Trauma and Acute Care Surgery

FAILURE TO RESCUE IN SURGICAL PATIENTS: A REVIEW FOR ACUTE CARE SURGEONS The Failure to Rescue (FTR) rate is defined as the mortality rate among patients who experience one or more complications. It has been used as an outcome metric for approximately 25 years, primarily in elective surgery populations, and has been shown to be associated with factors that are modifiable on the institutional level. Although the FTR metric was derived in elective surgical populations, modifications have been made in attempts to refine the metric and apply it to broader populations, including medical patients and non-elective surgical patients. However, study among emergency general surgery patients has been limited. In this review, we summarize the current knowledge surrounding FTR, including established risk factors and potential limitations of the metric in emergency general surgery (EGS) populations. We then discuss a conceptual model for FTR events and review strategies to minimize rates. Finally, we provide a brief overview of current areas of study and potential future directions in acute care surgery. Study Type Review article Corresponding author and requests for reprint requests: Justin Hatchimonji, MD MBE, Department of Surgery, University of Pennsylvania School of Medicine, 3400 Spruce St, 4 Maloney, Cell: 267-408-5825, justin.hatchimonji@uphs.upenn.edu Conflicts of Interest and Source of Funding: No authors have conflicts to declare. DNH is currently supported by a training grant through the National Heart, Lung, and Blood Institute. (K08HL131995) © 2019 Lippincott Williams & Wilkins, Inc.

Answer: Letter of the Editor Management of Devastating Duodenal Injuries No abstract available

Pneumatosis Not Created Equally: A case report No abstract available

Response to Letter to the editor: Article: TA501611 No abstract available

#EAST4ALL: An Introduction to the EAST Equity, Quality, and Inclusion Task Force Background The Eastern Association for the Surgery of Trauma (EAST) is an inclusive and supportive organization that focuses on development of the junior trauma surgeon. In 2019, there continues to be bias based on gender, race, ethnicity, religion, sexual orientation in our profession and society at large. We believe that EAST is uniquely positioned to investigate, quantify/categorize, and search for productive and effective solutions to these issues that affect our colleagues, profession, and patients. The EAST Equity, Quality and Inclusion Task Force, or #EAST4ALL, was thus created, with the goal of addressing these issues together as a community. Methods A series of Task Force meetings and teleconferences was held to collect subjective and objective data and experiences related to bias and equity issues and experiences. A uniquely structured #EAST4ALL Plenary Session was created to both introduce this initiative and to couple real-world experiential descriptives with related reviews of the relevant literature and the concept of "implicit bias". Results We share anecdotal and evidence-based examples of bias in trauma surgery presented at the inaugural #EAST4ALL Plenary Session along the axes of: i) childbearing & family concerns, ii) micro & macroaggressions, iii) gender, iv) race & ethnicity, iv) religion or country of origin, v) sexual orientation & gender identity. We then share our proposal and suggested courses of action for member-based solutions based on our various workgroups: a) Assessment & Research; b) Education; c) Guidelines & Processes; d) Mentorship, Dialogue & Collaboration. Conclusions Inequities and bias in the field of trauma surgery may have profound and deleterious impacts, lifelong for some, that we must acknowledge and eradicate. The dignity and respect we afford our patients, must be extended to each other. Our EAST Equity, Quality and Inclusion Task Force, with membership input, hopes to create a future that is truly an #EAST4ALL. Study type Original Article Level of evidence Level V Stephanie Bonne: Stephanie.bonne@rutgers.edu Brian H. Williams: brian@brianwilliamsmd.com Matthew Martin: traumadoc22@gmail.com Haytham Kaafarani: HKAAFARANI@mgh.harvard.edu William Weaver: wweaver07@gmail.com Rishi Rattan: rrattan@miami.edu Patricia Byers: pbyers@med.miami.edu D'Andrea Joseph: d'andrea.joseph@nyulangone.org Paula Ferrada: paula.ferrada@vcuhealth.org Bellal Joseph: bjoseph@surgery.arizona.edu Ariel Santos: Ariel.Santos@ttuhsc.edu Robert Winfield: rwinfield@kumc.edu Sandra DiBrito: dibrito@jhmi.edu Andrew Bernard: andrew.bernard@uky.edu Tanya L. Zakrison: tzakrison@icloud.com Correspondence: Stephanie Bonne, MD, FACS Rutgers New Jersey Medical School 150 Bergen Street, M-228 Newark, NJ 07103 The authors declare no conflicts of interest. Presented at the 32nd Eastern Association for the Surgery of Trauma Annual Scientific Assembly, January 15-19th, 2019, in Austin, TX. This work is unfunded. © 2019 Lippincott Williams & Wilkins, Inc.

Unplanned Readmission After Traumatic Injury: A Long-Term Nationwide Analysis Introduction Long-term outcomes after trauma admissions remains understudied. We analyzed the characteristics of inpatient readmissions within six-months of an index hospitalization for traumatic injury. Methods Using the 2010-2015 Nationwide Readmissions Database, which captures data from up to 27 U.S. States, we identified patients at least 15-years-old admitted to a hospital through an emergency department for blunt trauma, penetrating trauma, or burns. Exclusion criteria included hospital transfers, patients who died during their index hospitalizations, and hospitals with fewer than 100 trauma patients annually. After calculating the incidences of all-cause, unplanned inpatient readmissions within one-, three-, and six-months, we used multivariable logistic regression models to identify predictors of readmissions. Analyses adjusted for patient, clinical, and hospital factors. Results Among 2,763,890 trauma patients, the majority had blunt injuries (92.5%), followed by penetrating injuries (6.2%) and burns (1.5%). Overall, rates of inpatient readmissions were 11.1% within one-month, 21.6% within six-months, and 29.8% within six-months, with limited variability by year. After adjustment, the following were associated with all-cause six-months inpatient readmissions: male sex (adjusted odds ratio [aOR] 1.10 [95%-CI: 1.09-1.10]), comorbidities (aOR 1.21 [1.21-1.22]), low (first and second) income quartiles (aOR 1.08 [1.07-1.10] and aOR 1.04 [1.03-1.06] respectively), Medicare (aOR 1.65 [1.62-1.69]), Medicaid (aOR 1.51 [1.48-1.53]), being treated at private, investor owned hospitals (aOR 1.15 [1.12-1.18]), longer hospital length of stay (aOR 1.01 [1.01-1.01]) and patient disposition to short-term hospital (aOR 1.55 [1.49-1.62]), skilled nursing facility (aOR 1.43 [1.42-1.45]), home health care (aOR 1.27 [1.25-1.28]), or leaving against medical advice (aOR 1.85 [1.78-1.92]). Conclusion Unplanned readmission after trauma is high and remains this way six months after discharge. Understanding the factors that increase the odds of readmissions within one-, three-, and six-months offer a focus for quality improvement and have important implications for hospital benchmarking. Level of Evidence Level 3, Epidemiological Corresponding author: Joseph V. Sakran, MD, MPH, MPA Department of Surgery, Division of Acute Care Surgery Sheikh Zayed Tower, Suite 6107 Baltimore, MD 21287 Email: jsakran1@jhmi.edu Nicole Lunardi MSPH1 – nlunard1@jhmi.edu Ambar Mehta MD, MPH2 - amehta25@jhmi.edu Hiba Ezzeddine MD3 - hezzedd1@jhmi.edu Sanskriti Varma BS1 - sanvarma@jhmi.edu Robert Winfield MD4 – rwinfield@kumc.edu Alistair Kent MD3 - alistair.kent@jhmi.edu Joseph K Canner MHS3 - jcanner1@jhmi.edu Avery B Nathens MD, MPH, PhD5 -anathens@facs.org Bellal A Joseph MD4 - bjoseph@surgery.arizona.edu David T. Efron MD3 - defron1@jhmi.edu Joseph V. Sakran MD, MPH, MPA3 - jsakran1@jhmi.edu Disclosures: None. 32nd Annual Meeting of EAST AAST and Clinical Congress of Acute Care Surgery, January, 15-19 2019 in Austin, TX © 2019 Lippincott Williams & Wilkins, Inc.

Preventable death and interpersonal violence in the United States: who can be saved? Background: Public health initiatives to reduce mortality from penetrating trauma have largely developed from patterns of injury observed in military casualties, with a focus on hemorrhage control and use of tourniquets. Recent efforts show that injury patterns differ between civilian mass casualty events and combat settings, and no studies characterize wounding patterns in all types of civilian homicide. We hypothesize that many homicide deaths are due to non-survivable injuries, and that an effective strategy to reduce mortality must focus on both primary prevention as well as improvement in trauma pre-hospital care. Methods: We analyzed homicides from the National Violent Death Reporting System from 2012 to 2015. We excluded deaths due to poisoning, intentional neglect, or unknown weapon. Deaths were classified as "Dead on Scene (DOS)", "Dead on Arrival (DOA)", or "Dead at or After Hospital (DAH)" if the patient was admitted to a hospital. Injury patterns for penetrating weapons (firearms and sharp instruments) were further categorized. Results: We included 18,051 homicides, the vast majority of which were due to firearms (n=12901 or 71.5%) or sharp instruments (n=2265 or 12.5%). The most common injury patterns included wounds to the chest or head, with isolated extremity injuries representing a minority of both firearms deaths (n=397 of 12901, 3.1%) and deaths from sharp instruments (n=50 of 2265, 2.2%). Furthermore, over half of all deaths occurred pre-hospital, with only 13.3% of victims admitted prior to death. Conclusions: The vast majority of deaths from interpersonal violence are due to firearm injuries. Few deaths appear to be related to extremity hemorrhage alone, and over half of all fatally injured died at the scene. Strategies to decrease mortality from interpersonal violence must go beyond treating injuries that have already occurred, and must address violence prevention directly. Corresponding Author: Catherine G. Velopulos 12631 East 17th Ave., Mail Stop C313 Aurora, CO 80045 The authors have no conflicts of interest to declare and there is no funding source for the work presented. This work was presented at the 32nd Annual Meeting of the Eastern Association of the Surgery of Trauma, January 15-18, 2019 in Austin, Texas. Conflicts of Interest: The authors have no conflicts of interest to declare. Funding: There is no external funding source for the work presented. All authors are salaried at their respective institutions. © 2019 Lippincott Williams & Wilkins, Inc.

Protocols for Documentation of Electrical Injuries for Electrical Safety Inspectors and Emergency Medical Practitioners Type of Study This is a paper providing guidelines for medico-legal reporting. Background Electric shocks are common, and victims report difficulty in finding practitioners with knowledge of the injury. Medical Practitioners, especially in private practice, report lack of knowledge of the injury and lack of expertise in assessing and treating the injury. The authors are often requested to suggest investigation protocols, assessment protocols, and treatment protocols, and to provide educational information. Methods The international body establishing electrical standards on the effects of current on the body (International Electrotechnical Commission, Maintenance Team 4 (MT4) of Technical Committee 64 (TC64)) have established protocols for the factors which require documentation and reporting of the injury. This paper provides a narrative approach to using these protocols in accord with the standards (IEC 60479). The level of evidence is Level III (US/Canada classification). Type This paper collects together and collates physical and medical aspects of investigating electric shocks, and summarises those of importance, and which are potentially forgotten. The thoroughness of initial assessment is emphasised. Substance Summaries are set out to guide first attenders and emergency medical personnel as to findings and observations which must be recorded for later comprehensive medico-legal reporting and which are often overlooked. Conclusions Wider teaching in the nature of electric shocks will enhance assessment of victims and thorough recording of pertinent information and thus will enhance later medico-legal reporting. Many such factors are initially overlooked and lead to inadequate reporting for forensic purposes. Conflict of Interest Statement There are no conflicts of interest for either author in the preparation of this paper. Funding No funding has been received for the publication of this paper. © 2019 Lippincott Williams & Wilkins, Inc.

Rapid point-of-care detection and classification of direct-acting oral anticoagulants (DOACs) with the TEG® 6s: implications for trauma and acute care surgery Background The trauma patient on direct oral anticoagulant (DOAC) therapy pre-injury presents a challenge in trauma and acute care surgery. Our understanding of these patients is extrapolated from vitamin K antagonists. However, DOACs have different mechanisms of action, effects on laboratory coagulation assays, and reversal strategies. Rapid identification of DOACs in the blood will allow timely reversal of factor Xa inhibitors and direct thrombin inhibitors when necessary. The present study evaluated viscoelastic testing to detect and classify DOACs in patient blood samples. Methods This observational, prospective, open-label, multi-center study used point-of-care viscoelastic testing to analyze blood samples taken from patients with and without DOAC treatment, and healthy volunteers. Anti-factor Xa (AFXa) and direct thrombin inhibition (DTI) assays were used to establish reference ranges for viscoelastic testing parameters on the TEG® 6s system. These ranges were applied to produce a DOAC identification algorithm for patient blood samples. Internal consistency of the measurements as well as algorithm sensitivity and specificity were evaluated. Results Using the TEG® 6s system, the R parameter reference range was 0.6–1.5 minutes for the AFXa assay and 1.6–2.5 minutes for the DTI assay. Our identification algorithm using these ranges for ≤2.5 minutes has sensitives of 98.3% and 100% for factor Xa inhibitor and direct thrombin inhibitor detection, respectively. Specificity was 100%. Both classes of DOAC were detectable, even when samples were collected during the "trough" between doses of medication. Conclusions Point-of-care viscoelastic testing with TEG® 6s can detect and classify DOACs with high sensitivity and specificity. This tool can be employed to better determine the need for reversal in trauma and acute care surgery patients and guide optimal surgical timing in the acute setting. Level of Evidence Level II, prognostic and epidemiological study Correspondence: João Dias Signy Center, P.O.Box. 262, 1274 Signy-Centre, Switzerland jdias@haemonetics.com Presentations: Preliminary portions of this work were presented at the 64th annual meeting of the Scientific Standardization Committee of the International Society on Thrombosis and Haemostasis and at the European Society of Cardiology Congress. Conflict of interest statement: This study was supported by Haemonetics Corporation (Braintree, Massachusetts). JD, CL, JI, HH, FZ, AM, JH, HA were employees of Haemonetics Corporation at the time of the study. The authors have no other relevant financial interest in the products or companies described in this article. We have no disclosures of funding from any of the following organizations: National Institutes of Health (NIH); Wellcome Trust; and the Howard Hughes Medical Institute (HHMI). © 2019 Lippincott Williams & Wilkins, Inc.

EAST Presidential Address: EAST-A Legacy of Inclusion No abstract available