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While emergent, non-cardiac surgery can be safely performed in LVAD patients, the inherent perioperative challenges of these rare procedures and the perception that these patients may be poor surgical candidates can contribute to reluctance to perform necessary emergency general surgery (EGS) procedures. We, therefore, sought to identify predictors of inpatient mortality to assist perioperative decision-making.The Nationwide Inpatient Sample (2010-2015Q3) was used to identify patients with previously placed LVADs with a subsequent EGS admission diagnosis. Multivariable logistic regression analysis was performed to identify independent predictors of 30-day mortality, and a risk-adjusted probability of death was calculated for significant patient subgroups across age. Additional demographic variables were included in the regression due to clinical relevance.There were 1805 (weighted) LVAD-EGS patients with an overall mortality rate of 11%. Independent predictors of mortality were intestinal ischemia and sepsis present on admission. Patients older than 70 with sepsis had an 80% probability of in-hospital mortality (10.6 OR, 1.70-65.5 95% CI) while those over 70 presenting with intestinal ischemia had a 38% probability of death (3.6 OR, 1.50-8.78 95% CI). Mortality risk for younger patients with sepsis was still approximately 50%.Older LVAD patients presenting with either sepsis or intestinal ischemia have a substantial mortality risk while younger patients have a modest risk. These results can be used to guide treatment discussions when emergency surgery is being considered in LVAD patients.

Growing evidence supports improved survival with prehospital blood products. Recent trials show a benefit of prehospital tranexamic acid (TXA) administration in select subgroups. Our objective was to determine if receiving prehospital packed red blood cells (pRBC) in addition to TXA improved survival in injured patients at risk of hemorrhage.We performed a secondary analysis of all scene patients from the Study of Tranexamic Acid during Air and ground Medical Prehospital transport trial. Patients were randomized to prehospital TXA or placebo. Some participating EMS services utilized pRBC. Four resuscitation groups resulted: TXA, pRBC, pRBC+TXA, and neither. Our primary outcome was 30-day mortality and secondary outcome was 24-hour mortality. Cox regression tested the association between resuscitation group and mortality while adjusting for confounders.A total of 763 patients were included. Patients receiving prehospital blood had higher Injury Severity Scores in the pRBC (22 [10, 34]) and pRBC+TXA (22 [17, 36]) groups than the TXA (12 [5, 21]) and neither (10 [4, 20]) groups (p0.01). Mortality at 30 days was greatest in the pRBC+TXA and pRBC groups at 18.2% and 28.6% compared with the TXA only and neither groups at 6.6% and 7.4%, respectively. Resuscitation with pRBC+TXA was associated with a 35% reduction in relative hazards of 30-day mortality compared with neither (hazard ratio, 0.65; 95% confidence interval, 0.45-0.94; p = 0.02). No survival benefit was observed in 24-hour mortality for pRBC+TXA, but pRBC alone was associated with a 61% reduction in relative hazards of 24-hour mortality compared with neither (hazard ratio, 0.39; 95% confidence interval, 0.17-0.88; p = 0.02).For injured patients at risk of hemorrhage, prehospital pRBC+TXA is associated with reduced 30-day mortality. Use of pRBC transfusion alone was associated with a reduction in early mortality. Potential synergy appeared only in longer-term mortality and further work to investigate mechanisms of this therapeutic benefit is needed to optimize the prehospital resuscitation of trauma patients.Therapeutic/Care Management; Level III.

INTRODUCTION AND OBJECTIVE:Patients with high-grade renal trauma (HGRT) who undergo nephrectomy may be at higher risk for mortality compared to those who receive conservative management. However, n...

OBJECTIVE We sought to characterize the timing of administration of prehospital tranexamic acid (TXA) and associated outcome benefits. BACKGROUND TXA has been shown to be safe in the prehospital setting post-injury. METHODS We performed a secondary analysis of a recent prehospital randomized TXA clinical trial in injured patients. Those who received prehospital TXA within 1 hour (EARLY) from time of injury were compared to those who received prehospital TXA beyond 1 hour (DELAYED). We included patients with a shock index of >0.9. Primary outcome was 30-day mortality. Kaplan-Meier and Cox Hazard regression were utilized to characterize mortality relationships. RESULTS EARLY and DELAYED patients had similar demographics, injury characteristics, and shock severity but DELAYED patients had greater prehospital resuscitation requirements and longer prehospital times. Stratified Kaplan-Meier analysis demonstrated significant separation for EARLY patients (N = 238, log-rank chi-square test, 4.99; P = 0.03) with no separation for DELAYED patients (N = 238, log-rank chi-square test, 0.04; P = 0.83). Stratified Cox Hazard regression verified, after controlling for confounders, that EARLY TXA was associated with a 65% lower independent hazard for 30-day mortality [hazard ratio (HR) 0.35, 95% confidence interval (CI) 0.19-0.65, P = 0.001] with no independent survival benefit found in DELAYED patients (HR 1.00, 95% CI 0.63-1.60, P = 0.999). EARLY TXA patients had lower incidence of multiple organ failure and 6-hour and 24-hour transfusion requirements compared to placebo. CONCLUSIONS Administration of prehospital TXA within 1 hour from injury in patients at risk of hemorrhage is associated with 30-day survival benefit, lower incidence of multiple organ failure, and lower transfusion requirements.

BACKGROUND: Mechanical bowel preparation with antibiotics is associated with decreased surgical site infections (SSI) after colorectal surgery. However, antibiotics have side effects, such as vomiting. It is unknown how patient willingness to take antibiotics is affected by side effect severity. MATERIALS AND METHODS: This was a single-center study of 86 patients (37 undergoing colorectal surgery) using a modified standard gamble technique. We presented patients with four hypothetical scenarios, holding SSI reduction constant and varying antibiotic side effect severity. Patients reported willingness to take antibiotics using a scale from 0 to 100. Patients also reported the maximum level of side effects they would accept. We examined the association between side effect severity and willingness to take antibiotics with a multivariable mixedeffects regression model and investigated differences in surgical and nonsurgical patients. RESULTS: After adjusting for age, sex, and patient type, willingness scores decreased with increasing side effect severity. No side effects: 92 (CI 86,99), mild: 83 (CI 76,90), moderate: 76 (CI 69,83), and severe: 46 (CI 38,52), P < 0.001. Surgical patients were more willing to take antibiotics at all severity levels compared with nonsurgical patients, P < 0.001. Surgical (57%) and nonsurgical (58%) patients reported that they would accept moderate side effects. Patients with prior SSI (n = 5) would take antibiotics regardless of side effect severity. CONCLUSIONS: Increasing antibiotic side effect severity is associated with decreased willingness to take antibiotics during bowel preparation, despite a reduction in SSI. Adherence may be improved with strategies that increase patient education and decrease side effects during bowel preparation.

PURPOSE:We studied the current management trends for extraperitoneal bladder injuries and evaluated the use of operative repair versus catheter drainage, and the associated complications with each approach. MATERIALS AND METHODS:We prospectively collected data on bladder trauma from 20 level 1 trauma centers across the United States from 2013 to 2018. We excluded patients with intraperitoneal bladder injury and those who died within 24 hours of hospital arrival. We separated patients with extraperitoneal bladder injuries into 2 groups (catheter drainage vs operative repair) based on their initial management within the first 4 days and compared the rates of bladder injury related complications among them. Regression analyses were used to identify potential predictors of complications. RESULTS:From 323 bladder injuries we included 157 patients with extraperitoneal bladder injuries. Concomitant injuries occurred in 139 (88%) patients with pelvic fracture seen in 79%. Sixty-seven patients (43%) initially underwent operative repair for their extraperitoneal bladder injuries. The 3 most common reasons for operative repair were severity of injury or bladder neck injury (40%), injury found during laparotomy (39%) and concern for pelvic hardware contamination (28%). Significant complications were identified in 23% and 19% of the catheter drainage and operative repair groups, respectively (p=0.55). The only statistically significant predictor for complications was bladder neck or urethral injury (RR 2.69, 95% 1.21-5.97, p=0.01). CONCLUSIONS:In this large multi-institutional cohort, 43% of patients underwent surgical repair for initial management of extraperitoneal bladder injuries. We found no significant difference in complications between the initial management strategies of catheter drainage and operative repair. The most significant predictor for complications was concomitant urethral or bladder neck injury.

Medical educational research highlights the need for high-fidelity, multidisciplinary simulation training to teach complex decision-making skills, such as those taught in Advanced Trauma Life Support (ATLS). This approach is, however, expensive and time-intensive. Virtual reality (VR) education simulation may improve skill acquisition in a cost-effective and time-sensitive manner. We developed a novel trauma VR simulator (TVRSim) for providers to apply ATLS principles. We hypothesized in this pilot study that TVRSim could differentiate practitioner competency with increasing experience and would be well accepted.Providers at a Level I trauma center (acute care surgeons, novice (MS4PGY1), junior (PGY23), senior (PGY4-6) residents) ran a blunt, polytrauma VR code. Ten critical decision points were assessed: intubation, cricothyroidotomy, chest tube, intravenous access, focused abdominal sonography for trauma examination, pelvic binder, activation of massive transfusion protocol, administration of hypertonic saline, hyperventilation and decision to go to the operating room (OR). Learner assessment was based on frequency and time to correct decisions. Participant satisfaction was measured using validated surveys.All 31 providers intubated and obtained intravenous access. Novices and juniors frequently failed at hypertonic saline and hyperventilation decisions. Juniors often failed at cricothyroidotomy (60%) and OR (100%) decisions. Mean time to all decisions except going to the OR was longer for all groups compared to acute care surgeons. Mean number of decisions/min was significantly higher for surgeons and seniors compared to juniors and novices. Mortality was 92.3% for novices, 80% for juniors, 25% for seniors and 0% for the attendings. Participants found TVRSim comfortable, easy to use/interact with/performance enhancing, and helped develop skills and learning.In this pilot study using a sample of convenience, TVRSim was able to discern decision-making abilities among trainees with increasing experience. All trainees felt that the platform enhanced their performance and facilitated skill acquisition and learning. TVRSim could be a useful adjunct to teach and assess ATLS skills.Diagnostic Test or Criteria; Level IV.

BACKGROUND We sought to examine patterns of readmission after nonoperative trauma, including rates of delayed operative intervention and mortality. METHODS The Nationwide Readmissions Database (2013-2014) was queried for all adult trauma admissions and 30-day readmissions. Index admissions were classified as operative (OI) or nonoperative (NOI), and readmissions examined for major operative intervention (MOR). Multivariable regression modeling was used to evaluate risk for readmission requiring MOR and in-hospital mortality. RESULTS Of 2,244,570 trauma admissions, there were 59,573 readmissions: 66% after NOI, and 35% after OI. Readmission rate was higher after NOI compared with OI (3.6% vs. 1.7% p < 0.001). Readmitted NOI patients were older, with a higher proportion of Injury Severity Score ≥15 and were readmitted earlier (NOI median 8 days vs. OI 11 days). Thirty-one percent of readmitted NOI patients required MOR and experienced higher overall mortality compared with OI patients with operative readmission (NOI 2.9% vs. OI 2%, p = 0.02). Intracranial hemorrhage was an independent risk factor for NOI readmission requiring MOR in both the overall (hazard ratio, 1.11; 95% confidence interval [CI], 1.01-1.22) and Injury Severity Score of 15 or greater cohorts (hazard ratio, 1.46; 95% CI, 1.24-1.7), with a predominance of nonspine neurosurgical procedures (20.3% and 55.1%, respectively). Operative readmission after NOI cost a median of $17,364 (interquartile range, US $11,481 to US $27,816) and carried a total annual cost of US $147 million (95% CI, US $141 million to $154 million). CONCLUSIONS Nonoperative trauma patients have a higher readmission rate than operative index patients and nearly one third require operative intervention during readmission. Operative readmission carries a higher overall mortality rate in NOI patients and together accounts for nearly US $150 million in annual costs. LEVEL OF EVIDENCE Epidemiological, level III.

Background Indications for intervention after high-grade renal trauma (HGRT) remain poorly defined. Certain radiographic findings can be used to guide the management of HGRT. We aimed to assess the associations between initial radiographic findings and interventions for hemorrhage after HGRT and to determine hematoma and laceration sizes predicting interventions. Methods The Genitourinary Trauma Study is a multicenter study including HGRT patients from 14 Level I trauma centers from 2014 to 2017. Admission computed tomography scans were categorized based on multiple variables, including vascular contrast extravasation (VCE), hematoma rim distance (HRD), and size of the deepest laceration. Renal bleeding interventions included angioembolization, surgical packing, renorrhaphy, partial nephrectomy, and nephrectomy. Mixed-effect Poisson regression was used to assess the associations. Receiver operating characteristic analysis was used to define optimal cutoffs for HRD and laceration size. Results In the 326 patients, injury mechanism was blunt in 81%. Forty-seven (14%) patients underwent 51 bleeding interventions, including 19 renal angioembolizations, 16 nephrectomies, and 16 other procedures. In univariable analysis, presence of VCE was associated with a 5.9-fold increase in risk of interventions, and each centimeter increase in HRD was associated with 30% increase in risk of bleeding interventions. An HRD of 3.5 cm or greater and renal laceration depth of 2.5 cm or greater were most predictive of interventions. In multivariable models, VCE and HRD were significantly associated with bleeding interventions. Conclusion Our findings support the importance of certain radiographic findings in prediction of bleeding interventions after HGRT. These factors can be used as adjuncts to renal injury grading to guide clinical decision making. Level of evidence Prognostic and Epidemiological Study, Level III and Therapeutic/Care Management, Level IV.

The management of high-grade renal trauma (HGRT) and the indications for intervention are not well defined. The American Association for the Surgery of Trauma (AAST) renal grading does not incorporate some important clinical and radiologic variables associated with increased risk of interventions. We aimed to use data from a multi-institutional contemporary cohort to develop a nomogram predicting risk of interventions for bleeding after HGRT.From 2014 to 2017, data on adult HGRT (AAST grades III-V) were collected from 14 level 1 trauma centers. Patients with both clinical and radiologic data were included. Data were gathered on demographics, injury characteristics, management, and outcomes. Clinical and radiologic parameters, obtained after trauma evaluation, were used to predict renal bleeding interventions. We developed a prediction model by applying backward model selection to a logistic regression model and built a nomogram using the selected model.A total of 326 patients met the inclusion criteria. Mechanism of injury was blunt in 81%. Median age and injury severity score were 28 years and 22, respectively. Injuries were reported as AAST grades III (60%), IV (33%), and V (7%). Overall, 47 (14%) underwent interventions for bleeding control including 19 renal angioembolizations, 16 nephrectomies, and 12 other procedures. Of the variables included in the nomogram, a hematoma size of 12 cm contributed the most points, followed by penetrating trauma mechanism, vascular contrast extravasation, pararenal hematoma extension, concomitant injuries, and shock. The area under the receiver operating characteristic curve was 0.83 (95% confidence interval, 0.81-0.85).We developed a nomogram that integrates multiple clinical and radiologic factors readily available upon assessment of patients with HGRT and can provide predicted probability for bleeding interventions. This nomogram may help in guiding appropriate management of HGRT and decreasing unnecessary interventions.Prognostic and epidemiological study, level III.

To test the hypothesis that undergoing nephrectomy after high-grade renal trauma is associated with higher mortality rates.We gathered data from 21 Level-1 trauma centers through the Multi-institutional Genito-Urinary Trauma Study. Patients with high-grade renal trauma were included. We assessed the association between nephrectomy and mortality in all patients and in subgroups of patients after excluding those who died within 24 hours of hospital arrival and those with GCS≤8. We controlled for age, injury severity score (ISS), shock (systolic blood pressure90 mmHg), and Glasgow Coma Scale (GCS).A total of 1181 high-grade renal trauma patients were included. Median age was 31 and trauma mechanism was blunt in 78%. Injuries were graded as III, IV, and V in 55%, 34%, and 11%, respectively. There were 96 (8%) mortalities and 129 (11%) nephrectomies. Mortality was higher in the nephrectomy group (21.7% vs 6.5%, P.001). Those who died were older, had higher ISS, lower GCS, and higher rates of shock. After adjusting for patient and injury characteristics nephrectomy was still associated with higher risk of death (RR: 2.12, 95% CI: 1.26-2.55).Nephrectomy was associated with higher mortality in the acute trauma setting even when controlling for shock, overall injury severity, and head injury. These results may have implications in decision making in acute trauma management for patients not in extremis from renal hemorrhage.

BACKGROUND Emergency general surgery (EGS) encompasses a spectrum of time-sensitive and resource-intensive conditions, which require adequate and timely access to surgical care. Developing metrics to accurately quantify spatial access to care is critical for this field. We sought to evaluate the ability of the spatial access ratio (SPAR), which incorporates travel time, hospital capacity, and population demand in its ability to measure spatial access to EGS care and delineate disparities. METHODS We constructed a geographic information science platform for EGS-capable hospitals in California and mapped population location, race, and socioeconomic characteristics. We compared the SPAR to the shortest travel time model in its ability to identify disparities in spatial access overall and for vulnerable populations. Reduced spatial access was defined as >60 minutes travel time or lowest three classes of SPAR. RESULTS A total of 283 EGS-capable hospitals were identified, of which 142 (50%) had advanced resources. Using shortest travel time, only 166,950 persons (0.4% of total population) experienced prolonged (>60 minutes) travel time to any EGS-capable hospital, which increased to 1.05 million (2.7%) for advanced-resource centers. Using SPAR, 11.5 million (29.5%) had reduced spatial access to any EGS hospital, and 13.9 million (35.7%) for advanced-resource centers. Rural residents had significantly decreased access for both overall and advanced EGS services when assessed by SPAR despite travel times within the 60-minute threshold. CONCLUSION While travel time and SPAR showed similar overall geographic patterns of spatial access to EGS hospitals, SPAR identified a greater a greater proportion of the population as having limited access to care. Nearly one third of California residents experience reduced spatial access to EGS hospitals when assessed by SPAR. Metrics that incorporate measures of population demand and hospital capacity in addition to travel time may be useful when assessing spatial access to surgical services. LEVEL OF EVIDENCE Cross-sectional study, level VI.

Background Burnout, often regarded as an individual failing, rather than a systemic one, negatively impacts quality of care, patient safety and healthcare costs. Focusing on improving well-being can help mitigate burnout. This study examined protective factors that promote well-being and professional fulfillment in surgeons. Methods Using a purposive sample, 32 semi-structured 30-60-min interviews were conducted with surgeons of varying sub-specialties and rank. Abductive exploratory analysis was used to code and interpret interview transcripts and to build a conceptual model of surgeon well-being. Results Emergent protective factors were placed into one of three levels of implementation: individual, team-level, and institutional (figure). Individual factors for well-being included autonomy and adequate time to pursue non-clinical endeavors. Team-level factors consisted of adaptability, boundaries, and cohesion. Institutional factors related to diversifying performance evaluations and celebrating and recognizing individual value and contributions. Conclusions The conceptual model developed from the results of this study highlights factors important to surgeons’ professional well-being. This model can be used to guide quality improvement efforts.

BACKGROUND Renal trauma grading has a limited ability to distinguish patients who will need intervention after high-grade renal trauma (HGRT). A nomogram incorporating both clinical and radiologic factors has been previously developed to predict bleeding control interventions after HGRT. We aimed to externally validate this nomogram using multicenter data from level 1 trauma centers. METHODS We gathered data from seven level 1 trauma centers. Patients with available initial computed tomography (CT) scans were included. Each CT scan was reviewed by two radiologists blinded to the intervention data. Nomogram variables included trauma mechanism, hypotension/shock, concomitant injuries, vascular contrast extravasation (VCE), pararenal hematoma extension, and hematoma rim distance (HRD). Mixed-effect logistic regression was used to assess the associations between the predictors and bleeding intervention. The prediction accuracy of the nomogram was assessed using the area under the receiver operating characteristic curve and its 95% confidence interval (CI). RESULTS Overall, 569 HGRT patients were included for external validation. Injury mechanism was blunt in 89%. Using initial CT scans, 14% had VCE and median HRD was 1.7 (0.9-2.6) cm. Overall, 12% underwent bleeding control interventions including 34 angioembolizations and 24 nephrectomies. In the multivariable analysis, presence of VCE was associated with a threefold increase in the odds of bleeding interventions (odds ratio, 3.06; 95% CI, 1.44-6.50). Every centimeter increase in HRD was associated with 66% increase in odds of bleeding interventions. External validation of the model provided excellent discrimination in predicting bleeding interventions with an area under the curve of 0.88 (95% CI, 0.84-0.92). CONCLUSION Our results reinforce the importance of radiologic findings such as VCE and hematoma characteristics in predicting bleeding control interventions after renal trauma. The prediction accuracy of the proposed nomogram remains high using external data. These variables can help to better risk stratify high-grade renal injuries. LEVEL OF EVIDENCE Prognostic and epidemiological study, level III.

IMPORTANCE: In-hospital administration of tranexamic acid after injury improves outcomes in patients at risk for hemorrhage. Data demonstrating the benefit and safety of the pragmatic use of tranexamic acid in the prehospital phase of care are lacking for these patients. OBJECTIVE: To assess the effectiveness and safety of tranexamic acid administered before hospitalization compared with placebo in injured patients at risk for hemorrhage. DESIGN, SETTING, AND PARTICIPANTS: This pragmatic, phase 3, multicenter, double-blind, placebo-controlled, superiority randomized clinical trial included injured patients with prehospital hypotension (systolic blood pressure ≤90 mm Hg) or tachycardia (heart rate ≥110/min) before arrival at 1 of 4 US level 1 trauma centers, within an estimated 2 hours of injury, from May 1, 2015, through October 31, 2019. INTERVENTIONS: Patients received 1 g of tranexamic acid before hospitalization (447 patients) or placebo (456 patients) infused for 10 minutes in 100 mL of saline. The randomization scheme used prehospital and in-hospital phase assignments, and patients administered tranexamic acid were allocated to abbreviated, standard, and repeat bolus dosing regimens on trauma center arrival. MAIN OUTCOMES AND MEASURES: The primary outcome was 30-day all-cause mortality. RESULTS: In all, 927 patients (mean [SD] age, 42 [18] years; 686 [74.0%] male) were eligible for prehospital enrollment (460 randomized to tranexamic acid intervention; 467 to placebo intervention). After exclusions, the intention-to-treat study cohort comprised 903 patients: 447 in the tranexamic acid arm and 456 in the placebo arm. Mortality at 30 days was 8.1% in patients receiving tranexamic acid compared with 9.9% in patients receiving placebo (difference, –1.8%; 95% CI, –5.6% to 1.9%; P = .17). Results of Cox proportional hazards regression analysis, accounting for site, verified that randomization to tranexamic acid was not associated with a significant reduction in 30-day mortality (hazard ratio, 0.81; 95% CI, 0.59-1.11, P = .18). Prespecified dosing regimens and post-hoc subgroup analyses found that prehospital tranexamic acid were associated with significantly lower 30-day mortality. When comparing tranexamic acid effect stratified by time to treatment and qualifying shock severity in a post hoc comparison, 30-day mortality was lower when tranexamic acid was administered within 1 hour of injury (4.6% vs 7.6%; difference, −3.0%; 95% CI, −5.7% to −0.3%; P

Drug-specific agents for the reversal of direct oral anticoagulants (DOACs) were recently approved. We hypothesized that the approval of these reversal agents would lead improved outcomes for trauma patients taking DOACs.A multicenter, prospective (2015-2018), observational study of all adult trauma patients taking DOACs who were admitted to one of fifteen participating trauma centers was performed. The primary outcome was mortality.For 606 trauma patients on DOACs, those reversed were older (78 vs. 74, p = 0.007), more severely injured (ISS: 16 vs. 5, p 0.0001), had more severe head injuries (Head AIS: 2.9 vs. 1.3, p 0.0001), and higher mortality (11% vs. 3%, p = 0.001). Patients who received drug-specific agents (idarucizumab, andexanet alfa) had higher mortality (30% vs. 8%, p = 0.04) than those reversed with factor concentrates. However, the low usage of drug-specific reversal agents limits our ability to assess their efficacy and safety.DOAC reversal was not independently associated with mortality. At present, the overall usage of drug-specific reversal agents is too sparing to meaningfully assess outcomes in trauma.

Objective To find clinical or radiographic factors that are associated with angioembolization failure after high-grade renal trauma. Material and Methods Patients were selected from the Multi-institutional Genito-Urinary Trauma Study. Included were patients who initially received renal angioembolization after high-grade renal trauma (AAST grades III-V). This cohort was dichotomized into successful or failed angioembolization. Angioembolization was considered a failure if angioembolization was followed by repeat angiography and/or an exploratory laparotomy. Results A total of 67 patients underwent management initially with angioembolization, with failure in 18 (27%) patients. Those with failed angioembolization had a larger proportion ofgrade IV (72% vs 53%) and grade V (22% vs 12%) renal injuries. A total of 53 patients underwent renal angioembolization and had initial radiographic data for review, with failure in 13 cases. The failed renal angioembolization group had larger perirenal hematoma sizes on the initial trauma scan. Conclusion Angioembolization after high-grade renal trauma failed in 27% of patients. Failed angioembolization was associated with higher injury grade and a larger perirenal hematoma. Likely these characteristics are associated with high-grade renal trauma that may be less amenable to successful treatment after a single renal angioembolization.

In 2018 the American Association for the Surgery of Trauma revised renal injury grading. One change was inclusion of segmental kidney infarction under grade IV injuries. We aimed to assess how segmental kidney infarction will change the scope of grade IV injuries and compare bleeding control interventions in those with and without isolated segmental kidney infarction.We used high grade renal trauma data from 7 level 1 trauma centers from 2013 to 2018 as part of the Multi-institutional Genito-Urinary Trauma Study. Initial computerized tomography scans were reviewed to regrade the injuries. Injuries were categorized as isolated segmental kidney infarction if segmental parenchymal infarction was the only reason for inclusion under grade IV injury. All other grade IV injuries (including combined injury patterns) were categorized as without isolated segmental kidney infarction. Bleeding interventions were compared between those with and without isolated segmental kidney infarction.From 550 patients with high grade renal trauma and available computerized tomography, 250 (45%) were grade IV according to the 2018 American Association for the Surgery of Trauma grading system. Of these, 121 (48%) had isolated segmental kidney infarction. The majority of patients with isolated segmental kidney infarction (88%) would have been assigned a lower grade using the original 1989 grading system. Rate of bleeding control interventions was lower in isolated segmental kidney infarction compared to other grade IV injuries (7% vs 21%, p=0.002). Downgrading all patients with isolated segmental kidney infarction to grade III did not change the grading system's associations with bleeding interventions.Approximately half of the 2018 American Association for the Surgery of Trauma grade IV injuries have isolated segmental kidney infarction. Including isolated segmental kidney infarction in grade IV injuries increases the heterogeneity of these injuries without increasing the grading system's ability to predict bleeding interventions. In future iterations of the American Association for the Surgery of Trauma renal trauma grading isolated segmental kidney infarction could be reclassified as grade III injury.

BackgroundEmergency general surgery (EGS) diseases carry a substantial public health burden, accounting for over 3 million admissions annually. Due to their time-sensitive nature, ensuring adequate access to EGS services is critical for reducing patient morbidity and mortality. Travel-time alone, without consideration of resource supply and demand, may be insufficient to determine a regional health care system’s ability to provide timely access to EGS care. Spatial Access Ratio (SPAR) incorporates travel-time, as well as hospital-specific resources and capacity, to determine healthcare accessibility which may be more appropriate for surgical specialties. We therefore compared SPAR to travel-time in their ability to differentiate spatial access to EGS care for vulnerable populations.MethodsWe constructed a Geographic Information Science (GIS) platform using existing road networks, and mapped population location, race and socioeconomic characteristics, as well as all EGS-capable hospitals in California. We then compared the shortest travel time method to the gravity-based SPAR in their ability to identify disparities in spatial access for the population as a whole, and subsequently to describe socio-demographic disparities. Reduced spatial access was defined at > 60 minutes travel time, or lowest three classes of SPAR.Results283 EGS-capable hospitals were mapped, 142 (50%) of which had advanced resources. Using shortest travel time, 36.98M people (94.8%) were within 20-minutes driving time to any EGS capable hospital, and 33.49M (85.9%) to an advanced-resourced center. Only 166, 950 (0.4%) experienced prolonged (>60 minutes) travel time to any EGS-capable hospital, which increased to 1.05M (2.7%) for advanced-resources. Using SPAR, 11.5M (29.5%) of people had reduced spatial access to any EGS hospital, which increased to 13.9M (35.7%) when evaluating advanced-resource hospitals. The greatest disparities in spatial access to care were found for rural residents and Native Americans for both overall and advanced EGS services.ConclusionsWhile travel time and SPAR showed similar overall patterns of spatial access to EGS-capable hospitals, SPAR showed greater differentiation of spatial access across the state. Nearly one-third of California residents have limited or poor access to EGS hospitals, with the greatest disparities noted for Native American and rural residents. These findings argue for the use of gravity-based models such as SPAR that incorporate measures of population demand and hospital capacity when assessing spatial access to surgical services, and have implications for the allocation of healthcare resources to address disparities.

INTRODUCTION AND OBJECTIVE:A multi-institutional nomogram incorporating clinical and radiologic factors has been previously developed to predict bleeding interventions after high-grade renal trauma...

INTRODUCTION AND OBJECTIVE:Nephrectomy can be avoided in most patients even in cases of high-grade renal trauma (HGRT). The reasons for nephrectomy after trauma are complex but it is often done in ...

As trauma surgeons, we focus on the immediate care and needs of the injured patient every day. Historically, trauma and injury research has focused on outcomes such as mortality, complications, and length of stay; and process metrics such as time to CT scan, resuscitation checklist frequencies, or venous thromboembolism prophylaxis rates. These outcomes are perceived by healthcare providers to be important, but patients likely have different perceptions of what outcomes are most important to measure and improve. True patient-centered outcomes research involves the healthcare providers, and the entire team of stakeholders including patients and the community. Understanding the process of stakeholder engagement and the barriers trauma researchers must overcome to effectively enter this field of research is important. This summary aims to inform the trauma research community on the basics of patient-centered outcomes research, priorities for funding from the Patient-Centered Outcomes Research Institute, resources for collaboration around patient-centered outcomes research, and a unique career development and training opportunity for early career trauma surgeons to develop a skill set in patient-centered outcomes research.

Brain Trauma Foundation (BTF) guidelines reflect evidence-based best practices in management of traumatic brain injury. The aim of this study was to examine self-reported physician compliance and predictors of compliance related to BTF guidelines.We conducted an international, multidisciplinary survey examining self-reported adherence to BTF guidelines and multiple factors potentially affecting adherence. We also surveyed intracranial pressure monitoring practices.Of 154 physician respondents, 15.9% reported their institutions "always" follow BTF guidelines and 72.2% reported that they follow them "most of the time." Personal volume of traumatic brain injury cases and years in practice were not significantly related to adherence. Reported adherence varied significantly in association with respondent's institutional trauma level (P = 0.0010): 17.3% of practitioners at level I, 13.0% at level II, and 0% at level III trauma centers reported "always" following guidelines. Reported adherence to guidelines also varied significantly in association with provider specialty (P = 0.015) and institutional volume of severe traumatic brain injury cases (P = 0.008). Regarding intracranial pressure monitoring practices, 52% of respondents used external ventricular drains, 21% used intraparenchymal monitors, and 27% had no preference (P0.001). Of respondents not routinely using external ventricular drains, 36% claimed to "always" follow guidelines. There was no apparent association between type of intracranial pressure monitoring used and reported guideline adherence.Few respondents reported their institutions "always" follow BTF guidelines. General surgeons and providers at high-volume level I trauma centers were more likely to comply with guidelines. Differences in survey responses based on provider and institutional characteristics may help target educational efforts.

Beta blockers, a class of medications that inhibit endogenous catecholamines interaction with beta adrenergic receptors, are often administered to patients hospitalized after traumatic brain injury (TBI). We tested the hypothesis that beta blocker use after TBI is associated with lower mortality, and secondarily compared propranolol to other beta blockers.The American Association for the Surgery of Trauma Clinical Trial Group conducted a multi-institutional, prospective, observational trial in which adult TBI patients who required intensive care unit admission were compared based on beta blocker administration.From January 2015 to January 2017, 2,252 patients were analyzed from 15 trauma centers in the United States and Canada with 49.7% receiving beta blockers. Most patients (56.3%) received the first beta blocker dose by hospital day 1. Those patients who received beta blockers were older (56.7 years vs. 48.6 years, p0.001) and had higher head Abbreviated Injury Scale scores (3.6 vs. 3.4, p0.001). Similarities were noted when comparing sex, admission hypotension, mean Injury Severity Score, and mean Glasgow Coma Scale. Unadjusted mortality was lower for patients receiving beta blockers (13.8% vs. 17.7%, p = 0.013). Multivariable regression determined that beta blockers were associated with lower mortality (adjusted odds ratio, 0.35; p0.001), and propranolol was superior to other beta blockers (adjusted odds ratio, 0.51, p = 0.010). A Cox-regression model using a time-dependent variable demonstrated a survival benefit for patients receiving beta blockers (adjusted hazard ratio, 0.42, p0.001) and propranolol was superior to other beta blockers (adjusted hazard ratio, 0.50, p = 0.003).Administration of beta blockers after TBI was associated with improved survival, before and after adjusting for the more severe injuries observed in the treatment cohort. This study provides a robust evaluation of the effects of beta blockers on TBI outcomes that supports the initiation of a multi-institutional randomized control trial.Therapeutic/care management, level III.

INTRODUCTIONPatients with nontraumatic acute intracranial pathology benefit from neurointensivist care. Similarly, trauma patients with and without traumatic brain injury (TBI) fare better when treated by a dedicated trauma team. No study has yet evaluated the role of specialized neurocritical (NICU

Author(s): Keihani, Sorena; Rogers, Douglas M; Putbrese, Bryn E; Anderson, Ross E; Stoddard, Gregory J; Nirula, Raminder; Luo-Owen, Xian; Mukherjee, Kaushik; Morris, Bradley J; Majercik, Sarah; Piotrowski, Joshua; Dodgion, Christopher M; Schwartz, Ian; Elliott, Sean P; DeSoucy, Erik S; Zakaluzny, Scott; Sherwood, Brenton G; Erickson, Bradley A; Baradaran, Nima; Breyer, Benjamin N; Fick, Cameron N; Smith, Brian P; Okafor, Barbara U; Askari, Reza; Miller, Brandi D; Santucci, Richard A; Carrick, Matthew M; Allen, LaDonna; Norwood, Scott; Hewitt, Timothy; Burks, Frank N; Heilbrun, Marta E; Gross, Joel A; Myers, Jeremy B; in conjunction with the Trauma and Urologic Reconstruction Network of Surgeons | Abstract: BackgroundIn 2018, the American Association for the Surgery of Trauma (AAST) published revisions to the renal injury grading system to reflect the increased reliance on computed tomography scans and non-operative management of high-grade renal trauma (HGRT). We aimed to evaluate how these revisions will change the grading of HGRT and if it outperforms the original 1989 grading in predicting bleeding control interventions.MethodsData on HGRT were collected from 14 Level-1 trauma centers from 2014 to 2017. Patients with initial computed tomography scans were included. Two radiologists reviewed the scans to regrade the injuries according to the 1989 and 2018 AAST grading systems. Descriptive statistics were used to assess grade reclassifications. Mixed-effect multivariable logistic regression was used to measure the predictive ability of each grading system. The areas under the curves were compared.ResultsOf the 322 injuries included, 27.0% were upgraded, 3.4% were downgraded, and 69.5% remained unchanged. Of the injuries graded as III or lower using the 1989 AAST, 33.5% were upgraded to grade IV using the 2018 AAST. Of the grade V injuries, 58.8% were downgraded using the 2018 AAST. There was no statistically significant difference in the overall areas under the curves between the 2018 and 1989 AAST grading system for predicting bleeding interventions (0.72 vs. 0.68, p = 0.34).ConclusionAbout one third of the injuries previously classified as grade III will be upgraded to grade IV using the 2018 AAST, which adds to the heterogeneity of grade IV injuries. Although the 2018 AAST grading provides more anatomic details on injury patterns and includes important radiologic findings, it did not outperform the 1989 AAST grading in predicting bleeding interventions.Level of evidencePrognostic and Epidemiological Study, level III.

Trauma surgery moves fast. Clinical decisions and treatment of injured patients must occur expeditiously, or patients suffer. Trauma research also moves fast, and new high-quality studies about treatment of injured patients frequently reshape the field and our understanding of best practices. Historically, medicine relied on the dissemination of best practices through publication of manuscripts and the endorsement of trusted physicians to change practices. However, implementation of research has proven to be slow. When research does not reach the bedside, patients are not offered proven therapies or are treated with dated or ineffective therapies. Implementation science, or the rigorous studying of the timely uptake of evidence into routine practice, is the next vital frontier in surgery,1 with the potential to have a profound positive effect on the care provided to our patients. The purpose of this paper is to describe the principles of implementation science and propose their wider use in trauma care. This paper is published as an initiative of the Coalition for National Trauma Research (CNTR) to further advance high-quality research and promote sustainable research funding to improve the care of injured patients, commensurate with the burden of disease in the USA. We will review definitions of implementation, dissemination, and de-implementation, as well as research frameworks, study design, and funding opportunities. Implementation science is an umbrella term that includes implementation research, dissemination research, and de-implementation research. The key with implementation science is focusing on “how to do it” rather than “what to do.” As a result, the outcomes of interest are not those typically considered in outcomes research such as mortality or morbidity. To study implementation, we assume that the “best practice” treatment is already known. Implementation science focuses on how to obtain sustained use of the best practice treatment in real-world settings. Implementation research is the study …

High-quality clinical trials are needed to advance the care of injured patients. Traditional randomized clinical trials in trauma have challenges in generating new knowledge due to many issues, including logistical difficulties performing individual randomization, unclear pretrial estimates of treatment effect leading to often unpowered studies, and difficulty assessing the generalizability of an intervention given the heterogeneity of both patients and trauma centers. In this review, we discuss alternative clinical trial designs that can address some of these difficulties. These include pragmatic trials, cluster randomization, cluster randomized stepped wedge designs, factorial trials, and adaptive designs. Additionally, we discuss how Bayesian methods of inference may provide more knowledge to trauma and acute care surgeons compared with traditional, frequentist methods.

Background It is unknown whether replacing clinic follow-up visits with telephone follow-up for low-risk core emergency general surgery (cEGS) procedures is safe. We measured the efficacy of telephone follow-up to determine if it could safely reduce the need for routine postoperative clinic visits in this population. Study Design Low-risk nonelective laparoscopic appendectomy, laparoscopic cholecystectomy, umbilical hernia, and inguinal hernia repair patients received telephone follow-up for symptoms concerning for surgical complication within 10 days of discharge. Clinic appointments were made if critical thresholds were reached. Outcomes of interest included rates of completed telephone screens, clinic visits avoided, and missed complications at 30 days postoperatively. Results Of 402 patients screened, 62 (15.4%) were scheduled for a clinic visit due to threshold responses and 27 (6.7%) were scheduled per patient request, while 275 (68.4%) patients screened negative and did not attend a clinic visit. One hundred sixty-three (59.3%) of the negative screen cohort were contacted after 30 days. Nine (5.5%) patients in this cohort were diagnosed with low-grade complications; no high-grade (Clavien-Dindo ≥ 3) complications were missed by telephone screening. Twenty surgery-related complications were identified in the full patient population; early telephone screening successfully identified the single high-grade complication. Conclusions Post-discharge telephone follow-up in cEGS patients reduced the need for clinic follow-up visits by 68%. Missed complications were infrequent and low grade; telephone screening identified the single high-grade complication. Telephone follow-up for low-risk EGS patients is safe and increases efficiency of postoperative resource use.

Background: To evaluate the current practice patterns of practitioners managing high grade renal trauma and determine perceived need for a prospective trial on the management of renal trauma. Methods: We distributed an electronic survey to members of the American Association for the Surgery of Trauma (AAST) and The Society of Genitourinary Reconstructive Surgeons (GURS). The survey evaluated demographics, interventional radiology (IR) access, and renal trauma management. Descriptive statistics were utilized to analyze participants’ responses. Results: A total of 253 practitioners responded (age 48.4±10.4 years). The majority were acute care/trauma surgeons (ACS/TS) (63.2%), followed by urologists (34.4%) practicing at level 1 trauma centers (80.6%) in 39 US states. Most participants were in practice >10 years (62.8%); and had completed an ACS/TS (53.8%), or trauma/reconstructive urology (25.7%) fellowship. Ninety-five percent (241/253) found value in renal preservation with 74% utilizing IR embolization in the last year. However, there was wide variation in threshold for angiography, low rates of renal repair (24%) or packing (20%) and half reported performing a nephrectomy within the prior year. More than 80% believed there was value in a prospective trial to evaluate a protocol to decrease nephrectomy rates in renal trauma management. Conclusions: The majority of respondents had access to IR, reported comfort in renorrhaphy, and valued renal preservation. There was variation in thresholds for bleeding intervention, and nephrectomy was still a common management strategy. There is great interest among trauma surgeons and urologists for a prospective trial of renal trauma management aimed at decreasing nephrectomy when possible.

INTRODUCTION AND OBJECTIVES:Radiologic factors are important for predicting bleeding interventions after high-grade renal trauma (HGRT). We aimed to assess the associations between laceration size ...

INTRODUCTION AND OBJECTIVES:The American Association for the Surgery of Trauma (AAST) injury scale is the most widely used grading system for renal trauma. However, reproducibility of the AAST grad...

Rib fractures are a frequently identified injury in the trauma population. Not only are multiple rib fractures painful, but they are associated with an increased risk of adverse outcomes. Pneumonia in particular can be devastating, especially to an elderly patient, but other complications such as prolonged ventilation and increased intensive care and hospital durations of stay have a negative impact on the patient. Computed tomography scan is the best modality to diagnosis rib fractures but the treatment of fractures is still evolving. Currently patient care involves a multidisciplinary approach that includes pain control, aggressive pulmonary therapy, and possibly surgical fixation.

Background Impaired microvascular function leads to a poor outcome in a variety of medical conditions. Our aim was to determine whether vasodilator responses to acetylcholine (Ach) are impaired in human omental arterioles from patients with severe trauma. Materials and methods Patients with massive blood loss and severe shock requiring damage control procedures were included. Tissues were collected at the first (FEL) and the second explorative laparotomy (SEL). Control tissues were collected from nontrauma patients. Freshly isolated 50–200-μm-diameter omental arterioles were analysed using videomicroscopy. Dihydroethidine and DCF-DA fluorescence were used to assess reactive oxygen species (ROS) production. MnTBAP was used to determine the contribution of excess vascular superoxide contribution to endothelial dysfunction. Results After constriction (30–50%) with endothelin-1, dilation to graded doses of Ach (10−9–10−4 M) was greater in control vessels compared to FEL and SEL (max dilation at 10−4 M (MD) = 25 ± 3%, n = 8; and 59 ± 8%, n = 8, respectively, and controls MD = 93 ± 10%, n = 6, P < 0·05). Fluorescence imaging of ROS production showed significant increases in superoxide (225·46 ± 12·86; 215·77 ± 10·75 vs. 133·75 ± 7·26, arbitrary units; P < 0·05) and peroxide-related ROS (240·8 ± 20·42; 234·59 ± 28·86, vs. 150·78 ± 15·65, arbitrary units; P < 0·05), in FEL and SEL microvessels compared to control, respectively. FEL pretreated with MnTBAP demonstrated significant improvement in Ach-induced vasodilation (25·5 ± 3·0% vs. 79·5 ± 8·2%; P < 0·05). Conclusions Severe shock associated with microvascular endothelial dysfunction enhances production of ROS in human omental tissues. The altered flow regulation may contribute to a mismatch between local blood supply and demand, exacerbating abnormal tissue perfusion and function.

Background The current management paradigm for recurrent adhesive small bowel obstruction (SBO) is nonoperative. Rates of recurrence differ based on time interval between and number of previous occurrences. Optimal time to intervene has not been determined. Methods We constructed a Markov model to evaluate costs and quality of life on a hypothetical cohort of 40-year-old patients after their first episode of medical management for postoperative SBO. We estimated a relative risk reduction of .55 with surgical intervention and a relative risk increase of 2.1, 2.9, and 5.7 after the medical management of the 2nd, 3rd, and 4th SBO. Results Surgery performed after earlier episodes of SBO was more costly but also more effective. The cost difference between surgery after the 1st SBO recurrence vs the 2nd SBO recurrence was $1,643, with an increase of .135 quality-adjusted life years (QALYs), the incremental cost-effectiveness ratio was $12,170 per QALY. Conclusions Surgery after the first episode of SBO provides a small increase in QALY at a small cost since surgical intervention lowers the risk of recurrence.