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During the pandemic, hospitals implemented disaster plans to conserve resources while maintaining patient care. It was unclear how these plans impacted injury care and trauma surgeons.A 16 question survey assessing COVID-related hospital policy and resource allocation pre-COVID-19 peak (March), and a 19 question post-peak (June) survey was distributed to Trauma/Critical Care attending's via social media and the Western Trauma Association member email list.There were 120 pre- and 134 post-peak respondents. Most (95%) altered trauma PPE components, a nd 67% noted changes in their admission population pre-peak while 80% did so post-peak. Penetrating injury increased 56% at Level 1 centers and 27% at Level 2 centers. Altered ICU and transfusion criteria were noted with 25% relocating TBI patients, 17% revised rib fracture admission criteria, and 23% adjusted transfusion practices. Importantly, 12% changed their massive transfusion protocol, with 11% reducing the symptomatic transfusion threshold from 7 g/dL to 6 g/dL. Half (50%) disclosed impediments to patient care including PPE shortages and COVID test-related procedural delay (Fig. 2). While only 14% felt their institution was overwhelmed by COVID, the vast majority (81%) shared durable concerns about personal health and safety.Disparate approaches to COVID-19 preparedness and response characterize survey respondent facility actions. These disparities, especially between Level 1 and Level 2 centers, represent opportunities for the trauma community to coordinate best-practice planning and implementation in light of future consequence infection or pandemic care.

Unplanned hospital admission after intended outpatient surgery is an undesirable outcome. We aimed to develop a prediction model that estimates a patient's risk of conversion from outpatient surgery to inpatient hospitalization.This was a retrospective analysis using the American College of Surgeons National Surgical Quality Improvement Program database, 2005 to 2018. Conversion from outpatient to inpatient surgery was defined as having outpatient surgery and1 day hospital stay. The Surgical Risk Preoperative Assessment System was developed using multiple logistic regression on a training dataset (2005-2016) and compared to a model using the 26 relevant variables in the American College of Surgeons National Surgical Quality Improvement Program. The Surgical Risk Preoperative Assessment System was validated using a testing dataset (2017-2018). Performance statistics and Hosmer-Lemeshow plots were compared. Two high-risk definitions were compared: (1) the maximum Youden index, and (2) the cohort above the tenth decile of risk on the Hosmer-Lemeshow plot. The sensitivities, specificities, positive predictive values, negative predictive values, and accuracies were compared.In all, 2,822,379 patients were included; 3.6% of patients unexpectedly converted to inpatient. The 6-variable Surgical Risk Preoperative Assessment System model performed comparably to the 26-variable American College of Surgeons National Surgical Quality Improvement Program model (c-indices = 0.818 vs. 0.823; Brier scores = 0.0308 vs 0.0306, respectively). The Surgical Risk Preoperative Assessment System performed well on internal validation (c-index = 0.818, Brier score = 0.0341). The tenth decile of risk definition had higher specificity, positive predictive values, and accuracy than the maximum Youden index definition, while having lower sensitivity.The Surgical Risk Preoperative Assessment System accurately predicted a patient's risk of unplanned outpatient-to-inpatient conversion. Patients at higher risk should be considered for inpatient surgery, while lower risk patients could safely undergo operations at ambulatory surgery centers.

Supplementary Figure 2. PMA/ionomycin and anti-CD3/anti-CD28 induce up-regulation of PD-1 and Tim-3. Non-adherent cells from TILN were left untreated (US) or stimulated with anti-CD3/anti-CD28 or PMA/ionomycin (P/I) for 6 hours to assess cytokine expression. Expression of PD-1 and Tim-3 was analyzed concomitantly by flow cytometry.

Regional metastatic differentiated thyroid cancer (mDTC) provides a unique model in which to study the tumor–immune interface. These lymph node metastases persist for years, generally without progression to distant metastases. Although the immune system likely impedes disease progression, it is unsuccessful in eliminating disease. Our previous studies revealed that programmed death-1 (PD-1)+ T cells were enriched in tumor-involved lymph nodes (TILN). Tumor-associated leukocytes and tumor cells were collected from grossly involved lymph nodes from 12 patients to further characterize the phenotype and functional potential of mDTC-associated PD-1+ T cells. PD-1+CD4+ and PD-1+CD8+ T cells were enriched in 8 of 12 TILN samples. PD-1+ T cells coexpressed Tim-3 and CD69 and failed to downregulate CD27. CD8+ T cells, but not CD4+ T cells, from these samples were variably deficient in their ability to produce effector cytokines when compared with control TILNs that lacked resident PD-1+ T cells. PD-1+CD8+ T cells were capable of exocytosis but lacked intracellular perforin. Surprisingly, T-cell proliferative capacity was largely maintained in all samples. Thus, although PD-1 expression by mDTC-associated CD8+ T cells was associated with dysfunction, exhaustion was not complete. Notably, molecular markers of exhaustion did not translate to dysfunction in all samples or in CD4+ T cells. Regulatory T cells (Treg), PD-L1, and galectin-9 were commonly found in mDTC and likely contributed to the initiation of T-cell exhaustion and disease progression. Therapies that release the effects of PD-1 and Tim-3 and reduce the suppressive effects of Tregs may encourage tumor elimination in patients with mDTC. Cancer Immunol Res; 3(6); 620–30. ©2015 AACR.

Supplementary Figure 3. Stimulated Cytokine Production in Peripheral Blood T Cells. Lymphocytes from peripheral blood (A) or normal LN (B) were stimulated with PMA/ionomycin and analyzed by flow cytometry for cytokine expression. CD8+ or CD4+ T cells from PD-1loTim-3- (filled shapes) and PD-1+Tim-3+ (open shapes) TILN were compared for frequencies of IL-2+, TNFα+, and IFNγ+ cells. Mean and SEM are shown. No statistically significant differences were observed.

Supplementary Figure 1. PD-1+ T cells in TILN are largely CD45RO+RA-CCR7- effector memory cells (TEM). T cells from PB, normal lymph node, and TILN sections from patients 11 and 12 were analyzed by flow cytometry. CD8+ and CD4+ CD3+ T cells were gated assessed for expression of CD45RA, CD45RO, CCR7 and CD62L. PD-1+ populations were analyzed for memory marker phenotype in patients 11 and 12.

BACKGROUND: Pulmonary vascular microthrombi are a proposed mechanism of COVID-19 respiratory failure. We hypothesized that early administration of tissue plasminogen activator (tPA) followed by therapeutic heparin would improve pulmonary function in these patients. RESEARCH QUESTION: Does tPA improve pulmonary function in severe COVID-19 respiratory failure, and is it safe? STUDY DESIGN AND METHODS: Adults with COVID-19-induced respiratory failure were randomized from May14, 2020 through March 3, 2021, in two phases. Phase 1 (n = 36) comprised a control group (standard-of-care treatment) vs a tPA bolus (50-mg tPA IV bolus followed by 7 days of heparin; goal activated partial thromboplastin time [aPTT], 60-80 s) group. Phase 2 (n = 14) comprised a control group vs a tPA drip (50-mg tPA IV bolus, followed by tPA drip 2 mg/h plus heparin 500 units/h over 24 h, then heparin to maintain aPTT of 60-80 s for 7 days) group. Patients were excluded from enrollment if they had not undergone a neurologic examination or cross-sectional brain imaging within the previous 4.5 h to rule out stroke and potential for hemorrhagic conversion. The primary outcome was Pao2 to Fio2 ratio improvement from baseline at 48 h after randomization. Secondary outcomes included Pao2 to Fio2 ratio improvement of > 50% or Pao2 to Fio2 ratio of ≥ 200 at 48 h (composite outcome), ventilator-free days (VFD), and mortality. RESULTS: Fifty patients were randomized: 17 in the control group and 19 in the tPA bolus group in phase 1 and eight in the control group and six in the tPA drip group in phase 2. No severe bleeding events occurred. In the tPA bolus group, the Pao2 to Fio2 ratio was significantly (P < .017) higher than baseline at 6 through 168 h after randomization; the control group showed no significant improvements. Among patients receiving a tPA bolus, the Pao2 to Fio2 ratio at 48 h (16.9% [interquartile range (IQR), -8.3% to 36.8%] vs 29.8% [IQR, 4.5%-88.7%]; P = .11), the composite outcome (11.8% vs 47.4%; P = .03), VFD (0.0 [IQR, 0.0-9.0] vs 12.0 [IQR, 0.0-19.0]; P = .11), and in-hospital mortality (41.2% vs 21.1%; P = .19) did not reach statistically significant differences when compared with those of control participants. The patients who received a tPA drip did not experience benefit. INTERPRETATION: The combination of tPA bolus plus heparin is safe in severe COVID-19 respiratory failure. A phase 3 study is warranted given the improvements in oxygenation and promising observations in VFD and mortality. TRIAL REGISTRY: ClinicalTrials.gov; No.: NCT04357730; URL: www.clinicaltrials.gov.

Background Military data demonstrating an improved survival rate with whole blood (WB) have led to a shift toward the use of WB in civilian trauma. The purpose of this study is to compare a low-titer group O WB (LTOWB) massive transfusion protocol (MTP) to conventional blood component therapy (BCT) MTP in civilian trauma patients. Methods Trauma patients 15 years or older who had MTP activations from February 2019 to December 2020 were included. Patients with a LTOWB MTP activation were compared to BCT MTP patients from a historic cohort. Results 299 patients were identified, 169 received LTOWB and 130 received BCT. There were no differences in age, gender, or injury type. The Injury Severity Score was higher in the BCT group (27 vs 25, P = .006). The LTOWB group had a longer transport time (33 min vs 26 min, P < .001) and a lower arrival temperature (35.8 vs 36.1, P < .001). Other hemodynamic parameters were similar between the groups. The LTOWB group had a lower in-hospital mortality rate compared to the BCT group (19.5% vs 30.0%, P = .035). There were no differences in total transfusion volumes at 4 hours and 24 hours. No differences were seen in transfusion reactions or hospital complications. Multivariable logistic regression identified ISS, age, and 24-hour transfusion volume as predictors of mortality. Discussion Resuscitating severely injured trauma patient with LTOWB is safe and may be associated with an improved survival.

Background The Surgical Risk Preoperative Assessment System (SURPAS) uses eight variables to accurately predict postoperative complications but has not been sufficiently studied in emergency surgery. We evaluated SURPAS in emergency surgery, comparing it to the Emergency Surgery Score (ESS). Methods SURPAS and ESS estimates of 30-day mortality and overall morbidity were calculated for emergency operations in the 2009–2018 ACS-NSQIP database and compared using observed-to-expected plots and rates, c-indices, and Brier scores. Cases with incomplete data were excluded. Results In 205,318 emergency patients, SURPAS underestimated (8.1%; 35.9%) while ESS overestimated (10.1%; 43.8%) observed mortality and morbidity (8.9%; 38.8%). Each showed good calibration on observed-to-expected plots. SURPAS had better c-indices (0.855 vs 0.848 mortality; 0.802 vs 0.755 morbidity), while the Brier score was better for ESS for mortality (0.0666 vs. 0.0684) and for SURPAS for morbidity (0.1772 vs. 0.1950). Conclusions SURPAS accurately predicted mortality and morbidity in emergency surgery using eight predictor variables.

Objective: EMS use of lights and sirens has long been employed in EMS systems, despite an increased risk of motor vehicle collisions associated with their use. The specific aims of this study were ...

Introduction: The role of resuscitative thoracotomy in the emergency department (ED) for patients that have suffered severe thoracoabdominal trauma has been the subject of much debate. Most studies that characterize emergency thoracotomy are from urban, academic, and trauma centers. We sought to describe patient and hospital characteristics of a nationally representative sample of ED thoracotomy (EDT). Methods: The health-care cost and utilization project 2013 National ED Sample (NEDS) and the 2013 National Inpatient Sample (NIS) maintained by the agency for health-care research and quality were used to generate a nationally representative estimate of resuscitative thoracotomies performed in the ED. We obtained patient demographics and clinical characteristics and compared the descriptive statistics of the two datasets. Results: The NEDS dataset identified 124 unsuccessful EDTs, whereas the NIS dataset identified 77 admissions for thoracotomy. When weighted to create a national estimate, these represent 952 emergency thoracotomies performed in the US in 2013. Most were male (82.5% and 88.2% in NEDS and NIS, respectively). In addition, 32.9% and 36.4% in NEDS and NIS, respectively, were between the ages of 20 and 29. The majority of thoracotomies were performed at metropolitan teaching hospitals (64.2% and 75.3%, NEDS and NIS, respectively). The mean total ED charges for patients who had an unsuccessful thoracotomy were $32,664 and the mean total inpatient charges were $141,215. Conclusion: Nearly 1000 thoracotomies are performed annually on the day of presentation to U. S. hospitals. Although emergency thoracotomy for trauma is an infrequently performed procedure, it almost always occurs at an urban, high volume, and level I or level II trauma centers.

The modified Brain Injury Guidelines (mBIG) are an algorithm for treating patients with traumatic brain injury and intracranial hemorrhage by which selected patients do not require a repeat head computed tomography, a neurosurgery consult, or even an admission. The mBIG refined the original Brain Injury Guidelines (BIG) to improve safety and reproducibility. The purpose of this study is to assess safety and resource utilization with mBIG implementation.The mBIG were implemented at three Level I trauma centers in August 2017. A multicenter retrospective review of prospectively collected data was performed on adult mBIG 1 and 2 patients. The post-mBIG implementation period (August 2017 to February 2021) was compared with a previous BIG retrospective evaluation (January 2014 to December 2016).There were 764 patients in the two study periods. No differences were identified in demographics, Injury Severity Score, or admission Glasgow Coma Scale score. Fewer computed tomography scans (2 [1,2] vs. 2 [2,3], p0.0001) and neurosurgery consults (61.9% vs. 95.9%, p0.0001) were obtained post-mBIG implementation. Hospital (2 [1,4] vs. 2 [2,4], p = 0.013) and intensive care unit (0 [0,1] vs. 1 [1,2], p0.0001) length of stay were shorter after mBIG implementation. No difference was seen in the rate of clinical or radiographic progression, neurosurgery operations, or mortality between the two groups.After mBIG implementation, eight patients (1.6%) worsened clinically. Six patients that clinically progressed were discharged with Glasgow Coma Scale score of 15 without needing neurosurgery intervention. One patient had clinical and radiographic decompensation and required craniotomy. Another patient worsened clinically and radiographically, but due to metastatic cancer, elected to pursue comfort measures and died.This prospective validation shows the mBIG are safe, pragmatic, and can dramatically improve resource utilization when implemented.Therapeutic/Care Management; Level III.

Introduction Rural compared to urban populations in the US have increased colorectal cancer (CRC) incidence with known disparity in screening rates and mortality. We hypothesize that rural-urban disparities are different at a regional level. Methods We assessed screening rates according to the 2016 Behavioral Risk Factor Surveillance System guidelines using state and city-level data for county level estimates and correlating with county CRC mortality data from the National Cancer Institute. We used multivariable modeling to examine associations between rurality, screening rates, and mortality. Results Highest screening rate states had the smallest urban-rural disparities; lowest screening rate states had the largest disparities. Percent screened and urban-rural classification correlated significantly with mortality. Rural counties experienced ∼5 more deaths per 100,000 population even controlling for screening rates. Conclusions National urban-rural disparities in CRC screening mask greater state/regional disparities, not fully explaining the urban-rural mortality gap. Other factors (i.e. access to care, treatment differences) must be considered.

Background Indications for angioembolization (AE) following liver injury are not clearly defined. This study evaluated the outcomes and complications of hepatic AE. We hypothesize hepatic angioembolization is a useful adjunct to non-operative management of liver injury but with significant morbidity. Methods Subjects were identified utilizing trauma registries from centers in a regional trauma network from 2010 to 2017 with an Abbreviated Injury Scale (AIS) coded hepatic injury and an ICD9/10 for hepatic angiography (HA). Results 1319 patients with liver injuries were identified, with 30 (2.3%) patients undergoing HA: median ISS was 26, and median liver AIS was 4. Twenty-three subjects required AE. 81% had extravasation on CT from a liver injury. 63% underwent HA as initial intervention. 43% of AE subjects had liver-related complications with 35% 30-day readmission but with zero 30-day mortality. Conclusions While there were zero reported deaths, a high rate of morbidity and readmission was found. This may be due to the angioembolization or the liver injury itself.

Patients suspected of syncope frequently undergo laboratory and imaging studies to determine the etiology of the syncope. Variability exists in these workups across institutions. The purpose of this study was to evaluate the utilization and diagnostic yield of these workups and the patient characteristics associated with syncopal falls.A multi-institutional retrospective review was performed on adult patients admitted after a fall between 1/2017-12/2018. Syncopal falls were compared to non-syncopal falls.4478 patients were included. There were 795 (18%) patients with a syncopal fall. Electrocardiogram, troponin, echocardiogram, CT angiography (CTA), and carotid ultrasound were more frequently tested in syncope patients compared to non-syncope patients. Syncope patients had higher rates of positive telemetry/Holter monitoring, CTAs, and electroencephalograms.Patients who sustain syncopal falls frequently undergo diagnostic testing without a higher yield to determine the etiology of syncope.

Prehospital identification of the injured patient likely to require emergent care remains a challenge. End-tidal carbon dioxide (ETCO2) has been used in the prehospital setting to monitor respiratory physiology and confirmation of endotracheal tube placement. Low levels of ETCO2 have been demonstrated to correlate with injury severity and mortality in a number of in-hospital studies. We hypothesized that prehospital ETCO2 values would be predictive of mortality and need for massive transfusion (MT) in intubated patients.This was a retrospective multicenter trial with 24 participating centers. Prehospital, emergency department, and hospital values were collected. Receiver operating characteristic curves were created and compared. Massive transfusion defined as10 U of blood in 6 hours or death in 6 hours with at least 1 U of blood transfused.A total of 1,324 patients were enrolled. ETCO2 (area under the receiver operating characteristic curve [AUROC], 0.67; confidence interval [CI], 0.63-0.71) was better in predicting mortality than shock index (SI) (AUROC, 0.55; CI, 0.50-0.60) and systolic blood pressure (SBP) (AUROC, 0.58; CI, 0.53-0.62) (p0.0005). Prehospital lowest ETCO2 (AUROC, 0.69; CI, 0.64-0.75), SBP (AUROC, 0.75; CI, 0.70-0.81), and SI (AUROC, 0.74; CI, 0.68-0.79) were all predictive of MT. Analysis of patients with normotension demonstrated lowest prehospital ETCO2 (AUROC, 0.66; CI, 0.61-0.71), which was more predictive of mortality than SBP (AUROC, 0.52; CI, 0.47-0.58) or SI (AUROC, 0.56; CI, 0.50-0.62) (p0.001). Lowest prehospital ETCO2 (AUROC, 0.75; CI, 0.65-0.84), SBP (AUROC, 0.63; CI, 0.54-0.74), and SI (AUROC, 0.64; CI, 0.54-0.75) were predictive of MT in normotensive patients. ETCO2 cutoff for MT was 26 mm Hg. The positive predictive value was 16.1%, and negative predictive value was high at 98.1%.Prehospital ETCO2 is predictive of mortality and MT. ETCO2 outperformed traditional measures such as SBP and SI in the prediction of mortality. ETCO2 may outperform traditional measures in predicting need for transfusion in occult shock.Diagnostic test, level III.

BACKGROUND Geriatric trauma rates are increasing, yet trauma centers often struggle to provide autonomy regarding decision making to these patients. Advance care planning can assist with this process. Currently, there are limited data on the impact of advance directives (AD) in elderly trauma patients. The purpose of this study was to evaluate the prevalence of pre-injury AD in geriatric trauma patients and its impact on outcomes, with the hypothesis that ADs would not be associated with an increase in mortality. METHODS A multi-center retrospective review was conducted on patients older than 65 with traumatic injury between 2017 and 2019. Three level I trauma centers and one level II trauma center were included. Exclusion criteria were readmission, burn injury, transfer to another facility, discharge from emergency department, and mortality prior to being admitted. RESULTS There were 6,135 patients identified; 751 (12.2%) had a pre-injury AD. Patients in the AD+group were older (86 vs 77 years, p < 0.0001), more likely to be female (67% vs 54.8%, p < 0.0001), and had more comorbidities. Hospital length of stay and ventilator days were similar. In-hospital mortality occurred in 236 patients and 75.4% of them underwent withdrawal of care (WOC). The mortality rate was higher in AD+ group (10.5% vs 2.9%, p < 0.0001). No difference was seen in the rate of AD between the WOC+ and WOC- group (31.5% vs 39.6%, p = 0.251). A pre-injury AD was identified as an independent predictor of mortality, but not a predictor of WOC. CONCLUSION Despite a high WOC rate in patients over 65, most patients did not have an AD prior to injury. As the elderly trauma population grows, advance care planning should be better integrated into geriatric care to encourage a patient-centered approach to end-of-life care. LEVEL OF EVIDENCE Level IV. STUDY TYPE Prognostic and epidemiological.

Neighborhood measures of social vulnerability encompassing multiple sociodemographic factors can be used to quantify disparities in outcomes. We hypothesize patients with high Social Vulnerability Index (SVI) are at increased risk of morbidity following colectomy.We used local 2012-2017 National Surgical Quality Improvement Program (NSQIP) data to study colectomy patients, examining associations between SVI and postoperative outcomes.We included 976 patients from five hospitals. High SVI (75th percentile) was associated with increased postoperative morbidity on unadjusted analysis (OR 1.84, 95% CI 1.35-2.52, p 0.001); this association persisted after adjusting for demographics and comorbidities (OR 1.63, 95% CI 1.15-2.31, p = 0.005). The association with SVI was not significant after adjusting for perioperative risk modifiers such as emergent presentation (OR 1.37, 95% CI 0.95-1.98, p = 0.10).High social vulnerability is associated with increased postoperative complications. This effect appears mediated by perioperative risk factors, suggesting potential to improve outcomes by facilitating timely surgical intervention.

Several options exist for the diagnosis and management of suspected common duct stones. We hypothesized that a protocol-directed approach would shorten length of stay in this patient population.Patients from four participating institutions with a peak bilirubin4 mg/dL underwent surgery as the initial procedure, whereas patients with a bilirubin ≥4 mg/dL underwent endoscopy. The primary endpoint was length of stay. Analysis involved chi square and Wilcoxon-Mann-Whitney test with significance at p 0.05.214 patients were managed under the protocol during six-month study period. 111 patients (52%) required endoscopy and surgery. Length of stay and the number of MRCPs performed pre-operatively significantly decreased following protocol implementation (p 0.05)."Surgery first" approach in patients with bilirubin4 ml/dL resulted in low morbidity and mortality, reduced MRCP, and length of stay.

Background Numerous in-hospital scoring systems to activate massive transfusion protocols (MTP) have been proposed; however, to date, pre-hospital scoring systems have not been robustly validated. Many trauma centers do not have blood or pre-thawed plasma available in the trauma bay, leading to delays in balanced transfusion. This study aims to assess pre-hospital injury and physiologic parameters to develop a pre-hospital scoring system predictive of need for massive transfusion (MT) prior to patient arrival. Methods A retrospective review of all adult full and partial trauma team activations from July 2014–July 2018 from an urban level 2 trauma center was performed utilizing our trauma registry. Stepwise logistic regression analysis was performed to develop a new scoring system, with point totals assigned proportional to the odds ratios of requiring MT for each variable. Internal validation of the EMS-G score was performed using a subset of the data which was not utilized for development of the scoring system, and sensitivity and specificity were compared to previously validated in-hospital scoring systems applied in the pre-hospital setting. Results 763 patients were included with 94 patients (12.3%) receiving early MT, defined as 4 units pRBC in 4 h or ED death. In-hospital models for predicting MT such as Assessment of Blood Consumption (ABC) or Shock Index (SI) have sensitivities and specificities of 46/85% and 94/79% respectively for early MTP utilization based on pre-hospital data. Pre-hospital variables found to be predictive of MT were used to develop the EMS-G (Extremity, Mechanism, Shock Index, GCS) score. This system assigns obvious extremity injury–1-point, penetrating mechanism −2 points, shock index ≥0.9–2 points, GCS ≤8–3 points. A score of 3 or greater was chosen to maximize sensitivity and specificity for pre-hospital MT activation. EMS-G score based on pre-hospital report is 89% sensitive, 84% specific, with a PPV of 44% and NPV of 98% for early MT. Using this system, 25% of full and partial trauma team activations met criteria for pre-hospital MTP activation. Conclusion The EMS-G Score has increased sensitivity and specificity compared to the ABC Score in the pre-hospital setting and appears more appropriate than shock index alone at predicting massive transfusion. This scoring system allows trauma centers to activate MTP prior to patient arrival to ensure early and appropriate blood product administration without blood product wastage.

Background End-tidal carbon dioxide (ETCO2) is routinely used during elective surgery to monitor ventilation. The role of ETCO2 monitoring in emergent trauma operations is poorly understood. We hypothesized that ETCO2 values underestimate plasma carbon dioxide (pCO2) values during resuscitation for hemorrhagic shock. Methods Multicenter trial was performed analyzing the correlation between ETCO2 and pCO2 levels. Results Two hundred fifty-six patients resulted in 587 matched pairs of ETCO2 and pCO2. Correlation between these two values was very poor with an R of 0.04. 40.2% of patients presented to the operating room acidotic and hypercarbic with a pH less than 7.30 and a pCO2 greater than 45 mm Hg. Correlation was worse in patients that were either acidotic or hypercarbic. Forty-five percent of patients have a difference greater than 10 mm Hg between ETCO2 and pCO2. A pH less than 7.30 was predictive of an ETCO2 to pCO2 difference greater than 10 mm Hg. A difference greater than 10 mm Hg was predictive of mortality independent of confounders. Conclusion Nearly one half (45%) of patients were found to have an ETCO2 level greater than 10 mm Hg discordant from their PCO2 level. Reliance on the discordant values may have contributed to the 40% of patients in the operating room that were both acidotic and hypercarbic. Early blood gas analysis is warranted, and a lower early goal of ETCO2 should be considered. Level of evidence Therapeutic, level IV.

Choledocholithiasis is present in up to 15% of cholecystectomy patients. Treatment can be surgical, endoscopic, or via interventional radiology. We hypothesized significant heterogeneity between hospitals exists in the approach to suspected common duct stones.A retrospective review of patients that had a preoperative MRCP, endoscopic ultrasound, endoscopic retrograde cholangiopancreatogram (ERCP), or intra-operative cholangiogram was performed. Comparisons were by Wilcoxon-Mann-Whitney tests with significance of p 0.05 for paired variables and p 0.017 for multiple comparisons.Twelve participating institutions identified 1263 patients (409 men and 854 women) with a median age of 49 years (IQR: 31-94). Liver function tests (LFT's) were elevated in 939 patients (75%), median bilirubin level 1.75 mg/dl (IQ: 0.8-3.7 mg/dl) and median common duct size 7 mm (IQR 5-10 mm). The most common initial procedure was cholecystectomy with IOC at seven institutions, endoscopy at four and MRCP at one.Significant variation exists within the surgical community regarding suspected common duct stones. These results underscore the need for a protocol for common duct stones to minimize multiple, redundant interventions.

Background Early blood product resuscitation reduces trauma patient mortality from hemorrhage. This mortality benefit depends on a system that can rapidly identify actively bleeding patients, initiate massive transfusion protocol (MTP), and mobilize resources to the bedside. We hypothesized that process improvement efforts that identify patients early and mobilize appropriate blood products to the bedside for immediate use would improve mortality. Study Design Pre-implementation, MTP activation was at the discretion of the trauma surgeon, and only PRBCs were immediately available. In June 2016, the Assessment of Blood Consumption (ABC) score was incorporated in our pre-hospital triage process, and a process for thawed plasma to be available was developed. We performed a retrospective review of patients who were hypotensive on arrival or had MTP activated. We compared mortality and MTP component ratios 15 months pre- vs 15 months post-implementation. Results Activations of MTP increased 6-fold, while the specificity of the process remained the same. In patients receiving MTP, appropriate blood product transfusion ratios increased 44%. Overall and penetrating trauma mortality improved by 23% and 41%, respectively. When divided by the Injury Severity Score (ISS), penetrating trauma mortality decreased by 65% for the ISS subgroup 15 to 24 and by 38% for ISS subgroup ≥ 25. Length of stay, ICU length of stay, and readmission rates were not significantly different. Conclusions Delivery of balanced blood product resuscitation is essential to confer mortality benefits. Process improvement directed at early recognition of the hemorrhagic patient, immediate product availability, and product delivery to the bedside for transfusion allows for mortality reduction without increased resource use.

Introduction Post-procedural debrief is recommended to improve patient safety. We examined operating room (OR) clinicians’ perceptions of the impact of a multi-disciplinary debrief on OR culture. Methods A survey was administered to 182 OR clinicians at a major academic medical center. Attitudes toward the surgical debrief and its effect on patient safety and OR culture were evaluated. Results Majority of clinicians (58.2%) believed creating a culture of safety in the OR was a shared care team responsibility, however, surgical attendings and trainees were more likely to assign this responsibility to the surgical attending. Few circulating nurses and trainees felt comfortable initiating a surgical debrief. Overall clinicians agreed that a debrief would impact both patient safety outcomes and OR culture. Conclusions Clinicians felt implementation of a surgical debrief would positively affect the OR culture of safety by improving interdisciplinary communication and influencing the power hierarchy that exists in many ORs.

The Bowel Injury Prediction Score (BIPS) is a tool for identifying patients at risk for blunt bowel and mesenteric injury (BBMI) requiring surgery. BIPS is calculated by assigning one point for each of the following: (1) WBC ≥ 17,000, (2) abdominal tenderness, and (3) injury grade ≥ 4 (mesenteric contusion or hematoma with bowel wall thickening or adjacent interloop fluid collection) on CT scan. A total score ≥ 2 is associated with BBMI requiring surgery. We aimed to validate the BIPS as a predictor for patients with BBMIs requiring operative intervention in a multi-center prospective study.Patients were prospectively enrolled at 15 U.S. trauma centers following blunt trauma with suspicion of BBMI on CT scan between July 1, 2018 and July 31, 2019. The BIPS was calculated for each patient enrolled in the study.Of 313 patients, 38% had BBMI requiring operative intervention. Patients were significantly more likely to require surgery in the presence of abdominal tenderness (OR, 3.6; 95% CI, 1.6-8.0) and CT grade ≥ 4 (OR, 11.7; 95% CI, 5.7-23.7). Patients with a BIPS ≥ 2 were more than ten times more likely to require laparotomy than those with a BIPS 2 (OR, 10.1; 95% CI, 5.0-20.4). The sensitivity, specificity, positive predictive value (PPV), and negative predictive value (NPV) of a BIPS ≥ 2 for BBMI requiring surgery was 72% (CI 0.6-0.8), 78% (CI 0.7-0.8), 67% (CI 0.6-0.8), and 82% (CI 0.8-0.9), respectively. The AUROC curve for BIPS ≥ 2 was 0.75. The sensitivity, specificity, PPV, and NPV of a BIPS ≥ 2 for BBMI requiring surgery in patients with severe alteration in mental status (GCS 3-8) was 70% (CI 0.5-0.9), 92% (CI 0.8-1.0), 82% (CI 0.6-1.0), and 86% (CI 0.7-1.0), respectively.This prospective multi-center trial validates BIPS as a predictor of BBMI requiring surgery. Calculation of BIPS during the initial evaluation of trauma patients is a useful adjunct to help general surgeons taking trauma call determine operative versus non-operative management of patients with BBMI including those with severe alteration in mental status.

BACKGROUND Firearm injury remains a public health crisis. Whereas there have been studies evaluating causes of death in victims of civilian public mass shootings (CPMSs), there are no large studies evaluating injuries sustained and treatments rendered in survivors. The purpose of this study was to describe these characteristics to inform ideal preparation for these events. METHODS A multicenter, retrospective study of CPMS survivors who were treated at designated trauma centers from July 1, 1999 to December 31, 2017, was performed. Prehospital and hospital variables were collected. Data are reported as median (25th percentile, 75th percentile interquartile range), and statistical analyses were carried out using Mann-Whitney U, χ2, and Kruskal-Wallis tests. Patients who died before discharge from the hospital were excluded. RESULTS Thirty-one events involving 191 patients were studied. The median number of patients seen per event was 20 (5, 106), distance to each hospital was 6 (6, 10) miles, time to arrival was 56 (37, 90) minutes, number of wounds per patient was 1 (1, 2), and Injury Severity Score was 5 (1, 17). The most common injuries were extremity fracture (37%) and lung parenchyma (14%). Twenty-nine percent of patients did not receive paramedic-level prehospital treatment. Following arrival to the hospital, 27% were discharged from the emergency department, 32% were taken directly to the operating room/interventional radiology, 16% were admitted to the intensive care unit, and 25% were admitted to the ward. Forty percent did not require advanced treatment within 12 hours. The most common operations performed within 12 hours of arrival were orthopedic (15%) and laparotomy (15%). The most common specialties consulted were orthopedics (38%) and mental health (17%). CONCLUSION Few CPMS survivors are critically injured. There is significant delay between shooting and transport. Revised triage criteria and a focus on rapid transport of the few severely injured patients are needed. LEVEL OF EVIDENCE Therapeutic/care management, level IV.

Background: Pulmonary vascular microthrombi have been proposed as a mechanism of COVID19 respiratory failure. We hypothesized that early administration of tissue-plasminogen activator(tPA) followed by therapeutic heparin would improve pulmonary function in these patients. Methods: Adults with COVID-19-induced respiratory failure were randomized May14, 2020-March 3, 2021 in two phases: Phase-1(n=36): control (standard-of-care) vs tPA-Bolus (50mg tPA IV-bolus followed by 7 days of heparin (goal aPTT=60-80s); Phase-2(n=14): control vs tPA-Drip (50 mg of tPA IV-bolus, followed by tPA drip 2mg/hr plus heparin 500U/hour over 24 hours, then heparin to maintain aPTT 60-80s/7 days). The primary outcome was PaO2/FiO2 improvement at 48 hours post-randomization. Secondary outcomes included: PaO2/FiO2 improvement>50% or PaO2/FiO2>=200 at 48hrs(COMPOSITE), ventilator-free days(VFD) and mortality. Findings: Fifty patients were randomized: Phase 1:17 control, 19 tPA-Bolus; Phase 2: 8 control, 6 tPA-Drip. There were no severe bleeding events in intervention groups. In tPA-Bolus patients, PaO2/FiO2 was significantly(p

BackgroundSince the outset of the coronavirus disease 2019 (COVID-19) pandemic, published tracheostomy guidelines have generally recommended deferral of the procedure beyond the initial weeks of intubation given high mortality as well as concerns about transmission of the infection to providers. It is unclear whether tracheostomy in patients with COVID-19 infection facilitates ventilator weaning, and long-term outcomes are not yet reported in the literature.MethodsThis is a retrospective study of tracheostomy outcomes in patients with COVID-19 infection at a single-center academic tertiary referral intensive care unit. Patients underwent percutaneous tracheostomy at the bedside; the procedure was performed with limited staffing to reduce risk of disease transmission.ResultsBetween March 1 and June 30, 2020, a total of 206 patients with COVID-19 infection required mechanical ventilation and 26 underwent tracheostomy at a mean of 25±5 days after initial intubation. Overall, 81% of tracheostomy patients were liberated from the ventilator at a mean of 9±6 days postprocedure, and 54% were decannulated prior to hospital discharge at a mean of 21±10 days postprocedure. Sedation and pain medication requirements decreased significantly in the week after the procedure. In-hospital mortality was 15%. Among tracheostomy survivors, 68% were discharged to a facility.DiscussionThe management of patients with COVID-19 related respiratory failure can be challenging due to prolonged ventilator dependency. In our initial experience, outcomes post-tracheostomy in this population are encouraging, with short time to liberation from the ventilator, a high rate of decannulation prior to hospital discharge, and similar mortality to tracheostomy performed for other indications. Barriers to weaning ventilation in this cohort may be high sedation needs and ventilator dyssynchrony.Level of evidenceLevel V—Therapeutic/care management.

BACKGROUND: Opioid-related adverse events are a serious problem in hospitalized patients. Little is known about patients who are likely to experience opioid-induced respiratory depression events on the general care floor and may benefit from improved monitoring and early intervention. The trial objective was to derive and validate a risk prediction tool for respiratory depression in patients receiving opioids, as detected by continuous pulse oximetry and capnography monitoring. METHODS: PRediction of Opioid-induced respiratory Depression In patients monitored by capnoGraphY (PRODIGY) was a prospective, observational trial of blinded continuous capnography and oximetry conducted at 16 sites in the United States, Europe, and Asia. Vital signs were intermittently monitored per standard of care. A total of 1335 patients receiving parenteral opioids and continuously monitored on the general care floor were included in the analysis. A respiratory depression episode was defined as respiratory rate = 60 mm Hg for >= 3 minutes; apnea episode lasting >30 seconds; or any respiratory opioid-related adverse event. A risk prediction tool was derived using a multivariable logistic regression model of 46 a priori defined risk factors with stepwise selection and was internally validated by bootstrapping. RESULTS: One or more respiratory depression episodes were detected in 614 (46%) of 1335 general care floor patients (43% male; mean age, 58 +/- 14 years) continuously monitored for a median of 24 hours (interquartile range [IQR], 17-26). A multivariable respiratory depression prediction model with area under the curve of 0.740 was developed using 5 independent variables: age >= 60 (in decades), sex, opioid naivety, sleep disorders, and chronic heart failure. The PRODIGY risk prediction tool showed significant separation between patients with and without respiratory depression (P< .001) and an odds ratio of 6.07 (95% confidence interval [CI], 4.44-8.30;P< .001) between the high- and low-risk groups. Compared to patients without respiratory depression episodes, mean hospital length of stay was 3 days longer in patients with >= 1 respiratory depression episode (10.5 +/- 10.8 vs 7.7 +/- 7.8 days;P< .0001) identified using continuous oximetry and capnography monitoring. CONCLUSIONS: A PRODIGY risk prediction model, derived from continuous oximetry and capnography, accurately predicts respiratory depression episodes in patients receiving opioids on the general care floor. Implementation of the PRODIGY score to determine the need for continuous monitoring may be a first step to reduce the incidence and consequences of respiratory compromise in patients receiving opioids on the general care floor.

Acquired hemophilia A in postoperative patients can cause major bleeding and an accurate diagnosis is required for effective treatment. Standard treatment is costly, difficult to obtain, and takes 4 to 6 weeks to be effective. This article describes a patient successfully treated with recombinant factor VIIa, porcine factor VIII, plasmapheresis, rituximab, and high-dose corticosteroids.

Background The Surgical Risk Preoperative Assessment System accurately predicts postoperative complications in elective surgery using only 8 preoperative variables, but its performance in emergency surgery has not been evaluated. We hypothesized that the Surgical Risk Preoperative Assessment System accurately predicts postoperative complications in emergency surgery and compared its performance to that of the American College of Surgeons Surgical Risk Calculator. Methods We calculated the Surgical Risk Preoperative Assessment System and the American College of Surgeons Surgical Risk Calculator risk estimates in a random sample of 1,010 emergency surgery cases from the American College of Surgeons National Surgical Quality Improvement Program 2014 to 2017 database. Risk estimates were compared with known outcomes. Analyses included the Hosmer-Lemeshow goodness of fit graphs and P values, c-indexes, and Brier scores. Results Results were similar between the Surgical Risk Preoperative Assessment System and the American College of Surgeons Surgical Risk Calculator for mortality, urinary tract infection, cardiac, venous thromboembolism, and renal complications. The American College of Surgeons Surgical Risk Calculator underestimated morbidity compared with the Surgical Risk Preoperative Assessment System (16.04% American College of Surgeons Surgical Risk Calculator vs 24.88% Surgical Risk Preoperative Assessment System vs 24.3% observed). Both calculators overestimated readmission (7.67% American College of Surgeons Surgical Risk Calculator vs 5.18% Surgical Risk Preoperative Assessment System vs 4.1% observed). Conclusion Both calculators predicted mortality, urinary tract infection, cardiac, venous thromboembolism, and renal complications well, but readmissions relatively poorly. The Surgical Risk Preoperative Assessment System estimated overall morbidity accurately, while the American College of Surgeons Surgical Risk Calculator underestimated this risk.

Background COVID-19 threatens to quickly overwhelm our existing critical care infrastructure in the USA. Systemic tissue plasminogen activator (tPA) has been previously demonstrated to improve PaO2/FiO2 (mmHg) when given to critically ill patients with acute respiratory distress syndrome (ARDS). It is unclear to what extent tPA may impact population-based survival during the current US COVID-19 pandemic. Methods A decision analytic Markov state transition model was created to simulate the life critically ill COVID-19 patients as they transitioned to either recovery or death. Two patient groups were simulated (50,000 patients in each group); (1) Patients received tPA immediately upon diagnosis of ARDS and (2) patients received standard therapy for ARDS. Base case critically ill COVID-19 patients were defined as having a refractory PaO2/FiO2 of < 60 mmHg (salvage use criteria). Transition from severe to moderate to mild ARDS, recovery, and death were estimated. Markov model parameters were extracted from existing ARDS/COVID-19 literature. Results The use of tPA was associated with reduced mortality (47.6% [tTPA] vs. 71.0% [no tPA]) for base case patients. When extrapolated to the projected COVID-19 eligible for salvage use tPA in the USA, peak mortality (deaths/100,000 patients) was reduced for both optimal social distancing (70.5 [tPA] vs. 75.0 [no tPA]) and no social distancing (158.7 [tPA] vs. 168.8 [no tPA]) scenarios. Conclusions Salvage use of tPA may improve recovery of ARDS patients, thereby reducing COVID-19-related mortality and ensuring sufficient resources to manage this pandemic.

The global pandemic of COVID-19 has begun to oversaturate the world's medical capacity to accommodate a large surge of patients with acute respiratory distress syndrome (ARDS). Acute respiratory distress syndrome has no effective treatment besides supportive care, with the use of ventilatory strategies encompassing low tidal volumes that limit transpulmonary pressures being the mainstay. A consistent finding in ARDS is the deposition of fibrin in the airspaces and lung parenchyma, along with fibrin-platelet microthrombi in the pulmonary vasculature, which contribute to the development of progressive respiratory dysfunction and right heart failure. Similar pathologic findings have now been observed in lung specimens from patients infected with COVID-19. This physiologically destructive activation of the clotting system in ARDS results from enhanced activation and propagation of clot formation together with suppression of fibrinolysis, and is thought to be mediated by dysfunction of the pulmonary endothelium in the case of influenza A. Targeting the coagulation and fibrinolytic systems to improve the treatment of ARDS has been proposed since at least 2003. In particular, the use of plasminogen activators to limit ARDS progression and reduce ARDS-induced death has received strong support from animal models and a phase 1 human clinical trial. In 2001, Hardaway and colleagues showed that administration of either urokinase or streptokinase to patients with terminal ARDS reduced the expected mortality from 100% to 70% with no adverse bleeding events. Importantly, the majority of patients who ultimately succumbed died from renal or hepatic failure, rather than pulmonary failure. [First paragraph] ©2020, NIH (grant no. F32-HL134244), NIH (grant no. L30-GM120751)

The coronavirus disease 2019 (COVID‐19) pandemic has caused respiratory failure and associated mortality in numbers that have overwhelmed global health systems. Thrombotic coagulopathy is present in nearly three quarters of patients with COVID‐19 admitted to the intensive care unit, and both the clinical picture and pathologic findings are consistent with microvascular occlusive phenomena being a major contributor to their unique form of respiratory failure. Numerous studies are ongoing focusing on anticytokine therapies, antibiotics, and antiviral agents, but none to date have focused on treating the underlying thrombotic coagulopathy in an effort to improve respiratory failure in COVID‐19. There are animal data and a previous human trial demonstrating a survival advantage with fibrinolytic therapy to treat acute respiratory distress syndrome. Here, we review the extant and emerging literature on the relationship between thrombotic coagulopathy and pulmonary failure in the context of COVID‐19 and present the scientific rationale for consideration of targeting the coagulation and fibrinolytic systems to improve pulmonary function in these patients.

OBJECTIVE The objective was to evaluate the impact of evidence-based clinical decision support tools integrated directly into provider workflow in the electronic health record on utilization of computed tomography (CT) brain, C-spine, and pulmonary embolism (PE). METHODS Validated, well-accepted scoring tools for head injury, C-spine injury, and PE were embedded into the electronic health record in a manner minimally disruptive to provider workflow. This was a longitudinal, before/after study in five emergency departments (EDs) in a healthcare system with a common electronic health record. Attending ED physicians practicing during the entire study period were included. The main outcome measure was proportion of CTs ordered by provider (total number of CT scans of a given type divided by total patients seen by that provider) in aggregate in the pre- and post intervention period. RESULTS There were 235,858 total patient visits analyzed in this study with an absolute decrease of 6,106 CT scan ordering for the three studies. Across all sites, there was greater than 6% decrease in utilization of CT brain and CT C-spine (-10%, 95% CI = -13% to -7%, p

Published ahead of print January 17, 2017., BACKGROUND: Intermittent measurement of respiratory rate via observation is routine in many patient care settings. This approach has several inherent limitations that diminish the clinical utility of these measurements because it is intermittent, susceptible to human error, and requires clinical resources. As an alternative, a software application that derives continuous respiratory rate measurement from a standard pulse oximeter has been developed. We sought to determine the performance characteristics of this new technology by comparison with clinician-reviewed capnography waveforms in both healthy subjects and hospitalized patients in a low-acuity care setting. METHODS: Two independent observational studies were conducted to validate the performance of the Medtronic NellcorTM Respiration Rate Software application. One study enrolled 26 healthy volunteer subjects in a clinical laboratory, and a second multicenter study enrolled 53 hospitalized patients. During a 30-minute study period taking place while participants were breathing spontaneously, pulse oximeter and nasal/oral capnography waveforms were collected. Pulse oximeter waveforms were processed to determine respiratory rate via the Medtronic Nellcor Respiration Rate Software. Capnography waveforms reviewed by a clinician were used to determine the reference respiratory rate. RESULTS: A total of 23,243 paired observations between the pulse oximeter-derived respiratory rate and the capnography reference method were collected and examined. The mean reference-based respiratory rate was 15.3 ± 4.3 breaths per minute with a range of 4 to 34 breaths per minute. The Pearson correlation coefficient between the Medtronic Nellcor Respiration Rate Software values and the capnography reference respiratory rate is reported as a linear correlation, R, as 0.92 ± 0.02 (P < .001), whereas Lin’s concordance correlation coefficient indicates an overall agreement of 0.85 ± 0.04 (95% confidence interval [CI] +0.76; +0.93) (healthy volunteers: 0.94 ± 0.02 [95% CI +0.91; +0.97]; hospitalized patients: 0.80 ± 0.06 [95% CI +0.68; +0.92]). The mean bias of the Medtronic Nellcor Respiration Rate Software was 0.18 breaths per minute with a precision (SD) of 1.65 breaths per minute (healthy volunteers: 0.37 ± 0.78 [95% limits of agreement: –1.16; +1.90] breaths per minute; hospitalized patients: 0.07 ± 1.99 [95% limits of agreement: –3.84; +3.97] breaths per minute). The root mean square deviation was 1.35 breaths per minute (healthy volunteers: 0.81; hospitalized patients: 1.60). CONCLUSIONS: These data demonstrate the performance of the Medtronic Nellcor Respiration Rate Software in healthy subjects and patients hospitalized in a low-acuity care setting when compared with clinician-reviewed capnography. The observed performance of this technology suggests that it may be a useful adjunct to continuous pulse oximetry monitoring by providing continuous respiratory rate measurements. The potential patient safety benefit of using combined continuous pulse oximetry and respiratory rate monitoring warrants assessment.

BACKGROUND Historically, hemorrhage has been attributed as the leading cause (40%) of early death. However, a rigorous, real-time classification of the cause of death (COD) has not been performed. This study sought to prospectively adjudicate and classify COD to determine the epidemiology of trauma mortality. METHODS Eighteen trauma centers prospectively enrolled all adult trauma patients at the time of death during December 2015 to August 2017. Immediately following death, attending providers adjudicated the primary and contributing secondary COD using standardized definitions. Data were confirmed by autopsies, if performed. RESULTS One thousand five hundred thirty-six patients were enrolled with a median age of 55 years (interquartile range, 32-75 years), 74.5% were male. Penetrating mechanism (n = 412) patients were younger (32 vs. 64, p < 0.0001) and more likely to be male (86.7% vs. 69.9%, p < 0.0001). Falls were the most common mechanism of injury (26.6%), with gunshot wounds second (24.3%). The most common overall primary COD was traumatic brain injury (TBI) (45%), followed by exsanguination (23%). Traumatic brain injury was nonsurvivable in 82.2% of cases. Blunt patients were more likely to have TBI (47.8% vs. 37.4%, p < 0.0001) and penetrating patients exsanguination (51.7% vs. 12.5%, p < 0.0001) as the primary COD. Exsanguination was the predominant prehospital (44.7%) and early COD (39.1%) with TBI as the most common later. Penetrating mechanism patients died earlier with 80.1% on day 0 (vs. 38.5%, p < 0.0001). Most deaths were deemed disease-related (69.3%), rather than by limitation of further aggressive care (30.7%). Hemorrhage was a contributing cause to 38.8% of deaths that occurred due to withdrawal of care. CONCLUSION Exsanguination remains the predominant early primary COD with TBI accounting for most deaths at later time points. Timing and primary COD vary significantly by mechanism. Contemporaneous adjudication of COD is essential to elucidate the true understanding of patient outcome, center performance, and future research. LEVEL OF EVIDENCE Epidemiologic, level II.

BACKGROUND Burn injuries result in 50,000 annual admissions. Despite joint referral criteria from the American College of Surgeons (ACS) and American Burn Association (ABA), many severely injured patients are not treated at verified centers with specialized care. Only one prior study explores regional variation in access to burn centers, focusing on flight or driving distance without considering the size of the population accessing that center. We hypothesize that disparities exist in access to verified centers, measured at a population level. We aim to identify a subset of nonverified centers that, if verified, would most impact access to the highest level of burn care. METHODS We collected ABA data for all verified and nonverified adult burn centers and geocoded their locations. We used county-level population data and a two-step floating catchment method to determine weighted access in terms of total beds available locally per population. We compared regions, as defined by the ABA, in terms of overall access. Low access was calculated to be less than 0.3 beds per 100,000 people using a conservative estimate. RESULTS We identified 113 centers, 59 verified and 54 nonverified. Only 2.9% of the population lives in areas with no verified center in 300 miles; however, 24.7% live in areas with low access. Significant regional disparities exist, with 37.3% of the population in the Southern Region having low access as compared with just 10.5% in the Northeastern Region. We identified 8 nonverified centers that would most impact access in areas with no or low access. CONCLUSION We found significant disparities in access to verified center burn care and determined nonverified centers with the greatest potential to increase access, if verified. Our future directions include identifying barriers to verification, such as lack of fellowship-trained burn surgeons or lack of hospital commitment. LEVEL OF EVIDENCE Epidemiological, level III.

Background COVID-19 predisposes patients to a prothrombotic state with demonstrated microvascular involvement. The degree of hypercoagulability appears to correlate with outcomes; however, optimal criteria to assess for the highest-risk patients for thrombotic events remain unclear; we hypothesized that deranged thromboelastography measurements of coagulation would correlate with thromboembolic events. Study design Patients admitted to an ICU with COVID-19 diagnoses who had thromboelastography analyses performed were studied. Conventional coagulation assays, d-dimer levels, and viscoelastic measurements were analyzed using a receiver operating characteristic curve to predict thromboembolic outcomes and new-onset renal failure. Results Forty-four patients with COVID-19 were included in the analysis. Derangements in coagulation laboratory values, including elevated d-dimer, fibrinogen, prothrombin time, and partial thromboplastin time, were confirmed; viscoelastic measurements showed an elevated maximum amplitude and low lysis of clot at 30 minutes. A complete lack of lysis of clot at 30 minutes was seen in 57% of patients and predicted venous thromboembolic events with an area under the receiver operating characteristic curve of 0.742 (p = 0.021). A d-dimer cutoff of 2,600 ng/mL predicted need for dialysis with an area under the receiver operating characteristic curve of 0.779 (p = 0.005). Overall, patients with no lysis of clot at 30 minutes and a d-dimer > 2,600 ng/mL had a venous thromboembolic event rate of 50% compared with 0% for patients with neither risk factor (p = 0.008), and had a hemodialysis rate of 80% compared with 14% (p = 0.004). Conclusions Fibrinolysis shutdown, as evidenced by elevated d-dimer and complete failure of clot lysis at 30 minutes on thromboelastography predicts thromboembolic events and need for hemodialysis in critically ill patients with COVID-19. Additional clinical trials are required to ascertain the need for early therapeutic anticoagulation or fibrinolytic therapy to address this state of fibrinolysis shutdown.

Angioembolization (AE) is recommended for extravasation from liver injury on CT. Data supporting AE are limited to retrospective series that have found low mortality but high morbidity. These studies did not focus on stable patients. We hypothesized that AE is associated with increased complications without improving mortality in stable patients.We queried the 2016 Trauma Quality Improvement Project database for patients with grade III or higher liver injury (Organ Injury Score ≥ 3), blunt mechanism, with stable vitals (systolic blood pressure ≥ 90 mmHg and heart rate of 50 to 110 beats/min). Exclusion criteria were nonhepatic intra-abdominal or pelvic injury (Organ Injury Score ≥ 3), laparotomy less than 6 hours, and AE implementation more than 24 hours. Patients were matched 1:2 (AE to non-AE) on age, sex, Injury Severity Score, liver Organ Injury Score, arrival systolic blood pressure and heart rate, and transfusion in the first 4 hours using propensity score logistic modeling. Primary outcomes were in-hospital mortality, length of stay, transfusion, hepatic resection, interventional radiology drainage, and endoscopic procedure.There were 1,939 patients who met criteria, with 116 (6%) undergoing hepatic AE. Median time to embolization was 3.3 hours. After successfully matching on all variables, groups did not differ with respect to mortality (5.4% vs 3.2%; p = 0.5, AE vs non-AE, respectively) or transfusion at 4 to 24 hours (4.4% vs 7.5%; p = 0.4). A larger percentage of the AE group underwent interventional radiology drainage (13.3% vs 2.2%; p0.001), with more ICU days (4 vs 3 days; p = 0.005) and longer length of stay (10 vs 6 days; p0.001).Hepatic AE was associated with increased morbidity without improving mortality, suggesting the benefits of AE do not outweigh the risks in stable liver injury. Observing these patients is likely a more prudent approach.