Search

Patients who suffer a cardiac arrest from trauma rarely survive. Surgical control of hemorrhage cannot be obtained in time to prevent irreversible organ damage. Emergency preservation and resuscitation (EPR) was developed to utilize hypothermia to buy time to achieve hemostasis and allow delayed resuscitation. Large animal studies have demonstrated that cooling to tympanic membrane temperature 10 °C during exsanguination cardiac arrest can allow up to 2 h of circulatory arrest and repair of simulated injuries with normal neurologic recovery. The Emergency Preservation and Resuscitation for Cardiac Arrest from Trauma (EPR-CAT) trial is testing the feasibility and safety of initiating EPR. Study subjects include patients with penetrating trauma who lose a pulse within 5 minutes of hospital arrival and remain pulseless despite standard care. EPR is initiated via an intra-aortic flush of ice-cold saline solution. Following hemostasis, delayed resuscitation and rewarming are accomplished with cardiopulmonary bypass. The primary outcome is survival to hospital discharge without significant neurologic deficits. If trained team members are available, subjects can undergo EPR. If not, subjects can be enrolled as concurrent controls. Ten EPR and 10 control subjects will be enrolled. If successful, EPR could save the lives of trauma patients who are currently dying from exsanguinating hemorrhage.

The history of cardiopulmonary resuscitation and the Society of Critical Care Medicine have much in common, as many of the founders of the Society of Critical Care Medicine focused on understanding and improving outcomes from cardiac arrest. We review the history, the current, and future state of cardiopulmonary resuscitation.

The 2016 National Academies of Science, Engineering and Medicine report included a proposal to establish a National Trauma Research Action Plan. In response, the Department of Defense funded the Coalition for National Trauma Research to generate a comprehensive research agenda spanning the continuum of trauma and burn care from prehospital care to rehabilitation as part of an overall strategy to achieve zero preventable deaths and disability after injury. The Postadmission Critical Care Research panel was 1 of 11 panels constituted to develop this research agenda.We recruited interdisciplinary experts in surgical critical care and recruited them to identify current gaps in clinical critical care research, generate research questions, and establish the priority of these questions using a consensus-driven Delphi survey approach. The first of four survey rounds asked participants to generate key research questions. On subsequent rounds, we asked survey participants to rank the priority of each research question on a 9-point Likert scale, categorized to represent low-, medium-, and high-priority items. Consensus was defined as ≥60% of panelists agreeing on the priority category.Twenty-five subject matter experts generated 595 questions. By Round 3, 249 questions reached ≥60% consensus. Of these, 22 questions were high, 185 were medium, and 42 were low priority. The clinical states of hypovolemic shock and delirium were most represented in the high-priority questions. Traumatic brain injury was the only specific injury pattern with a high-priority question.The National Trauma Research Action Plan critical care research panel identified 22 high-priority research questions, which, if answered, would reduce preventable death and disability after injury.Diagnostic Tests or Criteria; Level IV.

Background: In July of 2013, the University of Maryland launched MarylandCCProject.com. This free-access educational website delivers asynchronous high-quality multidisciplinary critical care education targeted at critical care trainees. The lectures, presented in real time on-site, are recorded and available on the website or as a podcast on iTunes or Android. Thus, the curriculum can be easily accessed around the world. Objective: We sought to identify the impact this website has on current and former University of Maryland critical care trainees. Methods: A 32-question survey was generated using a standard survey generation tool. The survey was e-mailed in the fall of 2019 to the University of Maryland Multi-Departmental Critical Care current and graduated trainees from the prior 7 years. Survey data were collected through December 2019. The questions focused on user demographics, overall experience with the website, scope of website use, and clinical application of the content. Anonymous responses were electronically gathered. Results: A total of 186 current trainees and graduates were surveyed, with a 39% (n = 72) response rate. Of responders, 76% (55) use the website for ongoing medical education. The majority use the website at least monthly. Most users (63%, n = 35) access the lectures directly through the website. All 55 current users agree that the website has improved their medical knowledge and is a useful education resource. Platform use has increased and includes users from around the world. Conclusion: Based on our current data, the MarylandCCProject remains a valuable and highly used educational resource, impacting patient care both during and after critical care fellowship training.

To document two sources of validity evidence for simulation-based assessment in neurological emergencies. A critical aspect of education is development of evaluation techniques that assess learner’s performance in settings that reflect actual clinical practice. Simulation-based evaluation affords the opportunity to standardize evaluations but requires validation. We identified topics from the Neurocritical Care Society’s Emergency Neurological Life Support (ENLS) training, cross-referenced with the American Academy of Neurology’s core clerkship curriculum. We used a modified Delphi method to develop simulations for assessment in neurocritical care. We constructed checklists of action items and communication skills, merging ENLS checklists with relevant clinical guidelines. We also utilized global rating scales, rated one (novice) through five (expert) for each case. Participants included neurology sub-interns, neurology residents, neurosurgery interns, non-neurology critical care fellows, neurocritical care fellows, and neurology attending physicians. Ten evaluative simulation cases were developed. To date, 64 participants have taken part in 274 evaluative simulation scenarios. The participants were very satisfied with the cases (Likert scale 1–7, not at all satisfied—very satisfied, median 7, interquartile range (IQR) 7–7), found them to be very realistic (Likert scale 1–7, not at all realistic—very realistic, median 6, IQR 6–7), and appropriately difficult (Likert scale 1–7, much too easy—much too difficult, median 4, IQR 4–5). Interrater reliability was acceptable for both checklist action items (kappa = 0.64) and global rating scales (Pearson correlation r = .70). We demonstrated two sources of validity in ten simulation cases for assessment in neurological emergencies.

Background Hand motion analysis by video recording during surgery has potential for evaluation of surgical performance. The aim was to identify how technical skill during open surgery can be measured unobtrusively by video recording during a surgical procedure. We hypothesized that procedural-step timing, hand movements, instrument use and Shannon entropy differ with expertise and training and are concordant with a performance-based validated individual procedure score. Methods Surgeon and non-surgeon participants with varying training and levels of expertise were video recorded performing axillary artery exposure and control (AA) on un-preserved cadavers. Color-coded gloves permitted motion-tracking and automated extraction of entropy data from recordings. Timing and instrument-use metrics were obtained through observational video reviews. Shannon entropy measured speed, acceleration and direction by computer-vision algorithms. Findings were compared with individual procedure score for AA performance Results Experts had lowest entropy values, idle time, active time and shorter time to divide pectoralis minor, using fewer instruments. Residents improved with training, without reaching expert levels, and showed deterioration 12–18 months later. Individual procedure scores mirrored these results. Non-surgeons differed substantially. Conclusions Hand motion entropy and timing metrics discriminate levels of surgical skill and training, and these findings are congruent with individual procedure score evaluations. These measures can be collected using consumer-level cameras and analyzed automatically with free software. Hand motion with video timing data may have widespread application to evaluate resident performance and can contribute to the range of evaluation and testing modalities available to educators, training course designers and surgical quality assurance programs.

The patient with a bronchopleural fistula and acute respiratory distress syndrome can present a therapeutic challenge for the treating clinician. In this case, the authors describe the use of bedside thoracic sonography to show real-time improvement in a pneumothorax after initiation of high-frequency oscillatory ventilation. Sonography may have a role in the evaluation of ventilator strategies in the future, although validation of this application is still needed.

Background Interest in acute care surgery (ACS) has increased over the past 10 years as demonstrated by the linear increase in fellowship applicants to the different fellowships leading to ACS careers. It is unclear why interest has increased, whether various fellowship pathways attract different applicants or whether fellowship choice correlates with practice patterns after graduation. Methods An online survey was distributed to individuals previously registered with the Surgical critical care and Acute care surgery Fellowship Application Service. Fellowship program directors were also asked to forward the survey to current and former fellows to increase the response rate. Data collected included demographics, clinical interests and motivations, publications, and postfellowship practice patterns. Fisher's exact and Pearson's χ were used to determine significance. Results Trauma surgery was the primary clinical interest for all fellowship types (n = 273). Fellowship type had no impact on academic productivity or practice patterns. Most fellows would repeat their own fellowship. The 2-year American Association for the Surgery of Trauma-approved fellowship was nearly uniformly reported as the preferred choice among those who would perform a different fellowship. Career motivations were similar across fellowships and over time though recent trainees were more likely to consider predictability of schedule a significant factor in career choice. Respondents reported graduated progression to full responsibility, further exposure to trauma care and additional operative technical training as benefits of a second fellowship year. Conclusion American Association for the Surgery of Trauma-approved 2-year fellows appear to be the most satisfied with their fellowship choice. No differences were noted in academic productivity or practice between fellowships. Future research should focus on variability in trauma training and operative experience during residency and in practice to better inform how a second fellowship year would improve training for ACS careers. Level of evidence Descriptive, mixed methods, Level IV.

This article reviews four emerging endovascular hemorrhage control and extracorporeal perfusion techniques for management of trauma patients with profound hemorrhagic shock including hemorrhage-induced traumatic cardiac arrest: resuscitative endovascular balloon occlusion of the aorta, selective aortic arch perfusion, extracorporeal life support, and emergency preservation and resuscitation. The preclinical and clinical studies underpinning each of these techniques are summarized. We also present an integrated conceptual framework for how these emerging technologies may be used in the future care of trauma patients in both resource-rich and austere environments.

OBJECTIVE: Because open surgical skills training for trauma is limited in clinical practice, trauma skills training courses were developed to fill this gap, The aim of this report is to find supporting evidence for efficacy of these courses. The questions addressed are: What courses are available and is there robust evidence of benefit?DESIGN: We performed a systematic review of the training course literature on open trauma surgery procedural skills courses for surgeons using Kirkpatrick's framework for evaluating complex educational interventions. Courses were identified using Pubmed, Google Scholar and other databases.SETTING AND PARTICIPANTS: The review was carried out at the University of Maryland, Baltimore with input from civilian and military trauma surgeons, all of whom have taught and/or developed trauma skills courses.RESULTS: We found 32 course reports that met search criteria, including 21 trauma-skills training courses. Courses were of variable duration, content, cost and scope. There were no prospective randomized clinical trials of course impact. Efficacy for most courses was with Kirkpatrick level 1 and 2 evidence of benefit by self-evaluations, and reporting small numbers of respondents. Few courses assessed skill retention with longitudinal data before and after training. Three courses, namely: Advanced Trauma Life Support (ATLS), Advanced Surgical Skills for Exposure in Trauma (ASSET) and Advanced Trauma Operative Management (ATOM) have Kirkpatrick's level 2-3 evidence for efficacy. Components of these 3 courses are included in several other courses, but many skills courses have little published evidence of training efficacy or skills retention durability.CONCLUSIONS: Large variations in course content, duration, didactics, operative models, resource requirements and cost suggest that standardization of content, duration, and development of metrics for open surgery skills would be beneficial, as would translation into improved trauma patient outcomes. Surgeons at all levels of training and experience should participate in these trauma skills courses, because these procedures are rarely performed in routine clinical practice. Faculty running courses without evidence of training benefit should be encouraged to study outcomes to show their course improves technical skills and subsequently patient outcomes. Obtaining Kirkpatrick's level 3 and 4 evidence for benefits of ASSET, ATOM, ATLS and for other existing courses should be a high priority.

BackgroundCompartment syndrome is the excess swelling within an inelastic compartment leading to excessive compartment pressure. Lower limb trauma has a high risk of compartment syndrome, which is typically mitigated using a two-incision fasciotomy. Our previous findings showed surgeons sometimes perform incomplete fasciotomies due to misidentifying the septum between the lateral and superficial posterior compartments as the septum between the anterior and lateral compartments. We conjectured this may be due to variability in the septal position between individuals leading to misinterpretation of the septal identity.MethodsA retrospective analysis was performed using CT angiograms to analyze septal position between the anterior and lateral compartments of the leg of 100 patients randomly selected from the University of Maryland Shock Trauma Center database.ResultsAnalysis of septal position showed that (1) as the septum progresses distally down the leg, the relative septum position shifts anteriorly; and that (2) there was considerable variability in the intermuscular septum position between individuals even when accounting for the anterior to posterior progression of septal position.DiscussionThis variability could lead to erroneous septal identification in individuals with a very anteriorly located septum during a leg fasciotomy with the classic initial incision being insufficiently anterior. We propose making the lateral initial incision ‘two finger breadths posterior the tibia’ rather than the traditional ‘one finger breadth anterior’ to the fibula. This moves the initial incision slightly anteriorly, uses the more readily palpable tibia, and makes the medial and lateral incisions symmetrical at ‘two finger breadths’ from the tibia, simplifying the procedure.Level of evidenceLevel 3.

Telemedicine is perhaps the most rapidly growing area in health care. Approximately 15 million Americans receive medical assistance remotely every year. Yet rural communities face significant challenges in securing subspecialist care. In the United States, 25% of the population resides in rural areas, where less than 15% of physicians work. Current surgery residency programs do not adequately prepare surgeons for rural practice. Telementoring, wherein a remote expert guides a less experienced caregiver, has been proposed to address this challenge. Nonetheless, existing mentoring technologies are not widely available to rural communities, due to a lack of infrastructure and mentor availability. For this reason, some clinicians prefer simpler and more reliable technologies. This article presents past and current telementoring systems, with a focus on rural settings, and proposes aset of requirements for such systems. We conclude with a perspective on the future of telementoring systems and the integration of artificial intelligence within those systems.

Objective Emergency general surgery (EGS) patients presenting with sepsis remain a challenge. The Surviving Sepsis Campaign recommends a 30 mL/kg fluid bolus in these patients, but recent studies suggest an association between large volume crystalloid resuscitation and increased mortality. The optimal amount of pre-operative fluid resuscitation prior to source control in patients with intra-abdominal sepsis is unknown. This study aims to determine if increasing volume of resuscitation prior to surgical source control is associated with worsening outcomes. Methods We conducted an 8-year retrospective chart review of EGS patients undergoing surgery for abdominal sepsis within 24 h of admission. Patients in hemorrhagic shock and those with outside hospital index surgeries were excluded. We grouped patients by increasing pre-operative resuscitation volume in 10 ml/kg intervals up to > 70 ml/kg and later grouped them into Results Of the 301 patients included, the mean age was 55, 51% were male, 257 (85%) survived to discharge. With increasing fluid per kg (p = 0.004). Patients who received 30 ml/kg (p = 0.02). These groups had median qSOFA scores (1.0 vs. 1.0, p = 0.06). There were no differences in time to operation (6.1 vs 4.9 h p = 0.11), ventilator days (1 vs 3, p = 0.08), or hospital LOS (8 vs 9 days, p = 0.57). Relative risk regression correcting for age and physiologic factors showed no significant differences in mortality between the fluid groups. Conclusions Greater pre-operative resuscitation volumes were initially associated with significantly higher mortality, despite similar organ failure scores. However, fluid volumes were not associated with mortality following adjustment for other physiologic factors in a regression model. The amount of pre-operative volume resuscitation was not associated with differences in time to operation, ventilator days, ICU or hospital LOS.

Clinical research must be conducted while maintaining the welfare and rights of the research subjects. The standard informed consent process provides the potential subject with sufficient information regarding the risks and benefits of a particular intervention before deciding whether or not to participate. For research related to resuscitation, the patient is unable to provide consent, legally authorized representatives are not available, and the intervention needs to be initiated in a time-sensitive manner. In these situations, a process of an exception from informed consent has evolved to facilitate new advances in resuscitation. Once novel interventions for critical care or resuscitation become established, there may still be ongoing ethical issues related to when these interventions are deployed and when they should be discontinued.

To document two sources of validity evidence for simulation-based assessment in neurological emergencies.A critical aspect of education is development of evaluation techniques that assess learner's performance in settings that reflect actual clinical practice. Simulation-based evaluation affords the opportunity to standardize evaluations but requires validation.We identified topics from the Neurocritical Care Society's Emergency Neurological Life Support (ENLS) training, cross-referenced with the American Academy of Neurology's core clerkship curriculum. We used a modified Delphi method to develop simulations for assessment in neurocritical care. We constructed checklists of action items and communication skills, merging ENLS checklists with relevant clinical guidelines. We also utilized global rating scales, rated one (novice) through five (expert) for each case. Participants included neurology sub-interns, neurology residents, neurosurgery interns, non-neurology critical care fellows, neurocritical care fellows, and neurology attending physicians.Ten evaluative simulation cases were developed. To date, 64 participants have taken part in 274 evaluative simulation scenarios. The participants were very satisfied with the cases (Likert scale 1-7, not at all satisfied-very satisfied, median 7, interquartile range (IQR) 7-7), found them to be very realistic (Likert scale 1-7, not at all realistic-very realistic, median 6, IQR 6-7), and appropriately difficult (Likert scale 1-7, much too easy-much too difficult, median 4, IQR 4-5). Interrater reliability was acceptable for both checklist action items (kappa = 0.64) and global rating scales (Pearson correlation r = .70).We demonstrated two sources of validity in ten simulation cases for assessment in neurological emergencies.

To describe the current state of the art regarding management of the critically ill trauma patient with an emphasis on initial management in the ICU.A PubMed literature review was performed for relevant articles in English related to the management of adult humans with severe trauma. Specific topics included airway management, hemorrhagic shock, resuscitation, and specific injuries to the chest, abdomen, brain, and spinal cord.The basic principles of initial management of the critically ill trauma patients include rapid identification and management of life-threatening injuries with the goal of restoring tissue oxygenation and controlling hemorrhage as rapidly as possible. The initial assessment of the patient is often truncated for procedures to manage life-threatening injuries. Major, open surgical procedures have often been replaced by nonoperative or less-invasive approaches, even for critically ill patients. Consequently, much of the early management has been shifted to the ICU, where the goal is to continue resuscitation to restore homeostasis while completing the initial assessment of the patient and watching closely for failure of nonoperative management, complications of procedures, and missed injuries.The initial management of critically ill trauma patients is complex. Multiple, sometimes competing, priorities need to be considered. Close collaboration between the intensivist and the surgical teams is critical for optimizing patient outcomes.

Objectives In the United States, physician training in Critical Care Medicine has developed as a subspecialty of different primary boards, despite significant commonality in knowledge and skills. The Society of Critical Care Medicine appointed a multidisciplinary Task Force to examine alternative approaches for future training. Design The Task Force reviewed the literature and conducted informal discussions with key stakeholders. Specific topics reviewed included the history of critical care training, commonalities among subspecialties, developments since a similar review in 2004, international experience, quality patient care, and financial and workforce issues. Main results The Task Force believes that options for future training include establishment of a 1) primary specialty of critical care; 2) unified fellowship and certification process; or 3) unified certification process with separate fellowship programs within the current specialties versus 4) maintaining multiple specialty-based fellowship programs and certification processes. Conclusions 1) Changing the current Critical Care Medicine training paradigms may benefit trainees and patient care. 2) Multiple pathways into critical care training for all interested trainees are desirable for meeting future intensivist workforce demands. 3) The current subspecialties within separate boards are not "distinct and well-defined field[s] of medical practice" per the American Board of Medical Specialties. Recommendations for first steps are as follows: 1) as the society representing multidisciplinary critical care, the Society of Critical Care Medicine has an opportunity to organize a meeting of all stakeholders to discuss the issues regarding Critical Care Medicine training and consider cooperative approaches for the future. 2) A common Critical Care Medicine examination, possibly with a small percentage of base-specialty-specific questions, should be considered. 3) Institutions with multiple Critical Care Medicine fellowship programs should consider developing joint, multidisciplinary training curricula. 4) The boards that offer Critical Care Medicine examinations, along with national critical care societies, should consider ways to shorten training time.

Long-term retention of trauma procedural core-competency skills and need for re-training after a 1-day cadaver-based course remains unknown. We measured and compared technical skills for trauma core competencies at mean 14 months (38 residents), 30 months (35 practicing surgeons), and 46 months (10 experts) after training to determine if skill degradation occurs with time. Technical performance during extremity vascular exposures and lower-extremity fasciotomy in fresh cadavers measured by validated individual procedure score (IPS) was the primary outcome.We performed a prospective study between May 2013 and September 2016.Practicing surgeons had lower IPS and IPS component scores (p = 0.02 to 0.001) than residents (p 0.05) and experts (p0.002) for vascular procedures. Frequencies of errors were no different among residents and experts. Practicing surgeons made more critical errors (p0.05) than experts or residents. Experts had shortest time to proximal vascular control. Fasciotomy procedural errors occurred in all participants. Cluster analysis of anatomy vs procedural steps identified tertiles of performance and wide variance (32.5% practicing surgeons, 26.5% residents vs 13% experts) for vascular procedures. Vascular control duration20 minutes (n = 21) and failure to decompress fasciotomy compartments were correlated with incorrect landmarks and skin incisions. Modeling found interval trauma skills experience, not time since training, was associated with lower IPS.Practicing surgeons with low trauma skills experience since training had lower IPS and component scores (p = 0.02 to 0.001) and more errors compared with experts and residents (p0.05). Surgeons, including experts with low interval experience performing trauma procedures, may benefit from refreshing of correct landmarks and skin incision placement identification.

We present the anesthesia management protocol currently in development at our institution for those patients enrolled into the Emergency Preservation and Resuscitation for Cardiac Arrest from Trauma (EPR-CAT) Clinical Trial. Emergency preservation and resuscitation (EPR) utilizing saline and deep hypothermia is a novel approach for management of trauma patients who present with life threatening non-compressible hemorrhage. This pioneering technique has transitioned from laboratory animal studies to human clinical trials. Patients who experience witnessed cardiac arrest from penetrating trauma and fail conventional therapy are eligible for enrollment in the EPR-CAT trial. This concept involves replacing the patient’s blood volume with cold saline to rapidly induce hypothermia and drastically reduce the metabolic rate of the heart, brain, and other vital organs. It is expected that this approach should give surgeons up to 1 hour to operate and gain surgical hemostasis before hypoxic brain damage would otherwise occur. After surgical control of hemorrhage, patients are reperfused via cardiopulmonary bypass (CPB) with balanced blood products and rewarmed back to near normal temperatures. During cooling and CPB, the patients are anticoagulated with heparin with the goal of restoring normal coagulation after liberation from CPB. The primary outcome measure is survival to hospital discharge with minimal neurologic deficits.

Fluid administration in critically ill surgical patients must be closely monitored to avoid complications. Resuscitation guided by invasive methods are not consistently associated with improved outcomes. As such, there has been increased use of focused ultrasound and Arterial Pulse Waveform Analysis (APWA) to monitor and aid resuscitation. An assessment of these methods using the Grading of Recommendations Assessment, Development, and Evaluation (GRADE) framework is presented.A subsection of the Surgical Critical Care Task Force of the Practice Management Guideline Committee of EAST conducted two systematic reviews to address the use of focused ultrasound and APWA in surgical patients being evaluated for shock. Six population, intervention, comparator, and outcome (PICO) questions were generated. Critical outcomes were prediction of fluid responsiveness, reductions in organ failures or complications and mortality. Forest plots were generated for summary data and GRADE methodology was used to assess for quality of the evidence. Reviews are registered in PROSPERO, the International Prospective Register of Systematic Reviews (42015032402 and 42015032530).Twelve focused ultrasound studies and 20 APWA investigations met inclusion criteria. The appropriateness of focused ultrasound or APWA-based protocols to predict fluid responsiveness varied widely by study groups. Results were mixed in the one focused ultrasound study and 9 APWA studies addressing reductions in organ failures or complications. There was no mortality advantage of either modality versus standard care. Quality of the evidence was considered very low to low across all PICO questions.Focused ultrasound and APWA compare favorably to standard methods of evaluation but only in specific clinical settings. Therefore, conditional recommendations are made for the use of these modalities in surgical patients being evaluated for shock.Systematic Review, level II.

Background Mechanical chest compression devices deliver high-quality chest compressions. Early data suggests that mechanical devices may be superior to manual chest compressions in adults following an in-hospital cardiac arrest patients. To determine the feasibility of undertaking an effectiveness trial in this population, we undertook a feasibility randomised controlled trial. Methods We undertook a multi-centre parallel group feasibility randomised controlled trial (COMPRESS-RCT). Adult in-hospital cardiac arrest patients that were in a non-shockable rhythm were randomised in a 3:1 ratio to receive mechanical CPR (Jolfe AB/Stryker, Lund, Sweden) or ongoing manual CPR. Recruitment was led by the clinical cardiac arrest team. The primary study outcome was the proportion of eligible participants randomised in the study during site operational recruitment hours. Patients were enrolled under a model of deferred consent. We report data using descriptive statistics, point estimates and 95% confidence intervals. Results Over a two-year period, we recruited 127 patients across five UK hospitals. We recruited 55.2% (95% CI 48.5%–61.8%) of eligible study participants in site operational recruitment hours. Most participants were male (n = 76, 59.8%) with a mean age of 72 (95% CI: 69.9–74.9) years. Median arrest duration was 18 (IQR 13−29) minutes. In patients randomised to mech-CPR, median time from CPR start to device deployment was 11 (IQR 7−15) minutes. ROSC was achieved in 27.6% (n = 35) participants and 4.7% (n = 6) were alive at 30-days. Conclusion COMPRESS-RCT identified important factors that preclude progression to an effectiveness trial of mechanical CPR in the hospital setting in the UK. Findings will inform the design of future in-hospital intra-arrest intervention trials. ISRCTN38139840, date of registration 9th January 2017.

Exsanguinating trauma is a major cause of death from trauma. Fluid resuscitation strategies have evolved remarkably since the 1980’s. Crystalloids, particularly lactated Ringer’s solution, were the initial fluids of choice before administering blood products. Subsequent studies have demonstrated that balanced crystalloids are likely better than normal saline and that hypertonic saline or colloids have little benefit. For patients with severe hemorrhagic shock, however, early administration of blood products, including packed red blood cells, plasma, and platelets, as part of a damage control resuscitation strategy, improves outcomes. Large amounts of crystalloids should be avoided. Monitoring thromboelastography may help. In select patients, this strategy may include administration of tranexamic acid or prothrombin complex concentrates. For patients with evidence of ongoing hemorrhage, hypotensive or limited fluid resuscitation is appropriate until hemostasis has been achieved. Details of optimal fluids or blood pressure goals still need to be determined. Once hemostasis has been achieved, fluid resuscitation should continue in order to achieve appropriate endpoints, which may include normalization of vital signs and urine output, decreasing lactate level or base deficit, or a minimization of additional fluid responsiveness based upon echocardiography or pulse waveform analysis.

Disaster preparation and management are responsibilities for everyone in a healthcare facility. Whether natural or man-made, disasters and crises stress all facility resources including staff. Due to the extraordinary needs that accompany a disaster, opportunities for process improvement as well as education and training are readily discovered during drills as well as after actual events. A worthy goal is to be so well prepared that the entire facility is ready to respond in an appropriately integrated fashion regardless of the magnitude of the need. This chapter identifies key areas of disaster preparedness that specifically impact critical care practice and preparation in and outside of the ICU.

BACKGROUND Evidence-based research demonstrates that postoperative formalized handoff improves communication and satisfaction among hospital staff members, leading to improved patient outcomes. OBJECTIVE To improve postoperative patient safety in the surgical intensive care unit of a tertiary academic medical center. METHODS A verbal and written formal reporting method was designed, implemented, and evaluated. The intervention created an admission "time-out," allowing the handoff from surgical and anesthesia teams to the intensive care unit team and bedside nurses to occur in a more structured manner. Before and 1 year after implementation of the intervention, nurses completed surveys on the quality of postoperative handoff. RESULTS After the intervention, the proportion of nurses who reported receiving handoff from the surgical team increased from 20% to 60% (P < .001). More nurses felt satisfied with the surgical handoff (46% before vs 74% after the intervention; P < .001), and more nurses frequently felt included in the handoff process (42% vs 74%; P < .001). Nurses perceived improved communication with surgical teams (93%), anesthesia teams (89%), and the intensive care unit team (94%), resulting in a perception of better patient care (88%). CONCLUSION After implementation of a systematic multidisciplinary handoff process, surgical intensive care nurses reported improved frequency and completeness of the postoperative handoff process, resulting in a perception of better patient care.

Sudden cardiac death, whether in the hospital or out of the hospital, is a leading cause of death. Early recognition and activation of an emergency response, following the “chain of survival”, is critical. High quality Cardiopulmonary Resuscitation (CPR) should be initiated as soon as possible. Rescue breaths can be added when a qualified medical professional is available. Once emergency medical services personnel arrive for an out of hospital cardiac arrest or the “code team” arrives for an in hospital cardiac arrest, the Advanced Cardiovascular Life Support (ACLS) algorithm should be followed. For patients with pulseless ventricular tachycardia or ventricular fibrillation, early defibrillation improves the chances for restoration of spontaneous circulation and survival. The use of vasopressors and anti-arrhythmics are part of the protocol, though the benefits are unclear. Once trained airway providers are available, placement of an advanced airway, either supraglottic or endotracheal, can be considered after several minutes of CPR-ACLS, though optimal timing and clear benefit have not been established. For patients who remain comatose after resuscitation, initiation of Targeted Temperature Management can improve outcomes. Neuroprognostication is complex and should be delayed for at least 3-5 days after resuscitation and should be based upon multiple sources of information. This review contains 1 figure, 5 tables, and 44 references. Keywords: Cardiac arrest, cardiopulmonary resuscitation, anti-arrhythmics, airway management, targeted temperature management, prognostication

Critical errors increase postoperative morbidity and mortality. A trauma readiness index was used to evaluate critical errors in 4 trauma procedures. In comparison to practicing and expert surgeon benchmarks, we hypothesized that pretraining trauma readiness index including both vascular and nonvascular trauma surgical procedures can identify residents who will make critical errors.In a prospective study, trained evaluators used a standardized script to evaluate performance of brachial, axillary, and femoral artery exposure and proximal control and lower-extremity fasciotomy on unpreserved cadavers. Forty residents were evaluated before and immediately after Advanced Surgical Skills for Exposure in Trauma training, and 38 were re-evaluated 14 months later. Residents were compared to 34 practicing surgeons evaluated once 30 months after training, and 10 experts.Resident trauma readiness index increased with training (P.001), remained unchanged 14 month later and was higher, with lower variance than practicing surgeons (P.05). Expert trauma readiness index was higher than residents (P.004) and practicing surgeons (P.001). Resident training decreased critical errors when evaluated immediately and 14 months after Advanced Surgical Skills for Exposure in Trauma training. Practicing surgeons had more critical errors and performance variability than residents or experts. Experts had 5 to 7 times better error recovery than practicing surgeons or residents. Trauma readiness index area under the receiver operating curve with Youden Index0.60 or6 decile in their cohort, predicts a surgeon will make a critical error.Low trauma readiness index was associated with critical errors occurring in all surgeon cohorts and can identify surgeons in need of remedial intervention.

The advent of cardiopulmonary resuscitation (CPR) revolutionized the care of patients with cardiac arrest, now allowing survival of up to 30% after out-of-hospital arrest due to arrhythmia; however, outcomes for cardiac arrest after trauma remain dismal, with less than 10% survival despite the most aggressive modern resuscitation techniques. The short time interval between cardiac arrest and brain ischemia, the reduced efficacy of CPR in the patient with profound hypovolemia due to hemorrhage, and the speed of exsanguination from major vascular injury all conspire to limit the effectiveness of standard CPR in the critically injured patient. Beginning in the 1980s, researchers began to harness the effects of profound hypothermia in order to extend the window of survivability after traumatic arrest, allowing the critical time needed to obtain surgical hemostasis in otherwise lethal exsanguinating injuries. These studies have culminated in the emergency preservation and resuscitation (EPR) of the trauma patient. Rapid central arterial access is obtained and profound (10 °C) hypothermia induced with aortic infusion of cold saline. During this window of up to 1 h, damage control surgical techniques are applied to control hemorrhage and repair injuries, followed by controlled rewarming and reperfusion using cardiopulmonary bypass. In this review, we trace these techniques from their early theoretical development, through refinement in clinically relevant animal models, and into their present application in a currently-enrolling human clinical trial of EPR for cardiac arrest from trauma (EPR-CAT), as well as examine current topics, ongoing challenges, and future directions for emergency preservation and resuscitation research.

IMPORTANCE: The use of cricoid pressure (Sellick maneuver) during rapid sequence induction (RSI) of anesthesia remains controversial in the absence of a large randomized trial. OBJECTIVE: To test the hypothesis that the incidence of pulmonary aspiration is not increased when cricoid pressure is not performed. DESIGN, SETTING, AND PARTICIPANTS: Randomized, double-blind, noninferiority trial conducted in 10 academic centers. Patients undergoing anesthesia with RSI were enrolled from February 2014 until February 2017 and followed up for 28 days or until hospital discharge (last follow-up, February 8, 2017). INTERVENTIONS: Patients were assigned to a cricoid pressure (Sellick group) or a sham procedure group. MAIN OUTCOMES AND MEASURES: Primary end point was the incidence of pulmonary aspiration (at the glottis level during laryngoscopy or by tracheal aspiration after intubation). It was hypothesized that the sham procedure would not be inferior to the cricoid pressure. The secondary end points were related to pulmonary aspiration, difficult tracheal intubation, and traumatic complications owing to the tracheal intubation or cricoid pressure. RESULTS: Of 3472 patients randomized, mean (SD) age was 51 (19) years and 1777 (51%) were men. The primary end point, pulmonary aspiration, occurred in 10 patients (0.6%) in the Sellick group and in 9 patients (0.5%) in the sham group. The upper limit of the 1-sided 95% CI of relative risk was 2.00, exceeding 1.50, failing to demonstrate noninferiority (P = .14). The risk difference was −0.06% (2-sided 95% CI, −0.57 to 0.42) in the intent-to-treat population and −0.06% (2-sided 95% CI, −0.56 to 0.43) in the per protocol population. Secondary end points were not significantly different among the 2 groups (pneumonia, length of stay, and mortality), although the comparison of the Cormack and Lehane grade (Grades 3 and 4, 10% vs 5%; P 30 seconds, 47% vs 40%; P

Critically ill patients with acute neurologic conditions are at high risk for development of dysfunction of multiple extracerebral organs. They frequently need airway and ventilator support, and a lung-protective strategy is appropriate. Hemodynamic support is critical to prevent secondary brain injury from hypotension. These patients are at high risk for infectious complications and development of sepsis. Electrolyte abnormalities are common, particularly disorders of sodium metabolism. Controversy continues regarding optimal hemoglobin levels for transfusion. Allowing mild hyperglycemia does not seem to be harmful, though hypoglycemia should be avoided. Steroids may be indicated for specific neurologic diseases but otherwise have little role in the intensive care unit, except for refractory septic shock. Critically ill patients with acute neurologic conditions are very catabolic and require early enteral nutrition support, accompanied by stress ulcer prophylaxis in most circumstances. Optimizing extracerebral organ support can have a significant impact upon outcomes from acute neurologic conditions.

Trauma care requires rapid interventions to optimize the chances for survival. Many patients are either in shock or unconscious and are, therefore, unable to provide informed consent even for standard procedures. Research-related interventions must similarly be initiated rapidly with no opportunity to obtain consent from the patient or the patient's legally authorized representative. Federal regulations allow for an exception from informed consent in these circumstances once the investigators complete a process of community consultation and public disclosure. The challenges for investigators include how to define the at-risk community for enrollment in the trial and then how to adequately reach out to that community. Many approaches have been used, with varying success. What constitutes true engagement with the community needs to be further explored.

Background Optimal resuscitation of hypotensive trauma patients has not been defined. This trial was performed to assess the feasibility and safety of controlled resuscitation (CR) versus standard resuscitation (SR) in hypotensive trauma patients. Methods Patients were enrolled and randomized in the out-of-hospital setting. Nineteen emergency medical services (EMS) systems in the Resuscitation Outcome Consortium participated. Eligible patients had an out-of-hospital systolic blood pressure (SBP) of 90 mm Hg or lower. CR patients received 250 mL of fluid if they had no radial pulse or an SBP lower than 70 mm Hg and additional 250-mL boluses to maintain a radial pulse or an SBP of 70 mm Hg or greater. The SR group patients received 2 L initially and additional fluid as needed to maintain an SBP of 110 mm Hg or greater. The crystalloid protocol was maintained until hemorrhage control or 2 hours after hospital arrival. Results A total of 192 patients were randomized (97 CR and 95 SR). The CR and SR groups were similar at baseline. The mean (SD) crystalloid volume administered during the study period was 1.0 L (1.5) in the CR group and 2.0 L (1.4) in the SR group, a difference of 1.0 L (95% confidence interval [CI], 0.6-1.4). Intensive care unit-free days, ventilator-free days, renal injury, and renal failure did not differ between the groups. At 24 hours after admission, there were 5 deaths (5%) in the CR group and 14 (15%) in the SR group (adjusted odds ratio, 0.39; 95% CI, 0.12-1.26). Among patients with blunt trauma, 24-hour mortality was 3% (CR) and 18% (SR) with an adjusted odds ratio of 0.17 (0.03-0.92). There was no difference among patients with penetrating trauma (9% vs. 9%; adjusted odds ratio, 1.93; 95% CI, 0.19-19.17). Conclusion CR is achievable in out-of-hospital and hospital settings and may offer an early survival advantage in blunt trauma. A large-scale, Phase III trial to examine its effects on survival and other clinical outcomes is warranted. Level of evidence Therapeutic study, level I.

To identify causes and timing of mortality in trauma patients to determine targets for future studies.In trials conducted by the Resuscitation Outcomes Consortium in patients with traumatic hypovolemic shock (shock) or traumatic brain injury (TBI), hypertonic saline failed to improve survival. Selecting appropriate candidates is challenging.Retrospective review of patients enrolled in multicenter, randomized trials performed from 2006 to 2009. Inclusion criteria were as follows: injured patients, age 15 years or more with hypovolemic shock [systolic blood pressure (SBP) ≤ 70 mm Hg or SBP 71-90 mm Hg with heart rate ≥ 108) or severe TBI [Glasgow Coma Score (GCS) ≤ 8]. Initial fluid administered was 250 mL of either 7.5% saline with 6% dextran 70, 7.5% saline or 0.9% saline.A total of 2061 subjects were enrolled (809 shock, 1252 TBI) and 571 (27.7%) died. Survivors were younger than nonsurvivors [30 (interquartile range 23) vs 42 (34)] and had a higher GCS, though similar hemodynamics. Most deaths occurred despite ongoing resuscitation. Forty-six percent of deaths in the TBI cohort were within 24 hours, compared with 82% in the shock cohort and 72% in the cohort with both shock and TBI. Median time to death was 29 hours in the TBI cohort, 2 hours in the shock cohort, and 4 hours in patients with both. Sepsis and multiple organ dysfunction accounted for 2% of deaths.Most deaths from trauma with shock or TBI occur within 24 hours from hypovolemic shock or TBI. Novel resuscitation strategies should focus on early deaths, though prevention may have a greater impact.

Improving outcomes for patients who are resuscitated from cardiac arrest but remain comatose has been challenging. Over 50 years ago, Peter Safar, when describing what we now know as the ABCs of cardiopulmonary resuscitation, included the induction of hypothermia for patients who do not show signs of neurologic recovery within 30 minutes, utilizing this in a case report (1).

Patients who suffer a cardiac arrest from trauma have almost no chance of survival. They exsanguinate and suffer irreversible vital organ damage before surgeons are able to obtain haemostasis, despite rapid transport by emergency medical services, airway control, massive transfusions and an

Appropriate documentation and coding are critical for billing in the intensive care unit (ICU). Diagnoses are based on the International Statistical Classification of Diseases and Related Health Problems (e.g., ICD-9 or ICD-10). Procedures are coded based on the Current Procedural Terminology (CPT) system. Evaluation and management (E/M) services make up the vast majority of non–procedure-based care provided by physicians in the ICU environment. Critical care services (codes 99291 and 99292) represent a specific subset of the CPT codes for E/M with different requirements. Three criteria must be met to justify a critical care code. First, the physician must document that the patient is critically ill (i.e., the patient has impairment in one or more vital organ systems with a high probability of imminent or life-threatening deterioration). Second, critical care requires high-complexity medical decision making to support vital organ function and/or prevent further deterioration. Third, critical care codes are time based. The physician must document the time spent in “full attention” to the patient. Critical care can also be provided via telemedicine technologies. Reimbursement for these services requires appropriate credentialing and contracts with the hospital, as well as appropriate documentation. Hospital reimbursement is based on Medical Severity-Diagnosis Related Groups (MS-DRGs), as documented in the medical record. Based on performance, a portion of hospital reimbursement may be withheld if the rates for certain hospital-acquired conditions are too high. Accurate documentation serves to (1) provide good communication between providers, (2) justify billing, and (3) legally document what was done for the patient and why. This review contains 4 tables, and 13 references. Key words: critical care codes, evaluation and management codes, global surgical package, pay for performance

Patients who suffer a cardiac arrest from trauma rarely survive, even with aggressive resuscitation attempts, including an emergency department thoracotomy. Emergency Preservation and Resuscitation (EPR) was developed to utilize hypothermia to buy time to obtain hemostasis before irreversible organ damage occurs. Large animal studies have demonstrated that cooling to tympanic membrane temperature 10°C during exsanguination cardiac arrest can allow up to 2 hours of circulatory arrest and repair of simulated injuries with normal neurologic recovery.The Emergency Preservation and Resuscitation for Cardiac Arrest from Trauma trial has been developed to test the feasibility and safety of initiating EPR. Select surgeons will be trained in the EPR technique. If a trained surgeon is available, the subject will undergo EPR. If not, the subject will be followed as a control subject. For this feasibility study, 10 EPR and 10 control subjects will be enrolled.Study participants will be those with penetrating trauma who remain pulseless despite an emergency department thoracotomy.Emergency Preservation and Resuscitation will be initiated via an intra-aortic flush of a large volume of ice-cold saline solution. Following surgical hemostasis, delayed resuscitation will be accomplished with cardiopulmonary bypass.The primary outcome will be survival to hospital discharge without significant neurologic deficits. Secondary outcomes include long-term survival and functional outcome.Once data from these 20 subjects are reviewed, revisions to the inclusion criteria and/or the EPR technique may then be tested in a second set of EPR and control subjects.

BACKGROUND Work-hour restrictions have reduced operative experience for residents. The Advanced Surgical Skills for Exposure in Trauma (ASSET) course fills this training gap. Cadaver use has limitations including cost and availability. Hyper-realistic synthetic models may provide an alternative to cadavers. We compared same surgeon performance between synthetic and cadaveric models to determine interchangeability for formative evaluation. METHODS Forty residents (

Surgical patient outcomes are related to surgeon skills.To measure resident surgeon technical and nontechnical skills for trauma core competencies before and after training and up to 18 months later and to compare resident performance with the performance of expert traumatologists.This longitudinal study performed from May 1, 2013, through February 29, 2016, at Maryland State Anatomy Board cadaver laboratories included 40 surgical residents and 10 expert traumatologists.Performance was measured during extremity vascular exposures and lower extremity fasciotomy in fresh cadavers before and after taking the Advanced Surgical Skills for Exposure in Trauma (ASSET) course.The primary outcome variable was individual procedure score (IPS), with secondary outcomes of IPSs on 5 components of technical and nontechnical skills, Global Rating Scale scores, errors, and time to complete the procedure. Two trained evaluators located in the same laboratory evaluated performance with a standardized script and mobile touch-screen data collection.Thirty-eight (95%) of 40 surgical residents (mean [SD] age, 31 [2.9] years) who were evaluated before and within 4 weeks of ASSET training completed follow-up evaluations 12 to 18 months later (mean [SD], 14 [2.7] months). The experts (mean [SD] age, 52 [10.0] years) were significantly older and had a longer (mean [SD], 46 [16.3] months) interval since taking the ASSET course (both P .001). Overall resident cohort performance improved with increased anatomy knowledge, correct procedural steps, and decreased errors from 60% to 19% after the ASSET course regardless of clinical year of training (P .001). For 21 of 40 residents (52%), correct vascular procedural steps plotted against anatomy knowledge (the 2 IPS components most improved with training) indicates the resident's performance was within 1 nearest-neighbor classifier of experts after ASSET training. Five residents had no improvement with training. The Trauma Readiness Index for experts (mean [SD], 74 [4]) was significantly different compared with the trained residents (mean [SD], 48 [7] before training vs 63 [7] after training [P = .004] and vs 64 [6] 14 months later [P = .002]). Critical errors that might lead to patient death were identified by pretraining IPS decile of less than 0.5. At follow-up, frequency of resident critical errors was no different from experts. The IPSs ranged from 31.6% to 76.9% among residents for core trauma competency procedures. Modeling revealed that interval experience, rather than time since training, affected skill retention up to 18 months later. Only 4 experts and 16 residents (40%) adequately decompressed and confirmed entry into all 4 lower extremity compartments.This study found that ASSET training improved resident procedural skills for up to 18 months. Performance was highly variable. Interval experience after training affected performance. Pretraining skill identified competency of residents vs experts. Extremity vascular and fasciotomy performance evaluations suggest the need for specific anatomical training interventions in residents with IPS deciles less than 0.5.

We evaluated the association between TH use and "dose" and cumulative vasopressor and inotrope requirement, survival, and neurologic outcome.Therapeutic hypothermia (TH) improves outcome after cardiac arrest, but may increase vasopressor and inotrope requirements.Chart review of in- and out-of-hospital cardiac arrests between 1/1/2005 and 3/15/2010. Data included demographic information, category of post-cardiac arrest illness severity ((I) awake, (II) coma (not following commands but intact brainstem responses)+mild cardiopulmonary dysfunction (SOFA [Sequential Organ Failure Assessment] cardiac+respiratory score4), (III) coma+moderate-severe cardiopulmonary dysfunction (SOFA cardiac+respiratory score≥4), and (IV) coma without brainstem reflexes), cumulative vasopressor index (CVI), inotrope use, survival, and neurologic outcome. The "dose" of TH (hours*temperature below threshold) was calculated using thresholds of ≤34 °C and ≤35 °C. Data were analyzed using descriptive statistics, Student's t-test, Wilcoxon test, and chi-squared analysis. Linear and logistic regression evaluated the effect of hypothermia "dose" on total CVI, survival and neurologic outcome.Among 361 comatose patients, 233 (65%) received TH. Vasopressor administration (measured by CVI) was higher in normothermic subjects (60.2% vs. 46.4%; p=0.016). Using a 34 °C threshold, SOFA respiratory subscore and PEA arrest predicted total CVI. Using a 35 °C threshold, severity of coma, SOFA respiratory subscore, PEA arrest and use of inotropic agents in addition to vasopressors predicted total CVI. Initial motor examination predicted survival and neurologic outcome, while TH "dose" did not.TH delivery is not associated with vasopressor requirement. TH "dose" is not associated with total CVI, survival, or good outcome. Vasopressor or inotropic requirement should not contraindicate TH use.

BACKGROUND No specific treatment is available for hanging-induced cardiac arrest (CA). We hypothesized that targeted temperature management (TTM) may improve the outcome of hanging-induced CA patients at hospital discharge. METHODS A retrospective chart review of our trauma registry from January 1999 to September 2015 was conducted to identify patients 18 years or older with hanging as their injury type. All TTMs were performed to achieve 32°C to 34°C for 24 hours. The survival and Cerebral Performance Category scores at hospital discharge were determined. RESULTS We identified 138 patients. Their average age was 32.1 ± 10.0 years; 81.3% were men, and 69.8% were white. The mortality rate was 15.2% (21 of 138). Overall, 79.7% (110 of 138) of the near-hanging patients did not sustain out-of-hospital CA (non-CA), and 1.8% of them (2 of 110) received TTM. All 110 non-CA patients survived to hospital discharge and 99.1% (109 of 110) had good neurologic outcome. The remaining 20.3% (28 of 138) of hanging patients suffered out-of-hospital CA; six of these patients were dead on arrival and thus excluded from further analysis. TTM was performed for 40.9% (9 of 22) of the remaining CA patients; 44.4% (4 of 9) of TTM CA patients survived to hospital discharge versus 23.1% (3 of 13) of non-TTM CA patients. There were no significant differences between the overall survival and patients discharged with good neurologic outcome between the TTM and non-TTM CA groups. CONCLUSION Non-CA near-hanging patients are more likely to have favorable outcome than the CA patients. Our study was not large enough to detect survival and neurologic outcome differences between the TTM and non-TTM CA groups. A multicenter retrospective study is underway to determine the impact of TTM on the outcome of hanging-induced CA patients. LEVEL OF EVIDENCE Therapeutic study, level IV; prognostic study, level IV.