Every minute matters: Improving outcomes for penetrating trauma through prehospital advanced resuscitative care.

INTRODUCTION: Prehospital resuscitation with blood products is gaining popularity for patients with traumatic hemorrhage. The MEDEVAC trial demonstrated a survival benefit exclusively among patients who received blood or plasma within 15 minutes of air medical evacuation. In fast-paced urban EMS systems with a high incidence of penetrating trauma, mortality data based on the timing to first blood administration is scarce. We hypothesize a survival benefit in patients with severe hemorrhage when blood is administered within the first 15 minutes of EMS patient contact. METHODS: This was a retrospective analysis of a prospective database of prehospital blood (PHB) administration between 2021 and 2023 in an urban EMS system facing increasing rates of gun violence. PHB patients were compared to trauma registry controls from an era before prehospital blood utilization (2016-2019). Included were patients with penetrating injury and SBP ≤ 90 mmHg at initial EMS evaluation that received at least one unit of blood product after injury. Excluded were isolated head trauma or prehospital cardiac arrest. Time to initiation of blood administration before and after PHB implementation and in-hospital mortality were the primary variables of interest. RESULTS: A total of 143 patients (PHB = 61, controls = 82) were included for analysis. Median age was 34 years with no difference in demographics. Median scene and transport intervals were longer in the PHB cohort, with a 5-minute increase in total prehospital time. Time to administration of first unit of blood was significantly lower in the PHB vs. control group (8 min vs 27 min; p < 0.01). In-hospital mortality was lower in the PHB vs. control group (7% vs 29%; p < 0.01). When controlling for patient age, NISS, tachycardia on EMS evaluation, and total prehospital time interval, multivariate regression revealed an independent increase in mortality by 11% with each minute delay to blood administration following injury (OR 1.11, 95%CI 1.04-1.19). CONCLUSION: Compared to patients with penetrating trauma and hypotension who first received blood after hospital arrival, resuscitation with blood products was started 19 minutes earlier after initiation of a PHB program despite a 5-minute increase in prehospital time. A survival for early PHB use was demonstrated, with an 11% mortality increase for each minute delay to blood administration. Interventions such as PHB may improve patient outcomes by helping capture opportunities to improve trauma resuscitation closer to the point of injury. LEVEL OF EVIDENCE: Prospective, Level IV.

Faster refill in an urban emergency medical services system saves lives: A prospective preliminary evaluation of a prehospital advanced resuscitative care bundle.

INTRODUCTION: Military experience has demonstrated mortality improvement when advanced resuscitative care (ARC) is provided for trauma patients with severe hemorrhage. The benefits of ARC for trauma in civilian emergency medical services (EMS) systems with short transport intervals are still unknown. We hypothesized that ARC implementation in an urban EMS system would reduce in-hospital mortality. METHODS: This was a prospective analysis of ARC bundle administration between 2021 and 2023 in an urban EMS system with 70,000 annual responses. The ARC bundle consisted of calcium, tranexamic acid, and packed red blood cells via a rapid infuser. Advanced resuscitative care patients were compared with trauma registry controls from 2016 to 2019. Included were patients with a penetrating injury and systolic blood pressure ≤90 mm Hg. Excluded were isolated head trauma or prehospital cardiac arrest. In-hospital mortality was the primary outcome of interest. RESULTS: A total of 210 patients (ARC, 61; controls, 149) met the criteria. The median age was 32 years, with no difference in demographics, initial systolic blood pressure or heart rate recorded by EMS, or New Injury Severity Score between groups. At hospital arrival, ARC patients had lower median heart rate and shock index than controls ( p ≤ 0.03). Fewer patients in the ARC group required prehospital advanced airway placement ( p < 0.001). Twenty-four-hour and total in-hospital mortality were lower in the ARC group ( p ≤ 0.04). Multivariable regression revealed an independent reduction in in-hospital mortality with ARC (odds ratio, 0.19; 95% confidence interval, 0.05-0.68; p = 0.01). CONCLUSION: Early ARC in a fast-paced urban EMS system is achievable and may improve physiologic derangements while decreasing patient mortality. Advanced resuscitative care closer to the point of injury warrants consideration. LEVEL OF EVIDENCE: Therapeutic/Care Management; Level IV.

Impact of Prehospital Exsanguinating Airway-Breathing-Circulation Resuscitation Sequence on Patients with Severe Hemorrhage.

BACKGROUND: At the 2023 ATLS symposium, the priority of circulation was emphasized through the "x-airway-breathing-circulation (ABC)" sequence, where "x" stands for exsanguinating hemorrhage control. With growing evidence from military and civilian studies supporting an x-ABC approach to trauma care, a prehospital advanced resuscitative care (ARC) bundle emphasizing early transfusion was developed in our emergency medical services (EMS) system. We hypothesized that prioritization of prehospital x-ABC through ARC would reduce in-hospital mortality. STUDY DESIGN: This was a single-year prospective analysis of patients with severe hemorrhage. These patients were combined with our institution's historic controls before prehospital blood implementation. Included were patients with systolic blood pressure (SBP) less than 90 mmHg. Excluded were patients with penetrating head trauma or prehospital cardiac arrest. Two-to-one propensity matching for x-ABC to ABC groups was conducted, and the primary outcome, in-hospital mortality, was compared between groups. RESULTS: A total of 93 patients (x-ABC = 62, ABC = 31) met the inclusion criteria. There was no difference in patient age, sex, initial SBP, initial Glasgow Coma Score, and initial shock index between groups. When compared with the ABC group, x-ABC patients had significant improvement in vitals at emergency department admission. Overall mortality was lower in the x-ABC group (13% vs 47%, p < 0.001). Multivariable regression revealed that prehospital circulation-first prioritization was independently associated with decreased in-hospital mortality (odds ratio 0.15, 95% CI 0.04 to 0.54, p = 0.004). CONCLUSIONS: This is the first analysis to demonstrate a prehospital survival benefit of x-ABC in this subset of patient with severe injury and hemorrhagic shock. Standardization of prehospital x-ABC management in this patient population warrants special consideration.

Combined Endoscopic Robotic Surgery for Complex Colon Polyps.

BACKGROUND: Combined endoscopic robotic surgery is a surgical technique that modifies traditional endoscopic laparoscopic surgery with robotic assistance to aid in the removal of complex colonic polyps. This technique has been described in the literature but lacks patient follow-up data. OBJECTIVE: This study aimed to evaluate the safety and outcomes of combined endoscopic robotic surgery. DESIGN: A retrospective review of a prospective database. SETTING: East Jefferson General Hospital, Metairie, Louisiana. PATIENTS: Ninety-three consecutive patients who underwent combined endoscopic robotic surgery from March 2018 to October 2021 were included in the study. MAIN OUTCOME MEASURES: Operative time, intraoperative complication, 30-day postoperative complication, hospital length of stay, and follow-up pathology report results were the main outcome measures. RESULTS: Combined endoscopic robotic surgery was completed in 88 of 93 participants (95%). Among the 88 participants who completed combined endoscopic robotic surgery, the average age was 66 years (SD = 10), BMI was 28.8 kg/m 2 (SD = 6), and history of previous abdominal surgeries was 1 (SD = 1). Median operative time was 72 minutes (range, 31-184 minutes) and polyp size was 40 mm (range, 5-180 mm). The most common polyp locations were the cecum, ascending colon, and transverse colon (31%, 28%, 25%). Pathology mainly demonstrated tubular adenoma (76%). Data on 40 patients who underwent follow-up colonoscopy were available. The average follow-up time was 7 months (range, 3-22 months). One patient (2.5%) had polyp recurrence at the resection site. LIMITATIONS: Limitations for our study include a lack of randomization and follow-up rate to assess for recurrence. The low compliance rate may be due to procedure cancelations/difficulty scheduling because of changing coronavirus disease 2019 guidelines. CONCLUSIONS: Compared to literature-reported statistics for its laparoscopic counterpart, combined endoscopic robotic surgery was associated with decreased operation times and resection site polyp recurrence. See Video Abstract at http://links.lww.com/DCR/C208 . CIRUGA ROBTICA ENDOSCPICA COMBINADA PARA PLIPOS DE COLON COMPLEJOS: ANTECEDENTES:La cirugía robótica endoscópica combinada es una técnica quirúrgica que modifica la cirugía laparoscópica endoscópica tradicional con asistencia robótica para ayudar en la extracción de pólipos colónicos complejos. Esta técnica está previamente descrita en la literatura, pero carece de datos de seguimiento de los pacientes.OBJETIVO:Evaluar la seguridad y los resultados de la cirugía robótica endoscópica combinada.DISEÑO:Revisión retrospectiva de una base de datos prospectiva.AJUSTE:Hospital General East Jefferson, Metairie LouisianaPACIENTES:Noventa y tres pacientes consecutivos y sometidos a cirugía robótica endoscópica combinada por un solo cirujano colorrectal desde marzo de 2018 hasta octubre de 2021.PRINCIPALES MEDIDAS DE RESULTADO:Tiempo operatorio, complicación intraoperatoria, complicación posoperatoria a los 30 días, duración de la estancia hospitalaria y resultados del informe patológico de seguimiento.RESULTADOS:La cirugía robótica endoscópica combinada se completó en 88 de 93 (95%). Entre los 88 participantes que completaron la cirugía robótica endoscópica combinada, la edad promedio fue de 66 años (desviación estándar = 10), índice de masa corporal de 28,8 (desviación estándar = 6) y el historial de cirugías abdominales previas de 1 (desviación estándar = 1). La mediana del tiempo operatorio y el tamaño de los pólipos fueron 72 minutos (rango 31-184 minutos) y 40 milímetros (rango 5-180 milímetros), respectivamente. Las ubicaciones de pólipos más comunes fueron el ciego, colon ascendente y transverso (31%, 28%, 25%). La patología demostró principalmente adenoma tubular (76%). Los datos de 40 pacientes sometidos a una colonoscopia de seguimiento estaban disponibles. El tiempo medio de seguimiento fue de 7 meses (rango 3-22 meses). Un paciente (2,5%) presentó recurrencia polipoidea en el sitio de resección.LIMITACIONES:Las limitaciones de nuestro estudio incluyeron la falta de aleatorización y la tasa de seguimiento para evaluar la recurrencia. La baja tasa de seguimiento puede deberse a la renuencia del paciente en hacerse una colonoscopia o cancelaciones de procedimientos por la dificultad para programar debido a cambios de COVID-19.CONCLUSIÓN:En comparación con las estadísticas reportadas en la literatura para su contraparte laparoscópica, la cirugía robótica endoscópica combinada se asoció con reducción en tiempos de operación y recurrencia de pólipos en el sitio de resección. Consulte Video Resumen en http://links.lww.com/DCR/C208 . (Traducción - Dr. Fidel Ruiz Healy ).

Traumatic Injury in Pregnancy: A Propensity Score-Matched Analysis.

INTRODUCTION: Trauma represents the leading cause of nonobstetrical maternal death. How in-hospital outcomes of acutely injured pregnant patients (PP) compares to that of similarly aged nonpregnant control groups (CGs) has not been described. We hypothesized that PPs suffering acute traumatic injuries would have worse outcomes compared to a matched CG. MATERIALS AND METHODS: The American College of Surgeons Trauma Quality Improvement Program (TQIP) was used to identify traumatically injured females between 2017 and 2019. Propensity score matching on age, race, injury severity score , and type of trauma (blunt, penetrating, or other) was used to compare PPs and the CG. Primary outcomes were mortality, disposition, length of stay (LOS), and complications. RESULTS: A total of 1078 traumatically injured pregnant females were identified. Propensity score matching resulted in 990 patients in the PP and CG cohorts. After matching, PPs were more likely to be assault victims (11% versus 6%, P < 0.001), had longer length of stay (LOS) (5 versus 3 d, P < 0.001), and were more likely to require mechanical ventilation (26% versus 16%, P < 0.001) or intensive care unit (ICU) admission (44% versus 32%, P < 0.001). PPs were more likely to proceed directly to the operating room (OR)(34% versus 15%, P < 0.001) and less likely to be discharged home from the emergency department (ED) (1% versus 12%, P < 0.001). Complications and mortality rates were similar among PPs. CONCLUSIONS: After acute trauma, PPs did not have increased mortality or complications when compared to matched controls, although they were more likely to be victims of assault, directly proceed to the OR, require mechanical ventilation or ICU admission, and have longer LOSs.

A CIRCULATION-FIRST APPROACH FOR RESUSCITATION OF TRAUMA PATIENTS WITH HEMORRHAGIC SHOCK.

ABSTRACT: The original guidelines of cardiopulmonary resuscitation focused on the establishment of an airway and rescue breathing before restoration of circulation through cardiopulmonary resuscitation. As a result, the airway-breathing-circulation approach became the central guiding principle of resuscitation. Despite new guidelines by the American Heart Association for a circulation-first approach, Advanced Trauma Life Support guidelines continue to advocate for the airway-breathing-circulation sequence. Although definitive airway management is often necessary for severely injured patients, endotracheal intubation (ETI) before resuscitation in patients with hemorrhagic shock may worsen hypotension and precipitate cardiac arrest. In severely injured patients, a paradigm shift should be considered, which prioritizes restoration of circulation before ETI and positive pressure ventilation while maintaining a focus on basic airway assessment and noninvasive airway interventions. For this patient population, the most reasonable current strategy may be to target a simultaneous resuscitation approach, with immediate efforts to control hemorrhage and provide basic airway interventions while prioritizing volume resuscitation with blood products and deferring ETI until adequate systemic perfusion has been attained. We believe that a circulation-first sequence will improve both survival and neurologic outcomes for a traumatically injured patient and will continue to advocate this approach, as additional clinical evidence is generated to inform how to best tailor circulation-first resuscitation for varied injury patterns and patient populations.

Cost-Effectiveness of Universal Screening for Blunt Cerebrovascular Injury: A Markov Analysis.

BACKGROUND: Blunt cerebrovascular injury (BCVI) is a significant cause of morbidity and mortality after blunt trauma. Numerous screening strategies exist, although which is used is institution- and physician-dependent. We sought to identify the most cost-effective screening strategy for BCVI, hypothesizing that universal screening would be optimal among the screening strategies studied. STUDY DESIGN: A Markov decision analysis model was used to compare the following screening strategies for identification of BCVI: (1) no screening; (2) Denver criteria; (3) extended Denver criteria; (4) Memphis criteria; and (5) universal screening. The base-case scenario modeled 50-year-old patients with blunt traumatic injury excluding isolated extremity injures. Patients with BCVI detected on imaging were assumed to be treated with antithrombotic therapy, subsequently decreasing risk of stroke and mortality. One-way sensitivity analyses were performed on key model inputs. A single-year horizon was used with an incremental cost-effectiveness ratio threshold of $100,000 per quality-adjusted life-year. RESULTS: The most cost-effective screening strategy for patients with blunt trauma among the strategies analyzed was universal screening. This method resulted in the lowest stroke rate, mortality, and cost, and highest quality-adjusted life-year. An estimated 3,506 strokes would be prevented annually as compared with extended Denver criteria (incremental cost-effectiveness ratio of $71,949 for universal screening vs incremental cost-effectiveness ratio of $12,736 for extended Denver criteria per quality-adjusted life-year gained) if universal screening were implemented in the US. In 1-way sensitivity analyses, universal screening was the optimal strategy when the incidence of BCVI was greater than 6%. CONCLUSIONS: This model suggests universal screening may be the cost-effective strategy for BCVI screening in blunt trauma for certain trauma centers. Trauma centers should develop institutional protocols that take into account individual BCVI rates.

IMPACT OF TIME TO EMERGENCY DEPARTMENT RESUSCITATIVE AORTIC OCCLUSION AFTER NONCOMPRESSIBLE TORSO HEMORRHAGE.

ABSTRACT: Introduction: Time is an essential element in outcomes of trauma patients. The relationship of time to treatment in management of noncompressible torso hemorrhage (NCTH) with resuscitative endovascular balloon occlusion of the aorta (REBOA) or resuscitative thoracotomy (RT) has not been previously described. We hypothesized that shorter times to intervention would reduce mortality. Methods: A review of the Aortic Occlusion for Resuscitation in Trauma and Acute Care Surgery registry from 2013 to 2022 was performed to identify patients who underwent emergency department aortic occlusion (AO). Multivariate logistic regression was used to examine the impact of time to treatment on mortality. Results: A total of 1,853 patients (1,245 [67%] RT, 608 [33%] REBOA) were included. Most patients were male (82%) with a median age of 34 years (interquartile range, 30). Median time from injury to admission and admission to successful AO were 31 versus 11 minutes, respectively. Patients who died had shorter median times from injury to successful AO (44 vs. 72 minutes, P < 0.001) and admission to successful AO (10 vs. 22 minutes, P < 0.001). Multivariate logistic regression demonstrated that receiving RT was the strongest predictor of mortality (odds ratio [OR], 6.6; 95% confidence interval [CI], 4.4-9.9; P < 0.001). Time from injury to admission and admission to successful AO were not significant. This finding was consistent in subgroup analysis of RT-only and REBOA-only populations. Conclusions: Despite expedited interventions, time to aortic occlusion did not significantly impact mortality. This may suggest that rapid in-hospital intervention was often insufficient to compensate for severe exsanguination and hypovolemia that had already occurred before emergency department presentation. Selective prehospital advanced resuscitative care closer to the point of injury with "scoop and control" efforts including hemostatic resuscitation warrants special consideration.

The association between food insecurity and gun violence in a major metropolitan city.

BACKGROUND: Food insecurity (FI) is an important social determinant of health that is associated with many forms of violence. We hypothesized that FI would be associated with gun violence. METHODS: Firearm injury data was collected from 2016 to 2020 (n = 3115) at a single institution that serves as the only Level I trauma center in a major southern US city. The data were linked with Map the Meal Gap data, a publicly available data set, which estimates rates of county-level FI based on state-level FI and social determinants, including unemployment, poverty, disability, and other factors. Regression analysis was utilized to examine the relationship between FI with rates of overall gun trauma and odds of gun-related violence. Food insecurity by county of patient residence was categorized by rates less than the national average of 11.5% (low), between the national and state average (16.5%) (moderate), and greater than the state average (high). Out of state residents were excluded from the analyses. RESULTS: Of the 3,115 patients with firearm injuries identified, 138 (4.4%) resided in counties with low FI rates, 1048 (33.6%) in moderate FI, and 1929 (62.0%) in counties with high FI. Patients in regions of high FI were more likely to be a Level I trauma activation, a victim of assault, and have Medicaid or be self-pay. There was no significant difference in mortality by levels of FI. Food insecurity was significantly associated with firearm injury, with each percent increase in FI being related to approximately 56 additional gun-related injuries per 100,000 people (95% confidence interval, 54-59) and increased odds of the injury classified as assault (odds ratio, 1.13; 95% confidence interval, 1.07-1.19). CONCLUSION: Violence prevention initiatives targeting food insecure communities may help alleviate the US gun violence epidemic. Further, trauma center screening for household FI and in-hospital interventions addressing FI may help reduce gun violence recidivism. LEVEL OF EVIDENCE: Prognostic and Epidemiologic; Level IV.

Combined endoscopic robotic surgery for complex colonic polyp resection: case series.

BACKGROUND: The study objective was to evaluate combined endoscopic and robotic surgery, a novel surgical technique modifying traditional combined endoscopic laparoscopic surgery through robotic assistance, and characterize a series of patients who underwent the modified operative technique. METHODS: A retrospective case series was performed. The first thirty-seven consecutive patients who underwent combined endoscopic robotic surgery by a single colorectal surgeon from March 2018 to October 2019 were included. Main outcome measures included operative time, intra-operative complication, 30-day post-operative complication, and hospital length of stay. RESULTS: Combined endoscopic and robotic surgery was performed in 37 cases, 32 (86.5%) of which saw the technique through to completion. Median operative room time was 73 min (range 31-184 min). No intraoperative complications occurred and 2 (6.3%) experienced 30-day post-operative complications. Median hospital length of stay was 1.1 days (range 0.2-2.0 days). Median polyp size was 35 mm (range 20-130 mm). Polyps were resected from the following locations: cecum (37.5%), ascending colon (28.1%), transverse colon (21.9%), descending colon (3.1%), sigmoid colon (6.3%), and rectum (3.1%). Pathology demonstrated 77.4% tubular adenoma, 12.9% sessile serrated adenoma, 6.5% dysplasia, and 3.2% signet cell adenocarcinoma. CONCLUSION: Combined endoscopic robotic surgery was associated with decreased operative time, complication rates, and hospital length of stay compared to literature-reported statistics for combined endoscopic laparoscopic surgery. Increased confidence with 3-dimensional visualization and intracorporeal suturing using combined endoscopic and robotic surgery was noted. Additional studies are needed to further define the role of robotics in combined endoscopic surgery.

Impact of the 2014 NIH chronic graft-versus-host disease scoring criteria modifications assessed in a large cohort of severely affected patients.

In 2005, the National Institutes of Health (NIH) chronic graft-versus-host disease (cGVHD) consensus project provided diagnosis and staging criteria, based mostly on clinical experience and expert opinion. These criteria were revised in 2014, aiming to provide enhanced specificity and clarity. However, the impact of 2014 changes to the original NIH cGVHD severity scoring criteria has not been reported. In this study, 284 patients, prospectively enrolled on the National Cancer Institute's cross-sectional cGVHD natural history study, were scored using the 2005 NIH cGVHD criteria and then rescored according to the 2014 modifications. In comparing the two criteria, 2014 cGVHD global severity scoring resulted in a tendency toward being categorized as milder scores (75 vs. 72% of severe score per 2014, p = 0.0009), with a statistically significant shift in NIH liver and lung scores toward milder categories (p < 0.0001). 2005 and 2014 NIH global severity scores showed a significant association with reduced grip strength (p < 0.0001), reduced joint range of motion (p = 0.0003), and the subspecialist evaluation score (p < 0.0001). Poor survival prediction of the severe NIH lung score is also retained in the new criteria (p = 0.0012). These findings support the use of 2014 cGVHD scoring criteria in continuous efforts to develop better classification systems.