A Joint Trauma System Clinical Practice Guideline: Traumatic Brain Injury Management and Basic Neurosurgery in the Deployed Environment.

Management of the patient with moderate to severe brain injury in any environment can be time consuming and resource intensive. These challenges are magnified while forward deployed in austere or hostile environments. This Joint Trauma System Clinical Practice Guideline provides recommendations for the treatment and medical management of casualties with moderate to severe head injuries in an environment where personnel, resources, and follow-on care are limited. These guidelines have been developed by acknowledging commonly recognized recommendations for neurosurgical and neuro-critical care patients and augmenting those evaluations and interventions based on the experience of neurosurgeons, trauma surgeons, and intensivists who have delivered care during recent coalition conflicts.

To Drain or Not: Drainage Procedures Remain a Central Tenet of Management of Infected Collections in Acute Pancreatitis.

Recent literature advocates for delayed or avoidance of catheter drainage of infected peri-pancreatic collections (IPCs) in acute pancreatitis (AP). This may not be realistic for patients at academic centers, many of whom are critically ill. We retrospectively reviewed 72 patients admitted to our institution from 2016-2021 with AP and IPCs. 34.7% had a Bedside Index of Severity in Acute Pancreatitis (BISAP) score ≥3, and 56.9% had a Balthazar score of E. 65.3% were admitted to the ICU, 51.4% experienced respiratory failure, and 47.2% had acute renal failure. In-hospital mortality was 9.7%. Catheter-based drainage alone was the most frequent intervention. Only 8 individuals did not undergo any drainage. Individuals with severe AP complicated by IPCs are critically ill. Avoidance or delay of source control could lead to significant morbidity. Until further research is done on this population, drainage should remain a central tenet of management of IPCs.

The last days: The medical response of United States and allied military teams during the Afghanistan Exodus.

OBJECTIVES: The objective of this study is to describe the United States and allied military medical response during the withdrawal from Afghanistan. BACKGROUND: The military withdrawal from Afghanistan concluded with severe hostilities resulting in numerous civilian and military casualties. The clinical care provided by coalition forces capitalized on decades of lessons learned and enabled unprecedented accomplishments. METHODS: In this retrospective, observational analysis, casualty numbers, and operative information was collected and reported from military medical assets in Kabul, Afghanistan. The continuum of medical care and the trauma system, from the point of injury back to the United States was captured and described. RESULTS: Prior to a large suicide bombing resulting in a mass casualty event, the international medical teams managed distinct 45 trauma incidents involving nearly 200 combat and non-combat civilian and military patients over the preceding 3 months. Military medical personnel treated 63 casualties from the Kabul airport suicide attack and performed 15 trauma operations. US air transport teams evacuated 37 patients within 15 hours of the attack. CONCLUSION: Lessons learned from the last 20 years of combat casualty care were successfully implemented during the culmination of the Afghanistan conflict. Ultimately, the effort, teamwork, and system adaptability exemplify not only the attitudes and character of service members who provide modern combat casualty care but also the paramount importance of the battlefield learning health care system. A continued posture to maintain military surgical preparedness in unique environments remain crucial as the US military prepares for the future.Retrospective observational analysis. LEVEL OF EVIDENCE: Therapeutic/Care Management; Level V.

EFFECTS OF SARS COVID-19 POSITIVITY STATUS ON VENOUS THROMBOSIS AND PULMONARY EMBOLISM RATES IN TRAUMA PATIENTS.

ABSTRACT: Introduction : COVID-19-induced coagulopathy (CIC) can increase the risk of thromboembolism without underlying clotting disorders, even when compared with other respiratory viruses. Trauma has a known association with hypercoagulability. Trauma patients with concurrent COVID-19 infection potentially have an even greater risk of thrombotic events. The purpose of this study was to evaluate venous thromboembolism (VTE) rates in trauma patients with COVID-19. Methods : This study reviewed all adult patients (≥18 years of age) admitted to the Trauma Service from April through November 2020 for a minimum of 48 hours. Patients were grouped based off COVID-19 status and compared for inpatient VTE chemoprophylaxis regimen, thrombotic complications defined as deep vein thrombosis, pulmonary embolism, myocardial infarction, and cerebrovascular accident, intensive care unit (ICU) length of stay, hospital length of stay, and mortality. Results : A total of 2,907 patients were reviewed and grouped into COVID-19-positive (n = 110) and COVID-19-negative (n = 2,797) groups. There was no difference in terms of receiving deep vein thrombosis chemoprophylaxis or type, but a longer time to initiation in the positive group ( P = 0.0012). VTE occurred in 5 (4.55%) positive and 60 (2.15%) negative patients without a significant difference between the groups, as well as no difference in type of VTE observed. Mortality was higher ( P = 0.009) in the positive group (10.91%). Positive patients had longer median ICU LOS ( P = 0.0012) and total LOS ( P < 0.001). Conclusion : There were no increased rates of VTE complications between COVID-19-positive and -negative trauma patients, despite a longer time to initiation of chemoprophylaxis in the COVID-19-positive group. COVID-19-positive patients had increased ICU LOS, total LOS, and mortality, which are likely due to multifactorial causes but primarily related to their underlying COVID-19 infection.

Implementation of a Traumatic Brain Injury Guideline at A Department of Defense Level 1 Trauma Center.

BACKGROUND: Traumatic brain injury (TBI) is one of the most prevalent diagnoses among trauma populations and places significant strain on valuable rural hospital resources. Limited studies show safety and efficacy of implementation of a Brain Injury Guideline (BIG) protocol at a Department of Defense (DoD) Level 1 trauma center. MATERIALS AND METHODS: Data from patients diagnosed with traumatic brain injury during the study period were collected from our institutional trauma database. A retrospective review was performed on patients identified in the database to collect demographic and injury related data. All primary and secondary outcome data were analyzed using two-tailed Fischer's exact tests, Pearson Chi-square tests, and non-parametric Mann Whitney U tests. RESULTS: A total of 354 patients were included in the study, 189 pre-implementation and 165 post-implementation. Demographics, head injury severity, initial HCT findings, and BIG classification distributions were well-matched. There was a significant reduction in neurosurgical consultations (NSC) (98.4% pre- to 77.0% post-implementation, P<0.001) and ICU admissions (84.1% pre-, 74.5% post-implementation, P=0.025) following protocol implementation. There were no differences between groups in ICU LOS (P=0.239), incidence of worsening findings on RHCT (P=0.894), or in-hospital mortality (P=0.814). There was a slight reduction in hospital LOS from 4.0d pre-implementation to 3.0d post-implementation (P=0.043). CONCLUSIONS: Implementation of a BIG protocol at our Level 1 trauma center suggested at a relationship with fewer NSCs and ICU admissions. Management of mild and moderate TBI by acute care and trauma surgeons without direct neurosurgical oversight is safe and implies a reduction in utilization of hospital resources.

Safety and efficacy of low-titer O whole blood resuscitation in a civilian level I trauma center.

BACKGROUND: Military experience has shown low-titer O whole blood (LTOWB) to be safe and beneficial in the resuscitation of hemorrhaging trauma patients. However, few civilian centers use LTOWB for trauma resuscitation. We evaluated the early experience and safety of a LTOWB program at a level 1 civilian trauma center. METHODS: We retrospectively reviewed our trauma registry from January 2018 to June 2020 for patients admitted in shock (defined as ≥1 of the following: heart rate, >120 beats per minute; systolic blood pressure, <90 mm Hg; or shock index, >0.9) who received blood products within 24 hours. Patients were grouped by resuscitation provided: LTOWB (group 1), component therapy (CT; group 2), and LTOWB-CT (group 3). Safety, outcomes, and variables associated with LTOWB transfusion and mortality were analyzed. RESULTS: 216 patients were included: 34 in Group 1, 95 in Group 2, and 87 in Group 3. Patientsreceiving LTOWB were more commonly male (p<0.001) and had a penetrating injury (p=0.005). Groups 1 and 3 had higher median ISS scores compared to Group 2 (19 and 20 vs 17; p=0.01). Group 3 received more median units of blood product in the first 4h (p<0.001) and in the first 24h (p<0.001). There was no difference between groups in 24h mortality or transfusion-related complications (all p>0.05). Arrival ED SBP was associated with LTOWB transfusion (odds ratio [OR] 0.98, 95% confidence interval [CI] 0.95-1.00, p=0.03). ED lactate was independently associated with 24h mortality. (OR 1.27, CI 1.02-1.58, p=0.03). LTOWB transfusion was not associated with mortality (p=0.49). Abstract. CONCLUSION: Severely injured patients received LTOWB-CT and more overall product units but had similar 24 h mortality when compared with the LTOWB or CT groups. No increase in transfusion-related complications was seen after LTOWB transfusion. Low-titer O whole blood should be strongly considered in the resuscitation of trauma patients at civilian centers. LEVEL OF EVIDENCE: Retrospective, therapeutic, level IV.

Electronic trauma resuscitation documentation and decision support using T6 Health Systems Mobile Application: A combat trauma center pilot program.

BACKGROUND: The care of trauma patients in combat operations is handwritten on a five-page flow sheet. The process requires the manual scanning and uploading of paper documents to bridge the gap between electronic and paper record management. There is an urgent operational need for an information technology solution that will enable medics to better capture patient treatment information, which will improve long-term health care without impacting short-term care responsibilities. METHODS: We conducted a process improvement project to evaluate the ability of T6 Health Systems Mobile Application to improve combat casualty care data collection at a deployed trauma hospital. We performed a head-to-head comparison of the completeness and accuracy of data capture of electronic versus handwritten records to determine noninferiority. RESULTS: During the 90-day pilot, there were 131 trauma evaluations of which 53 casualty resuscitations (40.5%) were also documented in the electronic application. We compared completeness and accuracy of admit, prehospital, primary survey, secondary survey, interventions, and trends data. We found an overall 13% increase in data capture at 96% accuracy compared with the written record, suggesting that the electronic record was superior. Completion of electronic documentation compared with paper by section was statistically significantly higher for admitting data, 119.7% (p < 0.0001); prehospital, 116.2% (p = 0.0039); primary, 109.6% (p < 0.001); and secondary, 125.5% (p < 0.001). We also had the medical evacuation teams document prehospital and en route care and then synchronize the record in the trauma bay, allowing the trauma teams there to continue documenting on the same casualty record, likely contributing to superiority because teams did not have to redocument based on an oral report. CONCLUSION: Our pilot program in the deployed environment demonstrated a mobile technology that actually enhanced the completeness and accuracy of paper trauma documentation that has the capability of providing patient-specific decision support and real-time data analysis. LEVEL OF EVIDENCE: Care Management, level IV.

Prehospital adenosine, lidocaine, and magnesium has inferior survival compared with tactical combat casualty care resuscitation in a porcine model of prolonged hemorrhagic shock.

BACKGROUND: Adenosine, lidocaine, and magnesium (ALM) is a cardioplegic agent shown to improve survival by improving cardiac function, tissue perfusion, and coagulopathy in animal models of shock. We hypothesized prehospital ALM treatment in hemorrhagic shock would improve survival compared to current Tactical Combat Casualty Care (TCCC) resuscitation beyond the golden hour. METHODS: Swine were randomized to: (1) TCCC, (2) 2 mL·kg vehicle control (VC), (3) 2 mL·kg ALM + drip, (4) 4 mL·kg ALM + drip, 5) 4 mL·kg ALM + delayed drip at 0.5 mL·kg·h, 6) 4 mL/kg VC, 7) 4 mL·kg ALM for 15 minutes + delayed drip at 3 mL·kg·h. Animals underwent pressure controlled hemorrhage to mean arterial pressure (MAP) of 30 mm Hg (S = 0). Treatment was administered at T = 0. After 120 minutes of simulated prehospital care (T = 120) blood product resuscitation commenced. Physiologic variables were recorded and laboratories were drawn at specified time points. RESULTS: Tactical Combat Casualty Care demonstrated superior survival to all other agents. The VC and ALM groups had lower MAPs and systolic blood pressures compared with TCCC. Except for the VC groups, lactate levels remained similar with correction of base deficit after prehospital resuscitation in all groups. Kidney function and liver function remained comparable across all groups. Compared with baseline values, TCCC demonstrated significant hypocoagulability. CONCLUSION: Adenosine, lidocaine, and magnesium, as administered in this study, are inferior to current Hextend-based resuscitation for survival from prolonged hemorrhagic shock in this model. In survivors, ALM groups had lower systolic blood pressures and MAPs, but provided a protective effect on coagulopathy as compared to TCCC. Adenosine, lidocaine, and magnesium do not appear to be a suitable low volume replacement to current TCCC resuscitation. The reduced coagulopathy compared to TCCC warrants future studies of ALM, perhaps as a therapeutic adjunct.

Neoadjuvant chemoradiation therapy is beneficial for clinical stage T2 N0 esophageal cancer patients due to inaccurate preoperative staging.

BACKGROUND: It remains unclear if patients with clinical stage T2 N0 (cT2 N0) esophageal cancer should be offered induction therapy vs surgical intervention alone. METHODS: This was a retrospective cohort study of cT2 N0 patients undergoing induction therapy, followed by surgical resection, or resection alone, at the Johns Hopkins Hospital from 1989 to 2009. Kaplan-Meier analysis was used to compare all-cause mortality in cT2 N0 patients who had resection alone vs those who had induction chemoradiation therapy, followed by resection. RESULTS: A study cohort of 69 patients was identified and divided into two groups: 55 patients (79.7%) received induction therapy and 14 (20.3%) did not. No statistically significant difference in 5-year survival rate was observed for the two groups: 49.5% for the resection-only group and 53.8% for the induction group. More than 50% of cT2 N0 patients were understaged. CONCLUSIONS: For cT2 N0 esophageal cancer patients, the benefit of neoadjuvant therapy is still unclear. Induction therapy for cT2 N0 did not translate into a statistically significant improvement in survival. However, due to the significant understaging of T2 N0 patients, we recommend neoadjuvant therapy to all cT2N0 patients before operation.