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Background Antibiotic therapy has been proposed as an alternative to surgery for the treatment of appendicitis. Methods We conducted a pragmatic, nonblinded, noninferiority, randomized trial comparing antibiotic therapy (10-day course) with appendectomy in patients with appendicitis at 25 U.S. centers. The primary outcome was 30-day health status, as assessed with the European Quality of Life-5 Dimensions (EQ-5D) questionnaire (scores range from 0 to 1, with higher scores indicating better health status; noninferiority margin, 0.05 points). Secondary outcomes included appendectomy in the antibiotics group and complications through 90 days; analyses were prespecified in subgroups defined according to the presence or absence of an appendicolith. Results In total, 1552 adults (414 with an appendicolith) underwent randomization; 776 were assigned to receive antibiotics (47% of whom were not hospitalized for the index treatment) and 776 to undergo appendectomy (96% of whom underwent a laparoscopic procedure). Antibiotics were noninferior to appendectomy on the basis of 30-day EQ-5D scores (mean difference, 0.01 points; 95% confidence interval [CI], -0.001 to 0.03). In the antibiotics group, 29% had undergone appendectomy by 90 days, including 41% of those with an appendicolith and 25% of those without an appendicolith. Complications were more common in the antibiotics group than in the appendectomy group (8.1 vs. 3.5 per 100 participants; rate ratio, 2.28; 95% CI, 1.30 to 3.98); the higher rate in the antibiotics group could be attributed to those with an appendicolith (20.2 vs. 3.6 per 100 participants; rate ratio, 5.69; 95% CI, 2.11 to 15.38) and not to those without an appendicolith (3.7 vs. 3.5 per 100 participants; rate ratio, 1.05; 95% CI, 0.45 to 2.43). The rate of serious adverse events was 4.0 per 100 participants in the antibiotics group and 3.0 per 100 participants in the appendectomy group (rate ratio, 1.29; 95% CI, 0.67 to 2.50). Conclusions For the treatment of appendicitis, antibiotics were noninferior to appendectomy on the basis of results of a standard health-status measure. In the antibiotics group, nearly 3 in 10 participants had undergone appendectomy by 90 days. Participants with an appendicolith were at a higher risk for appendectomy and for complications than those without an appendicolith. (Funded by the Patient-Centered Outcomes Research Institute; CODA ClinicalTrials.gov number, NCT02800785.).

* Abbreviations: ALS — : advanced life support BLS — : basic life support EMS — : emergency medical services The National Association of EMS Physicians, along with these coauthoring associations: American Academy of Pediatrics, American College of Surgeons Committee on Trauma, EMS for Children Innovation and Improvement Center, Emergency Nurses Association, and National Association of State EMS Officials and as also endorsed by the National Association of Emergency Medical Technicians, believes that the delivery of high-quality and effective EMS care is dependent on several factors, including but not limited to the presence of the following: Several documents, including previous versions of this joint position statement, the National Model EMS Clinical Guidelines Version 2.2 , the 2018 National EMS Scope of Practice Model , the Clinical Credentialing of EMS Providers , Physician Oversight of Pediatric Care in Emergency Medical Services , Pediatric Readiness in Emergency Medical Services Systems , and core performance measures from the US Department of Health and Human Services Health Resources and Services Administration EMS for Children (EMSC) Program have been developed to lay the foundation of several of the concepts noted above.1–9 Ensuring that EMS providers are properly equipped to perform their clinical duties is an important function of oversight in EMS systems. In the past, this regulatory oversight has been based on the publication of minimum recommended equipment standards, including previous versions of this document.2–4 These efforts have attempted to provide a listing of the minimum items recommended for basic life support (BLS) and advanced life support (ALS) ground ambulances. The field of EMS … Address correspondence to John Lyng, MD, NRP, National Association of EMS Physicians, 4400 College Blvd, Suite 220, Overland Park, KS 66211. E-mail: jlyngmd{at}gmail.com

Introduction: Under current law in our rural state, there is no universal requirement for motorcyclists to wear helmets. Roughly 500 motorcycle crashes are reported by the state each year and only a fraction of those riders wear helmets. We sought to determine the difference in injury patterns and severity in helmeted versus non-helmeted riders. Methods: Retrospective review (2014–2018) of a single level 1 trauma center’s registry was done for subjects admitted after a motorcycle collision. Demographic, injury and patient outcome data were collected. Patients were stratified by helmet use (n = 81), no helmet use (n = 144), and unknown helmet use (n = 194). Statistical analysis used Student’s t-test or Pearson’s χ2 p-value ≤0.05 as significant. State Department of Transportation data registry for state level mortality and collision incidence over the same time period was also obtained. Results: Of the 2,022 state-reported motorcycle collisions, 419 individuals admitted to our trauma center were analyzed (21% capture). State-reported field fatality rate regardless of helmet use was 4%. Our inpatient mortality rate was 2% with no differences between helmet uses. Helmeted riders were found to have significantly fewer head and face injuries, higher GCS, lower face, neck, thorax and abdomen AIS, fewer required mechanical ventilation, shorter ICU length of stay, and had a greater number of upper extremity injuries and higher upper extremity AIS. Conclusions: Helmeted motorcyclists have fewer head, face, and cervical spine injuries, and lower injury severities: GCS and face, neck, thorax, abdomen AIS. Helmeted riders had significantly less mechanical ventilation requirement and shorter ICU stays. Non-helmeted riders sustained worse injuries. Practical Applications: Helmets provide safety and motorcycle riders have a 34-fold higher risk of death following a crash. Evaluating injury severities and patterns in motorcycle crash victims in a rural state with no helmet laws may provide insight into changing current legislation.

Background Frostbite is a cold injury that has the potential to cause considerable morbidity and long-term disability. Despite the complexity of these patients, diagnostic and treatment practices lack standardization. Thrombolytic therapy has emerged as a promising treatment modality, demonstrating impressive digit salvage rates. We review our experience with thrombolytic therapy for severe upper extremity frostbite. Methods Retrospective data on all frostbite patients evaluated at our institution from December 2017 to March 2018 was collected. A subgroup of patients with severe frostbite treated with intra-arterial thrombolytic therapy (IATT) were analysed. Results Of the 17 frostbite patients treated at our institution, 14 (82%) were male and the median age was 31 (range: 19–73). Substance misuse was involved in a majority of the cases (58.8%). Five (29.4%) patients with severe frostbite met inclusion criteria for IATT and the remaining patients were treated conservatively. Angiography demonstrated a 74.5% improvement in perfusion after tissue plasminogen activator thrombolysis. When comparing phalanges at risk on initial angiography to phalanges undergoing amputation, the phalangeal salvage rate was 83.3% and the digit salvage rate was 80%. Complications associated with IATT included groin hematoma, pseudoaneurysm and retroperitoneal hematoma. Conclusions Thrombolytic therapy has the potential to greatly improve limb salvage and functional recovery after severe frostbite when treated at an institution that can offer comprehensive, protocoled thrombolytic therapy. A multi-center prospective study is warranted to elucidate the optimal treatment strategy in severe frostbite.

BACKGROUND Over the past 30 years, the demographics, clinical characteristics, and management of trauma patients have changed dramatically. During this same period, the organ donor population has also changed. The interactions between these two demographic shifts have not been examined in a systematic way. We hypothesize that trauma victims continue to be an important source of organs. We set out to systematically examine traumatic donors in an attempt to identify opportunities to increase organ recovery and quality. METHODS In this retrospective analysis, we compared trauma donors (TDs) and non-TDs (NTDs) in the Scientific Registry of Transplant Recipients standard analysis files, a clinical data set collected by the Organ Procurement Transplant Network on all solid organ transplant candidates, donors, and recipients in the United States since 1987. RESULTS Scientific Registry of Transplant Recipients contained data on 191,802 deceased donors. The percentage of TDs decreased from 55.3% in 1987 to 35.8% in 2016 (p < 0.001) primarily due to a steady increase in NTDs. Trauma donors are younger and have fewer comorbidities while the percentage of donors who were public health service high risk or who underwent donation after cardiac death were clinically similar. The TDs produce more organs/donor (3.5 vs. 2.4, p < 0.001), are more likely to yield an extrarenal organ, and exhibit lower (better) Kidney Donor Risk Index scores, a predictor of graft longevity. These better outcomes are maintained after stratifying by age. CONCLUSION Over the past 30 years, the number of NTDs has increased much more than the number of TDs. However, TDs remain a critically important organ donor source, yielding more organs per donor, better quality kidneys, and a higher likelihood of extrarenal organs. Potential causes, such as improved resuscitation protocols, should be examined in the future. LEVEL OF EVIDENCE Retrospective review, level III.

Oversight of human subject research has evolved considerably since its inception. However, previous studies identified a lack of consistency of institutional review board (IRB) determination for the type of review required and whether informed consent is necessary, especially for prospective observational studies, which pose minimal risk of harm. We hypothesized that there is significant inter-institution variation in IRB requirements for the type of review and necessity of informed consent, especially for prospective observational trials without blood/tissue utilization. We also sought to describe investigators’ and IRB members’ attitudes toward the type of review and need for consent. Eastern Association for the Surgery of Trauma (EAST) and IRB members were sent an electronic survey on IRB review and informed consent requirement. We performed descriptive analyses as well as Fisher’s exact test to determine differences between EAST and IRB members’ responses. The response rate for EAST members from 113 institutions was 13.5%, whereas a convenience sample of IRB members from 14 institutions had a response rate of 64.4%. Requirement for full IRB review for retrospective studies using patient identifiers was reported by zero IRB member compared with 13.1% of EAST members (p=0.05). Regarding prospective observational trials without blood/tissue collection, 48.1% of EAST members reported their institutions required a full IRB review compared with 9.5% of IRB members (p=0.01). For prospective observational trials with blood/tissue collection, 80% of EAST members indicated requirement to submit a full IRB review compared with only 13.6% of IRB members (p

Pulmonary insufficiency is the most common complication after surgical procedures. From minor atelectasis to acute respiratory distress syndrome (ARDS), postoperative pulmonary insufficiency occurs in up to 50% of surgeries. Here we discuss the anatomy, mechanics, and pathophysiology of pulmonary insufficiency; preoperative and postoperative assessment of lung function; and treatment for pulmonary insufficiency with regard to atelectasis, pulmonary edema, and ARDS. Pulmonary insufficiency secondary to cardiac disease, thromboembolism, and central nervous system depression are discussed elsewhere. Preoperative identification of risk factors for pulmonary insufficiency and understanding the physiologic changes in the perioperative period can potentially mitigate postoperative respiratory failure.