SC restaurant offers free breakfast to first responders on New Year's Day

By Elise Franco Herald-Journal DUNCAN, S.C. — The Sialmas family is opening its arms, and it's kitchen, to the Upstate on New Year's Day. From 6 to 11 a.m. on Monday, Melissa and Christos Sialmas and their staff at Sialmas Family Restaurant will treat all emergency medical, safety and law enforcement personnel from Spartanburg and Greenville counties to free breakfast during the restaurant's ...

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Pneumocephalus after Epidural Injection

Publication date: Available online 30 December 2017
Source:The Journal of Emergency Medicine
Author(s): Jerel Chacko, Kelly Levis, Barry Hahn
BackgroundPneumocephalus, or air in the intracranial space, is most commonly encountered after trauma or surgery. Epidural injections are commonly performed in obstetrics and pain management. Complications are uncommon and include hemorrhage, cerebrospinal fluid leak, and infection. A rare complication is pneumocephalus, described in only a few case reports of epidural anesthesia.Case ReportWe describe a 34-year-old woman complaining of a generalized headache 6 days after an unremarkable vaginal delivery that was assisted by an epidural injection. A noncontrast computed tomography scan of the head revealed pneumocephalus secondary to epidural injection.Why Should an Emergency Physician Be Aware of This?Pneumocephalus is an uncommon but serious complication of an epidural procedure. Emergency physicians must be aware of this complication entity and maintain this entity in their differential diagnosis given the potential for significant morbidity.



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Profound Prolonged Bradycardia and Hypotension after Interscalene Brachial Plexus Block with Bupivacaine

Publication date: Available online 30 December 2017
Source:The Journal of Emergency Medicine
Author(s): Mathew Nelson, Alexandra Reens, Lara Reda, David Lee
BackgroundInterscalene brachial plexus blocks have been a routinely performed method of anesthesia for shoulder surgery that decreases the need for general anesthesia, length of stay, and recovery time. We describe a case of bupivacaine toxicity after an interscalene block.Case ReportThe patient was a 66-year-old man who presented to our Emergency Department by emergency medical services from an ambulatory surgery center where he had undergone rotator cuff surgery, with bradycardia and hypotension. His symptoms began upon completion of the surgery in which he received interscalene nerve block with bupivacaine and lidocaine. He was given three doses of 0.5 mg atropine and one dose of 1 mg epinephrine for a heart rate of 40 beats/min without any improvement prior to arrival. His bradycardia was refractory to atropine. He was started on a dopamine drip and transferred to the coronary care unit. The timing of his symptoms, minutes after his regional nerve block, and his complete recovery with only supportive care, make the diagnosis of bupivacaine toxicity likely.Why Should an Emergency Physician Be Aware of This?Despite the safety profile of local anesthetics, we must be aware of their potential side affects. Whereas most adverse reactions are secondary to misdirection of anesthetic or accidental vascular puncture, local anesthetic systemic toxicity (LAST) is the major cause of significant adverse events with regional anesthesia. As regional anesthesia becomes more common, emergency physicians must be more aware of the potential complications and be able to both diagnose and treat.



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Point-of-Care Ultrasound–Guided Percutaneous Cannulation of Extracorporeal Membrane Oxygenation: Make it Simple

Publication date: Available online 30 December 2017
Source:The Journal of Emergency Medicine
Author(s): Hong Joon Ahn, Jun Wan Lee, Ki Hyuk Joo, Yeon Ho You, Seung Ryu, Jin Woong Lee, Seung Whan Kim
BackgroundCannulation of the great vessels is required for extracorporeal membrane oxygenation (ECMO). Currently, there is no guideline for optimal imaging modalities during percutaneous cannulation of ECMO.ObjectiveThe purpose of this study was to describe percutaneous cannulation guided by point-of-care ultrasound (POCUS) for ECMO and compare it with fluoroscopy and landmark guidance.MethodsThree groups (POCUS-, fluoroscopy-, and landmark-guided) of percutaneous cannulation for ECMO were analyzed retrospectively in a tertiary academic hospital. In the POCUS-guided group, visual confirmation of guidewire and cannula by ultrasound in both the access and return cannula were essential for successful cannulation. Fluoroscopy- and landmark-guided groups were cannulated with the conventional technique.ResultsA total of 128 patients were treated by ECMO during the study period, of which 94 (73.4%) cases were venoarterial ECMO. This included 56 cases of extracorporeal cardiopulmonary resuscitation. Also, there were 30 (23.4%) cases of venovenous ECMO and 4 (3.1%) cases of venoarteriovenous ECMO. A total of 71 (55.5%) patients were cannulated under POCUS guidance, and 43 (33.6%) patients were cannulated under fluoroscopy guidance and 14 (10.9%) patients were cannulated by landmark guidance. No surgical cut downs were required. Misplacement of cannula occurred in 3 (2.3%) cases. All three occurred in the landmark-guided group.ConclusionsPOCUS-guided cannulation is comparable to fluoroscopy-guided cannulation in terms of avoiding cannula misplacement. In our experience, POCUS-guided cannulation is a useful strategy over fluoroscopy- and landmark-guided cannulation during peripheral ECMO.



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Texas college aims to bring medical students of different fields together

By Ruth Campbell Odessa American ODESSA, Texas — Odessa College’s Health Sciences Building is being renovated to allow everyone from emergency medical services students to nursing and radiologic technology pupils to mingle and cooperate. Vice President for Business Affairs Virginia Chisum said the two-story, 57,000-square-foot building is being remodeled in stages. Chisum said they started ...

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Development of a Patient Decision Aid for Syncope in the Emergency Department: the SynDA tool

Abstract

Objectives

To develop a patient decision aid to promote shared decision-making for stable, alert patients who present to the emergency department (ED) with syncope.

Methods

Using input from patients, clinicians, and experts in the field of syncope, health care design, and shared decision-making, we created a prototype of a paper-based decision aid to engage patients in the disposition decision (admission vs. discharge) after an unremarkable ED evaluation for syncope. In phase 1, we conducted 1-on-1 semi-structured exploratory interviews with 10 emergency physicians and 10 ED syncope patients. In phase 2, we conducted 1-on-1 directed interviews with 15 emergency care clinicians, 5 cardiologists, and 12 ED syncope patients to get detailed feedback on decision aid content and design. We iteratively modified the aid using feedback from each interviewee until clarity and usability had been optimized.

Results

The 11- x 17-inch, paper-based decision aid, titled SynDA, includes 4 sections: 1) Explanation of syncope, 2) Explanation of future risks, 3) Personalized 30-day risk estimate, and 4) Disposition options. The personalized risk estimate is calculated using a recently published syncope risk-stratification tool. This risk estimate is stated in natural frequency and graphically displayed using a 100-person color-coded pictogram. Patient-oriented questions are included to stimulate dialogue between patient and clinician. At the end of the development process, patient and physician participants expressed satisfaction with the clarity and usability of the decision aid.

Conclusions

We iteratively developed an evidence-based decision aid to facilitate shared decision-making for alert syncope patients after an unremarkable ED evaluation. Further testing is required to determine its effects on patient care. This decision aid has the potential to improve care for syncope patients and promote patient-centered care in emergency medicine.

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The Focused History and Physical - circa 100 BCE

Abstract

When modern physicians reflect on ‘ancient medicine’ or ‘Greek medicine,’ they typically think of Hippocrates and Galen. Few know of the raging, centuries-long intellectual debates among physicians about what exactly mattered in the treatment of illness, or about a group of physicians whose pattern-based, systematized approach to health and disease was a forerunner of how today's emergency medicine physicians evaluate and treat their patients.Methodist physicians (c. 100 BCE to 500 CE, active mostly in Rome but present throughout the Mediterranean world) were named after their “method” of healing.

This article is protected by copyright. All rights reserved.

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Paramedic - Winona Area Ambulance Service Inc.

Responds to emergent and non-emergent requests for emergency medical assistance under the guidelines of local medical direction. ESSENTIAL DUTIES AND RESPONSIBILITIES: 1. Demonstrate knowledge and understanding of, and compliance with, all Winona Area Ambulance Service policies and procedures. 2. Demonstrate the attitude of a Health Care Professional to include, but not be limited to: maintaining a ...

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Understanding EMS Scheduling Software & The Web of Information That Runs Your Business

There are many different web-based products for just about any service you can imagine in the EMS and public service industry. Most organizations use an HR Management system for on-boarding employees, managing their employment status and providing benefit enrollment. There are more and more HRIS vendors that have “do it all” systems with the addition of online time clock & attendance ...

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Platinum Educational Group Prepares for New CoAEMSP Requirements

GRAND RAPIDS, MI — Platinum Educational Group understands the struggles and obstacles that are presented to EMS educators when it pertains to accreditation. EMS training institutes, particularly paramedic programs, face stringent challenges like the NREMT Portfolio (where applicable), on-site reviews, and most recently the upcoming Appendix G requirements from Committee on Accreditation of Educational ...

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A comparison of two emergency medical dispatch protocols with respect to accuracy

Emergency medical dispatching should be as accurate as possible in order to ensure patient safety and optimize the use of ambulance resources. This study aimed to compare the accuracy, measured as priority lev...

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FirstNet now available for first responders across the U.S.

All 50 states, two territories and Washington, D.C. have joined FirstNet in order to give first responders access to the wireless broadband network

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An Interpretable Machine Learning Model for Accurate Prediction of Sepsis in the ICU

Objectives: Sepsis is among the leading causes of morbidity, mortality, and cost overruns in critically ill patients. Early intervention with antibiotics improves survival in septic patients. However, no clinically validated system exists for real-time prediction of sepsis onset. We aimed to develop and validate an Artificial Intelligence Sepsis Expert algorithm for early prediction of sepsis. Design: Observational cohort study. Setting: Academic medical center from January 2013 to December 2015. Patients: Over 31,000 admissions to the ICUs at two Emory University hospitals (development cohort), in addition to over 52,000 ICU patients from the publicly available Medical Information Mart for Intensive Care-III ICU database (validation cohort). Patients who met the Third International Consensus Definitions for Sepsis (Sepsis-3) prior to or within 4 hours of their ICU admission were excluded, resulting in roughly 27,000 and 42,000 patients within our development and validation cohorts, respectively. Interventions: None. Measurements and Main Results: High-resolution vital signs time series and electronic medical record data were extracted. A set of 65 features (variables) were calculated on hourly basis and passed to the Artificial Intelligence Sepsis Expert algorithm to predict onset of sepsis in the proceeding T hours (where T = 12, 8, 6, or 4). Artificial Intelligence Sepsis Expert was used to predict onset of sepsis in the proceeding T hours and to produce a list of the most significant contributing factors. For the 12-, 8-, 6-, and 4-hour ahead prediction of sepsis, Artificial Intelligence Sepsis Expert achieved area under the receiver operating characteristic in the range of 0.83–0.85. Performance of the Artificial Intelligence Sepsis Expert on the development and validation cohorts was indistinguishable. Conclusions: Using data available in the ICU in real-time, Artificial Intelligence Sepsis Expert can accurately predict the onset of sepsis in an ICU patient 4–12 hours prior to clinical recognition. A prospective study is necessary to determine the clinical utility of the proposed sepsis prediction model. The opinions or assertions contained herein are the private ones of the author/speaker and are not to be construed as official or reflecting the views of the Department of Defense, the Uniformed Services University of the Health Sciences, or any other agency of the U.S. Government. Supplemental digital content is available for this article. Direct URL citations appear in the printed text and are provided in the HTML and PDF versions of this article on the journal’s website (http://ift.tt/29S62lw). Drs. Nemati, Stanley, and Clifford received support for article research from the National Institutes of Health (NIH). Dr. Nemati’s institution received funding from the NIH, award number K01ES025445. Dr. Holder received funding from CR Bard, Inc. Dr. Buchman’s institution received funding from the Henry M. Jackson Foundation for his role as site director in Surgical Critical Care Institute, www.sc2i.org, funded through the Department of Defense’s Health Program – Joint Program Committee 6/Combat Casualty Care (USUHS HT9404-13-1-0032 and HU0001-15-2-0001); from Society of Critical Care Medicine for his role as Editor-in-Chief of “Critical Care Medicine”; and from Philips Corporation (unrestricted educational grant to a physician education association in South Korea so he could present the results of his research in eICU). Dr. Buchman received support for article research from the Henry M Jackson Foundation. Ms. Ramzi has disclosed that she does not have any potential conflicts of interest. For information regarding this article, E-mail: shamim.nemati@alum.mit.edu Copyright © by 2017 by the Society of Critical Care Medicine and Wolters Kluwer Health, Inc. All Rights Reserved.

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Update of a Systematic Review of Autoresuscitation After Cardiac Arrest

Objectives: There has been a growth in publications focusing on the phenomena of autoresuscitation in recent years. In 2010, we systematically reviewed the medical literature with the primary objective of summarizing the evidence on the timing of autoresuscitation. Healthcare professionals have continued to voice concerns regarding the potential for autoresuscitation. With this in mind, the objective of this brief report is to update the results of our original review of autoresuscitation. Data Sources: We applied the same search strategy described in our original article to update our findings to include articles published from January 2009 to September 2016. Study Selection and Data Extraction: We screened an additional 1,859 citations, after duplicates were removed, and then assessed 46 full-text articles for eligibility, from which 15 studies were included for data extraction. Data Synthesis: During the time period of this review, there have been 1) 10 additional adult and three pediatric case reports of autoresuscitation in patients after cessation of cardiopulmonary resuscitation; in those cases with continuous monitoring and confirmation of circulation, the longest events are reported to be 10 and 2 minutes, respectively for adults and children; 2) six adults (4%, total n = 162) with autoresuscitation events reported from two observational studies and one chart review of patients undergoing withdrawal of life-sustaining therapy; the longest time reported to be 89 seconds with electrocardiogram and invasive arterial blood pressure monitoring and 3 minutes with electrocardiogram monitoring only; 3) 12 pediatric patients studied with vital sign monitoring during withdrawal of life-sustaining therapy without any reports of autoresuscitation. Conclusions: Although case reports of autoresuscitation are hampered by variability in observation and monitoring techniques, autoresuscitation has now been reported in adults and children, and there appears to be a distinction in timing between failed cardiopulmonary resuscitation and withdrawal of life-sustaining therapy. Although additional prospective studies are required to clarify the frequency and predisposing factors associated with this phenomenon, clinical decision-making regarding patient management under uncertainty is required nonetheless. Both adult and pediatric healthcare professionals should be aware of the possibility of autoresuscitation and monitor their patients accordingly before diagnosing death. Supplemental digital content is available for this article. Direct URL citations appear in the printed text and are provided in the HTML and PDF versions of this article on the journal’s website (http://ift.tt/29S62lw). Supported, in part, by Canadian Blood Services. Ms. Hornby received funding from Canadian Blood Services (consultant) and disclosed that she is the Project Manager for a research program in deceased organ donation, funded by the Canadian Institutes of Health Research. The remaining authors have disclosed that they do not have any potential conflicts of interest. For information regarding this article, E-mail: lhornby@uottawa.ca Copyright © by 2017 by the Society of Critical Care Medicine and Wolters Kluwer Health, Inc. All Rights Reserved.

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Early diagnosis using canonical discriminant analysis of innate immune receptor gene expression profiles in a murine infectious or sterile systemic inflammation model

AbstractBACKGROUNDInfection in patients with systemic inflammation is difficult to diagnose with a single biomarker. We aimed to clarify the time course of change in the gene expression profile of innate immune receptors in infectious or sterile inflammation and to establish an early diagnostic method using canonical discriminant analysis (CDA) of the gene expression profile.METHODSTo compare infectious and sterile inflammation, we used cecal ligation and puncture (CLP) and 20% full-thickness burn injury (Burn) models. C57BL/6 mice underwent sham treatment (n=9×3 groups), CLP (n=12×3 groups), or Burn (n=12×3 groups) injury. Mice were sacrificed at 6, 12, and 24 hours after injury, and total RNA was extracted from whole blood. We used quantitative real-time PCR to investigate gene expression of innate immune receptors TLR2, TLR4, TLR9, NLRP3, and RIG-I. To evaluate all gene expression together as patterns, each value was standardized, and CDA was performed at each time point.RESULTSGene expression of TLR2 and TLR4 was already significantly increased in both CLP and Burn compared to sham mice at 6 hours after injury (p

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Activities of the THOR-AABB working party

The AABB (formerly the American Association of Blood Banks) is an international authority on transfusion medicine and tissue banking. The Trauma, Hemostasis and Oxygenation Research (THOR) Network is an international multidisciplinary network of civilian and military providers ranging from first responders and medics to critical care physicians, and from basic scientists to clinical trialists. The THOR Network’s vision is to improve outcomes from traumatic hemorrhagic shock by optimizing the acute phase of resuscitation. Its mission is to to develop and implement best practices for prehospital care through to the completion of the acute phase of hemorrhagic shock resuscitation. Thus, there is significant overlap between the missions of these two groups. To this end, the joint THOR-AABB working party (WP) was created in the summer of 2016 with a view to improving patient outcomes by the establishment of a formal collaboration between these two groups. The WP has been engaged in many different endeavors, from successfully changing the AABB’s standards for the administration of whole blood, to writing commentaries on the safety of uncrossmatched red blood cells and antibody titer methods and thresholds in potentially incompatible plasma products, to hosting a day-long symposium on blood product resuscitation of massively bleeding patients in conjunction with the AABB annual meeting. This review details the activities of the WP and indicates some future activities. Address correspondence and reprint requests to: Mark H. Yazer, MD, The Institute for Transfusion Medicine, 3636 Blvd of the Allies, Pittsburgh, PA, USA 15213, Phone 412 209-7522, Fax 412 209-4286, myazer@itxm.org The authors declare no conflicts of interest with this manuscript No financial support was obtained to prepare this manuscript © 2017 Lippincott Williams & Wilkins, Inc.

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Microfluidics: A high throughput system for the assessment of the endotheliopathy of trauma and the effect of timing of plasma administration on ameliorating shock associated endothelial dysfunction

AbstractBackgroundEarly resuscitation after trauma-hemorrhagic shock (HS) with plasma rather than crystalloid may ameliorate systemic endothelial cell (EC) injury and dysfunction (endotheliopathy of trauma [EOT]). We postulated that endothelial lined microfluidic networks would be a useful platform to study the endothelial cell activation/injury under flow conditions to mimic HS. We then used the microfluidic system to further characterize the protective effects and optimal timing of plasma infusion on the development of “EOT” in our model.MethodsHuman umbilical vein endothelial cells (HUVEC) were added to microfluidic flow channels and after overnight perfusion the cells were subsequently treated with epinephrine (epi) and exposed to hypoxia reoxygenation (HR). Media alone or 5% human plasma was perfused either immediately following treatment (early plasma) or after a 3 hr. delay (late plasma). Glycocalyx injury was indexed by fluorescent microscopy and shedding of syndecan-1 and hyaluronic acid (HLA). Endothelial markers of activation/injury were also measured and included soluble thrombomodulin (sTM), tissue plasminogen activator (tPA), plasminogen activator inhibitor (PAI-1) and angiopoietin 1 and 2 (Ang-1 and 2). Sheddase activity was indexed by ADAM metallopeptidase domain 17 (ADAM-17).ResultsEndothelial cell and glycocalyx barrier function studied using microfluidic devices are a more realistic model of the glycocalyx endothelial vascular barrier than studies performed on endothelial cells using static (no flow) conditions. Conditions that mimic the internal mileau following hemorrhagic shock result in glycocalyx degradation and an inflammatory prothrombotic response by the endothelium. “Early” use of plasma in the microfluidic channel perfusate mitigated against these effects. Later perfusion with plasma had no protective effect.ConclusionA temporal effect to plasma administration was noted in our biomimetic model of the endothelial vascular barrier following shock. This suggests a protective role to “early” plasma administration in the severely injured patient. Background Early resuscitation after trauma-hemorrhagic shock (HS) with plasma rather than crystalloid may ameliorate systemic endothelial cell (EC) injury and dysfunction (endotheliopathy of trauma [EOT]). We postulated that endothelial lined microfluidic networks would be a useful platform to study the endothelial cell activation/injury under flow conditions to mimic HS. We then used the microfluidic system to further characterize the protective effects and optimal timing of plasma infusion on the development of “EOT” in our model. Methods Human umbilical vein endothelial cells (HUVEC) were added to microfluidic flow channels and after overnight perfusion the cells were subsequently treated with epinephrine (epi) and exposed to hypoxia reoxygenation (HR). Media alone or 5% human plasma was perfused either immediately following treatment (early plasma) or after a 3 hr. delay (late plasma). Glycocalyx injury was indexed by fluorescent microscopy and shedding of syndecan-1 and hyaluronic acid (HLA). Endothelial markers of activation/injury were also measured and included soluble thrombomodulin (sTM), tissue plasminogen activator (tPA), plasminogen activator inhibitor (PAI-1) and angiopoietin 1 and 2 (Ang-1 and 2). Sheddase activity was indexed by ADAM metallopeptidase domain 17 (ADAM-17). Results Endothelial cell and glycocalyx barrier function studied using microfluidic devices are a more realistic model of the glycocalyx endothelial vascular barrier than studies performed on endothelial cells using static (no flow) conditions. Conditions that mimic the internal mileau following hemorrhagic shock result in glycocalyx degradation and an inflammatory prothrombotic response by the endothelium. “Early” use of plasma in the microfluidic channel perfusate mitigated against these effects. Later perfusion with plasma had no protective effect. Conclusion A temporal effect to plasma administration was noted in our biomimetic model of the endothelial vascular barrier following shock. This suggests a protective role to “early” plasma administration in the severely injured patient. Correspondence: Lawrence N. Diebel MD, Michael and Marian Ilitch Department of Surgery, 6C University Health Center, 4201 Saint Antoine, Detroit, MI 48201, Phone: 313-577-5314, Fax: 313-577-5310, Email: ldiebel@med.wayne.edu Conflicts of interest to disclose: None This study was presented at the 75th annual meeting of the AAST, September 13-16, 2017, in Baltimore, MD. © 2017 Lippincott Williams & Wilkins, Inc.

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Paramedic - Cole County EMS

Job Title: Paramedic Exempt: No Reports To: Assistant Chief/Deputy Chief/Chief Date Revised: February 14, 2017 Summary: Paramedics are accountable for responding to all assigned calls in the most appropriate, efficient, and professional manner, providing the highest standards of patient care while maintaining a safe and hazard-free environment. The Paramedic contributes to overall patient care in the ...

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Injuries Associated with Police Use of Force

AbstractBackgroundUse of Force [UOF] by police can result in serious injuries and fatalities. The risk of significant injuries associated with different force modalities is poorly defined. We sought to determine the incidence of police UOF and compare the likelihood of significant injury with different force modalities.MethodsA prospective multicenter observational study of all UOF incidents was conducted via mandatory UOF investigations at three mid-sized police agencies over a two year period. Expert physicians reviewed police and medical records to determine injury severity using a priori injury severity stratification criteria.ResultsThere were 893 UOF incidents, representing a UOF rate of 0.086% of 1,041,737 calls for service (1 in 1167) and 0.78 % of 114,064 criminal arrests(1 in 128). Suspects were primarily young (mean age 31 years, range 12-86) males (89%).The 1399 force utilizations included Unarmed Physical Force (n=710, 51%), Conducted Electrical Weapons [CEWs] (504, 30%), Chemical (88, 6.3%), Canines (47, 3.4%), Impact Weapons (9, 0.6%), Kinetic Impact Munitions (8, 0.6%), Firearms (6, 0.4%), and other (27, 1.9%).Among 914 suspects, 898 (98%) sustained no or mild injury after police UOF. Significant (moderate or severe) injuries occurred in 16 subjects (1.8%). Logistic regression analysis shows these are most associated with firearm and canine use. There was one fatality (0.1%) due to gunshots. No significant injuries occurred among 504 CEW uses (0%; 95% CI 0.0–0.9%).Of the 355 suspects transported to a medical facility, 78 (22%) were hospitalized. The majority of hospitalizations were unrelated to UOF (n=59, 76%), while a minority (n=19, 24%) were due to injuries related to police UOF.ConclusionsPolice UOF is rare. When force is used officers most commonly rely on unarmed physical force and CEWs. Significant injuries are rare. Transport for medical evaluation is a poor surrogate for significant injury due to UOF.Level of EvidenceLevel II (Prospective Study with less than large effect and no negative criteria) Background Use of Force [UOF] by police can result in serious injuries and fatalities. The risk of significant injuries associated with different force modalities is poorly defined. We sought to determine the incidence of police UOF and compare the likelihood of significant injury with different force modalities. Methods A prospective multicenter observational study of all UOF incidents was conducted via mandatory UOF investigations at three mid-sized police agencies over a two year period. Expert physicians reviewed police and medical records to determine injury severity using a priori injury severity stratification criteria. Results There were 893 UOF incidents, representing a UOF rate of 0.086% of 1,041,737 calls for service (1 in 1167) and 0.78 % of 114,064 criminal arrests(1 in 128). Suspects were primarily young (mean age 31 years, range 12-86) males (89%). The 1399 force utilizations included Unarmed Physical Force (n=710, 51%), Conducted Electrical Weapons [CEWs] (504, 30%), Chemical (88, 6.3%), Canines (47, 3.4%), Impact Weapons (9, 0.6%), Kinetic Impact Munitions (8, 0.6%), Firearms (6, 0.4%), and other (27, 1.9%). Among 914 suspects, 898 (98%) sustained no or mild injury after police UOF. Significant (moderate or severe) injuries occurred in 16 subjects (1.8%). Logistic regression analysis shows these are most associated with firearm and canine use. There was one fatality (0.1%) due to gunshots. No significant injuries occurred among 504 CEW uses (0%; 95% CI 0.0–0.9%). Of the 355 suspects transported to a medical facility, 78 (22%) were hospitalized. The majority of hospitalizations were unrelated to UOF (n=59, 76%), while a minority (n=19, 24%) were due to injuries related to police UOF. Conclusions Police UOF is rare. When force is used officers most commonly rely on unarmed physical force and CEWs. Significant injuries are rare. Transport for medical evaluation is a poor surrogate for significant injury due to UOF. Level of Evidence Level II (Prospective Study with less than large effect and no negative criteria) Corresponding Author/Address for Reprints: William P. Bozeman, MD, Wake Forest School of Medicine, Dept of Emergency Medicine, 1 Medical Center Blvd, Winston Salem, NC 27157, wbozeman@wakehealth.edu, Phone: (336) 716-6320 Fax (336) 716-1705 Funding: Department of Justice/National Institute of Justice Conflicts of Interest: None. National/International Meeting Presentations: 2013 American College of Emergency Physicians Scientific Assembly (Oct 14, 2013 in Seattle, WA) 122nd Annual Meeting of the International Association of Chiefs of Police (Oct 27, 2015 in Chicago, IL) © 2017 Lippincott Williams & Wilkins, Inc.

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Variability of Child Access Prevention Laws and Pediatric Firearm Injuries

Background: State-level Child Access Prevention (CAP) laws impose criminal liability on adults who negligently allow children access to firearms. CAP laws can be further divided into strong CAP laws which impose criminal liability for negligently stored firearms and weak CAP laws that prohibit adults from intentionally, knowingly, and/or recklessly providing firearms to a minor. We hypothesized that strong CAP laws would be associated with a greater reduction in pediatric firearm injuries than weak CAP laws. Methods: We constructed a cross-sectional national study using the HCUP-Kids Inpatient Database from 2006 and 2009 using weighted counts of firearm related admissions among children

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Clinical relevance of a p-value: Does TXA save lives after trauma or post-partum hemorrhage?

No abstract available

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The American Association for the Surgery of Trauma Uniform Grading of Hemorrhagic Emergency General Surgery Diseases

ABSTRACTConsistent grading of Emergency General Surgery (EGS) diseases is important for comparison of outcomes and development of EGS registries. The American Association for the Surgery of Trauma (AAST) Patient Assessment Committee has previously determined common EGS diseases and developed a grading system for measuring anatomic severity of 16 inflammatory/infectious EGS diseases. The specific aim of this project was to develop a uniform grading template for hemorrhagic EGS diseases managed by acute care surgeons and apply the template to common hemorrhagic EGS diseases.The AAST Patient Assessment Committee reviewed the literature and examined the existing grading systems available for common hemorrhagic EGS diseases. A uniform grading template was created with Grade I – occult hemorrhage, Grade II –minimal hemorrhage with no active bleeding, Grade III – limited hemorrhage with no active bleeding, Grade IV – moderate hemorrhage with active bleeding, and Grade V – large volume hemorrhage. The template was applied to four common hemorrhagic EGS diseases: bleeding esophageal varices (EV), hemorrhage from colonic diverticulosis (CD), bleeding peptic ulcer disease (PUD), and ruptured abdominal aortic aneurysm (AAA). We believe that physiologic parameters, volume loss, and rate of bleeding are essential co-determinants of outcomes in hemorrhagic conditions. However, adding to this an understanding of anatomic progression of disease may help inform treatment decisions and predict outcomes.Level of EvidenceIIIStudy TypeCurrent opinions Consistent grading of Emergency General Surgery (EGS) diseases is important for comparison of outcomes and development of EGS registries. The American Association for the Surgery of Trauma (AAST) Patient Assessment Committee has previously determined common EGS diseases and developed a grading system for measuring anatomic severity of 16 inflammatory/infectious EGS diseases. The specific aim of this project was to develop a uniform grading template for hemorrhagic EGS diseases managed by acute care surgeons and apply the template to common hemorrhagic EGS diseases. The AAST Patient Assessment Committee reviewed the literature and examined the existing grading systems available for common hemorrhagic EGS diseases. A uniform grading template was created with Grade I – occult hemorrhage, Grade II –minimal hemorrhage with no active bleeding, Grade III – limited hemorrhage with no active bleeding, Grade IV – moderate hemorrhage with active bleeding, and Grade V – large volume hemorrhage. The template was applied to four common hemorrhagic EGS diseases: bleeding esophageal varices (EV), hemorrhage from colonic diverticulosis (CD), bleeding peptic ulcer disease (PUD), and ruptured abdominal aortic aneurysm (AAA). We believe that physiologic parameters, volume loss, and rate of bleeding are essential co-determinants of outcomes in hemorrhagic conditions. However, adding to this an understanding of anatomic progression of disease may help inform treatment decisions and predict outcomes. Level of Evidence III Study Type Current opinions Source of Funding: None Corresponding Author: Gail T. Tominaga, M.D., Trauma Section, Scripps Memorial Hospital La Jolla, 9888 Genesee Ave, LJ 601, La Jolla, California 92037, Phone: 858-626-6362 (Trauma Office), 858-824-5001 (Answering Service); 858-531-6161 (cell), FAX: 858-626-6354. Email: Tominaga.gail@scrippshealth.org Conflicts of Interest: None Meeting presentation:12th Annual Academic Surgical Congress, 02/09/2017 in Las Vegas, Nevada Disclosure of Funding: None © 2017 Lippincott Williams & Wilkins, Inc.

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Raising the Standards on Whole Blood

No abstract available

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Under-triage in Trauma: Does an Organized Trauma Network Capture the Major Trauma Victim? A Statewide Analysis

ABSTRACTBACKGROUNDProper triage of critically injured trauma patients to accredited trauma centers (TCs) is essential for survival and patient outcomes. We sought to determine the percentage of patients meeting trauma criteria who received care at non-trauma centers (NTCs) within the statewide trauma system that exists in the state of Pennsylvania. We hypothesized that a substantial proportion of the trauma population would be undertriaged to NTCs with undertriage rates (UTR) decreasing with increasing severity of injury.METHODSAll adult (age ≥15) hospital admissions meeting trauma criteria (ICD-9: 800-959; Injury Severity Score [ISS]>9 or ISS>15) from 2003-2015 were extracted from the Pennsylvania Health Care Cost Containment Council (PHC4) database, and compared with the corresponding trauma population within the Pennsylvania Trauma Systems Foundation (PTSF) registry. PHC4 contains all hospital admissions within PA while PTSF collects data on all trauma cases managed at designated TCs (Level I-IV). The percentage of patients meeting trauma criteria who are undertriaged to NTCs was determined and Network Analyst Location-Allocation function in ArcGIS Desktop was used to generate geospatial representations of undertriage based on injury severity scores throughout the state.RESULTSFor ISS>9, 173,022 cases were identified from 2003-2015 in PTSF, while 255,263 cases meeting trauma criteria were found in the PHC4 database over the same timeframe suggesting UTR of 32.2%. For ISS>15, UTR was determined to be 33.6%. Visual geospatial analysis suggests regions with limited access to trauma centers comprise the highest proportion of undertriaged trauma patients.CONCLUSIONSDespite the existence of a statewide trauma framework for over 30 years, approximately, a third of severely-injured trauma patients are managed at hospitals outside of the trauma system in PA. Intelligent trauma system design should include an objective process like geospatial mapping rather than the current system which is driven by competitive models of financial and healthcare system imperatives.LEVEL OF EVIDENCELevel III epidemiological study BACKGROUND Proper triage of critically injured trauma patients to accredited trauma centers (TCs) is essential for survival and patient outcomes. We sought to determine the percentage of patients meeting trauma criteria who received care at non-trauma centers (NTCs) within the statewide trauma system that exists in the state of Pennsylvania. We hypothesized that a substantial proportion of the trauma population would be undertriaged to NTCs with undertriage rates (UTR) decreasing with increasing severity of injury. METHODS All adult (age ≥15) hospital admissions meeting trauma criteria (ICD-9: 800-959; Injury Severity Score [ISS]>9 or ISS>15) from 2003-2015 were extracted from the Pennsylvania Health Care Cost Containment Council (PHC4) database, and compared with the corresponding trauma population within the Pennsylvania Trauma Systems Foundation (PTSF) registry. PHC4 contains all hospital admissions within PA while PTSF collects data on all trauma cases managed at designated TCs (Level I-IV). The percentage of patients meeting trauma criteria who are undertriaged to NTCs was determined and Network Analyst Location-Allocation function in ArcGIS Desktop was used to generate geospatial representations of undertriage based on injury severity scores throughout the state. RESULTS For ISS>9, 173,022 cases were identified from 2003-2015 in PTSF, while 255,263 cases meeting trauma criteria were found in the PHC4 database over the same timeframe suggesting UTR of 32.2%. For ISS>15, UTR was determined to be 33.6%. Visual geospatial analysis suggests regions with limited access to trauma centers comprise the highest proportion of undertriaged trauma patients. CONCLUSIONS Despite the existence of a statewide trauma framework for over 30 years, approximately, a third of severely-injured trauma patients are managed at hospitals outside of the trauma system in PA. Intelligent trauma system design should include an objective process like geospatial mapping rather than the current system which is driven by competitive models of financial and healthcare system imperatives. LEVEL OF EVIDENCE Level III epidemiological study Corresponding Author: Frederick B. Rogers, MD, MS, FACS, Penn Medicine Lancaster General Health, 555 N. Duke St., Lancaster, PA, 17604, +1 (717) 544-5945 (tel); +1 (717) 544-5944 (fax); frogers2@lghealth.org Conflicts of Interest and Source of Funding: The authors report no proprietary or commercial interest in any product mentioned or concept discussed in this article. This study was funded in part by a grant from the Louise von Hess Medical Research Institute. This study was presented as a QuickShot presentation at the 76th Annual Meeting of the American Association for the Surgery of Trauma and Clinical Congress of Acute Care Surgery from September 13-16, 2017 in Baltimore, Maryland. © 2017 Lippincott Williams & Wilkins, Inc.

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Pediatric appendicitis: Is referral to a regional pediatric center necessary?

AbstractBackgroundAcute appendicitis is the most common emergent surgical procedure performed among children in the US, with an incidence exceeding 80,000 cases per year. Appendectomies are often performed by both pediatric surgeons and adult general/trauma acute care surgeons (TACS surgeons). We hypothesized that children undergoing appendectomy for acute appendicitis have equivalent outcomes whether a pediatric surgeon or a TACS surgeon performs the operation.MethodsA retrospective chart review was performed for patients 6-18 years of age, who underwent appendectomy at either a regional children’s hospital (CHCO, n=241) or an urban safety net hospital (n=347) between July 2010 and June 2015. The population of patients operated upon at the urban safety net hospital was further subdivided into those operated upon by pediatric surgeons (DHMC Peds, n=68) and those operated upon by adult TACS surgeons (DHMC TACS, n=279). Baseline characteristics and operative outcomes were compared between these patient populations utilizing one-way analysis of variance (ANOVA) and Chi-squared test for independence.ResultsWhen comparing the CHCO and DHMC TACS groups, there were no differences in the proportion of patients with perforated appendicitis, operative time, rate of operative complications, rate of postoperative infectious complications, or rate of 30-day readmission. Length of stay was significantly shorter for the DHMC TACS group than the CHCO group.ConclusionOur data demonstrate that among children >5yo undergoing appendectomy, length of stay, risk of infectious complications, and risk of readmission do not differ regardless of whether they are operated upon by pediatric surgeons or adult TACS surgeons, suggesting resources currently consumed by transferring children to hospitals with access to pediatric surgeons could be allocated elsewhere.Level of evidenceLevel III, economic/decision Background Acute appendicitis is the most common emergent surgical procedure performed among children in the US, with an incidence exceeding 80,000 cases per year. Appendectomies are often performed by both pediatric surgeons and adult general/trauma acute care surgeons (TACS surgeons). We hypothesized that children undergoing appendectomy for acute appendicitis have equivalent outcomes whether a pediatric surgeon or a TACS surgeon performs the operation. Methods A retrospective chart review was performed for patients 6-18 years of age, who underwent appendectomy at either a regional children’s hospital (CHCO, n=241) or an urban safety net hospital (n=347) between July 2010 and June 2015. The population of patients operated upon at the urban safety net hospital was further subdivided into those operated upon by pediatric surgeons (DHMC Peds, n=68) and those operated upon by adult TACS surgeons (DHMC TACS, n=279). Baseline characteristics and operative outcomes were compared between these patient populations utilizing one-way analysis of variance (ANOVA) and Chi-squared test for independence. Results When comparing the CHCO and DHMC TACS groups, there were no differences in the proportion of patients with perforated appendicitis, operative time, rate of operative complications, rate of postoperative infectious complications, or rate of 30-day readmission. Length of stay was significantly shorter for the DHMC TACS group than the CHCO group. Conclusion Our data demonstrate that among children >5yo undergoing appendectomy, length of stay, risk of infectious complications, and risk of readmission do not differ regardless of whether they are operated upon by pediatric surgeons or adult TACS surgeons, suggesting resources currently consumed by transferring children to hospitals with access to pediatric surgeons could be allocated elsewhere. Level of evidence Level III, economic/decision Conflicts of Interest and Source of Funding: The authors have no conflicts of interest nor sources of funding to disclose. Correspondence: Maggie M. Hodges, MD, MPH, Department of Surgery, University of Colorado Denver - Anschutz Medical Campus, Children’s Hospital Colorado, 12700 E. 19th Ave, Aurora, CO 80045. Email: maggie.hodges@ucdenver.edu, Phone: 303-724-4186 © 2017 Lippincott Williams & Wilkins, Inc.

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Transfer and Non-Transfer Patients in Isolated Low-Grade Blunt Pediatric Solid Organ Injury: Implications for Regionalized Trauma Systems

ABSTRACT:BackgroundRegionalization of trauma care is a national priority and hospitalization for blunt abdominal trauma, that may include transfer, is common among children. The objective of this study was to determine whether there were differences in mortality, treatment, or length of stay between patients treated at or transferred to a higher level trauma center and those not transferred and admitted to a lower level trauma center.MethodsCohort from Washington state trauma registry from 2000-2014 of patients 16 years or younger with isolated Grade I-III spleen, liver, or kidney injury.ResultsAmong 54034 patients 16 years or younger, the trauma registry captured 1177 (2.2 %) patients with isolated low grade solid organ injuries; 226 (19.2%) presented to a higher level trauma center, 600 (51.0%) presented to a lower level trauma center and stayed there for care, and 351 (29.8%) were transferred to a higher level trauma center. Forty patients (3.4%) underwent an abdominal operation. Among the 950 patients evaluated initially at a lower level trauma center, the risk of surgery did not differ significantly between those who were not transferred compared to those who were (RR 2.19 95%CI 0.80-6.01). The risk of total splenectomy was no different for patients who stayed at a lower level trauma center compared to those who were transferred to a higher level trauma center (RR 0.84 95%CI 0.33-2.16). Non-transferred patients had a 0.63 (95% CI: 0.45-0.88) times lower risk of staying in the hospital for an additional day compared to patients who were transferred to a higher level trauma center. One patient died.ConclusionFew pediatric patients with isolated low grade blunt solid organ injury require intervention and thus may not need to be transferred; trauma systems should revise their transfer policies. Prevention of unnecessary transfers is an opportunity for cost savings in pediatric trauma.Level of EvidenceIII, Epidemiological Background Regionalization of trauma care is a national priority and hospitalization for blunt abdominal trauma, that may include transfer, is common among children. The objective of this study was to determine whether there were differences in mortality, treatment, or length of stay between patients treated at or transferred to a higher level trauma center and those not transferred and admitted to a lower level trauma center. Methods Cohort from Washington state trauma registry from 2000-2014 of patients 16 years or younger with isolated Grade I-III spleen, liver, or kidney injury. Results Among 54034 patients 16 years or younger, the trauma registry captured 1177 (2.2 %) patients with isolated low grade solid organ injuries; 226 (19.2%) presented to a higher level trauma center, 600 (51.0%) presented to a lower level trauma center and stayed there for care, and 351 (29.8%) were transferred to a higher level trauma center. Forty patients (3.4%) underwent an abdominal operation. Among the 950 patients evaluated initially at a lower level trauma center, the risk of surgery did not differ significantly between those who were not transferred compared to those who were (RR 2.19 95%CI 0.80-6.01). The risk of total splenectomy was no different for patients who stayed at a lower level trauma center compared to those who were transferred to a higher level trauma center (RR 0.84 95%CI 0.33-2.16). Non-transferred patients had a 0.63 (95% CI: 0.45-0.88) times lower risk of staying in the hospital for an additional day compared to patients who were transferred to a higher level trauma center. One patient died. Conclusion Few pediatric patients with isolated low grade blunt solid organ injury require intervention and thus may not need to be transferred; trauma systems should revise their transfer policies. Prevention of unnecessary transfers is an opportunity for cost savings in pediatric trauma. Level of Evidence III, Epidemiological There are no conflicts of interest, financial or otherwise. Meeting Presentation: Innovations in Injury Prevention Science, Society for Advancement of Violence and Injury Research, September 18-20, 2017 in Ann Arbor, Michigan This study was supported by grant 5 T32 HD057822-08 from NICHD © 2017 Lippincott Williams & Wilkins, Inc.

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Development of a Trauma System and Optimal Placement of Trauma Centers Using Geospatial Mapping

ABSTRACTBACKGROUNDThe care of patients at individual trauma centers (TCs) has been carefully optimized, but not the placement of TCs within the trauma systems. We sought to objectively determine the optimal placement of trauma centers in Pennsylvania using geospatial mapping.METHODSWe used the Pennsylvania Trauma Systems Foundation (PTSF) and Pennsylvania Health Care Cost Containment Council (PHC4) registries for adult (age ≥15) trauma between 2003-2015 (n=377,540 and n=255,263). TCs and zip codes outside of PA were included to account for edge effects with trauma cases aggregated to the Zip Code Tabulation Area centroid of residence. Model assumptions included no prior TCs (clean slate), travel time intervals of 45, 60, 90 and 120 minutes, TC capacity based on trauma cases per bed size and candidate hospitals ≥200 beds. We used Network Analyst Location-Allocation function in ArcGIS Desktop to generate models optimally placing 1 to 27 TCs (27 current PA TCs) and assessed model outcomes.RESULTSAt a travel time of 60 minutes and 27 sites, optimally placed models for PTSF and PHC4 covered 95.6% and 96.8% of trauma cases in comparison with the existing network reaching 92.3% or 90.6% of trauma cases based on PTSF or PHC4 inclusion. When controlled for existing coverage, the optimal numbers of TCs for PTSF and PHC4 were determined to be 22 and 16, respectively.CONCLUSIONSThe clean slate model clearly demonstrates that the optimal trauma system for the state of Pennsylvania differs significantly from the existing system. Geospatial mapping should be considered as a tool for informed decision-making when organizing a statewide trauma system.LEVEL OF EVIDENCELevel III epidemiological study BACKGROUND The care of patients at individual trauma centers (TCs) has been carefully optimized, but not the placement of TCs within the trauma systems. We sought to objectively determine the optimal placement of trauma centers in Pennsylvania using geospatial mapping. METHODS We used the Pennsylvania Trauma Systems Foundation (PTSF) and Pennsylvania Health Care Cost Containment Council (PHC4) registries for adult (age ≥15) trauma between 2003-2015 (n=377,540 and n=255,263). TCs and zip codes outside of PA were included to account for edge effects with trauma cases aggregated to the Zip Code Tabulation Area centroid of residence. Model assumptions included no prior TCs (clean slate), travel time intervals of 45, 60, 90 and 120 minutes, TC capacity based on trauma cases per bed size and candidate hospitals ≥200 beds. We used Network Analyst Location-Allocation function in ArcGIS Desktop to generate models optimally placing 1 to 27 TCs (27 current PA TCs) and assessed model outcomes. RESULTS At a travel time of 60 minutes and 27 sites, optimally placed models for PTSF and PHC4 covered 95.6% and 96.8% of trauma cases in comparison with the existing network reaching 92.3% or 90.6% of trauma cases based on PTSF or PHC4 inclusion. When controlled for existing coverage, the optimal numbers of TCs for PTSF and PHC4 were determined to be 22 and 16, respectively. CONCLUSIONS The clean slate model clearly demonstrates that the optimal trauma system for the state of Pennsylvania differs significantly from the existing system. Geospatial mapping should be considered as a tool for informed decision-making when organizing a statewide trauma system. LEVEL OF EVIDENCE Level III epidemiological study Conflicts of Interest and Source of Funding: The authors report no proprietary or commercial interest in any product mentioned or concept discussed in this article. This study was funded in part by a grant from the Louise von Hess Medical Research Institute. This study was presented at the 76th Annual Meeting of the American Association for the Surgery of Trauma and Clinical Congress of Acute Care Surgery from September 13-16, 2017 in Baltimore, Maryland. Corresponding Author: Frederick B. Rogers, MD, MS, FACS; frogers2@lghealth.org 1, 555 N. Duke St., Lancaster, PA 17602, 717-544-5945 (tel), 717-544-5944 (fax) © 2017 Lippincott Williams & Wilkins, Inc.

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Prehospital Spine Immobilization/Spinal Motion Restriction in Penetrating Trauma: a Practice Management Guideline from the Eastern Association for the Surgery of Trauma (EAST)

ABSTRACTBackgroundSpine immobilization in trauma has remained an integral part of most emergency medical services (EMS) protocols despite a lack of evidence for efficacy and concern for associated complications, especially in penetrating trauma patients. We reviewed the published evidence on the topic of prehospital spine immobilization or spinal motion restriction in adult patients with penetrating trauma to structure a Practice Management Guideline.MethodsWe conducted a Cochrane style systematic review and meta-analysis, and applied GRADE methodology to construct recommendations. Qualitative and quantitative analyses were used to evaluate the literature on the critical outcomes of mortality, neurologic deficit, and potentially reversible neurologic deficit.ResultsA total of 24 studies met inclusion criteria, with qualitative review conducted for all studies. We used five studies for the quantitative review (meta-analysis). No study showed benefit to spine immobilization with regard to mortality and neurologic injury, even for patients with direct neck injury. Increased mortality was associated with spine immobilization, with RR 2.4 (CI 1.07, 5.41). The rate of neurologic injury or potentially reversible injury was very low, ranging from 0.002 to 0.076 and 0.00034 to 0.055, with no statistically significant difference for neurologic deficit or potentially reversible deficit, RR 4.16 (CI 0.56, 30.89), and RR 1.19 (CI 0.83, 1.70), although the point estimates favored no immobilization.ConclusionsSpine immobilization in penetrating trauma is associated with increased mortality and has not been shown to have a beneficial effect on mitigating neurologic deficits, even potentially reversible neurologic deficits. We recommend that spine immobilization not be used routinely for adult patients with penetrating trauma.Level of EvidenceLevel IIStudy TypeSystematic Review with Meta-analysis Background Spine immobilization in trauma has remained an integral part of most emergency medical services (EMS) protocols despite a lack of evidence for efficacy and concern for associated complications, especially in penetrating trauma patients. We reviewed the published evidence on the topic of prehospital spine immobilization or spinal motion restriction in adult patients with penetrating trauma to structure a Practice Management Guideline. Methods We conducted a Cochrane style systematic review and meta-analysis, and applied GRADE methodology to construct recommendations. Qualitative and quantitative analyses were used to evaluate the literature on the critical outcomes of mortality, neurologic deficit, and potentially reversible neurologic deficit. Results A total of 24 studies met inclusion criteria, with qualitative review conducted for all studies. We used five studies for the quantitative review (meta-analysis). No study showed benefit to spine immobilization with regard to mortality and neurologic injury, even for patients with direct neck injury. Increased mortality was associated with spine immobilization, with RR 2.4 (CI 1.07, 5.41). The rate of neurologic injury or potentially reversible injury was very low, ranging from 0.002 to 0.076 and 0.00034 to 0.055, with no statistically significant difference for neurologic deficit or potentially reversible deficit, RR 4.16 (CI 0.56, 30.89), and RR 1.19 (CI 0.83, 1.70), although the point estimates favored no immobilization. Conclusions Spine immobilization in penetrating trauma is associated with increased mortality and has not been shown to have a beneficial effect on mitigating neurologic deficits, even potentially reversible neurologic deficits. We recommend that spine immobilization not be used routinely for adult patients with penetrating trauma. Level of Evidence Level II Study Type Systematic Review with Meta-analysis Corresponding Author: Catherine Garrison Velopulos MD, MHS, FACS, University of Colorado School of Medicine, Trauma, Acute Care Surgery, and Critical Care. Email: Catherine.Velopulos@ucdenver.edu. Mailing Address: 12631 E. 17th Street, Room 6001, Aurora, Colorado 80045 Presented at: Eastern Association for the Surgery of Trauma 30th Annual Scientific Assembly, January 10-14, 2017, Hollywood, FL. Conflicts of Interest disclosure for all authors: Dr. Haut is supported by a research grant (1R01HS024547) from the Agency for Healthcare Research and Quality (AHRQ) titled “Individualized Performance Feedback on Venous Thromboembolism Prevention Practice.” Dr. Haut is supported by a contract (CE-12-11-4489) from the Patient-Centered Outcomes Research Institute (PCORI) titled “Preventing Venous Thromboembolism: Empowering Patients and Enabling Patient-Centered Care via Health Information Technology.” Dr. Haut receives royalties from Lippincott, Williams, & Wilkins for a book - "Avoiding Common ICU Errors". Dr. Haut is a paid consultant and speaker for the “Preventing Avoidable Venous Thromboembolism— Every Patient, Every Time” VHA IMPERATIV® Advantage Performance Improvement Collaborative and the Illinois Surgical Quality Improvement Collaborative "ISQIC." Dr. Haut was the paid author of a paper commissioned by the National Academies of Medicine titled “Military Trauma Care’s Learning Health System: The Importance of Data Driven Decision Making” which was used to support the report titled “A National Trauma Care System: Integrating Military and Civilian Trauma Systems to Achieve Zero Preventable Deaths After Injury.” None of these funding sources contributed to this work. © 2017 Lippincott Williams & Wilkins, Inc.

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A Combat Relevant Model for the Creation of Acute Lung Injury in Swine

No abstract available

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Trauma Laparoscopy from 1925-2017: Publication History and Study Demographics of an Evolving Modality

The use of laparoscopy in trauma surgery remains a debated topic, despite having been discussed in the literature for decades. The publication history of trauma laparoscopy was reviewed to identify trends, analyze study demographics, and summarize key papers, with hopes to better inform future areas of research. A systematic search of PubMed and Cochrane libraries was performed for English-language literature involving trauma laparoscopy through August 2017. Year published, number of subjects, study design, mechanism, type of laparoscopy (screening, therapeutic, diagnostic), journal, and location of study were recorded. Ten landmark papers were then chosen for discussion based upon high level of evidence and influence upon other work. In total, 281 articles on trauma laparoscopy, encompassing 11,816 subjects, have been published. Over three-quarters of the studies were case series or case reports (76.5%). Other types of studies included: 40 reviews (14.2%), 19 editorials (6.8%), 2 case-control studies (0.7%), 2 meta-analyses (0.7%), 2 randomized controlled trials (0.7%), and 1 systematic review (0.4%). Mechanism was blunt in 92 studies (32.7%), penetrating in 100 (35.5%), and 84 studies included both mechanisms (29.9%). All types of laparoscopy were discussed in the literature, with increasing representation of therapeutic laparoscopy in recent decade. The primary journals involved included Journal of Trauma and Surgical Endoscopy. Trauma laparoscopy has become a regular tool in the armamentarium of the trauma surgeon for the evaluation and treatment of hemodynamically stable patients, regardless of mechanism of injury. There has been near exponential growth in related research over the past three decades. The type of laparoscopy performed has evolved from a screening tool into a diagnostic and therapeutic modality. Despite the large number of publications and positive outcomes, there is still a lack of high level evidence in this field, and adequately powered studies are needed to further support this approach. Correspondence: Nova Szoka, MD, Assistant Professor, West Virginia University, One Medical Center Drive, PO Box 9238, Morgantown, WV 26506-9238, Phone 304-293-1728, Fax 304-293-6628. Nova.szoka@hsc.wvu.edu Conflict of interest statement: No conflicts are declared for all authors. Abstract presented at 2016 Society of American Gastrointestinal and Endoscopic Surgeons Annual Meeting, March 16-19, 2016 in Boston, Massachusetts. No funding received from NIH, Wellcome Trust, or HHMI. © 2017 Lippincott Williams & Wilkins, Inc.

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President Trump visits Fla. fire department after golf trip

By Wayne Washington The Palm Beach Post WEST PALM BEACH, Fla. — President Donald Trump capped a day spent largely at one of his golf clubs Wednesday with a brief visit to a West Palm Beach Fire Rescue station. Firefighters and paramedics at Fire Station 2 on Dixie Highway south of Southern Boulevard formed a semi-circle around the president as he took pictures with them, shook hands with them ...

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eCore with ePro Scheduling

Do you have continuous challenges with balancing work hours, minimize overtime and keep everything updated? Are you looking for a way to take control of this process and improve workflows? eCore's ePro Scheduler is an automated scheduling process that is built for the EMS industry. http://ift.tt/2Dq3EeE

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eCore with ePro Scheduling

Do you have continuous challenges with balancing work hours, minimize overtime and keep everything updated? Are you looking for a way to take control of this process and improve workflows? eCore's ePro Scheduler is an automated scheduling process that is built for the EMS industry. http://ift.tt/2Dq3EeE

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eCore with ePro Scheduling

Do you have continuous challenges with balancing work hours, minimize overtime and keep everything updated? Are you looking for a way to take control of this process and improve workflows? eCore's ePro Scheduler is an automated scheduling process that is built for the EMS industry. http://ift.tt/2Dq3EeE

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Are large fracture trials really possible? What we have learned from the randomized controlled damage control study?

Abstract

Purpose

Although they are considered the ‘gold standard’ of evidence-based medicine, randomized controlled trials are still a rarity in orthopedic surgery. In the management of patients with multiple trauma, there is a current trend toward ‘damage control orthopedics’, but to date, there is no proof of the superiority of this concept in terms of evidence-based medicine. The purpose of this article is to present unexpected difficulties we encountered in successfully completing our randomized controlled trial and to discuss the problematic differences between theoretically planning a trial and real-life practical experience of implementing the plan, with attention to published strategies.

Methods

The multicenter randomized controlled trial on risk adapted damage control orthopedic surgery of femur shaft fractures in multiple trauma patients (DCO study) was designed to determine whether ‘risk adapted damage control orthopedics’ of femoral shaft fractures is advantageous when treating multiple trauma patients. We compared our methods of study planning and realization point by point with published methods for conducting such trials.

Results

The study was methodically planned. We met the most prerequisites for successfully completing a large fracture trial, but experienced unexpected difficulties. After 2.5 years, the Deutsche Forschungsgemeinschaft suspended the financing because of low recruitment. The reasons were multifactorial.

Conclusions

We believe it is much more difficult to perform a large fracture trial in reality than to plan it in theory. Even the theoretically best designed trial can prove unsuccessful in its implementation. The question remains: are large fracture trials even possible? Hopefully YES!

Trial registration

Current Controlled Trials ISRCTN10321620. Date assigned: 09/02/2007.

Level of evidence

Level I.

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eCore with ePro Scheduling

Do you have continuous challenges with balancing work hours, minimize overtime and keep everything updated? Are you looking for a way to take control of this process and improve workflows? eCore's ePro Scheduler is an automated scheduling process that is built for the EMS industry. http://ift.tt/2Dq3EeE

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Outcomes of operative and nonoperative treatment of 3- and 4-part proximal humeral fractures in elderly: a 10-year retrospective cohort study

Abstract

Purpose

Despite a rising incidence in proximal humeral fractures, there is still no evidence for the best treatment option, especially for elderly patients. The aim of this retrospective cohort study was to evaluate health-related quality of life (HRQoL), functional outcome, pain and social participation in elderly patients, after operative and nonoperative treatment of displaced 3- and 4-part proximal humeral fractures.

Methods

150 patients aged ≥ 65, treated for a displaced 3- or 4-part proximal humeral fracture between 2004 and 2014, were invited to participate. Eventually 91 patients (61%) participated, of which 32 non-operatively treated patients were matched to 32 of the 59 operatively treated patients by propensity score matching. The EQ-5D, DASH, VAS for pain and WHODAS 2.0 Participation in Society domain were administered. Complications and reinterventions were registered.

Results

No significant difference was found between the two treatment groups in HRQoL (p = 0.43), function (p = 0.78) and pain (p = 0.19). A trend toward better social participation in the operative group (p = 0.09) was found. More complications and reinterventions occurred in the operative group than the nonoperative group, with 9 versus 5 complications (p = 0.37) and 8 versus 2 reinterventions (p = 0.08).

Conclusions

In this study, we found no evidence of a difference in HRQoL, functional outcome or pain 1–10 years after operative or nonoperative treatment in patients of 65 and older with a displaced 3- or 4-part humeral fracture. Operatively treated patients showed a trend toward better social participation but also higher reintervention rates.

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Factors associated with the true location of ingested fishbones

Objectives Fishbone ingestion is a common problem worldwide, and the first step for managing this condition is to locate the fishbone precisely. However, until now, no study has analysed the true location of fishbone and its associated factors. Thus, this study identified the factors predicting the true location of fishbone and subsequently attempted to provide a management algorithm for fishbone ingestion. Patients and methods This retrospective study was carried out at St Martin De Porres Hospital, Taiwan, between January 2015 and January 2016. All patients were diagnosed as having fishbone ingestion within the pharynx and underwent fishbone removal. Results This study included 198 consecutive patients with a mean age of 43.1 years (range: 1–84 years). The sensitivity of lateral neck radiography in the diagnosis of fishbone in the pharynx was only 22%. The fishbone locations were as follows: the tonsil in 72 (36.4%) patients, the tongue base/vallecula in 112 (56.6%) and the hypopharynx in 14 (7.0%). Multiple logistic regression analysis showed that patient age and fishbone length were significant independent risk factors associated with the true location of fishbone ingestion. Among all patients, fishbone was removed transorally under direct vision in 73 (36.9%) patients and using flexible nasopharyngoscopy in 125 (63.1%) patients. Conclusion Patient age and fishbone length are important independent factors associated with the location of ingested fishbone. Lateral neck radiography is not beneficial for diagnosing fishbone ingestion within the pharynx. Flexible nasopharyngoscopy, by contrast, is an important method for the diagnosis and treatment of fishbone ingestion within this location. Correspondence to Ying-Chou Lu, MD, Department of Otolaryngology, St Martin De Porres Hospital, No. 565, Sec. 2, Daya Road, Chiayi 11217, Taiwan (Republic of China) Tel: +886 5 2756000; fax: +886 5 2762905; e-mail: luyingchou@gmail.com Received August 13, 2017 Accepted November 19, 2017 Copyright © 2017 Wolters Kluwer Health, Inc. All rights reserved.

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Kan. high schools now required to teach CPR

The new standard makes Kansas the 38th state in the country to have CPR training as a high school graduation requirement

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Improvement of outcomes in patients with pelvic fractures and hemodynamic instability after the establishment of a Korean regional trauma center

Abstract

Purpose

Despite using a multidisciplinary treatment approach, the mortality rate of patients with hemodynamic instability from severe pelvic fractures is still 40–60%. We evaluated the improvement of outcomes in this patient population after the establishment of a regional trauma center in Korea.

Methods

We retrospectively reviewed the medical charts of 50 patients with hemodynamic instability due to pelvic fractures between March 2011 and November 2016. Patients were divided into two groups: the pre-trauma center (PTC) group (n = 23) and trauma center (TC) group (n = 27).

Results

Sixteen (32.0%) patients died of exsanguination. Patients in the TC group had shorter trauma resuscitation room stay (101 vs 273 min, p < 0.001) and underwent preperitoneal pelvic packing (PPP) more frequently (88.9 vs 8.7%, p < 0.001) than those in the PTC group. During the TC period, emergent procedures such as PPP and pelvic angiography were performed more frequently (92.6 vs 39.1%, p < 0.001). Although there was no statistical difference in the overall mortality rate between groups, patients in the TC group had less mortality due to hemorrhage (18.5 vs 47.8%, p = 0.027). Logistic regression analysis demonstrated that initial systolic blood pressure and establishment of trauma center were independent protective factors of mortality from hemorrhage [odds ratio (OR) 0.957, 95% confidence interval (CI) 0.926–0.988, p = 0.007; OR 0.134, 95% CI 0.028–0.633, p = 0.011].

Conclusions

Since the regional trauma center was established, emergent procedures such as pelvic angiography and PPP were performed more frequently, and mortality due to exsanguination was significantly decreased.

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Steven Knight becomes partner at Fitch & Associates

Knight will continue to lead the firm’s growing fire service practice PLATTE CITY, Mo. — Fitch & Associates, a leading public safety and health care consulting firm, has named Steven Knight partner, effective January 1, 2018. For more than three years, Dr. Knight has served as the firm’s Fire Service Practice Lead. In that role, he led numerous assessments of fire service operations ...

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EMS education needed: Overcoming the speed bumps of 2017

As 2017 draws to a close and 2018 approaches, I think it’s appropriate to look back on the EMS events of the last year, and try to draw some lessons that will help us prepare for what is to come. And the lesson I think we can all draw is, “Thank goodness it’s almost over.” 2017 turned out to be like that fantasy date with a supermodel: she looked great from afar, but over dinner ...

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Erythropoietin Does Not Alter Serum Profiles of Neuronal and Axonal Biomarkers After Traumatic Brain Injury: Findings From the Australian EPO-TBI Clinical Trial

Objective: To determine profiles of serum ubiquitin carboxy-terminal hydrolase L1 and phosphorylated neurofilament heavy-chain, examine whether erythropoietin administration reduce their concentrations, and whether biomarkers discriminate between erythropoietin and placebo treatment groups. Design: Single-center, prospective observational study. Setting: A sub-study of the erythropoietin-traumatic brain injury clinical trial, conducted at the Alfred Hospital, Melbourne, Australia. Patients: Forty-four patients with moderate-to-severe traumatic brain injury. Interventions: Epoetin alfa 40,000 IU or 1 mL sodium chloride 0.9 as subcutaneous injection within 24 hours of traumatic brain injury. Measurements and Main Results: Ubiquitin carboxy-terminal hydrolase L1, phosphorylated neurofilament heavy-chain, and erythropoietin concentrations were measured in serum by enzyme-linked immunosorbent assay from D0 (within 24 hr of injury, prior to erythropoietin/vehicle administration) to D5. Biomarker concentrations were compared between injury severities, diffuse versus focal traumatic brain injury and erythropoietin or placebo treatment groups. Ubiquitin carboxy-terminal hydrolase L1 peaked at 146.0 ng/mL on D0, significantly decreased to 84.30 ng/mL on D1, and declined thereafter. Phosphorylated neurofilament heavy-chain levels were lowest at D0 and peaked on D5 at 157.9 ng/mL. D0 ubiquitin carboxy-terminal hydrolase L1 concentrations were higher in diffuse traumatic brain injury. Peak phosphorylated neurofilament heavy-chain levels on D3 and D4 correlated with Glasgow Outcome Score–Extended, predicting poor outcome. Erythropoietin did not reduce concentrations of ubiquitin carboxy-terminal hydrolase L1 or phosphorylated neurofilament heavy-chain. Conclusions: Serum ubiquitin carboxy-terminal hydrolase L1 and phosphorylated neurofilament heavy-chain increase after traumatic brain injury reflecting early neuronal and progressive axonal injury. Consistent with lack of improved outcome in traumatic brain injury patients treated with erythropoietin, biomarker concentrations and profiles were not affected by erythropoietin. Pharmacokinetics of erythropoietin suggest that the dose given was possibly too low to exert neuroprotection. This work was performed at the Alfred Hospital and EnCor Biotechnology. Drs. Hellewell and Mondello contributed equally to this work. Dr. Hellewell was supported by a Centre of Excellence in Traumatic Brain Injury Research (CETBIR) Postdoctoral Fellowship. Drs. Little and Cooper’s institutions received funding from National Health and Medical Research Council (NHMRC) Australia. Dr. Little’s institution received funding from the Transport Accident Commission (TAC), and she disclosed that she project-managed the EPO-TBI RCT and received a salary via Monash University from the NHMRC and TAC grants for her work. Drs. Bellomo and Cooper disclosed off-label product use of erythropoietin in traumatic brain injury. Dr. Cooper’s institution received funding from Victorian Neurotrauma Initiative. The remaining authors have disclosed that they do not have any potential conflicts of interest. For information regarding this article, E-mail: hellewel@ualberta.ca Copyright © by 2017 by the Society of Critical Care Medicine and Wolters Kluwer Health, Inc. All Rights Reserved.

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Reliability and performance of the Swiss Emergency Triage Scale used by paramedics

Objectives No general emergency department triage scale has been evaluated for prehospital triage. The objective of this study was to evaluate the reliability and the performance of the Swiss Emergency Triage Scale (SETS) used by paramedics to determine the emergency level and orientation of simulated patients. Patients and methods In a prospective cross-sectional study, 23 paramedics evaluated 28 clinical scenarios with the SETS using interactive computerized triage software simulating real-life triage. The primary outcome was inter-rater reliability regarding the triage level among participants measured by intraclass correlation coefficient (ICC). Secondary outcomes were the accuracy of triage level and the reliability and accuracy of orientation of patients of at least 75 years to a dedicated geriatric emergency centre. Results Twenty-three paramedics completed the evaluation of the 28 scenarios (644 triage decisions). Overall, ICC for triage level was 0.84 (95% confidence interval: 0.77–0.99). Correct emergency level was assigned in 89% of cases, overtriage rate was 4.8%, and undertriage was 6.2%. ICC regarding orientation in the subgroup of simulated patients of at least 75 years was 0.76 (95% confidence interval: 0.61–0.89), with 93% correct orientation. Conclusion Reliability of paramedics rating simulated emergency situations using the SETS was excellent, and the accuracy of their rating was very high. This suggests that in Switzerland, the SETS could be safely used in the prehospital setting by paramedics to determine the level of emergency and guide patients to the most appropriate hospital. This is an open-access article distributed under the terms of the Creative Commons Attribution-Non Commercial-No Derivatives License 4.0 (CCBY-NC-ND), where it is permissible to download and share the work provided it is properly cited. The work cannot be changed in any way or used commercially without permission from the journal. http://ift.tt/1hexVwJ Correspondence to Olivier Grosgurin, MD, Department of Community, Primary Care and Emergency Medicine, Division of Emergency Medicine, Faculty of Medicine, Geneva University Hospitals, Gabrielle Perret-Gentil 2, 1205 Geneva, Switzerland Tel: +41 22 372 3311; fax: +41 22 372 8144; e-mail: olivier.grosgurin@hcuge.ch Received May 2, 2017 Accepted September 4, 2017 Copyright © 2017 Wolters Kluwer Health, Inc. All rights reserved.

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Trendelenburg position in the ED: many critically ill patients in the emergency department do not tolerate the Trendelenburg position

Objectives Critically ill patients in emergency departments (ED) frequently require catheterization of the internal jugular vein. For jugular insertion, the Trendelenburg position (TP) is recommended. However, many patients in the ED do not tolerate lying in the supine or even the head-down position, or TP is contraindicated for other reasons. The aim of our trial was to investigate to which extent TP is either not tolerated or contraindicated in the target population of patients admitted to the ED. Patients and methods This was a clinical observational trial, carried out in an ED of a Tertiary Healthcare Hospital, including critically ill patients. From October 2015 to January 2016, we enrolled 117 nonintubated patients up to 18 years admitted to the ED of Jena University Hospital, a Tertiary Healthcare Facility. Patients were positioned in TP (15° head-down) for a maximum of 10 min. If the position had to be abandoned for any reason, time to abandonment and reason for ending the position were recorded. 38.5% of all enrolled patients could not be positioned in TP because of contraindications (17.9%) or intolerance of the positioning (20.5%). Results and conclusion For central venous catheterization, TP remains the gold standard. Our trial shows the limitations of this positioning for critically ill patients. Almost 40% of the patients could not be tilted 15° head-down. Therefore, guideline recommendations should be reconsidered and alternatives should be sought. Correspondence to Hendrik Rueddel, MD, Department of Anesthesiology and Intensive Care Medicine, Jena University Hospital, Am Klinikum 1, 07747 Jena, Germany Tel: +49 364 1932 3101; fax: +49 364 1932 3102; e-mail: hendrik.rueddel@med.uni-jena.de Received May 24, 2017 Accepted November 19, 2017 Copyright © 2017 Wolters Kluwer Health, Inc. All rights reserved.

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“Validation of a new American Association for the Surgery of Trauma (AAST) anatomic severity grading system for acute cholecystitis.”

Background The American Association for the Surgery of Trauma (AAST) established anatomic grading to facilitate risk stratification and risk adjusted outcomes in emergency general surgery. Cholecystitis severity was graded based on clinical, imaging, operative, and pathologic criteria. We aimed to validate the AAST anatomic grading system for acute cholecystitis. Methods This is a retrospective cohort study including consecutive patients admitted with acute cholecystitis at an urban, tertiary medical center between 2013 and 2016. Grade I is acute cholecystitis, Grade II is gangrenous or emphysematous cholecystitis, Grade III is localized perforation, Grade IV and V have regional and systemic peritonitis, respectively. Concordance between the AAST grade and outcome including mortality, length of stay (LOS), ICU use, readmission, and complications were assessed using logistic regression. Results A total of 315 patients were included. There was very good interrater (2 independent raters) reliability for anatomic grading, κ=1.00, p

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USE OF OPEN AND ENDOVASCULAR SURGICAL TECHNIQUES TO MANAGE VASCULAR INJURIES IN THE TRAUMA SETTING: A REVIEW OF THE AAST PROOVIT REGISTRY

AbstractIntroductionVascular trauma data have been submitted to the American Association for the Surgery of Trauma PROspective Observational Vascular Injury Trial (PROOVIT) database since 2013. We present data to describe current use of endovascular surgery in vascular trauma.MethodsRegistry data from March 2013 to December 2016 were reviewed. All trauma patients who had an injury to a named artery, except the forearm and lower leg, were included. Arteries were grouped into anatomic regions and by compressible and non-compressible region for analysis. This review focused on patients with non-compressible transection, partial transection, or flow limiting defect injuries. Bivariate and multivariate analyses were used to assess the relationships between study variables.Results1143 patients from 22 institutions were included. Median age was 32 years (interquartile range IQR 23-48) and 76% (n=871) were male. Mechanisms of injury were 49% (n=561) blunt, 41% (n=464) penetrating, and 1.8% (n=21) of mixed aetiology. Gunshot wounds accounted for 73% (n=341) of all penetrating injuries. Endovascular techniques were used least often in limb trauma and most commonly in patients with blunt injuries to more than one region. Penetrating wounds to any region were preferentially treated with open surgery (74%, n=341/459). The most common indication for endovascular treatment was blunt non-compressible torso injuries (NCTI). These patients had higher injury severity scores and longer associated hospital stays, but required less packed red blood cells (PRBC), and had lower in hospital mortality than those treated with open surgery. On multivariate analysis, admission low hemoglobin concentration and abdominal injury were independent predictors of mortality.ConclusionsOur review of PROOVIT registry data demonstrates a high utilization of endovascular therapy among severely injured blunt trauma patients primarily with non-compressible torso hemorrhage. This is associated with decreased need for blood transfusion and improved survival despite longer length of stay.Level of EvidenceIII, Therapeutic/care management Introduction Vascular trauma data have been submitted to the American Association for the Surgery of Trauma PROspective Observational Vascular Injury Trial (PROOVIT) database since 2013. We present data to describe current use of endovascular surgery in vascular trauma. Methods Registry data from March 2013 to December 2016 were reviewed. All trauma patients who had an injury to a named artery, except the forearm and lower leg, were included. Arteries were grouped into anatomic regions and by compressible and non-compressible region for analysis. This review focused on patients with non-compressible transection, partial transection, or flow limiting defect injuries. Bivariate and multivariate analyses were used to assess the relationships between study variables. Results 1143 patients from 22 institutions were included. Median age was 32 years (interquartile range IQR 23-48) and 76% (n=871) were male. Mechanisms of injury were 49% (n=561) blunt, 41% (n=464) penetrating, and 1.8% (n=21) of mixed aetiology. Gunshot wounds accounted for 73% (n=341) of all penetrating injuries. Endovascular techniques were used least often in limb trauma and most commonly in patients with blunt injuries to more than one region. Penetrating wounds to any region were preferentially treated with open surgery (74%, n=341/459). The most common indication for endovascular treatment was blunt non-compressible torso injuries (NCTI). These patients had higher injury severity scores and longer associated hospital stays, but required less packed red blood cells (PRBC), and had lower in hospital mortality than those treated with open surgery. On multivariate analysis, admission low hemoglobin concentration and abdominal injury were independent predictors of mortality. Conclusions Our review of PROOVIT registry data demonstrates a high utilization of endovascular therapy among severely injured blunt trauma patients primarily with non-compressible torso hemorrhage. This is associated with decreased need for blood transfusion and improved survival despite longer length of stay. Level of Evidence III, Therapeutic/care management Corresponding Author: Major ER Faulconer MBBS FRCS, Department of Vascular Surgery, David Grant USAF Medical Center, Travis AFB, CA USA. robfaulconer@doctors.org.uk Conflicts of Interest and Sources of Funding No author has any conflicts of interest with respect to this study. No funding was received for the study. The project described was supported by the National Center for Advancing Translational Sciences (NCATS), National Institutes of Health (NIH), through grant #UL1 TR001860. This work was funded by the National Trauma Institute, Award # NTI-NTRR15-05, and supported by the Office of the Assistant Secretary of Defense for Health Affairs through the Defense Medical Research and Development Program under the prime award # W81XWH-15-2-0089. The U.S. Army Medical Research Acquisition Activity, 820 Chandler Street, Fort Detrick MD 21702-5014 is the awarding and administering acquisition office. Opinions, interpretations, conclusions and recommendations are those of the author and are not necessarily endorsed by the Department of Defense or the National Trauma Institute. Presentation Presented at the American Association for the Surgery of Trauma 76th Annual Meeting in Baltimore, 13-16th September 2017 in session XIIIB – Outcomes/Guidelines © 2017 Lippincott Williams & Wilkins, Inc.

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Examining Racial Disparities in the Time to Withdrawal of Life-Sustaining Treatment in Trauma

Introduction Racial disparities in medical treatment for seriously injured patients across the spectrum of care are well established, but racial disparities in end of life decision-making practices have not been well described. When time from admission to time to withdrawal of life-sustaining treatment (WLST) increases, so does the potential for ineffective care, healthcare resource loss, and patient and family suffering. We sought to determine the existence and extent of racial disparities in late WLST after severe injury. Methods We queried the American College of Surgeons’ (ACS) Trauma Quality Improvement Program (TQIP) (2013 – 2016) for all severely injured patients (injury severity score > 15, age > 16) with a WLST order > 24 hours after admission. We defined late WLST as care withdrawn at a time interval beyond the 75th percentile for the entire cohort. Univariate and multivariate analyses were performed utilizing descriptive statistics, and t-tests and chi-squared tests where appropriate. Multivariable regression analysis was performed with random effects to account for institutional-level clustering using late WLST as the primary outcome, and race as the primary predictor of interest. Results 13,054 patients from 393 centers were included in the analysis. Median time to WLST was 5.4 days (IQR 2.6-10.3). In our unadjusted analysis, African-American patients (10.1% vs 7.1%, p

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Whole Blood and Hextend: Bookends of Modern Tactical Combat Casualty Care Field Resuscitation and Starting Point For Multi-functional Resuscitation Fluid Development

ABSTRACTBackgroundHemorrhage is the leading cause of preventable death in traumatically injured civilian and military populations. Pre-hospital resuscitation largely relies on crystalloid and colloid intra-vascular expansion, as whole blood and component blood therapy are logistically arduous. In this experiment, we evaluated the bookends of Tactical Combat Casualty Care Guidelines recommendations of pre-hospital resuscitation with Hextend and whole blood in a controlled hemorrhagic shock model within non-human primates, as means of a multi-functional resuscitative fluid development.MethodsIn the non-human primate, a poly-trauma model was utilized, consisting of a musculoskeletal injury (femur fracture), soft tissue injury (15cm laparotomy), and controlled hemorrhage to a mean arterial pressure of 20 mmHg, demarcating the beginning of the shock period. Animals were randomized to pre-hospital interventions of whole blood or Hextend at T=0 minutes, and at T=90 minutes definitive surgical interventions and balanced sanguineous damage control resuscitation could be implemented. All animals were euthanized at T=480 minutes. Data are expressed as mean±SEM; significance, p

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NON-OPERATIVE MANAGEMENT OF ABDOMINAL SOLID ORGAN INJURIES FOLLOWING BLUNT TRAUMA IN ADULTS: RESULTS FROM AN INTERNATIONAL CONSENSUS CONFERENCE

ABSTRACTBackgroundNon-operative management (NOM) for blunt solid organ injuries has become the standard of care for patients who are hemodynamically stable, without other indications for explorative laparotomy. Our aims were to develop evidence-based guidelines to correctly identify the indications for NOM in adult blunt trauma patient, the best and most appropriate modality for follow-up, and the best techniques to manage complications.MethodsThe literature since 2000 to 2016 was systematically screened according to PRISMA [Preferred Reporting Items for Systematic Reviews and meta-analyses] protocol. Sixty-three 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 was held.ResultsIn stable patients, without other indications for surgery, NOM is the initial treatment of choice for splenic, hepatic and renal injuries, regardless of grade. NOM is indicated in grade I-II pancreatic trauma, without ductal injury. Contrast enhanced computed tomography is mandatory to correctly plan NOM. Angioembolization has proven to be an effective adjunct in NOM to control bleeding, thereby reducing the need for surgery. Endoscopic Retrograde Cholangio Pancreatography is useful to control biliary and pancreatic complications of NOM.ConclusionNOM is feasible even in high grade parenchymal injuries, but logistic and technical resources must be available 24/7 to safely manage the patients. Background Non-operative management (NOM) for blunt solid organ injuries has become the standard of care for patients who are hemodynamically stable, without other indications for explorative laparotomy. Our aims were to develop evidence-based guidelines to correctly identify the indications for NOM in adult blunt trauma patient, the best and most appropriate modality for follow-up, and the best techniques to manage complications. Methods The literature since 2000 to 2016 was systematically screened according to PRISMA [Preferred Reporting Items for Systematic Reviews and meta-analyses] protocol. Sixty-three 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 was held. Results In stable patients, without other indications for surgery, NOM is the initial treatment of choice for splenic, hepatic and renal injuries, regardless of grade. NOM is indicated in grade I-II pancreatic trauma, without ductal injury. Contrast enhanced computed tomography is mandatory to correctly plan NOM. Angioembolization has proven to be an effective adjunct in NOM to control bleeding, thereby reducing the need for surgery. Endoscopic Retrograde Cholangio Pancreatography is useful to control biliary and pancreatic complications of NOM. Conclusion NOM is feasible even in high grade parenchymal injuries, but logistic and technical resources must be available 24/7 to safely manage the patients. Corresponding Author/Reprints: Osvaldo Chiara, General Surgery-Trauma Team. Grande Ospedale Metropolitano Niguarda, Piazza Benefattori dell’Ospedale, 320162 Milano, Italy, email: ochiara@yahoo.com, Phone. +39 02 6444 5381, Mobile phone +39 320 4398219, Fax +39 02 6444 7210 DISCLOSURE The author O.C. has had a consultant fee with Acelity Company, San Antonio, TX since October 2016 and has speaker fees with Smith and Nephew during 2017 Centro Studi Libera Orlandi, Acelity, Baxter, ItalFarmaco, Johnson&Johnson and Takeda provided the sponsorship. This study was presented at the International Consensus Conference on Non Operative Management of Solid Organ Injuries on December 12, 2016, in Milan, Italy. © 2017 Lippincott Williams & Wilkins, Inc.

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Post-Discharge Adherence With Venous Thromboembolism Prophylaxis After Orthopedic Trauma: Results From a Randomized Controlled Trial of Aspirin vs. Low Molecular Weight Heparin

ABSTRACTBackgroundOrthopedic trauma patients are often treated with venous thromboembolism (VTE) chemoprophylaxis with aspirin or low molecular weight heparin (LMWH) after discharge from their index admission, but adherence patterns are not known. We hypothesized that overall adherence would be moderate and greater with aspirin compared to LMWH.MethodsWe conducted a randomized controlled trial of adult trauma patients with an operative extremity fracture or any pelvic/acetabular fracture requiring VTE prophylaxis. Patients were randomized to receive either LMWH 30mg BID or aspirin 81mg BID. Patients prescribed outpatient prophylaxis were contacted between 10 to 21 days after discharge to assess adherence measured by the validated Morisky Medication Adherence Scale (MMAS-8). Adherence scores were compared between the two treatment arms with similar results for intention-to-treat and as-treated analyses. As-treated multivariable logistic regression was performed to determine factors associated with low-medium adherence scores.Results150 patients (64 on LMWH, 86 on aspirin) on chemoprophylaxis at time of follow-up completed the questionnaire. As-treated analysis showed that adherence was high overall (mean MMAS 7.2 out of 8, SD 1.5) and similar for the two regimens (LMWH: 7.4 vs. aspirin: 7.0, p=0.13). However, patients on LMWH were more likely to feel hassled by their regimen (23% vs. 9%, p=0.02). In a multivariable model, low-medium adherence was associated with taking LMWH as the prophylaxis medication (aOR 2.34, CI 1.06 – 5.18, p=0.04), having to self-administer the prophylaxis (aOR 4.44, CI 1.45 – 13.61, p

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Lower emergency general surgery (EGS) mortality among hospitals with higher quality trauma care

ABSTRACTBackgroundPatients undergoing emergency general surgery (EGS) procedures are up to eight times more likely to die than patients undergoing the same procedures electively. This excess mortality is often attributed to non-modifiable patient factors including comorbidities and physiologic derangements at presentation, leaving few targets for quality improvement. Though the hospital-level traits that contribute to EGS outcomes are not well understood, we hypothesized that facilities with lower trauma mortality would have lower EGS mortality.MethodsUsing the Nationwide Inpatient Sample (2008-2011), we calculated hospital-level risk-adjusted trauma mortality rates for hospitals with >400 trauma admissions. We then calculated hospital-level risk-adjusted EGS mortality rates for hospitals with >200 urgent/emergent admissions for seven core EGS procedures (laparotomy, large bowel resection, small bowel resection, lysis of adhesions, operative intervention for ulcer disease, cholecystectomy, and appendectomy). We used univariable and multivariable techniques to assess for associations between hospital-level risk-adjusted EGS mortality and hospital characteristics, patient-mix traits, EGS volume, and trauma mortality quartile.ResultsData from 303 hospitals, representing 153,544 admissions, revealed a median hospital-level EGS mortality rate of 1.21%(inter-quartile range:0.86%-1.71%). After adjusting for hospital traits, hospital-level EGS mortality was significantly associated with trauma mortality quartile; as well as patients’ community income-level and race/ethnicity (p400 trauma admissions. We then calculated hospital-level risk-adjusted EGS mortality rates for hospitals with >200 urgent/emergent admissions for seven core EGS procedures (laparotomy, large bowel resection, small bowel resection, lysis of adhesions, operative intervention for ulcer disease, cholecystectomy, and appendectomy). We used univariable and multivariable techniques to assess for associations between hospital-level risk-adjusted EGS mortality and hospital characteristics, patient-mix traits, EGS volume, and trauma mortality quartile. Results Data from 303 hospitals, representing 153,544 admissions, revealed a median hospital-level EGS mortality rate of 1.21%(inter-quartile range:0.86%-1.71%). After adjusting for hospital traits, hospital-level EGS mortality was significantly associated with trauma mortality quartile; as well as patients’ community income-level and race/ethnicity (p

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