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Four-factor prothrombin complex concentrate (4F-PCC) is standard of care for emergent vitamin K antagonist (VKA) reversal but optimal dosing is uncertain. This meta-analysis estimated the proportion of patients treated with fixed dose (FD) 4F-PCC who achieved adequate reversal and compared safety and efficacy of FD versus weight-based dose (WB) strategies. This review was conducted according to PRISMA guidelines. Medline and Scopus were searched and included studies evaluating FD regimens and comparing FD and WB for emergent VKA reversal. Data was pooled using random effects. Subgroup analyses examined heterogeneity. Risk of bias was assessed with Newcastle-Ottawa Scale and RoB2 score. Twenty-three studies (n = 2055) were included with twelve (n = 1143) comparing FD versus WB. The proportion of patients achieving goal INR with FD varied depending on the INR target, being significantly higher for INR <2 (90.9%, 95% Confidence Interval (CI) 87.2, 94.06) compared to INR <1.6 (70.97%, 95%CI 65.33, 76.31). Compared to WB, FD was less likely to achieve a goal INR <1.6 (Risk Difference (RD) −13%, 95% CI −21, −4) but achieved similar reversal for a goal INR <2.0, (RD −1%, 95%CI −7, 4). There was no difference in hospital mortality (RD 4%, 95%CI −2, 9) or thrombosis (RD 0.0%, 95%CI −3, 3). FD VKA reversal was associated with significantly lower attainment of goal INR compared to WB with lower INR targets. This did not translate to differences in hospital mortality, but these results should be interpreted cautiously in light of the observational nature of the included studies. • Optimal dosing of four-factor prothrombin complex concentrate (4F-PCC) for vitamin K antagonist reversal is uncertain. • Emerging interest in fixed dose 4F-PCC is due to potential decreased risk of thrombosis and cost. • When compared to variable dose 4F-PCC, fixed dose may decrease the attainment of goal INR. • This decrease did not translate to differences in patient centered outcomes between dosing schema. [ABSTRACT FROM AUTHOR]

State guidelines for re-triage, or emergency inter-facility transfer, have never been characterized across the United States. All 50 states' Department of Health and/or Trauma System websites were reviewed for publicly available re-triage guidelines within their rules and regulations. Communication was made via phone or email to state agencies or trauma advisory committees to obtain or confirm the absence of guidelines where public data was unavailable. Guideline criteria were abstracted and grouped into domains of Center for Disease Control Field Triage Criteria: pattern/anatomy of injury, vital signs, special populations, and mechanisms of injury. Re-triage criteria were summarized across states using median and interquartile ranges for continuous data and frequencies for categorical data. Demographic data of states with and without re-triage guidelines were compared using the Wilcoxon rank sum test. Re-triage guidelines were identified for 22 of 50 states (44%). Common anatomy of injury criteria included head trauma (91% of states with guidelines), spinal cord injury (82%), chest injury (77%), and pelvic injury (73%). Common vital signs criteria included Glasgow Coma Score (91% of states) ranging from 8 to 14, systolic blood pressure (36%) ranging from 90 to 100 mm Hg, and respiratory rate (23%) with all using 10 respirations/minute. Common special populations criteria included mechanical ventilation (73% of states), age (68%) ranging from <2 or >60 years, cardiac disease (59%), and pregnancy (55%). No significant demographic differences were found between states with versus without re-triage guidelines. A minority of US states have re-triage guidelines. Characterizing existing criteria can inform future guideline development. [ABSTRACT FROM AUTHOR]

The coronavirus disease 2019 pandemic restricted movement of individuals and altered provision of health care, abruptly transforming health care-use behaviors. It serves as a natural experiment to explore changes in presentations for surgical diseases including acute appendicitis. The objective was to determine if the pandemic was associated with changes in incidence of acute appendicitis compared to a historical control and to determine if there were associated changes in disease severity. The study is a retrospective, multicenter cohort study of adults (N = 956) presenting with appendicitis in nonpandemic versus pandemic time periods (December 1, 2019–March 10, 2020 versus March 11, 2020–May 16, 2020). Corresponding time periods in 2018 and 2019 composed the historical control. Primary outcome was mean biweekly counts of all appendicitis presentations, then stratified by complicated (n = 209) and uncomplicated (n = 747) disease. Trends in presentations were compared using difference-in-differences methodology. Changes in odds of presenting with complicated disease were assessed via clustered multivariable logistic regression. There was a 29% decrease in mean biweekly appendicitis presentations from 5.4 to 3.8 (rate ratio = 0.71 [0.51, 0.98]) after the pandemic declaration, with a significant difference in differences compared with historical control (P =.003). Stratified by severity, the decrease was significant for uncomplicated appendicitis (rate ratio = 0.65 [95% confidence interval 0.47–0.91]) when compared with historical control (P =.03) but not for complicated appendicitis (rate ratio = 0.89 [95% confidence interval 0.52–1.52]); (P =.49). The odds of presenting with complicated disease did not change (adjusted odds ratio 1.36 [95% confidence interval 0.83–2.25]). The pandemic was associated with decreased incidence of uncomplicated appendicitis without an accompanying increase in complicated disease. Changes in individual health care–use behaviors may underlie these differences, suggesting that some cases of uncomplicated appendicitis may resolve without progression to complicated disease. [ABSTRACT FROM AUTHOR]

Purpose: The goal of this study was to determine the impact of surgical rib fixation (SRF) in a treatment protocol for severe blunt chest trauma. Materials and methods: Patients with flail chest admitted between September 2009 and June 2010 to our level I trauma center who failed traditional management and underwent SRF were matched with an historical group. Outcome variables evaluated include age, injury severity score, intensive care unit length of stay (LOS), hospital LOS, ventilator days, total number of rib fractures, and total number of segmental rib fractures. Results: The 2 groups were similar in age, injury severity score, intensive care unit LOS, hospital LOS, total number of rib fractures, and total segmental rib fractures. The operative group demonstrated a significant reduction in total ventilator days as compared with the nonsurgical group (4.5 [0-30] vs 16.0 [4-40]; P = .040). Patients with SRF were permanently liberated from the ventilator within a median of 1.5 days (0-8 days). Conclusions: Surgical rib fixation resulted in a significant decrease in ventilator days and may represent a novel approach to decreasing morbidity in flail chest patients when used as a rescue therapy in patients with declining pulmonary status. Larger studies are required to further identify these benefits [ABSTRACT FROM AUTHOR]

Purpose: This study aimed to identify predictive factors resulting in glucose values greater than 200 mg/dL in patients with trauma transitioned from an insulin infusion to a basal-bolus subcutaneous insulin regimen. Materials and Methods: Thirty-nine patients with trauma on goal enteral nutrition in the intensive care unit receiving an insulin infusion for at least 48 hours and transitioned to a basal-bolus regimen were retrospectively identified. Results: Ten patients had hyperglycemic events after transition. Hyperglycemia was significantly associated with increased age (42 [17] years vs 56 [13] years, P = .02), admission glucose (128 [39] mg/dL vs 214 [91] mg/dL, P = .015), and insulin drip rate 48 hours before transition (87 [38] units/d vs 127 [49] units/d, P = .012). There was no difference between groups with respect to injury severity, demographics, or physiologic parameters. Multiple regression analysis revealed that increased age (odds ratio [OR], 1.215 [1.000-1.477]; P =.05), increased admission blood glucose (OR, 1.053 [1.006-1.101]; P =.025), and higher insulin infusion rates 48 hours before transition (OR, 1.061 [1.009-1.116]; P =.020) predisposed patients to severe hyperglycemic episodes. Conclusions: Older patients with trauma and patients with higher blood glucose on admission are more likely to experience severe hyperglycemia when transitioned to basal-bolus glucose control. Higher insulin infusion rates at 48 hours before transition are also associated with severe hyperglycemia. [ABSTRACT FROM AUTHOR]

Abstract: Objective: Utilization of brain tissue oxygenation (pBtO2) is an important but controversial variable in the treatment of traumatic brain injury (TBI). We evaluated the correlation between pBtO2/CPP and pBtO2/ICP and determined the parameter most closely related to survival. Methods: Consecutive, adult patients with severe TBI and pBtO2 monitors were retrospectively identified. Time-indexed measurements of pBtO2, CPP and ICP were collected and correlation coefficients were determined. Patients were then stratified according to survival and pBtO2, CPP and ICP values were compared between groups. Results: There were 4169 time-indexed data points (i.e., pBtO2 with respective CPP and ICP values) in 15 patients. The cohort consisted of a mean age of 37±17years, ISS of 27±7 and GCS of 4.5±1.5. Survival was 53% (8/15). In a normal regression models, neither the ICP (p =0.58) nor the CPP (p =0.71) predict pBtO2 significantly. There was a significant difference in pBtO2 in survivors (31.5±3.1 vs. 25.2±4.8, p =0.010) but not in CPP or ICP. Survivors had a lower proportion of time with pBtO2 <25mmHg [20% (3.4–44.6) vs. 40% (16.2–89), p =0.049]. In contrast, survivors had a greater proportion of time with CPP<70 and no difference in the proportion of time with and ICP>20. Conclusions: CPP and ICP should not be used as surrogates for pBtO2 since cerebral oxygenation varies independently of cerebral hemodynamics and pressures. Brain tissue oxygen monitoring in patients with TBI provides unique information regarding cerebral oxygenation the utility of which remains to be fully described. Significance: CPP and ICP are not surrogates for pBtO2. Brain tissue oxygenation monitoring provides unique information for the treatment of traumatically injured patients. [Copyright &y& Elsevier]

Abstract: Purpose: The purposes of the study were to determine the incidence of adrenal insufficiency (AI) using several published techniques, compare the response rates using a low-dose (LD) corticotropin (ACTH) stimulation test vs a standard dose (SD), and identify the technique that is most closely related to vasopressor use. Materials and Methods: Consecutive adult patients who were undergoing open heart surgery for CAD or valvular disease were prospectively enrolled. Exclusion criteria included history of steroid use, operative steroid, or etomidate administration. Postoperatively, each patient underwent ACTH stimulation with 1 μg (LD) and 249 μg (SD), 60 minutes apart. Agreement among the tests was evaluated, and vasopressor use was compared between groups. Results: There were 40 patients evaluated. The incidence of AI based on operative change, postoperative values, and LD-ACTH and SD-ACTH tests was 53%, 38%, 60%, and 38%, respectively. Agreement between the LD- and SD-ACTH tests was 73% (κ = 0.476, P = .001). There was a significant difference in the need for (93% vs 52%, P = .013) and duration (18.9 [0-180.6] vs 0.6 [0-73.2] hours, P = .003) of vasopressor therapy in patients with and without AI but only using the SD-ACTH definition. Conclusion: The incidence of AI will vary greatly based on technique used for diagnosis. The SD-ACTH stimulation test should be used to determine AI in open heart patients postoperatively because of the close association with vasopressor usage. [Copyright &y& Elsevier]

Background: The reported risk of delayed intracranial hemorrhage (ICH) in a trauma patient on warfarin is estimated to be between 0.6% and 6%. The risk of delayed ICH in trauma patients taking novel oral anticoagulants (NOACs) is not well-defined.Objective: We hypothesized that there was a significant number of delayed presentations of ICH in patients on NOACs.Methods: A retrospective review of our trauma registry was performed on geriatric patients (age older than 64 years) who were initially evaluated at our level I trauma center, had fall from standing height or less, and were anticoagulated (warfarin or NOACs), from April 2017 to March 2018.Results: Seventy-seven patients met inclusion criteria. The mean age was 80 ± 7.7 years and 46% of patients were male. The admission head computed tomography scan was positive in 20.8% of patients. Positive scans were more common in patients on warfarin vs. NOACs (30% vs. 14%; p = 0.074) and had a significantly higher Injury Severity Score (median [interquartile range]: 9 [3-15] vs. 5 [1-9]; p = 0.030) and Abbreviated Injury Scale-Head score (median [interquartile range]: 1 [0-3] vs. 1 [0-2]; p = 0.035). The agreement between loss of consciousness (LOC) and ICH was 72% (κ = -0.064; p = 0.263). Fifty-one percent of patients had a repeat head CT. New ICH was diagnosed in 9.6% of patients. All of these patients were on NOACs.Conclusions: A fall from standing or less in anticoagulated geriatric patients is a significant mechanism of injury resulting in ICH. The absence of LOC does not eliminate the possibility of ICH. There is a significant risk of delayed ICH for patients on NOACs and repeat evaluations should be performed. A prospective multicenter evaluation of this finding is warranted. [ABSTRACT FROM AUTHOR]