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Data on duration of antibiotics in patients managed with an open abdomen (OA) due to intra-abdominal infection (IAI) are scarce. We hypothesized that patients with IAI managed with OA rather than closed abdomen (CA) would have higher rates of secondary infections (SIs) independent of the duration of the antibiotic treatment.This was an observational, prospective, multicenter, international study of patients with IAI requiring laparotomy for source control. Demographic and antibiotic duration values were collected. Primary outcomes were SI (surgical site, bloodstream, pneumonia, urinary tract) and mortality. Statistical analysis included ANOVA, chi-square/Fisher's exact test, and logistic regression.Twenty-one centers contributed 752 patients. The average age was 59.6 years, 43.6% were women, and 43.9% were managed with OA. Overall mortality was 16.1%, with higher rates among OA patients (31.6% vs 4.4%, p0.001). OA patients had higher Sequential Organ Failure Assessment (4.7 vs 1.8, p0.001), American Society of Anesthesiologists Physical Status (3.6 vs 2.7, p0.001), and APACHE II scores (16.1 vs 9.4, p0.001). The mean duration of antibiotics was 6.5 days (8.0 OA vs 5.4 CA, p0.001). A total of 179 (23.8%) patients developed SI (33.1% OA vs 16.8% CA, p0.001). Longer antibiotic duration was associated with increased rates of SI: 1 to 2 days, 15.8%; 3 to 5 days, 20.4%; 6 to 14 days, 26.6%; and more than 14 days, 46.8% (p0.001).Patients with IAI managed with OA had higher rates of SI and increased mortality compared with CA. A prolonged duration of antibiotics was associated with increased rates of SI. Increased antibiotic duration is not associated with improved outcomes in patients with IAI and OA.

Prehospital identification of the injured patient likely to require emergent care remains a challenge. End-tidal carbon dioxide (ETCO2) has been used in the prehospital setting to monitor respiratory physiology and confirmation of endotracheal tube placement. Low levels of ETCO2 have been demonstrated to correlate with injury severity and mortality in a number of in-hospital studies. We hypothesized that prehospital ETCO2 values would be predictive of mortality and need for massive transfusion (MT) in intubated patients.This was a retrospective multicenter trial with 24 participating centers. Prehospital, emergency department, and hospital values were collected. Receiver operating characteristic curves were created and compared. Massive transfusion defined as10 U of blood in 6 hours or death in 6 hours with at least 1 U of blood transfused.A total of 1,324 patients were enrolled. ETCO2 (area under the receiver operating characteristic curve [AUROC], 0.67; confidence interval [CI], 0.63-0.71) was better in predicting mortality than shock index (SI) (AUROC, 0.55; CI, 0.50-0.60) and systolic blood pressure (SBP) (AUROC, 0.58; CI, 0.53-0.62) (p0.0005). Prehospital lowest ETCO2 (AUROC, 0.69; CI, 0.64-0.75), SBP (AUROC, 0.75; CI, 0.70-0.81), and SI (AUROC, 0.74; CI, 0.68-0.79) were all predictive of MT. Analysis of patients with normotension demonstrated lowest prehospital ETCO2 (AUROC, 0.66; CI, 0.61-0.71), which was more predictive of mortality than SBP (AUROC, 0.52; CI, 0.47-0.58) or SI (AUROC, 0.56; CI, 0.50-0.62) (p0.001). Lowest prehospital ETCO2 (AUROC, 0.75; CI, 0.65-0.84), SBP (AUROC, 0.63; CI, 0.54-0.74), and SI (AUROC, 0.64; CI, 0.54-0.75) were predictive of MT in normotensive patients. ETCO2 cutoff for MT was 26 mm Hg. The positive predictive value was 16.1%, and negative predictive value was high at 98.1%.Prehospital ETCO2 is predictive of mortality and MT. ETCO2 outperformed traditional measures such as SBP and SI in the prediction of mortality. ETCO2 may outperform traditional measures in predicting need for transfusion in occult shock.Diagnostic test, level III.

Objective We aimed to evaluate resident operative times in relation to postgraduate year (PGY), case difficulty and resident stress while performing a single surgical procedure. Design We prospectively examined operative times for 268 laparoscopic cholecystectomies, and analyzed relationships between PGY, case difficulty, and resident surgeon stress utilizing electrodermal activity. Each case operative times were divided into 3 separate time periods. Case Start and End times were recorded, as well as the time between the start of the operation and the time until the cystic structures were divided (Division). Case difficulty was determined by multiple trained observers with a high inter-rater concordance. Setting University of Missouri, a tertiary academic medical institution. Participants All categorical general surgery residents at our institution. Results For each operative time period examined during laparoscopic cholecystectomy, operative time increased, with each incremental increase in difficulty resulting in approximately 130% longer times. Minimal differences in operative times were seen between PGY levels, except during the easiest cases (Start-End times: 38.5 ± 10.4 minutes vs 34.2 ± 10.8 minutes vs 28.9 ± 10.9 minutes, p 0.002). Resident stress poorly correlated with operative times regardless of case difficulty (Pearson coefficient range 0.0-0.22). Conclusions Operative times are longer with increasing case difficulty. PGY level and resident surgeon stress appear to have minimal to no correlation with operative times, regardless of case difficulty.

Surgical simulation has become an integral component of surgical training. Simulation proficiency determination has been traditionally based upon time to completion of various simulated tasks. We aimed to determine objective markers of proficiency in surgical simulation by comparing novel assessments with conventional evaluations of technical skill.Categorical general surgery residents completed 10 laparoscopic cholecystectomy modules using a high-fidelity simulator. We recorded and analyzed simulation task times, as well as number of hand movements, instrument path length, instrument acceleration, and participant affective engagement during each simulation. Comparisons were made to Objective Structured Assessment of Technical Skill (OSATS) and Accreditation Council for Graduate Medical Education Milestones, as well as previous laparoscopic experience, duration of laparoscopic cholecystectomies performed by participants, and postgraduate year. Comparisons were also made to Fundamentals of Laparoscopic Surgery task times. Spearman's rho was utilized for comparisons, significance set at0.50.University of Missouri, Columbia, Missouri, an academic tertiary care facility.Fourteen categorical general surgery residents (postgraduate year 1-5) were prospectively enrolled.One hundred forty simulations were included. The number of hand movements and instrument path lengths strongly correlated with simulation task times (ρ 0.62-0.87, p0.0001), FLS task completion times (ρ 0.50-0.53, p0.0001), and prior real-world laparoscopic cholecystectomy experience (ρ -0.51 to -0.53, p0.0001). No significant correlations were identified between any of the studied markers with Accreditation Council for Graduate Medical Education Milestones, Objective Structured Assessment of Technical Skill evaluations, total previous laparoscopic experience, or postgraduate year level. Neither instrument acceleration nor participant engagement showed significant correlation with any of the conventional markers of real-world or simulation skill proficiency.Simulation proficiency, measured by instrument and hand motion, is more representative of simulation skill than simulation task time, instrument acceleration, or participant engagement.

Clinical utility of algorithms to diagnose ventilator-associated pneumonia (VAP) in surgical patients has not been established. We aimed to test the diagnostic accuracy of two established methods to reliably diagnose VAP in acutely ill and injured surgical patients. After institutional review board approval, we prospectively collected data on 508 mechanically ventilated acute care surgery patients. Microbiologic samples were taken daily from all patients. Demographics, clinical, laboratory, and radiographic data were collected. The Johanson Criteria (JC) and Clinical Pulmonary Infection Score (CPIS) were calculated and analyzed. Sensitivity, specificity, and positive predictive values (PPV) and negative predictive value (NPV) were calculated in comparison to positive respiratory cultures. Of the 508 patients, 312 (61.4%) were acutely injured; emergent general surgery was performed in 141 (27.8%) patients, and 54 (10.6%) underwent elective operation. Positive respiratory cultures were identified in 198 (39%) of the 508 patients. JC diagnosed VAP in 291 (57.3%) patients (sensitivity 82.8%, specificity 59%, PPV 56.4%, NPV 84.3%, accuracy 68.3%). The CPIS resulted in 189 (37.2%) VAP diagnoses (sensitivity 61.1%, specificity 78.1%, PPV 64%, NPV 75.9%, and accuracy 71.5%). To address the inaccuracy of the algorithms, concordance testing was performed on the data to evaluate correlation between the algorithmic VAP diagnosis criteria and respiratory culture data. Nonconcordance with culture data diagnosis was identified with both JC (rho 0.41) and CPIS (rho 0.41). Sensitivity, specificity, PPV and NPV, and accuracy of both established clinical formulas was unacceptably low in acute care surgery patients.

Background Surgical resident ability to accurately evaluate one's own skill level is an important part of educational growth. We aimed to determine if differences exist between self and observer technical skill evaluation of surgical residents performing a single procedure. Materials and methods We prospectively enrolled 14 categorical general surgery residents (six post-graduate year [PGY] 1-2, three PGY 3, and five PGY 4-5). Over a 6-month period, following each laparoscopic cholecystectomy, residents and seven faculty each completed the Objective Structured Assessment of Technical Skills (OSATS). Spearman's coefficient was calculated for three groups: senior (PGY 4-5), PGY3, and junior (PGY 1-2). Rho (ρ) values greater than 0.8 were considered well correlated. Results Of the 125 paired assessments (resident-faculty each evaluating the same case), 58 were completed for senior residents, 54 for PGY3 residents, and 13 for junior residents. Using the mean from all OSATS categories, trainee self-evaluations correlated well to faculty (senior ρ 0.97, PGY3 ρ 0.9, junior ρ 0.9). When specific OSATS categories were analyzed, junior residents exhibited poor correlation in categories of respect for tissue (ρ −0.5), instrument handling (ρ 0.71), operative flow (ρ 0.41), use of assistants (ρ 0.05), procedural knowledge (ρ 0.32), and overall comfort with the procedure (ρ 0.73). PGY3 residents lacked correlation in two OSATS categories, operative flow (ρ 0.7) and procedural knowledge (ρ 0.2). Senior resident self-evaluations exhibited strong correlations to observers in all areas. Conclusions Surgical residents improve technical skill self-awareness with progressive training. Less-experienced trainees have a tendency to over-or-underestimate technical skill.

Objective Within the realm of surgical education, there is a need for objective means to determine surgical competence and resident readiness to operate independently. We propose a novel, objective method of assessing resident confidence and clinical competence based on measurement of electrodermal activity (EDA) during live surgical procedures. We hypothesized that with progressive training, EDA responses to the stress of performing surgery would exhibit decline, elucidating an objective correlate of clinical competence. Design EDA was measured using galvanic skin response sensors worn by residents performing laparoscopic cholecystectomy on sequential live human patients over an 8-month period. Baseline, phasic (peak) and tonic EDA responses were measured as a fractional change from baseline. Setting University of Missouri, Columbia, Missouri, an academic tertiary care facility. Participants Fourteen categorical general surgery residents and 5 faculty surgeons were voluntarily enrolled and participated through completion. Results Tonic fractional change (FC TONIC ) was highest in PGY3 residents compared with postgraduate year (PGY) 1 and 2 residents (7.199 vs. 2.100, p=0.004, 95% CI: 8.58-1.61 and PGY4 and 5 residents (7.199 vs. 2.079, p=0.002, 95% CI: 8.38-0.29). Phasic fractional change in EDA (FC PHASIC ) exhibited a progressive decline across resident training levels, with PGY1 and 2 residents having the highest response, and faculty displaying the lowest FC PHASIC responses. Statistical differences were seen between FC PHASIC faculty and PGY4 and 5 (3.596 vs. 6.180, p=0.004, 95% CI: 0.80-4.36), PGY4 and 5, and PGY3 (6.180 vs. 15.998, p=0.003, 95% CI: 3.33-16.3), as well as among all residents and faculty (13.057 vs. 3.596, p=0.004, 95% CI: 15.8-3.1). Conclusion Phasic EDA changes decrease with increasing clinical competence. For those participants with the lowest and highest levels of competence, tonic EDA changes are minimal. Tonic EDA changes follow an inverse-U shape with differing levels of clinical competence.

Duodenal stump blowout is a feared complication of Billroth II reconstruction after gastrectomy. Most commonly presenting in the early postoperative period, there is significant variation in the surgical management of the difficult duodenal stump due to complexity. Here, we report a highly unusual case of a delayed duodenal stump perforation secondary to a golf-ball sized enterolith without evidence of a cholecystoenteric fistula or afferent loop obstruction in a patient with a remote history of distal gastrectomy with Billroth II reconstruction. An 84-year-old man status post vagotomy and antrectomy with Billroth II reconstruction for peptic ulcer disease (PUD) 40 years ago presented with the acute onset of abdominal pain of 6 hours duration. The patient had focal peritonitis in the right upper quadrant (RUQ), hypoxia requiring 3 L of oxygen by nasal cannula and tachycardia with heart rate of 100 beats per minute. Laboratory findings were significant for a leukocytosis of 14 820/µL and metabolic acidosis. A CT scan demonstrated free air around the duodenal stump …

Background Training of emergency procedures is challenging and application is not routine in all health care settings. The debate over simulation as an alternative to live tissue training continues with legislation before Congress to banish live tissue training in the Department of Defense. Little evidence exists to objectify best practice. We sought to evaluate live tissue and simulation-based training practices in 12 life-saving emergency procedures. Methods In the study, 742 subjects were randomized to live tissue or simulation-training. Assessments of self-efficacy, cognitive knowledge, and psychomotor performance were completed pre- and post-training. Affective response to training was assessed through electrodermal activity. Subject matter experts gap analysis of live tissue versus simulation completed the data set. Results Subjects demonstrated pre- to post-training gains in self-efficacy, cognitive knowledge, psychomotor performance, and affective response regardless of training modality (P Conclusion Although simulation has made significant gains, no single modality can be identified definitively as superior. Wholesale abandonment of live tissue training is not warranted. We maintain that combined live tissue and simulation-based training add value and should be continued. Congressional mandates may accelerate simulation development and improve performance.

The mechanism of platelet dysfunction in acute traumatic coagulopathy is unknown. Traumatic brain injury is hypothesized as a cause, while some investigators presume platelets become "exhausted." We hypothesized that platelet hyperstimulation and consumption resulting from trauma leads to decreased platelet function secondary to depletion of platelet granules.Twenty-five trauma patients were divided into traumatic brain injury and no traumatic brain injury groups. Healthy volunteers served as controls. All had thromboelastography with platelet mapping and flow cytometric assays of mepacrine performed. Mepacrine uptake in unstimulated platelets was used for quantification of platelet content of dense granules.Twelve patients with traumatic brain injury and 13 patients without traumatic brain injury were enrolled. Twenty-one trauma patients showed adenosine diphosphate inhibition (30%) on thromboelastography with platelet mapping compared with the healthy volunteers who served as controls (P .01). Mepacrine assay showed a difference in mean fluorescent intensity for all trauma patients of 4,259 ± 1,341 compared with controls of 3,143 ± 709 (P = .044), correlating with greater quantities of dense granules. Neither adenosine diphosphate inhibition nor average difference in mean fluorescent intensity between traumatic brain injury and no traumatic brain injury groups were significant (P = .2).Trauma patients maintain their dense granule, contradicting the theory of platelet granule exhaustion as the etiology for platelet dysfunction in traumatic brain injury.

Whether anemia complicating traumatic brain injury (TBI) has an impact on patient outcomes is controversial; therefore, recommendations for blood transfusions for such patients are inconsistent. We hypothesized that patient outcome after TBI would be worse in patients with lower hemoglobin levels.We retrospectively reviewed records of patients with TBI and head Abbreviated Injury Scale3 with abnormal head computed tomography findings and neurologic injury. The relationships between initial hemoglobin and lowest hemoglobin during hospitalization at threshold values of ≤7, ≤8, ≤9, and ≤10 g/dL were investigated relative to Glasgow Outcome Score at last follow-up not exceeding 1 year.Of 939 patients meeting inclusion criteria, initial and lowest hemoglobin concentrations were significant predictors of poor outcome (P0.0001). For each 1 g/dL higher hemoglobin value, the likelihood of a good outcome increased by 33%. More severe levels of initial anemia were associated with lower Glasgow Coma Scale, greater head Abbreviated Injury Scale, and greater Injury Severity Score (P0.0001). Female patients had worse outcome than male patients only for initial hemoglobin between 7 and 8 g/dL (P0.05). Blood transfusion was associated with poorer outcome at hemoglobin levels ≤9 and ≤10 g/dL (P0.05), but not at lower hemoglobin thresholds.Patient outcome after TBI is worse in patients with lower hemoglobin. Initial hemoglobin and lowest hemoglobin after admission are independently associated with poor outcome. Our data support consideration of blood transfusion when hemoglobin is ≤8 g/dl.

Single institution studies have shown that clinical examination of the cervical spine (c-spine) is sensitive for clearance of the c-spine in blunt trauma patients with distracting injuries. Despite an unclear definition, most trauma centers still adhere to the notion that distracting injuries adversely affect the sensitivity of c-spine clinical examination. A prospective AAST multi-institutional trial was performed to assess the sensitivity of clinical examination screening of the c-spine in awake and alert blunt trauma patients with distracting injuries.During the 42-month study period, blunt trauma patients 18 years and older were prospectively evaluated with a standard c-spine examination protocol at 8 Level 1 trauma centers. Clinical examination was performed regardless of the presence of distracting injuries. Patients without complaints of neck pain, tenderness or pain on range of motion were considered to have a negative c-spine clinical examination. All patients with positive or negative c-spine clinical examination underwent computed tomography (CT) scan of the entire c-spine. Clinical examination findings were documented prior to the CT scan.During the study period, 2929 patients were entered. At least one distracting injury was diagnosed in 70% of the patients. A c-spine injury was found on CT scan in 7.6% of the patients. There was no difference in the rate of missed injury when comparing patients with a distracting injury to those without a distracting injury (10.4% vs. 12.6%, p = 0.601). Only one injury missed by clinical examination underwent surgical intervention and none had a neurological complication.Negative clinical examination may be sufficient to clear the cervical spine in awake and alert blunt trauma patients, even in the presence of a distracting injury. These findings suggest a potential source for improvement in resource utilization.Therapeutic/care management, level IV.

Clinical utility of algorithms to diagnose ventilator-associated pneumonia (VAP) in surgical patients has not been established. We aimed to test the diagnostic accuracy of two established methods to reliably diagnose VAP in acutely ill and injured surgical patients. After institutional review board approval, we prospectively collected data on 508 mechanically ventilated acute care surgery patients. Microbiologic samples were taken daily from all patients. Demographics, clinical, laboratory, and radiographic data were collected. The Johanson Criteria (JC) and Clinical Pulmonary Infection Score (CPIS) were calculated and analyzed. Sensitivity, specificity, and positive predictive values (PPV) and negative predictive value (NPV) were calculated in comparison to positive respiratory cultures. Of the 508 patients, 312 (61.4%) were acutely injured; emergent general surgery was performed in 141 (27.8%) patients, and 54 (10.6%) underwent elective operation. Positive respiratory cultures were identified in 198 (39%) of the 508 patients. JC diagnosed VAP in 291 (57.3%) patients (sensitivity 82.8%, specificity 59%, PPV 56.4%, NPV 84.3%, accuracy 68.3%). The CPIS resulted in 189 (37.2%) VAP diagnoses (sensitivity 61.1%, specificity 78.1%, PPV 64%, NPV 75.9%, and accuracy 71.5%). To address the inaccuracy of the algorithms, concordance testing was performed on the data to evaluate correlation between the algorithmic VAP diagnosis criteria and respiratory culture data. Nonconcordance with culture data diagnosis was identified with both JC (rho 0.41) and CPIS (rho 0.41). Sensitivity, specificity, PPV and NPV, and accuracy of both established clinical formulas was unacceptably low in acute care surgery patients.

Severe injury can lead to immune dysfunction and predispose patients to infection and death. Micro-RNAs regulate gene expression and may act as biomarkers for susceptibility to infection. The aim of this study was to examine the temporal and differential expression of previously identified dysregulated micro-RNAs in patients with severe injury.Fourteen severely injured patients requiring transfusion were enrolled prospectively in this study approved by our institutional review board. Inclusion criteria consisted of adult patients deemed clinically to be in hemorrhagic shock necessitating transfusion in the acute phase of their injury care. Peripheral blood samples were obtained after admission to the surgical intensive care unit and again at 6, 12, 24, and 48 hours after admission. The samples obtained at arrival to the intensive care unit and 24 and 48 hours later were analyzed in this data set. Fourteen healthy volunteers served as controls. The 10 dysregulated micro-RNAs identified in a prior study at the 12-hour time point and important genes in innate immunity were measured using quantitative reverse transcription-polymerase chain reaction.The participants were 21-77 years old (median, 42), 78% were male, and their Injury Severity Score ranged from 11 to 43 (median, 27); 11 had blunt and 3 had penetrating injuries. Three were intubated and 5 had received blood products before arrival at the hospital. Base deficit on hospital admission was 3-20 (median, 9). All patients required blood transfusion secondary to blood loss sustained during injury. Eleven of the 14 patients went directly to the operating room from the emergency department for control of the source of hemorrhage. Survival to discharge was 93%. Seven patients developed infection. Compared with healthy controls, miR-106a was downregulated at all time points compared with controls (P.05). miR-618 was upregulated in initial blood draws (P.05) and at 24 and 48 hours (P.06). Tumor necrosis factor α and human leukocyte antigen-DR (HLA-DR) were downregulated, and interleukin-10 and PD-L1 were upregulated (P.05). In patients who developed infection, miR-106a levels appeared more downregulated than those who did not develop infection.miR-106a was downregulated in trauma patients after major injury for up to 48 hours after intensive care unit admission. Tumor necrosis factor α and interleukin-10 are targeted by miR-106a, which are regulators of the immune response. Manipulation of micro-RNA expression may be a therapeutic target for immune dysfunction.

Ultrasound is a standard adjunct to the initial evaluation of injured patients in the emergency department. We sought to evaluate the ability of prehospital, in-flight thoracic ultrasound to identify pneumothorax. Non-physician aeromedical providers were trained to perform and interpret thoracic ultrasound. All adult trauma patients and adult medical patients requiring endotracheal intubation underwent both in-flight and emergency department ultrasound evaluations. Findings were documented independently and reviewed to ensure quality and accuracy. Results were compared to chest X-ray and computed tomography (CT). One hundred forty-nine patients (136 trauma/13 medical) met inclusion criteria. Mean age was 44.4 (18-94) years; 69 % were male. Mean injury severity score was 17.68 (1-75), and mean chest injury score was 2.93 (0-6) in the injured group. Twenty pneumothoraces and one mainstem intubation were identified. Sixteen pneumothoraces were correctly identified in the field. A mainstem intubation was misinterpreted. When compared to chest CT (n = 116), prehospital ultrasound had a sensitivity of 68 % (95 % confidence interval (CI) 46-85 %), a specificity of 96 % (95 % CI 90-98 %), and an overall accuracy of 91 % (95 % CI 85-95 %). In comparison, emergency department (ED) ultrasound had a sensitivity of 84 % (95 % CI 62-94 %), specificity of 98 % (95 % CI 93-99 %), and an accuracy of 96 % (95 % CI 90-98 %). The unique characteristics of the aeromedical environment render the auditory element of a reliable physical exam impractical. Thoracic ultrasonography should be utilized to augment the diagnostic capabilities of prehospital aeromedical providers.

Optimal dosing of prothrombin complex concentrate (PCC) has yet to be defined and varies widely due to concerns of efficacy and thrombosis. We hypothesized a dose of 15 IU/kg actual body weight of a three-factor PCC would effectively correct coagulopathy in acute care surgery patients. Retrospective review of 41 acute care surgery patients who received 15 IU/kg (610%) actual body weight PCC for correction of coagulopathy. Demographics, laboratory results, PCC dose, blood and plasma transfusions, and thrombotic complications were analyzed. We performed subset analyses of trauma patients and those taking warfarin. Mean age was 69 years (18–94 years). Thirty (73%) trauma patients, 8 (20%) emergency surgery patients, 2 (5%) burns, and 1 (2%) non-trauma neurosurgical patient were included. Mean PCC dose was 1305.4 IU (14.2 IU/kg actual body weight). Mean change in INR was 2.52 to 1.42 (p 0.00004). Successful correction (INR

Severe injury initiates an inflammatory response that can perpetuate immunological dysfunction, uncontrolled inflammation, and subsequent multisystem organ failure. MicroRNAs (miRNAs) have recently been identified as regulators of this inflammatory response. Our study sought to identify the differential expression of unique miRNAs and their correlations with genes of the Toll-like receptor (TLR) pathways, and clinical parameters in the severely injured.Fourteen trauma patients requiring transfusion were prospectively enrolled in this institutional review board-approved study. Inclusion criteria consisted of adult patients deemed clinically to be in hemorrhagic shock necessitating transfusion in the acute phase of their injury care. Peripheral blood samples were obtained after admission to the surgical intensive care unit. Expression of circulating mature miRNA from each patient, as well as from 10 healthy, age-matched controls, was determined and compared using the HiSeq 2500 sequencing system and the R software system. Gene expression of TLR signaling pathways for each patient was examined using custom gene expression polymerase chain reaction arrays. Statistical analyses were performed using general linear models and empirical Bayes methods to determine differential expression and Spearman's nonparametric correlation analysis.Subjects were 21-77 years old (mean, 42), 80% male, Injury Severity Score 11-43 (mean, 26), with 11 blunt and 3 penetrating injuries. Three were intubated and 5 received blood products before arrival. Base deficit upon hospital admission was 3 to 20 (mean, 9). All patients required blood transfusion secondary to blood loss sustained during injury. Survival to discharge was 93%. Controls were 27-64 years old (mean, 40) and 60% male. Sequencing analysis revealed 69 differentially expressed miRNAs (P .05) in the severely injured. Within the differentially expressed miRNAs, there were 12 direct and 6 indirect correlations with multiple genes involved in the TLR3 and TLR4 signaling pathways. The relationships between these same miRNAs and clinical parameters were also analyzed. We discovered 4 direct correlations with base deficit and HCO3, and 7 indirect correlations involving total fresh frozen plasma transfused, base deficit, HCO3, and PaCO2 levels.Differential expression and correlations between miRNAs, genes of the TLR pathways, and clinical parameters are unique findings in the severely injured and may lead to a greater understanding of the regulation of sterile inflammation after severe injury.

Object Patients with traumatic brain injury (TBI) are at risk for development of thromboembolic disease. The use of chemoprophylaxis in this patient group has not fully been characterized. The authors hypothesize that early chemoprophylaxis in patients with TBI is safe and efficacious. Methods In May 2009, a protocol was instituted for patients with TBI where chemoprophylaxis for thromboembolic disease (either 30 mg of Lovenox twice daily or 5000 U of heparin 3 times a day) was initiated 24 hours after an intracranial hemorrhage (ICH) was demonstrated as stable on head CT image. Two cohorts were evaluated: Cohort A included patients from May 2008 through April 2009 who had no routine administration of chemoprophylaxis, and Cohort B included patients from May 2009 through May 2010 after the protocol was instituted. The groups were compared, with the major outcomes being deep venous thrombosis (DVT), pulmonary embolism, and increase in size of ICH. Results Of the 312 patients with TBI who were seen during the study course, 236 patients met criteria for inclusion in the study: 107 patients in Cohort A and 129 patients in Cohort B. The DVT rate was 6 occurrences (5.61%) in Cohort A and 0 occurrences (0%) in Cohort B, which was a statistically significant difference (p = 0.0080). Pulmonary embolism was found in 4 patients (3.74%) in Cohort A and 1 patient (0.78%) in Cohort B, a difference that did not reach statistical significance (p = 0.18). Three instances (2.8%) in Cohort A and 1 instance (0.7%) in Cohort B of increased ICH occurred after starting anticoagulation for chemoprophylaxis; this was not statistically different (p = 0.33). Conclusions Use of chemoprophylaxis in TBI 24 hours after stable head CT is safe and decreases the rate of DVT formation.

Many patients undergo computed tomography (CT) scan before transfer to definitive care. Despite this, studies are often repeated on arrival to the trauma center. We evaluated a policy to provide formal in-house interpretation of images performed at outside hospitals. A 3-month retrospective analysis was performed. Two groups were compared. Patients in the in-house interpretation (IHI) group underwent in-house interpretation of outside images. Those images not meeting criteria were placed in the comparison group without in-house radiologic interpretation. Demographics, CT scan data, billing and productivity loss, and extrapolated cancer risk reduction were analyzed. There were no significant differences in demographic or injury data. Fewer total CT scans were performed in the IHI group (223 vs 320, P = 0.04). The IHI group underwent fewer repeated CT scans (25 vs 62, P = 0.02; odds ratio [OR], 0.53). Fewer patients were exposed to repeat CT scans (17 vs 32; OR, 0.48). Total hospital billings decreased by $188,285 ($4,592/patient) in the IHI group. Uncaptured work relative value units totaled 152.19 (3.71/patient) in the IHI group. Radiation exposure decreased by 8 per cent. Use of outside hospital imaging as the definitive evaluation of injured patients is safe and results in an overall decrease in radiation exposure and healthcare cost.

Concern about the potential of medical and surgical residents making errors when fatigued has led to a reduction in resident duty hours. However, this reduction in duty hours, coupled with a lack of, or inadequate training in dealing with fatigue, may result in decreased opportunities for residents to learn how to provide safe care when fatigued. We conducted structured interviews with 18 senior residents completing their residency programs to investigate existing fatigue training programs and their experiences in coping with fatigue as physicians. Most reported receiving some lectures on fatigue, and use of one or more strategies to cope with fatigue while providing patient care. Respondents reported moderate to high concern about their ability to provide safe patient care when fatigued once residency training was completed. Further research is needed related to fatigue awareness and training.

BACKGROUND The face of trauma surgery is rapidly evolving with a paradigm shift toward acute care surgery (ACS). The formal development of ACS has been viewed by some general surgeons as a threat to their practice. We sought to evaluate the impact of a new division of ACS to both departmental productivity and provider satisfaction at a University Level I Trauma Center. METHODS Two-year retrospective analysis of annual work relative value unit (wRVU) productivity, operative volume, and FTEs before and after establishment of an ACS division at a University Level I trauma center. Provider satisfaction was measured using a 10-point scale. Analysis completed using Microsoft Excel with a p value less than 0.05 significant. RESULTS The change to an ACS model resulted in a 94% increase in total wRVU production (78% evaluation and management, 122% operative; p

Tourniquet application has become first-line treatment for extremity hemorrhage on the battlefield and has seen increased use in the civilian arena. We hypothesized that an effective windlass tourniquet could be removed after application of a hemostatic dressing in a swine model of peripheral vascular injury. A tourniquet was placed proximally in 50 forelimb-injured swine after 30 seconds of hemorrhage with cessation of hemorrhage in all cases. Hemcon®, ActCel, Quikclot®, Celox™, or standard gauze was then placed over the wound with direct pressure for three minutes. The tourniquet was then removed. Success was determined if no bleeding was identified. Standard gauze resulted in a 100 per cent failure rate with active bleeding present after each application. Celox™ was successful in maintaining hemostasis in 6 of 10 (60%) subjects. Quikclot® succeeded in 80 per cent of subjects. ActCel maintained hemostasis in nine (90%) subjects, whereas HemCon® was successful in all instances (100%). All four hemostatic dressings were superior to gauze in maintaining hemostasis after removal of an effective tourniquet. Use of hemostatic dressings in conjunction with a tourniquet may reduce tourniquet times and improve outcomes in peripheral vascular injury and warrants further study.

Objective To determine the inflammatory effects of time-dependent exposure to the hypobaric environment of simulated aeromedical evacuation following traumatic brain injury (TBI). Methods Mice were subjected to a blunt TBI or sham injury. Righting reflex response (RRR) time was assessed as an indicator of neurologic recovery. Three or 24 h (Early and Delayed groups, respectively) after TBI, mice were exposed to hypobaric flight conditions (Fly) or ground-level control (No Fly) for 5 h. Arterial blood gas samples were obtained from all groups during simulated flight. Serum and cortical brain samples were analyzed for inflammatory cytokines after flight. Neuron specific enolase (NSE) was measured as a serum biomarker of TBI severity. Results TBI resulted in prolonged RRR time compared with sham injury. After TBI alone, serum levels of interleukin-6 (IL-6) and keratinocyte-derived chemokine (KC) were increased by 6 h post-injury. Simulated flight significantly reduced arterial oxygen saturation levels in the Fly group. Post-injury altitude exposure increased cerebral levels of IL-6 and macrophage inflammatory protein-1α (MIP-1α), as well as serum NSE in the Early but not Delayed Flight group compared to ground-level controls. Conclusions The hypobaric environment of aeromedical evacuation results in significant hypoxia. Early, but not delayed, exposure to a hypobaric environment following TBI increases the neuroinflammatory response to injury and the severity of secondary brain injury. Optimization of the post-injury time to fly using serum cytokine and biomarker levels may reduce the potential secondary cerebral injury induced by aeromedical evacuation.

The dichotomy between clinical and hospital revenue generation for trauma care is well established. Many trauma programs require hospital support for fiscal survival. We evaluated the impact of standardized clinical documentation to the hospital's bottom line at our trauma center.Standardized documentation templates for evaluation and management were created with a focus on accuracy and efficiency. Documentation was completed jointly by residents and faculty following standard guidelines of linkage. Trauma service characteristics, case mix index, reimbursement rate, payer distribution, hospital charges, cost, and payments were compared before and after standardization. Professional revenue was not evaluated. Analysis was performed using a commercially available spreadsheet computer application.A 24% increase in the hospital's net income for trauma care, constituting $1.45 million, was realized despite a 12% decrease in patient volume. Admission profitability increased by 42%. Collection rates and payer mix were unchanged. Increases in both injury severity score and case mix index were seen (P.05) after implementation of the program. Length of stay was decreased significantly.An effective standardized documentation strategy for trauma care results in significant fiscal gains in hospital reimbursement.

Background: Critical Care Air Transport Teams (CCATTs) are an integral component of modern casualty care, allowing early transport of critically ill and injured patients. Aeromedical evacuation of patients with significant pulmonary impairment is sometimes beyond the scope of CCATT because of limitations of the transport ventilator and potential for further respiratory deterioration in flight. The Acute Lung Rescue Team (ALRT) was developed to facilitate transport of these patients out of the combat theater. Methods: The United States TRANS-COM Regulation and Command/Control Evacuation System and the United States Army Institute of Surgical Research Joint Theater Trauma Registry databases were reviewed for all critical patients transported out of theater between November 2005 and March 2007. Patient demographics, diagnosis, and clinical history were abstracted and ALRT patients were compared with CCATT patients. Results: The ALRT was activated for 11 patients during the study period. Five patients were transported as a result of these activations. Trauma-related diagnoses were responsible for 82% of these requests. ALRT missions comprised 0.6% of all critical patient movements out of the combat theater and 1% of ventilator transports. Average FIO 2 was 0.92 ± 0.11 for ALRT patients and 0.53 ± 0.14 for CCATT patients (p = 0.005). ALRT patients required a mean positive end expiratory pressure of 19.0 cm H 2 O ± 2.2 cm H 2 O compared with 6.5 cm H 2 O ± 2.4 cm H 2 O in the CCATT group (p = 0.002). Conclusions: Lung injury in the combat theater severe enough to exceed the capability of CCATT transport is uncommon. Patients for whom ALRT was activated had significantly higher positive end expiratory pressure and FIO 2 than those transported by CCATT. One-fourth of patients for whom ALRT was considered died before the team could be launched; transport may have been a futile consideration in these patients. Patients with even severe acute respiratory distress syndrome can be successfully transported by experienced, equipped specialty teams.

We evaluated 16 surgical PGY1 residents during housestaff orientation. A METI ECS high-fidelity patient simulator was used as the simulated patient. Surgical critical care experts developed and locally validated patient care scenarios. All participants were oriented to the simulator and simulated ward setup prior to testing and were briefed on the patient’s location, operation, service, and chief resident to reproduce an evening checkout process. The simulated patients then developed common potentially life-threatening changes in clinical status. A ward nurse with standardized responses was available at the bedside throughout the simulation. Two evaluators assessed each intern’s performance with special attention to basic assessment, monitoring, and resource management skills. At the time of initial evaluation, only 31% of participants requested current vital signs. Twenty percent of interns monitored blood pressure despite ongoing patient deterioration, and only 27% placed the patient on a monitor. Although 63% of those tested performed a pulse examination at some point during the simulation, only 13% used interval pulse examinations to follow the patient’s status. Surprisingly, only 33% of interns requested help from an additional source (nursing or seniorlevel resident) at any point during the simulation. Even fewer (19%) called a senior-level resident early enough to prevent patient deterioration. Evaluation of entering surgery residents’ patient assessment skills using a high-fidelity patient simulator suggests a striking deficiency in the ability to manage acute changes in a patient’s status successfully. Additional training to address basic clinical skills, which are necessary to manage common postoperative ward emergencies effectively, is warranted.

OBJECTIVE En-route care necessitates the evacuation of seriously wounded service members requiring mechanical ventilation in aircraft where low light, noise, vibration, and barometric pressure changes create a unique clinical environment. Our goal was to evaluate ventilatory requirements, oxygenation, and oxygen use in flight and assess the feasibility of a computer interface in this austere environment. METHODS A personal computer was integrated with the pulse oximeter and ventilator data port used in aeromedical evacuation from Iraq to Germany. Ventilator settings, inspired oxygen (FiO2), tidal volume (VT), respiratory rate (RR), minute ventilation (VE), monitored values, heart rate (HR), and oxygen saturation (SpO2), were recorded continuously. Oxygen use was determined using the equation ([FiO2 - 21]/79) x (MVE). Additional data were obtained through the United States Air Force (USAF) Transcom Regulation and Command/Control Evacuation System (TRAC2ES) and the United States Army Institute of Surgical Research Joint Theater Trauma Registry databases. RESULTS During a 4 month time frame 117 hours of continuous recording was accomplished in 22 patients. Mean age was 27 +/- 9.83 and injury severity score military was 31.75 +/- 20.63 (range, 9-75). All patients survived transport. Mean values for ventilator settings were FiO2 (24-100%) of 49% +/- 13%, positive end-expiratory pressure of 6 +/- 2.5 (range, 0-17 cm H2O), RR of 15 +/- 2.4 (range, 10-22 breaths/min), and VT of 611 +/- 75 (range, 390-700 mL). Delivered VT in mililiter per kilogram was 6.9 +/- 1.30 and VE was 9.1 L/min +/- 1.4 L/min. Oxygen requirements for desired FiO2 and VE resulted in a mean oxygen usage of 3.24 L/min +/- 1.87 L/min (range, 1.6-10.2 L/min). There were 32 changes to FiO2, 18 changes to PEEP, 26 changes to RR, and 20 changes to VT during flight. Five patients under-went no recorded changes in flight. Three desaturation events (

When working with critical-care patients, doctors and nurses need a hands-free way to stay updated on the current status of incoming patients and their needed-care levels. This need to stay updated on new patients is even more critical in a natural disaster scenario where a large volume of patients with varying states of injuries need to be treated by a limited medical staff. Using Google Glass, we can open up new possibilities for mobile healthcare communication allowing for cloud-based coordination with other medical personnel even in a disaster scenario. In this paper, we present our 'Panacea Glass', a mobile cloud framework that allows triage personnel who require hands free communication capabilities along with situational-awareness of patient care coverage. We implement this framework within a WebRTC-based 'Responder Theater Application' with features such as video chat application on Google Glass devices, and use of virtual beacon tracking devices. Lastly, we show experiments conducted in determining optimal settings of the application, as well as its utility within an actual 'Lake Simulation'.

Background Antiplatelet therapy is a complicating factor in patients with traumatic brain injuries (TBI), as well as those with hemorrhagic cerebrovascular accidents (CVAs). Platelet Function Assay (PFA)-100 is a coagulation device that can detect platelet dysfunction caused by aspirin and adenosine diphosphate inhibition. Our retrospective study reviewed the effectiveness of PFA-100 in detecting platelet dysfunction caused by aspirin and clopidogrel and determined its clinical importance. Methods All patients with PFA-100 tests from January 2013 to February 2014 were collected. Diagnoses indicative of a TBI or CVA were chosen for analysis. Patients with a normal PFA-100 indicating no platelet dysfunction but with documented aspirin and/or clopidogrel use were selected. An extensive chart review was performed to determine the relevance to their clinical care. Results A total of 475 patients were evaluated with a PFA-100 from January 2013 to February 2014. PFA-100 detected platelet dysfunction as the result of pre-injury use of antiplatelet agents in TBI and CVA patients with a sensitivity of only 48.6% and a specificity of 74.8%. Had these antiplatelet medications been known during initial workup, these patients would have had a change in management that may have impacted their outcomes. Conclusion Despite its common usage, the PFA-100 is an unreliable tool to assist in the management of TBI and CVA patients. Additional investigation into alternative methods for detecting platelet dysfunction is warranted.

Communication with patients is essential to providing quality medical care. The study was conducted to evaluate the effects of language barriers on health care professionals. It is hypothesized that these language barriers are commonly perceived by health care professionals and they are a source of workplace stress in acute care environments. We designed and distributed a survey tool of staff experiences and attitudes regarding the English-Spanish language barrier among patients in an acute care surgical environment of a tertiary medical center. Responses were anonymous, stratified by professional role and comparisons made using paired t tests. Sixty-one nurses and 36 physicians responded to the survey. Overall, 95% of nurses reported that the language barrier was an impediment to quality care, whereas 88% of physicians responded similarly (P = .0004). More nurses than physicians report experiencing stress (97% vs. 78%) and the degree of stress appears to be greater for nurses (P.0001). The basis of stress was unique between the two groups. This study demonstrates that acute care hospital medical professionals perceive language barriers as an impediment to quality care delivery and as a source of workplace stress. Nurse and physician perceptions differ; therefore, strategies to address these language barriers should be specific to those professional roles. These barriers create a void in health care quality and safety that has effects on health care professionals.

• Background Language barriers are significant impediments to providing quality healthcare, and increased stress levels among nurses and physicians are associated with these barriers. However, little evidence supports the usefulness of a translation tool specific to healthcare. • Objectives To evaluate the effectiveness of a novel English-Spanish translator designed specifically for nurses and physicians. The hypothesis was that the translator would be useful and that use of the translator would decrease stress levels among nurses and physicians caring for Spanish-speaking patients. • Methods Novel English-Spanish translators were developed entirely on the basis of input from critical care nurses and physicians. After 7 months of use, users completed surveys. Usefulness of the translator and stress levels among users were reported. • Results A total of 60% of nurses (n = 32) and 71% (n = 25) of physicians responded to the survey. A total of 96% of physicians and 97% of nurses considered the language barrier an impediment to delivering quality care. Nurses reported significantly more stress reduction than did physicians (P = .01). Most nurses and physicians had used the translator during the survey period. Overall, 91% of nurses and 72% of physicians found that the translator met their needs at the bedside some, most, or all of the time. All nurses thought that they most likely would use the translator in the future. • Conclusions The translator was useful for most critical care nurses and physicians surveyed. Healthcare providers, especially nurses, experienced decreased stress levels when they used the translator.

Appendicitis and pregnancy are both common conditions, and when they co-exist, both the general surgeon and obstetrician are presented with unique challenges. Acute appendicitis is the most common cause of the acute abdomen during pregnancy, effecting 0.1–0.3 per cent of pregnancies each year. With an estimated 4 million deliveries per year in the United States, there are potentially as many as 12,000 cases of acute appendicitis to be managed by the general surgeon during pregnancy (Eur J Surg 1992;158:603–6; Curr Surg 2003;60:164–73). Laparoscopic appendectomy has become a routine procedure and is now widely performed in North America. Although laparoscopic appendectomy has been discussed during pregnancy, limited data is available on the role of laparoscopic appendectomy in the third trimester of pregnancy. In fact, some authors have advocated a gestational age of 26–28 weeks to be the upper gestational limit for successful completion of laparoscopic surgery (Obstet Gynecol Surg 2001;56:50–9). In this paper, we present two recent cases of successful laparoscopic appendectomy during late pregnancy without immediate complication to mother or fetus and a description of our operative technique.

Objective To evaluate the University of Kentucky experience in treating acute intestinal ischemia to elucidate factors that contribute to survival. Background Data Acute intestinal ischemia is reported to have a poor prognosis, with survival rates ranging from 0% to 40%. This is based on several reports, most of which were published more than a decade ago. Remarkably, there is a paucity of recent studies that report on current outcome for acute mesenteric ischemia. Methods A comparative retrospective analysis was performed on patients who were diagnosed with acute intestinal ischemia between May 1993 and July 2000. Patients were divided into two cohorts: nonthrombotic and thrombotic causes. The latter cohort was subdivided into three etiologic subsets: arterial embolism, arterial thrombosis, and venous thrombosis. Patient demographics, clinical characteristics, risk factors, surgical procedures, and survival were analyzed. Survival was compared with a collated historical series. Results Acute intestinal ischemia was diagnosed in 170 patients. The etiologies were nonthrombotic (102/170, 60%), thrombotic (58/170, 34%), or indeterminate (10/170, 6%). In the thrombotic cohort, arterial embolism accounted for 38% (22/58) of the cases, arterial thrombosis for 36% (21/58), and venous thrombosis for 26% (15/58). Patients with venous thrombosis were younger. Venous thrombosis was observed more often in men; arterial thrombosis was more frequent in women. The survival rate was 87% in the venous thrombosis group versus 41% and 38% for arterial embolism and thrombosis, respectively. Compared with the collated historical series, the survival rate was 52% versus 25%. Conclusions These results indicate that the prognosis for patients with acute intestinal ischemia is substantially better than previously reported.

Many patients undergo computed tomography (CT) scan before transfer to definitive care. Despite this, studies are often repeated on arrival to the trauma center. We evaluated a policy to provide formal in-house interpretation of images performed at outside hospitals. A 3-month retrospective analysis was performed. Two groups were compared. Patients in the in-house interpretation (IHI) group underwent in-house interpretation of outside images. Those images not meeting criteria were placed in the comparison group without in-house radiologic interpretation. Demographics, CT scan data, billing and productivity loss, and extrapolated cancer risk reduction were analyzed. There were no significant differences in demographic or injury data. Fewer total CT scans were performed in the IHI group (223 vs. 320, P = 0.04). The IHI group underwent fewer repeated CT scans (25 vs. 62, P = 0.02; odds ratio [OR], 0.53). Fewer patients were exposed to repeat CT scans (17 vs. 32; OR, 0.48). Total hospital billings decreased by $188,285 ($4,592/patient) in the IHI group. Uncaptured work relative value units totaled 152.19 (3.71/patient) in the IHI group. Radiation exposure decreased by 8 per cent. Use of outside hospital imaging as the definitive evaluation of injured patients is safe and results in an overall decrease in radiation exposure and healthcare cost.

Background Surgical airway creation has a high potential for disaster. Conventional methods can be cumbersome and require special instruments. A simple method utilizing three steps and readily available equipment exists, but has yet to be adequately tested. Objective Our objective was to compare conventional cricothyroidotomy with the three-step method utilizing high-fidelity simulation. Methods Utilizing a high-fidelity simulator, 12 experienced flight nurses and paramedics performed both methods after a didactic lecture, simulator briefing, and demonstration of each technique. Six participants performed the three-step method first, and the remaining 6 performed the conventional method first. Each participant was filmed and timed. We analyzed videos with respect to the number of hand repositions, number of airway instrumentations, and technical complications. Times to successful completion were measured from incision to balloon inflation. Results The three-step method was completed faster (52.1 s vs. 87.3 s; p = 0.007) as compared with conventional surgical cricothyroidotomy. The two methods did not differ statistically regarding number of hand movements (3.75 vs. 5.25; p = 0.12) or instrumentations of the airway (1.08 vs. 1.33; p = 0.07). The three-step method resulted in 100% successful airway placement on the first attempt, compared with 75% of the conventional method ( p = 0.11). Technical complications occurred more with the conventional method (33% vs. 0%; p = 0.05). Conclusion The three-step method, using an elastic bougie with an endotracheal tube, was shown to require fewer total hand movements, took less time to complete, resulted in more successful airway placement, and had fewer complications compared with traditional cricothyroidotomy.

Purpose Acute care surgery (ACS) remains in its infancy as a defined surgical specialty within hospital systems. Little has been published regarding the financial impact of this method of care delivery to hospital systems and departments when combining trauma, surgical critical care, emergent, and elective general surgery into a single practice model. We sought to compare hospital net income and divisional clinical productivity measures of a newly formed, university division of ACS based on patient type—trauma, emergency general surgery, and elective surgery—to determine the best avenues by which to focus on programmatic growth. Methods Single calendar year, retrospective review of hospital system income and divisional fiscal productivity of specific patient visits by patient type (trauma, emergent, or elective) admitted to or discharged by the acute care surgeons. Demographic data, payor mix, patient volumes, and operative rates were determined for each patient type. Fiscal contribution by patient type to both hospital and clinical productivity were measured by hospital net income and divisional work relative value units (wRVU) production respectively. The Chi-square test for independence compared payor mix and analysis of variance was used for comparison of fiscal performance between patient types. Results We included 1,492 patients in the analysis of calendar year 2010; 1,056 trauma (67% male; mean age, 41.9; range, 0–102), 346 emergent (53% male; mean age, 44.6; range, 15–91), and 90 elective (51% male; mean age, 46; range, 16–87) patient encounters met criteria for analysis. There were no differences in payor mix between patient types. Significant differences were seen in average per patient encounter hospital net income, divisional wRVU production and duration of stay. The ACS team ( n = 3) operated on 12% of trauma patients compared with 52% of emergent and 100% of elective surgery encounters. Hospital net income per patient was greatest for trauma encounters, whereas divisional clinical productivity per patient encounter was greatest for emergent patients. Elective encounters contributed negatively to hospital margins. Conclusion Per-patient hospital system income and a majority of clinical wRVU productivity remains greatest for the care of injured patients in our ACS practice model; emergent general surgical encounters demonstrate the greatest per-patient rates of divisional clinical productivity.

IntroductionEnd tidal CO2(ETCO2) has been established as a standard for confirmation of an airway, but its role is expanding. In certain settings ETCO2closely approximates the partial pressure of arterial CO2(PaCO2) and has been described as a tool to optimize a patient's ventilatory status. ETCO2monitors are increasingly being used by EMS personnel to guide ventilation in the prehospital setting. Severely traumatized and burn patients represent a unique population to which this practice has not been validated.HypothesisThe sole use of ETCO2to monitor ventilation may lead to avoidable respiratory acidosis.MethodsA consecutive series of patients with burns or trauma intubated in the prehospital setting over a 24-month period were evaluated. Prehospital arrests were excluded. Absence of ETCO2transport data and patients without an arterial blood gas (ABG) within 15 minutes of arrival were also excluded. Data collected included demographics, place and time of intubation, service performing intubation, ETCO2maintained en-route to hospital, and ABG upon arrival. Further data included length of stay, mortality, and injury severity scores.ResultsOne hundred sixty patients met the inclusion criteria. Prehospital ETCO2did not correlate with measured PaCO2(R2= 0.08). Mean ETCO2was significantly lower than mean PaCO2(34 mmHg vs 44 mmHg,P< .005). Patients arriving acidotic were more likely to die. Mean pH on arrival for survivors and decedents was 7.32 and 7.19 respectively (P< .001). Mortality, acidosis, higher base deficits, and more severe injury patterns were all predictors for a worse correlation between ETCO2and PaCO2and increased mean difference between the two values. Decedents and patients presenting with a pH 2and PaCO2. The data suggest that patients may be hypoventilated by prehospital providers in order to obtain a prescribed ETCO2.ConclusionETCO2is an inadequate tool for predicting PaCO2or optimizing ventilation in severely injured patients. Adherence to current ETCO2guidelines in the prehospital setting may contribute to acidosis and increased mortality. Consideration should be given to developing alternate protocols to guide ventilation of the severely injured in the prehospital setting.CooperCJ,KraatzJJ,KubiakDS,KesselJW,BarnesSL.Utility of prehospital quantitative end tidal CO2?.Prehosp Disaster Med.2013;28(2):1-6.