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

Purpose: Pelvic fracture evaluation with abdominopelvic computed tomography (CT) and formal CT cystography for rule out of urine bladder injury have been commonly employed in pediatric trauma patients. The additional delayed imaging required to obtain optimal CT cystography is, however, associated with increased doses of ionizing radiation to pelvic organs and represent a significant risk in the pediatric population for future carcinogenic risk. We hypothesized that avoidance of routine CT cystography among pediatric pelvic fracture victims would not result in an appreciable rate of missed bladder injuries and would aid in mitigating the radiation exposure risk associated with these additional images. Methods: A retrospective cohort study involving blunt trauma pelvic fractures among pediatric trauma patients (age

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

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

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

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

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

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

BackgroundThe traditional sequence of trauma care: Airway, Breathing, Circulation (ABC) has been practiced for many years. It became the standard of care despite the lack of scientific evidence. We hypothesized that patients in hypovolemic shock would have comparable outcomes with initiation of bleeding treatment (transfusion) prior to intubation (CAB), compared to those patients treated with the traditional ABC sequence.MethodsThis study was sponsored by the American Association for the Surgery of Trauma multicenter trials committee. We performed a retrospective analysis of all patients that presented to trauma centers with presumptive hypovolemic shock indicated by pre-hospital or emergency department hypotension and need for intubation from January 1, 2014 to July 1, 2016. Data collected included demographics, timing of intubation, vital signs before and after intubation, timing of the blood transfusion initiation related to intubation, and outcomes.ResultsFrom 440 patients that met inclusion criteria, 245 (55.7%) received intravenous blood product resuscitation first (CAB), and 195 (44.3%) were intubated before any resuscitation was started (ABC). There was no difference in ISS, mechanism, or comorbidities. Those intubated prior to receiving transfusion had a lower GCS than those with transfusion initiation prior to intubation (ABC: 4, CAB:9, p = 0.005). Although mortality was high in both groups, there was no statistically significant difference (CAB 47% and ABC 50%). In multivariate analysis, initial SBP and initial GCS were the only independent predictors of death.ConclusionThe current study highlights that many traumacenters are already initiating circulation firstprior to intubationwhen treating hypovolemic shock(CAB), even in patients with a low GCS. This practice was not associated with an increased mortality. Further prospective investigation is warranted.Trial registrationIRB approval number: HM20006627. Retrospective trial not registered.

ObjectivesTo perform the first direct comparison of the facial injuries sustained and treatment performed at USA and UK deployed medical treatment facilities (MTFs) in support of the military campaigns in Iraq and Afghanistan.SettingThe US and UK Joint Theatre Trauma Registries were scrutinised for all patients with facial injuries presenting alive to a UK or US deployed MTF between 1 March 2003 and 31 October 2011.ParticipantsUS and UK military personnel, local police, local military and civilians.Primary and secondary outcome measuresAn adjusted multiple logistic regression model was performed using tracheostomy as the primary dependent outcome variable and treatment in a US MTF, US or UK military, mandible fracture and treatment of mandible fracture as independent secondary variables.ResultsFacial injuries were identified in 16 944 casualties, with the most common being those to skin/muscle (64%), bone fractures (36%), inner/middle ear (28%) and intraoral damage (11%). Facial injuries were equally likely to undergo surgery in US MTF as UK MTF (OR: 1.06, 95% CI 0.4603 to 1.142, p=0.6656); however, variations were seen in injury type treated. In US MTF, 692/1452 (48%) of mandible fractures were treated by either open or closed reduction compared with 0/167 (0%) in UK MTF (χ2: 113.6; p≤0.0001). US military casualties who had treatment of their mandible fracture (open reduction and internal fixation or mandibulo-maxillary fixation) were less likely to have had a tracheostomy than those who did not undergo stabilisation of the fractured mandible (OR: 0.61, 95% CI 0.44 to 0.86; p=0.0066).ConclusionsThe capability to surgically treat mandible fractures by open or closed reduction should be considered as an integral component of deployed coalition surgical care in the future.

The battlefield has seen tremendous revolutions in military medical affairs (RMMAs) as a result of the last decade of continuous combat operations. The advances in deployed and en route combat casualty care are categorized as individual RMMAs shown in Table 1. As with prehospital advances, the basis for many of the RMMAs in the deployed hospital care environment as well as en route care was translated from civilian trauma practice but is realistic and relevant to the battlefield context. As the conflict evolved, the substantive data from the battlefield led to many new paradigms of treatment and evacuation. The successful implementation of many of these battlefield practices was then effectively translated back into the civilian injury care environment as has been typical of medical advances developed subsequent to previous conflicts of antiquity. The RMMAs that occurred during the last 10 years of combat casualty care are in the realm of deployed hospital care and en route care and are discussed in detail in this article.

BACKGROUND: The natural history of retained hemothorax (RH), in particular factors contributing to the subsequent development of empyema, is not well known. The intent of our study was to establish the modern incidence of empyema among patients with trauma and RH and identify the independent predictors for development of this complication. METHODS: An American Association for the Surgery of Trauma multicenter prospective observational trial was conducted, enrolling patients with placement of a thoracostomy tube within 24 hours of trauma admission, and subsequent development of RH was confirmed on computed tomography of the chest. Demographics, interventions, and outcomes were analyzed. Logistic regression analysis was used to identify the independent predictors for the development of empyema. RESULTS: Among 328 patients with posttraumatic RH from the 20 participating centers, overall incidence of empyema was 26.8% (n = 88). On regression analysis, the presence of rib fractures (adjusted odds ratio [OR], 2.3; 95% confidence interval [CI], 1.3-4.1; p = 0.006), Injury Severity Score of 25 or higher (adjusted OR, 2.4; 95% CI, 1.3-4.4; p = 0.005), and the need for any additional therapeutic intervention (adjusted OR, 28.8; 95% CI, 6.6-125.5; p < 0.001) were found to be independent predictors for the development of empyema for patients with posttraumatic RH. Patients with empyema also had a significantly longer adjusted intensive care unit stay (adjusted mean difference, 4.1; 95% CI, 1.3-6.9; p = 0.008) and hospital stay (adjusted mean difference, -7.9; 95% CI, -12.7 to -3.2; p = 0.01). CONCLUSION: Among patients with trauma and posttraumatic RH, the incidence of empyema was 26.8%. Independent predictors of empyema development after posttraumatic RH included the presence of rib fractures, Injury Severity Score of 25 or higher, and the need for additional interventions to evacuate retained blood from the thorax. Our findings highlight the need to minimize the risk associated with subsequent thoracic procedures among patients with critical illness and RH, through selection of the most optimal procedure for initial evacuation. LEVEL OF EVIDENCE: Prognostic study, level III.

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

Background Severely injured patients undergoing damage-control laparotomy (DCL) have multiple risk factors for adult respiratory distress syndrome (ARDS), making it challenging to differentiate the contributions of individual causative factors. We aimed to determine the relative contributions of ARDS risk factors. Methods Analysis of the prospectively collected American Association for the Surgery of Trauma Multi-institutional Open Abdomen Database was performed. Inclusion criteria were any patient, 18 years or older, undergoing DCL at 1 of 14 participating Level I trauma centers. Univariable and multivariable Cox regression analyses were performed to determine the association of variables with the development of ARDS during hospitalization. Results A total of 563 patients (78% men; mean [SD] age, 40 [18] years) were identified, of whom 77 developed ARDS (14%). Overall mortality was 23%, with a 39% mortality rate for ARDS patients. Univariable analysis demonstrated that Injury Severity Score (ISS, 1.03; 95% confidence interval [CI], 1.02-1.05), intraoperative (IO) estimated blood loss (hazard ratio [HR], 1.09; 95% CI, 1.04-1.13), IO plasma transfusion (HR, 1.17; 95% CI, 1.10-1.25), 24-hour colloid volume (HR, 1.07; 95% CI, 1.04-1.10), and 24-hour crystalloid volume (HR, 1.01; 95% CI, 1.00-1.01) were associated with the development of ARDS. Cox multivariable analysis demonstrated that ISS, IO plasma transfusions, and total fluid balance through 23 hours all increased the risk of ARDS development. Conclusion Severity of injury, plasma transfusions, and greater fluid administration by 24 hours were independently associated with ARDS development. Judicious use of plasma and other fluids may reduce rates of ARDS in this critically injured population. Level of evidence Prognostic study, level III; therapeutic study, level IV.

The natural history and optimal management of retained hemothorax (RH) after chest tube placement is unknown. The intent of our study was to determine practice patterns used and identify independent predictors of the need for thoracotomy.An American Association for the Surgery of Trauma multicenter prospective observational trial was conducted, enrolling patients with placement of chest tube within 24 hours of trauma admission and RH on subsequent computed tomography of the chest. Demographics, interventions, and outcomes were analyzed. Logistic regression analysis was used to identify the independent predictors of successful intervention for each of the management choices chosen and complications.RH was identified in 328 patients from 20 centers. Video-assisted thoracoscopy (VATS) was the most commonly used initial procedure in 33.5%, but 26.5% required two and 5.4% required three procedures to clear RH or subsequent empyema. Thoracotomy was ultimately required in 20.4%. The strongest independent predictor of successful observation was estimated volume of RH ≤300 cc (odds ratio [OR], 3.7 [2.0-7.0]; p0.001). Independent predictors of successful VATS as definitive treatment were absence of an associated diaphragm injury (OR, 4.7 [1.6-13.7]; p = 0.005), use of periprocedural antibiotics for thoracostomy placement (OR, 3.3 [1.2-9.0]; p = 0.023), and volume of RH ≤900 cc (OR, 3.9 [1.4-13.2]; p = 0.03). No relationship between timing of VATS and success rate was identified. Independent predictors of the need for thoracotomy included diaphragm injury (OR, 4.9 [2.4-9.9]; p0.001), RH900 cc (OR, 3.2 [1.4-7.5]; p = 0.007), and failure to give periprocedural antibiotics for initial chest tube placement (OR 2.3 [1.2-4.6]; p = 0.015). The overall empyema and pneumonia rates for RH patients were 26.8% and 19.5%, respectively.RH in trauma is associated with high rates of empyema and pneumonia. VATS can be performed with high success rates, although optimal timing is unknown. Approximately, 25% of patients require at least two procedures to effectively clear RH or subsequent pleural space infections and 20.4% require thoracotomy.

Background: "Failure to Rescue" is a term applied to clinical issues that, if unrecognized or improperly treated, lead to adverse outcomes. We examined the cognitive components of rescue through the use of a "War Games" simulator format. Our hypothesis was that junior and senior medical students would be less able than interns and residents to detail the actions needed to assess, intervene, and stabilize patients. Methods: Medical students and residents rotating on the trauma and surgical intensive care unit service participated. Twelve scenarios were created to focus on basic floor emergencies. Scores were assigned for clinical actions ordered. The scenarios were validated by two critical care attending physicians, and these scores were used as the expert group. Scores were assigned by two examiners, and the average of the grades in each area was used. The scores are a ratio of actual to possible correct responses in each section, and in the entire exercise. Results: Subjects were divided into third-year medical students (MS3), fourth-year students (MS4), first-year residents (PGY1), residents beyond their first year (PGY2+), and experts. There were 20 subjects and 5 experts (n = 85) in each group for a total of 140 simulated cases examined. On initial evaluation, MS4 and PGY2+ performed significantly worse than expert, and MS3 and PGy1 performed similarly to experts. On secondary evaluation, all groups performed significantly worse than the expert group. In determining the diagnosis, only MS3 differed significantly from the experts. On follow-up, and in total score, all performed significantly worse than the experts. Discussιon: All groups had significant deficits in cognitive performance compared with experts in the areas of secondary evaluation, follow-up of the presenting problem, and total performance in simple clinical scenarios. We must design educational systems that rapidly enhance the cognitive performance of students and residents before they are left to independently diagnose and intervene in life-threatening clinical situations.

A case report of endocarditis after tongue piercing is presented. Body piercing is a form of self-expression that is achieving greater acceptance and wider practice in modern society. Even in healthy individuals, significant health risks exist with this type of physical adornment. Despite this fact, no significant regulatory mechanisms are currently in place to guide practitioners of this craft or to protect the recipients of body piercing. Medical professionals should join the American Dental Association in their opposition of the practice of intraoral/perioral piercing and should call for the development of legislation protecting the recipients of such practices, particularly the population of young people in whom this type of body art is becoming increasingly prevalent.