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Algorithms for management of penetrating cervical vascular injuries (PCVIs) commonly call for immediate surgery with "hard signs" and imaging before intervention with "soft signs." We sought to analyze the association between initial examination and subsequent evaluation and management approaches.Analysis of PCVIs from the American Association for the Surgery of Trauma Prospective Observational Vascular Injury Treatment vascular injury registry from 25 US trauma centers was performed. Patients were categorized by initial examination findings of hard signs or soft signs, and subsequent imaging and surgical exploration/repair rates were compared.Of 232 PCVI patients, 110 (47%) had hard signs (hemorrhage, expanding hematoma, or ischemia) and 122 (53%) had soft signs. With hard signs, 61 (56%) had immediate operative exploration and 44% underwent computed tomography (CT) imaging. After CT, 20 (18%) required open surgical repair, and 7% had endovascular intervention. Of note, 21 (19%) required no operative intervention. A total of 122 patients (53%) had soft signs on initial examination; 37 (30%) had immediate surgery, and 85 (70%) underwent CT imaging. After CT, 9% had endovascular repair, 7% had open surgery, and 65 (53%) were observed. No difference in mortality was observed for hard signs patients undergoing operative management versus observation alone (23% vs. 17%, p = 0.6). Those with hemorrhage as the primary hard signs most often required surgery (76%), but no interventions were required in 19% of hemorrhage, 20% of ischemia, and 24% of expanding hematoma.Although hard signs in PCVIs are associated with the need for operative intervention, initial CT imaging can facilitate endovascular options or nonoperative management in a significant subgroup. Hard signs should not be considered an absolute indication for immediate surgical exploration.Prognostic/Epidemiological; Level IV.

Traumatic brain injury (TBI) and blunt thoracic aortic injury (BTAI) are the top two leading causes of death after blunt force trauma. Patients presenting with concomitant BTAI and TBI pose a specific challenge with respect to management strategy, because the optimal hemodynamic parameters are conflicting between the two pathologies. Early thoracic endovascular aortic repair (TEVAR) is often performed, even for minimal aortic injuries, to allow for the higher blood pressure parameters required for TBI management. However, the optimal timing of TEVAR for the treatment of BTAI in patients with concomitant TBI remains an active matter of controversy.The Aortic Trauma Foundation international prospective multicenter registry was used to identify all patients who had undergone TEVAR for BTAI in the setting of TBI from 2015 to 2020. The primary outcomes included delayed ischemic or hemorrhagic stroke, in-hospital mortality, and aortic-related mortality. The outcomes were examined among patients who had undergone TEVAR at emergent (6 vs ≥6 hours) or urgent (24 vs ≥24 hours) intervals.A total of 100 patients (median age, 43 years; 79% men; median injury severity score, 41) with BTAI (Society for Vascular Surgery BTAI grade 1, 3%; grade 2, 10%; grade 3, 78%; grade 4, 9%) and concomitant TBI who had undergone TEVAR were identified. Emergent repair was performed for 51 patients (51%). Comparing emergent repair (6 hours) to urgent repair (≥6 hours), no difference was found in delayed cerebral ischemic events (2.0% vs 4.1%; P = .614), in-hospital mortality (15.7% vs 22.4%; P = .389), or aortic-related mortality (2.0% vs 2.0%; P = .996) and no patient had experienced delayed hemorrhagic stroke. Likewise, repairs conducted in an urgent (24 hours) setting showed no differences compared with those completed in an emergent (≥24 hours) setting regarding delayed ischemic stroke (2.6% vs 4.3%; P = .548), in-hospital mortality (18.2% vs 21.7%; P = .764), or aortic-related mortality (1.3% vs 4.3%; P = .654), and no patient had experienced delayed hemorrhagic stroke.In contrast to prior retrospective efforts, results from the Aortic Trauma Foundation international prospective multicenter registry have demonstrated that neither emergent nor urgent TEVAR for patients with concomitant BTAI and TBI was associated with delayed stroke, in-hospital mortality, or aortic-related mortality. In these patients, the timing of TEVAR did not have an effect on the outcomes. Therefore, the decision to intervene should be guided by individual patient factors rather than surgical timing.

Although evidence suggests that racial and ethnic minority (REM) patients receive inadequate pain management in the acute care setting, it remains unclear if these disparities also occur during the prehospital period. The aim of this study is to assess the impact of race and ethnicity on prehospital analgesic utilization by emergency medical services (EMS) in trauma patients.Retrospective chart review of adult trauma patients aged 18-89 years old transported by EMS to our ACS verified Level 1 trauma center from 2014-2020. Patients who identified as Black, Asian, Native American, or Other for race and/or Hispanic or Latino or Unknown for ethnicity were considered REM. Patients who identified as White, non-Hispanic were considered White. Groups were compared in univariate and multivariate analysis. The primary outcome was prehospital analgesic administration.2,476 patients were transported by EMS (47% White and 53% REM). White patients were older (46 vs. 38, p0.001) and had higher rates of blunt trauma (76% vs. 60%, p0.001). There were no differences in injury severity score (ISS) (21 vs. 20, p=0.22). Although REM patients reported higher subjective pain rating (7.2 vs. 6.6, p=0.002), they were less likely to get prehospital pain medication (24% vs. 35%, p0.001) and that difference remained significant after controlling for baseline characteristics, transport method, pain rating, prehospital hypotension, and payor status (Adjusted OR [95% CI] 0.67 [0.47 - 0.96], p=0.03).Patients from racial and ethnic minority groups were less likely to receive prehospital pain medication after traumatic injury than White patients. Forms of conscious and unconscious bias contributing to this inequity need to be identified and addressed.

Introduction: Time is an essential element in outcomes of trauma patients. The relationship of time to treatment in management of noncompressible torso hemorrhage (NCTH) with resuscitative endovascular balloon occlusion of the aorta (REBOA) or resuscitative thoracotomy (RT) has not been previously described. We hypothesized that shorter times to intervention would reduce mortality. Methods: A review of the Aortic Occlusion for Resuscitation in Trauma and Acute Care Surgery registry from 2013 to 2022 was performed to identify patients who underwent emergency department aortic occlusion (AO). Multivariate logistic regression was used to examine the impact of time to treatment on mortality. Results: A total of 1,853 patients (1,245 [67%] RT, 608 [33%] REBOA) were included. Most patients were male (82%) with a median age of 34 years (interquartile range, 30). Median time from injury to admission and admission to successful AO were 31 versus 11 minutes, respectively. Patients who died had shorter median times from injury to successful AO (44 vs. 72 minutes, Plt; 0.001) and admission to successful AO (10 vs. 22 minutes, Plt; 0.001). Multivariate logistic regression demonstrated that receiving RT was the strongest predictor of mortality (odds ratio [OR], 6.6; 95% confidence interval [CI], 4.4-9.9; Plt; 0.001). Time from injury to admission and admission to successful AO were not significant. This finding was consistent in subgroup analysis of RT-only and REBOA-only populations. Conclusions: Despite expedited interventions, time to aortic occlusion did not significantly impact mortality. This may suggest that rapid in-hospital intervention was often insufficient to compensate for severe exsanguination and hypovolemia that had already occurred before emergency department presentation. Selective prehospital advanced resuscitative care closer to the point of injury with "scoop and control" efforts including hemostatic resuscitation warrants special consideration.

ImportanceAortic occlusion (AO) is a lifesaving therapy for the treatment of severe traumatic hemorrhagic shock; however, there remains controversy whether AO should be accomplished via resuscitative thoracotomy (RT) or via endovascular balloon occlusion of the aorta (REBOA) in zone 1.ObjectiveTo compare outcomes of AO via RT vs REBOA zone 1.Design, Setting, and ParticipantsThis was a comparative effectiveness research study using a multicenter registry of postinjury AO from October 2013 to September 2021. AO via REBOA zone 1 (above celiac artery) was compared with RT performed in the emergency department of facilities experienced in both procedures and documented in the prospective multicenter Aortic Occlusion for Resuscitation in Trauma and Acute Care Surgery (AORTA) registry. Propensity score matching (PSM) with exact institution matching was used, in addition to subgroup multivariate analysis to control for confounders. The study setting included the ED, where AO via RT or REBOA was performed, and participants were adult trauma patients 16 years or older.ExposuresAO via REBOA zone 1 vs RT.Main Outcomes and MeasuresThe primary outcome was survival. Secondary outcomes were ventilation-free days (VFDs), intensive care unit (ICU)–free days, discharge Glasgow Coma Scale score, and Glasgow Outcome Score (GOS).ResultsA total of 991 patients (median [IQR] age, 32 [25-48] years; 808 male individuals [81.9%]) with a median (IQR) Injury Severity Score of 29 (18-50) were included. Of the total participants, 306 (30.9%) had AO via REBOA zone 1, and 685 (69.1%) had AO via RT. PSM selected 112 comparable patients (56 pairs). REBOA zone 1 was associated with a statistically significant lower mortality compared with RT (78.6% [44] vs 92.9% [52]; P = .03). There were no significant differences in VFD greater than 0 (REBOA, 18.5% [10] vs RT, 7.1% [4]; P = .07), ICU-free days greater than 0 (REBOA, 18.2% [10] vs RT, 7.1% [4]; P = .08), or discharge GOS of 5 or more (REBOA, 7.5% [4] vs RT, 3.6% [2]; P = .38). Multivariate analysis confirmed the survival benefit of REBOA zone 1 after adjustment for significant confounders (relative risk [RR], 1.25; 95% CI, 1.15-1.36). In all subgroup analyses (cardiopulmonary resuscitation on arrival, traumatic brain injury, chest injury, pelvic injury, blunt/penetrating mechanism, systolic blood pressure ≤60 mm Hg on AO initiation), REBOA zone 1 offered an either similar or superior survival.Conclusions and RelevanceResults of this comparative effectiveness research suggest that REBOA zone 1 provided better or similar survival than RT for patients requiring AO postinjury. These findings provide the ethically necessary equipoise between these therapeutic approaches to allow the planning of a randomized controlled trial to establish the safety and effectiveness of REBOA zone 1 for AO in trauma resuscitation.

Blunt thoracic aortic injury (BTAI) is the second leading cause of death from blunt trauma. In the present study, we aimed to determine the outcomes of medical management (MM) for BTAI. We hypothesized from the results of several previously reported studies, that patients with a minimal aortic injury (BTAI grades 1 and 2) could safely be treated with definitive MM alone.The Aortic Trauma Foundation international prospective multicenter registry was used to examine the demographics, injury characteristics, management, and outcomes of patients with BTAI. We analyzed a subset of patients for whom MM was initiated as definitive therapy.From November 2016 to April 2020, 432 patients (median age, 41 years; 76% male; median injury severity score, 34) with BTAI (Society for Vascular Surgery grade 1, 23.6%; grade 2, 14.4%; grade 3, 51.2%; grade 4, 10.9%) were evaluated. Of the 432 patients, 245 (57%) had received MM in the initial period and 114 (26.4%) had received MM as the planned definitive therapy (grade 1, 59.6%; grade 2, 23.7%; grade 3, 15.8%; grade 4, 0.9%). The most common mechanism of BTAI was a motor vehicle collision (60.4%). Hypotension was present on arrival in 74 patients (17.2%). Continuous titratable infusion of antihypertensive medication was used for 49.1%, followed by intermittent bolus administration (29.8%), with beta-blockers (74.6%) the most common agent used. Treatments were targeted to a goal systolic blood pressure for 83.3%, most often to a target goal systolic blood pressure120 mm Hg (66.3%). The MM goals based on blood pressure control were attained in 64.0% (73 of 114). Twelve patients (10.5%; grade 1, 1; grade 2, 0; grade 3, 10; grade 4, 1) had required subsequent intervention after MM. Eleven patients (9.6%) had undergone thoracic endovascular aortic repair and one (0.9%) had required open repair for a grade 4 injury. The overall in-hospital mortality for patients selected for definitive MM was 7.9%. No aortic-related deaths had occurred in the patients receiving definitive MM.Approximately one in four patients with BTAI will receive MM as definitive therapy. The variation in the pharmacologic therapies used is considerable. MM for patients with minimal aortic injury (BTAI grades 1 and 2) is safe and effective, with a low overall intervention rate and no aortic-related deaths. These findings support the use of definitive MM for grade 2 BTAI.

An algorithmic-based approach to the initial triage and management of a patient with a mangled extremity is paramount. It is imperative to assess a patient with a mangled extremity in a systematic manner, proceeding through the ABCs of the primary survey and controlling any ongoing active hemorrhage as this is the acutely life-threatening concern for a mangled extremity. Extremity hemorrhage should be controlled via tourniquet, direct pressure, or packing. If unsuccessful, prompt surgical exploration and hemorrhage control are required. Persistent hemodynamic instability requires further evaluation to identify the source of hemorrhage, which may be external or intracavitary. Other etiologies can include cardiac, obstructive, or neurologic in etiology. The “life over limb” adage is key, and the mangled extremity should be addressed only after life-threatening problems have been stabilized. Further evaluations begin with a thorough physical exam followed by specific adjunct tests. Continued treatment of the extremity should begin with reduction of fractures followed by further specific evaluation of the vascular, neurologic, and soft tissue injuries to the extremity. Optimal care requires a multidisciplinary approach to the mangled extremity.

BACKGROUND Resuscitative endovascular balloon occlusion of the aorta (REBOA) is becoming a standardized adjunct for the management in patients with severe non-compressible torso hemorrhage (NCTH). Although guidelines have been developed to help with the best indications for REBOA utilization, no studies have addressed the significance of change in systolic blood pressure (ΔSBP) after REBOA insufflation. We hypothesized that ΔSBP would predict mortality in patients with NCTH and have utility as a surrogate marker for hemorrhage status. STUDY DESIGN This was an international, multicenter retrospective review of all patients managed with REBOA from the ABOTrauma Registry and the AORTA database. ΔSBP was defined as the difference between pre- and post-REBOA insertion SBP. Based on post-insertion SBP, patient hemorrhage status was categorized as responder or non-responder. A non-responder was defined as a hypotensive patient with systolic blood pressure

Although vascular surgery guidelines recommend immediate anticoagulation for acute occlusion of a peripheral artery, it is unclear whether trauma surgeons follow this practice. A survey regarding the use of perioperative anticoagulation was sent to surgeons who perform their own peripheral arterial repairs after traumatic injury to define contemporary practice patterns. This survey demonstrated minimal consensus opinion regarding the management of extremity vascular injuries, strongly suggesting the need for a consensus conference, meta-analysis, and prospective studies to guide further care.

BackgroundResuscitative endovascular balloon occlusion of the aorta (REBOA) is a less-invasive technique for aortic occlusion (AO). Commonly performed in the emergency department (ED), the role of intraoperative placement is less defined. We hypothesized that operating room (OR) placement is associated with increased in-hospital mortality.MethodsThe American Association for the Surgery of Trauma AORTA registry was used to identify patients undergoing REBOA. Injury characteristics and outcomes data were compared between OR and ED groups. The primary outcome was in-hospital mortality; secondary outcomes included total AO time, transfusion requirements, and acute kidney injury.ResultsLocation and timing of catheter insertion were available for 305 of 321 (95%) subjects. 58 patients underwent REBOA in the OR (19%). There were no differences with respect to sex, admission lactate, and Injury Severity Score. The OR group was younger (33 years vs. 41 years, p=0.01) and with more penetrating injuries (36% vs. 15%, pDiscussionOR REBOA placement is common and generally employed in patients with more stable admission physiology. OR placement was not associated with increased in-hospital mortality despite longer times to AO and definite hemostasis when compared with catheters placed in the ED.Level of evidenceIV; therapeutic/care management.

The Stop the Bleed initiative empowers and trains citizens as immediate responders, to recognize and control severe hemorrhage. We sought to determine the retention of short-term knowledge and ability to apply a Combat Application Tourniquet (CAT) in 10 nonmedical personnel. A standard "Stop the Bleed" (Bleeding Control) course was taught including CAT application. Posttraining performance was assessed at 30 days using a standardized mannequin with a traumatic below-knee amputation. Technique, time, pitfalls, and feedback were all recorded. No participant had placed a CAT before the initial class. After the initial class, self-report by a Likert scale survey revealed an increased confidence in tourniquet application from 2.4 pretraining to 4.7 posttraining. At 30 days, confidence decreased to 3.4 before testing. Six of 10 were successful at tourniquet placement. Completion time was 77.75 seconds (43-157 seconds). Successful participants reported a confidence level of 4.7

Introduction: The introduction of low profile devices designed for Resuscitative Endovascular Balloon Occlusion of the Aorta (REBOA) after trauma has the potential to change practice, outcomes and complication profiles related to this procedure. Methods: The AAST Aortic Occlusion for Resuscitation in Trauma and Acute Care Surgery (AORTA) registry was utilized to identify REBOA patients from 16 centers -comparing presentation, intervention and outcome variables for those REBOA via traditional 11-12 access platforms and trauma-specific devices requiring only 7 F access. Results:From Nov 2013-Dec 2017, 242 patients with completed data were identified, constituting 124 7F and 118 11-12F uses. Demographics of presentation were not different between the two groups, except that the 7F patients had a higher mean ISS (39.2 34.1, p = 0.028). 7F device use was associated with a lower cut-down requirement for access (22.6% vs. 37.3%, p = 0.049) and increased ultrasound guidance utilization (29.0% 23.7%, p = 0.049). 7F device afforded earlier aortic occlusion in the course of resuscitation (median 25.0 mins vs. 30 mins, p = 0.010), and had lower median PRBC (10.0 vs. 15.5 units, p = 0.006) and FFP requirements (7.5 vs. 14.0 units, p = 0.005). 7F patients were more likely to survive 24 hrs (58.1% vs. 42.4%, p = 0.015) and less likely to suffer in-hospital mortality (57.3% vs. 75.4%, p = 0.003). Finally, 7F device use was associated with a 4X lower rate of distal extremity embolism (20.0% vs. 5.6%, p = 0.014;OR 95% CI 4.25 [1.25-14.45]) compared to 11-12F counterparts. Conclusion: The introduction of trauma specific 7F REBOA devices appears to have influenced REBOA practices, with earlier utilization in severely injured hypotensive patients via less invasive means that are associated with lower transfusion requirements fewer thrombotic complications and improved survival. Additional study is required to determine optimal REBOA utilization.

Serious complications related to groin access have been reported with the use of resuscitative endovascular balloon occlusion of the aorta (REBOA). We performed a systematic review and meta-analysis to estimate the incidence of complications related to groin access from the use of REBOA in adult trauma patients.We identified articles in MEDLINE and EMBASE. We reviewed all studies that involved adult trauma patients who underwent the placement of a REBOA and included only those that reported the incidence of complications related to groin access. A meta-analysis of proportions was performed.We identified 13 studies with a total of 424 patients. REBOA was inserted most commonly by trauma surgeons or emergency room physicians. Information regarding puncture technique was reported in 12 studies and was available for a total of 414 patients. Percutaneous access and surgical cutdown were performed in 304 (73.4%) and 110 (26.5%) patients, respectively. Overall, complications related to groin access occurred in 5.6% of patients (n = 24/424). Lower limb amputation was required in 2.1% of patients (9/424), of which three cases (3/424 [0.7%]) were directly related to the vascular puncture from the REBOA insertion. A meta-analysis that used the logit transformation showed a 5% (95% CI 3%-9%) incidence of complications without significant heterogeneity (LR test: χ = 0.73, p = 0.2, Tau-square = 0.2). In a second meta-analysis, we used the Freeman-Tukey double arcsine transformation and found an incidence of complications of 4% (95% CI 2%-7%) with low heterogeneity (I = 16.3%).We found that the incidence of complications related to groin access was of 4-5% based on a meta-analysis of 13 studies published worldwide. Currently, there are no benchmarks or quality measures as a reference to compare, and thus, further work is required to identify these benchmarks and improve the practice of REBOA in trauma surgery.Systematic review and meta-analysis, level III.

The use of interventional procedures in trauma has increased steadily over the past 10 years. With advancements in both imaging and device technology, endovascular techniques have become part of the treatment algorithm for both large and small vessel injury. Endovascular therapy in trauma involves a minimally invasive, catheter-based approach, which can be used as a temporizing measure in patients in extremis or as definitive therapy in a wide variety of diagnoses. Sheaths, catheters, and guide wires are universal instruments, regardless of procedure. Devices passed over guide wires form the basis of diagnosis and treatment. Using this technology provides many advantages to traditional open surgical therapy, namely the avoidance of large and potentially morbid incisions. Angioembolization, stent grafting, and resuscitative endovascular balloon occlusion of the aorta (REBOA) are being used with increasing frequency in trauma centers, with established algorithms, multiinstitutional trials, and more published data available, particularly for solid-organ and pelvic hemorrhage. Key words: angiography, embolization, hemorrhage, resuscitative endovascular balloon occlusion of the aorta, stent graft

Dr. James Lawrence Cabell was one of the most important, farsighted, and influential surgical educators and leaders in the United States in the 19th century. He was appointed as Chair of Surgery and Physiology at the University of Virginia by Thomas Jefferson's successor as Rector of the University, James Madison, and held that Chair for over 50 years, the longest tenure of any American medical academician. He was a founding member of the American Medical Association, the American Surgical Association, and the National Board of Health. He is best remembered as an articulate, incessant, and early proponent of public health and the delivery of quality health care in the United States. His legacy and that of his protégés has continued to influence health care in this country, especially in the realm of the prevention and treatment of infectious diseases, even into the present time.

To determine the alterations in intracranial pressure (ICP) during U. S. Air Force Critical Care Air Transport Team transport of critically injured warriors with ICP monitoring by intraventricular catheter (IVC).Patients with an IVC following traumatic brain injury requiring aeromedical evacuation from Bagram to Landstuhl Regional Medical Center were studied A data logger monitored both ICP and arterial blood pressure and was equipped with an integral XYZ accelerometer to monitor movement.Eleven patients were studied with full collection of data from takeoff to landing. The number of instances of ICP20 mm Hg ranged from 0 to 238 and duration of instances ranged from 0 to 3,281 seconds. The number of instances of ICP±50% of the baseline ICP ranged from 0 to 921 and duration of instances ranged from 0 to 9,054 seconds. Five of the patients did not experience ICP20 mm Hg throughout their flight, but 10 patients showed instances of ICP±50% of baseline ICP.Patient movement results in changes in ICP both from external stimuli (vibration, noise) and from acceleration and deceleration forces. During transport, Critical Care Air Transport Team crews should prioritize monitoring and correcting ICP including additional sedation and/or venting IVC.