Objective:Violence against healthcare workers (HCWs), especially in emergency departments and trauma centers (TCs), is a significant and growing problem. HCWs have the highest numbers and annual rates of workplace violence (WPV) compared with any other private industry sector. There is less information about the rates of violence and stalking against trauma providers in TCs. We hypothesized that a majority of trauma surgeons and team members have experienced deliberate assaults in their TCs. Our secondary hypothesis was that a majority of trauma providers consider WPV a significant issue in their workplace. Methods:The American Association for Surgery of Trauma Disaster Committee invited 2,100 members to participate in an online survey in May and July 2024. Questions evaluated practice type, TC characteristics, training, experience with WPV, beliefs about WPV prevention, and potential WPV prevention strategies interventions. Results:The survey response rate was 10.9%, yet the prevalence of WPV in TCs was reported to be high. 63.9% of respondents were aware of a deliberate assault on an HCW in their TC or system. 42.5% had been assaulted personally, and 7.5% suffered injury as a result of a deliberate assault. Respondents generally agreed on the need for WPV prevention measures such as prevention education, metal detectors, armed police, or security, and were aware of deaths and disabilities among HCWs after assaults. However, they did not personally see WPV as a significant issue in their TCs. Conclusions:There is a high prevalence of WPV with significant effects on the entire trauma workforce, including elevated levels of emotional distress, burnout, post-traumatic stress disorder, and long-term irreversible physical injuries and deaths. Respondents agreed on the need for preventive measures but did not view WPV as a major issue in their own TCs. Research into this discrepancy, as well as effective strategies to reduce WPV in TCs, would support advocacy for improved legislation and policies aimed at preventing WPV in healthcare. Level of Evidence:V - Survey of expert opinion.

BACKGROUND:Increasing global conflicts continue to heighten the need for increased focus on preparedness for military physicians and surgeons. Simulation has recently been adopted by civilian surgical trainees to offset the problem of increased work hour restrictions and shift the current focus toward minimally invasive techniques. We hypothesized that just-in-time trauma training, incorporating both focused clinical and simulated experience at our civilian Level I Trauma Center, would increase the competence and confidence of international military physicians in trauma care. METHODS:We performed a feasibility study of five Ukrainian physicians (four surgeons and one anesthesiologist) undergoing an intensive 2-week trauma course taught by 25 American clinicians. The training consisted of several previously validated courses including Advanced Trauma Life Support (ATLS®), Advanced Surgical Skills for Exposure in Trauma (ASSE'J®), Advanced Trauma Operative Management (ATO ), and Basic Endovascular Skills for Trauma (BES'J®), among several additional simulated and clinical experiences. Pre- and post-course surveys were analyzed using paired t-tests to assess improvement in trauma care. RESULTS:All five physicians had significant improvement in confidence following the completion of the course, including the management of injuries to the neck, chest, abdomen, and extremities. Additionally, each clinician significantly improved in their confidence to perform common ATLS procedures and resuscitative endovascular balloon occlusion of the aorta skills. Overall, the mean confidence over all survey responses improved significantly following the completion of the course, 2.28 (precourse confid ence range 1.25-3.35) to 3.66 (post-course confidence range 2.95-4.22), p-value = 0.002. All five Ukrainian physicians successfully passed the corresponding post-tests and were certified as having completed ATLS, ATOM, ASSET, and BEST Conclusions: A military and civilian partnership in trauma preparedness is feasible to improve surgeon confidence in trauma care.

Background: Antibiotics are frequently administered prophylactically to trauma patients with various injury patterns to prevent infectious complications. Trauma patients may also require large volume resuscitation with blood products. Limited data are available to support antibiotic dosing recommendations in this population. We hypothesized that we would be able to develop a population pharmacokinetic model of cefazolin, a frequently used antibiotic in the trauma scenario, from remnant blood samples by pharmacokinetic analysis of trauma patients. Methods: Remnant plasma from standard of care chemistry/hematology assessments was retrieved within 48 h of collection and assayed to determine cefazolin concentrations. Population pharmacokinetic analyses were conducted in Pmetrics using R. Linear regression was conducted to assess the effect of blood product resuscitation volume on cefazolin pharmacokinetic parameters. Results: Cefazolin concentrations best fitted a two-compartment model (Akaike information criterion: 443.9). The mean +/- standard deviation parameters were total body clearance (4.3 +/- 1.9L), volume of the central compartment (V-c: 7.7 +/- 6.9L), and intercompartment transfer constants (k(12): 1.3 +/- 0.98 h(-1), k(21): 0.6 +/- 0.45 h(-1)). No statistical relationships were observed between blood products, volume of blood products, and cefazolin clearance or V-c (R-2: 0.0004-0.21, p = 0.08-0.95). Using a 5,000-patient Monte Carlo simulation, 2 g with repeated dosing every 2 h until end of surgery was required to achieve 93.2% probability of 100% free time above the minimum inhibitory concentration (MIC) (fT > MIC) at the ECOFF value for Staphylococcus aureus (2 mg/L). Conclusions: In these 15 trauma patients receiving blood transfusion, no relationship with blood volume resuscitation and cefazolin pharmacokinetics was observed. On the basis of this pharmacokinetic model, frequent cefazolin doses are required to maintain 100% fT > MIC.

ABSTRACT:As a powerful tool for discovering and documenting injury, the forensic autopsy has been incorporated into trauma care quality improvement. Autopsy findings are used to determine the Abbreviated Injury Scale (AIS) and Injury Severity Score (ISS) to assess a patient's trauma severity. Clinical trauma services use autopsy reports to educate, improve patient care, and strengthen the information used in epidemiological and injury prevention studies. However, there is sometimes a disconnect between the forensic pathologist's injury descriptions and the information needed by the trauma service and for AIS/ISS coding.We formed a collaboration between forensic pathologists and trauma teams to improve this communication. Accordingly, we describe injuries that are commonly overlooked or poorly described in autopsy reports, useful injury terminology, opportunities for trauma care improvement revealed by autopsies, and which medical examiner/coroner cases will most benefit from attention to specific injury details. We demonstrate how differences in injury description impact AIS/ISS results, and distill the detailed AIS manual into a pragmatic, concise, "quick reference" autopsy-directed guide for the forensic pathologist. Collaborations between trauma teams and forensic pathologists benefit each other and help communicate autopsy findings in a more clinically useful way to stakeholders to further benefit the living.

Background Fat Embolism Syndrome (FES) is a rare clinical phenomenon attributed to fat droplet embolization and subsequent multisystem organ failure, typically following traumatic orthopedic injury. It classically presents with hypoxemia, transient neurologic deficits, and skin changes that appear a day or more after the initial insult. Its exact mechanism remains unclear, although the mechanical obstruction of capillaries or production of toxic intermediaries following fat hydrolysis and extravasation of marrow have been described. Here, we present a new case of cerebral FES with symptom onset within 12 h and brain death within 48 h. Patient A 22-year-old male with multiple orthopedic fractures developed Fat Embolism Syndrome with neurological and respiratory symptoms within 12 h of presentation. Results The patient developed intractable cerebral edema and hypernatremia leading to brain death within 48 h. Conclusion Diffuse fat emboli can lead to rapid development of fatal cerebral edema even in the absence of anatomical shunts. MRI is the superior modality to detect FES and should be pursued early in patients with risk factors or clinical signs of neurologic involvement.

Objectives We evaluated the feasibility of implementing a Resuscitative Endovascular Balloon Occlusion of the Aorta (REBOA) program at our urban level 1 trauma center and evaluated early outcomes. Design A multidisciplinary committee including physicians (trauma surgery, emergency medicine, vascular surgery, and interventional radiology) and nurses created clinical practice guidelines for the placement of REBOA at our institution. All trauma surgeons and critical care board certified emergency medicine physicians were trained in placement and nurses received management training. A formal review process was implemented to identify areas for improvement. Finally, we instituted refresher training to maintain REBOA competency. Trauma patients with noncompressible torso hemorrhage from blunt or penetrating injuries who were partial or nonresponders to blood product resuscitation were included. Pregnant patients, children, or patients with significant hemothorax or suspected aortic or cardiac injury were excluded. Results Over seven months, eight catheters were successfully placed, all on the first attempt, including six in Zone 3 and two in Zone 1. All Zone 3 catheters were placed for pelvic fracture-related bleeding which were subsequently embolized. The Zone 1 catheters were placed immediately preoperatively for intraabdominal bleeding. Upon committee review, one critique was made regarding zone selection. One patient developed an arteriovenous fistula after placement which resolved without intervention. There were no other complications and all patients survived to discharge. Conclusions An REBOA program is feasible and safe following a comprehensive multidisciplinary effort. The efforts described here can be utilized by similar trauma programs for adaptation of this endovascular approach to bleeding control.

Mass casualty events particularly those requiring multiple simultaneous operating rooms are of increasing concern. Existing literature predominantly focuses on mass casualty care in the emergency department. Hospital disaster plans should include a component focused on preparing for multiple simultaneous operations. When developing this plan, representatives from all segments of the perioperative team should be included. The plan needs to address activation, communication, physical space, staffing, equipment, blood and medications, disposition offloading, special populations, and rehearsal.

Objective US trauma centers (TCs) must remain prepared for mass casualty incidents (MCIs). However, trauma surgeons may lack formal MCI training. The recent COVID-19 pandemic drove multiple patient surges, overloaded Emergency Medical Services (EMS) agencies, and stressed TCs. This survey assessed trauma surgeons’ MCI training, experience, and system and personal preparedness before the pandemic compared with the pandemic’s third year.Methods Survey invitations were emailed to all 1544 members of the American Association for the Surgery of Trauma in 2019, and then resent in 2022 to 1575 members with additional questions regarding the pandemic. Questions assessed practice type, TC characteristics, training, experience, beliefs about personal and hospital preparedness, likelihood of MCI scenarios, interventions desired from membership organizations, and pandemic experiences.Results The response rate was 16.7% in 2019 and 12% in 2022. In 2022, surgeons felt better prepared than their hospitals for pandemic care, mass shootings, and active shooters, but remained feeling less well prepared for cyberattack and hazardous material events, compared with 2019. Only 35% of the respondents had unintentional MCI response experience in 2019 or 2022, and even fewer had experience with intentional MCI. 78% had completed a Stop the Bleed (STB) course and 63% own an STB kit. 57% had engaged in family preparedness activities; less than 40% had a family action plan if they could not come home during an MCI. 100% of the respondents witnessed pandemic-related adverse events, including colleague and coworker illness, patient surges, and resource limitations, and 17% faced colleague or coworker death.Conclusions Trauma surgeons thought that they became better at pandemic care and rated themselves as better prepared than their hospitals for MCI care, which is an opportunity for them to take greater leadership roles. Opportunities remain to improve surgeons’ family and personal MCI preparedness. Surgeons’ most desired professional organization interventions include advocacy, national standards for TC preparedness, and online training.Level of evidence VII, survey of expert opinion.

BACKGROUND: Urban areas in the US are increasingly focused on mass casualty incident (MCI) response. We simulated prehospital triage scenarios and hypothesized that using hospital-based blood product inventories for on-scene triage decisions would minimize time to treatment. STUDY DESIGN: Discrete event simulations modeled MCI casualty injury and patient flow after a simulated blast event in Boston, MA. Casualties were divided into moderate (Injury Severity Score 9 to 15) and severe (Injury Severity Score >15) based on injury patterns. Blood product inventories were collected from all hospitals (n = 6). The primary endpoint was the proportion of casualties managed with 1:1:1 balanced resuscitation in a target timeframe (moderate, 3.5 U red blood cells in 6 hours; severe, 10 U red blood cells in 1 hour). Three triage scenarios were compared, including unimpeded casualty movement to proximate hospitals (Nearest), equal distribution among hospitals (Equal), and blood product inventory–based triage (Supply-Guided). RESULTS: Simulated MCIs generated a mean ± SD of 302 ± 7 casualties, including 57 ± 2 moderate and 15 ± 2 severe casualties. Nearest triage resulted in significantly fewer overall casualties treated in the target time (55% vs Equal 86% vs Supply-Guided 91%, p < 0.001). These differences were principally due to fewer moderate casualties treated, but there was no difference among strategies for severe casualties. CONCLUSIONS: In this simulation study comparing different triage strategies, including one based on actual blood product inventories, nearest hospital triage was inferior to equal distribution or a Supply-Guided strategy. Disaster response leaders in US urban areas should consider modeling different MCI scenarios and casualty numbers to determine optimal triage strategies for their area given hospital numbers and blood product availability.

INTRODUCTION: Rib fractures cause significant morbidity among geriatric trauma patients, and elderly patients are at increased risk for delirium. Regional anesthesia (RA) has been shown to reduce the need for deliriogenic pain medications. We hypothesized that early use of RA may be associated with decreased delirium among this patient population. METHODS: We performed a retrospective review at our Level I trauma center to identify patients with 2 or more rib fractures from 2018 to 2019. We collected demographics, regional anesthesia type/timing, and outcomes including all Confusion Assessment Method (CAM) assessments recorded for each patient throughout their hospitalization. We calculated percentage of CAM negativity for each hospitalization (percentage of CAM negativity = negative CAM assessments/total CAM assessments × 100). RESULTS: A total of 636 patients with more than 1 rib fracture were identified. A total of 323 patients were older than 60 years. A total of 81 (25.1%) underwent RA (46 epidurals, 26 erector spinae blocks, 7 serratus anterior blocks, and 2 paravertebral blocks), and 242 (74.9%) did not receive RA. Mean percentage of CAM negativity was higher among RA patients than non-RA patients (95.1% vs 91.3%, p = 0.04); however, subgroup analysis showed patients receiving RA after 36 hours of admission had no difference in percentage of CAM negativity compared with non-RA patients (90.2% vs 91.3%, p = 0.78; Figure). Timing of RA did not affect in-hospital mortality, overall length of stay, ICU length of stay, or ventilator days.Figure.: CAM, Confusion Assessment Method.CONCLUSION: Among elderly trauma patients with multiple rib fractures, regional anesthesia use is associated with decreased rates of delirium; however, this effect is lost when RA is initiated more than 36 hours after admission.

Introduction: Delirium is associated with adverse post-operative outcomes, long-term cognitive dysfunction, and prolonged hospitalization. Risk factors for its development include longer surgical duration, increased operative complexity and invasiveness, and medical comorbidities. This study aims to further evaluate the incidence of delirium and its impact on outcomes among patients undergoing both elective and emergency bowel resections.Methods: This is a retrospective cohort study using an institutional patient registry. All patients undergoing bowel resection over a 3.5-year period were included. The study measured the incidence of post-operative delirium via the nursing confusion assessment method. This incidence was then compared to patient age, emergency versus elective admission, length of stay, mortality, discharge disposition, and hospital cost.Results: A total of 1934 patients were included with an overall delirium incidence of 8.8%. Compared to patients without delirium, patients with delirium were more likely to have undergone emergency surgery, be greater than 70 y of age, have a longer length of stay, be discharged to a skilled nursing facility, and have a more expensive hospitalization. In addition, the overall mortality was 14% in patients experiencing delirium versus 0.1% in those that did not. Importantly, when broken down between elective and emergency groups, the mortality of those experiencing delirium was similar (11 versus 13%).Conclusions: The development of delirium following bowel resection is an important risk factor for worsened outcomes and mortality. Although the incidence of delirium is higher in the emergency surgery population, the development of delirium in the elective popu-lation infers a similar risk of mortality.(c) 2022 Elsevier Inc. All rights reserved.

Background: We analyzed the use of Extracorporeal Membranous Oxygenation (ECMO) in acute care surgery patients at our Level-1 trauma center. We hypothesized that this patient population has improved ECMO outcomes. Methods: This was a retrospective analysis of emergency general surgery and trauma patients placed on ECMO between the periods of October 2013 and February 2020. There were 10 surgical and 12 trauma patients studied, who eventually required ECMO support. ECMO support and ECMO type/modality were analyzed with injury and survival prognostic scores examined. Main results: Overall, 16 of the 22 patients survived to hospital discharge, for a survival rate of 73%. Mean age was 34.18 years. Mean hospital length of stay was 23.4 days with mean days on ECMO equal to 7.5. The net negative fluid balance was 5.36 L. Conclusions: The survival of our ECMO cohort is notably higher than previously cited studies. Our group demonstrated decreased length of time on ECMO, decreased length of stay in the hospital, and similar rates of complications compared to prior reports. ECMO is a useful modality in acute care surgical patients and should be considered in these patient populations. Our focus on net negative fluid balance for ECMO patients demonstrates improved survival. ECMO should be considered early in surgical patients and early in advanced trauma life support.

Background: Antibiotic prophylaxis is a common, established practice at trauma centers worldwide for patients presenting with various forms of serious injury. Many patients simultaneously present with hemorrhage. The current guidelines by the Eastern Association for the Surgery of Trauma recommend re-dosing prophylactic antibiotic agents for every 10 units of blood products administered. However, these guidelines are only mildly supported by dated research.Methods: A literature search was completed through Medline EBSCO Host using antibiotic prophylaxis and transfusion as keywords. Articles judged to be relevant to the study question were selected for full-text review. Case studies were not included. Altogether, 18 articles were cited in our results through this process.Results: Risk of infection increases in patients resuscitated with large volume of blood products. Animal models of trauma offered conflicting findings on whether blood loss and blood resuscitation altered tissue antibiotic concentrations compared with controls. Studies focused on antibiotic pharmacokinetics in non-trauma human patients revealed agreement surrounding reported decreases in serum and tissue concentrations, although there was discrepancy surrounding the clinical relevancy of the reported decreases.Conclusions: Trauma, hemorrhage, and transfusion impair the immune response resulting in increased incidence of infection. Both animal and human models of antibiotic pharmacokinetics show decreased serum and tissue concentrations during hemorrhage. However, available data are insufficient to conclude that trauma patients experiencing hemorrhage are at elevated risk of infection and thus require more frequent redosing of antibiotic agents than the current guidelines suggest. An upcoming, prospective study by our institution seeks to evaluate this question.

INTRODUCTION: Trauma is the leading cause of non-obstetric maternal death; however, providers may be unfamiliar and inconsistent with the management of these patients. We hypothesized that the obstetric trauma resuscitation course we created at one of the worlds largest simulation centers would be beneficial to learners’ education. METHODS: Trainees on the trauma, emergency surgery, and critical care services who were ATLS certified participated in an obstetric trauma resuscitation course. The participants performed a pre-course patient simulation with an evaluation tool. Next, they watched an educational presentation followed by participation in a different but similar obstetric patient simulation with the same evaluation tool (Figure). At the completion of the course, participants completed an anonymous survey.RESULTS: Trainees performed significantly better following the educational course (mean pre-test score: 65% vs mean post-test score: 90%, p < 0.05) indicating a significant increase in knowledge. Pre-course, the most frequently missed treatment interventions included: 1) recognizing important laboratory differences in pregnancy and 2) identifying the uterus as the source of hemorrhage. Both were significantly improved during the second simulation (p < 0.05). All participants strongly agreed that they would recommend this course to a colleague, reported increased confidence in the management of obstetric trauma patients and would apply the lessons learned to their clinical practice. CONCLUSION: We demonstrated that a novel simulation course is helpful to improve learners’ knowledge in managing the resuscitation of obstetric trauma patients. We will continue to evaluate this course with the goal of integrating it into the trauma curriculum at our institution.Figure

Introduction: Natural disasters may lead to increases in community violence due to broad social disruption, economic hardship, and large-scale morbidity and mortality. The effect of the COVID-19 pandemic on community violence is unknown. Methods: Using trauma registry data on all violence-related patient presentations in Connecticut from 2018 to 2021, we compared the pattern of violence-related trauma from pre-COVID and COVID pandemic using an interrupted time series linear regression model. Results: There was a 55% increase in violence-related trauma in the COVID period compared with the pre-COVID period (IRR: 1.55; 95%CI: 1.34-1.80; p-value<0.001) driven largely by penetrating injuries. This increase disproportionately impacted Black/Latinx communities (IRR: 1.61; 95%CI: 1.36-1.90; p-value<0.001). Conclusion: Violence-related trauma increased during the COVID-19 pandemic. Increased community violence is a significant and underappreciated negative health and social consequence of the COVID-19 pandemic, and one that excessively burdens communities already at increased risk from systemic health and social inequities.