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Background: Current data on tranexamic acid (TXA) supports early administration for severe hemorrhagic shock. Administration by EMS has been facilitated by developing protocols and standing orders informed by these data. In this study, patterns of TXA use by EMS agencies serving a large level 1 trauma center were examined. We hypothesized that current widespread TXA use often includes administration outside of data-driven indications., Methods: The trauma registry at a level 1 trauma center was queried for patients who received TXA. To determine the practice patterns and appropriateness of administration of TXA, patients' physiologic state in the prehospital environment based on EMS records, physiologic state on arrival to hospital, and interventions performed in both settings were examined. Over 20 separately managed EMS systems that administer TXA transport patients to this trauma center, allowing for a broad survey of practices., Results: From 2016 to 2021 1089 patients received TXA, 406 (37.3%) having treatment initiated by EMS services. Of these, the average prehospital systolic blood pressure (SBP) was 108.2 mmHg and initial ED SBP was 107.8 mmHg. Only 58.4% of these patients received blood transfusion after arrival to this trauma center. Compliance with standard indications was low with only 14.6% of administrations meeting any data-driven SBP indication. Similar levels of compliance were seen across high volume EMS services., Discussion: Tranexamic acid use has become common in trauma and has been adopted by many EMS systems. These results indicate TXA in the prehospital setting is over-used as administration is not being limited to indications that have shown benefit in prior data., Competing Interests: Declaration of Conflicting InterestsThe author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Introduction: Blunt cerebrovascular injury (BCVI) is an increasingly detected pattern in trauma with significant morbidity, putting patients at risk for subsequent stoke. Complex screening protocols exist to determine who should undergo CT angiography of the neck (CTAN) to evaluate for BCVI. Once identified, stroke incidence may be reduced with appropriate treatment across grades. We hypothesize that an expanded and simplified method for identifying patients with clinical suspicion for BCVI based upon injury above the clavicle (ATC) will illustrate a previously undiagnosed cohort of patients., Methods: A single-institution retrospective review of adult (age ≥18 years) blunt trauma patients with BCVI from January 1, 2010 to December 31, 2019 was conducted at a tertiary academic medical center. Patients undergoing CTAN were divided into 2 groups based upon qualification by either the expanded Denver criteria or clinical evidence of any injury ATC., Results: A total of 219 patients were diagnosed with BCVI (25 566 blunt trauma admissions, .9% incidence). Seventeen patients (8%) who did not satisfy expanded Denver were diagnosed with BCVI by ATC, most commonly undergoing CTAN due to facial trauma (n = 8). There were no differences in distribution of carotid artery injuries (CAI) and vertebral artery injuries (VAI) in the expanded Denver criteria group compared to the ATC group., Conclusions: CTAN for blunt trauma with any injury ATC is an easy-to-use screening tool and may be seamlessly included with initial whole-body imaging.

Since the Transfusion Requirements in Critical Care trial, studies have shown that acutely ill patients can drift as a low as 5 g/dL. This study reviews a transfusion trigger change to 6.5 g/dL, which we hypothesize will conserve resources and improve quality of care. This is a retrospective chart review at an urban Level I trauma center from January through December 2015 after our trauma service changed the transfusion trigger from 7 to 6.5 g/dL. Outcomes in patients before (TT7) and after (TT6.5) the change in transfusion threshold were then compared. One hundred thirty-one discrete patients were included in this trial, with 285 instances of a hemoglobin of 7 g/dL or less and 178 transfusions. Seventy-two patients were before the change in threshold and 59 after. There was no change in length of hospital stay, ICU stay, ventilator days, mortality, and organ system failure after change in the transfusion threshold. After initiation of a more conservative threshold, 72 units of blood were saved. Decreased transfusion threshold was associated with no worse outcomes associated with decreased resource utilization.

In some populations, intensive care unit (ICU) mobility has been shown to be safe and beneficial. We gathered data on 50 nonintubated surgical patients in a 10-bed surgical ICU (SICU) who met physiologic inclusion criteria beginning in May 2008 (A group). In January 2009, we began mandatory entry of computerized mobility orders as part of a standardized ICU order set. We also created a mobility protocol for nurses in this ICU. We then collected data on 50 patients in this postintervention cohort (B group). Both groups had similar baseline characteristics. A group patients had some form of mobility orders entered in 29 patients (58%) versus 47 patients (82%) in the B group, P < 0.05. In the A group, 11 patients (22%) were mobilized; in the B group, 40 patients (80%) were mobilized, P < 0.05. In our SICU patient population, mandatory entry of computerized mobility orders as part of a standard SICU order set and establishment of an ICU mobility nursing protocol was associated with an increase in number of mobility orders entered as well as an increase in SICU patient activity. Further studies should focus on measurement of the effect of mobility interventions on patient outcomes.

Mortality and amputation rates from acute arterial occlusion are reported from 7 to 37 per cent and 10 to 30 per cent, respectively. Recent data from thrombolysis or peripheral arterial surgery suggest no significant differences between initial management with surgical or thrombolytic therapy. Mortality and amputation rates were in the above ranges. The last 230 procedures (216 patients) over 10 years were reviewed. All graft occlusions, cardiac catheterization injuries, and aortic balloon-related thromboses were excluded. Immediate and delayed amputation rates were 6.5 and 0.9 per cent. Death occurred in 21 patients (9.7%), with only 6 deaths over the last 6 years (3.8%). Except for transesophageal echocardiography, perioperative studies were of limited value. Long-term anticoagulation was also not effective in preventing recurrent episodes. A mortality rate of 9.7 per cent and amputation rate of 7.4 per cent justifies an early aggressive surgical approach. Limited perioperative studies and less prolonged anticoagulation may also improve cost containment.

The 1990s will bring sweeping changes with managed care and capitation. To address this cost/quality paradox, selective intensive care utilization is coupled with clinical pathways as an innovative change for all patients having cerebral revascularization (CVR) or femoral revascularization (FR). From January 1, 1991 through June 30, 1995, data were accumulated on 2023 procedures in 1524 patients. The study was based on 848 CVRs and 1175 FRs. Intensive care unit (ICU) observation was necessary in 73 patients (3.6%) for cardiac or hypertensive management. Twenty-six patients (1.2%) transported to a vascular surgical floor from the postanesthesia recovery room required return to an ICU for complications during hospitalization. There were nine strokes or transient ischemic attacks (0.4%) in the CVR group, four myocardial infarctions (0.2%), and five perioperative deaths (0.3%). In the FR group, there were 14 deaths (0.9%). Readmission during the perioperative period, 30 days, was necessary in 46 patients (3.1%). Financial cost analysis revealed the mean adjusted cost for CVR in 1990 adjusted to 1995 dollars was $7223. The institution of case management reduced this to $4490 (37.8 per cent reduction in total hospital costs). The cost for FR in 1990 dollars adjusted to 1995 was $14,332 reduced to $5541 (a 59 per cent reduction in total hospital costs). This study suggests the use of clinical pathways does not impair quality of care, leads to no higher morbidity or mortality, and can produce significant cost savings to a hospital.

In a review of 134 aortic occlusions in 123 patients, there were 10 patients that suffered recurrent aortic occlusions (RAO). These patients developed RAO after revascularization for primary aortic occlusion and presented with signs and symptoms of acute lower extremity ischemia. The recurrent occlusions occurred in one native aorta and in 10 aortobifemoral grafts. The etiology of the primary aortic occlusion included chronic aortic occlusion in eight patients and acute aortic occlusion and aortic graft occlusion in one patient each. Original primary operations performed included aortoiliac thromboendarterectomy with Dacron patch aortoplasty (1 patient), AF bypass (8 patients), and aortofemoral graft thrombectomy (1 patient). All of the grafts had end-to-end proximal anastomoses, the diameter of which ranged from 12 to 16 mm. Secondary operations performed for RAO included six axillofemoral bypasses, four redo aortobifemoral bypasses, and one graft thrombectomy. All patients were managed with immediate anticoagulation, expeditious arteriography, and revascularization. There were no perioperative deaths, and no limbs were lost. No patient was lost to follow-up (mean 10 years). Extra-anatomic bypass has proved durable. Redo aortobifemoral bypass is useful in selected patients with surgically correctable lesions.

Poly arteritis nodosa (PAN) is a systemic vasculitis with a male: female ratio of 2:1 and a peak incidence in the fifth decade. Small to medium-sized arteries are involved by focal transmural inflammatory necrosis. Aneurysms with inflammatory destruction of the media also occur. The most frequently involved organs are the kidney, heart, lung, liver, and gastrointestinal tract. There are few reported cases of ischemic necrosis of the intestine and even fewer survivors. A 22-year-old woman was transferred to St. Thomas Hospital (Nashville, TN) after resection of 80 per cent of the small bowel for ischemic necrosis. She had a history of juvenile onset diabetes mellitus, recurrent abdominal pain, and splinter hemorrhages. Emergency aortogram and selective mesenteric arteriogram were performed. The celiac artery was not visualized and small aneurysms were present in the mesenteric and renal arteries. The patient was successfully resuscitated from a cardiac arrest in x ray from a cardiac tamponade. Laparotomy was performed to determine the viability of the bowel. The celiac, hepatic, and splenic arteries were found to be chronically occluded. Pathology of these arteries revealed a nonspecific arteritis. At a third operation, several more inches of small bowel were removed. Characteristic changes of PAN were present on all small bowel specimens. She was treated with high-dose cyclophosphamide and steroids for 6 months and has continued on low-dose cyclophosphamide. She is now 36 months from her original operation and is doing well on oral nutrition. Intestinal hemorrhage from aneurysm rupture or gangrene with perforation are gastrointestinal complications of PAN that the surgeon may be called upon to treat.(ABSTRACT TRUNCATED AT 250 WORDS)

An 8-year experience with treatment of 58 patients with ruptured abdominal aortic aneurysm (RAAA) is reviewed with hospital mortality of 25.9 per cent. Added to a previously reported experience, 115 patients have been treated over 25 years with 33 per cent mortality. Preoperative hypotension, free rupture, venous injury, and massive transfusion were found to be associated with mortality. Interhospital transfer, preexisting coronary or pulmonary disease, known aneurysm, anemia, delay in surgery, and operative time were not found to predict outcome. Some patients are normotensive at presentation, providing an excellent chance for survival when expeditious diagnosis and treatment are carried out. Optimal operative management, complications, and causes of death are discussed. The role of computed tomography (CT) in diagnosis is considered. Elective resection of known aneurysms is the most important factor in reducing deaths from RAAA. The role of regionalization of care is unclear, since some patients cannot be safely transported. However, some evidence for optimal results in specialized centers is presented.