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BackgroundEarly experience with indocyanine green-based fluorescent cholangiography during laparoscopic cholecystectomy suggests the potential to improve outcomes. However, the cost-effectiveness of routine use has not been studied. Our objective was to evaluate the cost-effectiveness of fluorescent cholangiography versus standard bright light laparoscopic cholecystectomy for noncancerous gallbladder disease.MethodsA Markov model decision analysis was performed comparing fluorescent cholangiography versus standard bright light laparoscopic cholecystectomy alone. Probabilities of outcomes, survival, toxicities, quality-adjusted life-years, and associated costs were determined from literature review and pooled analysis of currently available studies on fluorescent cholangiography (n= 37). Uncertainty in the model parameters was evaluated with 1-way and probabilistic sensitivity analyses, varying parameters up to 40% of their means. Cost-effectiveness was measured with an incremental cost-effectiveness ratio expressed as the dollar amount per quality-adjusted life-year.ResultsThe model predicted that fluorescent cholangiography reduces lifetime costs by $1,235 per patient and improves effectiveness by 0.09 quality-adjusted life-years compared to standard bright light laparoscopic cholecystectomy. Reduced costs were due to a decreased operative duration (21.20 minutes, P < .0001) and rate of conversion to open (1.62% vs 6.70%, P < .0001) associated with fluorescent cholangiography. The model was not influenced by the rate of bile duct injury. Probabilistic sensitivity analysis found that fluorescent cholangiography was both more effective and less costly in 98.83% of model iterations at a willingness-to-pay threshold of $100,000/quality-adjusted life year.ConclusionThe current evidence favors routine use of fluorescent cholangiography during laparoscopic cholecystectomy as a cost-effective surgical strategy. Our model predicts that fluorescent cholangiography reduces costs while improving health outcomes, suggesting fluorescence imaging may be considered standard surgical management for noncancerous gallbladder disease. Further study with prospective trials should be considered to verify findings of this predictive model.

Previous studies have suggested that many burn patients undergo unnecessary intubation due to concern for inhalation injury. We hypothesized that burn surgeons would intubate burn patients at a lower rate than non-burn acute care surgeons (ACSs). We performed a retrospective cohort study of all patients admitted to an American Burn Association-verified burn center who presented emergently following burn injury from June 2015 to December 2021. Patients excluded include polytrauma patients, isolated friction burns, and patients intubated prior to hospital arrival. Our primary outcome was intubation rates between burn and non-burn ACSs. 388 patients met inclusion criteria. 240 (62%) patients were evaluated by a burn provider and 148 (38%) were evaluated by a non-burn provider; the groups were well-matched. In total, 73 (19%) of patients underwent intubation. There was no difference in the rate of emergent intubation, diagnosis of inhalation injury on bronchoscopy, time to extubation, or incidence of extubation within 48 hours between burn and non-burn ACSs. We found no difference between burn and non-burn ACSs in the airway evaluation and management of burn patients. Surgical providers with acute care surgery backgrounds and Advanced Trauma Life Support training are well-equipped for initial airway management in burn patients. Further studies should seek to compare other types of provider groups to identify opportunities for intervention and education in preventing unnecessary intubations.

IntroductionPatient outcome prediction models are underused in clinical practice because of lack of integration with real-time patient data. The electronic health record (EHR) has the ability to use machine learning (ML) to develop predictive models. While an EHR ML model has been developed to predict clinical deterioration, it has yet to be validated for use in trauma. We hypothesized that the Epic Deterioration Index (EDI) would predict mortality and unplanned intensive care unit (ICU) admission in trauma patients.MethodsA retrospective analysis of a trauma registry was used to identify patients admitted to a level 1 trauma center for >24 hours from October 2019 to July 2020. We evaluated the performance of the EDI, which is constructed from 125 objective patient measures within the EHR, in predicting mortality and unplanned ICU admissions. We performed a 5 to 1 match on age because it is a major component of EDI, then examined the area under the receiver operating characteristic curve (AUROC), and benchmarked it against Injury Severity Score (ISS) and new injury severity score (NISS).ResultsThe study cohort consisted of 1,325 patients admitted with a mean age of 52.5 years and 91% following blunt injury. The in-hospital mortality rate was 2%, and unplanned ICU admission rate was 2.6%. In predicting mortality, the maximum EDI within 24 hours of admission had an AUROC of 0.98 compared with 0.89 of ISS and 0.91 of NISS. For unplanned ICU admission, the EDI slope within 24 hours of ICU admission had a modest performance with an AUROC of 0.66.ConclusionEpic Deterioration Index appears to perform strongly in predicting in-patient mortality similarly to ISS and NISS. In addition, it can be used to predict unplanned ICU admissions. This study helps validate the use of this real-time EHR ML-based tool, suggesting that EDI should be incorporated into the daily care of trauma patients.Level of evidencePrognostic, level III.

Ultrasonography for trauma is a widely used tool in the initial evaluation of trauma patients with complete ultrasonography of trauma (CUST) demonstrating equivalence to computed tomography (CT) for detecting clinically significant abdominal hemorrhage. Initial reports demonstrated high sensitivity of CUST for the bedside diagnosis of pneumothorax. We hypothesized that the sensitivity of CUST would be greater than initial supine chest radiograph (CXR) for detecting pneumothorax.A retrospective analysis of patients diagnosed with pneumothorax from 2018 through 2020 at a Level I trauma center was performed. Patients included had routine supine CXR and CUST performed prior to intervention as well as confirmatory CT imaging. All CUST were performed during the initial evaluation in the trauma bay by a registered sonographer. All imaging was evaluated by an attending radiologist. Subgroup analysis was performed after excluding occult pneumothorax. Immediate tube thoracostomy was defined as tube placement with confirmatory CXR within 8 hours of admission.There were 568 patients screened with a diagnosis of pneumothorax, identifying 362 patients with a confirmed pneumothorax in addition to CXR, CUST, and confirmatory CT imaging. The population was 83% male, had a mean age of 45 years, with 85% presenting due to blunt trauma. Sensitivity of CXR for detecting pneumothorax was 43%, while the sensitivity of CUST was 35%. After removal of occult pneumothorax (n = 171), CXR was 78% sensitive, while CUST was 65% sensitive (p0.01). In this subgroup, CUST had a false-negative rate of 36% (n = 62). Of those patients with a false-negative CUST, 50% (n = 31) underwent tube thoracostomy, with 85% requiring immediate placement.Complete ultrasonography of trauma performed on initial trauma evaluation had lower sensitivity than CXR for identification of pneumothorax including clinically significant pneumothorax requiring tube thoracostomy. Using CUST as the primary imaging modality in the initial evaluation of chest trauma should be considered with caution.Diagnostic Test study, Level IV.

Background Patients on antithrombotic medications presenting with blunt trauma are at risk for delayed intracranial hemorrhage. We hypothesized that clinically significant delayed intracranial hemorrhage is rare in patients presenting on antithrombotic medications and therefore routine, repeat head computed tomography imaging is not a cost-effective practice to monitor for delayed intracranial hemorrhage. Methods Patients presenting to our institution on antithrombotic (anticoagulant and antiplatelet) medications during a 5-y period from January 2014 through March 2019 who underwent a head computed tomography for blunt trauma were identified in our trauma registry. Patients with an initial negative head computed tomography underwent repeat imaging 6 h after their initial head computed tomography. Patient demographics, antithrombotic medication, international normalized ratio, Glasgow Coma Score, clinical change in neurologic status, and need for neurosurgical intervention were collected. Results Our institution evaluated 1,676 patients on antithrombotic therapy with blunt trauma. The initial head computed tomography was negative in 1,377 patients (82.0%). Of those with an initial negative head computed tomography, 12 patients (0.9%) developed an intracranial hemorrhage that was identified on the second head computed tomography. Delayed intracranial hemorrhage included 6 patients with intraventricular hemorrhage, 3 with subdural hematoma, 2 with subarachnoid hemorrhage, and 1 with an intraparenchymal hemorrhage. None of the patients with delayed intracranial hemorrhage developed a change in neurologic status, required an intracranial pressure monitor, or underwent neurosurgical intervention. The estimated total direct cost of the negative head computed tomography scans was $926,247. Conclusion Clinically significant delayed intracranial hemorrhage is rare in trauma patients on antithrombotic therapy, with an initial negative head computed tomography. Routine repeat head computed tomography imaging in patients with a negative scan on admission is not cost-effective.

BACKGROUND Trauma registries are used to identify modifiable injury risk factors for trauma prevention efforts. However, these may miss factors useful for prevention of bicycle-automobile collisions, such as vehicle speeds, driver intoxication, street conditions, and neighborhood characteristics. We hypothesize that (GIS) analysis of trauma registry data matched with a traffic accident database could identify risk factors for bicycle-automobile injuries and better inform injury prevention efforts. METHODS The trauma registry of a US Level I trauma center was used retrospectively to identify bicycle-motor vehicle collision admissions from January 1, 2010, to December 31, 2018. Data collected included demographics, vitals, injury severity scores, toxicology, helmet use, and mortality.Matching with the Statewide Integrated Traffic Records System was done to provide collision, victim and GIS information. The GIS mapping of collisions was done with census tract data including poverty level scoring. Incident hot spot analysis to identify statistically significant incident clusters was done using the Getis Ord Gi* statistic. RESULTS Of 25,535 registry admissions, 531 (2.1%) were bicyclists struck by automobiles, 425 (80.0%) were matched to Statewide Integrated Traffic Records System. Younger age (odds ratio [OR], 1.026; 95% confidence interval [CI], 1.013-1.040, p < 0.001), higher census tract poverty level percentage (OR, 0.976; 95% CI, 0.959-0.993, p = 0.007), and high school or less education (OR, 0.60; 95 CI, 0.381-0.968; p = 0.036) were predictive of not wearing a helmet. Higher census tract poverty level percentage (OR, 1.019; 95% CI, 1.004-1.034; p = 0.012) but not educational level was predictive of toxicology positive-bicyclists in automobile collisions. Geographic information systems analysis identified hot spots in the catchment area for toxicology-positive bicyclists and lack of helmet use. CONCLUSION Combining trauma registry data and matched traffic accident records data with GIS analysis identifies additional risk factors for bicyclist injury. Trauma centers should champion efforts to prospectively link public traffic accident data to their trauma registries. LEVEL OF EVIDENCE Prognostic and Epidemiological, level III.

Gallbladder disease frequently requires emergency general surgery (EGS). The Affordable Care Act (ACA) mandated health insurance coverage for all with the intent to improve access to care and decrease morbidity, mortality, and costs. We hypothesize that after the ACA open-enrollment in 2014 the number of EGS cholecystectomies decreased as access to care improved with a shift in EGS cholecystectomies to teaching institutions.A retrospective review of the National Inpatient Sample Database from 2012 to quarter 3 of 2015 was performed. Patients age 18-64, with a nonelective admission for gallbladder disease based on ICD-9 codes, were collected. Outcomes measured included cholecystectomy, complications, mortality, and wage index-adjusted costs. The effect of the ACA was determined by comparing preACA to postACA years.189,023 patients were identified. In the postACA period the payer distribution for admissions decreased for Self-pay (19.3% to 13.6%, P 0.001), Medicaid increased (26.3% to 34.0%, P 0.001) and Private insurance was unchanged (48.6% to 48.7%, P = 0.946). PostACA, admissions to teaching hospitals increased across all payer types, EGS cholecystectomies decreased, while complications increased, and mortality was unchanged. Median costs increased significantly for Medicaid and Private insurance while Self-pay was unchanged. Based on adjusted DID analyses for Insured compared to Self-pay patients, EGS cholecystectomies decreased (-2.7% versus -1.21%, P = 0.033) and median cost increased more rapidly (+$625 versus +$166, P = 0.017).The ACA has changed EGS, shifting the majority of patients to teaching institutions despite insurance type and decreasing the need for EGS cholecystectomy. The trend toward higher complication rate with increased overall cost requires attention.

Laparoscopic cholecystectomy (LC) is the most common elective abdominal surgery in the USA, with over 750,000 performed annually. Fluorescent cholangiography (FC) using indocyanine green dye (ICG) permits identification of extrahepatic biliary structures to facilitate dissection without requiring cystic duct cannulation. Achieving the “critical view of safety” with assistance of ICG cholangiogram may support identification of anatomy, safely reduce conversion to open procedures, and decrease operative time. We assess the utility of FC with respect to anatomic visualization during LC and its effects on patient outcomes. A retrospective review of a prospectively maintained database identified patients undergoing laparoscopic cholecystectomy at a single academic center from 2013 to 2019. Exclusion criteria were primary open and single incision cholecystectomy. Patient factors included age, sex, BMI, and Charlson Comorbidity Index. Outcomes included operative time, conversion to open procedure, length of stay (LOS), mortality rate, and 30-day complications. A multivariable logistic regression was performed to determine independent predictors for open conversion. A total of 1389 patients underwent laparoscopic cholecystectomy. 69.8% were female; mean age 48.6 years (range 15–94), average BMI 29.4 kg/m2 (13.3–55.6). 989 patients (71.2%) underwent LC without fluorescence and 400 (28.8%) underwent FC with ICG. 30-day mortality detected 2 cases in the non-ICG group and zero with ICG. ICG reduced operative time by 26.47 min per case (p

Introduction Previous studies have suggested many burn patients undergo unnecessary intubation due to concern for inhalation injury. There is a lack of clear consensus guidelines for intubation and thus there is significant variation in practice pattern. In this study we hypothesized intubation rates would differ between Acute Care Surgeons with specialized burn training and those without. Methods A retrospective analysis of 388 patients admitted to an ABA verified level 1 burn center who presented emergently following burn injury from 7/2015 to 12/2021 was performed. Patients excluded include polytrauma patients, isolated friction burns, and patients intubated prior to hospital arrival. All providers performing initial evaluation are Acute Care Surgeons, with a subset having additional specialized fellowship training and/or extensive burn experience. Our primary outcome was intubation rates between burn and non-burn trained providers. The Chi-Square and Mann-Whitney U statistical tests were used to compare categorical and continuous variables, respectively. Results There were 465 major burn patients admitted through the trauma bay and screened during the study period with 388 patients meeting inclusion criteria. The population was 72% male, with mean age of 44 years +- 21, TBSA of 12%, and COHgb level of 2.9%. In total, 73 (19%) of patients underwent intubation. The patients in the two provider groups did not differ in terms of age, gender, race, TBSA, COHgb level, or airway exam findings. 240 (62%) patients were evaluated by a burn provider and 148 (38%) were evaluated by a non-burn provider. There was no significant difference in the rate of emergent intubation of patients treated by burn vs non-burn trained providers (RR 0.71, CI 0.47 - 1.07). Of the patients who were intubated, there was no significant difference between burn and non-burn providers in the diagnosis of inhalation injury on bronchoscopy (RR 1.3, CI 0.91-1.85). In both groups, objective evidence of inhalation injury was found in only 68% of patients undergoing routine bronchoscopy following emergent intubation. Conclusions There was no significant difference in intubation rates between burn and non-burn trained acute care surgeons. This demonstrates that following standard ATLS and ABLS principles provides appropriate training in the evaluation, diagnosis, and treatment of inhalation injury. Interestingly, 32% of all patients intubated did not have evidence of inhalational injury on bronchoscopy following intubation. This study suggests that further research is needed to determine objective criteria for intubation guidelines when inhalation injury is suspected in the acute burn patient population. Applicability of Research to Practice Applicable

BACKGROUND The National Academies of Sciences, Engineering, and Medicine 2016 trauma system report recommended a National Trauma Research Action Plan (NTRAP) to strengthen and guide future trauma research. To address this recommendation, 11 expert panels completed a Delphi survey process to create a comprehensive research agenda, spanning the continuum of trauma care. We describe the gap analysis and high priority research questions generated from the NTRAP panel on prehospital and mass casualty trauma care. METHODS We recruited interdisciplinary national experts to identify gaps in the prehospital and mass casualty trauma evidence base and generate prioritized research questions using a consensus-driven Delphi survey approach. We included military and civilian representatives. Panelists were encouraged to use the PICO (Patient/Population, Intervention, Compare/Control, and Outcome) format to generate research questions. We conducted four Delphi rounds in which participants generated key research questions and then prioritized the questions on a 9-point Likert scale to low, medium, and high priority items. We defined consensus as ≥60% agreement on the priority category and coded research questions using a taxonomy of 118 research concepts in 9 categories. RESULTS 31 interdisciplinary subject matter experts generated 490 research questions, of which 433 (88%) reached consensus on priority. The rankings of the 433 questions were: 81 (19%) high priority, 339 (78%) medium priority, and 13 (3%) low priority. Among the 81 high priority questions, there were 46 taxonomy concepts, including: health systems of care (36 questions), interventional clinical trials and comparative effectiveness (32 questions), mortality as an outcome (30 questions); prehospital time/transport mode/level of responder (24 questions), system benchmarks (17 questions), and fluid/blood product resuscitation (17 questions).Conclusions This Delphi gap analysis of prehospital and mass casualty care identified 81 high priority research questions to guide investigators and funding agencies for future trauma research. LEVEL OF EVIDENCE not applicable.

Traumatic brain injury (TBI) is associated with functional deficits, impaired cognition, and medical complications that continue well after the initial injury. Many patients seek medical care at other health care facilities after discharge, rather than returning to the admitting trauma center, making assessment of readmission rates and readmission diagnoses difficult to determine. The objective of this study was to determine the incidence and factors associated with readmission to any acute care hospital after an index admission for TBI.The Nationwide Readmission Database was queried for all patients admitted with a TBI during the first 3 mo of 2015. Nonelective readmissions for this population were then collected for the remainder of 2015. Patients who died during the index admission were excluded. Demographic data, injury mechanism, type of TBI, the number of readmissions, days from discharge to readmission, readmission diagnosis, and mortality were studied.Of the 15,277 patients with an index admission for TBI, 5296 patients (35%) required at least 1 readmission. Forty percent of readmissions occurred within the first 30 d after discharge from the index trauma admission. The most common primary diagnosis on readmission was SDH, followed by septicemia, urinary tract infection, and aspiration. Readmission rates increased with age, with 75% of readmissions occurring in patients aged65 y. Initial discharge to a skilled nursing facility (Relative Risk [RR], 1.60) or leaving the hospital against medical advice (RR, 1.59) increased the risk of readmission. Patients with fall as their mechanism of injury and a subdural hematoma were more likely to require readmission compared with other types of mechanisms with TBI (RR, 1.59 and RR, 1.21, respectively; P 0.001). Notably, the first readmission was to a different hospital for 39.5% of patients and 46.9% of patients had admissions to at least one facility outside that of their original presentation.Hospital readmission is common for patients discharged after TBI. Elderly patients who fall with resultant subdural hematoma are at especially high risk for complications and readmission. Understanding potentially preventable causes for readmission can be used to guide discharge planning pathways to decrease morbidity in this patient population.

Background Methamphetamine (METH) use causes significant vasoconstriction, which can be severe enough to cause bowel ischemia. Methamphetamines have also been shown to alter the immune response. These effects could predispose METH users to poor wound healing, increased infections, and other post-operative complications. We hypothesized that METH users would have longer length of stay and higher rates of complications compared to non–METH users. Methods The trauma registry for our urban Level 1 trauma center was searched for patients that received an exploratory laparotomy from 2016 to 2019. A total 204 patients met criteria and 52 (25.5%) were METH positive. Length of stay (LOS), ventilator days, abbreviated injury scale (AIS), and wound class were compared using nonparametric statistics. Age and injury severity score (ISS) were compared using a Student's t-test. A Chi Square or Fisher's Exact test was used to compare sex, mechanism of injury, and rates of infectious complications. Results Methamphetamine-positive patients had a significantly higher rate of surgical site infections (7.4% versus 0%, P = 0.001). Patients that developed surgical site infection had equivalent rates of smoking and diabetes, as well as equivalent abdominal AIS and wound class compared to those who did not develop surgical site infection. Hospital and ICU LOS, ventilator days, ISS, and mortality were equivalent between METH positive and negative patients. Rates of other infectious complications were the same between groups. Conclusions Methamphetamine use is associated with an increased rate of surgical site infection after trauma laparotomy. Other serious complications and mortality were not affected by METH use.

The pandemic in 2020 has had economic, health, social, and cultural impacts on the entire world’s population. At the time of writing, the coronavirus disease 2019 (COVID-19), a contagious disease caused by severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2), had infected over 169 million people causing 3.5 million deaths with ongoing exponential growth in case numbers in many parts of the world. The impact of surgical care delivery has been profound. Initial orders to cancel elective surgery preserved inadequate stockpiles of personal protective equipment and prevented exposures of surgical patients to asymptomatic COVID-19-infected persons in the face of insufficient testing. However, this led to a backlog of elective surgery. There were also delays in presentation of acute surgical conditions, probably due to patient fears of contracting COVID-19 at hospitals. Surgeons were required to develop processes such as creation of dedicated COVID-19 operating rooms to prevent nosocomial spread of the disease and infection of the operating room team. Surgeons have provided surgical and critical care to COVID-19 patients during the current pandemic despite initial shortages of ventilators, PPE, and information. Surgeons are now successfully managing acute surgical complications of COVID-19 as well as COVID-19 patients presenting with trauma and non-COVID-19-related acute surgical conditions, despite early reports of poor outcomes. Lessons learned included issues in preparation, training, planning, provider wellness, burnout, surgical disparities, testing, PPE, operating rooms, cancellations of elective surgery, regional coordination, and information technology. Surgeons should be now ready to engage in advocacy efforts to ensure that the next pandemic can be better handled by the healthcare system.

Natural disasters and some man-made mass casualty events can produce enough injured patients to overwhelm local health care systems and create loss of healthcare infrastructure, including imaging resources. They may also require healthcare to be provided in austere, resource-limited environments. Current healthcare in high-income nations is extensively based on advanced medical imaging. Organisation for Economic Co-operation and Development (OECD) 2018 data indicates that from 100 to 271 CT scans per 1000 inhabitants were performed in US and EU countries [1]. In the surge of patients occurring during loss of utilities and nonavailability of advanced medical imaging, there may be a critical lack of image-based clinical decision-making support. This will be a severe challenge for trauma care providers. A method to screen and diagnose trauma and non-trauma conditions that is rapid enough to deal with a large patient surge is ultrasound.

Introduction Identifying modifiable risk factors for pediatric scald burn injury prevention efforts is an important function for burn registries. Geographic information systems (GIS) analysis can provide additional census tract data about patient home and injury location. We hypothesize that (GIS) analysis of burn registry data using census tract data could identify geographic areas and additional risk factors for pediatric scald burn injury prevention efforts. Methods The burn registry of a U.S. regional burn center was used retrospectively to identify burn admissions, ages 0–17, within the county from 1/1/2018 to 7/31/2020. Data collected included demographics, vitals, burn type and body surface area burned (BSA%), hospital charges, length of stay, complications, and mortality. GIS geocoding of patient home addresses with census tract data including poverty level, languages spoken at home and highest educational level was performed. Burn incident hot spot analysis to identify statistically significant burn incident clusters was done using the Getis Ord Gi* statistic. Results There were 1057 burn initial admissions during the study period, 152 (14.3%) patients were children 17 and younger with scald injury who were county residents. The average age was 4.0 ± 4.0 years, and 59.9% were male. Mean scald injury BSA was 4.9% ± 5.7, 14/152 admissions (9.2%) had a burn ≥10% BSA. There were no in-hospital deaths. 120/728 county census tracts were identified as high risk with higher rates of child scald injury admissions than the countywide mean of 1.27 cases/1000 children. Regression analysis of high-risk census tracts were more likely to have increased poverty levels (O.R. 3.30, 95% C.I.: 1.1–9.7, p< 0.031) and lower educational attainment (O.R. 1.10, 95% C.I.: 1.0–1.18, p< 0.047). Non-white race, unemployment level, living with grandparents and speaking Spanish at home were non-significant risk factors. GIS analysis identified geographic hot spots for child scald injury admissions (p< 0.001). Conclusions GIS analysis of county burn registry data identified census tracts with increased poverty and lower educational attainment levels to have an increased risk of pediatric scald injury admission. Burn prevention efforts should be focused on these high-risk areas.

Multiple organ failure (MOF) continues to be an evolving phenotype, plaguing intensive care units worldwide. While exact mechanisms and pathways for the development of MOF continue to be debated and discovered, it is clear that the development of organ dysfunction and failure negatively impacts outcomes of critically ill surgical patients. This chapter aims to review the entity and evolution of MOF in regard to its epidemiology, different phenotypes, various clinical manifestations, and role of nutritional supplementation.

BACKGROUND Identification of occult hypovolemia in trauma patients is difficult. We hypothesized that in acute trauma patients, the response of ultrasound-measured minimum inferior vena cava diameter (IVCDMIN), IVC Collapsibility Index (IVCCI), minimum internal jugular diameter (IJVDMIN) or IJV Collapsibility Index (IJVCI) after up to 1 hour of fluid resuscitation would predict 24-hour resuscitation intravenous fluid requirements (24FR). METHODS An NTI-funded, American Association for the Surgery of Trauma Multi-Institutional Trials Committee prospective, cohort trial was conducted at four Level I Trauma Centers. Major trauma patients were screened for an IVCD of 12 mm or less or IVCCI of 50% or less on initial focused assessment sonographic evaluations for trauma. A second IVCD was obtained 40 minutes to 60 minutes later, after standard-of-care fluid resuscitation. Patients whose second measured IVCD was less than 10 mm were deemed nonrepleted (NONREPLETED), those 10 mm or greater were repleted (REPLETED). Prehospital and initial resuscitation fluids and 24FR were recorded. Demographics, Injury Severity Score, arterial blood gasses, length of stay, interventions, and complications were recorded. Means were compared by ANOVA and categorical variables were compared via χ. Receiver operating characteristic curves analysis was used to compare the measures as 24FR predictors. RESULTS There were 4,798 patients screened, 196 were identified with admission IVCD of 12 mm or IVCCI of 50% or less, 144 were enrolled. There were 86 REPLETED and 58 NONREPLETED. Demographics, initial hemodynamics, or laboratory measures were not significantly different. NONREPLETED had smaller IVCD (6.0 ± 3.7 mm vs. 14.2 ± 4.3 mm, p < 0.001) and higher IVCCI (41.7% ± 30.0% vs. 13.2% ± 12.7%, p < 0.001) but no significant difference in IJVD or IJVCCI. REPLETED had greater 24FR than NONREPLETED (2503 ± 1751 mL vs. 1,243 ± 1,130 mL, p = 0.003). Receiver operating characteristic analysis indicates IVCDMIN predicted 24FR (area under the curve [AUC], 0.74; 95% confidence interval [CI], 0.64-0.84; p < 0.001) as did IVCCI (AUC, 0.75; 95% CI, 0.65-0.85; p < 0.001) but not IJVDMIN (AUC, 0.48; 95% CI, 0.24-0.60; p = 0.747) or IJVCI (AUC, 0.54; 95% CI, 0.42-0.67; p = 0.591). CONCLUSION Ultrasound assessed IVCDMIN and IVCCI response initial resuscitation predicts 24-hour fluid resuscitation requirements. LEVEL OF EVIDENCE Diagnostic tests or criteria, level II.

Tibia fractures are common after trauma. Prior studies have shown that delays in treatment are associated with poor outcomes. A subpopulation of our patients are transported from Mexico, adding barriers to prompt care. We hypothesized that patients with tibia fractures crossing from Mexico would have delays in treatment and subsequently worse outcomes.The trauma registry of an American College of Surgeons-verified level 1 trauma center was retrospectively reviewed for all tibia fractures admitted from 2010 to 2015. Data collection included demographics, country of injury, characterization of injuries, interventions, complications, and outcomes. Patients were subdivided into those injured in the United States and in Mexico, and the two groups were compared.A total of 498 patients were identified, 440 from the United States and 58 from Mexico. Mexico patients were more severely injured overall, with higher injury severity scores and a higher percentage of patients with abbreviated injury scale scores ≥3 for both head and chest regions. Mexico patients had longer times from injury to admission, as well as increased times to both debridement of open fractures and operative fixation after admission. On subgroup analysis of patients with isolated tibia fractures (other system abbreviated injury scale 3), times from arrival to treatment and injury severity score were no longer statistically different.Patients crossing the border from Mexico with tibia fractures have delays in time to admission and from admission to operative management, although this is primarily due to other severe injuries. Ongoing systems development is required to minimize delays in care and optimize outcomes.

IntroductionSince their release in 2017, standing electric motorized scooters (eScooters) have risen in popularity as an alternative mode of transportation. We sought to examine the incidence of injury, injury patterns, prevalence of helmet and drug and alcohol use in eScooter trauma.MethodsThis was a multi-institutional retrospective case series of patients admitted for injuries related to operation of an eScooter following the widespread release of these devices in September 2017 (September 1, 2017 to October 31, 2018). Demographics, drug and alcohol use, helmet use, admission vitals, injuries, procedures, hospital and intensive care unit length of stay (LOS), death, and disposition were analyzed.Results103 patients were admitted during the study period, and monthly admissions increased significantly over time. Patients were young men (mean age 37.1 years; 65% male), 98% were not wearing a helmet. Median LOS was 1 day (IQR 1–3). 79% of patients were tested for alcohol and 48% had a blood alcohol level >80 mg/dL. 60% of patients had a urine toxicology screen, of which 52% were positive. Extremity fractures were the most frequent injury (42%), followed by facial fractures (26%) and intracranial hemorrhage (18%). Median Injury Severity Score was 5.5 (IQR 5–9). One-third of patients (n=34) required an operative intervention, the majority of which were open fixations of extremity and facial fractures. No patients died during the study. The majority of patients were discharged home (86%).ConclusioneScooter-related trauma has significantly increased over time. Alcohol and illicit substance use among these patients was common, and helmet use was extremely rare. Significant injuries including intracranial hemorrhage and fractures requiring operative intervention were present in over half (51%) of patients. Interventions aimed at increasing helmet use and discouraging eScooter operation while intoxicated are necessary to reduce the burden of eScooter-related trauma.Level of evidenceLevel IV.

Specialized trauma intensive care unit (TICU) care impacts patient outcomes. Few studies describe where and how TICU care is delivered. We performed an assessment of TICU structure and function at a sample of US trauma center TICUs.This was a multicenter study in which participants supplied information about their trauma centers, staff, clinical protocols, processes of care, and study TICU (the ICU admitting the majority of trauma patients).Forty-five Level I trauma centers trauma centers enrolled through the American Association for the Surgery of Trauma multi-institutional trials platform; 71.1% had less than 750 beds and 55.5% treated 1,000 to 2,999 trauma activations/year. The median number of hospital ICU beds was 109 [66-185]. 46.7% were "closed" ICUs, 20% were "open," and 82.2% had mandatory intensivist consultation. 42.2% ICUs were classified as trauma (≥80% of patients were trauma), 46.7% surgical/trauma, and 11.1% medical-surgical. Trauma ICUs had a median 10 [7-12] intensivists. Intensivists were present 24 hours/day in 80% of TICUs. Centers reported a median of 8 (interquartile range [IQR], 6-10) full-time trauma surgeons, whose ICU duties comprised 25% (IQR, 20%-40%) of their clinical time and 20% (IQR, 20-33) of total work time. A median 16 (IQR, 12-23) ICU beds in use were staffed by 10 (IQR, 7-14) nurses. There was considerable variation in the number and type of protocols used and in diagnostic methods for ventilator-associated pneumonia. Daily patient care checklists were used by 80% of ICUs. While inclusion of families on rounds was performed in 91.1% of ICUs, patient- and family-centered support programs were less common.A study of structure and function of TICUs at a sample of Level I trauma centers revealed that presence of nontrauma patients was common, critical care is a significant component of trauma surgeons' professional practice, and significant variation exists in care delivery models and protocol use. Opportunities may exist to improve care through sharing of best practices.Therapeutic/Care management, level IV.

Acute surgeons are faced with the daunting task of making a diagnosis and treatment plan in situations of limited time, information, and resources in patients with life- and limb-threatening conditions. Adoption of bedside ultrasonography by the clinician, also called point-of-care ultrasonography (POCUS), has become an essential part of the practice of acute care surgery. POCUS can identify significant abdominal trauma, differentiate shock states, and identify pneumothorax in a rapid, repeatable, and safe manner. It can also facilitate, speed, and enhance the safety of invasive procedures. Medical students are now being taught ultrasonography skills in their junior years of medical school. Surgical residencies and fellowships are increasingly adopting ultrasound curricula. The quality of ultrasound equipment and images is improving, ease of use is better, and cost of equipment has decreased significantly. Acute surgeons who understand the abilities and limitations of POCUS are better equipped to manage surgical crises.

Acute care surgery (ACS) diagnoses are responsible for approximately a quarter of the costs of inpatient care in the US government, and individuals will be responsible for a larger share of the costs of this healthcare as the population ages. ACS as a specialty thus has the opportunity to meet a significant healthcare need, and by optimizing care delivery models do so in a way that improves both quality and value. ACS practice models that have maintained or added emergency general surgery (EGS) and even elective surgery have realized more operative case volume and surgeon satisfaction. However, vulnerabilities exist in the ACS model. Payer mix in a practice varies by geography and distribution of EGS, trauma, critical care, and elective surgery. Critical care codes constitute approximately 25% of all billing by acute care surgeons, so even small changes in reimbursement in critical care can have significant impact on professional revenue. Staffing an ACS practice can be challenging depending on reimbursement and due to uneven geographic distribution of available surgeons. Empowered by an understanding of economics, using team-oriented leadership inherent to trauma surgeons, and in partnership with healthcare organizations and regulatory bodies, ACS surgeons are positioned to significantly influence the future of healthcare in the USA.

Introduction Recovery from burn injury is a prolonged process often requiring post-discharge services such as rehabilitation or skilled nursing care. Affordable Care Act Open Enrollment (ACA-OE) began in January 2014 providing access to medical insurance for millions of previously uninsured Americans. Whether improved insurance coverage has improved access to post-discharge care for patients admitted with burn injury is unknown. We hypothesized that the ACA would improve insurance coverage for patients admitted with burn injury and that medical insurance would be associated with increased access to post-discharge care services. Methods The Nationwide Readmission Database was queried to identify patients ages 18–65 with an index admission for cutaneous burn injury using ICD-9 & ICD-10 codes. Patients with Medicare or those that died during the index admission were excluded. Pre-ACA-OE admissions (2013, Q1-Q3) were compared with post-ACA admissions (2016, Q1-Q3) to evaluate the effects the ACA-OE of insurance status, length of stay, discharge disposition, 30- and 90-day readmission rates. Results There were 12,932 burn-injured patients included with 5,389 patients in 2013 and 7,543 patients in 2016. Post-ACA, Medicaid insurance increased from 33.0% to 43.9% (p< 0.001) while self-pay decreased from 25.8% to 13.7% (p< 0.001). Private insurance status did not change after implementation of the ACA (41.2% vs. 42.4%). Post-ACA-OE, overall routine discharge home decreased from 79.4% to 77.7% (p=0.02) while discharge to a care facility increased from 7.2% to 8.7% (p=0.002). Length of stay was not different between groups (8.9 ± 15.9 days vs. 9.0 ± 15.5 days). Medicaid patients had the highest readmission rates at 30- and 90-days (see Figure). Medicaid patients had decreased 90-day non-elective readmission rates post-ACA-OE (22.4% to 20.0%, p=0.041). Predictors of non-elective 90-day readmission were Medicaid insurance (OR 2.06, CI 1.76–2.40, p< 0.001) and older age (OR 1.03, CI 1.02–1.03, p< 0.001). Conclusions The ACA-OE increased access to insurance for burn patients. Discharges to care facilities after burn injury increased post-ACA-OE and was associated with decreased 90-day readmission. Ongoing advocacy efforts are need to improve access to post-burn care resources to optimize recovery from injury. Applicability of Research to Practice Awareness of the impacts of health policy and insurance coverage on access to post-discharge resources and readmission rates after burn injury.

BACKGROUND Acute care surgery (ACS) comprises trauma, surgical critical care, and emergency general surgery (EGS), encompassing both operative and nonoperative conditions. While the burden of EGS and trauma has been separately considered, the global footprint of ACS has not been fully characterized. We sought to characterize the costs and scope of influence of ACS-related conditions. We hypothesized that ACS patients comprise a substantial portion of the US inpatient population. We further hypothesized that ACS patients differ from other surgical and non-surgical patients across patient characteristics. METHODS We queried the National Inpatient Sample 2014, a nationally representative database for inpatient hospitalizations. To capture all adult ACS patients, we included adult admissions with any International Classification of Diseases-9th Rev.-Clinical Modification diagnosis of trauma or an International Classification of Diseases-9th Rev.-Clinical Modification diagnosis for one of the 16 AAST-defined EGS conditions. Weighted patient data were presented to provide national estimates. RESULTS Of the 29.2 million adult patients admitted to US hospitals, approximately 5.9 million (20%) patients had an ACS diagnosis. ACS patients accounted for US $85.8 billion, or 25% of total US inpatient costs (US $341 billion). When comparing ACS to non-ACS inpatient populations, ACS patients had higher rates of health care utilization with longer lengths of stay (5.9 days vs. 4.5 days, p < 0.001), and higher mean costs (US $14,466 vs. US $10,951, p < 0.001. Of all inpatients undergoing an operative procedure, 27% were patients with an ACS diagnosis. Overall, 3,186 (70%) of US hospitals cared for both trauma and EGS patients. CONCLUSION Acute care surgery patients comprise 20% of the inpatient population, but 25% of total inpatient costs in the United States. In addition to being costly, they overall have higher health care utilization and worse outcomes. This suggests that there is an opportunity to improve clinical trajectory for ACS patients that in turn, can affect the overall US health care costs. LEVEL OF EVIDENCE Epidemiologic, level III.

Management of the critically injured patient is optimized by a coordinated team effort in an organized trauma system that allows for rapid assessment and initiation of life-preserving therapies. This initial assessment must proceed systematically and be prioritized according to physiologic necessity for survival. Beginning in the prehospital setting, coordination, preparation, and appropriate triage of the injured are crucial to facilitating rapid resuscitation of the trauma patient. Next, active efforts to support airway, breathing, circulation, and disability are performed with simultaneous intervention to treat life-threatening injuries and restore hemodynamic stability in the primary survey. With ongoing evaluation and continued resuscitation, a secondary survey provides a head-to-toe assessment of the patient allowing for further diagnosis of injuries and triage to more definitive care. This review contains 12 figures, 8 tables and 63 references Key Words: advanced trauma life support, definitive airway, FAST/eFAST, field triage, Glasgow coma scale, primary survey, 1:1:1 resuscitation, secondary survey

Summary Events after the sinking of the hospital ship Llandovery Castle on June 27, 1918, by the German submarine U-86 outraged Canadians. Survivors aboard a single life raft gave evidence that many of the 234 souls lost had made it to lifeboats but were rammed and shot by the submarine. Many of those who died were nurses. Three German officers were charged with war crimes after the war. The submarine’s captain evaded capture. The remaining two officers’ defence that they were following the captain’s orders failed and they were convicted. This ruling was used as a precedent to dismiss similar claims at the war crime trials after the Second World War. It is also the basis of the order given to members of modern militaries, including the Canadian Armed Forces, that it is illegal to carry out an illegal order.

INTRODUCTION:Lack of insurance coverage increases complications and mortality from surgical procedures. The 2014 Affordable Care Act (ACA) Open Enrollment (OE) insured more Americans, but it is unknown if this improved outcomes from emergency general surgery (EGS) procedures. This study seeks to determine how ACA OE coverage changes outcomes in EGS. METHODS:This is a retrospective review using the Nationwide Inpatient Sample database from 2012 to 2014. Patients aged 18 to 64 years undergoing EGS procedures were identified by International Classification of Diseases, Ninth Revision, codes. Medicare patients were excluded. Patient demographics, hospital characteristics, and Charlson comorbidity index were obtained. Outcomes were measured by mortality, complications, and calculated costs. Univariate and difference-in-differences multivariate analyses were performed to determine the effect of the ACA OE on EGS outcomes. RESULTS:A total of 304,110 EGS cases were identified. After Medicare patients were excluded, there were 275,425 cases. In 2014, Medicaid admissions increased 18.2% from 18,495 to 22,615 (p < 0.001) and self-pay admissions decreased 33% from 14,938 to 10,630 (p < 0.001). Mortality significantly increased for self-pay patients in 2014 from 0.81% to 1.22% (p < 0.001). Difference-in-differences analysis indicated that, after risk adjustment, the ACA OE was associated with a small reduction in mortality for insured patients (-0.12%, p = 0.034), increased complications (1.4%, p = 0.009), and increased wage-index adjusted mean costs (4.6%, p < 0.001). There was a significant increase in Medicare (+26.5%) and private (+12.2%, p < 0.001) insurance admissions in teaching hospitals, while nonteaching hospitals had fewer EGS admissions with a greater reduction in uninsured EGS admissions. CONCLUSIONS:The ACA OE created a significant reduction in uninsured EGS admissions but did not reduce EGS mortality. Mortality decreased in insured patients but increased in uninsured patients, indicating that the ACA OE primarily insured lower-risk patients. The ACA OE did increase cost and complications in insured admissions. Teaching hospitals saw the majority of the increase in Medicaid and private insurance EGS admissions. A national registry would improve future study of insurance policy on EGS outcomes. LEVEL OF EVIDENCE:Economic analysis, level IV.

The pregnant abdominal trauma patient presents a unique diagnostic challenge. This study aimed to evaluate the accuracy of abdominal sonography for the detection of clinically important injuries in pregnant abdominal trauma patients. A retrospective review was performed of a trauma center database from 2001 to 2011. Medical records were reviewed to determine initial abdominal imaging test results and clinical course. Sensitivity, specificity, positive predictive value, and negative predictive value of ultrasound for detection of traumatic injury were calculated. Of 19,128 patients with suspected abdominal trauma, 385 (2 %) were pregnant. Of these, 372 (97 %) received ultrasound as the initial abdominal imaging test. All 13 pregnant patients who did not receive ultrasound received abdominal CT. Seven pregnant patients underwent both ultrasound and CT. Seven ultrasound examinations were positive, leading to one therapeutic Cesarean section and one laparotomy. One ultrasound was considered false positive (no injury was seen on subsequent CT). There were 365 negative ultrasound examinations. Of these, 364 were true negative (no abdominal injury subsequently found). One ultrasound was considered false negative (a large fetal subchorionic hemorrhage seen on subsequent dedicated obstetrical ultrasound). Sensitivity and positive predictive value were 85.7 %. Specificity and negative predictive value were 99.7 %. Abdominal sonography is an effective and sufficient imaging examination in pregnant abdominal trauma patients. When performed as part of the initial assessment using an abbreviated trauma protocol with brief modifications for pregnancy, ultrasound minimizes diagnostic delay, obviates radiation risk, and provides high sensitivity for injury in the pregnant population.

Liberal use of computed tomography of the abdomen and pelvis (CTAP) in the screening of blunt abdominal trauma (BAT) has heightened concerns for increased radiation exposure and costs. We sought to demonstrate that in a select group of BAT patients, complete ultrasonography of trauma (CUST) is equivalent to routine CTAP but with significantly decreased radiation and costs.A retrospective analysis of patients screened for BAT from 2000 to 2011 in a Level 1 trauma center was performed. CUST was available from 8:00 AM to 11:00 PM daily, while CTAP was performed thereafter. Decision to perform CTAP or CUST overnight was made by the attending surgeon based on clinical examination. False negatives (FNs) were described as either a negative CUST or CTAP finding, which later required exploratory laparotomy. Medicare rates and previous data were used for the estimation of cost and radiation exposure.There were 19,128 patients screened for BAT. A total of 12,577 patients (65.8%) initially underwent CUST, and 6,548 (34.2%) underwent CTAP; 11,059 patients (58% of the total BAT patients) avoided a CTAP, yielding an estimated savings of $6.5 million and 188,003 mSv less radiation during the course of the study. Compared with the CTAP group, patients undergoing CUST had lower Injury Severity Score (ISS) (8.1 vs. 9.6), were older (44.7 years vs. 35.2 years), and experienced less traumatic brain injury (61.4% vs. 69.3%) (all with p0.002). Mortality was higher in the CUST group (1.8% vs. 1.2%, p = 0.02), but it was insignificant when adjusted for age older than 65 years (1.1% vs. 0.9%, p = 0.23) or head injury (0.6% and 0.3%, p = 0.4). FN CUST and FN CTAP were 0.29% and 0.1%, respectively (p = nonsignificant), with similar mortality (20% vs. 0%, p = 0.44).CUST is equivalent to routine CTAP for BAT screening and leads to an average of 42% less radiation exposure and more than $591,000 savings per year.Diagnostic study, level IV; therapeutic/care management study, level IV.

The cost and risks of red blood cell (RBC) transfusions, along with evidence of overuse, suggest that improving transfusion practices is a key opportunity for health systems to improve both the quality and value of patient care. Previous work, which included a BestPractice Advisory (BPA), was adapted in a quality improvement project designed to reduce both exposure to unnecessary blood products and costs.A prospective, pre-post study was conducted at an academic medical center with a diverse patient population. All noninfant inpatients without gastrointestinal bleeding who were not within 12 hours of surgical procedures were included. The interventions were education, a BPA, and other enhancements to the computerized provider order entry system.The percentage of multiunit (≥ 2 units) RBC transfusions decreased from 59.9% to 41.7% during the intervention period and to 19.7% postintervention (p 0.0001). The percentage of inpatient RBC transfusion units administered for hemoglobin (Hb) ≥ 7 g/dL declined from 72.3% to 57.8% during the intervention period and to 38.0% for the postintervention period (p 0.0001). The overall rate of inpatient RBC transfusion (units administered per 1,000 patient-days without exclusions) decreased from 89.8 to 78.1 during the intervention period and to 72.7 during the postintervention period (p 0.0001). The estimated annual cost savings was $1,050,750.The interventions reduced multiunit transfusions (by 67.1%) and transfusions for Hb ≥ 7 g/dL (by 47.4%). The improvement in the overall transfusion rate (19.0%) was less marked, limited by better baseline performance relative to other centers.