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Background Life-threatening hemorrhage from extremity injuries can be effectively controlled in the prehospital environment through direct pressure, wound packing, and the use of tourniquets. Early tourniquet application has been prioritized for rapid control of severe extremity hemorrhage and is a cornerstone of prehospital trauma resuscitation guidelines. Emergency physicians must be knowledgeable regarding the initial assessment and appropriate management of patients who present with a prehospital tourniquet in place. Discussion An interdisciplinary group of experts including emergency physicians, trauma surgeons, and tactical and Emergency Medical Services physicians collaborated to develop a stepwise approach to the assessment and removal (discontinuation) of an extremity tourniquet in the emergency department after being placed in the prehospital setting. We have developed a best-practices guideline to serve as a resource to aid the emergency physician in how to safely remove a tourniquet. The guideline contains five steps that include: 1) Determine how long the tourniquet has been in place; 2) Evaluate for contraindications to tourniquet removal; 3) Prepare for tourniquet removal; 4) Release the tourniquet; and 5) Monitor and reassess the patient. Conclusion These steps outlined will help emergency medicine clinicians appropriately evaluate and manage patients presenting with tourniquets in place. Tourniquet removal should be performed in a systematic manner with plans in place to immediately address complications.

To discuss the concerns, motivations, and accomplishments of the law enforcement community with respect to gun violence. To raise awareness of the scope of the problem of gun violence from the law enforcement perspective. Gun violence impacts civilians and the law enforcement community in different ways, with similar outcomes. A multidisciplinary approach of education, legislation, and enforcement may best impact trending US gun violence. The law enforcement community can help to define gun violence as a public health crisis. Working relationships between the police, health care providers, legislators, and community leaders are extremely important in the national conversation about gun violence prevention.

Previously, our group developed the Parkland grading scale for cholecystitis (PGS) to stratify gallbladder (GB) disease severity that can be determined immediately when performing laparoscopic cholecystectomy (LC). In prior studies, PGS demonstrated excellent interrater reliability and was internally validated as an accurate measure of LC outcomes. Here, we compare PGS against a more complex cholecystitis severity score developed by the national trauma society, American Association for the Surgery of Trauma (AAST), which requires clinical, operative, imaging, and pathologic inputs, as a predictor of LC outcomes.Eleven acute care surgeons prospectively graded 179 GBs using PGS and filled out a postoperative questionnaire regarding the difficulty of the surgery. Three independent raters retrospectively graded these GBs using PGS from images stored in the electronic medical record. Three additional surgeons then assigned separate AAST scores to each GB. The intraclass correlation coefficient statistic assessed rater reliability for both PGS and AAST. The PGS score and the median AAST score became predictors in separate linear, logistic, and negative binomial regression models to estimate perioperative outcomes.The average intraclass correlation coefficient of PGS and AAST was 0.8647 and 0.8341, respectively. Parkland grading scale for cholecystitis was found to be a superior predictor of increasing operative difficulty (R, 0.566 vs. 0.202), case length (R, 0.217 vs. 0.037), open conversion rates (area under the curve, 0.904 vs. 0.757), and complication rates (area under the curve, 0.7039 vs. 0.6474) defined as retained stone, small-bowel obstruction, wound infection, or postoperative biliary leak. Parkland grading scale for cholecystitis performed similar to AAST in predicting partial cholecystectomy, readmission, bile leak rates, and length of stay.Both PGS and AAST are accurate predictors of LC outcomes. Parkland grading scale for cholecystitis was found to be a superior predictor of subjective operative difficulty, case length, open conversion rates, and complication rates. Parkland grading scale for cholecystitis has the advantage of being a simpler, operative-based scale which can be scored at a single point in time.Single institution, retrospective review, level IV.

Background The Parkland Grading Scale for Cholecystitis (PGS) was developed as an intraoperative grading scale to stratify gallbladder (GB) disease severity during laparoscopic cholecystectomy (LC). We aimed to prospectively validate this scale as a measure of LC outcomes. Methods Eleven surgeons took pictures of and prospectively graded the initial view of 317 GBs using PGS while performing LC (LIVE) between 9/2016 and 3/2017. Three independent surgeon raters retrospectively graded these saved GB images (STORED). The Intraclass Correlation Coefficient (ICC) statistic assessed rater reliability. Fisher's Exact, Jonckheere-Terpstra, or ANOVA tested association between peri-operative data and gallbladder grade. Results ICC between LIVE and STORED PGS grades demonstrated excellent reliability (ICC = 0.8210). Diagnosis of acute cholecystitis, difficulty of surgery, incidence of partial and open cholecystectomy rates, pre-op WBC, length of operation, and bile leak rates all significantly increased with increasing grade. Conclusions PGS is a highly reliable, simple, operative based scale that can accurately predict outcomes after LC. Table of contents summary The Parkland Grading Scale for Cholecystitis was found to be a reliable and accurate predictor of laparoscopic cholecystectomy outcomes. Diagnosis of acute cholecystitis, surgical difficulty, incidence of partial and open cholecystectomy rates, pre-op WBC, operation length, and bile leak rates all significantly increased with increasing grade.

Introduction Patients who sustain orthopaedic trauma are at an increased risk of venous thromboembolism (VTE), including fatal pulmonary embolism (PE). Current guidelines recommend low-molecular-weight heparin (LMWH) for VTE prophylaxis in orthopaedic trauma patients. However, emerging literature in total joint arthroplasty patients suggests the potential clinical benefits of VTE prophylaxis with aspirin. The primary aim of this trial is to compare aspirin with LMWH as a thromboprophylaxis in fracture patients. Methods and analysis PREVENT CLOT is a multicentre, randomised, pragmatic trial that aims to enrol 12 200 adult patients admitted to 1 of 21 participating centres with an operative extremity fracture, or any pelvis or acetabular fracture. The primary outcome is all-cause mortality. We will evaluate non-inferiority by testing whether the intention-to-treat difference in the probability of dying within 90 days of randomisation between aspirin and LMWH is less than our non-inferiority margin of 0.75%. Secondary efficacy outcomes include cause-specific mortality, non-fatal PE and deep vein thrombosis. Safety outcomes include bleeding complications, wound complications and deep surgical site infections. Ethics and dissemination The PREVENT CLOT trial has been approved by the ethics board at the coordinating centre (Johns Hopkins Bloomberg School of Public Health) and all participating sites. Recruitment began in April 2017 and will continue through 2021. As both study medications are currently in clinical use for VTE prophylaxis for orthopaedic trauma patients, the findings of this trial can be easily adopted into clinical practice. The results of this large, patient-centred pragmatic trial will help guide treatment choices to prevent VTE in fracture patients. Trial registration number NCT02984384.

Importance Trauma is the leading cause of death for US individuals younger than 45 years, and uncontrolled hemorrhage is a major cause of trauma mortality. The US military’s medical advancements in the field of prehospital hemorrhage control have reduced battlefield mortality by 44%. However, despite support from many national health care organizations, no integrated approach to research has been made regarding implementation, epidemiology, education, and logistics of prehospital hemorrhage control by layperson immediate responders in the civilian sector. Objective To create a national research agenda to help guide future work for prehospital hemorrhage control by laypersons. Evidence Review The 2-day, in-person, National Stop the Bleed (STB) Research Consensus Conference was conducted on February 27 to 28, 2019, to identify and achieve consensus on research gaps. Participants included (1) subject matter experts, (2) professional society–designated leaders, (3) representatives from the federal government, and (4) representatives from private foundations. Before the conference, participants were provided a scoping review on layperson prehospital hemorrhage control. A 3-round modified Delphi consensus process was conducted to determine high-priority research questions. The top items, with median rating of 8 or more on a Likert scale of 1 to 9 points, were identified and became part of the national STB research agenda. Findings Forty-five participants attended the conference. In round 1, participants submitted 487 research questions. After deduplication and sorting, 162 questions remained across 5 a priori–defined themes. Two subsequent rounds of rating generated consensus on 113 high-priority, 27 uncertain-priority, and 22 low-priority questions. The final prioritized research agenda included the top 24 questions, including 8 for epidemiology and effectiveness, 4 for materials, 9 for education, 2 for global health, and 1 for health policy. Conclusions and Relevance The National STB Research Consensus Conference identified and prioritized a national research agenda to support laypersons in reducing preventable deaths due to life-threatening hemorrhage. Investigators and funding agencies can use this agenda to guide their future work and funding priorities. Funding Agencies|Gillian Reny Stepping Strong Center for Trauma Innovation; National Center for Disaster Medicine and Public Health

Standard low-molecular-weight heparin dosing may be suboptimal for venous thromboembolism prophylaxis. We aimed to identify independent predictors of subprophylactic Xa (subXa) levels in trauma patients treated under a novel early chemoprophylaxis algorithm.A retrospective analysis of trauma patients from July 2016 to June 2017 who received enoxaparin 40 mg twice daily and had peak Xa levels drawn was performed. Patients were divided into cohorts based on having a subXa (0.2 IU/mL) or prophylactic (≥0.2 IU/mL) Xa level.In all, 124 patients were included, of which 38 (31%) had subXa levels, and 17 (14%) had Xa levels greater than 0.4 IU/mL. Of the subXa cohort, 35 (92%) had their dosage increased, and the repeat Xa testing that was done in 32 revealed that only 75% reached prophylactic levels. The median time to the initiation of chemoprophylaxis was 21.9 hours (interquartile range [IQR], 11.45-35.07 hours). Patients who were defined as having lower risk of having a complication as a result of bleeding had a shorter time to starting prophylaxis than those at higher risk (18.39 hours [IQR 5.76-26.51 hours] vs. 29.5 hours [IQR 16.23-63.07 hours], p0.01).There was no difference in demographics, weight, body mass index, creatinine, creatinine clearance, injury severity score, type of injury, weight-based dose, time to chemoprophylaxis, or bleeding complications between the cohorts. No independent predictors of subXa level were identified on multivariable logistic regression.A significant number of trauma patients fail to achieve prophylactic Xa levels. Intrinsic factors may prevent adequate prophylaxis even with earlier administration and higher dosing of low-molecular-weight heparin.Therapeutic, level IV.

Background The main objective of this study was to compare detection rates of clinically significant thoracolumbar spine (TLS) fracture between computed tomography (CT) imaging of the chest, abdomen, and spine (CT CAP) and CT for the thoracolumbar spine (CT TL). Methods We retrospectively identified patients at our institution with a TLS fracture over a two-year period that had both CT CAP and reformatted CT TL imaging. The sensitivity of CT CAP to identify fracture was calculated for each fracture type. Results A total of 516 TLS fractures were identified in 125 patients using reformatted CT TL spine imaging. Overall, 69 of 512 fractures (13%) were missed on CT CAP that were identified on CT TL. Of those, there were no clinically significant missed fractures. Conclusions CT CAP could potentially be used as a screening tool for clinically significant TLS injuries.

Laparoscopic appendectomy (LA) is the standard of care for the treatment of acute appendicitis. There is an ongoing debate regarding the optimal management of appendicitis, which led us to study outcomes after an appendectomy at a large safety-net hospital. We hypothesize that despite a high-risk population, LA remains a safe and effective treatment for acute appendicitis. A retrospective review was performed of all patients who underwent an appendectomy from 2011 to 2013. The primary end point was significant morbidity defined as a score of three or greater on the Clavien-Dindo scale of surgical morbidity. Thousand hundred and sixty-four patients underwent an appendectomy. A total of 1102 (94.7%) patients underwent either an LA or laparoscopic converted to open appendectomy, and 62 (5.3%) patients underwent an open appendectomy (OA). Two hundred and forty six patients (21.1%) had complicated appendicitis. Laparoscopic converted to OA conversion rate was 4.4 per cent and differed between years (P < 0.001). LA had a significantly shorter length of stay, shorter length of postoperative antibiotics, and less postoperative morbidity. When limited to only patients with complicated appendicitis, major morbidity was still greater in the OA group (22.6 vs 52.0%, P = 0.001). Length of stay was significantly longer in the OA group [3.42 (2.01, 5.97) vs 7.04 (5.05, 10.13), P < 0.001]. Odds for complication were 2.6 times greater in the OA group compared with the LA group. In the absence of peritonitis and systemic illness necessitating urgent laparotomy, patients who are laparoscopic surgical candidates should be offered an LA. Our study demonstrates that these patients have better outcomes and shorter hospital stays.

BACKGROUND The National Center for Statistics and Analysis reports at least eight deaths and 1,160 daily injuries due to distracted driving (DD) in the United States. Drivers younger than 20 years are most likely to incur a distraction-related fatal crash. We aimed to determine short- and long-term impact of a multimodal educational program including student-developed interventions, simulated driving experiences, and presentations by law enforcement and medical personnel. METHODS A single-day program aimed at teen DD prevention was conducted at a high school targeting students aged 15 years to 19 years old. Students were surveyed before, after, and at 6 weeks. We surveyed age, gender, knowledge, and experience regarding DD. Summary statistics were obtained at each survey time point. Bivariate and multivariable analysis were conducted to assess whether change in responses varied over time points. Multivariable models were adjusted for sex and urban and rural driving. RESULTS Preintervention, postintervention, and 6-week follow-up surveys were completed by 359, 272 (76%), and 331 (92%) students, respectively. At baseline and 6-week follow-up, the most frequent passenger-reported DD behaviors were cell phone (63% [63% at follow-up) and radio use (61% [63%]). Similarly, the most frequent driver-reported DD behaviors were cell phone (68% [72%]) and radio use (79% [80%]). When students were asked, "How likely are you to use your cell phone while driving?" they answered "never" 35%, 70%, and 46% on the preintervention, postintervention, and 6-week surveys. They were less likely to report consequences to be worse or change in attitude to a great extent at 6 weeks (p < 0.01). Gender and urban or rural driving were not significantly associated with responses. CONCLUSIONS While DD education may facilitate short-term knowledge and attitude changes, there appears to be no lasting effect. Research should be focused toward strategies for longer-term impact. LEVEL OF EVIDENCE Therapeutic study, level II.

BACKGROUND Injuries sustained by civilians from interaction with police are a polarizing contemporary sociopolitical issue. Few comprehensive studies have been published using national hospital-based data. The aim of this study was to examine the epidemiology of these injuries to better understand this mechanism of injury. METHODS Patients entered into the National Trauma Data Bank (NTDB) (January 2007 to December 2012) with E-codes E970.0 to E976.0 (International Classification of Diseases, Ninth Revision, Clinical Modification), identifying injuries associated with law enforcement in the course of legal action, were enrolled. Patients' demographics, injury characteristics, procedures, and outcomes were collected and analyzed. Patients injured by other civilians (E960.0-E968.0) were used for comparison. RESULTS Of 4,146,428 patients in the NTDB, 7,203 (0.17%) were injured during interaction with police. The numbers of patients in consecutive study years were 858, 1,103, 1,148, 1,274, 1,316, and 1,504. The incidence of these injuries was stable over time (0.17-0.18%) (p = 0.129). Patients had a median age of 31 years (range, 0-108), and 94.3% were male. Median injury severity score was 9 (interquartile range [IQR], 4-17). The most common mechanism of injury was gunshot wound (44%).Patients were white, 43%; black, 30%; Hispanic, 17%; Asian, 1%; and Other, 9%. As a proportion of the total race-specific NTDB trauma population, there was an average of 1.13 white patients, 2.71 Hispanic patients, and 3.83 black patients per 1,000. Mechanism, injury severity score, and outcomes did not vary by race. Compared to patients injured by civilians, patients injured by police are more likely to be white (43% vs 25%, p < 0.001) and injured by gunshot wounds (44% vs 32%, p < 0.001). CONCLUSIONS Based on data from trauma centers across the United States, the rate of injuries sustained during interactions with police has been stable over time. Gunshot wounds are the most common mechanism of injury. Proportionally, black patients are the most frequently injured race. When compared to patients injured by civilians, however, patients injured by police are more likely to be white. This study provides a step toward a better understanding of police-associated injuries. LEVEL OF EVIDENCE Prognostic/epidemiologic study, level III.

Post Traumatic Stress Disorder (PTSD) has become a focus for the care of trauma victims, but the incidence of PTSD in those who care for injured patients has not been well studied. Our hypothesis was that a significant proportion of health care providers involved with trauma care are at risk of developing PTSD.A system-wide survey was applied using a modified version of the Primary Care PTSD Screen [PC-PTSD], a validated PTSD screening tool currently being used by the VA to screen veterans for PTSD. Pre-hospital and in-hospital care providers including paramedics, nurses, trauma surgeons, emergency medicine physicians, and residents were invited to participate in the survey. The survey questionnaire was anonymously and voluntarily performed online using the Qualtrix system. Providers screened positive if they affirmatively answered any three or more of the four screening questions and negative if they answered less than three questions with a positive answer. Respondents were grouped by age, gender, region, and profession.546 providers answered all of the survey questions. The screening was positive in 180 (33%) and negative in 366 (67%) of the responders. There were no differences observed in screen positivity for gender, region, or age. Pre-hospital providers were significantly more likely to screen positive for PTSD compared to the in-hospital providers (42% vs. 21%, P0.001). Only 55% of respondents had ever received any information or education about PTSD and only 13% of respondents ever sought treatment for PTSD.The results of this survey are alarming, with high proportions of healthcare workers at risk for PTSD across all professional groups. PTSD is a vastly underreported entity in those who care for the injured and could potentially represent a major problem for both pre-hospital and in-hospital providers. A larger, national study is warranted to verify these regional results.

Military and civilian trauma can be distinctly different but the leading cause of preventable trauma deaths in the prehospital environment, extremity hemorrhage, does not discriminate. The current paper is the most comprehensive review of limb tourniquets employable in the tactical combat casualty care environment and provides the first update to the CoTCCC-recommended limb tourniquets since 2005. This review also highlights the lack of unbiased data, official reporting mechanisms, and official studies with established criteria for evaluating tourniquets. Upon review of the data, the CoTCCC voted to update the recommendations in April 2019.

Background Trauma prediction scores such as Revised Trauma Score (RTS) and Trauma and Injury Severity Score (TRISS)) are used to predict mortality, but do not include comorbidities. We analyzed the American Society of Anesthesiologists physical status (ASA PS) for predicting mortality in trauma patients undergoing surgery. Methods This multicenter, retrospective study compared the mortality predictive ability of ASA PS, RTS, Injury Severity Score (ISS), and TRISS using a complete case analysis with mixed effects logistic regression. Associations with mortality and AROC were calculated for each measure alone and tested for differences using chi-square. Results Of 3,042 patients, 230 (8%) died. The AROC for mortality for TRISS was 0.938 (95%CI 0.921, 0.954), RTS 0.845 (95%CI 0.815, 0.875), and ASA PS 0.886 (95%CI 0.864, 0.908). ASA PS + TRISS did not improve mortality predictive ability (p = 0.18). Conclusions ASA PS was a good predictor of mortality in trauma patients, although combined with TRISS it did not improve predictive ability.

Background Soft-tissue infections in women with subcutaneous injection drug use are often polymicrobial. Case A 21-year-old nulliparous woman presented at 14-15 weeks of gestation with several gluteal abscesses related to subcutaneous injection of heroin. She was well appearing, afebrile, and without findings of systemic illness. After empiric broad-spectrum intravenous antibiotics, same-day incision and drainage was performed. Immediately after the procedure, she developed refractory hypotension, severe tachycardia, pulmonary edema, and leukemoid reaction (white blood cell count 80×10/L). Cardiac arrest ensued, and she died within 4 hours of onset of sepsis and within 24 hours of presentation. Wound cultures identified Clostridium novyi. Conclusion Local, soft-tissue infections that includes C novyi can result in rapidly fatal, toxin-mediated septic shock in pregnant women with high-risk social behavior.

Discontinuity of the bowel following intestinal injury and resection is a common practice in damage control procedures for severe abdominal trauma. However, there are concerns that complete occlusion of the bowel, especially in the presence of hypotension or edema that may result in ischemic bowel changes or increase bacterial or toxin translocation. This was a retrospective study from three Level-1 trauma centers. Included were trauma patients who required bowel resection and damage control. The study population was stratified into two groups based on the management for bowel injury: bowel discontinuity versus primary anastomosis. Outcomes included anastomotic leak, organ space infection, bowel ischemia, and mortality. A total of 167 cases were included. In 84 cases, continuity of the bowel was established, and in 83, the bowel was left in discontinuity. The epidemiological, admission, and intraoperative physiological characteristics, the abdominal Abbreviated Injury Scale, type of intra-abdominal injury, and transfusion requirements were similar in the two study groups. The mortality was 8.3 % in the continuity group and 16.9 % for the discontinuity group (p = 0.096). On the crude bivariate and adjusted regression analyses, there was a higher rate of bowel ischemia at the take-back operation in the discontinuity group (p = 0.003 for the crude and p = 0.034 for the adjusted). The organ space infection and anastomotic leak rate were not significantly different between the study groups. Discontinuity of the bowel following damage control operation is associated with a higher risk of bowel ischemia than in patients with anastomosis. Further prospective observational and randomized studies are warranted. III.

Objectives To report results of a protocol to lessen incidence of pulmonary embolism (PE) among orthopaedic trauma patients. Design Retrospective review. Setting Level 1 trauma center. Patient/participants Orthopaedic trauma inpatients were included in the study. Intervention On arrival, an orthopaedic trauma patient's PE risk is calculated using a previously developed tool. If possible, patients at high risk are given their first dose of enoxaparin before leaving the emergency room. If other injuries preclude enoxaparin, then chemoprophylaxis is held for 24 hours. Twenty-four hours after arrival, the patient's ability to receive enoxaparin is reassessed. If possible, enoxaparin is started, with dosing twice a day. If enoxaparin is still contraindicated, a removable inferior vena cava filter is placed. Adequacy of enoxaparin dosing is tested using anti-factor Xa assay, drawn 4 hours after the third dose of enoxaparin. If the anti-factor Xa result is less than 0.2 IU/mL, a removable inferior vena cava filter is placed. If the result is 0.2-0.5 IU/mL, enoxaparin dosing is continued. If greater than 0.5 IU/mL, the dose of enoxaparin is reduced. Outcome measure The main outcome measure was rate of PE. Results From September 1, 2015 to December 31, 2015, our hospital admitted 420 orthopaedic trauma patients. Fifty-one patients were classed as high risk for PE. In September through December 2015, 9 sustained PE, 1 of which was fatal. From September 1, 2016 to December 31, 2016, our hospital admitted 368 orthopaedic trauma patients with comparable age and Injury Severity Score to 2015. Forty patients were at high risk for PE, 1 sustained a nonfatal PE. PE incidence from September to December 2016 was significantly lower than in 2015 (P = 0.02). Overall, 26 patients managed under the new protocol had IVCFs placed, 21 had their filters removed, and 3 died with filters in place. There were no complications during filter placement or removal. One patient had hemorrhage felt to be attributable to enoxaparin. Conclusions Our protocol emphasizes more robust enoxaparin dosing, and more frequent use of IVCF, but only among those at high risk. We lessened the incidence of PE, with a low complication rate. Level of evidence Therapeutic Level III. See Instructions for Authors for a complete description of levels of evidence.

Background Open abdomen (OA) and temporary abdominal closure (TAC) are common techniques to manage several surgical problems in trauma and emergency general surgery (EGS). Patients with an OA are subjected to prolonged mechanical ventilation. This can lead to increased rates of ventilator-associated pneumonia (VAP). We hypothesized that patients who were extubated with an OA would have a decrease in ventilator hours and as a result would have a lower rate of VAP without an increase in extubation failures. Methods A retrospective review was performed of all trauma and EGS patients managed at our institution with OA and TAC from January 2014 to February 2016. Patients were divided into cohorts consisting of those who were successfully extubated with an OA and those who were not. The number of extubation events and ventilator-free hours were calculated for each patient. Adverse events such as the need for reintubation with an OA and VAP were collected. Results Fifty-two patients (20 trauma, 32 EGS) were managed with an OA and TAC during the study period. Twenty-five patients (6 trauma, 19 EGS) had at least one extubation event with an OA. Median extubation events per patient was 3 (interquartile range, 1-5). The median ventilator-free hours for patients who were extubated was 101 hours (interquartile range, 39.42-260.46). Patients that were never extubated with an OA had higher rates of VAP (30.8% vs. 3.8%, p = 0.01). Conclusion This study provides much needed data regarding the feasibility of extubation in trauma and EGS patients managed with an OA and TAC. Benefits of early extubation may include lower VAP rates in this population. Plans for reexploration hinder the decision to extubate in these patients. Level of evidence Therapeutic study, level IV.

Active-Shooter Response at a Health Care Facility The “run, hide, fight” response to an active-shooter event may work in many places, but health care facilities should consider a different approach...

Background Although the survivability of military extremity hemorrhage is well documented, equivalent civilian data are limited. We analyzed statewide autopsy records in Maryland to determine the number of hemorrhagic deaths that might have been potentially survivable with prompt hemorrhage control. Similar analyses of battlefield deaths led to life-saving changes in military medical practice. Study Design This is a retrospective study of decedent records. The objective is to estimate the number of hemorrhagic deaths that might have been prevented by prompt placement of an extremity tourniquet. Maryland autopsy records from 2002 to 2016 were selected using the following search terms: amputation, arm/arms, avulsion, exsanguination, extremity/extremities, leg/legs. The records were analyzed by applying a checklist of previously developed military criteria to characterize deaths as potentially survivable or nonsurvivable with prompt use of a tourniquet. Suicides and decedents less than 18 years old were excluded. The study did not use information about living participants. Two expert reviewers independently evaluated and scored the death records. Deaths were classified as either potentially survivable or nonsurvivable. A third reviewer broke any ties. Results There were 288 full autopsy records included in the final analysis. Of the eligible decedents reviewed during the 14-year period, 124 of 288 had potentially survivable wounds; 164 had nonsurvivable wounds. Conclusions Over the 14-year study interval, 124 Maryland decedents—an average of 9 per year—might have been saved with prompt placement of a tourniquet. If extrapolated, approximately 480 people in the US might be saved per year. These results provide evidence to support educating and equipping the public to provide bleeding control.

Trauma patients may be at elevated risk for subsequent suicide; however, it is unclear whether patients at risk can be identified during their initial presentation following injury. The objectives of this study were to evaluate the use of a standardized clinical decision support system for suicide risk screening developed by our hospital system and to determine the incidence of positive suicide screenings in our trauma population.Adult trauma patient screenings were performed by nursing staff during the triage process using the Columbia Suicide Severity Rating Scale, Clinical Practice Screener, Recent (C-SSRS). Adult trauma patients who had a suicide risk screening completed from February 2015 to November 2015 were evaluated retrospectively. Patients were divided into cohorts consisting of those with positive and negative screening assessments. Significance was set at α = 0.05. Statistical analysis was performed using Student t test and a χ test where appropriate.Overall, 3,623 of 3,712 patients (98%) completed a suicide risk screening during the study period. Those who went unscreened were not evaluated due to altered mental status/intubation/emergent surgery (97%), death (1%), or an unwillingness to cooperate (2%). The suicide risk screening result was positive in 161 of 3,623 patients (4%) in the study cohort. On univariate analysis, patients with a positive suicide risk screen result were more likely to be white (43% vs 32%; p = 0.01), identify English as their primary language (91% vs 73%; p0.01), have insurance coverage (48% vs 28%; p0.01), and were more likely to initiate a low-level trauma activation (27% vs 16%; p0.01) than those who had a negative screening result. A positive suicide risk assessment result was moderately associated with patients of white race (odds ratio, 1.83; 95% confidence interval, 1.27-2.65) on multivariable logistic regression.Our universal suicide screening process identifies an at-risk subpopulation of trauma patients.Prognostic study, level III; therapeutic, level IV.

Recent military studies demonstrated an association between prehospital tourniquet use and increased survival. The benefits of this prehospital intervention in a civilian population remain unclear. The aims of our study were to evaluate tourniquet use in the civilian population and to compare outcomes to previously published military experience. We hypothesized that incorporation of tourniquet use in the civilian population will result in an overall improvement in mortality.This is a preliminary multi-institutional retrospective analysis of prehospital tourniquet (MIA-T) use of patients admitted to nine urban Level 1 trauma centers from January 2010 to December 2013. Patient demographics and mortality from a previous military experience by Kragh et al. (Ann Surg. 2009;249:1-7) were used for comparison. Patients younger than 18 years or with nontraumatic bleeding requiring tourniquet application were excluded. Data were analyzed using a two-tailed unpaired Student's t test with p0.05 as significant.A total of 197 patients were included. Tourniquets were applied effectively in 175 (88.8%) of 197 patients. The average Injury Severity Score (ISS) for MIA-T versus military was 11 ± 12.5 versus 14 ± 10.5, respectively (p = 0.02). The overall mortality and limb amputation rates for the MIA-T group were significantly lower than previously seen in the military population at 6 (3.0%) of 197 versus 22 (11.3%) of 194 (p = 0.002) and 37 (18.8%) of 197 versus 97 (41.8%) of 232 (p = 0.0001), respectively.Our study is the largest evaluation of prehospital tourniquet use in a civilian population to date. We found that tourniquets were applied safely and effectively in the civilian population. Adaptation of this prehospital intervention may convey a survival benefit in the civilian population.Epidemiologic study, level V.

OBJECT Screening, management, and follow-up of Grade 3 and 4 blunt carotid artery injuries (BCAIs) remain controversial. These high-grade BCAIs were analyzed to define their natural history and establish a rational management plan based on lesion progression and cerebral infarction. METHODS A retrospective review of a prospectively maintained database of all blunt traumatic carotid and vertebral artery injuries from August 2003 to April 2013 was performed, and Grade 3 and 4 BCAIs were identified. The authors define Grade 3 injuries as stenosis of the vessel greater than 50%, or the development of a pseudoaneurysm, and Grade 4 injuries as complete vessel occlusion. Demographic information, imaging findings, number of images obtained per individual, length of radiographic follow-up examination, radiographic outcome at end of follow-up period, treatment(s), and documentation of ischemic stroke or transient ischemic attack (TIA) were recorded. RESULTS Fifty-three Grade 3 BCAIs in 44 patients and 5 Grade 4 BCAIs in 5 patients were identified and had available follow-up information. The mean follow-up duration for Grade 3 BCAIs was 113 days, and the mean follow-up for Grade 4 BCAIs was 78 days. Final imaging of Grade 3 BCAIs showed that 53% of cases were radiographically stable, 11% had resolved, and 11% were improved, whereas 25% had radiographically worsened. In terms of treatment, 75% of patients received aspirin (ASA) alone, 5% received various medications, and 2% received no treatment. Eighteen percent of the patients in the Grade 3 BCAI group underwent endovascular intervention, and in all of these cases, treatment with ASA was continued after the procedure. Final imaging of the Grade 4 BCAIs showed that 60% remained stable (with persistent occlusion), whereas the remaining arteries improved (with recanalization of the vessel). All patients in the Grade 4 BCAI follow-up group were treated with ASA, although in 1 patient treatment was transitioned to Coumadin. There were 3 cases of cerebral infarction that appeared to be related to Grade 3 BCAIs (7% of 44 patients in the Grade 3 group), and 1 case of stroke that appeared to be related to a Grade 4 BCAI. All identified cases of stroke developed soon after hospital admission. CONCLUSIONS Although the posttraumatic cerebral infarction rate may be overestimated, the results of this study suggest that the Grade 3 and 4 BCAIs carry the highest stroke risk of the blunt cerebrovascular injuries, and those infarctions were identified on or shortly after hospital admission. Despite a 40% recanalization rate in the Grade 4 BCAI group and an 89% rate of persistent pseudoaneurysm in the Grade 3 BCAI group, follow-up imaging showed progressive worsening without radiographic improvement in only a small number of patients, and these findings alone did not correlate with adverse clinical outcome. Follow-up protocols may require amending; however, further prospective studies are needed to make conclusive changes as they relate to management.

Background Gallbladders (GBs) with severe inflammation have longer operative times and an increased risk for complications. We propose a grading system using intraoperative images to better stratify GB inflammation. Methods After reviewing the intraoperative images of GBs obtained during several hundred laparoscopic cholecystectomies, we developed a five-tiered grading system based on anatomy and inflammatory changes. Fifty intraoperative photographs were taken prior to dissection and then distributed to 11 surgeons who rated each GB's severity per the grading system. The two-way random effects Intraclass Correlation Coefficient (ICC) was used to assess the reliability among the raters. Results The ICC among the raters of GB severity was 0.804 (95% CI: 0.733 to 0.867; p = 0.0001). Nineteen GB images had greater than 82% agreement and 16 were clustered around GBs with severe inflammation (grades 3–5). Conclusion This study proposes a simple, reliable grading system that characterizes GB complexity based on inflammation and anatomy.

Nearly half of all states have legalized medical marijuana or recreational-use marijuana. As more states move toward legalization, the effects on injured patients must be evaluated. This study sought to determine effects of cannabis positivity at the time of severe injury on hospital outcomes compared with individuals negative for illicit substances and those who were users of other illicit substances. A Level I trauma center performed a retrospective chart review covering subjects over a 2-year period with toxicology performed and an Injury Severity Score (ISS) of more than 16. These individuals were divided into the negative and positive toxicology groups, further divided into the marijuana-only, other drugs-only, and mixed-use groups. Differences in presenting characteristics, hospital length of stay, intensive care unit (ICU) stays, ventilator days, and death were compared. A total of 8,441 subjects presented during the study period; 2,134 (25%) of these had toxicology performed; 843 (40%) had an ISS of more than 16, with 347 having negative tests (NEG); 70 (8.3%) substance users tested positive only for marijuana (MO), 323 (38.3%) for other drugs-only, excluding marijuana (OD), and 103 (12.2%) subjects showed positivity for mixed-use (MU). The ISS was similar for all groups. No differences were identified in Glasgow Coma Scale (GCS), ventilator days, blood administration, or ICU/hospital length of stay when comparing the MO group with the NEG group. Significant differences occurred between the OD group and the NEG/MO/MU groups for GCS, ICU length of stay, and hospital charges. Cannabis users suffering from severe injury demonstrated no detrimental outcomes in this study compared with nondrug users. Language: en

Active shooter and intentional mass casualty events (AS/IMCE) are increasing in frequency in the United States and around the world. Despite this, and despite a focus on “all-hazards” preparedness in many communities, the response to these incidents is often inadequate. Convened to examine these incidents, and others like them, the group now known as the Hartford Consensus has worked to improve survival from AS/IMCEs. A critical component of the effort to improve survival from these events has been the integration of hemorrhage control training and the lessons learned from the implementation of the Tactical Combat Casualty Care program. Ultimately, through integrated hemorrhage control training in law enforcement agencies, fire-rescue/EMS departments and the public in general, the goal of the Hartford Consensus is to craft a seamless system of hemorrhage control across all spaces in the United States and beyond. Using this goal, and the tools mentioned in this chapter, we should move closer to zero preventable deaths from trauma.

A significant proportion of patients appeared to arrive at our American Burn Association-verified burn center intubated without clear benefit. The current study aims to evaluate regional prehospital intubation practices and their outcomes. All consecutive admissions from November 2012 to June 2014 were reviewed for data points associated with intubation. Demographics and outcomes for patients who were intubated before arrival or within 24 hours of admission were compared using χ, Fisher's exact test, and the Kruskal-Wallis test as appropriate. During this period, 958 patients were admitted. Of these, 120 were intubated before arrival, and 91 survived their injuries. Of these 91 survivors, 45 were extubated within 2 days, suggesting unnecessary intubation rate in 37.5%. Intubation-related complications were roughly three times as common among those intubated before arrival (12.5% vs 4.4%). Patients intubated before arrival to our burn center had a shorter median duration of intubation (1.0 vs 4.0 days), median hospital LOS (5.0 vs 22.0 days), and median intensive care unit length of stay (3.0 vs 10.0 days). Furthermore, we found a significant difference in the pattern of ventilator support duration between those arriving intubated, with a median of 2.0 days, and those intubated at our burn center, with a median of 5.5 days. Patients intubated by pre burn center providers have shorter intubation durations and shorter hospitalizations, suggesting inappropriate use of resources. Impending loss of airway appears unlikely among patients with adequate gas exchange at the time of examination. The current criteria for prehospital intubation should be revised to more accurately identify those who truly benefit from advanced airway maneuvers.

BACKGROUND: In the past decade, more than 300,000 people in the United States have died from firearm injuries. Our goal was to assess the effectiveness of two particular prevention strategies, restrictive licensing of firearms and concealed carry laws, on firearm-related injuries in the U.S. Restrictive licensing was defined to include denials of ownership for various offenses, such as performing background checks for domestic violence and felony convictions. Concealed carry laws allow licensed individuals to carry concealed weapons. METHODS: A comprehensive review of the literature was performed. We used GRADE (Grading of Recommendations Assessment, Development, and Evaluation) methodology to assess the breadth and quality of the data specific to our PICO (Population, Intervention, Comparator, Outcomes) questions. RESULTS: A total of 4673 studies were initially identified, then seven more added after two subsequent, additional literature reviews. Of these, 3623 remained after removing duplicates; 225 case reports, case series, and reviews were excluded, and 3379 studies were removed because they did not focus on prevention or did not address our comparators of interest. This left a total of 14 studies which merited inclusion for PICO 1 and 13 studies which merited inclusion for PICO 2. CONCLUSION: PICO 1: We recommend the use of restrictive licensing to reduce firearm-related injuries.PICO 2: We recommend against the use of concealed carry laws to reduce firearm-related injuries.This committee found an association between more restrictive licensing and lower firearm injury rates. All 14 studies were population-based, longitudinal, used modeling to control for covariates, and 11 of the 14 were multi-state. Twelve of the studies reported reductions in firearm injuries, from 7-40%. We found no consistent effect of concealed carry laws. Of note, the varied quality of the available data demonstrates a significant information gap, and this committee recommends that we as a society foster a nurturing and encouraging environment that can strengthen future evidence based guidelines. LEVEL OF EVIDENCE: Systematic review, level III. Language: en

Objective We undertook the current investigation to explore how the pressures of serving as a surrogate decision-maker (SDM) for an acutely ill family member influence attitudes regarding clinical investigation. Methods We conducted a prospective study involving SDMs for critically ill patients cared for in the ICUs of two urban hospitals. Measurements included participation in focus groups designed to explore perceptions of ICU care and clinical research. Audiotapes were transcribed and analyzed to identify common patterns and themes using grounded theory. Demographic and clinical data were summarized using standard statistical methods. Results Seventy-four SDMs (corresponding to 24% of eligible patients) participated. Most SDMs were women and described long-term relationships with the patients represented. SDMs described their role as "overwhelming," their emotions were accentuated by the fatigue of the ICU experience, and they relied on family members, social contacts, and religion as sources of support. Altruism was reported as a common motivation for potential study participation, a sentiment often strengthened by the critical illness episode. Although research was viewed as optional, some SDMs perceived invitation for research participation as tacit acknowledgment of therapeutic failure. SDMs expressed a preference for observational studies (perceived as low risk) over interventional designs (perceived as higher risk). Trust in the ICU team and the research enterprise seemed tightly linked. Conclusions Despite significant emotional duress, SDMs expressed interest in investigation and described multiple factors motivating participation. Consent processes that minimize the effects of anxiety may be one strategy to enhance recruitment.

BACKGROUND: The ABCs of trauma resuscitation begin with the airway evaluation, and effective airway management is imperative in the care of a patient with critical injury. The Eastern Association for the Surgery of Trauma Practice Management Guidelines committee aimed to update the guidelines for emergency tracheal intubation (ETI) published in 2002. These guidelines were made to assist clinicians with decisions regarding airway management for patients immediately following traumatic injury. The goals of the work group were to develop evidencebased guidelines to (1) characterize patients in need of ETI and (2) delineate the most appropriate procedure for patients undergoing ETI. METHODS: A search of the National Library of Medicine and the National Institutes of Health MEDLINE database was performed using PubMed (www.pubmed.gov). RESULTS: The search retrieved English-language articles published from 2000 to 2012 involving patients who had sustained blunt trauma, penetrating trauma, or heat-related injury and had developed respiratory system insufficiency or required ETI in the immediate period after injury (first 2 hours after injury). Sixty-nine articles were used to construct this set of practice management guidelines. CONCLUSION: The data supported the formation of six Level 1 recommendations, four Level 2 recommendations, and two Level 3 recommendations. In summary, the decision to intubate a patient following traumatic injury is based on multiple factors, including the need for oxygenation and ventilation, the extent and mechanism of injury, predicted operative need, or progression of disease. Rapid sequence intubation with direct laryngoscopy continues to be the recommended method for ETI, although the use of airway adjuncts such as blind insertion supraglottic devices and video laryngoscopy may be useful in facilitating successful ETI and may be preferred in certain patient populations. There is no pharmacologic induction agent of choice for ETI; however, succinylcholine is the neuromuscular blockade agent recommended for rapid sequence intubation. (J Trauma Acute Care Surg. 2012;73: S333YS340. Copyright * 2012 by Lippincott Williams & Wilkins)

Scheduled repeat head computed tomography after mild traumatic brain injury has been shown to have limited use for predicting the need for an intervention. We hypothesized that repeat computed tomography in persons with intracranial hemorrhage and a Glasgow Coma Scale (GCS) score of 13 to 15, without clinical progression of neurologic symptoms, does not impact the need for neurosurgical intervention or discharge GCS scores.This prospective cohort study followed all patients presenting to our urban Level I trauma center with intracranial hemorrhage and a GCS score of 13 to 15 from February 2010 to December 2010. Subjects were divided into two groups: those in whom repeat CT scans were performed routinely (ROUTINE) and those in whom they were performed selectively (SELECTIVE) based on changes in clinical examination. CT scanning decisions were made at the discretion of the neurosurgical service attending physician.One hundred forty-five patients met the inclusion criteria (ROUTINE, n = 92; SELECTIVE, n = 53). Group demographics, including age, sex, and presenting GCS score were not significantly different. Of SELECTIVE patients, six (11%) required a repeat head computed tomography for a neurologic change, with one having a radiographic progression of hemorrhage (16%) versus 26 (28%) of 92 in the ROUTINE group showing a radiographic progression. No patient in either group required medical or neurosurgical intervention based on repeat scan. The number of CT scans performed differed between the two groups (three scans in ROUTINE vs. one scan in SELECTIVE, p0.001), as did the intensive care unit (2 days vs. 1 day, p0.001) and hospital (5 days vs. 2 days, p0.001) lengths of stay. Discharge GCS score was similar for both groups (15 vs. 15, p = 0.37). One death occurred in the SELECTIVE group, unrelated to intracranial findings. The negative predictive value of a repeat CT scan leading to neurosurgical intervention with no change in clinical examination was 100% for both groups.A practice of selective repeat head CT scans in patients with traumatic brain injury admitted with a GCS score of 13 to 15 decreases use of the test and is associated with decreased hospital length of stay, without impacting discharge GCS scores.Diagnostic study, level II.

Clinical studies conducted in intensive care units are associated with logistical and ethical challenges. Diseases investigated are precipitous and life-threatening, care is highly technological, and patients are often incapacitated and decision-making is provided by surrogates. These investigations increasingly involve collection of genetic data. The manner in which the exigencies of critical illness impact attitudes regarding genetic data collection is unstudied. Given interest in understanding stakeholder preferences as a foundation for the ethical conduct of research, filling this knowledge gap is timely. The conduct of opinion research in the critical care arena is novel. This brief report describes the development of parallel patient/surrogate decision-maker quantitative survey instruments for use in this environment. Future research employing this instrument or a variant of it with diverse populations promises to inform research practices in critical illness gene variation research.

Background The aim of this study was to prospectively duplicate previous retrospective findings showing that prestorage leukoreduction blunts the detrimental effect of aging on banked packed red blood cells transfused after injury. Methods Over 19 months, trauma patients transfused with ≥4 U of packed red blood cells and surviving ≥24 hours were followed. The age of each unit was collected. Results The cohort consisted of 153 patients. All models showed no association between advancing blood age and the likelihood of developing multiple-organ dysfunction syndrome or infections, regardless of whether the mean age of blood was analyzed as a continuous variable, as a percentage of blood received that was 14 or Conclusions This prospective study duplicates previous retrospective findings of an abrogation of the detrimental effects of advancing mean packed red blood cell age on outcomes after trauma by performing prestorage leukoreduction.

Despite the traditional teaching of early and aggressive airway management in thermally injured patients, paramedics and medical providers outside of burn centers receive little formal training in this difficult skill set. However, the initial airway management of these patients is often performed by these preburn center providers (PBCPs). The purpose of this study was to evaluate the authors' experience with patients intubated by PBCPs and subsequently managed at the authors' center. A retrospective review of a level I burn center database was undertaken. All records of patients arriving intubated were reviewed. From January 1982 to June 2005, 11,143 patients were admitted to the regional burn center; 11.4% (n = 1,272) were intubated before arrival. In this group, mean age was 37.1 years, mean burn size was 35.3% TBSA, and mean length of hospital stay was 27.0 days. Approximately 26.3% were suspected of having an inhalation injury, and this was confirmed by either bronchoscopy or clinical course in 88.6% of this subgroup. Mortality in patients arriving intubated was 30.8%, and these were excluded from the rest of the analysis. In the surviving 879 intubated patients, reasons reported by PBCPs for intubation included "airway swelling" in 34.1%, "prophylaxis" in 27.9%, and "ventilation or oxygenation needs" in 13.2%. Of these patients, 16.3% arrived directly from the scene, with the remainder arriving from another hospital facility. Of all survivors who arrived intubated, 11.9% were extubated on the day of admission, 21.3% were extubated on the first postburn day (PBD), and 8.2% were extubated on the second PBD. No patients who were extubated on PBD1 or PBD2 had to be reintubated. A significant number of burn patients have their initial airway management by PBCPs. Of these, a significant number are extubated soon after arrival at the burn center without adverse sequelae. Rationale for their initial intubation varies, but education is warranted in the prehospital community to reduce unnecessary intubation of the burn patient.

Background Residents' duty-hour limitations and the trends towards closed-staffing for surgical critical care (SCC) have reshaped educational paradigms. No study has yet addressed the impact of these changes on resident SCC training. In our study, we investigated residents' experiences and perceptions of SCC education and practice. Methods At the end of the academic year 2007–2008, we distributed anonymous surveys to categorical general surgery residents in a large, university-based residency. All dedicated SCC rotations are currently completed by the end of PGY3. The survey measured residents' ratings of teaching, experiences, satisfaction, and self-assessed comfort with common SCC diseases and procedures. Results The response rate was 78% ( n = 52/67). At the time of the survey, the 52 respondents had completed 9.3 ± 4.5 wk of SCC rotations. Despite no rotations beyond PGY3, senior residents (PGYs 4/5) reported significantly greater SCC training time (13.1 versus 7.8 wk) and comfort managing SCC diseases and procedures than juniors (PGY 3). Attendings were rated the most effective didactic teachers, and senior residents the most effective procedural teachers. The mean education satisfaction score was 3.9 ± 0.9 (5 = extremely satisfied). Residents anticipated performing minimal SCC management of their own patients, but most felt that SCC-trained surgeons should manage critically ill surgery patients. Seniors reported greater SCC fellowship interest (19% versus 0%). The addition of acute care surgery increased interest in 30% of respondents. Conclusions Senior residents reported greater comfort with SCC management despite the lack of senior SCC rotations, whilst dedicated training time for junior residents appears to be declining. Residents wish subspecialist care for their critically ill patients, but the low interest in SCC fellowships suggests future physician shortages in this subspecialty.

Since the inception of allogeneic blood transfusion, the search for an alternative to the use of stored packed red blood cells has been underway. Over the last 10 years, modified hemoglobin solutions in the form of hemoglobin-based oxygen carriers (HBOCs) have made significant strides toward becoming clinically available and useful. Although HBOCs are not yet ready for regular use in the clinical arena, this may change in the near future as HBOC products continue to improve and as the elucidation of the mechanisms of any adverse effects becomes clearer. In the mean time, we must further the development of alternative strategies for the "hemoglobin bridge" so desperately needed by many critically ill patients.

Background: To examine police compliance with policies for the proper use of conductive electrical devices (CEDs) and, in turn, track any associated medical events following CED application. Methods: Prospective, population-based, 15-month study of police activations of CEDs after their introduction into the police force of a large U.S. city (residential population, 1.25 million). Local policy for use was consistent with the recommendations of International Association of Chiefs of Police. Data collected included age, sex, predefined rationale for use, target distance, activation duration, total energy delivered, policy compliance, and medical findings or events within the first 12 hours. Results: Among 426 consecutive CED activations (November 1, 2004 through January 31, 2006), the suspects' mean age (years ± standard deviation) was 30 ± 10 (range, 13-72) years and 90.4% were male. Suspects' mean distance from the officer was 5.0 ± 4.5 feet (range, 0-21). Reasons for use included: evading or resisting arrest (33.3%, n = 142), public intoxication or disorderly conduct (15.8%, n = 76), interrupting a felony in progress (9.3%, n = 45), and interrupting an assault on an officer or public servant (6.0%, n = 29). Mean total duration of exposures was 8.6 ± 5.9 seconds, and total energy delivered per suspect was 227 ± 156 joules. Officers followed policy in all cases and, accordingly, all suspects rapidly received medical evaluation or simple first aid. No suspect required further treatment except one who was later found to have severe toxic hyperthermia and who died within 2 hours of activation despite rapid on-scene intervention. In 5.4% of deployments (n = 23), CED use was deemed to have dearly prevented the use of lethal force by police. Conclusion: Police were compliant with policy in all cases, and, in addition to avoiding the use of lethal force in a significant number of circumstances, the safety of CED use was demonstrated despite one death subsequently attributed to lethal toxic hyperthermia. Collaborative nationwide research using similar registries is strongly recommended to document compliance and ensure ongoing safety monitoring.

Hospital surge capacity has been advocated to accommodate large increases in demand for healthcare; however, existing urban trauma centers and emergency departments (TC/EDs) face barriers to providing timely care even at baseline patient volumes. The purpose of this study is to describe how alternate-site medical surge capacity absorbed large patient volumes while minimizing impact on routine TC/ED operations immediately after Hurricane Katrina.From September 1 to 16, 2005, an alternate site for medical care was established. Using an off-site space, the Dallas Convention Center Medical Unit (DCCMU) was established to meet the increased demand for care. Data were collected and compared with TC/ED patient volumes to assess impact on existing facilities.During the study period, 23,231 persons displaced by Hurricane Katrina were registered to receive evacuee services in the City of Dallas, Texas. From those displaced, 10,367 visits for emergent or urgent healthcare were seen at the DCCMU. The mean number of daily visits (mean +/- SD) to the DCCMU was 619 +/- 301 visits with a peak on day 3 (n = 1,125). No patients died, 3.2% (n = 257) were observed in the DCCMU, and only 2.9% (n = 236) required transport to a TC/ED. During the same period, the mean number of TC/ED visits at the region's primary provider of indigent care (Hospital 1) was 346 +/- 36 visits. Using historical data from Hospital 1 during the same period of time (341 +/- 41), there was no significant difference in the mean number of TC/ED visits from the previous year (p = 0.26).Alternate-site medical surge capacity provides for safe and effective delivery of care to a large influx of patients seeking urgent and emergent care. This protects the integrity of existing public hospital TC/ED infrastructure and ongoing operations.

OBJECT Proper screening, management, and follow-up of Grade 1 and 2 blunt carotid artery injuries (BCIs) remains controversial. These low-grade BCIs were analyzed to define their natural history and establish a rational management plan based on lesion progression and cerebral infarction. METHODS A retrospective review of a prospectively maintained database of all blunt traumatic carotid and vertebral artery injuries treated between August 2003 and April 2013 was performed and Grade 1 and 2 BCIs were identified. Grade 1 injuries are defined as a vessel lumen stenosis of less than 25%, and Grade 2 injuries are defined as a stenosis of the vessel lumen between 25% and 50%. Demographic information, radiographic imaging, number of imaging sessions performed per individual, length of radiographic follow-up, radiographic outcome at end of follow-up, treatment(s) provided, and documentation of ischemic stroke or transient ischemic attack were recorded. RESULTS One hundred seventeen Grade 1 and 2 BCIs in 100 patients were identified and available for follow-up. The mean follow-up duration was 60 days. Final imaging of Grade 1 and 2 BCIs demonstrated that 64% of cases had resolved, 13% of cases were radiographically stable, and 9% were improved, whereas 14% radiographically worsened. Of the treatments received, 54% of cases were treated with acetylsalicylic acid (ASA), 31% received no treatment, and 15% received various medications and treatments, including endovascular stenting. There was 1 cerebral infarction that was thought to be related to bilateral Grade 2 BCI, which developed soon after hospital admission. CONCLUSIONS The majority of Grade 1 and 2 BCIs remained stable or improved at final follow-up. Despite a 14% rate of radiographic worsening in the Grade 1 and 2 BCIs cohort, there were no adverse clinical outcomes associated with these radiographic changes. The stroke rate was 1% in this low-grade BCIs cohort, which may be an overestimate. The use of ASA or other antiplatelet or anticoagulant medications in these low-grade BCIs did not appear to correlate with radiographic injury stability, nor with a decreased rate of cerebral infarction. Although these data suggest that these Grade 1 and 2 BCIs may require less intensive radiographic follow-up, future prospective studies are needed to make conclusive changes related to treatment and management.