Trauma and Acute Care Surgery

Point-of-care Resuscitation Research: From Extreme to Mainstream: Trauma Association of Canada Fraser Gurd Lecture 2019 The Gurd Family surgical legacy was deeply intertwined with National service in both World Wars. My own personal research mission has attempted to emulate such service, by enhancing the tools and techniques available to facilitate point-of-care (POC) diagnosis and resuscitation in extreme and adverse environments. Our efforts involving POC diagnosis/resuscitation and the telementored guidance of those remotely responding to catastrophic injury have included collaborations with NASA, the Canadian Space Agency, the Canadian Forces, its democratic allies, and non-governmental surgical organizations. Research has been conducted in resuscitative suites and operating theatres, research laboratories, parabolic flight aircraft, on humanitarian surgical missions, and from ski-hills and firehalls. The initial phases of these efforts involved inaugural studies in resuscitative sonography including defining the EFAST examination. Although the original work was commissioned for Space Medicine, generalization to mainstream practice further justifies space medicine research. Iterative steps in advancing telementored resuscitation have subsequently involved the maturation of space mandated telementored ultrasound support (TMUS), exploration of TMUS in terrestrial clinical practice, and the creation of increasingly mobile (hand-held) TMUS solutions. Subsequently it was recognized that tele-ultrasound is simply one informatic dimension of remote telemedicine, and current efforts are focused in a Program known as TeleMentored Ultrasound Supported Medical Interactions (TMUSMI) of remote responders required to intervene with catastrophic trauma. While this research program has yielded many techniques and findings that have benefited mainstream terrestrial practice, these investigations are currently ongoing, and we hope to demonstrate that TMUSMI may benefit all Canadians especially those in remote areas, as well as potentially every global inhabitant without immediate access to care. Further, we propose that to abstract fully utilize these techniques, a new specialty, that of the remote medical mentor will be required, a new specialty that will require the creation and scientific validation of its principles and techniques. Address for Correspondence AW Kirkpatrick Regional Trauma Services EG 23 Foothills Medical Services 1403 29 ST NW Calgary, Alberta T2N 2T9 This manuscript was an invited Podium Presentation at the Annual Scientific Meeting of the Trauma Association of Canada, as the named Fraser Gurd Lecture 2019. Conflict of Interest No funding of any kind was provided to prepare this manuscript. AW Kirkpatrick continues to serve in the Canadian Forces Medical Services. AW Kirkpatrick has consulted for the Acelity and Innovative Trauma Care Corporations. © 2019 Lippincott Williams & Wilkins, Inc.

Ketamine Infusion for Pain Control in Adult Patients with Multiple Rib Fractures No abstract available

Promotility Agents For The Treatment Of Ileus In Adult Surgical Patients: A Practice Management Guideline From The Eastern Association For The Surgery Of Trauma Background Ileus is a common challenge in adult surgical patients with estimated incidence to be 17%-80%. The main mechanisms of the postoperative ileus pathophysiology are fluid overload, exogenous opioids, neurohormonal dysfunction, gastrointestinal stretch and inflammation. Management includes addressing the underlying cause and supportive care. Multiple medical interventions have been proposed, but effectiveness is uncertain. A working group of the Eastern Association for the Surgery of Trauma (EAST) aimed to evaluate the effectiveness of metoclopramide, erythromycin, and early enteral nutrition (EEN) on ileus in adult surgical patients and to develop recommendations applicable in a daily clinical practice. Methods Literature search identified 45 papers appropriate for inclusion. The Grading of Recommendations Assessment, Development and Evaluation (GRADE) methodology was applied to evaluate the effect of metoclopramide, erythromycin, and EEN on the resolution of ileus in adult surgical patients based on selected outcomes: return of normal bowel function, attainment of enteral feeding goal, and hospital length of stay (LOS). The recommendations were made based on the results of a systematic review, a meta-analysis, and evaluation of levels of evidence. Results The level of evidence for all PICOs was assessed as low. Neither metoclopramide nor erythromycin were effective in expediting the resolution of ileus. Analyses of 32 randomized controlled trials showed that EEN facilitates return of normal bowel function, achieving enteral nutrition goals, and reducing hospital LOS. Conclusion In patients who have undergone abdominal surgery, we strongly recommend EEN to expedite resolution of Ileus, but we cannot recommend for or against the use of either metoclopramide or erythromycin to hasten the resolution of ileus in these patients. Level of Evidence Level II Type of Study Therapeutic Corresponding Author: Nikolay Bugaev, MD, Division of Trauma & Acute Care Surgery, Tufts Medical Center, Tufts University School of Medicine, Boston, MA, nbugaev@tuftsmedicalcenter.org, 800 Washington St, #4488, Boston, MA, 02111, Tel. 617-636-4488, Fax 617-636-8172 Conflict of Interests: no conflicts to disclose The manuscript was presented as a podium presentation at the 31st Eastern Association for the Surgery of Trauma (EAST) Annual Scientific Assembly. January 11, 2018: Lake Buena Vista, Florida. Disclosures of Funding: nothing to disclose. © 2019 Lippincott Williams & Wilkins, Inc.

Variability in international normalized ratio and activated partial thromboplastin time after injury are not explained by coagulation factor deficits Introduction Conventional coagulation assays (CCAs), PT/INR (prothrombin time/international normalized ratio) and aPTT (activated partial thromboplastin time), detect clotting factor (CF) deficiencies in hematologic disorders. However, there is controversy about how these CCAs should be used to diagnose, treat and monitor trauma-induced coagulopathy. Study objectives were to determine whether CCA abnormalities are reflective of deficiencies of coagulation factor activity in the setting of severe injury. Methods Patients without previous CF deficiency within a prospective database at an ACS verified Level 1 trauma center had CF activity levels, PT/INR, aPTT, and fibrinogen levels measured upon Emergency Department arrival from 2014-2017. Linear regression assessed how CF activity explained the aPTT and PT/INR variation. Prolonged CCA values were set as INR>1.3 and aPTT>34sec. CF deficiency was defined as <30% activity, except for fibrinogen, defined as <150mg/dL. Results Sixty patients with a mean age of 35.8 (std dev:13.6) years and median new injury severity score (NISS) of 32 (IQR:12-43) were included; 53.3% sustained blunt injuries, 23.3% required massive transfusion, and mortality was 11.67%. Overall, 44.6% of the PT/INR variance and 49.5% of the aPTT variance remained unexplained by CF activity. Deficiencies of CFs were: common pathway 25%; extrinsic pathway 1.7%, and intrinsic pathway 6.7%. The positive predictive value for CF deficiencies were: 1)PT/INR>1.3:4.4% for extrinsic pathway, 56.5% for the common pathway; 2) aPTT>34 sec:16.7% for the intrinsic pathway, 73.7% for the common pathway. Conclusion Almost half of the variances of PT/INR and aPTT were unexplained by CF activity. Prolonged PT/INR and aPTT were poor predictors of deficiencies in the intrinsic or extrinsic pathways, however, they were indicators of common pathway deficiencies. Corresponding Author: Ernest E Moore, MD, Email: ernest.moore@dhha.org Phone: 303-724-2685, Fax: 303-720-2682, Mailing Address: 655 Bannock Street Denver, CO 80203 Disclosure: Research reported in this publication was supported in part by the National Institute of General Medical Sciences grants: T32-GM008315 and P50-GM49222, the National Heart Lung and Blood Institute UM1-HL120877, in addition to the Department of Defense USAMRAA and W81XWH-12-2-0028. The content is solely the responsibility of the authors and does not necessarily represent the official views of the National Institutes of Health, the National Heart, Lung, and Blood institute, or the Department of Defense. Additional research support was provided by Haemonetics (Haemonetics, Niles, IL, USA) with shared intellectual property. © 2019 Lippincott Williams & Wilkins, Inc.

Blunt Rupture of Two Cardiac Chambers Following a Motor Vehicle Collision No abstract available

Reply to Letter: Observing Pneumothoraces: The 35 Millimeter Rule Is Safe for Both Blunt and Penetrating Chest Trauma No abstract available

A Preliminary Analysis of Level IV Trauma Centers within an Organized Trauma System Background The effect of Level IV trauma center (TC) accreditation within an existing trauma network remains understudied. This study compared pre- to post-accreditation data from Level IV TCs within a mature trauma system in Pennsylvania to determine whether TC designation affected time to and/or rate of transfer to definitive care. Level IV TCs were hypothesized to have a decreased time to transfer following accreditation and improved mortality. Methods The Pennsylvania Trauma Systems Foundation (PTSF) collects pre- and post-designation data from hospitals pursuing accreditation. Data from PTSF between 2012 and 2017 was analyzed. Variables of interest included patient demographics, injury severity, mortality and incidence of surgical interventions pre- to post-credentialing. A multilevel mixed-effects logistic regression model assessed the adjusted impact of Level IV TC accreditation on transfer rate. ArcGIS Desktop was used for geospatial mapping of lives and geographic area covered by the addition of Level IV TCs in Pennsylvania Results Five hospitals underwent Level IV credentialing from 2012-2017, providing data on 5,076 cases (Pre: 2,395 [47.2%]; Post: 2,681 [52.8%]). No significant difference in age, admission Glasgow Coma Scale score, or shock index was observed pre to post-accreditation. A difference in transfer rate was observed after credentialing in unadjusted (62.7% vs. 63.3%; p<0.014) and adjusted analyses (AOR: 1.13, p=0.389). There was a trend toward reduced odds of mortality post-credentialing (AOR: 0.59, p=0.261). Major surgical intervention decreased (Pre: 0.42%, Post: 0.04%; p=0.004). Conclusion Level IV TC accreditation has beneficial effects on increased transfer rates and may improve mortality. It is important to continue to observe the impact of Level IV TCs on patient outcomes within a mature trauma system. Level of Evidence III; prognostic and epidemiological Corresponding Author: Frederick B. Rogers, MD, MS, MA, FACS; Frederick.Rogers@pennmedicine.upenn.edu, 555 N. Duke St., Lancaster, PA 17602, 717-544-5945 (tel), 717-544-5944 (fax) All authors have neither conflict of interest nor disclosure of funding or proprietary interest to declare on the materials or subject matter discussed herein. This study was accepted for a Quick Shot presentation at the 32nd Annual Scientific Assembly of the Eastern Association for the Surgery of Trauma held in Austin, Texas from January 15-19, 2019. © 2019 Lippincott Williams & Wilkins, Inc.

Cholecystitis Complicated by Intrathoracic Gallbladder No abstract available

Commentary: Blunt Rupture of Two Cardiac Chambers Following a Motor Vehicle Collision No abstract available

TITRATE TO EQUILIBRATE AND NOT EXSANGUINATE!: CHARACTERIZATION AND VALIDATION OF A NOVEL PARTIAL RESUSCITATIVE ENDOVASCULAR BALLOON OCCLUSION OF THE AORTA CATHETER IN NORMAL AND HEMORRHAGIC SHOCK CONDITIONS Background Resuscitative Endovascular Balloon Occlusion of the Aorta (REBOA) is a significant advancement in the control of non-compressible truncal hemorrhage. However, its ischemic burden and reperfusion injury following balloon deflation limits its utilization. Partial restoration of aortic flow during REBOA has the potential to balance hemorrhage control and ischemia. This study validates the mechanics, physiology, and optimal partial flow rates using a prototype partial REBOA (pREBOA) device. Methods 25 swine underwent placement of aortic flow probes and zone 1 pREBOA. Experiment 1(N=5) animals were not injured and assessed the tested the catheters ability to titrate and control flow. Experiment 2 (N=10) added 20% hemorrhage and either solid organ, or abdominal vascular injury to compare flow rate and re-bleeding from injuries. Experiment 3 (N=10) swine were similarly prepared, hemorrhaged, and underwent pREBOA at set partial flow rates for 2hr followed by complete deflation for 30min. Results Balloon volume at minimum flow (mean .09 L/min) was 3.5-6.0mL. Half maximal flow was achieved with 56.5% of maximum balloon inflation. pREBOA allowed very fine titration of flow rates. Rebleeding occurred at 0.45-0.83 L/min. Distal flow of 0.7 L/min had 50% survival, 0.5 had 100% survival, and 0.3L had 50% survival with mean end lactates of 9.6, 12.6, and 13.3 respectively. There was a trend towards hyperkalemia and hypocalcemia in non-survivors. Conclusions The pREBOA device demonstrated a high level of titratability for restoration of aortic flow. An optimal partial flow of 0.5L/min was effective at hemorrhage control while limiting the burden of ischemic injury, and extending the tolerable duration of zone 1 occlusion. Aggressive calcium supplementation prior to and during partial occlusion and reperfusion may be warranted to prevent hyperkalemic arrest. Level of Evidence III Study Type Therapeutic Presented at the 49th Annual Meeting of the Western Trauma Association, March 03-08, 2019 in Snowmass, CO This work was supported by a Department of Defense Medical Research and Development Program (DMRDP) research grant under the DHP 6.7 program: Proposal D6.7 16 C2 I 16 J9 1490, "Intermittent Resuscitative Endovascular Balloon Occlusion of the Aorta (REBOA) for Severe Non-compressible Truncal Hemorrhage" Conflicts of Interest: The authors have no conflicts of interest to declare and have received no financial or material support related to this manuscript Disclaimer: The results and opinions expressed in this article are those of the authors, and do not reflect the opinions or official policy of the United States Army or the Department of Defense. Corresponding Author: Matthew J. Martin, MD, FACS, Trauma and Emergency Surgery Service, Scripps Mercy Hospital, 550 Washington Avenue, Suite 641, San Diego, CA 92127, (619) 299-2600, traumadoc22@gmail.com © 2019 Lippincott Williams & Wilkins, Inc.

Alexandros Sfakianakis
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alsfakia@gmail.com