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Background Outcomes following pancreatic trauma have not improved significantly over the past two decades. A 2013 Western Trauma Association algorithm highlighted emerging data that might improve the diagnosis and management of high-grade pancreatic injuries (HGPIs; grades III-V). We hypothesized that the use of magnetic resonance cholangiopancreatography, pancreatic duct stenting, operative drainage versus resection, and nonoperative management of HGPIs increased over time. Methods Multicenter retrospective review of diagnosis, management, and outcomes of adult pancreatic injuries from 2010 to 2018 was performed. Data were analyzed by grade and time period (PRE, 2010-2013; POST, 2014-2018) using various statistical tests where appropriate. Results Thirty-two centers reported data on 515 HGPI patients. A total of 270 (53%) had penetrating trauma, and 58% went directly to the operating room without imaging. Eighty-nine (17%) died within 24 hours. Management and outcomes of 426 24-hour survivors were evaluated. Agreement between computed tomography and operating room grading was 38%. Magnetic resonance cholangiopancreatography use doubled in grade IV/V injuries over time but was still low.Overall HGPI treatment and outcomes did not change over time. Resection was performed in 78% of grade III injuries and remained stable over time, while resection of grade IV/V injuries trended downward (56% to 39%, p = 0.11). Pancreas-related complications (PRCs) occurred more frequently in grade IV/V injuries managed with drainage versus resection (61% vs. 32%, p = 0.0051), but there was no difference in PRCs for grade III injuries between resection and drainage.Pancreatectomy closure had no impact on PRCs. Pancreatic duct stenting increased over time in grade IV/V injuries, with 76% used to treat PRCs. Conclusion Intraoperative and computed tomography grading are different in the majority of HGPI cases. Resection is still used for most patients with grade III injuries; however, drainage may be a noninferior alternative. Drainage trended upward for grade IV/V injuries, but the higher rate of PRCs calls for caution in this practice. Level of evidence Retrospective diagnostic/therapeutic study, level III.

The implementation of pragmatic clinical trials (PCTs) can be accompanied by unique regulatory challenges. In this paper, we describe the experience and management of regulatory noncompliance during a 25-site acute care PCT. During the trial, the study team conducted a comprehensive audit of all enrollment forms (informed consent and Health Insurance Portability and Accountability Act authorization forms) and related study documentation. A review of 997 participants' enrollment forms identified 138 (13.8%) that required reporting to the institutional review board due to noncompliance. To prevent subsequent noncompliance, the study team developed and introduced a revised participant tracking system, reviewed all enrollment documentation, and retrained sites regarding study procedures. Based on these experiences, we developed a set of recommendations for future PCTs to ensure both operational success and regulatory compliance.

Background The optimal level of care for hemodynamically stable patients with isolated blunt hepatic, renal, or splenic injuries (solid organ injuries [SOIs]) is unknown. We sought to characterize interhospital variability in intensive care unit (ICU) admission of such patients and to determine whether greater hospital-level ICU use would be associated with improved outcomes. Methods We conducted a retrospective cohort study using the 2015 and 2016 National Trauma Data Bank. We included adult patients with blunt trauma with SOIs with an Abbreviated Injury Scale score of 2 to 4. We excluded patients with other significant injuries, hypotension, or another indication for ICU admission, and hospitals with less than 10 eligible patients. We categorized hospitals into quartiles based on the proportion of eligible patients admitted to an ICU. The primary outcome was a composite of organ failure (cardiac arrest, acute lung injury/acute respiratory failure, or acute kidney injury), infection (sepsis, pneumonia, or catheter-related blood stream infection), or death during hospitalization. Results Among 14,312 patients at 444 facilities, 7,225 (50%), 5,050 (35%), and 3,499 (24%) had splenic, hepatic, and renal injuries, respectively. The median proportion of ICU use was 44% (interquartile range, 27-59%, range 0-95%). The composite outcome occurred in 180 patients (1.3%), with death in 76 (0.5%), organ failure in 97 (0.7%), and infection in 53 (0.4%). Relative to hospitals with the lowest ICU use (quartile 1), greater hospital-level ICU use was not associated with decreased likelihood of the composite outcome (adjusted odds ratios, 1.31; 95% confidence interval [95% CI], 0.88-1.95; 0.81; 95% CI, 0.52-1.26; and 0.94; 95% CI, 0.62-1.43 for quartiles 2-4, respectively) or its components. Unplanned ICU transfer was no more likely with lower hospital-level ICU use. Conclusion Admission location of stable patients with isolated mild to moderate abdominal SOIs is variable across hospitals, but hospitalization at a facility with greater ICU use is not associated with substantially improved outcomes. Level of evidence Therapeutic/care management, Level IV.

BackgroundOlder adults with isolated rib fractures are often admitted to an intensive care unit (ICU) because of presumedly increased morbidity and mortality. However, evidence-based guidelines are limited. We sought to identify characteristics of these patients that predict the need for ICU care.Materials and methodsWe analyzed patients ≥50y old at our center during 2013-2017 whose only indication for ICU admission, if any, was isolated rib fractures. The primary outcome was any critical care intervention (e.g., intubation) or adverse event (e.g., hypoxemia) (CCIE) based on accepted critical care guidelines. We used stepwise logistic regression to identify characteristics that predict CCIEs.ResultsAmong 401 patients, 251 (63%) were admitted to an ICU. Eighty-three patients (33%) admitted to an ICU and 7 (5%) admitted to the ward experienced a CCIE. The most common CCIEs were hypotension (10%), frequent respiratory therapy (9%), and oxygen desaturation (8%). Predictors of CCIEs included incentive spirometry

Traumatic injury affects over 2.6 million U.S. adults annually and elevates risk for a number of negative health consequences. This includes substantial psychological harm, the most prominent being posttraumatic stress disorder (PTSD), with approximately 21% of traumatic injury survivors developing the disorder within the first year after injury. Posttraumatic stress disorder is associated with deficits in physical recovery, social functioning, and quality of life. Depression is diagnosed in approximately 6% in the year after injury and is also a predictor of poor quality of life. The American College of Surgeons Committee on Trauma suggests screening for and treatment of PTSD and depression, reflecting a growing awareness of the critical need to address patients' mental health needs after trauma. While some trauma centers have implemented screening and treatment or referral for treatment programs, the majority are evaluating how to best address this recommendation, and no standard approach for screening and treatment currently exists. Further, guidelines are not yet available with respect to resources that may be used to effectively screen and treat these disorders in trauma survivors, as well as who is going to bear the costs. The purpose of this review is: (1) to evaluate the current state of the literature regarding evidence-based screens for PTSD and depression in the hospitalized trauma patient and (2) summarize the literature to date regarding the treatments that have empirical support in treating PTSD and depression acutely after injury. This review also includes structural and funding information regarding existing postinjury mental health programs. Screening of injured patients and timely intervention to prevent or treat PTSD and depression could substantially improve health outcomes and improve quality of life for this high-risk population. LEVEL OF EVIDENCE: Review, level IV.

Introduction Current guidelines recommend nonoperative management (NOM) of low-grade (American Association for the Surgery of Trauma-Organ Injury Scale Grade I-II) pancreatic injuries (LGPIs), and drainage rather than resection for those undergoing operative management, but they are based on low-quality evidence. The purpose of this study was to review the contemporary management and outcomes of LGPIs and identify risk factors for morbidity. Methods Multicenter retrospective review of diagnosis, management, and outcomes of adult pancreatic injuries from 2010 to 2018. The primary outcome was pancreas-related complications (PRCs). Predictors of PRCs were analyzed using multivariate logistic regression. Results Twenty-nine centers submitted data on 728 patients with LGPI (76% men; mean age, 38 years; 37% penetrating; 51% Grade I; median Injury Severity Score, 24). Among 24-hour survivors, definitive management was NOM in 31%, surgical drainage alone in 54%, resection in 10%, and pancreatic debridement or suturing in 5%. The incidence of PRCs was 21% overall and was 42% after resection, 26% after drainage, and 4% after NOM. On multivariate analysis, independent risk factors for PRC were other intra-abdominal injury (odds ratio [OR], 2.30; 95% confidence interval [95% CI], 1.16-15.28), low volume (OR, 2.88; 1.65, 5.06), and penetrating injury (OR, 3.42; 95% CI, 1.80-6.58). Resection was very close to significance (OR, 2.06; 95% CI, 0.97-4.34) (p = 0.0584). Conclusion The incidence of PRCs is significant after LGPIs. Patients who undergo pancreatic resection have PRC rates equivalent to patients resected for high-grade pancreatic injuries. Those who underwent surgical drainage had slightly lower PRC rate, but only 4% of those who underwent NOM had PRCs. In patients with LGPIs, resection should be avoided. The NOM strategy should be used whenever possible and studied prospectively, particularly in penetrating trauma. Level of evidence Therapeutic Study, level IV.

Introduction Patients who sustain orthopaedic trauma are at an increased risk of venous thromboembolism (VTE), including fatal pulmonary embolism (PE). Current guidelines recommend low-molecular-weight heparin (LMWH) for VTE prophylaxis in orthopaedic trauma patients. However, emerging literature in total joint arthroplasty patients suggests the potential clinical benefits of VTE prophylaxis with aspirin. The primary aim of this trial is to compare aspirin with LMWH as a thromboprophylaxis in fracture patients. Methods and analysis PREVENT CLOT is a multicentre, randomised, pragmatic trial that aims to enrol 12 200 adult patients admitted to 1 of 21 participating centres with an operative extremity fracture, or any pelvis or acetabular fracture. The primary outcome is all-cause mortality. We will evaluate non-inferiority by testing whether the intention-to-treat difference in the probability of dying within 90 days of randomisation between aspirin and LMWH is less than our non-inferiority margin of 0.75%. Secondary efficacy outcomes include cause-specific mortality, non-fatal PE and deep vein thrombosis. Safety outcomes include bleeding complications, wound complications and deep surgical site infections. Ethics and dissemination The PREVENT CLOT trial has been approved by the ethics board at the coordinating centre (Johns Hopkins Bloomberg School of Public Health) and all participating sites. Recruitment began in April 2017 and will continue through 2021. As both study medications are currently in clinical use for VTE prophylaxis for orthopaedic trauma patients, the findings of this trial can be easily adopted into clinical practice. The results of this large, patient-centred pragmatic trial will help guide treatment choices to prevent VTE in fracture patients. Trial registration number NCT02984384.

BACKGROUND Trauma is the leading cause of death in children, and most deaths occur within 24 hours of injury. A better understanding of the causes of death in the immediate period of hospital care is needed. METHODS Trauma admissions younger than 18 years from 2009 to 2019 at a Level I pediatric trauma center were reviewed for deaths (n = 7,145). Patients were stratified into ages 0-6, 7-12, and 13-17 years old. The primary outcome was cause of death, with early death defined as less than 24 hours after trauma center arrival. RESULTS There were 134 (2%) deaths with a median age of 7 years. The median time from arrival to death was 14.4 hours (interquartile range, 0.5-87.8 hours). Half (54%) occurred within 24 hours. However, most patients who survived initial resuscitation in the emergency department died longer than 24 hours after arrival (69%). Traumatic brain injury was the most common cause of death (66%), followed by anoxia (9.7%) and hemorrhage (8%). Deaths from hemorrhage were most often in patients sustaining gunshot wounds (73% vs. 11% of all other deaths, p < 0.0001), more likely to occur early (100% vs. 50% of all other deaths, p = 0.0009), and all died within 6 hours of arrival. Death from hemorrhage was more common in adolescents (21.4% of children aged 13-17 vs. 6.3% of children aged 0-6, and 0% of children aged 7-12 p = 0.03). The highest case fatality rates were seen in hangings (38.5%) and gunshot wounds (9.6%). CONCLUSION Half of pediatric trauma deaths occurred within 24 hours. Death from hemorrhage was rare, but all occurred within 6 hours of arrival. This is a critical time for interventions for bleeding control to prevent death from hemorrhage in children. Analysis of these deaths can focus efforts on the urgent need for development of new hemorrhage control adjuncts in children. LEVEL OF EVIDENCE Epidemiological study, level IV.

Key Points Question Is a greater hospital-level tendency to admit older patients with rib fractures as an isolated injury to the intensive care unit (ICU) associated with improved outcomes for those patients? Findings In this cohort study of 23 951 patients aged 65 years and older, ICU use per trauma center varied from 0% to 92% of patients with isolated rib fractures. Greater ICU use was associated with a reduction in a composite adverse outcome of death, unplanned intubation, or pneumonia. Meaning These findings suggest that admission to an ICU may improve the outcomes of older patients with isolated chest wall injuries., This cohort study characterizes interhospital variability in intensive care unit vs non–intensive care unit admission of older patients with isolated rib fractures and evaluates whether greater hospital-level use of intensive care units is associated with improved outcomes., Importance The optimal level of care for older patients with rib fractures as an isolated injury is unknown. Objectives To characterize interhospital variability in intensive care unit (ICU) vs non-ICU admission of older patients with isolated rib fractures and to evaluate whether greater hospital-level use of ICU admission is associated with improved outcomes. Design, Setting, and Participants This cohort study included trauma patients aged 65 years and older with isolated rib fractures who were admitted to US trauma centers participating in the National Trauma Data Bank between January 1, 2015, and December 31, 2016. Patients were excluded if they had other significant injuries, were intubated or had assisted respirations in the emergency department (ED), or had a Glasgow Coma Scale (GCS) score of less than 9 in the ED. Hospitals with fewer than 10 eligible patients were excluded. Data analysis was conducted from May 2019 through September 2020. Exposures Admission to the ICU. Main Outcomes and Measures Composite of unplanned intubation, pneumonia, or death during hospitalization. Results Among 23 951 patients (11 066 [46.2%] women; mean [SD] age, 77.0 [7.2] years) at 573 hospitals, the median (interquartile range) proportion of ICU use was 16.7% (7.4%-32.0%), but this varied from a low of 0% to a high of 91.9%. The composite outcome occurred in 787 patients (3.3%), with unplanned intubation in 317 (1.3%), pneumonia in 180 (0.8%), and death in 451 (1.9%). Accounting for the hierarchical nature of the data and adjusting for propensity scores reflecting factors associated with ICU admission, receiving care at a hospital with the greatest ICU use (quartile 4), compared with a hospital with the lowest ICU use, was associated with decreased likelihood of the composite outcome (adjusted odds ratio, 0.71; 95% CI, 0.55-0.92). Conclusions and Relevance In this study, admission location of older patients with isolated rib fractures was variable across hospitals, but hospitalization at a center with greater ICU use was associated with improved outcomes. It may be warranted for hospitals with low ICU use to admit more such patients to an ICU.

Introduction A balance between work and life outside of work can be difficult for practicing physicians to achieve, especially for trauma surgeons. Work-life balance (WLB) has been associated with burnout and career changes. The specific aim of this study was to investigate factors associated with WLB for trauma surgeons. We hypothesized that trauma surgeons are dissatisfied with their WLB, and there are modifiable factors that can be adjusted to improve and maintain WLB. Methods Survey study of AAST members including detailed questions regarding demographics, clinical practice, family, lifestyle, and emotional support. Primary outcome was WLB, while the secondary outcome was surgeon burnout. Results A total of 1,383 American Association for the Surgery of Trauma members received an email with the survey, and 291 (21%) completed the survey. There was a total of 125 members (43%) satisfied with their WLB, and 166 (57%) were not. Factors independently associated with satisfying WLB included hobbies (2.3 [1.1-4.7], p = 0.03), healthy diet (2.6 [1.2-4.4], p = 0.02), exercise (2.6 [1.3-5.1], p = 0.006), vacation weeks off (1.3 [1.0-1.6], p = 0.02), and fair compensation (2.6 [1.3-5.3], p = 0.008). Conversely, factors independently associated with a poor WLB included being midcareer (0.3 [0.2-0.7], p = 0.002), more work hours (0.4 [0.2-0.7], p = 0.006), fewer awake hours at home (0.2 [0.1-0.6], p = 0.002), and feeling that there is a better job (0.4 [0.2-0.9], p = 0.02]. Risk factors for burnout were the same as those for poor WLB. Conclusion Only 43% of trauma surgeons surveyed were satisfied with their WLB, and 61% reported burnout. Modifiable factors independently associated with a satisfying WLB were related to lifestyle and fair compensation. Factors independently associated with poor WLB and suffering burnout were being midcareer, increased hours at work, decreased awake hours at home, and feeling that there was a better job for yourself. Many factors associated with trauma surgeon WLB are modifiable. Trauma surgeons, as well as trauma leaders, should focus on these modifiable factors to optimize WLB and minimize burnout. Level of evidence Care management, Level III.

Objective We seek to identify the current role and practices of the surgery morbidity and mortality (M&M) conference in academic surgery departments in the United States and Canada. Design, Setting, and Participants All members of the Society of Surgical Chairs, a program of the American College of Surgeons, were e-mailed an IRB-approved 28-question electronic survey in fall 2017. Up to 3 reminders were sent. Results Responses from 129/186 (69%) departments of surgery were received. Nearly all departments (96%) continue to have a departmental M&M conference. The M&M conference is typically weekly (93%), between 7 and 9 AM (80%), on weekdays during which there are no scheduled elective operations (84%). Attendance is mandatory for residents (98%), but required for faculty in only 49% of departments. Fewer than half of all departments (44%) have written guidelines as to which complications should be reported to M&M. Most conferences are prepared case presentations (89%), but may include unprepared discussions (17%), case-based educational presentations (30%), or a combination (28%). The most common classification category was by root case of the error (60%) and preventability (58%). Most departments keep electronic and/or physical M&M reports, while 21% maintain a relational database and 25% do not retain records. While almost all (96%) departments reported participating in at least one national quality improvement program, these are not often linked to the M&M process. Conclusions M&M is predominantly seen as an educational conference based on a few select cases. Departmental quality is monitored with hospital-driven or national quality improvement efforts. Integration of hospital-based quality metric programs with surgery M&M conference is uncommon and represents an opportunity for hospital-department collaboration.

Introduction Pancreatic trauma results in high morbidity and mortality, in part caused by the delay in diagnosis and subsequent organ dysfunction. Optimal operative management strategies remain unclear. We therefore sought to determine CT accuracy in diagnosing pancreatic injury and the morbidity and mortality associated with varying operative strategies. Methods We created a multicenter, pancreatic trauma registry from 18 Level 1 and 2 trauma centers. Adult, blunt or penetrating injured patients from 2005 to 2012 were analyzed. Sensitivity and specificity of CT scan identification of main pancreatic duct injury was calculated against operative findings. Independent predictors for mortality, adult respiratory distress syndrome (ARDS), and pancreatic fistula and/or pseudocyst were identified through multivariate regression analysis. The association between outcomes and operative management was measured. Results We identified 704 pancreatic injury patients of whom 584 (83%) underwent a pancreas-related procedure. CT grade modestly correlated with OR grade (r 0.39) missing 10 ductal injuries (9 grade III, 1 grade IV) providing 78.7% sensitivity and 61.6% specificity. Independent predictors of mortality were age, Injury Severity Score (ISS), lactate, and number of packed red blood cells transfused. Independent predictors of ARDS were ISS, Glasgow Coma Scale score, and pancreatic fistula (OR 5.2, 2.6-10.1). Among grade III injuries (n = 158, 22.4%), the risk of pancreatic fistula/pseudocyst was reduced when the end of the pancreas was stapled (OR 0.21, 95% CI 0.05-0.9) compared with sewn and was not affected by duct stitch placement. Drainage alone in grades IV (n = 25) and V (n = 24) injuries carried increased risk of pancreatic fistula/pseudocyst (OR 8.3, 95% CI 2.2-32.9). Conclusion CT is insufficiently sensitive to reliably identify pancreatic duct injury. Patients with grade III injuries should have their resection site stapled instead of sewn and a duct stitch is unnecessary. Further study is needed to determine if drainage alone should be employed in grades IV and V injuries. Level of evidence Epidemiologic/Diagnostic study, level III.

Background Traditionally, clinicians present complications at surgical morbidity and mortality (M&M) conferences, and the AHRQ Patient Safety Indicators (PSIs) use inpatient administrative data to identify certain adverse outcomes. Although both methods are used to identify adverse events and inform quality improvement efforts, these 2 methods might not overlap. Study Design This is a retrospective observational study of all hospitalizations at a single academic department of surgery (including subspecialties) in 2016 involving a PSI-defined event (PSIs 03, 05 to 15) identified by surgery faculty and residents for review by departmental M&M conference or administrative data (according to AHRQ, version 6.0). Pediatric cases were excluded. We analyzed the degree to which these 2 processes captured PSI-defined events and reasons for exclusion by each process. Results Among 6,563 surgical hospitalizations, 647 hospitalizations (9.9%) had at least 1 complication identified by the M&M process or the PSIs (or both). Of these hospitalizations, 116 had at least 1 PSI-defined event (for a total of 149 PSI-defined events) captured by either M&M or the PSIs. Most complications (n = 82 [88.2%]) identified by M&M alone were excluded by PSI criteria (as intended), but 11 true PSI events (ie false negatives) were identified by M&M only. In contrast, pressure ulcers and central venous catheter-related bloodstream infections were detected exclusively by the PSIs and not reported via M&M. There was limited overlap, with 18 events (12.1%) captured by both processes. Conclusions Surgical M&M and the PSIs are complementary approaches to identifying complications. Both case-finding processes should be used to inform quality improvement efforts.

BACKGROUND Patients undergoing emergency general surgery (EGS) procedures are up to eight times more likely to die than patients undergoing the same procedures electively. This excess mortality is often attributed to nonmodifiable patient factors including comorbidities and physiologic derangements at presentation, leaving few targets for quality improvement. Although the hospital-level traits that contribute to EGS outcomes are not well understood, we hypothesized that facilities with lower trauma mortality would have lower EGS mortality. METHODS Using the Nationwide Inpatient Sample (2008-2011), we calculated hospital-level risk-adjusted trauma mortality rates for hospitals with more than 400 trauma admissions. We then calculated hospital-level risk-adjusted EGS mortality rates for hospitals with more than 200 urgent/emergent admissions for seven core EGS procedures (laparotomy, large bowel resection, small bowel resection, lysis of adhesions, operative intervention for ulcer disease, cholecystectomy, and appendectomy). We used univariable and multivariable techniques to assess for associations between hospital-level risk-adjusted EGS mortality and hospital characteristics, patient-mix traits, EGS volume, and trauma mortality quartile. RESULTS Data from 303 hospitals, representing 153,544 admissions, revealed a median hospital-level EGS mortality rate of 1.21% (interquartile range, 0.86%-1.71%). After adjusting for hospital traits, hospital-level EGS mortality was significantly associated with trauma mortality quartile as well as patients' community income-level and race/ethnicity (p < 0.05 for all). Mean risk-adjusted EGS mortality was 1.09% (95% confidence interval, 0.94-1.25%) at hospitals in the lowest quartile for risk-adjusted trauma mortality, and 1.64% (95% confidence interval, 1.48-1.80%) at hospitals in the highest quartile of trauma mortality (p < 0.01). Sensitivity analyses limited to (1) high-mortality procedures and (2) high-volume facilities; both found similar trends (p < 0.01). CONCLUSIONS Patients at hospitals with lower risk-adjusted trauma mortality have a nearly 33% lower risk of mortality after admission for EGS procedures. The structures and processes that improve trauma mortality may also improve EGS mortality. Emergency general surgery-specific systems measures and process measures are needed to better understand drivers of variation in quality of EGS outcomes. LEVEL OF EVIDENCE Epidemiological, level III; Care management, level IV.

Trauma is the leading cause of death among patients 46 years or younger, and having a system in place for the care of the injured is of paramount importance to the health of a community. The growth and development of civilian trauma systems has not been an easy process. The concept of regionalized health care that the trauma system models has been emulated by other specialized and time-sensitive areas of medicine, notably stroke and acute cardiac events. Continued process improvement, public education, support and involvement, a sound infrastructure, and integrated technology should remain our focus.

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

Purpose of review The current review discusses the supplemental use of vitamin C as an adjunct in the management of sepsis and septic shock. Recent findings The antioxidant properties of vitamin C are touted to be useful in modulating the inflammatory response, decreasing vasopressor requirements, and improving resuscitation. Current resuscitation practices are focused on addressing the hemodynamic instability and ensuring adequate oxygen delivery to tissues. The conceptual framework of the use of vitamin C during a resuscitation is to modulate in a beneficial fashion the inflammatory response to sepsis while concomitantly resuscitating and treating the infection. While there is promising animal and burn-related data on improved fluid resuscitation with the use of vitamin C as an adjunct, the most recent meta-analyses of the available data fail to show a survival benefit in sepsis, and concerns regarding nephrotoxicity remain. Summary Although there are large number of animal studies, only a few small prospective and retrospective studies in humans address the use of vitamin C to treat sepsis. Further research in a controlled and randomized fashion is needed to determine if vitamin C is effective in this role. While there is a promise of ascorbate's addition to the sepsis bundle as an adjunct to resuscitation, the evidence is not conclusive.

ImportanceTo date, few multisite investigations have evaluated early interventions for injured patients with posttraumatic stress disorder (PTSD) symptoms.ObjectiveTo simultaneously assess the effectiveness and implementation of a brief stepped collaborative care intervention targeting PTSD and comorbidity.Design, Setting, and ParticipantsA stepped-wedge cluster randomized clinical trial was conducted at 25 US level I trauma centers. Participants included hospitalized survivors of physical injury who underwent a 2-step evaluation for PTSD symptoms. Patients reporting high levels of distress on the PTSD Checklist (PCL-C) were randomized (N = 635) per the stepped-wedge protocol to enhanced usual care control (n = 370) or intervention (n = 265) conditions. The study was conducted from January 4, 2016, through November 2019. Data analysis was performed from November 4, 2019, to December 8, 2020.InterventionsThe Trauma Survivors Outcomes and Support collaborative care intervention included proactive injury case management that assisted patients transitioning from hospital inpatient to outpatient and community settings. The intervention also integrated evidence-based pharmacotherapy and psychotherapeutic elements targeting PTSD symptoms and comorbidity.Main Outcomes and MeasuresThe primary study outcome was PTSD symptoms assessed with the PCL-C at baseline in the surgical ward and at 3, 6, and 12 months postinjury. Secondary outcomes included depressive symptoms, alcohol use, and physical function. Subgroup analyses examined the effect of baseline risk factors for enduring PTSD and quality of protocol implementation on study outcomes. Primary statistical analyses were conducted using the intent-to-treat sample.ResultsA total of 327 men (51.5%) were included in analysis; mean (SD) age was 39.0 (14.2) years. The investigation attained follow-up of 75% to 80% of the participants at 3 to 12 months. The intervention lasted a mean (SD) of 122 (132) minutes. Mixed model regression analyses revealed statistically significant changes in PCL-C scores for intervention patients compared with control patients at 6 months (difference, −2.57; 95% CI, −5.12 to −0.03; effect size, 0.18; P P = .35). Subgroup analyses revealed larger PTSD treatment effects for patients with 3 or more baseline risk factors for enduring PTSD and for patients, including firearm injury survivors, treated at trauma centers with good or excellent protocol implementation. Intervention effects for secondary outcomes did not attain statistical significance.Conclusions and RelevanceA brief stepped collaborative care intervention was associated with significant 6-month but not 12-month PTSD symptom reductions. Greater baseline PTSD risk and good or excellent trauma center protocol implementation were associated with larger PTSD treatment effects. Orchestrated efforts targeting policy and funding should systematically incorporate the study findings into national trauma center requirements and verification criteria.Trial RegistrationClinicalTrials.gov Identifier: NCT02655354

OBJECTIVE To examine the performance of the Corticosteroid Randomization After Significant Head injury (CRASH) trial prognostic model in older patients with traumatic brain injury. SETTING The National Study on Costs and Outcomes of Trauma cohort, established at 69 hospitals in the United States in 2001 and 2002. PARTICIPANTS Adults with traumatic brain injury and an initial Glasgow Coma Scale score of 14 or less. DESIGN The CRASH-CT model predicting death within 14 days was deployed in all patients. Model performance in older patients (aged 65-84 years) was compared with that in younger patients (aged 18-64 years). MAIN MEASURES Model discrimination (as defined by the c-statistic) and calibration (as defined by the Hosmer-Lemeshow P value). RESULTS CRASH-CT model discrimination was not significantly different between the older (n = 356; weighted n = 524) and younger patients (n = 981; weighted n = 2602) and was generally adequate (c-statistic 0.83 vs 0.87, respectively; P = .11). CRASH-CT model calibration was adequate for the older patients and inadequate for younger patients (Hosmer-Lemeshow P values .12 and .001, respectively), possibly reflecting differences in sample size. Calibration-in-the-large showed no systematic under- or overprediction in either stratum. CONCLUSION The CRASH-CT model may be valid for use in a geriatric population.

Humans are able to compensate for significant blood loss with little change in traditional vital signs. We hypothesized that an algorithm, which recognizes compensatory changes in photoplethysmogram (PPG) waveforms, could detect active bleeding and ongoing volume loss in injured patients.Injured adults were prospectively enrolled at a level I trauma center. PPG data collection was conducted using a custom-made pulse oximeter. Waveform data were post-processed by an algorithm to calculate the compensatory reserve index (CRI), measured on a scale of 1 to 0, with 1 indicating fully compensated and 0 indicating no reserve, or decompensation. CRI was compared to clinical findings.Fifty patients were enrolled in the study; 3 had incomplete data, 3 had indeterminate bleeding, 12 were actively bleeding, and 32 were not bleeding. The mean initial CRI of bleeding patients was significantly lower compared with the non-bleeding patients (CRI 0.17, 95% CI = 0.13-0.22 vs. CRI 0.56, 95% CI = 0.49-0.62, P 0.001). Using a cut-off of 0.21 had a sensitivity of 0.97 and specificity of 0.83 for identifying bleeding patients. CRI had a higher sensitivity than heart rate (75%), systolic blood pressure (63%), shock index (27%), base deficit (29%), lactate (80%), hemoglobin (50%), and hematocrit (50%). During ongoing bleeding, CRI decreased following fluid resuscitation, and conversely increased for patients who were not bleeding.A novel computational algorithm that recognizes subtle changes in PPG waveforms can quickly and noninvasively discern which patients are actively bleeding and continuing to bleed with high sensitivity and specificity in acutely injured patients.

The investigation aimed to compare two approaches to the delivery of care for hospitalized injury survivors, a patient-centered care transition intervention versus enhanced usual care.This pragmatic comparative effectiveness trial randomized 171 acutely injured trauma survivors with three or more early postinjury concerns and high levels of emotional distress to intervention (I; n = 85) and enhanced usual care control (C; n = 86) conditions. The care transition intervention components included care management that elicited and targeted improvement in patients' postinjury concerns, 24/7 study team cell phone accessibility, and stepped-up care. Posttraumatic concerns, symptomatic distress, functional status, and statewide emergency department (ED) service utilization were assessed at baseline and over the course of the 12 months after injury. Regression analyses assessed intervention and control group outcome differences over time.Over 80% patient follow-up was attained at each time point. Intervention patients demonstrated clinically and statistically significant reductions in the percentage of any severe postinjury concerns expressed when compared to controls longitudinally (Wald chi-square = 11.29, p = 0.01) and at the six-month study time point (C = 74%, I = 53%; Fisher's exact test, p = 0.02). Comparisons of ED utilization data yielded clinically significant cross-sectional differences (one or more three- to six-month ED visits; C = 30.2%, I = 16.5%, [relative risk (95% confidence interval] C versus I = 2.00 (1.09, 3.70), p = 0.03) that did not achieve longitudinal statistical significance (F (3, 507) = 2.24, p = 0.08). The intervention did not significantly impact symptomatic or functional outcomes.Orchestrated investigative and policy efforts should continue to evaluate patient-centered care transition interventions to inform American College of Surgeons' clinical guidelines for U.S. trauma care systems.

Author(s): Pieracci, Fredric M; Johnson, Jeffrey L; Stovall, Robert T; Jurkovich, Gregory J

Blunt injury to the aorta, diaphragm, and esophagus are unusual and are typically the result of a significant transfer of energy and hence are typically accompanied by other injuries. The associated injury can detract attention, leading to lethal delays in the recognition of blunt injury to the aorta, esophagus, and diaphragm. Improved cross-sectional imaging techniques (CT scanning) and a better understanding of the subtle signs of blunt injury to the aorta, diaphragm, and even esophagus has lessened, but not eliminated, the delay in diagnosis. Changes in management of aortic injuries continue to involve, largely stimulated by the more widespread application of endovascular techniques, and a better understanding of the natural history of less severe grades of injury. Early and primary repair of an acute blunt diaphragm injury remains the standard. Blunt esophageal injury, perhaps the rarest in this category, can largely be excluded on the basis of a detailed thoracic CT scan, although the role of esophageal endoscopy or esophagography remains essential diagnostic tools. The management of these rare injuries is often controversial. This review will examine the recent literature regarding these uncommon injuries, emphasizing recent clinical trials and guidelines.

Refinement of criteria for both screening and initiation of empiric therapy in ventilator-associated pneumonia (VAP) will minimize antibiotic overuse. We hypothesized that variables within the commonly used Clinical Pulmonary Infection Score (CPIS) have unfavorable test performance characteristics.Consecutive bronchoalveolar lavage (BAL) cultures obtained from surgical intensive care unit patients were abstracted (2009-2012). Ventilator-associated pneumonia was defined as ≥10(5) cfu/mL. The CPIS both without (CPISclinical) and with (CPISclinical+GS) the result of gram stain (GS) was calculated. Test performance characteristics for the sample, as well as several subgroups, were compared.One thousand thirteen lower respiratory tract cultures from 492 patients were analyzed; 438 (43.2%) of cultures were classified as VAP, and 310 of 492 patients (62.4%) had ≥1 episode of VAP. Both CPISclinical and CPISclinical+GS had poor discrimination for VAP (Receiver-operating characteristic area under the curve=0.55 and 0.66, respectively). Sensitivity of CPISclinical using a threshold of6 was 21%; the lowest threshold for CPISclinical for which the sensitivity was at least 85% was 3. The highest sensitivity among the individual CPIS components was new CXR infiltrate (91.1%). Among the subset of cultures sent during the early VAP window (days intubated 2-5), organisms on GS had a sensitivity of 93.3%. The CPISclinical, CPISclinical+GS, organisms, and neutrophils on GS parameters all became less accurate in both the late VAP window and when screening for recurrent VAP. Every case of VAP had at least one of the following: 1) fever; 2) new CXR infiltrate, or 3) organisms on GS.In this series of BALs, traditional screening tools for VAP missed the majority of microbiological confirmed cases. Screening based on either new CXR infiltrate or fever yielded an acceptably high sensitivity. The only scenario identified in which empiric antibiotics could be withheld safely was the absence of organisms on GS in the early VAP window.

This study was designed to define the gaps in essential and desirable (E/D) case volumes that may prompt reevaluation of the acute care surgery (ACS) curriculum or restructuring of the training provided.A review of the first 2 years of ACS case log entry (July 2011 to June 2013) was performed. Individual trainee logs were evaluated to determine how often they performed each case on the E/D list. Trainees described cases using current procedural terminology codes, which had been previously mapped to the E/D list.There were 29 trainees from 15 programs (Year 1) and 30 trainees from 13 programs (Year 2) who participated in case log entry, with some overlap between the years. There were a total of 487 fellow-months of data with an average of 14.6 current procedural terminology codes per month and 175.5 per year for cases on the E/D list versus 12 and 143.5 for cases not on the E/D list, respectively. Overall, the most common essential cases were laparotomy for trauma (1,463; 705 in Year 1, 758 in Year 2), tracheostomy (665; 372 in Year 1, 293 in Year 2) and gastrostomy tubes (566; 289 in Year 1, 277 in Year 2). There are a total of 73 types of essential operations and 45 types of desirable operations in the current curriculum. There were 16 distinct codes (13.6%) never used, of which 6 overlapped with other codes. Based on body region, the 10 E/D codes never used by any fellow were as follows: one head/face, lateral canthotomy; five neck; elective neck dissections; one thoracic, vascular trauma to chest; three pediatrics, inguinal hernia repair and small bowel obstruction treatments.The current ACS trainees lack adequate head/neck and pediatric experience as defined by the ACS curriculum. Restructuring rotations at individual institutions and a focus on novel educational modalities may be needed to augment the individual institutional exposure. Reevaluation of the curriculum may be warranted.

BACKGROUND Over the past decade, the American Association for the Surgery of Trauma Acute Care Surgery (ACS) fellowship program has matured to 20 verified programs. As part of an ongoing curricular evaluation, we queried the current practice patterns of the graduates of ACS fellowship programs regarding their view on their ACS training. We hypothesized that the majority of ACS fellowship graduates would be practicing ACS in academic Level I trauma centers and that fellowship training was pivotal in their career. METHODS Graduates of American Association for the Surgery of Trauma-certified ACS fellowships completed an online survey that included practice demographics, specific categories of cases delineated by the current ACS curriculum, and perceived impact of training. RESULTS Surveys were submitted by 56 of 77 graduates for a completion rate of 73%. The majority of respondents were male (68%) aged 40 years or younger (80%). All but four completed ACS fellowship training in last 5 years (93%), and 83% completed fellowship in the last 3 years. Regarding their current practice, broadly defined ACS predominated (96%) with 2% practicing only trauma surgery and 2% only general surgery. Practice settings were 64% urban, 29% suburban, and 7% rural locations, with 84% of graduates practicing in a hospital-based group. The practitioner's hospital was identified as university/university-affiliated in 53%, community in 38%, and military in 9%, with 91% identified as a teaching hospital; trauma designation was identified as Level I (55%), Level II (39%), and other (6%). The graduates' average current practice mix is 10% elective general surgery, 29% emergency general surgery, 32% trauma, 25% surgical critical care, and 4% other (burn, bariatric, vascular, and thoracic). Only 16% of graduates do not perform elective cases. Case specifics demonstrated 92% of graduates perform vascular cases, 88% perform thoracic cases, and 70% perform complex hepatobiliary. Practice elements that were satisfiers included (1) scope of practice, (2) case mix, (3) percentage emergency general surgery, (4) lifestyle, (5) case complexity (with 3 and 4 tied). Graduates agreed the ACS fellowship training prepared them well for practice and was worth the time invested (both 82%), increased their marketability and self-confidence (80%), and prepared them well for academics (71%) and administration (63%). Of those surveyed, 93% would encourage others to do an ACS fellowship. CONCLUSION Although 93% of graduates practice in urban/suburban areas, there was a mixture of university, university-affiliated, and community institutions and an almost even division of Levels I and II designation. Graduates demonstrate ongoing use of their acquired advanced operative training, particularly in vascular and thoracic surgery. The majority of ACS fellowship graduates were practicing ACS and felt fellowship training was valuable in their career path and that they would recommend it to others.

Background The role of stenting for blunt cerebrovascular injuries (BCVI) continues to be debated, with a trend toward more endovascular stenting. With the recent intracranial stenting trial halted in favor of medical therapy, however, management of BCVI warrants reassessment. The study purpose was to determine if antithrombotic therapy, rather than stenting, was effective in post-injury patients with high-grade vascular dissections and pseudoaneurysms. Study Design In 1996, we began screening for BCVI. After the 2005 report on the risks of carotid stenting for BCVI, a virtual moratorium was placed on stenting at our institution; our primary therapy for BCVI has been antithrombotics. Patients with grade II (luminal narrowing >25%) and grade III (pseudoaneurysms) injuries were included in the analysis. Results Grade II or III BCVIs were diagnosed in 195 patients. Before 2005, 25% (21 of 86) of patients underwent stent placement, with 2 patients suffering stroke. Of patients treated with antithrombotics, 1 had a stroke. After 2005, only 2% (2 of 109) of patients with high-grade injuries had stents placed. After 2005, no patient treated with antithrombotics suffered a stroke and there was no rupture of a pseudoaneurysm. Conclusions Antithrombotic treatment for BCVI is effective for stroke prevention. Routine stenting entails increased costs and potential risk for stroke, and does not appear to provide additional benefit. Intravascular stents should be reserved for the rare patient with symptomatology or a markedly enlarging pseudoaneurysm.

BACKGROUND: The diagnosis of blunt abdominal trauma can be challenging and resource intensive. Observation with serial clinical assessments plays a major role in the evaluation of these patients, but the time required for intra-abdominal injury to become clinically apparent is unknown. The purpose of this study was to determine the amount of time required for an intra-abdominal injury to become clinically apparent after blunt abdominal trauma via physical examination or commonly followed clinical values. METHODS: A retrospective review of patients who sustained blunt trauma resulting in intra-abdominal injury between June 2010 and June 2012 at a Level 1 academic trauma center was performed. Patient demographics, injuries, and the amount of time from emergency department admission to sign or symptom development and subsequent diagnosis were recorded. All diagnoses were made by computed tomography or at the time of surgery. Patient transfers from other hospitals were excluded. RESULTS: Of 3,574 blunt trauma patients admitted to the hospital, 285 (8%) experienced intra-abdominal injuries. The mean (SD) age was 36 (17) years, the majority were male (194 patients, 68%) and the mean (SD) Injury Severity Score (ISS) was 21 (14). The mean (SD) time from admission to diagnosis via computed tomography or surgery was 74 (55) minutes. Eighty patients (28%) required either surgery (78 patients, 17%) or radiographic embolization (2 patients, 0.7%) for their injury. All patients who required intervention demonstrated a sign or symptom of their intra-abdominal injury within 60 minutes of arrival, although two patients were intervened upon in a delayed fashion. All patients with a blunt intra-abdominal injury manifested a clinical sign or symptom of their intra-abdominal injury, resulting in their diagnosis within 8 hours 25 minutes of arrival to the hospital. CONCLUSION: All diagnosed intra-abdominal injuries from blunt trauma manifested clinical signs or symptoms that could prompt imaging or intervention, leading to their diagnosis within 8 hours 25 minutes of arrival to the hospital. All patients who required an intervention for their injury manifested a sign or symptom of their injury within 60 minutes of arrival. (J Trauma Acute Care Surg. 2014;76:1020Y1023. Copyright * 2014 by Lippincott Williams & Wilkins) LEVEL OF EVIDENCE: Therapeutic study, level IV. Epidemiologic study, level III.

Object Evidence-based management (EBM) guidelines for severe traumatic brain injuries (TBIs) were promulgated decades ago. However, the extent of their adoption into bedside clinical practices is not known. The purpose of this study was to measure compliance with EBM guidelines for management of severe TBI and its impact on patient outcome. Methods This was a retrospective study of blunt TBI (11 Level I trauma centers, study period 2008–2009, n = 2056 patients). Inclusion criteria were an admission Glasgow Coma Scale score ≤ 8 and a CT scan showing TBI, excluding patients with nonsurvivable injuries—that is, head Abbreviated Injury Scale score of 6. The authors measured compliance with 6 nonoperative EBM processes (endotracheal intubation, resuscitation, correction of coagulopathy, intracranial pressure monitoring, maintaining cerebral perfusion pressure ≥ 50 cm H2O, and discharge to rehabilitation). Compliance rates were calculated for each center using multivariate regression to adjust for patient demographics, physiology, injury severity, and TBI severity. Results The overall compliance rate was 73%, and there was wide variation among centers. Only 3 centers achieved a compliance rate exceeding 80%. Risk-adjusted compliance was worse than average at 2 centers, better than average at 1, and the remainder were average. Multivariate analysis showed that increased adoption of EBM was associated with a reduced mortality rate (OR 0.88; 95% CI 0.81–0.96, p < 0.005). Conclusions Despite widespread dissemination of EBM guidelines, patients with severe TBI continue to receive inconsistent care. Barriers to adoption of EBM need to be identified and mitigated to improve patient outcomes.

Background and Aims In 2005 the American College of Surgeons passed a mandate requiring that level I trauma centers have mechanisms to identify and intervene with problem drinkers. The aim of this investigation was to determine if a multi-level trauma center intervention targeting both providers and patients would lead to higher-quality alcohol screening and brief intervention (SBI) when compared with trauma center mandate compliance without implementation enhancements. Design Cluster randomized trial in which intervention site (site n = 10, patient n = 409) providers received 1-day workshop training on evidence-based motivational interviewing (MI) alcohol interventions and four 30-minute feedback and coaching sessions; control sites (site n = 10, patient n = 469) implemented the mandate without study team training enhancements. Setting Trauma centers in the United States of America. Participants A total of 878 blood alcohol-positive in-patients with and without traumatic brain injury (TBI). Measurements MI skills of providers were assessed with fidelity coded standardized patient interviews. All patients were interviewed at baseline and 6- and 12-months post-injury with the Alcohol Use Disorders Identification Test (AUDIT). Findings Intervention site providers consistently demonstrated enhanced MI skills compared with control providers. Intervention patients demonstrated an 8% reduction in AUDIT hazardous drinking relative to controls over the course of the year after injury (relative risk = 0.88, 95%, confidence interval = 0.79, 0.98). Intervention patients were more likely to demonstrate improvements in alcohol use problems in the absence of traumatic brain injury (TBI) (P = 0.002). Conclusion Trauma center providers can be trained to deliver higher-quality alcohol screening and brief intervention (SBI) than untrained providers, which is associated with modest reductions in alcohol use problems, particularly among patients without TBI.

A case log was created by the American Association for the Surgery of Trauma Acute Care Surgery (ACS) committee to track trainee operative experiences, allowing them to enter their cases in the form of Current Procedural Terminology (CPT) codes. We hypothesized that the number of cases an ACS trainee performed would be similar to the expectations of a fifth-year general surgery resident and that the current list of essential and desired cases (E/D list) would accurately reflect cases done by ACS trainees.The database was queried from July 1, 2011, to June 30, 2012. Trainees were classified as those in American Association for the Surgery of Trauma-accredited fellowships (ACC) and those in ACS fellowships not accredited (non-ACC). CPT codes were mapped to the E/D list. Cases entered manually were individually reviewed and assigned a CPT code if possible or listed as "noncodable." To compensate for nonoperative rotations and noncompliance, case numbers were analyzed both annually and monthly to estimate average case numbers for all trainees. In addition, case logs of trainees were compared with the E/D list to assess how well it reflected actual trainee experience.Eighteen ACC ACS and 11 non-ACC ACS trainees performed 16.4 (12.6) cases per month compared with 15.7 (14.2) cases for non-ACC ACS fellows (p = 0.71). When annualized, trainees performed, on average, 195 cases per year. Annual analysis led to similar results. The E/D list captured only approximately 50% of the trainees' operative experience. Only 77 cases were categorized as pediatric.ACS trainees have substantial operative experience averaging nearly 200 major cases during their ACS year. However, high variability exists in the number of essential or desirable cases being performed with approximately 50% of the fellows' operative experience falling outside the E/D list of cases. Modification of the fellows' operative experience and/or the rotation requirements seems to be needed to provide experience in E/D cases.

In studies of trauma patients with rib fractures, conclusions on the benefits derived from epidural analgesia are inconsistent. The purpose of this study was to further evaluate placement and efficacy of epidural analgesia nationwide.This was a retrospective cohort study of prospectively gathered data from the National Study on Cost and Outcomes of Trauma database, a multisite prospective study of injured patients aged 18 years to 84 years. Patients were treated at 69 participating hospitals (18 Level I trauma centers and 51 nontrauma centers) across the United States. Our analysis was limited to patients with a blunt mechanism of injury and a thoracic maximum Abbreviated Injury Scale (MAXAIS) score of 2 or greater. Excluded were patients who were not potential candidates for epidural placement, such as patients with significant head and spine injuries (head MAXAIS score2 or spine MAXAIS score2), significant neurologic impairment (best motor Glasgow Coma Scale [GCS] score4), unstable pelvic fractures, coagulopathy, or those who died within 48 hours.The National Study on Cost and Outcomes of Trauma database contains 5,043 patients, of whom 836 (16.5%) were identified as potential candidates for epidural placement. Of patients included in the study, 100 patients (12%) had epidural catheters placed. The likelihood of epidural catheter placement was significantly higher in trauma centers as compared with nontrauma centers (adjusted odds ratio, 3.06; 95% confidence interval [CI] 1.80-5.22). In the epidural group compared with those not receiving a catheter, the adjusted (including trauma center status) odds of death in patients with three or more rib fractures at 30, 90, and 365 days was 0.08 (95% CI, 0.01-0.43), 0.09 (95% CI, 0.02-0.42), and 0.12 (95% CI, 0.04-0.42), respectively.Trauma centers are more likely to place epidural catheter in patients with rib fractures. In this multicenter study, epidural catheter placement was associated with a significantly decreased risk of dying in patients with blunt thoracic injury of three or more rib fractures.Therapeutic study, level II.

BackgroundThe optimal time to initiate venous thromboembolism pharmacoprophylaxis after blunt abdominal solid organ injury is unknown.MethodsPostinjury coagulation status was characterized using thromboelastography (TEG) in trauma patients with blunt abdominal solid organ injuries; TEG was divided into 12-hour intervals up to 72 hours.ResultsForty-two of 304 patients (13.8%) identified underwent multiple postinjury thromboelastographic studies. Age (P = .45), gender (P = .45), and solid organ injury grade (P = .71) were similar between TEG and non-TEG patients. TEG patients had higher Injury Severity Scores compared with non-TEG patients (33.2 vs 18.3, respectively, P < .01). Among the TEG patients, the shear elastic modulus strength and maximum amplitude values began in the normal range within the first 12-hour interval after injury, increased linearly, and crossed into the hypercoagulable range at 48 hours (15.1 ± 1.9 Kd/cs and 57.6 ± 1.6 mm, respectively; P < .01, analysis of variance).ConclusionsPatients sustaining blunt abdominal solid organ injuries transition to a hypercoagulable state approximately 48 hours after injury. In the absence of contraindications, pharmacoprophylaxis should be considered before this time for effective venous thromboembolism prevention.

The liberal use of computed tomographic (CT) scanning during the evaluation of injured children has increased their exposure to the risks of ionizing radiation. We hypothesized that CT imaging performed for mechanism of injury alone is unnecessary and that serious or life-threatening injury is rarely identified.All pediatric blunt trauma team evaluations (age15 years) at a pediatric Level 2 trauma center over 72 months were reviewed. CT findings in patients with normal Glasgow Coma Scale (GCS) score, vital signs (VS), and physical examination (PE) (Group I) were compared with Group II (GCS score15), Group III (abnormal VS/PE), and Group IV (abnormal GCS score, VS/PE). Variables associated with any positive finding were entered into a multiple logistic regression model to assess for independent contributions. Each patient's total effective radiation dose from CT scans in millisieverts was calculated using an age-adjusted scale.A total 174 children met trauma team activation criteria (mean [SD] age, 7 [5] years; 63% male; mean [SD] Injury Severity Score [ISS], 10 [10]). A total of 153 (88%) were imaged by CT (I, 54 of 66; II, 25 of 25; III, 49 of 57; IV, 25 of 26). No patient in Group I had a serious finding on CT compared with Group II (17 of 77), III (25 of 111), and IV (18 of 72). Mortality was 4%. Radiation dose (mSv) from CT was not different among the groups (I, 17 [14]; II, 29 [13]; III, 21 [16]; IV, 27 [17]). By univariate analysis, GCS score of less than 15 (p0.01) and respiratory rate of greater than 30 (p = 0.09) were associated with a positive CT finding. By logistic regression analysis, GCS score of less than 15 remained the only variable associated significantly with a positive finding (odds ratio, 6.7; 95% confidence interval, 3-14; p0.01).In children imaged based only on mechanism, no patient had a serious positive finding but was subjected to radiation doses associated with an increased risk of future malignancy. The use of CT imaging in injured children in the absence of a physiologic or anatomic abnormality does not seem to be justified.Care management study, level IV.

Background Urinary tract infection (UTI) in trauma patients is associated with increased mortality. Whether the urinalysis (UA) is an adequate test for a urinary source of fever in the ICU trauma patient has not been demonstrated. We hypothesized that the UA is a valuable screen for UTI in the febrile, critically ill trauma patient. Study Design All trauma ICU patients in our surgical ICU who had a fever (temperature >38.0°C), urinary catheter, UA, and a urine culture between January 1, 2011 and December 13, 2011 were reviewed. A positive UA was defined as positive leukocyte esterase, positive nitrite, WBC > 10/high power field, or presence of bacteria. A positive urine culture was defined as growth of ≥10 5 colony forming units (cfu) of an organism irrespective of the UA result or ≥10 3 cfu in the setting of a positive UA. A UTI was defined as positive urine culture without an alternative cause of the fever. Results There were 232 UAs from 112 patients that met criteria. The majority (75%) of patients were men; the mean age was 40 (±16) years. Of the 232 UAs, 90 (38.7%) were positive. There were 14 UTIs. The sensitivity, specificity, positive predictive value, and negative predictive value of the UA for UTI were 100%, 65.1%, 15.5%, and 100%, respectively. Conclusions A negative UA reliably excludes a catheter-associated UTI in the febrile, trauma ICU patient with a 100% negative predictive value, and it can rapidly direct the clinician toward more likely sources of fever and reduce unnecessary urine cultures.

Objective In 2005, the American College of Surgeons passed a mandate requiring that Level I trauma centers have a mechanism to identify patients who are problem drinkers and have the capacity to provide an intervention for patients who screen positive. The aim of the Disseminating Organizational Screening and Brief Intervention Services (DO-SBIS) cluster randomized trial is to test a multilevel intervention targeting the implementation of high-quality alcohol screening and brief intervention (SBI) services at trauma centers. Method Twenty sites selected from all United States Level I trauma centers were randomized to participate in the trial. Intervention site providers receive a combination of workshop training in evidence-based motivational interviewing (MI) interventions and organizational development activities prior to conducting trauma-center-based alcohol SBI with blood-alcohol-positive injured patients. Control sites implement care as usual. Provider MI skills, patient alcohol consumption, and organizational acceptance of SBI implementation outcomes are assessed. Results The investigation has successfully recruited provider, patient and trauma center staff samples into the study, and outcomes are being followed longitudinally. Conclusion When completed, the DO-SBIS trial will inform future American College of Surgeons' policy targeting the sustained integration of high-quality alcohol SBI at trauma centers nationwide.

Despite being the leading cause of death in the United States for individuals 46 years and younger and the primary cause of death among military service members, trauma care research has been underfunded for the last 50 years. Sustained federal funding for a coordinated national trauma clinical research program is required to advance the science of caring for the injured. The Department of Defense is committed to funding studies with military relevance; therefore, it cannot fund pediatric or geriatric trauma clinical trials. Currently, trauma clinical trials are often performed within a single site or a small group of trauma hospitals, and research data are not available for secondary analysis or sharing across studies. Data-sharing platforms encourage transfer of research data and knowledge between civilian and military researchers, reduce redundancy, and maximize limited research funding. In collaboration with the Department of Defense, trauma researchers formed the Coalition for National Trauma Research (CNTR) in 2014 to advance trauma research in a coordinated effort. CNTR's member organizations are the American Association for the Surgery of Trauma (AAST), the American College of Surgeons Committee on Trauma (ACS COT), the Eastern Association for the Surgery of Trauma (EAST), the Western Trauma Association (WTA), and the National Trauma Institute (NTI). CNTR advocates for sustained federal funding for a multidisciplinary national trauma research program to be conducted through a large clinical trials network and a national trauma research repository. The initial advocacy and research activities underway to accomplish these goals are presented.

BackgroundAttempts are made with emergency department thoracotomy (EDT) to salvage trauma patients who present to the hospital in extremis. The EDT allows for relief of cardiac tamponade, internal cardiac massage, and proximal hemorrhage control. Minimally invasive techniques, such as endovascular hemorrhage control (EHC) are available, but their noninferiority to EDT remains unproven. Before adopting EHC, it is important to evaluate the current outcomes of EDT. We hypothesized that EDT survival has improved during the last 4 decades, and outcomes stratified by pre-hospital CPR and injury patterns will provide benchmarks for success-to-rescue and survival outcomes for patients in extremis.Study designConsecutive trauma patients undergoing EDT from 1975 to 2014 were prospectively observed as part of quality improvement. Predicted probabilities of survival were adjusted for pre-hospital CPR, mechanism of injury, injury pattern, patient demographics, and time period of EDT using logistic regression. Success-to-rescue was defined as return of spontaneous circulation with blood pressure permissive for transfer to the operating room.ResultsThere were 1,708 EDTs included, with an overall 419 (24%) success-to-rescue patients and 106 survivors (6%), and 1,394 (79%) of these patients had pre-hospital CPR and 900 (54%) had penetrating wounds. The most common injury patterns were chest (29%), multisystem with head (27%), and multisystem without head (21%). Penetrating injury was associated with higher survival than blunt trauma (9% vs 3% p < 0.001). Success-to-rescue increased from 22% in 1975 to 1979 to 35% over the final 5 years (p < 0.001); survival increased from 5% to 14% (p < 0.001).ConclusionsOutcomes of EDT have improved over the past 40 years. In the last 5 years, STR was 35% and overall survival was 14%. These prospective observational data provide benchmarks to define the role of EHC as an alternative approach for patients arriving in extremis.

BACKGROUND: In order to increase trauma-related research and elevate trauma on the national research agenda, the National Trauma Institute (NTI) issued calls for proposals, selected funding recipients and coordinated sixteen federally funded (Department of Defense [DoD]) trauma research awards over a four-year period. We sought to collect and describe the lessons learned from this activity in order to inform future researchers of barriers and facilitators. METHODS: Fifteen principal investigators participated in semi-structured interviews focused on study management issues such as securing institutional approvals, screening and enrollment, multi-site trials management, project funding, staffing and institutional support. NTI Science Committee meeting minutes and study management data were included in the analysis. Simple descriptive statistics were generated and textual data were analyzed for common themes. RESULTS: PIs reported challenges in obtaining institutional approvals, delays in study initiation, screening and enrollment, multi-site management and study funding. Most were able to successfully resolve challenges and have been productive in terms of scholarly publications, securing additional research funding and training future trauma investigators. CONCLUSIONS: Lessons learned in the conduct of the first two funding rounds managed by NTI are instructive in four key areas: regulatory processes, multi-site coordination, adequate funding and the importance of an established research infrastructure to ensure study success. Recommendations for addressing institution-related and investigator-related challenges are discussed along with ongoing advocacy efforts to secure sustained federal funding of a national trauma research program commensurate with the burden of injury. LEVEL OF EVIDENCE: Not applicable. Language: en

Each year in the USA, 1.5–2.5 million Americans are so severely injured that they require inpatient hospitalization. Multiple conditions including posttraumatic stress disorder (PTSD), alcohol and drug use problems, depression, and chronic medical conditions are endemic among physical trauma survivors with and without traumatic brain injuries. The trauma survivors outcomes and support (TSOS) effectiveness-implementation hybrid trial is designed to test the delivery of high-quality screening and intervention for PTSD and comorbidities across 24 US level I trauma center sites. The pragmatic trial aims to recruit 960 patients. The TSOS investigation employs a stepped wedge cluster randomized design in which sites are randomized sequentially to initiate the intervention. Patients identified by a 10-domain electronic health record screen as high risk for PTSD are formally assessed with the PTSD Checklist for study entry. Patients randomized to the intervention condition will receive stepped collaborative care, while patients randomized to the control condition will receive enhanced usual care. The intervention training begins with a 1-day on-site workshop in the collaborative care intervention core elements that include care management, medication, cognitive behavioral therapy, and motivational-interviewing elements targeting PTSD and comorbidity. The training is followed by site supervision from the study team. The investigation aims to determine if intervention patients demonstrate significant reductions in PTSD and depressive symptoms, suicidal ideation, alcohol consumption, and improvements in physical function when compared to control patients. The study uses implementation science conceptual frameworks to evaluate the uptake of the intervention model. At the completion of the pragmatic trial, results will be presented at an American College of Surgeons’ policy summit. Twenty-four representative US level I trauma centers have been selected for the study, and the protocol is being rolled out nationally. The TSOS pragmatic trial simultaneously aims to establish the effectiveness of the collaborative care intervention targeting PTSD and comorbidity while also addressing sustainable implementation through American College of Surgeons’ regulatory policy. The TSOS effectiveness-implementation hybrid design highlights the importance of partnerships with professional societies that can provide regulatory mandates targeting enhanced health care system sustainability of pragmatic trial results. ClinicalTrials.gov NCT02655354 . Registered 27 July 2015.