Pediatric emergency resuscitative thoracotomy: A Western Trauma Association, Pediatric Trauma Society, and Eastern Association for the Surgery of Trauma collaborative critical decisions algorithm.

LEVEL OF EVIDENCE: Literature synthesis and expert opinion, Level V.

Blunt pancreatic trauma: A Western Trauma Association critical decisions algorithm.

BACKGROUND: The Western Trauma Association (WTA) has undertaken publication of best practice clinical practice guidelines on multiple trauma topics. These guidelines are based on scientific evidence, case reports, and best practices per expert opinion. Some of the topics covered by this consensus group do not have the ability to have randomized controlled studies completed because of complexity, ethical issues, financial considerations, or scarcity of experience and cases. Blunt pancreatic trauma falls under one of these clinically complex and rare scenarios. This algorithm is the result of an extensive literature review and input from the WTA membership and WTA Algorithm Committee members. METHODS: Multiple evidence-based guideline reviews, case reports, and expert opinion were compiled and reviewed. RESULTS: The algorithm is attached with detailed explanation of each step, supported by data if available. CONCLUSION: Blunt pancreatic trauma is rare and presents many treatment challenges.

Real-time infection prediction with wearable physiological monitoring and AI to aid military workforce readiness during COVID-19.

Infectious threats, like the COVID-19 pandemic, hinder maintenance of a productive and healthy workforce. If subtle physiological changes precede overt illness, then proactive isolation and testing can reduce labor force impacts. This study hypothesized that an early infection warning service based on wearable physiological monitoring and predictive models created with machine learning could be developed and deployed. We developed a prototype tool, first deployed June 23, 2020, that delivered continuously updated scores of infection risk for SARS-CoV-2 through April 8, 2021. Data were acquired from 9381 United States Department of Defense (US DoD) personnel wearing Garmin and Oura devices, totaling 599,174 user-days of service and 201 million hours of data. There were 491 COVID-19 positive cases. A predictive algorithm identified infection before diagnostic testing with an AUC of 0.82. Barriers to implementation included adequate data capture (at least 48% data was needed) and delays in data transmission. We observe increased risk scores as early as 6 days prior to diagnostic testing (2.3 days average). This study showed feasibility of a real-time risk prediction score to minimize workforce impacts of infection.

Evaluation and management of traumatic pneumothorax: A Western Trauma Association critical decisions algorithm.

ABSTRACT: This is a recommended algorithm of the Western Trauma Association for the management of a traumatic pneumothorax. The current algorithm and recommendations are based on available published prospective cohort, observational, and retrospective studies and the expert opinion of the Western Trauma Association members. The algorithm and accompanying text represents a safe and reasonable approach to this common problem. We recognize that there may be variability in decision making, local resources, institutional consensus, and patient-specific factors that may require deviation from the algorithm presented. This annotated algorithm is meant to serve as a basis from which protocols at individual institutions can be developed or serve as a quick bedside reference for clinicians. LEVEL OF EVIDENCE: Consensus algorithm from the Western Trauma Association, Level V.

Association Between American Board of Surgery Initial Certification and Risk of Receiving Severe Disciplinary Actions Against Medical Licenses.

Importance: Board certification is used as a marker of surgeon quality and professionalism. Although some research has linked certification in surgery to outcomes, more research is needed. Objective: To measure associations between surgeons obtaining American Board of Surgery (ABS) certification and examination performance with receiving future severe disciplinary actions against their medical licenses. Design, Setting, and Participants: Retrospective analysis of severe license action rates for surgeons who attempted ABS certification based on certification status and examination performance. Surgeons who attempted to become certified were classified as certified or failing to obtain certification. Additionally, groups were further categorized based on whether the surgeon had to repeat examinations and whether they ultimately passed. The study included surgeons who initially attempted certification between 1976 and 2017 (n = 44 290). Severe license actions from 1976 to 2018 were obtained from the Federation of State Medical Boards, and certification data were obtained from the ABS database. Data were analyzed between 1978 and 2008. Main Outcomes and Measures: Severe license action rates were analyzed across certified surgeons and those failing to obtain certification, as well as across examination performance groups. Results: The final dataset included 36 197 men (81.7%) and 8093 women (18.3%). The incidence of severe license actions was significantly greater for surgeons who attempted and failed to obtain certification (incidence rate per 1000 person-years = 2.49; 95% CI, 2.13-2.85) than surgeons who were certified (incidence rate per 1000 person years = 0.77; 95% CI, 0.71-0.83). Adjusting for sex and international medical graduate status, the risk of receiving a severe license action across time was also significantly greater for surgeons who failed to obtain certification. Surgeons who progressed further in the certification examination sequence and had fewer repeated examinations had a lower incidence and less risk over time of receiving severe license actions. Conclusions and Relevance: Obtaining board certification was associated with a lower rate of receiving severe license actions from a state medical board. Passing examinations in the certification examination process on the first attempt was also associated with lower severe license action rates. This study provides supporting evidence that board certification is 1 marker of surgeon quality and professionalism.

Gunshot wounds and blast injuries to the face are associated with significant morbidity and mortality: results of an 11-year multi-institutional study of 720 patients.

BACKGROUND: Gunshot wounds and blast injuries to the face (GSWBIFs) produce complex wounds requiring management by multiple surgical specialties. Previous work is limited to single institution reports with little information on processes of care or outcome. We sought to determine those factors associated with hospital complications and mortality. METHODS: We performed an 11-year multicenter retrospective cohort analysis of patients sustaining GSWBIF. The face, defined as the area anterior to the external auditory meatuses from the top of the forehead to the chin, was categorized into three zones: I, the chin to the base of the nose; II, the base of the nose to the eyebrows; III, above the brows. We analyzed the effect of multiple factors on outcome. RESULTS: From January 1, 2000, to December 31, 2010, we treated 720 patients with GSWBIF (539 males, 75%), with a median age of 29 years. The wounding agent was handgun in 41%, explosive (shotgun and blast) in 20%, rifle in 6%, and unknown in 33%. Prehospital or resuscitative phase airway was required in 236 patients (33%). Definitive care was rendered by multiple specialties in 271 patients (38%). Overall, 185 patients died (26%), 146 (79%) within 48 hours. Of the 481 patients hospitalized greater than 48 hours, 184 had at least one complication (38%). Factors significantly associated with any of a total of 207 complications were total number of operations (p < 0.001), Revised Trauma Score (RTS, p < 0.001), and head Abbreviated Injury Scale (AIS) score (p < 0.05). Factors significantly associated with mortality were RTS (p < 0.001), head AIS score (p < 0.001), total number of operations (p < 0.001), and age (p < 0.05). An injury located in Zone III was independently associated with mortality (p < 0.001). CONCLUSION: GSWBIFs have high mortality and are associated with significant morbidity. The multispecialty involvement required for definitive care necessitates triage to a trauma center and underscores the need for an organized approach and the development of effective guidelines. LEVEL OF EVIDENCE: Therapeutic/care management, level III.

Single-drug sedation with fentanyl for prehospital postintubation sedation in trauma patients.

BACKGROUND: A fentanyl-only (FO) regimen for prehospital postintubation sedation in trauma patients was compared with the standard protocol (SP) of fentanyl + benzodiazepine. METHODS: Intubated patients transported to a Level I trauma center from December 1, 2005, to April 30, 2009, were retrospectively reviewed. Before 2007, only SP was used; afterward both regimens were used. Groups were compared for hemodynamic and neurologic parameters in the prehospital setting and trauma bay, fluid volumes, time until general or neurosurgical intervention (NSI), and other outcomes. RESULTS: Groups were comparable with respect to age, sex, mechanism, alcohol level, intensive care unit length of stay, and hospital length of stay. Comorbidities were similar except hypertension (p = 0.019), and stroke (p = 0.029) were more frequent in FO patients. Prehospital heart rate and Glasgow Coma Scale (GCS) were similar. Trauma bay hemodynamic parameters and fluid resuscitation volumes were comparable, but pupil nonreactivity was more frequent in the FO group both overall (p = 0.032) and when comparing only patients with traumatic brain injury (TBI; p = 0.014). The incidence of TBI was comparable. Although the frequency of craniotomy (13% FO vs. 7% SP) and mortality (17% FO vs. 11% SP) were not statistically different overall, in patients with TBI, there was a higher incidence of NSI (28% vs. 14%, p = 0.015), craniotomy (14% vs. 3%, p = 0.02), and time to initial NSI (446 minutes vs. 193 minutes, p = 0.042) in the FO patients. CONCLUSIONS: In this study, an FO regimen was associated with similar hemodynamic but worse neurologic variables compared with the SP regimen. Prospective evaluation is warranted before adoption of this regimen, especially in TBI patients.

Age: is it all in the head? Factors influencing mortality in elderly patients with head injuries.

BACKGROUND: Elderly patients, an increasing segment of the population, who sustain traumatic brain injury (TBI) are known to have worse outcomes, including higher mortality. This objective of this study was to examine the Crash Injury Research Engineering Network and to determine at what age motor vehicle crash fatalities from head injuries increased. METHODS: The Crash Injury Research Engineering Network database was queried from 1996 to 2009. Study inclusion criteria were adult vehicle occupants with TBI, with an Abbreviated Injury Scale score ≥2. The age at which mortality increased was calculated. Patients younger and older than this cutoff age were compared to determine differences in crash characteristics. The determined cutoff age was compared with one found in a larger, population-based database. RESULTS: There were 915 patients who met the study criteria. An increase in mortality was seen at age 60 years despite no difference in Injury Severity Score and a decrease in crash severity. Patients ≤60 years were more likely to have alcohol involved, to be in a rollover crash, and had higher crash speeds. Comparing the element of the crash attributed to the head injury, the patients >60 years were more likely to have struck the airbag, door, and seat. An analysis of the larger database revealed an increase in mortality at age 70 years. CONCLUSIONS: There was a higher mortality secondary to head injuries in those older than 60 years involved in motor vehicle crashes. Improved safety measures in vehicle design may decrease the number of head injuries seen in the older population.

Teaching breaking bad news using mixed reality simulation.

BACKGROUND: Our novel teaching approach involved having students actively participate in an unsuccessful resuscitation of a high fidelity human patient simulator with a gun shot wound to the chest, followed immediately by breaking bad news (BBN) to a standardized patient wife (SPW) portrayed by an actress. METHODS: Brief education interventions to include viewing a brief video on the SPIKES protocol on how to break bad news, a didactic lecture plus a demonstration, or both, was compared to no pretraining by dividing 553 students into four groups prior to their BBN to the SPW. The students then self-assessed their abilities, and were also evaluated by the SPW on 21 items related to appearance, communication skills, and emotional affect. All received cross-over training. RESULTS: Groups were equal in prior training (2 h) and belief that this was an important skill to be learned. Students rated the experience highly, and demonstrated marked improvement of self-assessed skills over baseline, which was maintained for the duration of the 12-wk clerkship. Additionally, students who received any of the above training prior to BBN were rated superior to those who had no training on several communication skills, and the observation of the video seemed to offer the most efficient way of teaching this skill in a time delimited curriculum. CONCLUSION: This novel approach was well received and resulted in improvement over baseline. Lessons learned from this study have enhanced our curricular approach to this vital component of medical education.

Pregnancy is not a sufficient indicator for trauma team activation.

BACKGROUND: Trauma complicates 6% to 7% of all pregnancies. Adverse outcomes are rare when monitoring is normal and early warning signs absent. Trauma systems often use pregnancy as the sole criterion (PSC) for partial trauma team activation. This study compares outcomes of pregnant patients presenting with PSC versus other physiologic, mechanistic, or anatomic (OPMA) activation criteria. METHODS: Three hundred fifty-two consecutive obstetric partial trauma team activation patients (2000-2005) were grouped by length of gestation and evaluated for activation criteria and early maternal and fetal outcomes. Data were analyzed using descriptive statistics and analysis of variance. RESULTS: Patients ranged in age from 16 to 44 (mean age, 28 +/- 6.4) and in weeks gestation between 1 and 40 weeks (mean, 25 +/- 8 weeks). Eighty-two percent had been in vehicle crashes. One hundred eighty-eight (58%) were activated based on PSC and 137 on OPMA. No PSC patient had injuries sufficient to warrant trauma service admission. Ninety-four percent of all PSCs of <20 weeks were discharged home from the emergency department. There were no maternal mortalities. There were four fetal mortalities; two pregnancies were terminally compromised before the trauma event. No patient in the PSC group required admission to the trauma service. There were seven cases of abruption (2%) and 18 cases of vaginal bleeding or discharge (6%). No case of vaginal bleeding or abruption in the first 20 weeks was hypotensive at the scene or on arrival. CONCLUSION: In this study, pregnancy was not an independent predictor of the need for trauma team activation. Standard OPMA trauma activation criteria apply equally to pregnant and nonpregnant patients. These data provide support for more judicious allocation of scarce trauma systems resources.