Introduction Low molecular weight heparin (LMWH) is the standard for venous thromboembolic (VTE) chemo-prophylaxis in trauma patients; however, inconsistencies in the use of LMWH exist. The objective of this study was to assess VTE outcomes in response to a chemo-prophylaxis protocol guided by patient physiology (eg, creatinine clearance) and comorbidities. Methods ACS TQIP Benchmark Reports at a level 1 trauma center using a patient physiology and comorbidity directed VTE chemo-prophylaxis protocol were analyzed for Spring 2019 to Fall 2021. Patient demographics, VTE rates and pharmacologic VTE prophylaxis type were collected for “All Patients” and “Elderly” (TQIP: age ≥ 55 years) cohorts. Results Data was analyzed for 1919183 “All Hospitals” (AH) and 5843 patients single institution (SI) using the physiologic and comorbidity guided VTE chemo-prophylaxis protocol. Elderly subgroup had 701965 (AH) and 2939 (SI) patients. Use of non-LMWH chemo-prophylaxis was significantly higher at SI: All patients = 62.6% SI vs 22.1% ( P < .01); Elderly = 68.8% SI vs 28.1% AH ( P < .01). VTE, DVT, and PE rates for All Patients and Elderly subgroup were significantly reduced at SI, except Elderly PE which was statistically equivalent. Conclusions Protocol-driven VTE chemo-prophylaxis was associated with significantly lower LMWH use accompanied by significant reductions in All VTE, DVT, PE, and Elderly VTE and DVT with no difference in Elderly PE rates. These results may imply that adherence to a physiologic and comorbidity directed chemo-prophylaxis protocol, rather than LMWH, reduces VTE events in trauma patients. Further investigation to elucidate best practice is warranted.

Introduction: Post-injury respiratory failure is defined as inadequate gas exchange secondary to dysfunction of the chest wall, alveoli, pulmonary circulation, or central nervous system. Acute Respiratory Distress Syndrome (ARDS) develops in 12–25% of traumatically injured patients, and the lungs are the most common organ system affected in post-injury multiple organ failure (MOF). Pathophysiology: Acute respiratory failure is generally the result of two conditions: hypoxia and hypercapnia, which can precipitate failure independently or simultaneously. Hypoxia in defined as PaO2 < 50 mmHg, and hypercapnia is defined as PCO2 > 45 mmHg, with decreased minute ventilation. The pathophysiology of acute respiratory failure due to ARDS stems from both direct and indirect mechanisms of injury. Diagnosis: The diagnosis of acute post-injury respiratory failure/ARDS can be rapidly established and acted upon with bedside clinical exam and arterial blood gas analysis, precluding the need for advanced imaging or other technologically sophisticated diagnostics. Treatment: The main principles of respiratory failure treatment are: (1) support the patient while identifying and treating the underlying cause, and (2) prevent further pulmonary injury while supporting recovery. The ARDSnet mechanical ventilator protocol provides an evidence-based means to implement these principles in patients with PaO2/FiO2 ratios ≤300, bilateral infiltrates consistent with pulmonary edema, and no evidence of left atrial hypertension. Adjunctive rescue therapies when ARDSnet fails, such as prone positioning and ECMO, are possible but limited by resources in many practice environments. Outcomes/Long-term effects: The over-arching disease severity of post-injury respiratory failure/ARDS is underscored by outcomes in the adult population, with in-hospital mortality reaching 40% and 5-year mortality at 60%. Pulmonary fibrosis is a long-term sequela of ARDS for which an effective treatment remains obscure.

Objectives:The application of surgical stabilization of rib fractures (SSRF) remains inconsistent due to evolving indications and perceived associated morbidity. By implementing thoracoscopic-assisted rib plating (TARP), a minimally invasive SSRF approach, we expanded our SSRF application to patients who otherwise might not be offered fixation. This report presents our initial experience, including fixation in super elderly (aged ≥85 years), and technical lessons learned.Methods:This was a retrospective cohort study at a level 1 trauma center of admitted patients who underwent TARP between August 2019 and October 2020. Patient demographics, injury characteristics, surgical indications and outcomes are represented as mean±SD, median or percentage.Results:A total of 2134 patients with rib fractures were admitted. In this group, 39 SSRF procedures were performed, of which 54% (n=21) were TARP. Average age was 68.5±16 years. Patients had a median of 5 fractured ribs, with an average of 1 rib that was bicortically displaced, and 19% presented with 'clicking' on inspiration. Patient outcomes were a mean hospital length of stay (LOS) of 11±3.7 days, mean postoperative LOS of 8 days, and mean intensive care unit LOS of 6.6±2.9 days. Five patients were ≥85 years old with a mean age of 90.8±4.7 years. They presented with an average of 4 rib fractures, of which an average of 2.4 ribs were plated. The procedure was well tolerated in this age group with a hospital LOS of 9.4±2 days, and all five patients were discharged to a rehab facility with no in-hospital mortalities.Conclusion:Our experience incorporating TARP at our institution demonstrated feasibility of the technique and application across a broad range of patients. This approach and its application warrants further evaluation and potentially expands the application of SSRF..

Objective To develop an unembalmed human cadaveric lower limb model as a more realistic environment for testing self-expanding nitinol stents. We studied conformational changes and strain induced by knee flexion in nitinol stents deployed in the popliteal artery (PA). Methods One Lifestent (R) each was deployed into one limb of four cadavers (control group), while the contralateral leg received a different stent (Absolute (R), Protege Everflex (R), Supera (R), and Gore Viabahn (R)). The limbs were mounted on a quasi-static knee rig (QKR) and X-ray imaging was performed at pre-defined knee flexion angles. A least-squares solution to the equation of a circle was used to assess radius of curvature at flexion points (FP), and nominal strain was calculated for each stented artery. Results There were differences but also some similarities in conformational changes seen in the various stents. Knee flexion produced at least two FP in all stents. The mean radius of curvature decreased with increasing degrees of flexion but more so in distal (main) than proximal (accessory) FP (22 mm vs. 11 mm) in all stents. Supera (R) stent had the greatest relative radii of curvatures, and Absolute (R) stent had the highest strain value in comparison to the contralateral PA as the control group. Conclusion This study describes a novel human cadaveric limb model for testing self-expanding nitinol stents implanted in the PA. Several parameters of conformational change in the stented PA such as FP formation, FP translocation and strain induced by axial compression were described. These may be useful for developing new stents for the PA location.