BackgroundMost patients with pneumomediastinum from blunt injury have a self-limited condition and additional testing is no longer recommended given the low incidence in underlying aerodigestive injury. This study characterizes practice patterns in evaluating patients with diagnosed pneumomediastinum.MethodsData from a level 1 trauma center were analyzed from 2013 to 2022 for blunt trauma patients with pneumomediastinum diagnosed by imaging of the chest. Outcomes analyzed included mechanism of injury, diagnostic studies, procedures, and presence of an aerodigestive injury.Results351 patients were included; 71% were male; 35% were transfers. The most common mechanisms of injury were MVC (54%), fall (11%), and motorcycle/ATV accident (11%). 227 patients had pneumomediastinum and pneumothorax on CT (65%). Of the 124 with isolated pneumomediastinum on CT scan (35%), 96 had reliable mental status (GCS ≥13) and all were asymptomatic of an aerodigestive injury. 9 (9.4%) underwent endoscopy or esophagram with no injuries identified. No patients were diagnosed with an esophageal injury. Seven patients (2%) were diagnosed with tracheal injury; all presented with physical exam findings (subcutaneous emphysema, respiratory failure, and/or dysphonia), none with isolated pneumomediastinum. 12 patients (9.6%) were transferred with isolated pneumomediastinum. Of the transfer population, twenty did not meet criteria for trauma activation upon arrival (16%) and five were discharged from the emergency department (4%).ConclusionAerodigestive injuries amongst patients with radiographically diagnosed pneumomediastinum are rare. However, many asymptomatic patients are assessed with additional diagnostic tests and are potentially overtriaged with transfers to higher levels of care.

BACKGROUND:Helmet laws vary by state. North Carolina (NC) requires all motorcyclists to be helmeted, whereas South Carolina (SC) requires helmets only for drivers younger than 21 years of age. We examined helmet use data and outcomes among motorcycle crash (MCC) patients evaluated at a Level I trauma center with a catchment area spanning the 2 states. STUDY DESIGN:A retrospective cohort study was conducted of all adult MCC victims evaluated by the trauma department at an American College of Surgeons-verified Level 1 trauma center between July 2012 and July 2022. Helmet usage was compared by state, and outcomes were compared by helmet status. RESULTS:A total of 2,196 patients were evaluated following MCC; 86.3% were helmeted. Patients injured from NC were more likely to be helmeted when compared with SC (94 vs 52%, respectively, p < 0.001). Helmeted patients had a lower Injury Severity Score (13.6 vs 16.0, p = 0.001). Helmeted patients were more likely to be discharged from the emergency department (13% vs 10%) and were less likely to be admitted to the ICU (25% vs 39%, p < 0.001). In-hospital mortality for helmeted patients was 4% vs 7% in unhelmeted patients (p = 0.05). CONCLUSIONS:Patients from NC were more likely to be helmeted when compared with SC. Unhelmeted patients had more severe injuries, were more likely to be admitted, and require ICU-level care.

BACKGROUND:The role for routine follow-up imaging in nonoperative management (NOM) of blunt splenic injury (BSI) remains controversial. Delayed complications, specifically vascular abnormalities such as pseudoaneurysms are associated with failure of NOM (FNOM). This study examined a ten-year experience with NOM of BSI and the influence of repeat imaging. Our centers have no guidelines for follow-up imaging. METHODS:A retrospective cohort study was conducted including all trauma patients with BSI admitted within a regional trauma system (two Level III and one Level I ACS-verified trauma centers) between 2013 and 2022. Patient demographics, injury features, imaging and outcomes were obtained from trauma registry data and chart review. Patients undergoing splenectomy 6 hours or more after presentation were categorized as FNOM. RESULTS:A total of 1815 patients presented with BSI during the study period. Urgent splenectomy was performed in 15.6 % (N=283). The rate of FNOM was 3.4 % (N=62). Among the 1532 patients initially managed nonoperatively, 139 (9.1 %) underwent a follow-up CT scan. Most scans were obtained in response to clinical changes, while 13.7 % (N= 19) were obtained for splenic surveillance. Follow-up scans were followed by 8 splenectomies and 9 embolizations. Among the 19 scans performed for surveillance, two revealed a pseudoaneurysm; one of which underwent embolization. Results are limited by a low rate of screening imaging and a lack of long-term outcome information. CONCLUSION:A low rate of FNOM was achieved despite less than 2 % (19/1532) of patients undergoing screening follow-up imaging. These findings suggest that there is limited opportunity for routine surveillance imaging to improve outcomes in BSI. Reimaging in response to clinical changes is a cost-effective alternative.

BACKGROUND:Unexpected ICU admissions are a key quality metric in trauma care. The purpose of this study is to identify the most common causes of unplanned ICU admissions among trauma patients at an ACS-verified level 1 trauma center. METHODS:A retrospective review was conducted of all trauma patients with unplanned admission to the ICU at a level 1 trauma center between 2019 and 2021. Unplanned ICU admissions were categorized into (1) "bounce-backs," patients previously admitted to the ICU and (2) "upgrades," patients who had not previously been cared for in the ICU. RESULTS:Of 300 unexpected ICU transfers, bounce-backs accounted for 69% and upgrades 31%. The most common injuries were traumatic brain injuries (40%) and rib fractures (41.3%). In-hospital mortality rate was 10% and did not significantly differ between bounce-backs and upgrades (12 vs 5%, P = .92). Respiratory distress was the most common cause of transfer (41.1%), followed by neurologic (29.6%) and cardiovascular decline (21.2%). Patients were on average 928 mL fluid positive 72 hours prior to transfer (t > 0, P < .0001), and 295 mL fluid positive in the 24 hours prior to transfer (t > 0, P .0003). Patients transferred for respiratory distress were no more fluid over-balanced than those transferred for other reasons. CONCLUSION:We found a large percent of unplanned transfers occurring within 48 hours of admission or transfer out of the ICU suggesting under-triage as a leading cause of bounce-backs and upgrades. Respiratory distress was the leading cause of transfer. These findings highlight opportunities for targeted interventions.

INTRODUCTION:Identifying patients who can be safely managed in lower-level trauma centers is critical to avoid overburdening level I centers. This study examines the transfer patterns and outcomes of blunt splenic injury (BSI) patients cared for at 2 regional level III trauma centers as compared to an associated level I center. METHODS:A retrospective cohort study was conducted including all trauma patients with BSI admitted to 2 level III trauma centers (TC3) and a level I center (TC1) between 2012 and 2022. Patients were broken into 3 categories: TC1, TC3, and transfer patients (transferred from TC3 to TC1). RESULTS:A total of 1480 patients were admitted to TC1, 208 patients to TC3, and 128 were transferred. 22.7% of transfer patients were children. No difference in splenic injury grade was seen between patients managed at TC1 and TC3. Patients presenting to TC1 had more severe concomitant injuries. Patients underwent urgent splenectomy at similar rates at TC1 and TC3 (15.1 vs 18.7%, P = .1). Successful nonoperative management was achieved at similar rates (81.3 vs 75.5%, P = .1). When controlling for ISS and ED disposition, there was no significant difference in length of stay (LOS), ICU LOS, and inpatient mortality between TC1 and TC3. CONCLUSION:Level III centers effectively managed BSI achieving comparable outcomes to the level 1 center. Transfers commonly occurred in pediatric and multisystem trauma patients, though high-grade splenic injuries were not predictive of transfer. High-grade BSI can be safely managed at level III centers without need for transfer.

Venous thromboembolism (VTE) is a challenging dilemma in the management of the injured patient. Trauma resulting in hospitalization is an independent risk for development of VTE, which can occur early following injury. The pathophysiology is ascribed to Virchow’s triad-stasis, endothelial injury, and hypercoagulable state. All three of these are present in the multi-injured patient. The mainstay of treatment is prevention typically with a heparinoid and mechanical compression devices. Risk assessment, prophylactic and therapeutic dosing and time regimens, diagnostic modalities for pulmonary embolus (PE), use of inferior vena cava filter devices, and indications for thrombolysis and thrombectomy are detailed within this chapter.

BACKGROUND:Intercostal nerve cryoablation is an adjunctive measure that has demonstrated pain control, decrease in opioid consumption, and decrease in hospital length of stay (LOS) in patients who undergo surgical stabilization of rib fractures (SSRF). METHODS:SSRF patients from January 2015 to September 2021 were retrospectively compared. All patients received multimodal pain regimens post-operatively and the independent variable was intraoperative cryoablation. RESULTS:241 patients met inclusion criteria. 51 (21%) underwent intra-operative cryoablation during SSRF and 191 (79%) did not. Patients with standard treatment consumed 9.4 more daily MME (p = 0.035), consumed 73 percent more post-operative total MME (p = 0.001), spent 1.55 times as many days in the intensive care unit (p = 0.013), and spent 3.8 times as many days on the ventilator than patients treated with cryoablation, respectively. Overall hospital LOS, operative case time, pulmonary complications, MME at discharge, and numeric pain scores at discharge were no different (all p>0.05). CONCLUSION:Intercostal nerve cryoablation during SSRF is associated with fewer ventilator days, ICU LOS, total post-operative, and daily opioid use without increasing time in the operating room or perioperative pulmonary complications.

Background/Objectives Older adults are at risk for adverse outcomes after trauma, but little is known about post-acute survival as state and national trauma registries collect only inpatient or 30-day outcomes. This study investigates long-term, out-of-hospital mortality in geriatric trauma patients. Methods Level I Trauma Center registry data were matched to the US Social Security Death Index (SSDI) to determine long-term and out-of-hospital outcomes of older patients. Blunt trauma patients aged ≥65 were identified from 2009 to 2015 in an American College of Surgeons Level 1 Trauma Center registry, n = 6289 patients with an age range 65-105 years, mean age 78.5 ± 8.4 years. Dates of death were queried using social security numbers and unique patient identifiers. Demographics, injury, treatments, and outcomes were compared using descriptive and univariate statistics. Results Of 6289 geriatric trauma patients, 505 (8.0%) died as an inpatient following trauma. Fall was the most common mechanism of injury (n = 4757, 76%) with mortality rate of 46.5% at long-term follow-up; motor vehicle crash (MVC) (n = 1212, 19%) had long-term mortality of 27.6%. Overall, 24.1% of patients died within 1 year of trauma. Only 8 of 488 patients who died between 1 and 6 months post-trauma were inpatient. Mortality rate varied by discharge location: 25.1% home, 36.4% acute rehabilitation, and 51.5% skilled nursing facility, P < .0001. Conclusion Inpatient and 30-day mortality rates in national outcome registries fail to fully capture the burden of trauma on older patients. Though 92% of geriatric trauma patients survived to discharge, almost one-quarter had died by 1 year following their injuries.

BACKGROUND:End-tidal carbon dioxide (ETCO2) has previously shown promise as a predictor of shock severity and mortality in trauma. ETCO2 monitoring is non-invasive, real-time, and readily available in prehospital settings, but the temporal relationship of ETCO2 to systemic oxygen transport has not been thoroughly investigated in the context of hemorrhagic shock. METHODS:A validated porcine model of hemorrhagic shock and resuscitation was used in male Yorkshire swine (N ​= ​7). Both ETCO2 and central venous oxygenation (SCVO2) were monitored and recorded continuously in addition to other traditional hemodynamic variables. RESULTS:Linear regression analysis showed that ETCO2 was associated with ScvO2 both throughout the experiment (β ​= ​1.783, 95% confidence interval (CI) [1.552-2.014], p ​< ​0.001) and during the period of most rapid hemorrhage (β ​= ​4.896, 95% CI [2.416-7.377], p ​< ​0.001) when there was a marked decrease in ETCO2. CONCLUSIONS:ETCO2 and ScvO2 were closely associated during rapid hemorrhage and continued to be temporally associated throughout shock and resuscitation.

BACKGROUND:The purpose of this study was to evaluate the safety and efficacy of early venous thromboembolism (VTE) chemoprophylaxis following blunt solid organ injury. METHODS:A retrospective review of patients was performed for patients with blunt solid organ injury between 2009-2019. Enoxaparin was initiated when patients had <1g/dl Hemoglobin decline over a 24 h period. These patients were then categorized by initiation: ≤48 h and >48 h. RESULTS:There were 653 patients: 328 (50.2%) <48 h and 325 (49.8%) ≥48 h. Twenty-nine (4.4%) developed VTE. Patients in ≥48 h group suffered more frequent VTE events (6.5% vs 2.4%, p = 0.021). Non-operative failure occurred in 6 patients (1.9%) in ≥48 h group, and 5 patients (1.5%) < 48 h group. Blood transfusion following chemophrophylaxis initiation was required in 69 (21.3%) in ≥48 h group, and 46 (14.0%) in < 48 h group, occurring similarly between groups (p=0.021). CONCLUSION:Stable hemoglobin in the first 24 h is an efficacious, objective measure that allows early initiation of VTE chemoprophylaxis in solid organ injury. This practice is associated with earlier initiation of and fewer VTE events.

Background The paradigm of Acute Care Surgery (ACS) emerged in response to decreasing operative opportunities for trauma surgeons and increasing need for surgical coverage in disciplines to which the expertise of trauma surgeons naturally extends. While the continued evolution of this specialty remains largely beneficial, unintended consequences may have arisen along the way. One aspect of ACS that remains to be thoroughly investigated is the impact of the electronic health record (EHR). The purpose of this study is to objectively quantify EHR usage for ACS and compare it to other general surgery specialties. Methods EHR user data were collected for fifteen ACS attendings and thirty-seven general surgery attendings from October 2014 to September 2019. Comparative analysis was conducted using two-tailed t-tests. Subgroup analysis was conducted for subspecialties included in the general surgery group. Results ACS attendings opened almost 3 times as many charts as general surgery attendings per month (180 vs 64 charts/month, P < .0001), and ultimately spent more time on the EHR as a result (10 vs 6.4 hours/month, P < .0001). Documentation was the most time consuming EHR task for both groups. Although ACS attendings spent less overall time per patient chart, the proportion of time spent on certain EHR tasks was similar to that of general surgery colleagues. Discussion The EHR imposes a disproportionate burden on ACS attendings compared to their general surgery counterparts, and additional study is warranted to improve usage. EHR usage burden has workforce implications for trainees considering a career in ACS.

Background Emergency general surgery (EGS) patients presenting at tertiary care hospitals may bypass local hospitals with adequate resources. However, many tertiary care hospitals frequently operate at capacity. We hypothesized that understanding patient geographic origin could identify opportunities for enhanced system triage and optimization and be an important first step for EGS regionalization and care coordination that could potentially lead to improved utilization of resources. Methods We analyzed patient zip code and categorized EGS patients who were cared for at our tertiary care hospital as potentially divertible if the southern region hospital was geographically closer to their home, regional hospital admission (RHA) patients, or local admission (LA) patients if the tertiary care facility was closer. Baseline characteristics and outcomes were compared for RHA and LA patients. Results Of 14 714 EGS patients presenting to the tertiary care hospital, 30.2% were categorized as RHA patients. Overall, 1526 (10.4%) patients required an operation including 527 (34.5%) patients who were potentially divertible. Appendectomy and cholecystectomy comprised 66% of the operations for potentially divertible patients. Length of stay was not significantly different (P = .06) for RHA patients, but they did have lower measured short-term and long-term mortality when compared to their LA counterparts (P < .05). Conclusions EGS diagnoses and patient geocode analysis can identify opportunities to optimize regional operating room and bed utilization. Understanding where EGS patients are cared for and factors that influenced care facility will be critical for next steps in developing EGS regionalization within our system.

The use of vena cava filters (VCF) is a common procedure utilized in the prevention of pulmonary embolism (PE), yet VCFs have some significant and known complications, such as strut penetration and migration. Deep vein thrombosis (DVT) and PE remain a major cause of morbidity and mortality in the United States. It is estimated that as many as 900,000 individuals are affected by these each year with estimates suggesting that nearly 60,000-100,000 Americans die of DVT/PE each year. Currently, the preferred treatment for DVT/PE is anticoagulation. However, if there are contraindications to anticoagulation, an inferior vena cava (IVC) filter can be placed. These filters have both therapeutic and prophylactic indications. Therapeutic indications (documented thromboembolic disease) include absolute or relative contraindications to anticoagulation, complication of anticoagulation, failure of anticoagulation, propagation/progression of DVT during therapeutic anticoagulation, PE with residual DVT in patients with further risk of PE, free-floating iliofemoral IVC thrombus, and severe cardiopulmonary disease and DVT. There are also prophylactic indications (no current thromboembolic disease) for these filters. These include severe trauma without documented PE or DVT, closed head injury, spinal cord injury, multiple long bone fractures, and patients deemed at high risk of thromboembolic disease (immobilized or intensive care unit). Interruption of the IVC with filters has long been practiced and is a procedure that can be performed on an outpatient basis. There are known complications of filter placement, which include filter migration within the vena cava and into various organs, as well as filter strut fracture. This case describes a 66-year-old woman who was found to have a filter migration and techniques that were utilized to remove this filter.

BACKGROUND:The amount of time spent on the electronic health record is often cited as a contributing factor to burnout and work-related stress in nurses. Increased electronic health record use also reduces the time nurses have for direct contact with patients and families. There has been minimal investigation into the amount of time intensive care unit nurses spend on the electronic health record.OBJECTIVE:To quantify the amount of time spent by intensive care unit nurses on the electronic health record.METHODS:In this observational study, active electronic health record use time was analyzed for 317 intensive care unit nurses in a single institution from January 2019 through July 2020. Monthly data on electronic health record use by nurses in the medical, neurosurgical, and surgical-trauma intensive care units were evaluated.RESULTS:Full-time intensive care unit nurses spent 28.9 hours per month on the electronic health record, about 17.5% of their clinical shift, for a total of 346.3 hours per year. Part-time nurses and those working as needed spent 20.5 hours per month (17.6%) and 7.4 hours per month (14.2%) on the electronic health record, respectively. Neurosurgical and medical intensive care unit nurses spent 25.0 hours and 19.9 hours per month, respectively. Nurses averaged 23 clicks per minute during use. Most time was spent on the task of documentation at 12.3 hours per month, which was followed by medical record review at 2.6 hours per month.CONCLUSION:Intensive care unit nurses spend at least 17% of their shift on the electronic health record, primarily on documentation. Future interventions are necessary to reduce time spent on the electronic health record and to improve nurse and patient satisfaction.

INTRODUCTION: Traumatic brain injuries (TBI) are associated with significant resource use. Select minimal TBI can potentially be treated in lower-acuity settings with fewer resources. The Updated Brain Injury Guidelines (UBIG) criteria (2018) were developed to guide resource use including hospital transfers. Our study examined the usefulness of UBIG to determine appropriate triage of minimal TBI within a regional trauma system. METHODS: A trauma system registry was queried (American College of Surgeons–verified Level I trauma center and 2 verified Level III trauma centers) for adult patients (18 years or older) with an AIS-Head score greater than 0. Penetrating injuries were excluded. The study period was 2020 to 2021. The primary outcome was mortality. Secondary outcomes included progression on imaging, neurosurgical intervention, clinical deterioration, and length of stay (Table). UBIG was compared to Injury Severity Score via generalized linear models as a benchmark for predictivity capability. Statistical analysis was performed with R version 4.0.5. Table. - Validation of Updated Brain Injury Guidelines (UBIG) Results Variable UBIG1 (n = 93) UBIG2 (n = 235) UBIG3 (n = 193) p Value Age (mean, y) 53.4 ± 21.2) 61.1 ± 20.5 64.9 ± 21 <0.0001 Sex (% male) 56 (60.9%) 142 (60.4%) 111 (57.5) 0.7906 Hospital length of stay (d) 3.9 ± 4.7 4.43 ± 7.2 8.2 ± 10.6) <0.0001 Worsening subsequent imaging 1 (1.1%) 14 (6%) 26 (13.5%) 0.0004 Clinical worsening 4 (4.4%) 23 (9.8%) 46 (23.8%) <0.0001 Neurosurgical intervention 0 (0%) 7 (3%) 43 (22.3) <0.0001 Mortality 1 (1.1%) 5 (2.1%) 15 (7.8%) 0.0039 Mortality odds ratio (95% CI) ref 1.9 (0.3–37.3) 7.5 (1.5–136.7) Clinical worsening odds ratio (95% CI) ref 2.4 (0.9–8.3) 6.9 (2.7–23.4) RESULTS: A total of 521 patients were identified (93 UBIG1, 235 UBIG2, 193 UBIG3). There was a significant difference between UBIG groups for outcomes of mortality, age, length of stay, worsening imaging, clinical deterioration, and neurosurgical intervention (all p < 0.05). For study outcomes, UBIG sensitivity was 63% to 86%, specificity was 68% to 71%, and AUC was 0.67 to 0.78. An extended model incorporating demographic variables demonstrated improved sensitivity (86%) and specificity (78%) with AUC of 0.86. CONCLUSION: UBIG classification can be safely applied to the triage of trauma patients presenting with TBI. Increasing UBIG status is associated with worse outcomes. Mild TBI patients with UBIG1 without other significant injuries are appropriate for management at Level III trauma centers. Our predictive model incorporating UBIG with age, sex, ethnicity, and race suggested improved accuracy compared with the UBIG alone.

Polycomb group (PcG) genes are required for heritable silencing of target genes. Many PcG mutants have chromatin bridges and other mitotic defects in early embryos. These phenotypes can arise from defects in S phase or mitosis, so the phenotype does not show when PcG proteins act in cell cycle regulation. We analyzed the cell cycle role of the proximal subunit of Polyhomeotic (PhP) in Drosophila. Time-lapse imaging reveals that chromatin bridges formed during mitosis are able to resolve but sometimes result in chromosome breakage. Chromosome bridging is also observed in canonical cell cycles occurring in larval brains and is therefore not unique to the rapid embryonic cycles. PhP colocalizes with chromatin in S phase but not in mitosis in early embryos, indicating a direct role in DNA synthesis. Time lapse imaging of ph(p) mutants reveals an acceleration of S phase, showing that ph(p) regulates S phase length. Like ph(p) mutations, mutations in DNA damage checkpoints result in S phase acceleration. Consistent with this model, mutations in ph do not affect DNA synthesis rates, but exhibit impaired ability to block cell cycle progression following exposure to gamma-rays. Our data show that the mitotic defects of ph(p) are caused by defects in the DNA damage response that occurs after DNA replication in S phase, and we propose that PhP has a direct role in DNA damage repair.

Background Operative management of emergency general surgery (EGS) diagnoses involves a range of procedures which can carry high morbidity and mortality. Little is known about the impact of obesity on patient outcomes. The aim of this study was to examine the association between body mass index (BMI) >30 kg/m2 and mortality for EGS patients. We hypothesized that obese patients would have increased mortality rates. Methods A regional integrated health system EGS registry derived from The American Association for the Surgery of Trauma EGS ICD-9 codes was analyzed from January 2013 to October 2015. Patients were stratified into BMI categories based on WHO classifications. The primary outcome was 30-day mortality. Longer-term mortality with linkage to the Social Security Death Index was also examined. Univariate and multivariable analyses were performed. Results A total of 60 604 encounters were identified and 7183 (11.9%) underwent operative intervention. Patient characteristics include 53% women, mean age 58.2 ± 18.7 years, 64.2% >BMI 30 kg/m2, 30.2% with chronic obstructive pulmonary disease, 19% with congestive heart failure, and 31.1% with diabetes. The most common procedure was laparoscopic cholecystectomy (36.4%). Overall, 90-day mortality was 10.9%. In multivariable analysis, all classes of obesity were protective against mortality compared to normal BMI. Underweight patients had increased risk of inpatient (OR = 1.9, CI = 1.7-2.3), 30-day (OR = 1.9, CI = 1.7-2.1), 90-day (OR = 1.8, CI 1.6-2.0), 1-year (OR = 1.8, CI = 1.7-2.0), and 3-year mortality (OR = 1.7, CI = 1.6-1.9). Conclusions When stratified by BMI, underweight EGS patients have the highest odds of death. Paradoxically, obesity appears protective against death, even when controlling for potentially confounding factors. Increased rates of nonoperative management in the obese population may impact these findings.

BACKGROUND Rib fractures are common in trauma patients and are associated with significant morbidity and mortality. Adequate analgesia is essential to avoid the complications associated with rib fractures. Opioids are frequently used for analgesia in these patients. This study compared the effect of a multimodal pain regimen (MMPR) on inpatient opioid use and outpatient opioid prescribing practices in adult trauma patients with rib fractures. STUDY DESIGN A pre-post cohort study of adult trauma patients with rib fractures was conducted at a Level I trauma center before (PRE) and after (POST) implementation of an MMPR. Patients on long-acting opioids before admission and those on continuous opioid infusions were excluded. Primary outcomes were oral opioid administration during the first 5 days of hospitalization and opioids prescribed at discharge. Opioid data were converted to morphine milligram equivalents (MMEs). RESULTS Six hundred fifty-three patients met inclusion criteria (323 PRE, 330 POST). There was a significant reduction in the daily MME during the second through fifth days of hospitalization; and the average inpatient MME over the first five inpatient days (23 MME PRE vs. 17 MME POST, p = 0.0087). There was a significant reduction in the total outpatient MME prescribed upon discharge (322 MME PRE vs. 225 MME POST, p = 0.006). CONCLUSION The implementation of an MMPR in patients with rib fractures resulted in significant reduction in inpatient opioid consumption and was associated with a reduction in the quantity of opiates prescribed at discharge. LEVEL OF EVIDENCE Therapeutic/Care Management; level IV.

Background Resuscitative thoracotomy and clamshell thoracotomy are performed in the setting of traumatic arrest with the intent of controlling hemorrhage, relieving tamponade, and providing open chest cardiopulmonary resuscitation. Historically, return of spontaneous circulation rates for penetrating traumatic arrest as well as out of hospital survival have been reported as low as 40% and 10%. Vascular access can be challenging in patients who have undergone a traumatic arrest and can be a limiting step to effective resuscitation. Atrial cannulation is a well-established surgical technique in cardiac surgery. Herein, we present a case series detailing our application of this technique in the context of acute trauma resuscitation during clamshell thoracotomy for traumatic arrest in the emergency department. Methods A retrospective case series of atrial cannulation during traumatic arrest was conducted in Charlotte, NC at Carolinas Medical Center an urban level 1 trauma center. Results The mean rate of return of spontaneous circulation in our series, 60%, was greater than previously published upper limit of return of spontaneous circulation for penetrating causes of traumatic arrest. Discussion Intravenous access can be difficult to establish in the hypovolemic and exsanguinating patient. Traditional methods of vascular access may be insufficient in the setting of central vascular injury. Atrial appendage cannulation during atrial cannulation is a quick and reliable technique to achieve vascular access that employs common methods from cardiac surgery to improve resuscitation of traumatic arrest.