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Trauma center mortality rates are benchmarked to expected rates of death based on patient and injury characteristics. The expected mortality rate is recalculated from pooled outcomes across a trauma system each year, obscuring system-level change across years. We hypothesized that risk-adjusted mortality would decrease over time within a state-wide trauma system.We identified adult trauma patients presenting to Level I and II Pennsylvania trauma centers, 1999-2018, using the Pennsylvania Trauma Outcomes Study. Multivariable logistic regression generated risk-adjusted models for mortality in all patients, and in key subgroups: penetrating torso injury, blunt multisystem trauma, and patients presenting in shock.Of 162,646 included patients, 123,518 (76.1%) were white and 108,936 (67.0%) were male. The median age was 49 (interquartile range [IQR] 29-70), median injury severity score was 16 (IQR 10-24), and 87.5% of injuries were blunt. Overall, 9.9% of patients died, and compared to 1999, no year had significantly higher adjusted odds of mortality. Overall mortality was significantly lower in 2007-2009 and 2011-2018. Of patients with blunt, multisystem injuries, 17.7% died, and adjusted mortality improved over time. Mortality rates were 24.9% for penetrating torso injury, and 56.9% for shock, with no significant change. Mortality improved for patients with ISS25, but not for the most severely injured.Over 20 years, Pennsylvania trauma centers demonstrated improved risk-adjusted mortality rates overall, but improvement remains lacking in high-risk groups despite numerous innovations and practice changes in this time period. Identifying change over time can help guide focus to these critical gaps.

Hemorrhage, and particularly noncompressible torso hemorrhage (NCTH) remains a leading cause of potentially preventable prehospital death from trauma in the United States and globally. A subset of severely-injured patients either die in the field or develop irreversible hemorrhagic shock before they can receive hospital definitive care, resulting in poor outcomes. The focus of this opinion paper is to delineate (a) the need for existing trauma systems to adapt so that potentially life-saving advanced resuscitation and truncal hemorrhage control interventions can be delivered closer to the point-of-injury in select patients, and (b) a possible mechanism through which some trauma systems can train and incorporate select prehospital advanced resuscitative care teams to deliver those interventions.

BACKGROUND: Acute traumatic coagulopathy often accompanies traumatic brain injury (TBI) and may impair cognitive recovery. Antithrombin III (AT-III) reduces the hypercoagulability of TBI. Antithrombin III and heparinoids such as enoxaparin (ENX) demonstrate potent anti-inflammatory activity, reducing organ injury and modulating leukocyte (LEU) activation, independent of their anticoagulant effect. It is unknown what impact AT-III exerts on cerebral LEU activation and blood-brain barrier (BBB) permeability after TBI. We hypothesized that AT-III reduces live microcirculatory LEU-endothelial cell (EC) interactions and leakage at the BBB following TBI. METHODS: CD1 mice (n = 71) underwent either severe TBI (controlled cortical impact (CCI), 6-m/s velocity, 1-mm depth, and 4-mm diameter) or sham craniotomy and then received either AT-III (250 IU/kg), ENX (1.5 mg/kg), or vehicle (saline) every 24 hours. Forty-eight hours post-TBI, cerebral intravital microscopy visualized in vivo penumbral microvascular LEU-EC interactions and microvascular leakage to assess BBB inflammation/permeability. Body weight loss and the Garcia neurological test (motor, sensory, reflex, balance) served as surrogates of clinical recovery. RESULTS: Both AT-III and ENX similarly reduced in vivo penumbral LEU rolling and adhesion (p < 0.05). Antithrombin III also reduced live BBB leakage (p < 0.05). Antithrombin III animals demonstrated the least 48-hour body weight loss (8.4 ± 1%) versus controlled cortical impact and vehicle (11.4 ± 0.5%, p < 0.01). Garcia neurological test scores were similar among groups. CONCLUSION: Antithrombin III reduces post-TBI penumbral LEU-EC interactions in the BBB leading to reduced neuromicrovascular permeability. Antithrombin III further reduced body weight loss compared with no therapy. Further study is needed to determine if these AT-III effects on neuroinflammation affect longer-term neurocognitive recovery after TBI.

Advances in combat casualty care have improved combat survivability over the past two decades. However, these outcomes remain incompletely framed in the broader context of combat casualty outcomes over the past eighty years. We hypothesized that starting with World War II, combat survival worsened at the beginning of each new conflict but then improved over time. To evaluate long-term trends in combat casualty outcomes, monthly combat injuries and deaths during World War II, the Korean conflict, the Vietnam conflict, Operation Iraqi Freedom (OIF), and Operation Enduring Freedom (OEF) were collated. From these numbers, we calculated the monthly case fatality rate (CFR), the killed in action rate (%KIA), and the died of wounds rate (%DOW). We analyzed these metrics for significant trends during and between each conflict using linear and Loess regression. We then simulated alternate outcome scenarios by eliminating outcome variability. In this comprehensive analysis, CFR decreased over the study period in parallel with a decrease in %KIA. When examining individual conflicts, however, several unfavorable trends emerged including a spike in all fatality measures at the end of Vietnam and a rise in %DOW over the course of Korea and OIF. In comparing CFR at the beginning of each conflict to the best CFR from the prior conflict, high mortality outliers occurred in every conflict after a period of relative peace, and a clear "peacetime effect" occurred in both World War II and Vietnam. Eliminating these negative trends and the attendant preventable deaths would have reduced combat fatalities over the course of eighty years by 107,256 (39.7%). In summary, although combat mortality rates have generally improved since World War II, closer examination indicates several unfavorable trends both during and between conflicts. Identifying factors behind these trends will reveal further opportunities to improve combat casualty outcomes in the future. LEVEL OF EVIDENCE: III, Epidemiological.

ImportanceThe burden of firearm violence in US cities continues to rise. The role of access to trauma center care as a trauma system measure with implications for firearm injury mortality has not been comprehensively evaluated.ObjectiveTo evaluate the association between geospatial access to care and firearm injury mortality in an urban trauma system.Design, Setting, and ParticipantsRetrospective cohort study of all people 15 years and older shot due to interpersonal violence in Philadelphia, Pennsylvania, between January 1, 2015, and August 9, 2021.ExposuresGeospatial access to care, defined as the predicted ground transport time to the nearest trauma center for each person shot, derived by geospatial network analysis.Main Outcomes and MeasuresRisk-adjusted mortality estimated using hierarchical logistic regression. The population attributable fraction was used to estimate the proportion of fatalities attributable to disparities in geospatial access to care.ResultsDuring the study period, 10 105 people (910 [9%] female and 9195 [91%] male; median [IQR] age, 26 [21-28] years; 8441 [84%] Black, 1596 [16%] White, and 68 other [Conclusions and RelevanceThese findings indicate that geospatial access to care may be an important trauma system measure, improvements to which may result in reduced deaths from gun violence in US cities.

Numerous surgical advances have resulted from exchanges between military and civilian surgeons. As part of the U.S. National Library of Medicine Michael E. DeBakey Fellowship in the History of Medicine, we conducted archival research to shed light on the lessons that civilian surgery has learned from the military system and vice-versa. Several historical case studies highlight the need for immersive programs where surgeons from the military and civilian sectors can gain exposure to the techniques, expertise, and institutional knowledge the other domain provides. Our findings demonstrate the benefits and promise of structured programs to promote reciprocal learning between military and civilian surgery.

Background Geriatric patients are at increased risk of injury following low-energy mechanisms and are less tolerant of injury. Current criteria for trauma team activation (TTA) often miss these injuries. We evaluated a novel triage process for an expedited Emergency Medicine Physician evaluation protocol (T3) for at-risk geriatric sub-populations not meeting trauma team activation (TTA) criteria. Methods Retrospective review of injured patients (≥65 years) from a Level II Trauma Center with an Injury Severity Score (ISS < 16), prior to (Pre-T3, Jan 2007-Oct 2009), and after (Post-T3, Jan 2010-Oct 2012), implementation of T3, as well as a contemporary period (CP, Jan 2013-Oct 2015). Demographics, physiologic variables, and timeliness of care were measured. Rates of ICU admission, operative procedures and lengths of stay and in-hospital mortality were compared for all periods. Logistic regression analysis determined variables independently associated with mortality. Results Post-T3, 49.2% of geriatric registry patients underwent T3 with a reduction in key time intervals. Median time to evaluation (42.1 mins vs 61.7 min, p

BACKGROUND Severe traumatic brain injury (TBI) patients are at high risk for early aspiration and pneumonia. How pneumonia impacts neurological recovery after TBI is not well characterized. We hypothesized that, independent of the cerebral injury, pneumonia after TBI delays and worsens neurological recovery and cognitive outcomes. METHODS Fifteen CD1 male mice were randomized to sham craniotomy or severe TBI (controlled cortical impact [CCI] - velocity 6 m/s, depth 1.0 mm) ± intratracheal lipopolysaccharide (LPS-2 mg/kg in 0.1 mL saline) as a pneumonia bioeffector. Neurological functional recovery by Garcia Neurologic Testing (GNT) and body weight loss were recorded daily for 14 days. On Days 6-14, animals underwent Morris Water Maze learning and memory testing with cued trials (platform visible), spatial learning trials (platform invisible, spatial cues present), and probe (memory) trials (platform removed, spatial clues present). Intergroup differences were assessed by the Kruskal-Wallis test with Bonferroni correction (p < 0.05). RESULTS Weight loss was greatest in the CCI + LPS group (maximum 24% on Day 3 vs. 8% [Sham], 7% [CCI], both on Day 1). GNT was lowest in CCI + LPS during the first week. Morris Water Maze testing demonstrated greater spatial learning impairment in the CCI + LPS group vs. Sham or CCI counterparts. Cued learning and long-term memory were worse in CCI + LPS and CCI as compared to Sham. CONCLUSION A pneumonia bioeffector insult after TBI worsens weight loss and mortality in a rodent model. Not only is spatial learning impaired, but animals are more debilitated and have worse neurologic performance. Understanding the adverse effects of pneumonia on TBI recovery is the first step d patients.

Background Public health measures were instituted to reduce COVID-19 spread. A decrease in total emergency department volume followed, but the impact on injury is unknown. With lockdown and social distancing potentially increasing domicile discord, we hypothesized that intentional injury increased during COVID-19, driven primarily by an increase in penetrating trauma. Study Design A retrospective review of acute adult patient care in an urban Level I trauma center assessed injury patterns. Presenting patient characteristics and diagnoses from 6 weeks pre to 10 weeks post statewide stay-at-home orders (March 16, 2020) were compared, as well as with 2015-2019. Subsets were defined by intentionality (intentional vs nonintentional) and mechanism of injury (blunt vs penetrating). Fisher exact and Wilcoxon tests were used to compare proportions and means. Results There were 357 trauma patients that presented pre stay-at-home order and 480 that presented post stay-at-home order. Pre and post groups demonstrated differences in sex (35.6% vs 27.9% female; p = 0.02), age (47.4 ± 22.1 years vs 42 ± 20.3 years; p = 0.009), and race (1.4% vs 2.3% Asian; 63.3% vs 68.3% Black; 30.5% vs 22.3% White; and 4.8% vs 7.1% other; p = 0.03). Post stay-at-home order mechanism of injury revealed more intentional injury (p = 0.0008). Decreases in nonintentional trauma after adoption of social isolation paralleled declines in daily emergency department visits. Compared with earlier years, 2020 demonstrated a significantly greater proportion of intentional violent injury during the peripandemic months, especially from firearms. Conclusions Unprecedented social isolation policies to address COVID-19 were associated with increased intentional injury, especially gun violence. Meanwhile, emergency department and nonintentional trauma visits decreased. Pandemic-related public health measures should embrace intentional injury prevention and management strategies.

IMPORTANCE: The outcomes of firearm injuries in the United States are devastating. Although firearm mortality and costs have been investigated, the long-term outcomes after surviving a gunshot wound (GSW) remain unstudied. OBJECTIVE: To determine the long-term functional, psychological, emotional, and social outcomes among survivors of firearm injuries. DESIGN, SETTING, AND PARTICIPANTS: This prospective cohort study assessed patient-reported outcomes among GSW survivors from January 1, 2008, through December 31, 2017, at a single urban level I trauma center. Attempts were made to contact all adult patients (aged ≥18 years) discharged alive during the study period. A total of 3088 patients were identified; 516 (16.7%) who died during hospitalization and 45 (1.5%) who died after discharge were excluded. Telephone contact was made with 263 (10.4%) of the remaining patients, and 80 (30.4%) declined study participation. The final study sample consisted of 183 participants. Data were analyzed from June 1, 2018, through June 20, 2019. EXPOSURES: A GSW sustained from January 1, 2008, through December 31, 2017. MAIN OUTCOMES AND MEASURES: Scores on 8 Patient-Reported Outcomes Measurement Information System (PROMIS) instruments (Global Physical Health, Global Mental Health, Physical Function, Emotional Support, Ability to Participate in Social Roles and Activities, Pain Intensity, Alcohol Use, and Severity of Substance Use) and the Primary Care PTSD (posttraumatic stress disorder) Screen for the Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition. RESULTS: Of the 263 patients who survived a GSW and were contacted, 183 (69.6%) participated. Participants were more likely to be admitted to the hospital compared with those who declined (150 [82.0%] vs 54 [67.5%]; P = .01). Participants had a median time from GSW of 5.9 years (range, 4.7-8.1 years) and were primarily young (median age, 27 years [range, 21-36 years]), black (168 [91.8%]), male (169 [92.3%]), and employed before GSW (pre-GSW, 139 [76.0%]; post-GSW, 113 [62.1%]; decrease, 14.3%; P = .004). Combined alcohol and substance use increased by 13.2% (pre-GSW use, 56 [30.8%]; post-GSW use, 80 [44.0%]). Participants had mean (SD) scores below population norms (50 [10]) for Global Physical Health (45 [11]; P

The fields of healthcare and public health regularly generate new innovations and evidence-based practices designed to alleviate suffering, improve quality of care, and help systems to function more efficiently. But while there is no shortage of well-established ideas about how to improve performance, disseminating what works remains a challenging and, at times, elusive enterprise. Adopting the principles of a learning healthcare system (LHS) can create an engine for embedding research-based and evidence-supported interventions and practices like Damage Control Resuscitation (DCR) into clinical care. An important facet of DCR is the need to bring it to the patients most in need and at an early interval after life-threatening injury and exsanguination. Thus, we address how different components of the trauma LHS (prehospital, en route, and in-hospital care) must integrate data, experience, and report outcomes to continuously learn, identify gaps, and direct further research and improvement. Prior to concluding, the chapter will briefly look at what it might take to introduce DCR at national scale.

Background Geriatric patients are at increased risk of injury following low-energy mechanisms and are less tolerant of injury. Current criteria for trauma team activation (TTA) often miss these injuries. We evaluated a novel triage process for an expedited Emergency Medicine Physician evaluation protocol (T3) for at-risk geriatric sub-populations not meeting trauma team activation (TTA) criteria. Methods Retrospective review of injured patients (≥65 years) from a Level II Trauma Center with an Injury Severity Score (ISS < 16), prior to (Pre-T3, Jan 2007-Oct 2009), and after (Post-T3, Jan 2010-Oct 2012), implementation of T3, as well as a contemporary period (CP, Jan 2013-Oct 2015). Demographics, physiologic variables, and timeliness of care were measured. Rates of ICU admission, operative procedures and lengths of stay and in-hospital mortality were compared for all periods. Logistic regression analysis determined variables independently associated with mortality. Results Post-T3, 49.2% of geriatric registry patients underwent T3 with a reduction in key time intervals. Median time to evaluation (42.1 mins vs 61.7 min, p

Advanced practitioners (APs) have been successfully integrated into the clinical care of injured patients. Given the expanding role of APs in trauma care, we hypothesized that APs can perform Performance Improvement and Patient Safety (PIPS) peer review at a level comparable with trauma surgeons. For Phase 1, cases previously reviewed by a trauma surgeon were randomly selected by the PIPS coordinator and peer reviewed by an AP. The trauma surgeons' and APs' reviews were compared. For Phase 2, cases requiring concurrent review were peer reviewed by both an AP and an MD, who were blinded to each other's review. Both the APs' and trauma surgeons' reviews of the same medical record were presented at a bimonthly performance improvement (PI) meeting. In Phase 1, 46 PI cases were reviewed including 22 deaths. Trauma surgeons and APs had high concordance (96.0%) regarding appropriateness or inappropriateness of care (κ = 0.774). Among disagreements, APs were 3 times more likely than trauma surgeons to determine care to be inappropriate. Trauma surgeons and APs had similarly high concordance (95.5%) regarding preventability of mortality (κ = 0.861). In Phase 2, 38 PI cases were reviewed, including 31 deaths. Trauma surgeons and APs had high concordance (89.0%) regarding appropriateness or inappropriateness of care (κ = 0.585). Among disagreements, trauma surgeons and APs had similarly high concordance (86.2%) regarding preventability of mortality (κ = 0.266). We found that APs had high concordance with trauma surgeons regarding medical record reviews and are thus able to effectively review medical records for the purposes of PIPS.

Background The relationship between high volume and improved outcomes has been described for a host of elective high-impact, low-frequency procedures, but there are little data to support such a relationship in high-impact low-frequency procedures in trauma. Using emergency department thoracotomy (EDT) as a model, we hypothesized that patients presenting to centers with higher institutional volumes of EDT would have improved survival referent to those presenting to lower volume institutions. Methods We queried the Pennsylvania Trauma Outcomes Study registry from 2007 to 2015 for all EDTs performed at Level I and II centers identified by ICD-9 procedure codes and a location stamp indicating the emergency department. We examined patient-level risk factors for survival in univariate regression and multivariable regression models. Centers were divided into tertiles of mean annual EDT volume, and the association between mean annual EDT volume and patient survival was examined using logistic regression after controlling for patient factors. Results 1,399 EDTs were performed at 28 centers. Overall survival was 6.8%. After controlling for patient age, mechanism of injury, signs of life, and injury severity, patients presenting to centers in the highest tertile of volume had significantly higher odds of survival compared with patients presenting to centers in the lowest tertile of volume (OR 4.56, 95% CI 1.43-14.50). Conclusions Patients presenting to centers with higher mean annual volume of EDTs have improved survival compared with those presenting to institutions with lower mean annual EDT volume. Efforts to understand the etiology of this finding may lead to interventions to improve outcomes at lower-volume centers. Level of evidence Prognostic/Epidemiological, level III; Therapeutic, level IV.

We sought to determine whether state firearm legislation correlated with firearm-related fatality rates (FFR) during a 15-year period.The politicized and controversial topic of firearm legislation has been grossly understudied when the relative impact of American firearm violence is considered. Scientific evidence regarding gun legislation effectiveness remains scant.Demographic and intent data (1999-2013) were collected from the Centers for Disease Control and Prevention's Web-Based Injury Statistics Query and Reporting System database and compared by state firearm legislation rankings with respect to FFR. State scorecards were obtained from firearm-restrictive (Brady Campaign/Law Center against Gun Violence [BC/LC]) and less-restrictive (National Rifle Association) groups. FFR were compared between restrictive and least-restrictive states during 3 periods (1999-2003, 2004-2008, 2009-2013).During 1999 to 2013, 462,043 Americans were killed by firearms. Overall FFR did not change during the 3 periods (10.89 ± 3.99/100,000; 10.71 ± 3.93/100,000; 11.14 ± 3.91/100,000; P = 0.87). Within each period, least-restrictive states had greater unintentional, pediatric, and adult suicide, White and overall FFR than restrictive states (all P0.05). Conversely, no correlation was seen, during any of the 3 time periods, with either homicide or Black FFR-population subsets accounting for 41.7% of firearm deaths.Restrictive firearm legislation is associated with decreased pediatric, unintentional, suicide, and overall FFR, but homicide and Black FFR appear unaffected. Future funding and research should be directed at both identifying the most effective aspects of firearm legislation and creating legislation that equally protects every segment of the American population.

Introduction Surgical Intensive Care Unit (SICU) patients “boarding” in ICUs other than the designated home unit have been shown to suffer increased rates of complications. We hypothesized that ICU rounding practices are different when SICU patients are housed in home vs. boarding ICUs. Material and methods SICU rounds were observed at an academic quaternary medical center. Individual patient rounding time and order seen on rounds along with patient data and demographics were recorded. Multivariable regression analysis was used for comparison between patients. Results Non-boarders were older, observed on a later post ICU admission day and were more likely to be mechanically ventilated. Boarded patients were often seen at the end of rounds and for less time. Not being a boarder, age, APACHE II score on admission, vasopressor use, and positive pressure ventilation all predicted increased rounding time. Conclusions Surgical ICU patients boarding in non-preferred units are often seen at the end of rounds, result in a greater reliance upon telephone communication, and receive less bedside attention from ICU provider teams.

Although the ideal situation for combat trauma care would be to deploy only providers with proven expertise and deep experience, the reality is that the volume of deployment taskings, particularly during periods of high operational tempo, requires the deployment of surgeons who are just recently out of residency training or who have been in practice for many years that did not involve any exposure to trauma care. For the new graduate, some common questions and sources of anxiety are as follows: How close to the “action” will I be and how busy has the area where I’m going been? Will I be the only surgeon or will I have backup? If I have backup, what is their level of experience? How experienced is my support staff? What diagnostic capabilities will I have available? How will I deal with injuries that I’ve never encountered before? For those surgeons who have been out of residency training for some time but who have had very little exposure to trauma care, we continue to struggle with the optimal way to attain some degree of trauma proficiency and then to maintain or enhance that skill set to avoid major degradation before and between deployments. This chapter will discuss these issues and offer practical advice from the perspective of the two coauthors: one a junior surgeon who has recently graduated from residency training and the other a surgeon who now has multiple deployments under her belt but who faced her first deployments as a junior staff surgeon.

Early trauma deaths have the potential for salvage with immediate surgery. We studied time from injury to death in this group to qualify characteristics and quantify time to the operating room, yielding the greatest opportunity for salvage.The Pennsylvania Trauma Outcomes Study (PTOS) is a comprehensive registry including all Pennsylvania trauma centers. PTOS was queried for adult trauma patients from 1999 to 2010 dying within 4 hours of injury. The distribution of time to death (TD) was examined for subgroups according to mechanism of injury, hypotension (defined as systolic blood pressure ≤ 90 mm Hg), and operation required. The 5th percentile (TD5) and the 50th percentile (TD50) were calculated from the distributions and compared using the Mann-Whitney U-test.The PTOS yielded 6,547 deaths within 4 hours of injury. The overall TD5 and TD50 were 0:23 (hour:minute) and 0:59, respectively. Median penetrating injury times were significantly shorter than blunt injury times (TD5/TD50, 0:19/0:43 vs. 0:29/1:10). Median time was significantly shorter for hypotensive versus normotensive patients (TD5/TD50, 0:22/0:52 vs. 0:43/2:18). Operative subgroups had different TD5/TD50 (abdominal surgery [n = 607], 1:07/2:26; thoracic surgery [n = 756] 0:25/1:25; vascular surgery [n = 156], 0:35/2:15; and cranial surgery [n = 18], 1:20/2:42).Early trauma deaths have the potential for salvage with immediate surgery. We found TD to vary based on mechanism of injury, presence of hypotension, and type of surgery needed. With the use of TD5 and TD50 benchmarks in these subgroups, a trauma system may determine if decreased time to the operating room decreases mortality. Trauma systems can use these data to further improve prehospital and initial hospital phases of care for this subset of early death trauma patients.Epidemiologic study, level III.

BACKGROUND Intensive care units (ICUs) function frequently at capacity, requiring incoming critically ill patients to be placed in alternate geographically distinct ICUs. In some medical ICU populations, "boarding" in an overflow ICU has been associated with increased mortality. We hypothesized that surgical ICU patients experience more complications when boarding in an overflow ICU and that the frequency of these complications are greatest in boarders farthest from the home unit (HU). METHODS A 5-year (June 2005 to June 2010) retrospective review of a prospectively maintained ICU database was performed, and demographics, severity of illness, length of stay, and incidence of ICU complications were extracted. Distances between boarding patients' rooms and the HU were measured. Complications occurring in patients located in the same floor (BUSF) and different floor (BUDF) boarding units were compared and stratified by distance from HU to the patient room. Logistic regression was used to develop control for known confounders. RESULTS A total of 7,793 patients were admitted to the HU and 833 to a boarding unit (BUSF, n = 712; BUDF, n = 121). Boarders were younger, had a lower length of stay, and Acute Physiology and Chronic Health Evaluation II and were more often trauma/emergency surgery patients. Compared with in-HU patients, the incidence of aspiration pneumonia (2.2% vs. 3.6%, p < 0.01) was greater in BUSF patients and highest in those farthest from the HU (odds ratio [OR], 2.39; p = 0.01). Delirium occurred less often in HU than in BUDF patients (3.3% vs. 8.3 %, p < 0.01), and both delirium (OR, 6.09, p < 0.01) and ventilator-associated pneumonia (OR, 4.49, p < 0.05) were more frequent in patients farther from the HU. CONCLUSION Certain ICU complications occur more frequently in boarding patients particularly if they are located on a different floor or far from the HU. When surgical ICU bed availability forces overflow admissions to non-home ICUs, greater interdisciplinary awareness, education, and training may be needed to ensure equivalent care and outcomes. LEVEL OF EVIDENCE Epidemiologic study, level III. Therapeutic study, level IV.

Background Arterial shunting is a well-described method to control hemorrhage and rapidly reestablish flow, but optimal shunt dwell times remain controversial. We hypothesized that prolonged shunt dwell times of more than 6 hours are related to adverse outcomes after major arterial injury. Methods A review (2005-2013) of all patients with arterial shunts placed after traumatic injury at our urban Level I trauma center was undertaken. Patients who died prior to shunt removal (n = 7) were excluded. Shunt complications were defined as dislodgement, thrombosis, and distal ischemia. Patients were compared on the basis of shunt complications with respect to clinical parameters. Results The 42 patients who underwent arterial shunting after major vascular injury were primarily young (median, 26 years; interquartile range [IQR], 22-31 years) males (97.6%), severely injured (Injury Severity Score, 17.5 [IQR, 14-29]; shunted vessel Abbreviated Injury Scale score, 4 [IQR, 3-4]) by gunshot (85.7%) requiring neck/torso (33.3%) or upper-extremity (19.1%) or lower-extremity (47.6%) shunts. Thirty-five patients survived until shunt removal, and 5 (14.3%) of 35 developed shunt complications. Demographics and clinical characteristics were compared between those with shunt dwell times of less than 6 hours (n = 19) and more than 6 hours (n = 16). While patients appeared to have a greater injury burden overall in the group with dwell times of more than 6 hours, there were no statistical differences between groups with respect to age, gender, initial systolic blood pressure or hemodynamics during the shunt dwell period, use of vasopressors, Abbreviated Injury Scale score of the shunted vessel, Injury Severity Score, or outcomes including limb amputation or mortality. No patients (0/19) with shunt dwell times of less than 6 hours developed complications, whereas 5 (31.3%) of 16 patients with dwell times of more than 6 hours developed shunt complications (p = 0.05). Conclusions In this civilian series, 14% of patients with arterial shunts developed shunt complications. Our data suggest that limiting shunt dwell times to less than 6 hours when clinically feasible may decrease adverse outcomes. Level of evidence Therapeutic/care management study, level IV.

Introduction Little is known regarding the confidence of military surgeons prior to combat zone deployment. Military surgeons are frequently deployed without peers experienced in combat surgery. We hypothesized that forward surgical team experience (FSTE) increases surgeon confidence with critical skill sets. Methods We conducted a national survey of military affiliated personnel. We used a novel survey instrument that was piloted and validated by experienced military surgeons to collect demographics, education, practice patterns, and confidence parameters for trauma and surgical critical care skills. Skills were defined as crucial operative techniques for hemorrhage control and resuscitation. Surveyors were blinded to participants, and surveys were returned electronically via REDCap database. Data were analyzed with SPSS using appropriate models. Significance was considered p Results Of 174 distributed surveys, 86 were completed. Nine individuals failed to characterize their FSTE, thus leaving a sample size of 77. At the time of first deployment, 78.4% were alone or with less experienced surgeons and 53.2% had less than 2 yr of post-residency practice. The respondents' confidence in damage control techniques and seven other trauma skills increased relative to FSTE. After adjusting for years of practice, number of trauma resuscitations performed per month and pre-deployment training, there remained a significant positive association between FSTE and confidence in damage control, thoracic surgery, extremity/junctional hemorrhage control, trauma systems administration, adult critical care and airway management. Conclusions Training programs and years of general surgery practice do not replace FSTE among military surgeons. Pre-deployment training that mimics FST skill sets should be developed to improve military surgeon confidence and outcomes. Level of evidence Prognostic and Epidemiologic, Level IV.

Leadership plays a key role in trauma team management and might affect the efficiency of patient care. Our hypothesis was that a positive relationship exists between the trauma team members' perception of leadership and the efficiency of the injured patient's initial evaluation.We conducted a prospective observational study evaluating trauma attending leadership (TAL) over 5 months at a level 1 trauma center. After the completion of patient care, trauma team members evaluated the TAL's ability using a modified Campbell Leadership Descriptor Survey tool. Scores ranged from 18 (ineffective leader) to 72 (perfect score). Clinical efficiency was measured prospectively by recording the time needed to complete an advanced trauma life support (ATLS)-directed resuscitation. Assessment times across Leadership score groups were compared using Kruskal-Wallis and Mann-Whitney tests (p0.05, statistically significant).Seven attending physicians were included with a postfellowship experience ranging from ≤1 to 11 years. The average leadership score was 59.8 (range, 27-72). Leadership scores were divided into 3 groups post facto: low (18-45), medium (46-67), and high (68-72). The teams directed by surgeons with low scores took significantly longer than teams directed by surgeons with high scores to complete the secondary survey (14 ± 4 minutes in contrast to 11 ± 2 minutes, p0.009) and to transport the patient for CT evaluation (19 ± 5 minutes in contrast to 14 ± 4 minutes; p0.001). Attending surgeon experience also affected clinical efficiency with teams directed by less experienced surgeons taking significantly longer to complete the primary survey (p0.05).The trauma team's perception of leadership is associated positively with clinical efficiency. As such, more formal leadership training could potentially improve patient care and should be included in surgical education.

The global response to the 12 January 2010 earthquake in Haiti revealed the ability to mobilise medical teams quickly and effectively when academic medical centres partner non-governmental organisations (NGO) that already have a presence in a zone of devastation. Most established NGOs based in a certain region are accustomed to managing the medical conditions that are common to that area and will need additional and specialised support to treat the flux of myriad injured persons. Furthermore, an NGO with an established presence in a region prior to a disaster appears better positioned to provide sustained recovery and rehabilitation relief. Academic medical centres can supply these essential specialised resources for a prolonged time. This relationship between NGOs and academic medical centres should be further developed prior to another disaster response. This model has great potential with regard to the rapid preparation and worldwide deployment of skilled medical and surgical teams when needed following a disaster, as well as to the subsequent critical recovery phase.

High-grade renal injuries have traditionally been treated operatively. Alternatively, embolotherapy is used to control hemorrhage, but there are few studies that validate this practice after renal injury. Embolotherapy may offer an effective and safe means to arrest hemorrhage after high-grade blunt renal injury.Retrospective analysis was performed of high-grade renal injury (grade III or higher). Patients who were initially treated with arteriography were compared with those who underwent surgery. Statistical analysis was performed with Wilcoxon rank-sum and χ(2) tests.Sixty-nine patients were identified, 28 of whom had contrast agent extravasation on computed tomography (CT). Of these 69 patients, 17 underwent operation and 20 underwent arteriography. The surgical cohort had a higher injury severity score (39.6 vs 24.2; P.01), but there was no difference in renal injury grade (P = .9). The arteriography cohort received significantly more contrast medium (P.001). Contrast agent extravasation was confirmed angiographically in six of 12 patients who had this finding on CT, and embolotherapy controlled bleeding in all six. No significant difference was noted in transfusion need, recurrent hemorrhage, creatinine level at discharge, glomerular filtration rate, or length of stay (P.4 for each endpoint). There was a trend toward a longer stay in the intensive care unit in the surgical cohort and a higher likelihood of discharge to home in the arteriography group (P = .08 for each endpoint).Embolotherapy offers a safe means to diagnose and arrest hemorrhage after renal injury. The additional contrast agent needed for imaging does not increase the incidence of nephropathy irrespective of renal injury grade.

Brain tissue oxygenation (PbtO2)-guided management facilitates treatment of reduced PbtO2 episodes potentially conferring survival and outcome advantages in severe traumatic brain injury (TBI). To date, the nature and effectiveness of commonly used interventions in correcting compromised PbtO2 in TBI remains unclear. We sought to identify the most common interventions used in episodes of compromised PbtO2 and to analyze which were effective.A retrospective 7-year review of consecutive severe TBI patients with a PbtO2 monitor was conducted in a Level I trauma center's intensive care unit or neurosurgical registry. Episodes of compromised PbtO2 (defined as20 mm Hg for 0.25-4 hours) were identified, and clinical interventions conducted during these episodes were analyzed. Response to treatment was gauged on how rapidly (ΔT) PbtO2 normalized (20 mm Hg) and how great the PbtO2 increase was (ΔPbtO2). Intracranial pressure (ΔICP) and cerebral perfusion pressure (ΔCPP) also were examined for these episodes.Six hundred twenty-five episodes of reduced PbtO2 were identified in 92 patients. Patient characteristics were: age 41.2 years, 77.2% men, and Injury Severity Score and head or neck Abbreviated Injury Scale score of 34.0 ± 9.2 and 4.9 ± 0.4, respectively. Five interventions: narcotics or sedation, pressors, repositioning, FIO2/PEEP increases, and combined sedation or narcotics + pressors were the most commonly used strategies. Increasing the number of interventions resulted in worsening the time to PbtO2 correction. Triple combinations resulted in the lowest ΔICP and dual combinations in the highest ΔCPP (p0.05).Clinicians use a limited number of interventions when correcting compromised PbtO2. Using strategies employing many interventions administered closely together may be less effective in correcting PbO2, ICP, and CPP deficits. Some PbtO2 deficits may be self-limited.

On Tuesday, January 12, 2010 at 16:53 local time, a magnitude 7.0 M(w) earthquake struck Haiti. The global humanitarian attempt to respond was swift, but poor infrastructure and emergency preparedness limited many efforts. Rapid, successful deployment of emergency medical care teams was accomplished by organizations with experience in mass disaster casualty response. Well-intentioned, but unprepared, medical teams also responded. In this report, we describe the preparation and planning process used at an academic university department of anesthesiology with no preexisting international disaster response program, after a call from an American-based nongovernmental organization operating in Haiti requested medical support. The focus of this article is the pre-deployment readiness process, and is not a post-deployment report describing the medical care provided in Haiti.A real-time qualitative assessment and systematic review of the Hospital of the University of Pennsylvania's communications and actions relevant to the Haiti earthquake were performed. Team meetings, conference calls, and electronic mail communication pertaining to planning, decision support, equipment procurement, and actions and steps up to the day of deployment were reviewed and abstracted. Timing of key events was compiled and a response timeline for this process was developed. Interviews with returning anesthesiology members were conducted.Four days after the Haiti earthquake, Partners in Health, a nonprofit, nongovernmental organization based in Boston, Massachusetts, with20 years of experience providing medical care in Haiti contacted the University of Pennsylvania Health System to request medical team support. The departments of anesthesiology, surgery, orthopedics, and nursing responded to this request with a volunteer selection process, vaccination program, and systematic development of equipment lists. World Health Organization and Centers for Disease Control guidelines, the American Society of Anesthesiology Committee on Trauma and Emergency Preparedness, published articles, and in-country contacts were used to guide the preparatory process.An organized strategic response to medical needs after an international natural disaster emergency can be accomplished safely and effectively within 6 to 12 days by an academic anesthesiology department, with medical system support, in a center with no previously established response system. The value and timeliness of this response will be determined with further study. Institutions with limited experience in putting an emergency medical team into the field may be able to quickly do so when such efforts are executed in a systematic manner in coordination with a health care organization that already has support infrastructure at the site of the disaster.

Historically, patients with penetrating cardiac injuries have enjoyed the best survival after emergency department thoracotomy (EDT), but further examination of these series reveals a preponderance of cardiac stab wound (SW) survivors with only sporadic cardiac gunshot wound (GSW) survivors. Our primary study objective was to determine which patients requiring EDT for penetrating cardiac or great vessel (CGV) injury are salvageable.All patients who underwent EDT for penetrating CGV injuries in two urban, level I trauma centers during 2000 to 2007 were retrospectively reviewed. Demographics, injury (mechanism, anatomic injury), prehospital care, and physiology (signs of life [SOL], vital signs, and cardiac rhythm) were analyzed with respect to hospital survival.The study population (n = 283) comprised young (mean age, 27.1 years +/- 10.1 years) men (96.1%) injured by gunshot (GSW, 88.3%) or SWs (11.7%). Patients were compared by injury mechanism and number of CGV wounds with respect to survival (SW, 24.2%; GSW, 2.8%; p0.001; single, 9.5%; multiple, 1.4%; p = 0.003). Three predictors-injury mechanism, ED SOL, and number of CGV wounds-were then analyzed alone and in combination with respect to hospital survival. Only one patient (0.8%) with multiple CGV GSW survived EDT.When the cumulative impact of penetrating injury mechanism, ED SOL, and number of CGV wounds was analyzed together, we established that those sustaining multiple CGV GSWs (regardless of ED SOL) were nearly unsalvageable. These results indicate that when multiple CGV GSWs are encountered after EDT, further resuscitative efforts may be terminated without limiting the opportunity for survival.

M T b d d w f b a s i f t n ecrotizing soft-tissue infection (NSTI) was first described y Hippocrates circa 500 BC, when he wrote, “Many were ttacked by the erysipelas all over the body when the excitng cause was a trivial accident . . . flesh, sinews, and bones ell away in large quantities . . . there were many deaths.” espite many advances in our understanding of this disease nd great improvements in medical care, the mortality asociated with NSTI has not changed in the last 30 years and emains 25% to 35%. Mortality is directly proportional to ime to intervention. In addition, prevalence of this disase is such that the average practitioner will see only one or wo cases in his or her career. Physicians cannot be suffiiently familiar with NSTI to proceed rapidly with accurate iagnosis and the necessary management. The purpose of his article is to provide an evidence-based review of the icrobiology, pathophysiology, diagnosis, and treatment f NSTI. Because there are no adequately powered, ranomized, and blinded studies, the recommendations are ased on retrospective and nonblinded study data vailable. NSTI was described as “hospital gangrene” by British aval surgeons in the 18th and 19th century. Dr Joseph ones, a Confederate Army surgeon, was the first person to escribe this disorder in a large group of patients in 1871, hen he reported on 2,642 cases and found a mortality rate f 46%. In 1883, the French physician, Jean Alfred ournier, described a similar NSTI of the perineum in five ale patients—a process that continues to bear his name. It s now described in both male and female patients. In the nsuing years, many other terms, such as necrotizing erysiplas, streptococcal gangrene, and suppurative fasciitis, have een also been used. Because the gas-forming organism, lostridium perfringens, can be associated with this infecion, it has also been referred to as “Clostridial gangrene” or gas gangrene.” In 1951, Dr Wilson proposed the term necrotizing fascitis to include both gas-forming and non gas-forming ne

Obejctive Patients, family members and ICU nurses have a higher level of satisfaction with the semiclosed ICU model. Whether or not resident physicians have this same reaction has not yet been investigated. We hypothesized that surgical residents would have improved job satisfaction with the transition from a mandatory consultation SICU to a semiclosed SICU model. Design Prospective, longitudinal survey. Setting Tertiary-care University Hospital. Participants Categorical general surgery residents. Interventions Change from mandatory consultation SICU to semiclosed SICU. Measurements and Main Results Categorical surgery residents at a tertiary-care university hospital were surveyed at 3 time points during and after the transition from a mandatory consultation SICU to a semiclosed SICU. The survey consisted of 12 questions designed to gauge the residents' overall job satisfaction as related to the SICU. All questions were on a 5-point Likert scale. Analysis of variance for trend and Fisher exact test were performed to compare the responses. 97 surveys were received. The response rates for the 3 periods were 66, 62 and 72%. Residents were less likely to feel “out of the loop” regarding the care of their ICU patients in the later periods (p = 0.046). There was significant improvement over time in scores for the statement “there is often confusion about placing orders for the care of my patients in the ICU” (p = 0.001). The critical care team's management of all orders in the SICU significantly improved resident job satisfaction over the 3-year period (p = 0.027). There were no significant differences between the responses of junior and senior residents. Conclusions Resident satisfaction improved significantly over time with the transition from a mandatory consultation SICU to a semiclosed SICU.

Pancreatic injuries are rare, with penetrating mechanisms being causative in majority of cases. They can create major diagnostic and therapeutic challenges and require multiple diagnostic modalities, including multislice high-definition computed tomography, magnetic resonance cholangiopancreatography, endoscopic retrograde cholangiopancreatography, ultrasonography, and at times, surgery and direct visualization of the pancreas. Pancreatic trauma is frequently associated with duodenal and other severe vascular and visceral injuries. Mortality is high and usually related to the concomitant vascular injury. Surgical management of pancreatic and pancreatic-duodenal trauma is challenging, and multiple surgical approaches and techniques have been described, up to and including pancreatic damage control and later resection and reconstruction. Wide surgical drainage is a key to any surgical trauma technique and access for enteral nutrition, or occasionally parenteral nutrition, are important adjuncts. Morbidity associated with pancreatic trauma is high and can be quite severe. Treatment of pancreatic trauma-related complications often requires a combination of interventional, endoscopic, and surgical approaches.

To review the rationale for the regionalization of adult critical care and discuss how lessons from the trauma experience may be relevant to this debate.Narrative review and opinion.Variation in the quality of critical care among hospitals has prompted calls for regionalization of care for critically ill patients. Because of similarities between trauma and critical care, trauma is often cited as a model for the regionalization of critical care services. In reality, there are both important similarities and differences between trauma and critical care. In addition, many lessons from the trauma experience directly apply to future efforts to regionalize critical care services. In this article, we review the analogy between the regionalization of trauma and critical care and discuss how the trauma experience both supports and limits the argument for creation of a formal regionalized system of care for the critically ill. If regionalization efforts in critical care are to proceed, the lessons of the trauma experience can inform policy decisions and provide insight into the design and implementation of an effective regionalized system.

To determine the usefulness of adrenal vein sampling (AVS) in patients referred for surgical management of primary aldosteronism (PA).From July 2001 to September 2006, 12 patients with a mean age of 49.3 years (range 31-65 yrs) presented for evaluation. All patients had PA based on serologic screening tests and were evaluated with CT abdominal imaging. Eleven (92%) patients underwent AVS with corticotropin stimulation. Ten patients underwent laparoscopic adrenalectomy for resection of an aldosterone-producing adenoma.All patients had an adrenal adenoma seen on CT, mean size 14.8 mm (range 6-27 mm). AVS was performed in the 11 patients. When compared with CT findings, eight (73%) patients demonstrated aldosterone hypersecretion from the adrenal with the adenoma. Two (18%) patients demonstrated hypersecretion from the contralateral, normal-appearing gland. One (9%) patient demonstrated bilateral aldosterone hypersecretion, consistent with bilateral adrenal hyperplasia. After surgical removal of the gland that demonstrated hypersecretion on AVS, all patients experienced resolution of hypokalemia, five (50%) patients had resolution of hypertension, and five (50%) patients had significant reductions in the number of hypertensive medications.AVS is a superior test when compared with CT imaging in subtype identification of PA and for determination of occult hypersecretion from the adrenal. Patients who are evaluated for potential adrenalectomy should routinely undergo AVS.

Background Use of transthoracic echocardiography (TTE) in documenting cardiac disorders is well accepted. This study reviews institutional experience with TTE in the clinical setting of pulmonary embolism (PE). Study Design Retrospective review of surgical ICU patients who underwent TTE within 72 hours of diagnosis of PE, from January 2005 to March 2007. Collected data included symptoms, clinical suspicion of PE, preexisting conditions, operative procedures, TTE findings, presence of deep venous thrombosis, and treatments used for PE. Preexisting TTEs, when available, were compared with those obtained after acute PE. TTEs subsequent to the first post-PE study were analyzed for change in severity of findings. Results Thirty-one patients (12 men, 19 women, mean age 66 years, APACHE II 18.1) were included. Twenty-two had high, and nine had moderate, clinical suspicion for PE. Radiographic diagnosis of PE was made by computed tomography (25 of 31) and by ventilation-perfusion scans (6 of 31). Twelve of 31 patients had extremity deep venous thrombosis by duplex ultrasonography. Tricuspid regurgitation was the most common TTE finding (28 of 31), followed by pulmonary hypertension (24), dilated right ventricle (23), right heart strain (19), and underfilled, hyperdynamic left ventricle (17). Seventeen patients had previous or "baseline" echocardiograms, and when compared with the post-PE TTE, all patients demonstrated worsening in at least one TTE finding. Conclusions This study identified findings that can be used in prospective evaluation of TTE for suspected PE. The importance of baseline TTE has also been emphasized. Additional prospective evaluation of TTE in diagnosis of suspected PE in the ICU is warranted.

Background Decisions regarding admissions/discharges in the surgical intensive care unit (SICU) can potentially strain the relationship between the critical care team and the primary surgery service. We hypothesized that a multidisciplinary system of arbitration, led by an intensivist, is a safe and workable solution to SICU patient triage, which leads to consensus between critical care team and primary services. Methods Demographic, illness severity, readmission, and outcome data were collected prospectively on consecutive patients in a large academic center SICU. Arbitration was directed by an intensivist and a charge nurse, with regular meetings. Representation from various hospital departments (admissions, operating room, nursing, and housekeeping) was included. Decisions on patient discharge from the SICU were compared between the primary service (represented by the Chief resident) and the SICU arbitrator. Results A total of 289 patients were admitted to SICU during the 2-month study period, with 952 arbitration decisions. Good agreement exists between the primary service and the arbitrator regarding SICU patient suitability for discharge (Kappa = 0.85). Seventeen patients (5.9%) were readmitted, with 14 (82%) surviving to hospital discharge. None of the readmitted patients was originally discharged over the primary service objection. Day of discharge APACHE II scores of readmitted patients did not differ from those not readmitted (8.2 vs 7.7). Readmissions had longer hospital stays, equivalent SICU stays, and higher mortality (18%) than for patients overall (2.8%). Conclusions A dedicated intensivist, supported by a multidisciplinary team, can make arbitration decisions in the SICU that seem to be safe and generally concordant with the primary surgical team of the patient. Additional larger-scale investigation of arbitration in the SICU is warranted.

In the United States, firearms are involved in tens of thousands of deaths and injuries each year. The magnitude of this problem prompted the National Academy of Sciences (NAS) to issue a report in 2004 detailing the strengths and limitations of existing research on the relationship between firearms and violence. In response, a multidisciplinary group of experts in the field of firearms and violence formed the National Research Collaborative on Firearm Violence. The Collaborative met for 2 days in June 2005 to (1) critically review the main findings of the NAS report and (2) define a research agenda that could fill research and data gaps and inform policy that reduces gun-related crime, deaths and injuries. This article summarizes the Collaborative's conclusions and identifies priorities for research and funding.

This White Paper summarizes the state of readiness of combat surgeons and provides action recommendations that address the problems of how to train, sustain, and retain them for future armed conflicts. As the basis for the 2014 Scudder Oration, I explored how to secure an improved partnership between military and civilian surgery, which would optimize learning platforms and embed military trauma personnel at America's academic medical universities for trauma combat casualty care (TCCC). To craft and validate these recommendations, I conducted an integrative and iterative process of literature reviews, interviews of military and civilian leaders, and a survey of military-affiliated surgeons. The recommended action points advance the training of combat surgeons and their trauma teams by creating an expanded network of TCCC training sites and sourcing the cadre of combat-seasoned surgeons currently populating our civilian and military teaching hospitals and universities. The recommendation for the establishment of a TCCC readiness center or command within the Medical Health System of the Department of Defense includes a military and civilian advisory board, with the reformation of a think tank of content experts to address high-level solutions for military medicine, readiness, and TCCC.