BACKGROUND:Although primary anastomosis (with or without proximal diversion) offers improved morbidity and higher reversal rates compared with Hartmann procedure, little is known about real-world factors influencing surgical decision making in acute diverticulitis. METHODS:We conducted a mixed methods survey of surgeons treating diverticulitis, recruited through national colorectal and acute care/trauma surgical organizations. Surgeons were surveyed on their decision-making process, patient considerations, personal experience, and practice structure using a web-based survey. The primary outcome was percentage of primary anastomoses performed for diverticulitis in the past year. RESULTS:We recorded 439 survey responses; 233 (53%) were colorectal surgeons and 99 (23%) acute care surgeons. The median (interquartile range) number of primary anastomoses and Hartmann procedures performed for acute diverticulitis in the past year was 3.0 (1.0, 5.0) and 4.0 (2.0, 6.0), respectively, per surgeon. Roughly a third of surgeons reported performing primary anastomosis a majority (58.3%-100%) of the time. High anticipated surgical difficulty and hemodynamic instability were considered the most important situational and patient factors when deciding to perform a Hartmann procedure over a primary anastomosis. On multivariable analysis, acute care surgical specialty (odds ratio 0.41, 95% confidence interval 0.26-0.65; P < .001) was associated with a lower percentage of primary anastomoses performed. CONCLUSIONS:In this national survey, only one-third of surgeons performed primary anastomosis most of the time for diverticulitis. Patient acuity, high anticipated surgical difficulty, and the presence of proper operative assistance are some of the most important factors surgeons consider when deciding between a Hartmann procedure and primary anastomosis.

There are a variety of methods for obtaining enteral access for patients requiring short- or long-term enteral feeding. This article reviews indications, contraindications, and techniques for placement of nasoenteric access, percutaneous endoscopic gastrostomy, open and laparoscopic gastrostomy and jejunostomy, and gastrojejunostomy. The diagnosis and management of complications from these procedures is also discussed as are pearls and pitfalls for each technique.

BACKGROUND:Chest tubes for traumatic pneumothorax are commonly managed with initial suction before transition to water seal, despite limited evidence supporting this practice. We hypothesized that initial water seal would reduce chest tube duration without increasing complications. STUDY DESIGN:We conducted a single-center, pragmatic, month-based cluster-randomized study of adult trauma patients with pneumothorax requiring chest tube placement from October 2024 to May 2025. Patients with a hemothorax component >300 mL or chest tube placement before computed tomography were excluded. Patients were assigned by alternating calendar month to initial suction or water seal; subsequent management was at clinician discretion. The primary outcome was initial chest tube duration. The trial was registered at ClinicalTrials.gov (NCT06688734). RESULTS:Among 3,372 trauma admissions, 133 patients required chest tubes for pneumothorax and 72 met inclusion criteria (37 suction, 35 water seal). Four patients died before chest tube removal and were excluded from the primary outcome analysis. Initial water seal was associated with shorter median initial chest tube duration compared with suction (41 vs 51 hours, p = 0.001) and shorter total chest tube duration (44 vs 60 hours, p = 0.011). Complications, secondary interventions, and mortality were similar between groups (all p > 0.05). CONCLUSIONS:Initial water seal management was associated with shorter chest tube duration without an observed increase in complications. These findings challenge routine initial suction for selected patients with traumatic pneumothorax and support evaluation of an initial water seal strategy in larger multicenter studies.

Background:Treatment of blunt traumatic spinal cord injuries (SCIs) often includes maintaining elevated mean arterial blood pressures (MAP) to enhance perfusion to the spinal cord. Optimal hyperperfusion protocols and treatment algorithms have yet to be delineated due to a paucity of large volume prospective studies. This study aims to identify predictors of neurological improvement in American Spinal Injury Association (ASIA) impairment score following blunt SCI. Study design:Prospective (January 10, 2021 to June 1, 2023) multicenter study included blunt SCI patients age >18 with complete neurological examination documented on hospital arrival. Patients were divided into two groups: neurological improvement and no improvement, based on their change in ASIA score from arrival to hospital discharge. Results:A total of 19 centers contributed 222 patients of those, 164 had pre-ASIA and post-ASIA scores. The ASIA improvement group had 36 patients (22%). There was no statistical difference in the median percentage of time patients spent at a MAP >85 mm Hg during treatment 80.7% (IQR 63.6, 93.4) no improvement vs 83.6% (IQR 70.1, 93.0) in the improvement, (p=0.87). There was no difference in the median duration of MAP treatment in hours between the groups (95.6 hours (IQR 62.55, 113.48) in the no improvement group versus 96 (IQR 72, 113.5) (p=0.40) in the improvement group). Conclusions:Overall, 22% of all blunt SCI patients saw an improvement in their ASIA score. Adherence to and length of MAP augmentation was not a statistically significantly different between groups. Level of evidence:Level IV Therapeutic/Care Management.

Health literacy can be a key factor in patient outcomes and self-management, yet the overall role of health literacy in burn outcomes is not well known. Understanding the effects of health literacy on burn patients can allow us to better care for them and anticipate needs and boundaries for a safe disposition. Our burn center aims to perform routine health literacy screening for all patients. This study examines the health literacy of burn survivors and seeks to determine its effect on unplanned emergency room visits within 30 days of discharge. Single-center, retrospective review of all patients admitted to the burn service between 2018-2024 who completed the Brief Health Literacy Screen (BHLS) at admission. BHLS scores were divided into low (< 9), moderate (9-11) and high (>11). The burn registry was queried for those who returned to the emergency department within 30 days of original disposition. For simplicity, disposition was divided into four categories: home without services, home with services, discharged to inpatient facility with wound care services, or discharged to a location other than home without wound care services (jail, unhoused, inpatient psychiatric facility, against medical advice). Multiple logistic regression was performed to determine the effect of BHLS on unplanned returns to ED. Covariates included total body surface area, LOS, Charleson Comorbidity Index (CCI), and disposition. After eliminating patients < 18yo, in hospital mortalities, and those with missing data or BHLS screens, our study group included 1079 patients. Of these patients, 7% (n=77) had unplanned return visits to the emergency department within 30 days of discharge. 156 (14.5%) patients had low health literacy scores, 271 (25.1%) had moderate scores, and 652 (60.4%) had high scores. When controlling for other factors, health literacy did not affect return to the ED within 30 days of discharge. Interestingly, disposition to a location other than home without structured wound care in place significantly increased the likelihood of an unplanned return to the ED at 30 days (OR 8.24, 95% CI 3.11-21.84, p< 0.05). Contrary to our initial hypothesis, low BHLS scores were not associated with return to the emergency department within 30 days of discharge. However, discharge anywhere except home without structured wound care services was found to increase the likelihood of return to ED. As many of our patients fall into this category, further research could elucidate ways to improve disposition planning within this subset of patients. Finally, analysis was limited by the fact that only 36% of burn patients were screened in the study timeframe, well below hospital average of 71%. Understanding the factors that lead to unplanned return visits to the ED can help us better care for our patients and prepare them for discharge. N/A

Battlefield medicine has advanced trauma care knowledge throughout history and continues to do so now. However, as war has become less common and civilian trauma continues to occur, civilian trauma centers have become essential in maintaining competency in casualty care. Military-civilian partnerships, such as the US Army Military Civilian Trauma Team Training program and the Strategic Medical Asset Readiness Training program, allow military medical personnel to practice complex trauma care in high-volume trauma centers. Civilian centers benefit from both the deployed experience of the military personnel and extra skilled personnel contributing to their practice without the salary costs. Although both sides have potential drawbacks, these partnerships represent one strategy to meet the military's goal of decreasing battlefield mortality.

BACKGROUND:Resuscitation strategies for massive hemorrhage increasingly involve the use of low-titer group O whole blood (LTOWB) due to evidence suggesting improved patient outcomes. However, the potential risk of incorrect ABO typing following LTOWB administration, possibly leading to mis-transfusion, remains insufficiently explored. This case series aims to highlight the potential risk of ABO mistyping associated with LTOWB transfusions in trauma settings. STUDY DESIGN AND METHODS:We retrospectively reviewed three cases involving trauma patients who received LTOWB transfusions at a high-volume urban Level 1 Trauma Center. ABO and RhD typing were performed using automated column agglutination technology (Ortho ID-MTS™), and discordant typing results prompted further investigations to confirm patients' true ABO type and identify mis-transfusions. RESULTS:All three patients initially received LTOWB due to traumatic hemorrhage. Initial ABO typing after LTOWB administration incorrectly identified the patients as group O. Follow-up investigations later confirmed their true blood types as group A. Two cases resulted in subsequent inadvertent transfusions of ABO-incompatible plasma. Although no severe adverse clinical outcomes occurred, these events were reported to regulatory bodies as biologic product deviations. DISCUSSION:Our findings highlight a rare but clinically significant risk of ABO typing errors following LTOWB transfusion, primarily due to contamination of patient samples with donor blood. Such errors carry the potential for acute hemolytic reactions, underscoring the critical need for strict adherence to sampling protocols. Whenever possible, ABO typing should be performed prior to LTOWB administration, and samples should be drawn from a site contralateral to the transfusion.

Introduction: Tennessee allocates funding to support the statewide trauma system. To better understand the costs of trauma center readiness outlined by ACS, our legislature challenged the trauma council to accurately determine the exact value for our state. Methods: Readiness components were devised from the 2014 edition of the Optimal Resources Document and state guidelines. Cost queries were sent to financial leadership of hospitals participating in the state trauma system for 2022. Data was deidentified and values vetted by an independent accounting firm. Values are reported in dollars for both state and average costs per trauma center by level. Costs were broken into administrative, clinical staff, OR availability and education/outreach. Results: Data was submitted from 5 level I, 1 level II, 8 level III, and 4 CRPC (Comprehensive Regional Pediatric Center). Total statewide costs totaled $171,000,000. Average costs for all components per level I/II was 20.6, level III 3.6, and CRPC 4.4 million dollars. The range across level I/II was 13.4 to 25.8 million dollars. Average I/II OR cost was 2.4 million and the highest provider cost was anesthesia at 2.3 million. Average education/outreach was $107,000 at Level I/II and includes registry and manager/coordinator costs for training. Conclusions: Trauma readiness is extremely costly at roughly $20,000,000 per level I/II center, $3,760,000 per level III, and $4,350,000 per CRPC. This value has doubled from that previously reported by a neighboring state. State and national leaders must be aware of costs and the need of support for trauma care when allocating health care funding.

ABSTRACT Background: In 2018, the U.S. Army Surgeon General created the Army Medical Department Military-Civilian Trauma Team Training (AMCT3) program to enhance the clinical proficiency of medical personnel serving on Army trauma teams called forward resuscitative surgical detachments (FRSDs). FRSDs provide resuscitative and surgical care to wounded patients in the deployed environment until they can be medically evacuated to a higher level of care. Through AMCT3, FRSD personnel work at civilian trauma centers while not deployed in order to maintain their combat casualty care competency. Purpose: This article describes an innovative nursing-specific AMCT3 program model in which Army nurses serving on an FRSD are embedded within a level 1 trauma center for a 3-year assignment. The goal of the program, which was established at Vanderbilt University Medical Center (VUMC) in Nashville, Tennessee, is to improve participants' clinical proficiency and skills in preparation for the next major military conflict, with the aim of reducing preventable battlefield deaths. Methods: The VUMC Military Affairs Committee, in consultation with Army medical leaders, developed a unique 3-part model for a nursing partnership program at VUMC. This model includes separate tracks for critical care and emergency nurses. The nurses receive training in their specialty, cross-training in the opposite track, and other professional development opportunities. A critical care nurse and an emergency nurse were assigned to the program in January 2022 and September 2022, respectively. Results: Between January 2022 and June 2023, the critical care nurse completed all the required individual critical task lists—specialty-specific clinical skills Army medical personnel must be competent in before deployment—except for 1, obtaining intra-abdominal pressure. Conclusion: The VUMC AMCT3 nursing partnership training model ensures that Army nurses are highly prepared to function as part of the FRSD and to provide superior combat casualty care in a resource-limited environment.

Background: Noncompressible torso hemorrhage remains a leading cause of potentially preventable deaths. Resuscitative Endovascular Balloon Occlusion of the Aorta (REBOA) has emerged as an adjunct temporizing hemorrhage control. The complete occlusion strategy with the ER-REBOA catheter can cause distal ischemia when used for longer than 30 min. To specifically address this limitation, the pREBOA-PRO catheter was developed. The objective of the current study is to investigate the impact of longer, partial occlusion times provided by pREBOA-PRO on acute kidney injury and mortality. Methods: This is a retrospective analysis of the Aortic Occlusion for Resuscitation in Trauma and Acute Care Surgery registry as of August 2023. Patients in the pREBOA-PRO group (n = 110) receiving partial occlusion in Zone 1 were contrasted to patients in the ER-REBOA group (n = 752) treated with complete occlusion in Zone 1. Between-group comparisons included demographics, clinical presentation, aortic occlusion strategy, clinical complications, and mortality. Results: Demographics, clinical presentation, and mortality were indistinguishable between groups, except for age which was higher in the ER-REBOA group (44 vs. 38, P < 0.002). The partial aortic occlusion strategy was employed more often in the pREBOA-PRO group (87% vs. 33%, P < 0.05) and for longer periods (59 min vs. 50 min, P < 0.003). In contrast, AKI occurred less frequently in the pREBOA-PRO group (19% vs. 33%, P < 0.05). Conclusions: The more frequently partial and longer occlusion times in Zone 1 with the use of pREBOA-PRO resulted in lower AKI incidence suggesting that this newer device is a safer extended bridge to hemorrhage control.

BACKGROUND:Laparoscopic subtotal cholecystectomy (SC) is used for the difficult cholecystectomy, but published experience with resource use for SC is limited. We hypothesized that the need for advanced resources are common after SC. STUDY DESIGN:This was a retrospective review of laparoscopic cholecystectomies between 2017 and 2021 at a large center. SC cases were identified using a medical record tool. Baseline characteristics were assessed with Student's t -test and chi-square test. Primary outcome was endoscopic retrograde cholangiography (ERC) within 60 days. Secondary outcomes were reconstituted SC on postoperative ERC and length of stay (LOS). Uni- and multivariable logistic regression were used for binary outcomes. Multiple linear regression was used for LOS. Covariates included were age, sex, BMI, and American Society of Anesthesiology class. RESULTS:A total of 1,222 laparoscopic cholecystectomies were performed between 2017 and 2021. Of these, 87 (7%) were SC. Male (p < 0.001) and older (p < 0.001) patients were more likely to undergo SC. Odds of postoperative ERC were higher in the SC group (odds ratio 9.79, 95% CI 5.90 to16.23, p < 0.001). There was no difference in preoperative ERC (17% vs 21%, p = 0.38). Reconstituting SC had lower odds of postoperative ERC (odds ratio 0.12, 95% CI 0.023 to 0.58, p = 0.009). LOS was 1.81 times higher in the SC group (p ≤ 0.001). Postoperative ERC was not associated with LOS (p = 0.24). CONCLUSIONS:We present one of the largest single-center series of SC. Patients who underwent SC are more likely to be male, older, have higher American Society of Anesthesiology class, and have increased LOS. SC should be performed when access to ERC and interventional radiology is available. In the absence of these adjuncts, reconstituting SC decreases the need for early ERC, but long-term outcomes are unknown.

BACKGROUND:Partial occlusion of the aorta is a resuscitation technique designed to maximize proximal perfusion while allowing a graduated amount of distal flow to reduce the ischemic sequelae associated with complete aortic occlusion. The pREBOA-PRO catheter affords the ability to titrate perfusion as hemodynamics allows; however, the impact of this new technology for resuscitative endovascular balloon occlusion of the aorta (REBOA) on blood use and other resuscitative requirements is currently unknown. We hypothesize that patients undergoing REBOA with the pREBOA-PRO catheter will utilize partial occlusion, when appropriate, and decrease overall resuscitative requirements when compared to patients undergoing REBOA with the ER-REBOA catheter. METHODS:The entire American Association for the Surgery of Trauma Aortic Occlusion for Resuscitation in Trauma and Acute Care Surgery registry was used to compare resuscitation requirements between all ER-REBOA and pREBOA. Unpaired t tests were used to compare resuscitation strategies including packed red blood cells (PRBCs), fresh frozen plasma (FFP), platelets, cryoprecipitate, crystalloids, and need for pressors. RESULTS:When comparing ER-REBOA (n = 800) use to pREBOA (n = 155), initial patient presentations were similar except for age (44 years vs. 40 years, p = 0.026) and rates of blunt injury (78.4% vs. 78.7% p < 0.010). Zone 1 occlusion was used less often in ER-REBOA (65.8 vs. 71.7, p = 0.046). Partial occlusion was performed in 85% of pREBOA compared with 11% in ER-REBOA ( p < 0.050). Vitals at the time of REBOA were worse in ER-REBOA and received significantly more units of PRBCs, FFP, platelets, and liters of crystalloids than pREBOA ( p < 0.05). Rates of ARDS and septic shock were lower in pREBOA ( p < 0.05). CONCLUSION:When comparing pREBOA to ER-REBOA, there has been a rise in Zone 1 and partial occlusion. In our pilot analysis of the Aortic Occlusion for Resuscitation in Trauma and Acute Care Surgery registry, there was a reduction in administration of PRBCs, FFP, platelets, and crystalloids. Although further prospective studies are required, this is the first to demonstrate an association between pREBOA, partial occlusion, and reduced blood use and resuscitative requirements. LEVEL OF EVIDENCE:Therapeutic/Care Management; Level IV.

Guidelines provide varying recommendations for the prophylactic antimicrobial treatment of open fractures. This single-center, retrospective cohort study was conducted to determine how well an institutional prophylactic antibiotic protocol covered pathogens associated with open fractures. The authors included adult trauma patients with one or more open fractures and a positive culture from the site of the open fracture, and compared outcomes between patients who were covered by prophylactic antibiotics with patients not covered by prophylactic antibiotics. Of 957 patients evaluated, 75 were included, with 40 patients (53%) covered by the prophylactic antibiotics received. Multidrug-resistant pathogens were isolated in 23 (58%) patients covered versus 26 (74%) patients not covered (p = 0.128). The median time to positive culture was less in patients not covered by initial antibiotics compared with those who were covered (30.2 vs. 102.1 days; p = 0.003). Over half of the patients developed cultures with pathogens that were covered by their initial antibiotic prophylaxis. (Journal of Surgical Orthopaedic Advances 33(2):084-087, 2024).

BackgroundRapidly localizing and controlling bleeding is central to treating hemorrhagic shock. While REBOA allows temporary control, identifying the source of bleeding remains challenging. CT imaging with REBOA in place may provide information to direct hemorrhage control. The purpose of this study is to provide a descriptive summary of data comparing patients who did and did not undergo CT scan following REBOA deployment. Our hypothesis was that performing CT scan after REBOA placement in select patients is safe and can guide management of hemorrhagic shock.MethodsWe queried the AAST AORTA registry for patients receiving REBOA at our level 1 trauma center from May 2017 to December 2021. Clinical data was obtained through the Trauma Registry of the American College of Surgeons (TRACS). Comparison groups were those who underwent CT scan after REBOA deployment versus those who did not undergo CT scan after REBOA deployment. The primary outcome was inhospital mortality, and secondary outcomes included hospital-, ICU-, and ventilator-free days.Results61 patients underwent CT scan with REBOA in place; 25 patients proceeded directly to hemorrhage control. Patients with REBOA prior to CT were more likely to have blunt mechanism, higher ISS, pelvic bleeding, and zone 3 REBOA placement. Mortality was not significantly different (51 % vs. 64 %). Patients who underwent CT with REBOA were more likely to undergo hemorrhage control in interventional radiology (43 % vs. 0 %). There was no difference in hospital-, ICU-, and ventilator-free days.DiscussionWe demonstrate the feasibility of performing CT in select trauma patients who undergo REBOA. We describe a pathway to enable expeditious workup and management of these patients. Optimal hemorrhage control management is impacted by CT scans when it can be performed. It is important to note that this is a severely injured patient population, and mortality is high even when hemorrhage is controlled.Level of EvidenceIII

INTRODUCTION:The AUA recommends delayed-phase imaging (DPI) in renal injuries to evaluate the collecting system. A renal trauma imaging protocol for early conservative management of urinary extravasation (UE) was implemented to improve guideline adherence. We aimed to determine if increased adherence led to changes in outcomes. METHODS:Patients with American Association for the Surgery of Trauma III to V renal injury presenting from January 2018 to September 2022 were identified from an institutional trauma registry. Patients were included if a contrasted CT scan of the abdomen was obtained on admission. Frequency of DPI and patient outcomes were compared before and after protocol implementation. RESULTS:Of 223 included patients, 131 (58.7%) were pre protocol and 92 (41.3%) were post protocol. Following protocol implementation, the rate of DPI on admission nearly doubled from 32.8% to 58.7% (P < .001). The rate of follow-up cross-sectional imaging increased from 18.3% to 58.7% (P < .001). Although there were no significant differences in rates of immediate or delayed interventions following protocol implementation, the postprotocol immediate intervention rate did decrease to 0%. Readmissions due to symptomatic UE were unchanged after protocol implementation (0.0% vs 0.0%). CONCLUSIONS:Implementation of a multidisciplinary renal trauma early imaging and management protocol improved AUA guideline adherence. With protocol adherence, there was also an elimination of immediate interventions for UE. Despite decreases in early intervention, there was no significant increase in interval interventions or UE-related readmissions. More research is needed to determine the role for routine follow-up imaging in conservative management of high-grade renal trauma.

BACKGROUND:Thoracic epidural catheters (TECs) are useful adjuncts to multimodal pain regimens in traumatic rib fractures. However, TEC placement is limited by contraindications, patient risk profile, and provider availability. Continuous peripheral infusion of ketamine and/or lidocaine is an alternative that has a modest risk profile and few contraindications. We hypothesized that patients with multiple traumatic rib fractures receiving TECs would have better pain control, in terms of daily morphine milligram equivalents (MMEs) and mean pain scores (MPSs) when compared with continuous peripheral infusions of ketamine and/or lidocaine. METHODS:We retrospectively analyzed traumatic rib fracture admissions to a level 1 trauma center between January 2018 and December 2020. We evaluated two treatment groups: TEC only and continuous infusion only (drip only). A linear mixed-effects model evaluated the association of MME with treatment group. An interaction term of treatment group by time (days 1-7) was included to allow estimating potential time-dependent treatment effect on MME. A zero-inflated Poisson mixed-effects model evaluated the association of treatment with MPS. Both models adjusted for confounders. RESULTS:A total of 1,647 patients were included. After multivariable analysis, a significant, time-varying dose-response relationship between treatment group and MME was found, indicating an opioid-sparing effect favoring the TEC-only group. The opioid-sparing benefit for TEC-only therapy was most prominent at day 3 (27.4 vs 36.5 MME) and day 4 (27.3 vs 36.2 MME) ( p < 0.01). The drip-only group had 1.21 times greater MPS than patients with TEC only ( p < 0.001). CONCLUSION:Drip-only analgesia is associated with higher daily MME use and MPS, compared with TEC only. The maximal benefit of TEC therapy appears to be on days 3 and 4. Prospective, randomized comparison between groups is necessary to evaluate the magnitude of the treatment effect. LEVEL OF EVIDENCE:Therapeutic/Care Management; Level III.