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BACKGROUND Despite the widespread institution of modern massive transfusion protocols with balanced blood product ratios, survival for patients with traumatic hemorrhage receiving ultramassive transfusion (UMT) (defined as ≥20 U of packed red blood cells [RBCs]) in 24 hours) remains low and resource consumption remains high. Therefore, we aimed to identify factors associated with mortality in trauma patients receiving UMT in the modern resuscitation era. METHODS An Eastern Association for the Surgery of Trauma multicenter retrospective study of 461 trauma patients from 17 trauma centers who received ≥20 U of RBCs in 24 hours was performed (2014-2019). Multivariable logistic regression and Classification and Regression Tree analysis were used to identify clinical characteristics associated with mortality. RESULTS The 461 patients were young (median age, 35 years), male (82%), severely injured (median Injury Severity Score, 33), in shock (median shock index, 1.2; base excess, -9), and transfused a median of 29 U of RBCs, 22 U of fresh frozen plasma (FFP), and 24 U of platelets (PLT). Mortality was 46% at 24 hours and 65% at discharge. Transfusion of RBC/FFP ≥1.5:1 or RBC/PLT ≥1.5:1 was significantly associated with mortality, most pronounced for the 18% of patients who received both RBC/PLT and RBC/FFP ≥1.5:1 (odds ratios, 3.11 and 2.81 for mortality at 24 hours and discharge; both p < 0.01). Classification and Regression Tree identified that age older than 50 years, low initial Glasgow Coma Scale, thrombocytopenia, and resuscitative thoracotomy were associated with low likelihood of survival (14-26%), while absence of these factors was associated with the highest survival (71%). CONCLUSION Despite modern massive transfusion protocols, one half of trauma patients receiving UMT are transfused with either RBC/FFP or RBC/PLT in unbalanced ratios ≥1.5:1, with increased associated mortality. Maintaining focus on balanced ratios during UMT is critical, and consideration of advanced age, poor initial mental status, thrombocytopenia, and resuscitative thoracotomy can aid in prognostication. LEVEL OF EVIDENCE Prognostic, level III.

Background School violence continues to afflict our educational institutions. In response, an institutional initiative was launched to train educators and school support staff in life-saving skills aimed at hemorrhage control. Methods The American College of Surgeons Committee on Trauma “Stop the Bleed” (STB) Program was promoted as a quality improvement initiative to schools within the geographic catchment area of this Level I Trauma Center. Participants were given the opportunity to take precourse, and postcourse confidence inventories using a Likert Scale. Statistical analysis of the 324 precourse to postcourse evaluations measuring change in confidence was used to evaluate improvement in readiness of school systems to respond in mass casualty incidents. Results Students enrolled in the STB Program were offered the opportunity to assess their confidence precourse and postcourse in reference to 7 questions. Precourse and postcourse Likert Scale inventories were compared and analyzed to assess the strength of the improvement in confidence using Student’s t-test, where P < .05 is statistically significant. Students demonstrated improvement ( P < .006) that was statistically significant across all 7-question relating to enhance confidence postcourse compared with the precourse. Discussion This STB quality initiative has demonstrated a statistically significant improvement in the confidence of teachers and school personnel to render lifesaving care in the event of a mass casualty or isolated incident of life-threatening hemorrhage. These results support the validity of the training in making a difference in this subpopulation of responders.

Introduction: Under current law in our rural state, there is no universal requirement for motorcyclists to wear helmets. Roughly 500 motorcycle crashes are reported by the state each year and only a fraction of those riders wear helmets. We sought to determine the difference in injury patterns and severity in helmeted versus non-helmeted riders. Methods: Retrospective review (2014–2018) of a single level 1 trauma center’s registry was done for subjects admitted after a motorcycle collision. Demographic, injury and patient outcome data were collected. Patients were stratified by helmet use (n = 81), no helmet use (n = 144), and unknown helmet use (n = 194). Statistical analysis used Student’s t-test or Pearson’s χ2 p-value ≤0.05 as significant. State Department of Transportation data registry for state level mortality and collision incidence over the same time period was also obtained. Results: Of the 2,022 state-reported motorcycle collisions, 419 individuals admitted to our trauma center were analyzed (21% capture). State-reported field fatality rate regardless of helmet use was 4%. Our inpatient mortality rate was 2% with no differences between helmet uses. Helmeted riders were found to have significantly fewer head and face injuries, higher GCS, lower face, neck, thorax and abdomen AIS, fewer required mechanical ventilation, shorter ICU length of stay, and had a greater number of upper extremity injuries and higher upper extremity AIS. Conclusions: Helmeted motorcyclists have fewer head, face, and cervical spine injuries, and lower injury severities: GCS and face, neck, thorax, abdomen AIS. Helmeted riders had significantly less mechanical ventilation requirement and shorter ICU stays. Non-helmeted riders sustained worse injuries. Practical Applications: Helmets provide safety and motorcycle riders have a 34-fold higher risk of death following a crash. Evaluating injury severities and patterns in motorcycle crash victims in a rural state with no helmet laws may provide insight into changing current legislation.

BackgroundMuch has been written from the social science perspective surrounding surgeons’ stress and burn out. The literature is sparse in reference to scientific investigations of the hemodynamic effect of that stress. This prospective clinical study quantifies the physiologic impact of performing surgery upon the acute care surgeon.MethodsOver 2.5 years, monitoring devices were affixed to surgeons prior to entering the operating room, and physiologic variables were documented every 30 minutes. Qualifying cases were projected as being greater than 2 hours with a baseline preoperative measurement obtained. Variables recorded included blood pressure (BP), heart rate (HR), rate pressure product (RPP), oxygen saturation (O2sat), and end-tidal carbon dioxide (ET CO2).ResultsStatistically significant differences ( P < .05) were found between baseline data to the maximum recording during the surgical operation for: BP (min 101 ± 6.6 (mmHg)-max 117 ± 5.1 (mmHg)), HR (min 70.5 ± 6.2 (bpm)-max 83.7 ± 9.0 (bpm)), O2sat (min 97 ± 2.0 (%)-max 100 ± 0.22(%)), and ET CO2(min 34.1 ± 1.15 mmHg-max 38 ± 1.7 mmHg) ( P < .0001). The RPP ranged from 10.49 mmHg/min to 15.88 mmHg/min with a mean of 14.00 mmHg/min.DiscussionThe practice of surgery is considered demanding in training and lifestyle in comparison to other medical specialties. This data is among the first to demonstrate the negative physiological impact of surgery upon the metabolic demand of the surgeon. The longitudinal implications of increased physiologic demand over time may have cardiovascular and cerebrovascular consequences.

Objective Unintentional window falls represent a preventable source of injury and death in children. Despite major campaigns in some larger cities, there continue to be unintentional falls from windows throughout the United States. We aimed to identify risk factors and trends in unintentional window falls in the pediatric population in a national and regional sample. Methods A retrospective analysis of annual emergency department (ED) visits from the National Electronic Injury Surveillance System using product codes specific to windows, as well as patient encounters for unintentional window falls from January 2007 to August 2017 using site-specific trauma registries from 10 tertiary care children's hospitals in New England. National and state-specific census population estimates were used to compute rates per 100,000 population. Results There were 38,840 ED visits and 496 regional patients who unintentionally fell from a window across the study period between 0 and 17 years old. The majority of falls occurred in children under the age of 6 and were related to falls from a second story or below. A decreased trend in national ED visits was seen, but no change in rates over time for regional trauma center encounters. A high number of falls was found to occur in smaller cities surrounding metropolitan areas and from single family residences. Conclusions Falls from windows represent a low proportion of overall types of unintentional sources of injury in children but are a high risk for severe disability. These results provide updated epidemiologic data for targeted intervention programs, as well as raise awareness for continued education and advocacy.

This quality improvement project was undertaken to improve trauma service referral compliance to an existing home-based elderly fall prevention program through the implementation of a daily management system (DMS). Operational excellence, a hospital-wide initiative, provided the foundation for improvement efforts. This initiative went through a series of 5 plan, do, study, and act (PDSA) cycles and demonstrated significant improvement in referrals from 0% to 100%. Compliance with referrals after the retirement of the key performance indicator remained high at 95.5%. Results from this project provided support for the framework set forth in DMS and PDSA improvement methodologies as a feasible option to implement quality and process improvement projects. Further study in this area is warranted.

Background Moose-motor vehicle collisions (MMVC) are especially dangerous to vehicle occupants because of the height and mass of the animal, which often collapses the roof and has a direct impact into the passenger compartment. Study Design Public data on MMVC were obtained from the states of New England (NE), and trauma registry data from centers in NH and ME. Results For all of NE, the annual incidence of reported MMVC has declined from a peak of >1,200 in 1998, but has still averaged >500 over the last 5 years, predominantly in ME, NH, and VT. Public education may have contributed to the decline, but the moose population has also apparently decreased due to environmental changes. In NE, MMVCs are most frequent in the summer months and evening hours. Maine data on crashes involving wild ungulates from 2003 to 2017 document 50,281 collisions with deer and 7,061 collisions with moose; 26 of the latter (0.37%) resulted in a human fatality. Logistic regression models demonstrate that vehicle occupant mortality, after controlling for multiple factors related to vehicle speed, is greatly increased when striking a moose rather than a deer (odds ratio [OR] 13.4, 95% CI 6.3, 28.7). In these data, there were no fatalities among occupants of Swedish cars, which are specifically engineered to tolerate MMVC. Three NH/ME trauma centers registered 124 cases of MMVC: median Injury Severity Score was 9; 5 patients died (4%); and 76 patients (61%) had injuries of the head, face, and/or cervical spine. Conclusions Moose-motor vehicle collisions remain a frequent and serious hazard to motor vehicle occupants in northern NE. Trauma services should recognize characteristic injury patterns. Continuing public education, cautious driving, and moose herd management are warranted.

Our group has developed a ‘Step Up’ approach to the application of Resuscitative Endovascular Balloon Occlusion of the Aorta (REBOA) in a rural trauma system. This incorporates viewing REBOA as a spectrum of technology. Examples of REBOA technology use to improve outcomes and provision of our system’s clinical practice guideline for the Step-Up application of REBOA technology in the care of trauma patients are presented.