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OBJECTIVE Pain and disability among surgeons can lead to practice restrictions, early retirement, and physician burnout. This project sought to address the physical well-being of surgical residents by teaching ergonomic principles, a “microbreaks” model, and stretching exercises aimed at targeting the four anatomical areas identified as most problematic for surgeons. DESIGN Three modules, led by physical therapists, were presented to surgical residents over the course of the 2018-2019 academic year. These modules targeted specific problem areas for surgeons according to current literature. A perioperative micro-break model was also presented. Pre- and post-lecture surveys were administered to document pain, applicability of lecture content and effectiveness for use in the operating room (OR), and were reviewed retrospectively. SETTING Jackson Memorial Hospital, DeWitt Daughtry Family Department of Surgery, Division of General Surgery, Miami, Florida RESULTS A large number of participants reported pain in one or more body part (87%) prior to beginning this ergonomic training and 39% indicated that this pain was performance-limiting. The majority of residents (93%) who attended Module #3 reported that learning the targeted exercises and microbreaks model would help them physically perform better in the OR and, in fact, after practicing these exercises during this Module, 85% of residents reported decreased pain, especially in the areas of the cervical and lumbar spine. CONCLUSIONS Preliminary data indicate that this novel curriculum was perceived as valuable by surgical residents and that practicing these targeted exercises reduced pain, particularly in the neck and lower back. Further research is needed to determine the longitudinal effects of this ergonomics curriculum on surgical resident well-being and whether these exercises will be effective in reducing pain and enhancing performance in the OR setting.

Background Augmented renal clearance (ARC; i.e., creatinine clearance [CLCr] ≥ 130 mL/min) has an incidence of 14%-80% in critically ill patients and has been associated with therapy failures for renally cleared drugs. However, the clinical implications of ARC are poorly defined. We hypothesize that modifiable risk factors that contribute to ARC can be identified in severely injured trauma patients and that these risk factors influence clinical outcome. Methods In 207 trauma intensive care unit patients, 24-h CLCr was correlated with clinical estimates of glomerular filtration rate (by Cockroft-Gault, modification of diet in renal disease, or chronic kidney disease epidemiology), and clinical outcomes (infection, venous thromboembolism [VTE], length of stay, and mortality). Results The population was 45 ± 20 y, 68% male, 77% blunt injury with injury severity score of 24 (17-30). Admission serum creatinine was 1.02 ± 0.35 mg/dL, CLCr was 154 ± 77 mL/min, VTE incidence was 15%, ARC incidence was 57%, and mortality was 11%. Clinical estimates of glomerular filtration rate by Cockroft-Gault, modification of diet in renal disease, chronic kidney disease epidemiology underestimated actual CLCr by 20%, 22%, or 15% (all P Conclusions ARC occurs in more than half of all high-risk trauma intensive care unit patients and is underestimated by standard clinical equations. ARC was not associated with increased incidence of VTE or infection but rather is associated with younger healthier males and reduced mortality. ARC seems to be a beneficial compensatory response to trauma.

In comparison to the general patient population, trauma patients show higher level detections of bloodborne infectious diseases, such as Hepatitis and Human Immunodeficiency Virus. In comparison to bloodborne pathogens, the prevalence of respiratory infections such as SARS-CoV-2 and how that relates with other variables, such as drug usage and trauma type, is currently unknown in trauma populations. Here, we evaluated SARS-CoV-2 seropositivity and antibody isotype profile in 2,542 trauma patients from six Level-1 trauma centers between April and October of 2020 during the first wave of the COVID-19 pandemic. We found that the seroprevalence in trauma victims 18-44 years old (9.79%, 95% confidence interval/CI: 8.33 11.47) was much higher in comparison to older patients (45-69 years old: 6.03%, 4.59-5.88; 70+ years old: 4.33%, 2.54 – 7.20). Black/African American (9.54%, 7.77 – 11.65) and Hispanic/Latino patients (14.95%, 11.80 – 18.75) also had higher seroprevalence in comparison, respectively, to White (5.72%, 4.62 7.05) and Non-Latino patients (6.55%, 5.57 – 7.69). More than half (55.54%) of those tested for drug toxicology had at least one drug present in their system. Those that tested positive for narcotics or sedatives had a significant negative correlation with seropositivity, while those on anti-depressants trended positive. These findings represent an important consideration for both the patients and first responders that treat trauma patients facing potential risk of respiratory infectious diseases like SARS-CoV-2.

Background: No previous studies have determined the incidence of acute kidney injury (AKI) in trauma patients treated with vancomycin + meropenem (VM) versus vancomycin + cefepime (VC). The purpose...

Uniformity in surgical education is challenging because surgical experience is based on rotation assignments. With work hour restrictions, the likelihood of residents being exposed to rare or unusual cases is diminished. Telemedicine may create a new learning paradigm for surgical education and supplement exposure for rare or unusual cases. A retrospective review (2010–2016) of teleconferences involving trauma centers worldwide was conducted. Participating hospitals included centers from underdeveloped countries to first world nations. Trauma cases were discussed among surgeons with different levels of experience and resource availability. Data collected included types of cases, anatomic injury patterns, hospital location, and the number of telemedicine centers and viewers participating. Seventy-three hospitals in 64 cities, spanning 27 countries, participated in 276 telemedicine grand round conferences. Cases discussed included penetrating trauma (47%), blunt trauma (42%), and blast injury (4%). The anatomic regions included were the thorax (28%), abdomen (26%), thoracoabdominal region (13%), neck (7%), and pelvis (6%). The most common injury discussed was vascular in nature (18%), followed by the lung, liver, diaphragm, and heart. The most common vascular lesion was in the aorta (18%), followed by the iliac vessels (8%) and the vena cava (7%). Telemedicine is a valuable tool, allowing the dissemination of diverse experiences. Most cases presented evaluated rare injuries or complex surgical approaches, which are not commonly seen on trauma sites. Learning different approaches in the management of complex trauma will make surgeons more prepared to deal with challenging cases.

In June 2016, an advanced extracorporeal membrane oxygenation (ECMO) program consisting of a multidisciplinary team was initiated at a large level-one trauma center. The program was created to standardize management for patients with a wide variety of pathologies, including trauma. This study evaluated the impact of the advanced ECMO program on the outcomes of traumatically injured patients undergoing ECMO. A retrospective cohort study was performed on all patients sustaining traumatic injury who required ECMO support from January 2014 to September 2017. The primary outcome was to determine survival in trauma ECMO patients in the two timeframes, before and after initiation of the advanced ECMO program. Secondary outcomes included complication rates, length of stay, ventilator usage, and ECMO days. One hundred and thirty eight patients were treated with ECMO during the study period. Of the 138 patients, 22 sustained traumatic injury. Seven patients were treated in our pre-group and 15 in our post-group. The majority of patients were treated with VV ECMO. Our post group VV ECMO extracorporeal survival rate was 64% and our survival to discharge was 55%. This study demonstrated an improvement in survival after implementation of our advanced ECMO program. The implementation of a multidisciplinary trauma ECMO team dedicated to the rescue of critically ill patients is the key for achieving excellent outcomes in the trauma population.

A significant proportion of readmissions occurs at a different hospital than the index admission, and is thus missed by current quality metrics. No study has examined all-hospital adult 30-day readmission rates, including different hospitals, following burn injury across the United States. The purpose of this study was to evaluate nationwide readmission rates, potential risk factors, and ultimately the burden of burn injury readmission, including readmission to a different hospital. The 2010-2014 Nationwide Readmissions Database was queried for patients admitted for burn. Multivariate logistic regression identified risk factors and associated cost for 30-day readmission at index and different hospitals. There were 94,759 patients admitted during the study period, with 7.4% (n = 7000) readmitted and of those, 29.2% (n = 2047) readmitted to a different hospital. The most common reason for readmission was infection (29.4% [n = 1990]). Risk factors for unplanned 30-day readmission to any hospital included burn of lower limbs (odds ratio [OR] 1.29, [1.21-1.37], P < .01), third degree burns (OR 1.31, [1.22-1.41], P < .01), Charlson Comorbidity Index ≥2 (OR 1.48, [1.37-1.60], P < .01), depression (OR 1.30, [1.19-1.41], P < .01), and psychoses (OR 1.53, [1.40-1.67], P < .01). Risk factors unique to readmission to a different hospital included: length of stay greater than 7 days (OR 2.07, [1.78-2.40], P < 0.01), and initial admission to a metropolitan teaching hospital (OR 1.50, [1.26-1.78], P < .01). Previously unreported, one in three burn readmissions nationally occur at a different hospital, have unique risk factors, and are costlier. Current hospital benchmarking underestimates readmission by failing to capture this unique subpopulation.

Mechanical ventilation after general surgery is associated with worse outcomes, prolonged hospital stay, and increased health care cost. Postoperatively, patients admitted to the intensive care unit (ICU) may be categorized into 1 of 3 groups: extubated patients (EXT), patients with objective medical indications to remain ventilated (MED), and patients not meeting these criteria, called "discretional postoperative mechanical ventilation" (DPMV). The objectives of this study were to determine the incidence of DPMV in general surgery patients and identify the associated operative factors.At a large, tertiary medical center, we reviewed all surgical cases performed under general anesthesia from April 1, 2008 to February 28, 2015 and admitted to the ICU postoperatively. Patients were categorized into 1 of 3 cohorts: EXT, MED, or DPMV. Operative factors related to the American Society of Anesthesiologists Physical Status (ASA PS), duration of surgery, surgery end time, difficult airway management, intraoperative blood and fluid administration, vasopressor infusions, intraoperative arterial blood gasses, and ventilation data were collected. Additionally, anesthesia records were reviewed for notes indicating a reason or rationale for postoperative ventilation. Categorical variables were compared by χ test, and continuous variables by analysis of variance or Kruskal-Wallis H test. Categorical variables are presented as n (%), and continuous variables as mean ± standard deviation or median (interquartile range) as appropriate. Significance level was set at P≤ .05.Sixteen percent of the 3555 patients were categorized as DPMV and 12.2% as MED. Compared to EXT patients, those classified as DPMV had received significantly less fluid (2757 ± 2728 mL vs 3868 ± 1885 mL; P.001), lost less blood during surgery (150 [20-625] mL vs 300 [150-600] mL; P.001), underwent a shorter surgery (199 ± 215 minutes vs 276 ± 143 minutes; P.001), but received more blood products, 900 (600-1800) mL vs 600 (300-900) mL. The DPMV group had more patients with high ASA PS (ASA III-V) than the EXT group: 508 (90.4%) vs 1934 (75.6%); P.001. Emergency surgery (ASA E modifier) was more common in the DPMV group than the EXT group: 145 (25.8%) vs 306 (12%), P.001, respectively. Surgery end after regular working hours was not significantly higher with DPMV status compared to EXT. DPMV cohort had fewer cases with difficult airway when compared to EXT or MED. When compared to MED patients, those classified as DPMV received less fluid (2757 ± 2728 mL vs 4499 ± 2830 mL; P.001), lost less blood (150 [20-625] mL vs 500 [200-1350] mL; P.001), but did not differ in blood products transfused or duration of surgery.In our tertiary medical center, patients often admitted to the ICU on mechanical ventilation without an objective medical indication. When compared to patients admitted to the ICU extubated, those mechanically ventilated but without an objective indication had a higher ASA PS class and were more likely to have an ASA E modifier. A surgery end time after regular working hours or difficult airway management was not associated with higher incidence of DPMV.

Arginine vasopressin (AVP) is often used as an alternative pressor to catecholamines (CATs). However, unlike CATs, AVP is a powerful antidiuretic that could promote edema. We tested the hypothesis that AVP promoted cerebral edema and/or increased requirements for osmotherapy, relative to those who received CATs, for cerebral perfusion pressure (CPP) management after traumatic brain injury (TBI). This is a retrospective review of 286 consecutive TBI patients with intracranial pressure monitoring at a single institution from September 2008 to January 2015. Cerebral edema was quantitated using CT attenuation in prespecified areas of gray and white matter. Results: To maintain CPP >60 mm Hg, 205 patients required no vasopressors, 41 received a single CAT, 12 received AVP, and 28 required both. Those who required no pressors were generally less injured; required less hyperosmolar therapy and less total fluid; and had lower plasma Na, lower intracranial pressure, less edema, and lower mortality (all P < 0.05). Edema; daily mean, minimum, and maximum Na levels; and mortality were similar with AVP versus CATs, but the daily requirement of mannitol and 3 per cent NaCl were reduced by 45 and 35 per cent (both P < 0.05). In patients with TBI who required CPP therapy, AVP reduced the requirements for hyperosmolar therapy and did not delay resolution or increase cerebral edema compared with CATs.

Burn injury results in a severe systemic inflammatory response which is associated with the development of acute respiratory distress syndrome (ARDS), even without associated inhalation injury. Venous-venous extracorporeal membrane oxygenation (VV-ECMO) has been implemented in various cases of ARDS to provide support and allow for protective lung ventilation strategies. We report the case of a 27-year-old man presenting with a 60% total body surface area partial thickness burn who developed refractory ARDS with Murray Score of 3.75. ECMO was initiated on hospital day 9 for a total of 10 days with concurrent lung-protective ventilation. He subsequently recovered and was discharged on hospital day 48. ECMO should be considered as an adjunctive strategy in burn patients without inhalation injury to minimize ventilator-induced lung injury when high levels of support are needed to achieve adequate ventilation in patients with ARDS.

Florida considers the International Classification Injury Severity Score (ICISS) from hospital discharges within a geographic region in the apportionment of trauma centers (TCs). Patients with an ICISS

Background Acute fibrinolysis shutdown is associated with early mortality after trauma; however, no previous studies have investigated the incidence of persistent fibrinolysis or its association with mortality. We tested the hypothesis that persistent fibrinolysis shutdown is associated with mortality in critically ill trauma patients. Study Design Thromboelastography was performed on ICU admission in 181 adult trauma patients and at 1 week in a subset of 78 patients. Fibrinolysis shutdown was defined as LY30 ≤ 0.8% and was considered transient if resolved by 1 week postinjury or persistent if not. Logistic regression adjusted for age, sex, hemodynamics, and Injury Severity Score (ISS). Results Median age was 52 years, 88% were male, and median ISS was 27, with 56% transient fibrinolysis shutdown, 44% persistent fibrinolysis shutdown and 12% mortality. Median LY30 was 0.23% (interquartile range [IQR] 0% to 1.20%) at admission and 0.10% (IQR 0% to 2.05%) at 1 week. Transient shutdown more often occurred after head injury (p = 0.019); persistent shutdown was more often associated with penetrating injury (29% vs 9%; p = 0.020), lower LY30 at ICU admission (0.10% vs 1.15%; p Conclusions Persistent fibrinolysis shutdown is associated with late mortality after trauma. A high index of suspicion should be maintained, especially in patients with penetrating injury, reduced LY30 on admission, and/or receiving blood product transfusion. Judicious use of tranexamic acid is advised in this cohort.

BACKGROUND: Portable noninvasive Heart Rate Complexity (HRC) and Compensatory Reserve Measurement (CRM) monitors have been developed to triage supine combat casualties. Neither monitor has been tested in upright individuals during physical exercise. This study tests the hypothesis that exercise evokes proportional changes in HRC and CRM.METHODS: Two instruments monitored volunteers (9 civilian and 11 soldiers) from the Army Trauma Training Department (ATTD) before, during, and following physical exercise. One recorded heart rate (HR, bpm), cardiac output (CO, L · min−1), heart rate variability (HRV, root mean square of successive differences, ms), and HRC (Sample Entropy, unitless). The other recorded HR, pulse oximetry (Spo2, %), and CRM (%).RESULTS: Baseline HR, CO, HRV, HRC, and CRM averaged 72 ± 1 bpm, 5.6 ± 1.2 L · min−1, 48 ± 24 ms, 1.9 ± 0.5, and 85 ± 10% in seated individuals. Exercise evoked peak HR and CO at > 200% of baseline, while HRC and CRM were simultaneously decreased to minimums that were ≤ 50% of baseline (all P < 0.001). HRV changes were variable and unreliable. Spo2 remained consistently above 95%. During a 60 min recovery, HR and CRM returned to baseline on parallel tracks (t1/2=11 ± 8 and 18 ± 14 min), whereas HRC recovery was slower than either CRM or HR (t1/2=40 ± 18 min, both P < 0.05).DISCUSSION: Exercise evoked qualitatively similar changes in CRM and HRC. CRM recovered incrementally faster than HRC, suggesting that vasodilation, muscle pump, and respiration compensate faster than cardiac autonomic control in young, healthy volunteers. Both HRC and CRM appear to provide reliable, objective, and noninvasive metrics of human performance in upright exercising individuals.Mulder MB, Eidelson SA, Buzzelli MD, Gross KR, Batchinsky AI, Convertino VA, Schulman CI, Namias N, Proctor KG. Exercise-induced changes in compensatory reserve and heart rate complexity. Aerosp Med Hum Perform. 2019; 90(12):1009–1015.

Electrocutions during tree trimming or fruit harvesting are occasionally reported in the public media, but the actual incidence is unknown. Some fruit trees (eg, mango and avocado) can exceed 30 feet, with dense foliage concealing the fruit and overlying power lines so burns associated with harvesting these fruits are often exacerbated with falls. However, there are limited data on this subject. To fill this gap, we provide some of the first information on this unique injury pattern. All electrocutions from 2013 to 2018 were retrospectively reviewed at an ABA-verified burn center. Demographics, injury patterns, and complications were analyzed. Of 97 electrocutions, 22 (23%) were associated with fruit procurement. This population was aged 43 ± 14 years, 95% (n = 21) male, injury severity score of 15 ± 13, and total body surface area burned 4% [1%-9%]. Third-degree burns were present in 36% (n = 8). ICU admission was required in 59% (n = 13) and 39% of the survivors required operative interventions for the burn. Compartment syndrome occurred in 18% (n = 4) and 14% (n = 3) patients required amputations. Falls complicated the care in 50% (n = 11), with associated head, chest, and/or extremity trauma. Mortality was 32% (n = 7), with three patients presenting dead on arrival. All but 3 injuries occurred between June and December, coinciding with mango and avocado season. Electrocution during fruit picking is a seasonal injury often exacerbated by falls. Management is challenging, and favorable outcome depends on recognition of the complexity of the polytrauma.

Objective Over the past 10 years, the BMW Accident Research Program (ARP) has investigated how and why occupants are injured in motor vehicle crashes by reconstructing the crash. This research discusses the 2006-2017 ARP case study methodology and comprehensively describes the cases investigated over the past decade. Methods Accident research program cases are selected according to emerging trends and issues identified by BMW. Driver interviews, inspection approvals, police reports, and medical records are obtained. ARP case investigations involve a multidisciplinary team of engineers, automobile crash experts, and a trauma team. For each case, the team reconstructs the crash and explores in detail the crash characteristics, injury outcomes, as well as case significance and countermeasures that could have prevented the crash or mitigated the severity of the crash or injuries sustained. Results The ARP investigated 476 BMW-involved crashes between 2006 and 2017 in the United States. The majority of the crash investigations involved a frontal crash (55%). The other crash types included rollover (17%), nearside (13%), farside (9%), and rear crashes (5%). Crash characteristics such as roadway departure (26%), fatality (8%), elderly (>65 years old) occupant crashes (7%), crashes preceded by a medical event (4%), and crashes preceded by the driver falling asleep at the wheel (4%) are particularly informative in regards to advanced driver assistance systems (ADAS) role. The distribution of Maximum Abbreviated Injury Scale (MAIS) scores for the occupants were AIS 1 (23%), AIS 2 (33%), AIS 3 (10%), AIS 4 (4%), and AIS 5 + (7%); 16% of crashes involved uninjured occupants and 7% included no injury information. Conclusions In-depth case reviews of moderate and severe crashes remain vital to determine emerging trends, patterns of crash injury, and analysis of driver assistance systems and other factors with potential to prevent the crash or limit severity.

Background: Blood transfusion is a known risk factor for infection in trauma patients. Differences based on mechanism of injury have not been well described. We hypothesize that infection risk in trauma patients with early blood transfusion is different based on blunt or penetrating mechanism of injury. Patients and Methods: Adults admitted to the trauma intensive care unit from January 2010 through January 2015 were reviewed retrospectively. Those receiving transfusion after 24 h were excluded. Infections were defined as positive bronchoalveolar lavage, blood, urine, wound, or abdominal cultures. Logistic regression identified independent predictors of infection. Significance was considered at p ≤ 0.05. Results: With blunt trauma (n = 625), the transfusion rate was 36% (n = 223), with 30% (n = 186) infections. Those with an infection were more severely injured, had a higher operation rate, lower Glasgow Coma Score (GCS), longer hospital stay, and higher transfusion rate (all p

The objective of this study was to re-evaluate and simplify the Greenfield risk assessment profile (RAP) for venous thromboembolism (VTE) in trauma using information readily available at the bedside.Retrospective review of 1233 consecutive admissions to the trauma intensive care unit from August 2011-January 2015. Univariate analyses were performed to determine which RAP risk factors were significant contributors to VTE. Multivariable logistic regression was used to develop models for risk stratification. All results were considered statistically significant at P ≤ 0.05.The study population was as follows: age 44 ± 19, 75% male, 72% blunt, injury severity score 21 ± 13, RAP score 9 ± 5, and 8% mortality. Groups were separated into +VTE (n = 104) and -VTE (n = 1129). They were similar in age, gender, mechanism, and mortality, but injury severity and RAP scores were higher in the +VTE group (all P 0.0001). The +VTE group had more transfusions and longer time to prophylaxis (all P 0.05). Receiving four or more transfusions in the first 24 h (odds ratio [OR], 2.60; 95% confidence interval [CI], 1.64-4.13), Glasgow coma score8 for4 h (OR, 2.13; 95% CI, 1.28-3.54), pelvic fracture (OR, 2.26; 95% CI, 1.44-3.57), age 40-59 y (OR, 1.70; 95% CI, 1.10-2.63), and2-h operation (OR, 1.80; 95% CI, 1.14-2.85) predicted VTE with an area under the receiver operator curve of 0.729, which was comparable with 0.740 for the RAP score alone.VTE risk in trauma can be easily assessed using only five risk factors, which are all readily available at the bedside (transfusion, Glasgow coma scale, pelvic fracture, prolonged operation, and age). This simplified model provides similar predictive ability to the more complicated RAP score. Prospective validation of a simplified risk assessment score is warranted.

Whole body vibration (WBV) has been shown to improve strength in extremities with healed burn wounds. We hypothesize that WBV reduces pain during rehabilitation compared to standard therapy alone. Patients with ≥1% TBSA burn to one or more extremities from October 2014 to December 2015 were randomized to vibration (VIBE) or control. Each burned extremity was tested separately within the assigned group. Patients underwent one to three therapy sessions (S1, S2, S3) consisting of five upper and/or lower extremity exercises with or without WBV. Pain was assessed pre-, mid-, and postsession on a scale of 1 to 10. Mean pain scores at S1 to S3 were compared between groups with paired samples t-tests. An independent t-test was used to compare differences in pain scores between groups. Continuous variables were compared using a t-test or Mann-Whitney U test, and categorical variables were compared using a χ or Fisher's exact test, as appropriate. Forty-eight randomized test extremities (VIBE = 26, control = 22) were analyzed from a total of 31 subjects. There were no significant differences between groups in age, gender, overall TBSA, TBSA in the test extremity, pain medication use before therapy session, or skin grafting before therapy session. At S1, S2, and S3, there was a statistically significant decrease in mid- and postsession pain compared to presession pain in VIBE vs controls. Exposure to WBV decreased pain during and after physical therapy. This modality may be applicable to a variety of soft tissue injuries and warrants additional investigation.

Although firearms account for less than 5 % of all pediatric injuries, they have the highest associated case fatality rate.The registry at a Level-1 trauma center was used to identify firearm injuries (18 years of age) from 1991 to 2011. Descriptive statistics and risk-adjusted multivariate analyses (MVA) were performed.Overall, 1085 patients were identified. Immediate operations were performed in 33 % (n = 358) of patients with most having abdominal surgery (n = 214). Survival was 86 %, but higher for African Americans (OR = 1.92) than for Hispanics (p = 0.006). African Americans were more likely to sustain extremity (OR = 2.26) and less head (OR = 0.36) injuries than Hispanics (p 0.001). Analysis by injury location showed that head (OR = 14.1) had the highest associated mortality. Other significant predictors included multiple major injury (defined by Abbreviated Injury Scale) with central nervous system involvement (OR = 7.30) and single injuries to the chest (OR = 2.68). These findings were compared to abdominal injuries as the baseline (p 0.02). MVA demonstrated that Caucasian children had higher mortality (OR = 6.12) vs. Hispanics (p = 0.031). Children admitted with initial pH ≤ 7.15 (OR = 14.8), initial hematocrit ≤30 (OR = 3.24), or Injury Severity Score (ISS) 15 (OR = 1.08) had higher mortality rates (p 0.05).Independent significant indicators of mortality include low initial pH or hematocrit, Caucasian race, high ISS, and those who sustain head injuries.

For logistic reasons, a bolus of 6% hydroxyethyl starch (HES 450/0.7 in lactated electrolyte injection) is recommended for battlefield resuscitation even though it has risks of mortality and acute kidney injury (AKI) in certain patient populations. The purpose of this study was to test the hypothesis that victims of penetrating trauma have no increased risks of AKI and/or death when receiving a single bolus of HES during initial fluid resuscitation.816 consecutive admissions with penetrating trauma were reviewed. Patients who died within 24 hours were excluded. Propensity scores and a 1:1 fixed ratio nearest neighbor matching were used to compare those who received HES to those who did not. Data were expressed as mean ± SD and significance was assessed at p0.05.The cohort was 88% male, age 35 ± 14 years, injury severity score of 10 ± 10, with a 3.8% rate of AKI, and 3.2% rate of mortality. HES was administered to 121 (14.8%) patients. In HES and no HES propensity matched groups, the rate of AKI was 3.8% vs. 4.8% (p = 0.749) and the 90-day mortality rate was 3.8% vs. 4.8% (p = 0.749).An increased risk of mortality or AKI was not observed in penetrating trauma patients who were resuscitated with low volume HES.

A previous study demonstrated basic proof of principle of the value of a miniature wireless vital signs monitor (MWVSM, MiniMedic, Athena GTX, Des Moines, Iowa) for battlefield triage However, there were unanswered questions related to sensor reliability and uncontrolled conditions in the prehospital environment. This study determined whether MWVSM sensors track vital signs and allow for appropriate triage compared to a gold standard bedside monitor in trauma patients. This was a prospective study in 59 trauma intensive care unit patients. Systolic blood pressure, temperature, heart rate (HR), skin temperature, and pulse oximetry (SpO2) were displayed on a bedside monitor for 60 minutes. Shock index (SI) was calculated. A separate MWVSM monitor was attached to the forehead and finger of each patient. Data from each included pulse wave transit time (PWTT), temperature, HR, SpO2, and a summary status termed "Murphy Factor" (MF), which ranges from 0 to 5. Patients are classified as "routine" if MF = 0 to 1 or SI = 0 to 0.7, "priority" if MF = 2 to 3 or SI = 0.7 to 0.9, and "critical" if MF = 4 to 5 or SI ≥ 0.9. Forehead and finger MWVSM HRs both differed from the monitor (both p0.001), but the few beats per minute differences were clinically insignificant. Differences in MWVSM SpO2 (1-7%) and temperature (6-13°F) from the monitor were site specific (all p0.001). Forehead PWTT (271 ± 50 ms) was less (p0.001) than finger PWTT (315 ± 42 ms); both were dissociated from systolic blood pressure (r(2)0.05). The SI distributed patients about equally as "routine," "priority," and "critical," whereas MF overtriaged to "routine" and undertriaged to "critical" for both sensors (all p0.001). Our findings suggest that MF does not accurately predict the most critical patients, likely because erroneous PWTT values confound MF calculations. MF and the MWVSM are promising, but require fine-tuning before deployment.

Objective: Some drivers involved in motor vehicle crashes across the United States may be identified as at risk of subsequent injury by a similar mechanism. The purpose of this study was to perform a national review of the risk factors for hospitalization for a new injury due to a subsequent motor vehicle crash. It was hypothesized that presenting to a different hospital after subsequent injury would result in worse patient outcomes when compared to presentation at the same hospital. Methods: The Nationwide Readmissions Database for 2010–2014 was queried for all inpatient hospitalizations with injury related to motor vehicle traffic. The primary patient outcome of interest was subsequent motor vehicle crash–related injury within 1 year. The secondary patient outcomes were different hospital subsequent injury presentation, higher Injury Severity Score (ISS), longer length of stay (LOS), and in-hospital death after subsequent injury. The analysis of secondary patient outcomes was performed only on patients who were reinjured. Univariable analysis was performed for each outcome using all variables during the index admission. Multivariable logistic regression was performed using all significant (P < .05) variables on univariate analysis. Results were weighted for national estimates. Results: During the study period, 1,008,991 patients were admitted for motor vehicle–related injury; 12,474 patients (1.2%) suffered a subsequent injury within 1 year. From the reinjured patients, 32.9% presented to a different hospital, 48.9% had a higher ISS, and 22.1% had a longer LOS. The in-hospital mortality rate after subsequent injury was 1.1%. Presentation to a different hospital for subsequent injury was associated with a longer LOS (odds ratio [OR] = 1.32; 95% confidence interval [CI], 1.20–1.45; P < .01) and a higher ISS (OR = 1.38; 95% CI, 1.27–1.49; P < .01). Motorcyclists were more likely to suffer subsequent injury (OR = 1.39; 95% CI, 1.32–1.46; P < .01) and motorcycle passengers were more likely to present to a different hospital with a subsequent injury (OR = 2.49; 95% CI, 1.73–3.59; P < .01). Alcohol abuse was associated with subsequent injury (OR = 1.12; 95% CI, 1.07–1.18; P < .01). Conclusions: Nearly a third of patients suffering subsequent motor vehicle crash–related injury after an initial motor vehicle crash in the United States present to a different hospital. These patients are more likely to suffer more severe injuries and longer hospitalizations due to their subsequent injury. Future efforts to prevent these injuries must consider the impact of this fragmentation of care and the implications for quality and cost improvements.

Hypertrophic scarring is a fibroproliferative process that occurs following a third-degree dermal burn injury, producing significant morbidity due to persistent pain, itching, cosmetic disfigurement, and loss of function due to contractures. Ablative fractional lasers have emerged clinically as a fundamental or standard therapeutic modality for hypertrophic burn scars. Yet the examination of their histopathological and biochemical mechanisms of tissue remodeling and comparison among different laser types has been lacking. In addition, deficiency of a relevant animal model limits our ability to gain a better understanding of hypertrophic scar pathophysiology. To evaluate the effect of ablative fractional lasers on hypertrophic third-degree burn scars, we have developed an in vivo Red Duroc porcine model. Third-degree burn wounds were created on the backs of animals, and burn scars were allowed to develop for 70 days before treatment. Scars received treatment with either CO2 or erbium: yttrium aluminum garnet (YAG) ablative fractional lasers. Here, we describe the effect of both lasers on hypertrophic third-degree burn scars in Red Duroc pigs. In this report, we found that Er:YAG has improved outcomes versus fractional CO2. Molecular changes noted in the areas of dermal remodeling indicated that matrix metalloproteinase 2, matrix metalloproteinase 9, and Decorin may play a role in this dermal remodeling and account for the enhanced effect of the Er:YAG laser. We have demonstrated that ablative fractional laser treatment of burn scars can lead to favorable clinical, histological, and molecular changes. This study provides support that hypertrophic third-degree burn scars can be modified by fractional laser treatment.

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

Introduction: A recent report published by the American Society of Anesthesiologists (ASA) task force on central venous access suggests the use of real time ultrasound for placing central venous lines. As in our center there is no ultrasound device specific for this purpose, a decision to test the hypothesis whether anatomic landmark for central venous catheterization is effective in experienced hands was made. Methods: A retrospective review of a prospectively collected database was performed for the period January 2002 to June 2013. Five hundred fifty patients underwent long-term central venous catheter placement. All procedures were performed by experienced (>50 placements) surgeons utilizing standard techniques. Results: Males slightly predominated, corresponding to 51.3% (n=282) of the total population. The most frequent cannulated vein was the subclavian vein (n=451/82%). The Right Subclavian Vein (RSV) was the first choice for catheterization (n=410/74.5%). 83.5% (n=459) of the punctures were successful on the first attempt. Complications included arterial puncture (n=36/6.5%), hematoma (n=16/2.9%) and pneumothorax (n=4/0.7%). Ultrasound was used in selective high-risk cases (7.3%). Conclusion: The data suggests that with proper skill and experience, landmark anatomic position is effective for central venous catheterization, however ultrasound is helpful in specific difficult cases.

This disaster complexity case study examines Spain's deadliest train derailment that occurred on July 24, 2013 on the outskirts of Santiago de Compostela, Galicia, Spain. Train derailments are typically survivable. However, in this case, human error was a primary factor as the train driver powered the Alvia train into a left curve at more than twice the posted speed. All 13 cars came off the rails with many of the carriages careening into a concrete barrier lining the curve, leading to exceptional mortality and injury. Among the 224 train occupants, 80 (36%) were killed and all of the remaining 144 (4%) were injured. The official investigative report determined that this crash was completely preventable.

Venous duplex ultrasound (VDU) is the modality of choice for surveillance of venous thromboembolism (VTE), but there is controversy about its appropriate implementation as a screening method. We hypothesize that VDU surveillance in trauma patients at high risk for VTE decreases the rate of pulmonary embolism (PE).One thousand two hundred and eighty-two trauma ICU admissions were screened with Greenfield's Risk Assessment Profile from August 2011 to September 2014. Four hundred and two patients were identified as high risk for VTE (Risk Assessment Profile ≥10). Those who received weekly VDU to evaluate for deep vein thrombosis (n = 259 [64%]) were compared with those who did not (n = 143 [36%]). Parametric data are reported as mean ± SD and nonparametric data are reported as median (interquartile range). Statistical significance was determined at an α level of 0.05.The overall study population was 47 ± 19 years old and 75% were male, 78% of injuries were blunt mechanism, Injury Severity Score was 28 ± 13, Risk Assessment Profile was 14 ± 4, and mortality was 14.3%. Deep vein thrombosis rate was 11.6% (n = 30) in the surveillance group vs 2.1% (n = 3) in the non-surveillance group (p0.001). Deep vein thromboses detected in the surveillance group were managed with systemic anticoagulation (43%) or with IVC filter placement (57%). In the surveillance group, the PE rate was 1.9% (n = 5) vs 7.0% (n = 10) in the non-surveillance group (p = 0.014).Trauma patients at high risk for VTE and who received VDU surveillance and early management of deep vein thrombosis have decreased rates of pulmonary embolism.

Obesity negatively affects outcomes after trauma and surgery; results after burns are more limited and controversial. The purpose of this study was to determine the effect of obesity on clinical and economic outcomes after thermal injury.The National Inpatient Sample was queried for adults from 2005-2009 with International Classification of Diseases-9 codes for burn injury. Demographics and clinical outcomes of obese and nonobese cohorts were compared. Univariate and multivariate analysis using logistic regression models were performed. Data are expressed as median (interquartile range) or mean ± standard deviation and compared at P 0.05.In 14,602 patients, 3.3% were obese (body mass index ≥30 kg/m(2)). The rate of obesity increased significantly by year (P0.001). Univariate analysis revealed significant differences between obese and nonobese patients in incidence of wound infection (7.2% versus 5.0%), urinary tract infection (7.2% versus 4.6%), deep vein thrombosis in total body surface area (TBSA) ≥10% (3.1% versus 1.1%), pulmonary embolism in TBSA ≥10% (2.3% versus 0.6%), length of stay [6 d (8) versus 5 d (9)], and hospital costs ($10,122.12 [$18,074.72] versus $7892.07 [$17,191.96]) (all P 0.05). Death occurred less frequently in the obese group (1.9% versus 4%, P = 0.021). Significant predictors of grouped adverse events (urinary tract infection, wound infection, deep vein thrombosis, and pulmonary embolism) on multivariate analysis include obesity, TBSA ≥20%, age, and black race (all P ≤ 0.05).Obesity is an independent predictor of adverse events after burn injury; however, obesity is associated with decreased mortality. Our findings highlight the potential clinical and economic impact of the obesity epidemic on burn patients nationwide.

The aim of this study was to examine the impact of a telemedical robot on trauma intensive care unit (TICU) clinician teamwork (i.e., team attitudes, behaviors, and cognitions) during patient rounds.Thirty-two healthcare providers who conduct rounds volunteered to take surveys assessing teamwork attitudes and cognitions at three time periods: (1) the onset of the study, (2) the end of the 30-day control period, and (3) the end of the 30-day experimental period, which immediately followed the control period. Rounds were recorded throughout the 30-day control period and 30-day experimental period to observe provider behaviors. For the initial 30 days, there was no access to telemedicine. For the final 30 days, the rounding healthcare providers had access to the RP-7 robot (Intouch Health Inc., Santa Barbara, CA), a telemedical tool that can facilitate patient rounds conducted away from bedside.Using a one-tailed, one-way repeated-measures analysis of variance (ANOVA) to compare trust at Times 1, 2, and 3, there was no significant effect on trust: F(2, 14)=1.20, p=0.16. When a one-tailed, one-way repeated-measures ANOVA to compare transactive memory systems (TMS) at Times 1, 2, and 3 was conducted, there was no significant effect on TMS: F(2, 15)=1.33, p=0.15. We conducted a one-tailed, one-way repeated-measures ANOVA to compare team psychological safety at Times 1, 2, and 3, and there was no significant effect on team psychological safety: F(2,15)=1.53, p=0.12. There was a significant difference in communication between rounds with and without telemedicine [t(25)=-1.76, p0.05], such that there was more task-based communication during telerounds. Telemedicine increased task-based communication and did not negatively impact team trust, psychological safety, or TMS during rounds.Telemedicine may offer advantages for some teamwork competencies without sacrificing the efficacy of others and may be adopted by intact rounding teams without hindering teamwork.

We test the hypothesis that prehospital interventions (PHIs) performed by skilled emergency medical service providers during ground or air transport adversely affect outcome in severely injured trauma patients.Consecutive trauma activations (March 2012 to June 2013) transported from the scene by air or ground emergency medical service providers were reviewed. PHI was defined as intubation, needle decompression, tourniquet, cricothyroidotomy, or advanced cardiac life support.In 3,733 consecutive trauma activations (71% blunt, 25% penetrating, 4% burns), age was 39 years, 74% were male, Injury Severity Score (ISS) was 5, and Glasgow Coma Score (GCS) was 15, with 32% traumatic brain injury (TBI) and 7% overall mortality. Those who received PHI (n = 130, 3.5% of the trauma activations) were more severely injured: ISS (26 vs. 5), GCS (3 vs. 15), TBI (57% vs. 31%), Revised Trauma Score (RTS, 5.45 vs. 7.84), Trauma and Injury Severity Score (TRISS, 1.32 vs. 4.89), and mortality (56% vs. 5%) were different (all p0.05) than those who received no PHI. Air crews transported 22% of the patients; more had TBI, blunt injury, high ISS, and long prehospital times (all p0.05), but mortality was similar to those transported by ground. In the most severely injured patients with signs of life who received a PHI, the ISS, prehospital times, and proportions of TBI, blunt trauma, and air transport were similar, but mortality was significantly lower (43% vs. 23%, p= 0.021).In our urban trauma system, PHIs are associated with a lower incidence of mortality in severely injured trauma patients and do not delay transport to definitive care.Prognostic/epidemiologic study, level III; therapeutic study, level IV.

We hypothesize there are coagulation profile changes associated both with initiation of thromboporphylaxis (TPX) and with change in platelet levels in trauma patients at high-risk for venous thromboembolism (VTE). A total of 1203 trauma intensive care unit patients were screened with a VTE risk assessment profile. In all, 302 high-risk patients (risk assessment profile score ≥ 10) were consented for weekly thromboelastography. TPX was initiated between initial and follow-up thromboelastography. Seventy-four patients were analyzed. Upon admission, 87 per cent were hypercoagulable, and 81 per cent remained hypercoagulable by Day 7 ( P = 0.504). TPX was initiated 3.4 ± 1.4 days after admission; 68 per cent received unfractionated heparin and 32 per cent received low-molecular-weight heparin. The VTE rate was 18 per cent, length of stay 38 (25–37) days, and mortality of 17.6 per cent. In all, 76 per cent had a rapid clotting time at admission versus 39 per cent at Day 7 ( P < 0.001); correcting from 7.75 (6.45–8.90) minutes to 10.45 (7.90–15.25) minutes ( P < 0.001). At admission, 41 per cent had an elevated maximum clot formation (MCF) and 85 per cent had at Day 7 ( P < 0.001); increasing from 61(55–65) mm to 75(69–80) mm ( P < 0.001). Platelets positively correlated with MCF at admission (r = 0.308, R2 = 0.095, P = 0.008) and at Day 7 (r = 0.516, R2 = 0.266, P < 0.001). Change in platelet levels correlated with change in MCF (r = 0.332, R2 = 0.110, P = 0.005). In conclusion, hypercoagulability persists despite the use of TPX. Although clotting time normalizes, MCF increases in correlation with platelet levels. As platelet function is a dominant contributor to sustained trauma-evoked hypercoagulability, antiplatelet therapy may be indicated in the management of severely injured trauma patients.

BACKGROUND There are many benefits of repair over ligation of major venous injuries (MVIs) following penetrating trauma, but the risk of pulmonary embolism (PE) is not well defined. We hypothesized that rates of PE are comparable between repair and ligation of MVI. METHODS All penetrating trauma patients with MVI requiring an operation from 2003 to 2012 (n = 158) were retrospectively reviewed. Propensity scores were based on a logistic regression model using patient and injury characteristics. A 1:1 fixed ratio nearest neighbor matching was performed to compare outcomes of the repair and ligation cohorts. Data are reported as mean ± SD if parametric, or median (interquartile range) if not, and compared using a t test, Mann-Whitney U-test, χ2, or Fisher's exact test, as appropriate. RESULTS The population was 89% male, age 32 ± 12 years, 74% gunshot wound, Injury Severity Score of 19 ± 13, length of stay of 9 (18) days, 3.8% PE, and a mortality of 21.5%. Repair was performed in 37% (n = 59), ligation was performed in 60% (n = 94), and 3% required both. With ligation versus repair, ligation patients were generally more critically injured; 48-hour survival was 78% versus 93% (p = 0.0083), initial Glasgow Coma Scale (GCS) score was 12 ± 5 versus 14 ± 3 (p = 0.003), initial base excess was -9 ± 8 versus -5 ± 5 mEq/L (p = 0.003), more packed red blood cells were transfused (12 (14) U vs. 9 (12) U; p = 0.032), and major arterial injury was more likely (86% vs. 42%, p < 0.001), but the PE rate was identical (5.9%) in propensity-matched cohorts. In those who developed a PE, all were receiving standard thromboprophylaxis. CONCLUSION Following penetrating trauma, the risk of PE between repair and ligation of MVI is comparable. LEVEL OF EVIDENCE Epidemiologic study, level III.

The association between tranexamic acid (TXA) and fibrinolysis shutdown is unknown. We hypothesize that TXA is associated with fibrinolysis shutdown in critically injured trauma patients.Two hundred eighteen critically injured adults admitted to the intensive care unit at an urban Level I trauma center from August 2011 to January 2015 who had thromboelastography performed upon intensive care unit admission were reviewed. Groups were stratified based on fibrinolysis shutdown, which was defined as LY30 of 0.8% or less. Continuous variables were expressed as mean ± standard deviation or median (interquartile range). Poisson regression analysis was used to determine predictors of shutdown.Patients were age 46 ± 18 years, 81% male, 75% blunt trauma, Injury Severity Score of 28 ± 13, 16% received TXA, 64% developed fibrinolysis shutdown, and mortality was 15%. In the first 24 hours, 4 (2-9) units packed red blood cells and 2 (0-6) units fresh frozen plasma were administered. Those with shutdown had worse initial systolic blood pressure (114 ± 38 mm Hg vs. 129 ± 43 mm Hg, p = 0.006) and base deficit (-5 ± 6 mEq/L vs -3 ± 5 mEq/L, p = 0.013); received more packed red blood cells [6 (2-11) vs. 2 (1-5) units, p0.0001], and fresh frozen plasma [3 (0-8) vs. 0 (0-4) units, p0.0001]; and more often received TXA (23% vs. 4%, p0.0001). After controlling for confounders, TXA (relative risk, 1.35; 95% confidence interval, 1.10-1.64; p = 0.004) and cryoprecipitate transfusion (relative risk, 1.29; 95% confidence interval, 1.07-1.56; p = 0.007) were independently associated with fibrinolysis shutdown.Patients who received TXA were at increased risk of fibrinolysis shutdown compared with patients who did not receive TXA. We recommend that administration of TXA be limited to severely injured patients with evidence of hyperfibrinolysis and recommend caution in those with evidence of fibrinolysis shutdown.Therapeutic, level III.

No previous studies have established the optimal antifactor Xa (anti-Xa) level to guide thromboprophylaxis (TPX) dosing with enoxaparin in trauma patients. We hypothesize that achieving 0.2-0.4 IU/mL anti-Xa will decrease venous thromboembolism (VTE) rates after trauma.This was a retrospective review of 194 intensive care unit patients sustaining blunt or penetrating trauma from January 2015 to March 2017. All received initial enoxaparin (30 mg BID subcutaneous) and mechanical devices for TPX. Peak anti-Xa levels were drawn after each third dose. The enoxaparin dose was adjusted up to a maximum of 60 mg BID subcutaneous until a peak level of 0.2-0.4 IU/mL was achieved. Data are expressed as mean ± SD if parametric or median (IQR) if not.The Greenfield Risk Assessment Profile score was 9 ± 4, Injury Severity Score 23 ± 14, and hospital length of stay 19 (11-38) days. The overall VTE rate was 7.2% (n = 14), with 10 deep venous thromboses (DVT) and 5 pulmonary emboli (PE). One patient had both a DVT and PE. The median time to VTE diagnosis was 14 (7-17) days. In those diagnosed with a VTE, 50.0% (n = 7) never reached 0.2-0.4 IU/mL anti-Xa and 42.8% (n = 6) were diagnosed with a VTE after achieving these levels. Prophylactic levels were achieved initially in 64 (33.0%) patients, and achieved later in 38 (19.6%) additional patients, giving an overall prophylactic rate of 52.6% (n = 102). There were no differences in VTE (6.9% vs. 7.6%, p = 0.841), DVT (3.9% vs. 6.5%, p = 0.413), or PE (3.9% vs. 1.1%, p = 0.213) rates between those who became prophylactic and those who did not.There was no difference in VTE incidence between those achieving anti-Xa peak levels of 0.2-0.4 IU/mL and those who did not. Furthermore, these levels were never achieved in some trauma patients despite repeated dosing over a10-day period.Therapeutic study, level IV.

Normal saline (NS) is not used for trauma resuscitation because of its potential for acidosis. Lactated Ringer's (LR) is preferred instead. However, the two crystalloids have never been compared in trauma patients. We hypothesized that NS would be an acceptable fluid for resuscitation in the trauma patient. In 2011, a Level I trauma center switched resuscitation fluid from LR to NS. Admissions before and after the change were retrospectively reviewed. Demographics, vitals, blood work, and fluid intake were recorded over 24 hours. Acidosis level, stratified by Injury Severity Score (ISS), was compared. Four hundred ten patients were included, 207 in the LR cohort and 203 in the NS. Chloride (LR 105.26 ± 4.75 vs NS 106.48 ± 4.19), base excess (-2.53 ± 3.77 vs -3.28 ± 4.15), pH (7.37 ± 0.08 vs 7.36 ± 0.07), and bicarbonate (22.83 ± 3.45 vs 21.65 ± 5.06) were statistically different but not clinically significant. This was also true when results were stratified by ISS. In addition, there was no difference in the number of blood gases drawn between the groups (584 vs 544, P = nonsignificant). NS resuscitation is a safe, viable alternative to LR in the trauma population studied. Its use carries a potentially substantial cost savings on a national level.

Background Evaluating the cervical spine in the obtunded trauma patient is a subject fraught with controversy. Some authors assert that a negative computed tomography (CT) scan is sufficient. Others argue that CT alone misses occult unstable injuries, and magnetic resonance imaging (MRI) will alter treatment. This study examines the data in an urban, county trauma center to determine if a negative cervical spine CT scan is sufficient to clear the obtunded trauma patient. Methods Records of all consecutive patients admitted to a level 1 trauma center from January 2000 to December 2011 were retrospectively analyzed. Patients directly admitted to the intensive care unit with a Glasgow Coma Scale score ≤13, contemporaneous CT and MRI, and a negative CT reading were included. The results of the cervical spine MRI were analyzed. Results A total of 309 patients had both CT and MRI, 107 (35%) of whom had negative CTs. Mean time between CT and MRI was 16 d. Of those patients, seven (7%) had positive acute traumatic findings on MRI. Findings included ligamentous injury, subluxation, and fracture. However, only two of these patients required surgical intervention. None had unstable injuries. Conclusions In the obtunded trauma patient with a negative cervical spine CT, obtaining an MRI does not appear to significantly alter management, and no unstable injuries were missed on CT scan. This should be taken into consideration given the current efforts at cost-containment in the health care system. It is one of the larger studies published to date.

IntroductionFor trauma triage, the US Army has developed a portable heart rate complexity (HRC) monitor, which estimates cardiac autonomic input and the activity of the hypothalamic-pituitary-adrenal (HPA) axis. We hypothesize that autonomic/HPA stress associated with predeployment training in U.S. Army Forward Surgical Teams will cause changes in HRC.Materials and MethodsA prospective observational study was conducted in 80 soldiers and 10 civilians at the U.S. Army Trauma Training Detachment. Heart rate (HR, b/min), cardiac output (CO, L/min), HR variability (HRV, ms), and HRC (Sample Entropy, unitless), were measured using a portable non-invasive hemodynamic monitor during postural changes, a mass casualty (MASCAL) situational training exercise (STX) using live tissue, a mock trauma (MT) STX using moulaged humans, and/or physical exercise.ResultsBaseline HR, CO, HRV, and HRC averaged 72 ± 11b/min, 5.6 ± 1.2 L/min, 48 ± 24 ms, and 1.9 ± 0.5 (unitless), respectively. Supine to sitting to standing caused minimal changes. Before the MASCAL or MT, HR and CO both increased to ~125% baseline, whereas HRV and HRC both decreased to ~75% baseline. Those values all changed an additional ~5% during the MASCAL, but an additional 10 to 30% during the MT. With physical exercise, HR and CO increased to >200% baseline, while HRV and HRC both decreased to 40 to 60% baseline; these changes were comparable to those caused by the MT. All the changes were P ConclusionsVarious forms of HPA stress during Forward Surgical Team STXs can be objectively quantitated continuously in real time with a portable non-invasive monitor. Differences from resting baseline indicate stress anticipating an impending STX whereas differences between average and peak responses indicate the relative stress between STXs. Monitoring HRC could prove useful to field commanders to rapidly and objectively assess the readiness status of troops during STXs or repeated operational missions. In the future, health care systems and regulatory bodies will likely be held accountable for stress in their trainees and/or obliged to develop wellness options and standardize efforts to ameliorate burnout, so HRC metrics might have a role, as well.

Only one previous case report has described scald burns secondary to hair braiding in pediatric patients. The present case study is the largest to date of scald burns as a result of hair braiding in children and adults. Charts of all 1609 female patients seen at a single burn center from 2008 to 2014 were retrospectively reviewed to identify patients with scald burns attributed to hair braiding. Demographics, injury severity, injury patterns, and complications were analyzed. Twenty-six patients (1.6%) had scald burns secondary to hair braiding with median TBSA 3%. Eighty-five percent of patients were pediatric with median age 8 years. Injury patterns were as follows: back (62%), shoulder (31%), chest (15%), buttocks (15%), abdomen (12%), arms (12%), neck (12%), and legs (4%). No patients required operative intervention. Three patients were admitted to the hospital. Two patients required time off from school for 6 and 10 days post burn for recovery. Complications included functional limitations (n = 2), hypertrophic scarring (n = 1), cellulitis requiring antibiotics (n = 1), and anxiety requiring medical/psychological therapy (n = 2). This peculiar mechanism of injury not only carries inherent morbidity that includes the risks of functional limitations, infection, and psychological repercussions but also increases usage of resources through hospital admissions and multiple clinic visits. Further work in the form of targeted outreach programs is necessary to educate the community regarding this preventable mechanism of injury.

BACKGROUND: Pediatric gunshot wounds remain an important cause of morbidity and mortality in the United States. Recent experience in the urban pediatric population has not been extensively documented. METHODS: A retrospective review of the trauma registry identified all pediatric (age 0-16 y) gunshot wound injuries between October 1991 and August 2011. We evaluated demographic, injury location, disposition, and outcome data. We applied descriptive statistics and χ(2) with significance level set to P ≤ 0.05. RESULTS: We treated 740 patients at our trauma center. Patients tended to be male (82%) and African American (72%), and most frequently were shot in the abdomen, back, or pelvic regions (26%). Patients with head or neck injuries experienced the highest mortality rate (35%), whereas the mortality rate overall was 12.7%. A total of 23% of patients were discharged directly, but 32% required an operation. We grouped data into five equal time periods, demonstrating that after decreasing through the 1990s, pediatric gunshot wounds presenting to our hospital are steadily increasing. CONCLUSIONS: We identified certain demographic and temporal trends regarding pediatric gunshot wounds, and the overall number of injuries appears to be increasing. Language: en

BACKGROUND Hypercoagulability is a homeostatic response to trauma, but relatively little information is available about coagulation changes after burn injury. Therefore, we tested the hypothesis that burn patients are hypercoagulable at admission and/or during recovery. METHODS A prospective observational trial was conducted at an American Burn Association verified Burn Center. Thromboelastography (TEG) was performed on blood drawn from indwelling catheters upon admission and weekly for those who remained hospitalized. Routine and special coagulation tests were performed on stored samples. Data are expressed as median (interquartile range). RESULTS Twenty-four patients (88% male) were enrolled, with a median age of 49 (20) years and a median total body surface area burn of 29% (23%); 21 experienced thermal burns (4 inhalational injuries), and 3 had electrical burns. There were no significant differences in TEG or coagulation assays between patients with thermal versus electrical burn injury, but there were significant differences between men versus women and between those with or without inhalational injury. Sixteen patients had repeat samples 1 week after intensive care unit admission. The repeat TEG was more hypercoagulable (all p < 0.05). Fibrinogen and natural anticoagulation proteins (protein C, protein S, and antithrombin III) were also increased (all p < 0.05). Two patients (8%) developed venous thromboembolism (VTE); TEG reaction time, fibrinogen, and partial thromboplastin time were decreased (all p < 0.05) at admission compared with those with no VTE. All changes occurred despite pharmacologic thromboprophylaxis. There was no significant correlation between TEG and total body surface area or between TEG and fluid balance. CONCLUSION In general, burn patients have normal coagulation parameters at admission but become hypercoagulable during recovery. However, those who are hypercoagulable at admission may have an increased risk of VTE. Additional monitoring and/or thromboprophylaxis may be indicated. LEVEL OF EVIDENCE Epidemiologic/prognostic study, level III.

Chest tube thoracostomies are common surgical procedures, but little is known about how practitioners learn the skill. This study evaluates the frequency with which correctly performed tasks are executed by subjects during chest tube thoracostomies.In this prospective study, we developed a mobile-learning module, containing stepwise multimedia guidance on chest tube insertion. Next, we developed and tested a 14-item checklist, modeled after key skills in the module. Participants, defined as "novice" (fewer than 10 chest tubes placed) or "expert" (10 or more placed), were assigned to either the video or control group. A trained clinician used the checklist to rate participants while they inserted a chest tube on a TraumaMan simulator.University of Miami, Miller School of Medicine, a tertiary care academic institution.Current medical students, residents, and the United States Army Forward Surgical Team members rotating through the institution. One hundred twenty-eight subjects entered and finished the study.One hundred twenty-eight subjects enrolled in the study; 86 (67%) were residents or US Army Forward Surgical Team members, 66 (77%) were novices, and 20 (23%) were experts. Novices most frequently connected the tube to suction (91%), adequately dissected the soft tissue (82%), and scrubbed or anesthetized appropriately (80%). They least frequently completed full finger sweeps (33%), avoided the neurovascular bundle (35%), and performed a controlled pleural puncture (39%). Comparing the novice video group with the novice control group, the video group was more likely to correctly perform a finger sweep (42%, p0.001) and clamp the distal end of the chest tube (42%, p0.001). Of all the steps, experts least frequently completed full finger sweeps (70%) and avoided the neurovascular bundle (75%). Comparing the expert video group with the expert control group, the video group was more likely to correctly perform finger sweeps, the incision, and clamping the distal chest tube (20%, p = not significant).Avoiding the neurovascular bundle, controlled pleural entry, and finger sweeps are most often performed incorrectly among novices. This information can help instructors to emphasize key didactic steps, possibly easing trainees' learning curve.

This study tests the hypothesis that a change in hematocrit (ΔHct) during initial trauma work-up is as reliable as conventional vital signs for detecting bleeding, even with ongoing fluid resuscitation. Consecutive trauma patients admitted to a Level I trauma center receiving two Hct measurements during initial resuscitation between January 2010 and January 2011 were stratified based on estimated blood loss greater than 250 mL (bleeding) or nonbleeding. Sensitivity, specificity, and receiver operating characteristic curves were calculated for systolic blood pressure (SBP), heart rate, base deficit, and ΔHct. In 168 (72%) nonbleeding versus 64 (28%) bleeding patients, age and gender were similar. Arrival SBP was highly specific (90 to 99%) but poorly sensitive (13 to 31%) for detecting bleeding. Combinations of vital signs increased specificity, albeit at the expense of sensitivity. For bleeding versus nonbleeding patients (all receiving resuscitation fluid), ΔHct was 9.0 versus 1.8, ΔHct/liter was 4.8 versus 1.5, and ΔHct/liter/hour was 2.8 vs 0.6 (all P < 0.001). Only SBP (area under the curve [AUC] 0.608 to 0.695) and ΔHct (AUC 0.731 to 0.921) were significant for identifying bleeding with ΔHct 6 or greater being the best predictor (sensitivity 89%, specificity 95%, AUC 0.921). During ongoing fluid resuscitation of a trauma victim, ΔHct is the single most reliable indicator of continuing blood loss. A ΔHct 6 or greater during initial resuscitation is highly suspicious for ongoing blood loss, but even lesser changes have predictive value. Altogether, these results support the idea that fluid shifts are rapid after hemorrhage and Hct can be valuable during initial trauma assessment.

Trauma during pregnancy is among leading causes of non-pregnancy-related maternal death (MD). This study describes risk factors for MD from trauma during pregnancy in a large urban population.We queried an urban Level One Trauma Center registry for the medical records of pregnant women suffering trauma from 1990 to 2007. Associations were examined between maternal demographics, injury mode details, injury characteristics, and risk of maternal death upon arrival to the emergency room.Overall, 351 patients were identified. Most traumas was caused by motor vehicle collision (71.8 %), accounting for 78.9 % of MD, followed by gun shot wound (10.3 %), stabbing (8.5 %), falls (4.3 %), and assaults (4 %). Abdominal and head injuries were more frequent in cases of MD compared with patients admitted to the hospital (33.3 vs. 25.1 % abdominal, 55.6 vs. 29.4 % head; p0.001). A greater proportion of MDs were characterized by lack of restraint use (66.7 %) compared to women admitted to the hospital (47.7 %) and women discharged after observation (43.1 %); p = 0.014. ER deaths had more negative base excess scores than women who were admitted or discharged (-14 vs. -3 vs. -2; p0.001), lower blood pH values (6.96 vs. 7.40 vs. 7.44; p0.001), greater Injury Severity Scores (ISS) (44.4 vs. 11.49 vs. 2.66; p0.001), and lower Revised Trauma Scores (RTS) (0.5 vs. 7.49 vs. 7.83; p0.001).Lack of restraint use in the pregnant population is associated with increased MD. Although not validated in the pregnant population, the ISS and RTS were associated with maternal mortality outcomes.

Maintaining burn patients' body temperature during surgery is a significant challenge. Although increasing the ambient operating room (OR) temperature and other passive rewarming methods help, such measures have limited effectiveness and prove taxing on OR personnel. Initial studies indicate that an intravascular warming catheter may improve and sustain burn patient body temperatures. The authors hypothesize that the warming catheter is similarly effective at maintaining normothermia despite a lower OR temperature than in a cohort of matched control burn patients. This is a retrospective case-control study involving patients with major burns treated between January 2006 and June 2011. Cases received an intravascular warming catheter, whereas controls receive traditional temperature conserving interventions. As the catheters maintained body temperature, the room temperature was gradually lowered to normal. Twenty-three patients were involved in 31 cases using the catheter, compared with 39 controls in 62 surgeries. The mean temperature deviation for each catheter group was -0.76 ± 1°C and -0.80 ± 0.9°C for the control group. Given 20-minute intervals throughout the operations, the mean patient temperature for cases and controls never deviated by more than 1°C. OR staff satisfaction has improved with decreased room temperatures. An intravenous warming catheter reliably maintained patient core body temperature during surgery. To date, this is the largest cohort study of such a catheter among burn patients. This system may be more effective than current warming techniques, with the potential to decrease the total number of procedures and the time to complete wound closure.

The American Burn Association recommends that patients with toxic epidermal necrolysis-Stevens Johnson syndrome (TEN-SJS) or burn inhalation injuries would benefit from admission or transfer to a burn center (BC). This study examines to what extent those criteria are observed within a regional burn network. Hospital discharge data from 2000 to 2010 was obtained for all hospitals within the South Florida regional burn network. Patients with International Classification of Disease-9th revision discharge diagnoses for TEN-SJS or burn inhalation injury and their triage destination were compared using burn triage referral criteria to determine whether the patients were triaged differently from American Burn Association recommendations. Two hundred ninety-nine TEN-SJS and 131 inhalation injuries were admitted to all South Florida hospitals. Only 25 (8.4%) of TEN-SJS and 27 (21%) of inhalation injuries were admitted to the BC. BC patients had greater length of stay (TEN-SJS 22 vs 10 days; inhalation 13 vs 7) and were more likely to be funded by charity or be self-paid (TEN-SJS 24 vs 9.5%, P = .025; inhalation 44 vs 14%, P < .001), but less likely to hold some form of private or government insurance (TEN-SJS 72 vs 88%, P = .02; inhalation 48 vs 81%, P = .006). TEN-SJS BC patients were more frequently discharged home for self-care (76 vs 50%, P = .006). Non-BC patients were more often discharged to other healthcare facilities (28 vs 0% TEN-SJS, 20 vs 7.4% inhalation). Inappropriate triage may occur in more than 3 out of 4 of the TEN-SJS and inhalation injury patients within our burn network. Unfamiliarity with triage criteria, patient insurance status, and overcoding may play a role. Further studies should fully characterize the problem and implement education or incentives to encourage more appropriate triage.