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We aimed to identify and describe demand-side factors that have been used to support ATLS global promulgation, as well as current gaps in demand-side incentives.We performed a cross-sectional survey about demand-side factors that influence the uptake and promulgation of ATLS and other trauma-related CME courses. The survey was sent to each of the four global ATLS region chiefs and 80 ATLS country directors. Responses were described and qualitative data were analyzed using a content analysis framework.Representatives from 30 countries and each region chief responded to the survey (40% response rate). Twenty of 30 country directors (66%) reported that there were some form of ATLS verification requirements. ATLS completion, not current verification, was often the benchmark. Individual healthcare systems were the most common agency to require ATLS verification (37% of countries) followed by medical/surgical accreditation boards (33%), governments (23%), training programs (27%), and professional societies (17%). Multiple credentialing frameworks were reported including making ATLS verification a requirement for: emergency unit or trauma center designation (40%), contract renewal or promotion (37%); professional licensing (37%); training program graduation (37%); and increases in remuneration (3%). Unique demand-side incentives were reported including expansion of ATLS to non-physician cadre credentialing and use of subsidies.ATLS region chiefs and country directors reported a variety of demand-side incentives that may facilitate the promulgation of ATLS. Actionable steps include: (i) shift incentivization from ATLS course completion to maintenance of verification; (ii) develop an incentive toolkit of best practices to support implementation; and (iii) engage leadership stakeholders to use demand-side incentives to improve the training and capabilities of the providers they oversee to care for the injured.

Hyperbaric oxygen therapy (HBOT) involves treating patients by providing 100% oxygen through inhalation while inside a treatment pressurized chamber. The oxygen acts as a drug and the hyperbaric chamber as the dosing device. The effect of hyperbaric hyperoxia is dose dependent and, therefore, treatment depth and duration are important when considering its use. HBOT can either be the primary method of treatment or used adjunctively to medications or surgical techniques. The underpinning physiology is to bring oxygen-rich plasma to hypoxic tissue, preventing reperfusion injury, strengthening immune responsiveness, and encouraging new collagen deposition as well as endothelial cell formation.

Introduction The Stop the Bleed course was initiated in response to the Hartford Consensus and over 1 million people have been taught basic bleeding control techniques. Our study sought to determine the extent to which this training has been utilized. Methods Surveys were sent by email to students that had taken the Stop the Bleed course through our institution in 2017 or 2018. Data were collected utilizing the REDCap system and statistical calculations were performed. Results 2505 surveys were sent with 445 (18%) responses. The mean age of respondents was 48 years of age, 343 (77%) were female, and 230 (52%) were in the medical field. There were 17 respondents (3.8%) that stated they had utilized the techniques taught in the course; 16 out of 17 put pressure on a wound, 7 packed a wound, and 6 used a tourniquet. Patients had been injured by a variety of mechanisms including gunshot wound, stabbing, accidental laceration, and motor vehicle collision. Patients had good outcomes with 3 out of 17 surviving to emergency medical services arrival without known final outcome and the remaining 14 were known to do well. Conclusion The Stop the Bleed course is important to enable bystanders to provide hemorrhage control. Our study shows that the techniques have been utilized with 17 treated patients having a good outcome and while a utilization rate of 3.8% may appear low, it is similar to the utilization rate of cardiopulmonary resuscitation instruction of 2%.

The aim of this brief report is to raise awareness of necrotizing soft-tissue infections caused by Clostridium tetani in intravenous drug users, highlight the potentially unique dangers of this infection in this specific patient population, and outline the course of treatment currently considered the standard of care.

Patients who develop occult septic shock (OSS) are associated with worse outcomes than those with early septic shock (ESS). Patients with skin and soft tissue infection (SSTI) may have underlying organ dysfunction due to OSS, yet the prevalence and the outcomes of patients with SSTI and early versus occult shock have not been described. This study compared the clinical characteristics of SSTI patients and the prevalence of having no septic shock (NSS), ESS, or OSS.We retrospectively analyzed charts of adult patients who were transferred from any emergency department to our academic center between January 1, 2014, and December 31, 2016. Outcomes of interest were the development of OSS and acute kidney injury (AKI). We performed logistic regressions to measure the association between clinical factors with the outcomes and created probability plots to show the relationship between key clinical variables and outcomes of OSS or AKI.Among 269 patients, 218 (81%) patients had NSS, 16 (6%) patients had ESS, and 35 (13%) patients had OSS. Patients with OSS had higher mean serum lactate concentrations than patients with NSS (3.5 vs. 2.1 mmol/L,13% of the patients with SSTI developed OSS. Patients with OSS had elevated serum lactate concentration and higher SOFA score than those with NSS. Increased SOFA score is a predictor for the development of OSS.

Purpose To test the hypothesis that baseline optical coherence tomography (OCT) measures predict visual field (VF) progression in a cohort of patients with suspected or established glaucoma and to compare their performance to semiquantitative optic disc measures. Design This was an observational cohort study. Methods The setting of this study was an academic institution. The study population included 171 eyes of 95 patients with good-quality baseline retinal nerve fiber layer (RNFL) and macular OCT images and disc photographs with >2 years of follow-up and ≥5 VFs. The observation procedures were baseline macular and RNFL OCT measures and cup-to-disc ratio and disc damage likelihood score. The main outcome measure was prediction of glaucomatous VF deterioration according to trend and event analyses. Results Median (interquartile range) baseline mean deviation and follow-up were -2.9 (-6.4 to -1.1) dB and 54 (44–65) months, respectively. Seventeen and 25 eyes progressed by final visit based on pointwise event analysis and trend analysis of visual field index (VFI), respectively. Thinner central corneal thickness (P = .005), female gender (P = .015), and thinner average peripapillary RNFL (P = .001) predicted VF progression on proportional hazard models. Thinner RNFL at baseline (P = .006) or thinner average ganglion cell-inner plexiform layer (P = .028) along with higher baseline VFI (P = .018 and .048, respectively) predicted VFI progression. Neither optic disc measures predicted VF progression in any of the explored models. Conclusions Baseline structural OCT measures predicted subsequent VF progression in contrast to semi-quantitative optic disc measures. OCT-based structural measures should be included in prognostic models of glaucomatous VF deterioration.

Necrotizing lung infections (NLI) are rare occurrences; however, they can be devastating if not managed appropriately. NLI represent a spectrum of disease from lung abscess to pulmonary gangrene. The most common causes of NLI are Staphylococcus aureus and Streptococcus pneumoniae (pneumococcus). The mainstay of treatment is the early and aggressive use of appropriate antibiotics. If the infection extends to the pleural space causing an effusion or an empyema, drainage of the pleural space is necessary. If drainage of the pleural space fails or if sepsis is not controlled with antibiotics, then surgical debridement or drainage is needed. These patients require a multi-disciplinary team to provide optimal critical care and often times have long-term pulmonary dysfunction. This chapter will focus on NLI and the nuances of treatment.

Background In blunt trauma, orthopedic injuries are often associated with cerebral and torso injuries. The optimal timing for definitive care is a concern. The aim of the study was to develop evidence-based guidelines for damage-control orthopedic (DCO) and early total care (ETC) of pelvic and long-bone fractures, closed or open, and mangled extremities in adult trauma patients with and without associated injuries. Methods The literature since 2000 to 2016 was systematically screened according to Preferred Reporting Items for Systematic Reviews and meta-analyses protocol. One hundred twenty-four articles were reviewed by a panel of experts to assign grade of recommendation and level of evidence using the Grading of recommendations Assessment, Development, and Evaluation system, and an International Consensus Conference, endorsed by several scientific societies was held. Results The choice between DCO and ETC depends on the patient's physiology, as well as associated injuries. In hemodynamically unstable pelvic fracture patient, extraperitoneal pelvic packing, angioembolization, external fixation, C-clamp, and resuscitative endovascular balloon occlusion of the aorta are not mutually exclusive. Definitive reconstruction should be deferred until recovery of physiological stability. In long bone fractures, DCO is performed by external fixation, while ETC should be preferred in fully resuscitated patients because of better outcomes. In open fractures early debridement within 24 hours should be recommended and early closure of most grade I, II, IIIa performed. In mangled extremities, limb salvage should be considered for non-life-threatening injuries, mostly of upper limb. Conclusion Orthopedic priorities may be: to save a life: control hemorrhage by stabilizing the pelvis and femur fractures; to save a limb: treat soft tissue and vascular injuries associated with fractures, stabilize fractures, recognize, and prevent compartmental syndrome; to save functionality: treat dislocations, articular fractures, distal fractures. While DCO is the best initial treatment to reduce surgical load, ETC should be applied in stable or stabilized patients to accelerate the recovery of normal functions. Level of evidence Systematic review of predominantly level II studies, level II.

A brain tumor is one of the hazardous diseases. Hence, it is necessary to detect the brain tumor appropriately. The detection of brain tumor by processing of magnetic resonance image (MRI) is one of the medical imaging techniques. It is most difficult task for clinical experts to extract the brain tumor by manual inspection because there is variation in tumor size, shape and location. Hence, image processing technique is used for detection of brain tumor. In this paper, by using K means clustering method brain MRI image is segregated in clusters. Then the cluster with tumor is found. But noise can degrade the quality of the image and it can affect the performance of segmentation process. Hence, anisotropic diffusion filter is used for noise reduction, before segmentation process. Morphological operations are applied to segmented image for image enhancement. Finally, the tumor is detected. Some useful features are extracted using gray- level co-occurrence matrix.

Little data exist about management of wounds created by debridement in necrotizing soft tissue infections (NSTIs). Multiple wound coverage techniques exist, including complete primary wound closure, split-thickness skin grafting, secondary intention, and flap creation. We hypothesized that all wound coverage techniques would be associated with high rates of successful wound coverage and low crossover rates to other wound coverage techniques. NSTIs over a three-year period were retrospectively reviewed. Both the initial and secondary wound coverage techniques (if necessary) were recorded. The primary outcome was the ability to achieve complete wound coverage. Overall, 46 patients with NSTIs had long-term data available. Of the patients undergoing split-thickness skin grafting as the initial wound coverage technique, 8/8 (100%) achieved complete wound coverage; and of those undergoing flap creation, 1/1 (100%) achieved complete wound coverage; and of those undergoing complete primary wound closure, 4/4 (100%) achieved complete wound coverage. Of the patients undergoing secondary intention as the initial wound coverage technique, 5/33 (15.2%) achieved complete wound coverage and 28/33 (84.8%) required a secondary wound coverage technique with split-thickness skin grafting. All 46 patients achieved long-term successful wound coverage. Time to wound coverage did not vary with initial wound coverage technique ( P = 0.44). Split-thickness skin grafting, flap creation, complete primary wound closure, and secondary intention are all reasonable choices for initial wound coverage for NSTIs. Although secondary intention had a low success rate as an initial wound coverage technique, all patients ultimately achieved complete wound coverage without a significant increase in time to coverage.

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.

Multiple factors are associated with mortality in necrotizing soft tissue infection, such as organ dysfunction and underlying medical comorbidities, but are not often modifiable. Operative interventions are an attractive modifiable variable in modern management of extremity necrotizing soft tissue infection, but the influence of amputation and advanced wound management techniques on mortality is unknown.A single-institution review was performed of extremity necrotizing soft tissue infection . Admission demographics, organ dysfunction, and operative interventions were investigated. The primary outcome was mortality. Advanced wound management techniques were considered flap creation or use of a dermal matrix substitute for coverage of neurovascular structures, tendon, or bone.Overall, 124 patients with extremity necrotizing soft tissue infection were included, with 112 of 124 (90.3%) patients living and 12 of 124 (9.7%) patients dying. Patients who lived had a lower Sequential Organ Failure Assessment score (1.00 [interquartile range, 5] vs 10.50 [interquartile range, 11], P.001), but no difference in use of amputation (11.6% vs 25.0%, P = .19) or advanced wound management techniques (12.5% vs 0%, P = 0.36), respectively. Indications for amputation in the 16 patients who underwent amputation included nonsalvageable limb in 13 of 16 (81.3%), medical comorbidity in 2 of 16 (12.5%), and a nonsalvageable limb and medical comorbidity in 1 of 16 (6.3%) patients. In multivariate analysis, only the Sequential Organ Failure Assessment score remained associated with mortality (odds ratio 1.315, 95% confidence interval 1.146-1.509, P.001) CONCLUSION: Use of amputation or advanced wound management techniques was not associated with mortality in patients with extremity necrotizing soft tissue infection. At centers able to provide the critical care support, aggressive use of limb salvage may not affect mortality.

Objectives Surgical residents express confidence in performing specific vascular exposures before training, but such self-reported confidence did not correlate with co-located evaluator ratings. This study reports residents' self-confidence evaluated before and after Advanced Surgical Skills for Exposure in Trauma (ASSET) cadaver-based training, and 12-18 mo later. We hypothesize that residents will better judge their own skill after ASSET than before when compared with evaluator ratings. Methods Forty PGY2-7 surgical residents performed four procedures: axillary artery (AA), brachial artery (BA), femoral artery exposure and control (FA), and lower extremity fasciotomy (FAS) at the three evaluations. Using 5-point Likert scales, surgeons self-assessed their confidence in anatomical understanding and procedure performance after each procedure and evaluators rated each surgeon accordingly. Results For all the three evaluations, residents consistently rated their anatomical understanding (p < 0.04) and surgical performance (p < 0.03) higher than evaluators for both FA and FAS. Residents rated their anatomical understanding and surgical performance higher (p < 0.005) than evaluators for BA after training and up to 18 mo later. Only for third AA evaluation were there no rating differences. Conclusions Residents overrate their anatomical understanding and performance abilities for BA, FA, and FAS even after performing the procedures and being debriefed three times in 18 mo.

Necrotizing soft tissue infection of the perineum, or Fournier's gangrene (FG), is a morbid and mortal diagnosis. Despite the severity of FG, the optimal definitive wound closure strategy is unknown, as are long-term wound outcomes. A retrospective review was performed over a 3-year period at a single trauma center. Patients were managed according to our institutional approach focusing on primary wound closure and secondary intention healing in residual wounds. Overall 168 patients were included. Complete primary wound closure was accomplished in 39.9 per cent of patients. Patients undergoing primary wound closure were primarily male (89.6 vs 64.4%, P < 0.001), had lower mean sequential organ failure assessment (SOFA) scores (1.70 ± 2.30 vs 2.98 ± 3.36, P = 0.004), more often had perineum-limited FG (67.2 vs 42.6%, P = 0.003), and required fewer debridements (2.40 vs 2.79, P = 0.02). On logistic regression, predictors of primary closure included gender (odds ratio 4.643, 95% confidence interval 1.885–11.437, P = 0.001) and SOFA score (odds ratio 0.834, 95% confidence interval 0.727–0.957, P = 0.01). Wound healing rates increased over time, to an 82.1 per cent wound healing rate without further intervention at greater than six months of follow-up. Wounds healed with secondary intention ranged from 70 to 9520 cm3 and primary closure ranged from 126 to 6912 cm3, whereas wounds requiring skin grafts ranged from 405 to 16,170 cm3. Complete primary wound closure is often achievable in FG patients. Using this standardized approach to FG wound management, even large wounds and wounds undergoing secondary intention healing will often close with long-term wound care and do not require flap creation or early skin grafting.

The American Association for the Surgery of Trauma Diversity, Equity, and Inclusion (DEI) Ad Hoc Committee organized a luncheon symposium with a distinguished panel of experts to discuss how to ensure a diverse surgical workforce. The panelists discussed the current state of DEI efforts within surgical departments and societal demographic changes that inform and necessitate surgical workforce adaptations. Concrete recommendations included the following: obtain internal data, establish DEI committee, include bias training, review hiring and compensation practices, support the department members doing the DEI work, commit adequate funding, be intentional with DEI efforts, and develop and support alternate pathways for promotion and tenure.

Purpose To test the hypotheses that: (1) structure–function (SF) relationships between visual fields (VF) and Bruch's membrane opening-based minimum rim width (BMO-MRW) measurements are superior to those for peripapillary retinal nerve fiber layer (pRNFL) in perimetric glaucoma; (2) BMO-MRW measurements may extend the utility of structural measurement across the range of glaucoma severity; and (3) to estimate the influence of Bruch's membrane opening (BMO) size on BMO-MRW measurements. Methods One hundred eight perimetric glaucoma eyes (68 patients) with good quality spectral-domain optical coherence tomography images of the optic disc and pRNFL, and reliable VF within 6 months were recruited. Relationship of global and sectoral BMO-MRW and pRNFL thickness with corresponding VF parameters and the influence of normalizing BMO-MRW (on BMO circumference, nBMO-MRW) on SF relationships were investigated. Broken-stick models were used to compare the point at which pRNFL and BMO-MRW parameters reached their measurement floor. Results The median (interquartile range) of VF mean deviation was −5.9 (−12.6 to −3.6) dB. Spearman correlation coefficients between pRNFL, BMO-MRW, and nBMO-MRW measures and corresponding VF cluster average deviations ranged between 0.55 to 0.80, 0.35 to 0.66, and 0.38 to 0.65, respectively. Bruch's membrane opening–MRW parameters demonstrated weaker SF relationships compared with pRNFL globally and in temporal, temporal-superior, and nasal-inferior sectors (P < 0.03). Normalization of BMO-MRW did not significantly influence SF relationships. Conclusions Structure–function relationships were somewhat weaker with BMO-MRW parameters compared with pRNFL in eyes with perimetric glaucoma. Bruch's membrane opening–MRW normalization did not significantly change SF relationships in this group of eyes with mild departures from average BMO size.

Little data exist about management of wounds created by debridement in necrotizing soft tissue infections (NSTIs). Multiple wound coverage techniques exist, including complete primary wound closure, split-thickness skin grafting, secondary intention, and flap creation. We hypothesized that all wound coverage techniques would be associated with high rates of successful wound coverage and low crossover rates to other wound coverage techniques. NSTIs over a three-year period were retrospectively reviewed. Both the initial and secondary wound coverage techniques (if necessary) were recorded. The primary outcome was the ability to achieve complete wound coverage. Overall, 46 patients with NSTIs had long-term data available. Of the patients undergoing split-thickness skin grafting as the initial wound coverage technique, 8/8 (100%) achieved complete wound coverage; and of those undergoing flap creation, 1/1 (100%) achieved complete wound coverage; and of those undergoing complete primary wound closure, 4/4 (100%) achieved complete wound coverage. Of the patients undergoing secondary intention as the initial wound coverage technique, 5/33 (15.2%) achieved complete wound coverage and 28/33 (84.8%) required a secondary wound coverage technique with split-thickness skin grafting. All 46 patients achieved long-term successful wound coverage. Time to wound coverage did not vary with initial wound coverage technique (

This chapter will describe the common procedures done during the resuscitation of a badly injured patient. We will strive to provide a practical approach to those who deal with injured patients in the hope that this will aid those practitioners and ultimately the patients. Emergency care also entails some immediate lifesaving operations, usually within 1 h with simultaneous resuscitation. During emergency procedures, complications can be minimized if meticulous techniques are adopted. Pleural decompression is a common procedure following major injury and can be a lifesaving procedure; although it is relatively simple, complications can occur if attention to detail is not used. Pericardial window and transdiaphragmatic pericardial window at the time of laparotomy are diagnostic and potential temporarily therapeutic procedures in patients who may have hemopericardium. A median sternotomy is the ideal incision to access the heart and the anterior mediastinal great vessels. The most rapid method of accessing the chest is via an anterolateral thoracotomy: this incision can be performed rapidly and is versatile, as it can be brought across the sternum into a clamshell thoracotomy. Obtaining hemostasis in patients who are bleeding in the pelvis following major pelvic fractures can be challenging: pelvic packing can be lifesaving. Aortic occlusion can be obtained with REBOA which can provide temporary control of hemorrhage almost anywhere in the body.

This case report describes an immunocompromised patient with a skin boil that progressed to necrotizing fasciitis. The aim of this brief report is to raise awareness regarding necrotizing soft tissue infections caused by an unusual organism, Kocuria rosea, a typically non-pathogenic organism, and outline the course of treatment currently considered to be the standard of care.

PURPOSE: To test the hypothesis that the fovea-Bruch’s membrane opening axis angle (FoBMO angle) influences the thickness symmetry of the macular ganglion cell/inner plexiform layer (GCIPL) across the temporal horizontal meridian in normal subjects. DESIGN: Cross-sectional diagnostic study at a tertiary academic center. METHODS: One hundred sixteen eyes of 60 normal subjects aged 40–85 years underwent spectral-domain optical coherence tomography (SD-OCT) imaging. The FoBMO angle was estimated on en face infrared SD-OCT images. Posterior Pole Algorithm images acquired with Spectralis SD-OCT were used to define vertical asymmetry as follows. The average thickness difference between the 3 most temporal superpixels above and below the horizontal meridian, the second row of superpixels from the horizontal meridian, and 3 central superpixels above and below the horizontal meridian were calculated. Factors influencing GCIPL thickness asymmetry were explored and changes in thickness asymmetry as a function of FoBMO angle were investigated. RESULTS: No demographic or clinical factors affected temporal GCIPL asymmetry (p >0.05 for all). A more (negatively) tilted FoBMO angle was associated with relatively thinner inferior compared to superior GCIPL thickness in superpixels immediately adjacent to the temporal raphe (p

Necrotizing soft tissue infection of the perineum, or Fournier's gangrene (FG), is a morbid and mortal diagnosis. Despite the severity of FG, the optimal definitive wound closure strategy is unknown, as are long-term wound outcomes. A retrospective review was performed over a 3-year period at a single trauma center. Patients were managed according to our institutional approach focusing on primary wound closure and secondary intention healing in residual wounds. Overall 168 patients were included. Complete primary wound closure was accomplished in 39.9 per cent of patients. Patients undergoing primary wound closure were primarily male (89.6 vs 64.4%, P0.001), had lower mean sequential organ failure assessment (SOFA) scores (1.70 ± 2.30 vs 2.98 ± 3.36, P = 0.004), more often had perineum-limited FG (67.2 vs 42.6%, P = 0.003), and required fewer debridements (2.40 vs 2.79, P = 0.02). On logistic regression, predictors of primary closure included gender (odds ratio 4.643, 95% confidence interval 1.885-11.437, P = 0.001) and SOFA score (odds ratio 0.834, 95% confidence interval 0.727-0.957, P = 0.01). Wound healing rates increased over time, to an 82.1 per cent wound healing rate without further intervention at greater than six months of follow-up. Wounds healed with secondary intention ranged from 70 to 9520 cm3 and primary closure ranged from 126 to 6912 cm3, whereas wounds requiring skin grafts ranged from 405 to 16,170 cm3. Complete primary wound closure is often achievable in FG patients. Using this standardized approach to FG wound management, even large wounds and wounds undergoing secondary intention healing will often close with long-term wound care and do not require flap creation or early skin grafting.

Background Necrotizing soft tissue infections (NSTIs) are highly morbid infections often requiring critical care and transfusion support. We explored a large 2-year experience from a regional trauma center with a dedicated soft tissue service (STS) in an attempt to identify factors in current care with potential for improving outcomes for these critically ill patients. Methods New adult (>17 years) STS admissions, 2008–2009, were identified from the Trauma Registry. Patient records were extracted and assessed via descriptive statistics, univariate analysis, and multivariable logistic regression models. Results Mortality among 253 eligible primary admissions was 8.3% overall and 10.3% for those with an admission diagnosis of NSTI. No significant differences in wound characteristics, use of VAC (vacuum-assisted closure) dressing or hyperbaric oxygen, or wound microbiology emerged between survivors and nonsurvivors. Median time to first debridement was 5 h (interquartile range, 2–21 h). Multivariable modeling indicated association of worse outcome (death or discharge to chronic/rehab care) with age >60 years [odds ratio (OR), 3.82; P < 0.001], anemia (OR, 0.98; P = 0.03), increasing number of transfusions (OR, 1.09; P < 0.001), NSTI diagnosis (OR, 2.47; P = 0.005), preexisting diabetes mellitus (OR, 3.20; P = 0.001), and low admission hemoglobin (OR, 0.80; P = 0.004). Conclusions Mortality was less than previously reported. Number of transfusions and anemia at admission emerged as risk factors for poor outcomes. Future research should focus on the effects of transfusion on NSTI outcomes, on potentially confounding factors, and on whether a restrictive transfusion strategy reduces mortality.

There is current need for objective measures of sciatic nerve mobility in patients with sciatic-type pain. The objective of the study was to assess the feasibility and reliability of ultrasound elastography to quantify sciatic nerve displacement and shear strain at the sciatic nerve-hamstring muscle interface during active and passive knee extension-flexion exercises performed while sitting in healthy people. Ultrasound elastography showed excellent intrarater within-session reliability for assessing sciatic nerve displacement and sciatic nerve-hamstring muscle interface shear strain during active knee extension-flexion exercises. These findings will inform similar future work conducted in patients with sciatic-type pain.

Elderly patients already face declining physiologic reserve and frequently have one or more comorbidities. They may face barriers to accessing medical care that result in delay in the diagnosis and treatment of their necrotizing soft tissue infection (NSTI). Sepsis, commonly seen with NSTI carries a higher mortality rate in elderly patients. Hospital complication and comorbidities also contirbute the overall higher mortality seen in the geriatric patient population. Even after discharge from the hospital, geriatric patients have more decline in social and physical functioning than younger patients. Recovery following amputation is a particular challenge for older patients and they may not regain their independence.

PurposeTo test the hypothesis that structural and functional measures predict contrast sensitivity (CS) outcomes in glaucomatous eyes.DesignCross-sectional prospective study.MethodsOne hundred five eyes of 65 patients who underwent macular spectral-domain optical coherence tomography imaging, 24-2 standard achromatic visual fields (VF), and CS measurement on the same day were enrolled. Association of CS at 4 spatial frequencies (3,6, 12, and 18 cycles per degree, cpd) with structural and functional outcomes was explored with correlation and regression analyses.ResultsThe median (IQR) 24-2 visual field mean deviation was-7.6 (-11.1 to-3.0). Significant correlations were found between CS at 6 cpd and ganglion cell/inner plexiform layer thickness at inferotemporal and inferonasal macular sectors (ρ= 0.222, P= .023 and ρ= 0.209, P= .032, respectively). CS at 6 cpd demonstrated higher correlations with full macular thickness measurements, the strongest of which was with the central macular thickness in the superior 6× 3-degree region (ρ= 0.311, P= .001). Contrast sensitivity at 6cpd also had the strongest correlation with mean deviation of the 4 central VF points (ρ=-0.420; P < .001). There was a significant correlation between logMAR visual acuity and contrast sensitivity at 6, 12, and 18 cpd (ρ=-0.306, ρ=-0.348 and ρ=-0.241, P < .013, respectively).ConclusionsStructural and functional measures showed a fair relationship with contrast sensitivity. This association was most prominent between full-thickness macular measures or central VF parameters and CS at 6 cpd. Contrast sensitivity was not a reliable surrogate for glaucoma severity in this cross-sectional study.

Antibiotic management of Fournier's gangrene (FG) is without evidence-based guidelines and is based on expert opinion. The effect of duration of antibiotic therapy on outcomes in FG is unknown.A retrospective review was performed of FG patients from 2012 to 2015 at a single institution. Patients were managed by our institutional practice of complete primary wound closure as possible, with antibiotic duration according to physician judgment. Patients were stratified into multiple durations of antibiotic administration.Overall, 168 patients with FG were included. When examining multiple stratifications of antibiotic therapy of 7 days or less, 8 days to 10 days, 11 days to 14 days, or 15 days or more of antibiotics, there was no significant difference in mortality (p = 0.11), primary closure (p = 0.75), surgical site infection (SSI) (p = 0.52), or Clostridium difficile infection (p = 0.63). There were no cases of recurrent FG in any antibiotic stratification. Mortality was not increased (p = 1.00) and ability to achieve primary closure was not decreased (p = 0.08) with initial antibiotic therapy exclusive of cultured organisms.Shorter antibiotic courses for patients in whom source control is obtained and initial antibiotic selection exclusive of many resistant organisms were not associated with worse outcomes in FG.Therapeutic, level IV.

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.

Background The internationally recognized Advanced Trauma Operative Management (ATOM) course uses a 1:1 student-to-faculty teaching model. This study examines a two student to one faculty ATOM teaching model. Materials and methods We randomly assigned 16 residents to four experienced ATOM faculty members. Half started with the one-student model and the other half with the two-student model and then switched using the same faculty. Students and faculty completed forms on the educational value of the two models (1 = very poor; 2 = poor; 3 = average; 4 = good; and 5 = excellent) and identified educational preferences and recommendations. Results We assigned educational values for the 13 procedures as follows: All faculty rated the one-student model as excellent; six members rated the two-student model as excellent, and seven as good. Students rated 50%–75% as excellent and 12%–44% as good for the two-student model, and 56%–81% as excellent and 12%–44% as good for the one-student model. Given resource constraints, all faculty and 88% of students preferred the two-student model. With no resource constraints, 75% of students and 50% of faculty chose the two-student model. All faculty and students rated both models “acceptable.” Overall, 81% of students and 50% of faculty rated the two-student model better. All faculty members recommended that the models be optional; 94% of students recommended that they be either optional (50%) or a two-student model (44%). Performing or assisting on each procedure twice was considered an advantage of the two-student model. Conclusions The two-student teaching model was acceptable and generally preferred in this study. With appropriately trained faculty and students, the two-student model is feasible and should result in less animal usage and possibly wider promulgation.

Background The Advanced Surgical Skills for Exposure in Trauma (ASSET) course was developed to address limited experience of residents and practicing surgeons (PS) in rapid exposure of major blood vessels for trauma. This one day, case based, scenario driven, fresh cadaver dissection course emphasizes rapid surgical exposure of the vasculature of the neck, chest, abdomen, pelvis and extremities with additional focus on fasciotomies and pelvic packing. Contained herein are the results of the first 25 courses. Methods Data collected from 25 ASSET courses conducted between September 2010 and February 2012 included self-reported comfort level (5 point Likert scale) with each of 25 specific skills before and upon completion of the course, and evaluation of the course content. Statistical analysis was accomplished using the Student t -test with α set at P Results Ninety-one surgical trainees and 123 PS were taught at 11 ASSET sites. Self-assessed comfort levels for all 25 queried skills and exposures improved significantly over baseline with P values ranging from 1.6 × 10 −7 to 3.9 × 10 −41 . Participants gained new knowledge (4.83 on 5 point scale); learned new techniques (4.83), felt better prepared to expose traumatically injured vessels (4.88), and would recommend the course to a colleague (4.92). Conclusions The ASSET course was well received and significantly improved self-reported confidence in the exposures needed to care for trauma in both surgical trainees and PS. Ongoing experience with this course will enable more comprehensive psychometric analysis and further validation of this curriculum.

Necrotizing soft tissue infection caused by bowel perforation is uncommon. Failure to diagnose and treat it in a timely manner adds to the already significant associated mortality and morbidity. As with necrotizing soft tissue infections resulting from other causes, the initial presentation can be subtle. Laboratory studies and imaging may supplement clinical judgement to improve diagnostic accuracy. Once diagnosed antibiotics are promptly administered and urgent surgery performed. Prolonged resuscitation should not delay surgery. Spread to the gluteal region and thigh can occur. Evaluation with careful examination, imaging, and/or exploration might be required. Extensive debridements are the rule rather than the exception. Multiple procedures aimed at source control, removal of dead and infected tissue followed by wound stabilization are necessary. Long intensive care unit and hospital stays are standard. Post discharge rehabilitative services are required in all but a few patients. With comprehensive care that includes nutritional and physical therapy acceptable outcomes can be achieved.

Glaucoma Macular SD-OCT Outcome Measures: Comparison of Local Structure-Function Relationships and Dynamic Range Arezoo Miraftabi, 1,2 Navid Amini, 1 Esteban Morales, 1 Sharon Henry, 1 Fei Yu, 1,3 Abdolmonem Afifi, 3 Anne L. Coleman, 1 Joseph Caprioli, 1 and Kouros Nouri-Mahdavi 1 Glaucoma Division, Stein Eye Institute, David Geffen School of Medicine, University of California, Los Angeles, Los Angeles, California, United States 2 Eye Research Center, Rasoul Akram Hospital, Iran University of Medical Sciences, Tehran, Iran Department of Biostatistics, Jonathan and Karin Fielding School of Public Health, University of California, Los Angeles, Los Angeles, California, United States Correspondence: Kouros Nouri- Mahdavi, 100 Stein Plaza, Los An- geles, CA, 90095, USA; nouri-mahdavi@jsei.ucla.edu. Submitted: March 28, 2016 Accepted: July 14, 2016 Citation: Miraftabi A, Amini N, Morales E, et al. Macular SD-OCT outcome measures: comparison of local struc- ture-function relationships and dy- namic range. Invest Ophthalmol Vis Sci. 2016;57:4815–4823. DOI:10.1167/iovs.16-19648 P URPOSE . We tested the hypothesis that the macular ganglion cell layer (GCL) thickness demonstrates a stronger structure-function (SF) relationship and extends the useful range of macular measurements compared with combined macular inner layer or full thickness. M ETHODS . Ninety-eight glaucomatous eyes and eight normal eyes with macular spectral domain optical coherence tomography (SD-OCT) volume scans and 10-2 visual fields were enrolled. Inner plexiform layer (IPL), GCL, macular retinal nerve fiber layer (mRNFL), ganglion cell-inner plexiform layer (GCIPL), ganglion cell complex (GCC), and full thickness (FT) measurements were calculated for 8 3 8 arrays of 38 superpixels. Main outcome measures were local structure- function relationships between macular superpixels and corresponding sensitivities on 10-2 fields after adjusting for ganglion cell displacement, dynamic range of measurements, and the change point (total deviation value where macular parameters reached measurement floor). R ESULTS . Median (interquartile range [IQR]) mean deviation was 7.2 (11.6 to 3.2) dB in glaucoma eyes. Strength of SF relationships was highest for GCIPL, GCL, GCC, and IPL (q ¼ 0.635, 0.627, 0.621, and 0.577, respectively; P 0.046 for comparisons against GCIPL). Highest SF correlations coincided with the peak of GCL thickness, where the dynamic range was widest for FT (81.1 lm), followed by GCC (65.7 lm), GCIPL (54.9 lm), GCL (35.2 lm), mRNFL (27.5 lm), and IPL (20.9 lm). Change points were similar for all macular parameters (7.8 to 8.9 dB). C ONCLUSIONS . GCIPL, GCL, and GCC demonstrated comparable SF relationships while FT, GCC, and GCIPL had the widest dynamic range. Measurement of GCL did not extend the range of useful structural measurements. Measuring GCL does not provide any advantage for detection of progression with current SD-OCT technology. Keywords: macular imaging, SD-OCT, dynamic range, structure-function dentification of glaucoma progression is a pivotal task in day- to-day management of glaucoma, to which various structural and functional measures have been applied. The advent of spectral-domain optical coherence tomography (SD-OCT) has provided the glaucoma research community with a powerful tool for detecting early glaucoma or its progression. Many reports have highlighted the potential role of retinal nerve fiber layer (RNFL), 1,2 although more research is needed to better understand its limitations and the appropriate circumstances for its application. Some recent investigations have demon- strated the utility and added value of macular SD-OCT imaging for detecting glaucoma, but its role remains less well defined with respect to progression. 3–10 Thanks to development of segmentation algorithms applied to SD-OCT imaging, various inner macular parameters are now available to investigators and clinicians. 3,11,12 These include single layer measurements such as ganglion cell (GCL), inner plexiform (IPL), or retinal nerve fiber layer, combination of inner retinal layers such as the ganglion cell-inner plexiform layer (GCIPL) and the ganglion cell complex (GCC), which includes the combined I thickness of the GCIPL and macular RNFL (mRNFL), or the full retinal thickness. The comparative utility of these various thickness parameters for detection of glaucoma progression is unknown. To this aim, the strength of the corresponding structure-function relationships and the comparative dynamic range of these parameters need to be compared. Another issue of interest is the point of change on structure-function plots at which each parameter reaches its measurement floor. We hypothesized that the macular GCL has a stronger correlation with central visual field sensitivities and may extend the range of useful structural measurements compared with other individual or combined inner retinal layers and may be a better outcome measure for detection of glaucoma progression. To this aim, this study was carried out to compare: (1) localized structure-function relationships between GCL and other macular thickness measurements, (2) the dynamic range of macular structural parameters, and (3) the change point for these parameters (i.e., the approximate threshold sensitivity beyond which the structural measures do not provide much additional information). iovs.arvojournals.org j ISSN: 1552-5783 This work is licensed under a Creative Commons Attribution-NonCommercial-NoDerivatives 4.0 International License.

A part of damage-control laparotomy is to leave the fascial edges and the skin open to avoid abdominal compartment syndrome and allow further explorations. This condition, known as open abdomen (OA), although effective, is associated with severe complications. Our aim was to develop evidence-based recommendations to define indications for OA, techniques for temporary abdominal closure, management of enteric fistulas, and methods of definitive wall closure.The literature from 1990 to 2014 was systematically screened according to PRISMA [Preferred Reporting Items for Systematic Reviews and Meta-analyses] protocol. Seventy-six articles were reviewed by a panel of experts to assign grade of recommendations (GoR) and level of evidence (LoE) using the GRADE [Grading of Recommendations Assessment, Development, and Evaluation] system, and an international consensus conference was held.OA in trauma is indicated at the end of damage-control laparotomy, in the presence of visceral swelling, for a second look in vascular injuries or gross contamination, in the case of abdominal wall loss, and if medical treatment of abdominal compartment syndrome has failed (GoR B, LoE II). Negative-pressure wound therapy is the recommended temporary abdominal closure technique to drain peritoneal fluid, improve nursing, and prevent fascial retraction (GoR B, LoE I). Lack of OA closure within 8 days (GoR C, LoE II), bowel injuries, high-volume replacement, and use of polypropylene mesh over the bowel (GoR C, LoE I) are risk factors for frozen abdomen and fistula formation. Negative-pressure wound therapy allows to isolate the fistula and protect the surrounding tissues from spillage until granulation (GoR C, LoE II). Correction of fistula is performed after 6 months to 12 months. Definitive closure of OA has to be obtained early (GoR C, LoE I) with direct suture, traction devices, component separation with or without mesh. Biologic meshes are an option for wall reinforcement if bacterial contamination is present (GoR C, LoE II).OA and negative-pressure techniques improve the care of trauma patients, but closure must be achieved early to avoid complications.

DOI: 10.1167/tvst.5.4.5 Article Local Variability of Macular Thickness Measurements With SD-OCT and Influencing Factors Arezoo Miraftabi 1,2 , Navid Amini 1 , Jeff Gornbein 1 , Sharon Henry 1 , Pablo Romero 1 , Anne L. Coleman 1 , Joseph Caprioli 1 , and Kouros Nouri-Mahdavi 1 Glaucoma Division, Stein Eye Institute, David Geffen School of Medicine, University of California-Los Angeles, Los Angeles, CA, USA Eye Research Center, Rasoul Akram Hospital, Iran University of Medical Sciences, Tehran, Iran Correspondence: Kouros Nouri- Mahdavi, MD MSc, 100 Stein Plaza, Los Angeles, CA 90095, USA. e-mail: nouri-mahdavi@jsei.ucla.edu Received: 25 September 2015 Accepted: 9 May 2016 Published: 19 July 2016 Keywords: SD-OCT; macular imag- ing; glaucoma; variability Citation: Miraftabi A, Amini N, Gornbein J, et al. Local variability of macular thickness measurements with SD-OCT and influencing fac- tors. Trans Vis Sci Tech. 2016;5(4):5, doi:10.1167/tvst.5.4.5 Purpose: To compare the intrasession variability of spectral-domain optical coherence tomography (SD-OCT)-derived local macular thickness measures and explore influencing factors. Methods: One hundred two glaucomatous eyes (102 patients) and 21 healthy eyes (21 subjects) with three good quality macular images during the same session were enrolled. Thickness measurements were calculated for 38 superpixels for the inner plexiform (IPL), ganglion cell (GCL), or retinal nerve fiber layers (mRNFL), GC/IPL, ganglion cell complex, and full macular thickness. Spatial distribution and magnitude of measurement errors (ME; differences between the 3 individual superpixel values and their mean) and association between MEs and thickness, age, axial length, and image quality were explored. Results: MEs had a normal distribution with mostly random noise along with a small fraction of outliers (1.2%–6.6%; highest variability in mRNFL and on the nasal border) based on M-estimation. Boundaries of 95% prediction intervals for variability reached a maximum of 3 lm for all layers and diagnostic groups after exclusion of outliers. Correlation between proportion of outliers and thickness measures varied among various parameters. Age, axial length, or image quality did not influence MEs (P . 0.05 for both groups). Conclusions: Local variability of macular SD-OCT measurements is low and uniform across the macula. The relationship between superpixel thickness and outlier proportion varied as a function of the parameter of interest. Translational Relevance: Given the low and uniform variability within and across eyes, definition of an individualized ‘variability space’ seems unnecessary. The variability measurements from this study could be used for designing algorithms for detection of glaucoma progression. Introduction Glaucoma is characterized by progressive loss of retinal ganglion cells (RGCs). With the advent of spectral-domain optical coherence tomography (SD- OCT), there has been increased interest in measuring RGC loss or thinning of the inner retina in the macula. 1–5 Approximately 50% of the RGCs are located within 4.5 mm (168) of the foveal center. 6 The central macula is the only part of the retina where the RGC layer is more than one cell thick; the peak RGC density occurs approximately 750 to 1100 lm from the center of the fovea. 6 Regional inner retinal thickness measurements such as ganglion cell/inner plexiform layer (GC/IPL) thickness perform as well as regional retinal nerve fiber layer (RNFL) thickness measures for detection of early glaucoma. 3,4,7 Hood et al. 8 demonstrated that GC/IPL thinning could be demonstrated in a group of patients with preperimet- ric glaucoma, although other studies have not found macular thickness to perform as well as RNFL thickness for detection of glaucoma in such pa- tients. 5,9 The role of macular SD-OCT imaging for detec- tion of glaucoma progression is yet to be fully elucidated. Early results have indicated its potential use. 10–12 Reproducibility of any structural outcome measure is one of the main determinants of how TVST j 2016 j Vol. 5 j No. 4 j Article 5 This work is licensed under a Creative Commons Attribution-NonCommercial-NoDerivatives 4.0 International License.

Glaucoma is a chronic optic neuropathy characterized by slow loss of the retinal ganglion cells (RGC) and their axons. Early damage to RGC axons is considered to occur at the level of the lamina cribrosa (LC), a multilayered connective tissue structure through which all the RGC axons pass when leaving the eye to form the optic nerve.1 Hence, studying the anatomy of the optic nerve head (ONH) and the peripapillary area is important for studying the mechanisms by which glaucoma damages these structures. Historically, the inner edge of the sclera, called the border tissue of Elschnig, has been presumed to form the clinical optic disc margin or outer boundary of the anterior neural canal. The complex relationships of the tissues bordering the neural canal now is better understood thanks to availability of in vivo imaging of the peripapillary region with spectral domain optical coherence tomography (SD-OCT). Strouthidis et al.2 recently proposed that the appearance of the clinical disc margin depended mainly on the colocation of the inner edge of the Bruch's membrane (BM) and the border tissue of Elschnig (BTE). The direction of the BTE has been shown to vary around the ONH and internally oblique, externally oblique, and nonoblique configurations have been well defined.3,4 The termination of the BM around the optic nerve forms the BM opening (BMO), which defines the anterior most boundary of the neural canal and commonly is the narrowest part of the neural canal. In monkeys, the clinical disc margin consistently localizes to BMO,3,5 while based on findings by Reis et al.,6 this is not the case in humans. In human eyes, BM overhang (i.e., extension of BM beyond the BTE) is common. The BMO area may better predict the number of ganglion cell axons in individual eyes or indicate the best location for centering SD-OCT's disc/retinal nerve fiber layer (RNFL) measurement cube,7 although it is likely that the narrowest region of the neural canal determines the axonal complement of a given eye. In addition, it has been demonstrated that neuroretinal rim area measurements based on the minimum distance between the inner edge of BMO and the internal limiting membrane (minimum rim width [MRW]) are superior to those based on clinical disc margin (horizontal rim width).8 Also, MRW measurements have been found to perform better or at least as well as peripapillary RNFL thickness measurements for discriminating glaucoma from normal eyes and demonstrate similar structure–function relationships compared to RNFL.8,9 To date, most clinical disc area measurements are based on identification of the clinical disc margin by experienced observers either on optic disc photographs or on images obtained with scanning laser ophthalmoscopy (such as the Heidelberg Retina Tomograph [HRT]). Some of the current SD-OCT machines have an automated algorithm for locating the inner edge of the BMO. Whether the relationship between the BMO and the clinical disc margin (CDM) is a function of the size of the optic disc is unknown; likewise, it is unclear whether BMO area can change over time in glaucoma. This study was performed to test the hypothesis that the anatomical relationship of the CDM and BMO is a function of the BMO area (BMOA). We also tested the hypothesis that the relationship between the clinical disc margin and BMO was different between glaucoma and normal eyes with less mismatch in glaucoma eyes.

Complex wounds present a challenge to both the surgeon and patient in operative management, long-term care, cosmetic outcome, and effects on lifestyle, self-image, and general health. Each patient with complex wounds usually manifests multiple risk factors for their development. This article focuses on complex wounds involved with traumatic and orthopedic blunt or penetrating injuries, particularly in the extremities, as well as massive soft tissue infections including necrotizing fasciitis, gas gangrene, and Fournier gangrene. The principles of management of complex wounds involve assessing the patient's clinical status and the wound itself, appropriate timing of intervention, providing antibiotic therapy when necessary, and planning and executing surgical therapy, including the establishment of a clean wound bed and closure/reconstructive strategies.

We appreciate the thoughts and comments provided by Allen et al in their correspondence to the editor. The care of the trauma patient requires an interdisciplinary approach. The American College of Surgeons Committee on Trauma (ACS COT), along with its partner organizations, such as American College of Emergency Physicians (ACEP), has diligently tried to make trauma center criteria centered on the patient and the multidisciplinary team concept. Resuscitative Endovascular Balloon Occlusion of the Aorta (REBOA) has emerged as a potential technique for controlling previously lethal truncal hemorrhage in trauma patients, but its optimal role in the management of hemorrhagic shock has yet to be established. The purpose of the ACS and ACEP joint statement is to keep the focus on patient safety in the use of this device. We believe there is insufficient evidence to support the widespread adoption of REBOA1 in both civilian trauma centers and non-trauma centers where there is not immediate access to definitive hemorrhage control . This stance is due to concerns of the negative consequences of (1) prolonged ischemia and (2) delay of hemorrhage control as documented in published studies.2 In addition, the Joint Trauma Systems Clinical Practice Guideline notes, ‘… there is currently a paucity of evidence to guide the specific length …

The Joint Statement from the American College of Surgeons Committee on Trauma and the American College of Emergency Physicians (ACEP) regarding the clinical use of Resuscitative Endovascular Balloon Occlusion of the Aorta (REBOA) is intended to serve as a guide for the safe introduction and use of REBOA as a resuscitative tool for a select group of critically ill civilian trauma patients.1 Patient safety and quality care are at the forefront of these recommendations and we stand behind the statement. In no way did we intend to diminish or impair the Department of Defense physician leadership’s ability to implement combat casualty care clinical practice guidelines for REBOA implementation in deployed settings. We admire and appreciate the numerous contributions to care of the injured patient that have emerged from the years of conflict in Iraq and Afghanistan. They are a testimony to what unity of purpose, resiliency and creativity can bring in the quest …

Resuscitative Endovascular Balloon Occlusion of the Aorta (REBOA) provides a new tool in selected patients for the management of non-compressible torso hemorrhage.1–3 Recent improvements in technology have facilitated more rapid placement through smaller femoral access sheaths, which may reduce access-related complications.4 However, high grade evidence to guide REBOA use is limited, and there is a substantial complication risk should this approach be used inappropriately.5 To address the current state of implementation of this new therapeutic strategy, the American College of Surgeons Committee on Trauma (ACS COT) has worked in collaboration with the American College of Emergency Physicians to issue this joint policy statement which addresses the current practice relevant to patient indications, potential complications, implementation, patient management, and training of providers. We urge trauma centers to consider these factors in the adoption of this approach.