Venovenous extracorporeal membrane oxygenation experience in a community level I trauma center.

BACKGROUND: There is limited literature of venovenous extracorporeal membrane oxygenation use in a community, non-university, setting in the trauma population. METHODS: We reviewed our cases over 2 years from March 2018 to March 2020. This study was conducted in a community hospital with a General Surgery residency with no direct affiliation to a medical school. Primary outcome reviewed was survival to discharge. Secondary outcomes included duration of extracorporeal membranous oxygenation (ECMO) support, blood transfusion requirement, complications, and disposition. RESULTS: Five patients were cannulated during this time period. All patients survived to discharge. Mean time on ECMO was 153.4 h or 6.4 days (range 60-216 h). All patients required a transfusion while cannulated, with a mean of 10 units PRBC transfused (range 3-24). One patient required CPR, one required cessation of heparin drip for bleeding, and one had clinical signs of a stroke. Three patients were discharged to long-term acute care facilities and the other two to acute rehab. CONCLUSIONS: Community level I trauma centers are capable of handling trauma patients requiring ECMO. It does require a multi-disciplinary team of surgical intensivists and cardiothoracic surgeons along with the support of nursing, respiratory therapists, and perfusionists. The outcomes in this limited series show that ECMO can be a tool utilized in the community setting.

Trauma center admission risk conditions and the probability for developing alcohol withdrawal syndrome: A retrospective study.

BACKGROUND: Because the proportion of trauma patients developing alcohol withdrawal syndrome (AWS) is low, AWS risk conditions have not been precisely delineated. We aimed to create multifactor screening strategies to assess probabilities for the likelihood of developing AWS. METHODS: We performed a retrospective chart review of 1,011 trauma patients admitted to a Level I trauma center to investigate the associations between AWS and probable AWS risk conditions. Included patients were adults who met trauma registry inclusion criteria and had blood alcohol concentration (BAC) testing performed. Patients were excluded if they had a traumatic brain injury with a Glasgow Coma Score (GCS) ≤ 8, or no BAC testing performed. We defined heavy drinking as daily drinking or >7 per week. RESULTS: AWS had univariate associations with heavy drinking history, Injury Severity Score (ISS) ≥15, psychiatric disorders, liver disease, smoking history, in-hospital bronchodilator administration, age ≥45, male sex, Intensive Care Unit (ICU) admission, serum aspartate aminotransferase (AST) ≥40 U/L, and cognitive preservation (GCS ≥13 with BAC ≥100 mg/dL) (all, p < 0.05). ICU admission, AST ≥40 U/L, cognitive preservation, male sex, and age ≥45 had associations with ISS ≥15 or alcohol misuse (all, p < 0.0001). For patients with age ≥45 and heavy drinking history or age <45 and heavy drinking history with ISS ≥15 and ICU admission, the AWS proportion (15.3%) was greater in comparison to other patients (0.3%). The AWS risk score was the sum of the following nine conditions, assigned a zero when the condition was absent and one when present (range 0-9): ISS ≥15, psychiatric disorders, liver disease, smoking history, in-hospital bronchodilator administration, age ≥45, male sex, AST ≥40 U/L, and cognitive preservation. The AWS proportion was greater with a risk score of 5-9 (16.8%) than of 0-4 (1.2%; p < 0.0001). CONCLUSIONS: AWS in the setting of traumatic injury is associated with multiple risk conditions. The presence of multiple risk conditions might have additive effects that could contribute toward a clinical manifestation of AWS. The identified risk conditions may be associated with a hyperadrenergic state.

Delayed intracranial hemorrhage in elderly anticoagulated patients sustaining a minor fall.

BACKGROUND: Falls are a common cause of hospitalization, morbidity, and mortality among the elderly in the United States. Evidence-based imaging recommendations for evaluation of delayed intracranial hemorrhage (DICH) are not generally agreed upon. The purpose of this project was to evaluate the incidence of DICH detected by head computer tomography (CT) among an elderly population on pre-injury anticoagulant or antiplatelet (ACAP) therapy. METHODS: Data from a Level 1 Trauma Center trauma registry was used to assess the incidence of DICH in an elderly population of patients (≥65 years) who sustained a minor fall while on pre-injury ACAP medications. Counts and percentages are reported. RESULTS: Data on 1076 elderly trauma patients were downloaded, of which 838 sustained a minor fall and 513 were found to be using a pre-injury ACAP medication. One patient (0.46%) with a DICH was identified out of 218 patients who received a routine repeat head CT. Aspirin and warfarin were the most common pre-injury ACAP medications and 19.27% (42/218) of patients were found to be using multiple ACAP medications. CONCLUSIONS: Universal screening protocols promote immediate-term patient safety, but do so at a great expense with respect to health expenditures and increased radiation exposure. This analysis highlights the need for an effective risk assessment tool for DICH that would reduce the burden of unnecessary screenings while still identifying life-threatening intracranial hemorrhages in affected patients.

Trauma Boot Camp: A Simulation-Based Pilot Study.

INTRODUCTION: Interns are often unprepared to effectively communicate in the acute trauma setting. Despite the many strengths of the Advanced Trauma Life Support (ATLS) program, the main shortcoming within the course is the deficiency of teamwork and leadership training. In this study, we describe the creation of an interdisciplinary boot camp in which interns' basic trauma knowledge, level of confidence, and teamwork skills are assessed. METHODS: We designed a one-day, boot camp curriculum for interns of various specialties with the purpose of improving communication and teamwork skills for effective management of acute trauma patients. Our curriculum consisted of a one-day, twelve-hour experience, which included trauma patient simulations, content expert lectures, group discussion of video demonstrations, and skill development workstations. Baseline and acquired knowledge were assessed through the use of confidence surveys, cognitive questionnaires, and a validated evaluation tool of teamwork and leadership skills for trauma Results: Fifteen interns entered the boot camp with an overall confidence score of 3.2 (1-5 scale) in the management of trauma cases. At the culmination of the study, there was a significant increase in the overall confidence level of interns in role delegation, leadership, Crisis Resource Management (CRM) principles, and in the performance of primary and secondary surveys. No significant changes were seen in determining and effectively using the Glasgow Coma Scale, Orthopedic splinting/reduction skills, and effective use of closed-loop communication. CONCLUSION: An intensive one-day trauma boot camp demonstrated significant improvement in self-reported confidence of CRM concepts, role delegation, leadership, and performance of primary and secondary surveys. Despite the intensive curriculum, there was no significant improvement in overall teamwork and leadership performance during simulated cases. Our boot camp curriculum offers educators a unique framework to which they can apply to their own training program as a foundation for effective leadership and teamwork training for interns.

Laparoscopic repair of a traumatic bladder rupture.

Laparoscopic repair of the traumatic intraperitoneal bladder rupture is a proven, safe, and effective technique in the appropriate setting. A 23-year-old male with traumatic intraperitoneal bladder rupture proven by cystogram after a motor vehicle collision was successfully repaired via a laparoscopic approach. We describe the technique in detail including 2-layer closure and follow-up care. A review of the literature using PubMed with the key words [laparoscopic repair bladder injury] AND [bladder trauma] was performed. We recommend the consideration of laparoscopic repair of the intraperitoneal bladder rupture in more trauma patients who meet criteria.