semantically similar with treatment indications. Indications were matched with treatments and categorized as indicated, missed (indicated but not performed), or non-indicated. Automated results were then compared with manual review and precision and recall were calculated for each treatment determination. Results NLP identified 184 treatments. Automated timeline summarization was completed for all patients. Treatments were characterized as indicated in a subset of cases including: 69% (18 of 26) for airway, 54.5% (6 of 11) for IO access, 11.1% (1 of 9) for needle decompression, 55.6% (10 of 18) for TXA, 60% (9 of 15) for PRBC, 12.9% (4 of 31) for crystalloid bolus, and 60% (3 of 5) for chest compression system. The most commonly non-indicated treatment was crystalloid bolus (22 of 142 patients). Overall, the automated NLP system performed with high precision and recall with over 70% of comparisons achieving precision and recall of greater than 80%. Conclusion NLP methodologies show promise for enabling automated extraction of procedural indication data and timeline summarization. Future directions should focus on optimizing and expanding these techniques to scale and facilitate broader trauma care performance monitoring. Level of Evidence Diagnostic Tests or Criteria, Level III This study was presented at the 78th annual meeting of American Association for the Surgery of Trauma Meeting, September 18-21, 2019, in Dallas, Texas Correspondence: Christopher J. Tignanelli, M.D., Assistant Professor of Surgery, University of Minnesota, 420 Delaware St SE, MMC 195, Minneapolis, MN 55455, Office: (612) 626-1968, Fax: (612) 626-0439. Email: ctignane@umn.edu Reprints will not be available from the authors. The authors have no conflicts of interest to disclose © 2020 Lippincott Williams & Wilkins, Inc.

Pediatric Extremity Vascular Trauma: It Matters Where it is Treated Background Extremity vascular injuries in children are rare events that present unique therapeutic challenges. The absence of a pediatric-specific protocol for definitive care of these injuries risks variability in treatment practices and outcomes. Using a nationwide dataset, we investigated variations in the management and outcomes of pediatric patients with peripheral vascular trauma and characterized differences based on hospital category. Methods Retrospective cohort study using the American College of Surgeons (ACS) National Trauma Data Bank to identify patients aged 16 years or younger with extremity vascular trauma admitted in calendar year 2016. Hospitals were categorized as ACS-verified pediatric trauma centers (level I or II), ACS-verified adult trauma centers (level I or II), or other hospitals (all other trauma centers and non-designated hospitals). Patient data were evaluated by hospital category. Results Among 164,882 pediatric admissions, 702 patients were identified for analysis. There were 430 (61.3%) patients with upper extremity injuries, 270 (38.5%) with lower extremity injuries, and 2 (0.2%) had both. Mean age was 11.5 years and 51.6% were blunt-injured. Overall, 40.2% were admitted to pediatric trauma centers, 28.9% to adult trauma centers, and 30.9% to other hospitals. Hospitals without ACS trauma center verification had a significantly higher amputation rate than any ACS-verified adult or pediatric center (p = 0.013). Conclusion The incidence of pediatric extremity vascular injury is low. Hospitals with ACS trauma center verification have greater pediatric limb salvage rates than those without verification. Future study should seek to identify specific regional or resource-related factors that contribute to this disparity. Level of Evidence Level III. Epidemiological Address Correspondence to: Romeo C. Ignacio, MD, Division of Pediatric Surgery, Rady Children’s Hospital San Diego, 3020 Children’s Way, MC 5136, San Diego, CA 92123. Phone: 858-966-7711. Fax: 858-966-7712. Email: r1ignacio@ucsd.edu Sources of Funding: This research did not receive any specific grant from funding agencies in the public, commercial, or not-for-profit sectors. Declarations of Interest: The authors report no proprietary or commercial interest in any product mentioned or concept discussed in this article. Conflict of Interest: The authors report no conflict of interest. This work was presented as a podium presentation at the 78th Annual Meeting of The American Association for the Surgery of Trauma, September 18-21, 2019 in Dallas, Texas. © 2020 Lippincott Williams & Wilkins, Inc.

An Analysis of Overtriage and Undertriage by Advanced Life Support Transport in a Mature Trauma System Background While issues regarding triage of severely injured trauma patients are well publicized, little information exists concerning the difference between triage rates for patients transported by advanced life support (ALS) and basic life support (BLS). We sought to analyze statewide trends in undertriage (UT) and overtriage (OT) to address this question, hypothesizing that there would be a difference between the UT and OT rates for ALS compared to BLS over a 13-year period. Methods All patients submitted to Pennsylvania Trauma Outcomes Study database from 2003-2015 were analyzed. UT was defined as not calling a trauma alert for patients with an Injury Severity Score (ISS) ≥16. OT was defined as calling a trauma alert for patients with an ISS≤9. A logistic regression was used to assess mortality between triage groups in ALS and BLS. A multinomial logistic regression assessed the adjusted impact of ALS vs BLS transport on UT and OT versus normal triage while controlling for age, sex, Glasgow Coma Score (GCS), systolic blood pressure (SBP), pulse, Shock Index and injury year. Results A total of 462,830 patients met inclusion criteria, of which 115,825 had an ISS≥16 and 257,855 had an ISS≤9. Both ALS and BLS had significantly increased mortality when patients were undertriaged compared to the reference group. Multivariate analysis in the form of a multinomial logistic regression revealed that patients transported by ALS had a decreased adjusted rate of undertriage (RRR: 0.92, 95% CI 0.87-0.97, p=0.003) and an increased adjusted rate of overtriage (RRR: 1.59, 95% CI 1.54-1.64, p<0.001) compared to patients transported by BLS. Conclusions Compared to their BLS counterparts, while undertriage is significantly lower, overtriage is substantially higher in ALS—further increasing the high levels of resource (over)utilization in trauma patients. Undertriage in both ALS and BLS are associated with increased mortality rates. Additional education, especially in the BLS provider, on identifying the major trauma victim may be warranted based on the results of this study. Level of Evidence Epidemiological; Level III Corresponding Author: Frederick B. Rogers, MD, MS, FACS, 555 N. Duke St., Lancaster, PA 17602, 717-544-5945 (tel), 717-544-5944 (fax), Frederick.Rogers@pennmedicine.upenn.edu Author Disclosure Statement: All authors have neither conflicts of interest nor disclosures of funding or proprietary interest to declare on the materials or subject matter discussed herein. This study was accepted for a poster presentation at the 78th Annual Meeting of the American Association for the Surgery of Trauma and Clinical Congress of Acute Care Surgery from September 18-21, 2019 in Dallas, Texas © 2020 Lippincott Williams & Wilkins, Inc.

Defining Inclusion Criteria for the Prehospital Administration of Lyophilized Plasma in Urban Civilian Pediatric Trauma No abstract available

Freeze Dried Plasma For The Resuscitation of Traumatized Pediatric Patients: response No abstract available

The American Association for the Surgery of Trauma (AAST) emergency surgery guidelines for acute pancreatitis: Are we missing significant opportunities for reflection? No abstract available