Enmeshment of emergency trauma providers (ETPs) into the United States health-care fabric resulted in the establishment of a formalized surgical critical care fellowship and certification for emergency medicine trainees. The aim of this study was to compare trauma outcomes for surgery-trained providers (STPs) and ETPs at our institution, hypothesizing patient outcome equivalency. We performed an institutional review board–exempt institutional registry review (January 1, 2004 to August 1, 2018), comparing 74 STPs and 6 ETPs. Comparator variables included all-cause mortality, all-cause morbidity, CTimaging studies per provider, time in ED (min), hospital/ICU lengths of stay, ICU admissions, and functional outcomes on discharge. Statistical comparisons included chi-square test for categorical data and analysis of covariance for continuous data (adjustments made for patient age, Injury Severity Score, and trauma mechanism; all P < 0.20). Statistical significance was set at P < 0.05, with an equivalence study design. A total of 33,577 trauma resuscitations were reviewed (32,299 STP-led and 1,278 ETP-led). Except for patient age (STP 50.2 ± 25.9 vs ETP 54.9 ± 25.3 years), Injury Severity Score (8.47 ± 8.14 vs 9.22 ± 8.40), and ICU admissions (16.1% vs 18.8%), we noted no significant intergroup differences. ETPs’ performance was equivalent to that of STPs for all primary comparator variables (mortality, morbidity, CT utilization, time in the ED, lengths of stay, and functional outcomes). Incorporation of ETPs into our trauma center resulted in outcome parity between ETPs and STPs, while simultaneously expanding the expertise and experiential diversity within our multidisciplinary team. This study provides support for further incorporation of ETPs as equal partners across the growing network of United States regional trauma centers.

The relationship between trauma volumes and patient outcomes continues to be controversial, with limited data available regarding the effect of month-to-month trauma volume variability on clinical results. This study examines the relationship between monthly trauma volume variations and patient mortality at seven Level I Trauma Centers located in the Eastern United States. We hypothesized that higher monthly trauma volumes may be associated with lower corresponding mortality.

INTRODUCTION Pancreatic trauma results in high morbidity and mortality, in part caused by the delay in diagnosis and subsequent organ dysfunction. Optimal operative management strategies remain unclear. We therefore sought to determine CT accuracy in diagnosing pancreatic injury and the morbidity and mortality associated with varying operative strategies. METHODS We created a multicenter, pancreatic trauma registry from 18 Level 1 and 2 trauma centers. Adult, blunt or penetrating injured patients from 2005 to 2012 were analyzed. Sensitivity and specificity of CT scan identification of main pancreatic duct injury was calculated against operative findings. Independent predictors for mortality, adult respiratory distress syndrome (ARDS), and pancreatic fistula and/or pseudocyst were identified through multivariate regression analysis. The association between outcomes and operative management was measured. RESULTS We identified 704 pancreatic injury patients of whom 584 (83%) underwent a pancreas-related procedure. CT grade modestly correlated with OR grade (r2 0.39) missing 10 ductal injuries (9 grade III, 1 grade IV) providing 78.7% sensitivity and 61.6% specificity. Independent predictors of mortality were age, Injury Severity Score (ISS), lactate, and number of packed red blood cells transfused. Independent predictors of ARDS were ISS, Glasgow Coma Scale score, and pancreatic fistula (OR 5.2, 2.6–10.1). Among grade III injuries (n = 158, 22.4%), the risk of pancreatic fistula/pseudocyst was reduced when the end of the pancreas was stapled (OR 0.21, 95% CI 0.05–0.9) compared with sewn and was not affected by duct stitch placement. Drainage alone in grades IV (n = 25) and V (n = 24) injuries carried increased risk of pancreatic fistula/pseudocyst (OR 8.3, 95% CI 2.2–32.9). CONCLUSION CT is insufficiently sensitive to reliably identify pancreatic duct injury. Patients with grade III injuries should have their resection site stapled instead of sewn and a duct stitch is unnecessary. Further study is needed to determine if drainage alone should be employed in grades IV and V injuries. LEVEL OF EVIDENCE Epidemiologic/Diagnostic study, level III.

The most severely injured patients who arrive to emergency departments (EDs) in extremis present the most difficult challenge to traumatologists. For decades, unacceptably high mortality rates in this subset of patients evaded even the most extreme and invasive life‐saving intervention – the ED thoracotomy (EDT).[1‐3] The physiological premise behind the EDT is to perform three essential maneuvers: to relieve cardiac tamponade, to control hemorrhage, and to achieve temporary aortic occlusion.[4] Aortic cross‐clamping during EDT increases coronary blood flow, cardiac output, mean arterial pressure, carotid blood flow, and brain perfusion/ oxygenation.[5] The success of this procedure is varied depending on the cause of traumatic cardiac arrest, but a review of 868 patients from a single center showed an approximate 5% survival rate.[6] According to literature compilation by Pust and Namias, average survival for blunt traumatic EDT was 1.6%, with corresponding figure being approximately 10 times higher (16.8%) for penetrating traumatic EDT.[7] It has been postulated that significant contribution to morbidity and mortality within the EDT population may be associated with the thoracotomy itself,[8] suggesting that the performance of EDT should be restricted to a subset of patients who – based on best available scientific evidence – have the most reasonable chance of survival. By any measure, the performance of EDT simply to ensure “procedural skills maintenance” is ethically questionable, and there are increasing doubts about the benefit of entering an uninjured body cavity to address an injury elsewhere.

Organ procurement (OP) from donors after brain death and circulatory death represents the primary source of transplanted organs. Despite favorable laws and regulations, OP continues to face challenges for a number of reasons, including institutional, personal, and societal barriers. This focused review presents some of the key components of a successful OP program at a large, high-performing regional health network. This review focuses on effective team approaches, aggressive resuscitative strategies, optimal communication, family support, and community outreach efforts.

INTRODUCTION:Advanced age has been traditionally associated with worse traumatic brain injury (TBI) outcomes. Although prompt neurosurgical intervention (NSI, craniotomy or craniectomy) may be life-saving in the older trauma patient, it does not guarantee survival and/or return to preinjury functional status. The aim of this study was to determine whether a simple score, based entirely on the initial cranial computed tomography (CCT) is predictive of the need for NSI and key outcome measures (e.g., morbidity and mortality) in the older (age 45+ years) TBI patient subset. We hypothesized that increasing number of categorical CCT findings is independently associated with NSI, morbidity, and mortality in older patients with severe TBI. METHODS:After IRB approval, a retrospective study of patients 45 years and older was performed using our Regional Level 1 Trauma Center registry data between June 2003 and December 2013. Collected variables included patient demographics, Injury Severity Score (ISS), Abbreviated Injury Scale Head (AISh), brain injury characteristics on CCT, Glasgow Coma Scale (GCS), Intensive Care Unit (ICU) and hospital length of stay (LOS), all-cause morbidity and mortality, functional independence scores, as well as discharge disposition. A novel CCT scoring tool (CCTST, scored from 1 to 8+) was devised, with one point given for each of the following findings: subdural hematoma, epidural hematoma, subarachnoid blood, intraventricular blood, cerebral contusion/intraparenchymal blood, skull fracture, pneumocephalus, brain edema/herniation, midline shift, and external (skin/face) trauma. Descriptive statistics and univariate analyses were conducted with 30-day mortality, in-hospital morbidity, and need for NSI as primary end-points. Secondary end-points included the length of stay in the ICU (ICULOS), step-down unit (SDLOS), and the hospital (HLOS) as well as patient functional outcomes, and postdischarge destination. Factors associated with the need for NSI were determined using matched NSI (n = 310) and non-NSI (n = 310) groups. All other analyses examined the combined patient sample (n = 620). Variables achieving a significance level of P < 0.20 were included in the logistic regression. Receiver operating characteristic curves, with corresponding area under the curve (AUC) determinations, were also analyzed. Statistical significance was set at α = 0.05. Data are presented as percentages, mean ± standard deviation, or adjusted odds ratios (AORs) with 95% confidence intervals (95% CIs). RESULTS:A total of 620 patients were analyzed, including 310 patients who underwent NSI and 310 age- and ISS-matched non-NSI controls. Average patient age was 72.8 ± 13.4 years (64.1% male, 99% blunt trauma, mean ISS 25.1 ± 8.68, and mean AISh/GCS of 4.63/10.9). CCTST was the only variable independently associated with NSI (AOR 1.23, 95% CI 1.06-1.42) and was inversely proportional to initial GCS and functional outcome scores on discharge. Increasing CCTST was associated with greater mortality, morbidity, HLOS, SDLOS, ICULOS, and ventilator days. On multivariate analysis, factors independently associated with mortality included AISh (AOR 2.70, 95% CI 1.21-6.00), initial GCS (AOR 1.14, 1.07-1.22), and CCTST (AOR 1.31, 1.09-1.58). Variables independently associated with in-hospital morbidity included CCTST (AOR 1.16, 1.02-1.34), GCS (AOR 1.05, 1.01-1.09), and NSI (AOR 2.62, 1.69-4.06). Multivariate models incorporating factors independently associated with each respective outcome displayed good overall predictive characteristics for mortality (AUC 0.787) and in-hospital morbidity (AUC 0.651). Finally, modified CCTST demonstrated good overall predictive ability for NSI (AUC 0.755). CONCLUSION:This study found that the number of discrete findings on CCT is independently associated with major TBI outcome measures, including 30-day mortality, in-hospital morbidity, and NSI. Of note, multivariate models with best predictive characteristics incorporate both CCTST and GCS. CCTST is easy to calculate, and this preliminary investigation of its predictive utility in older patients with TBI warrants further validation, focusing on exploring prognostic synergies between CCTST, GCS, and AISh. If independently confirmed to be predictive of clinical outcomes and the need for NSI, the approach described herein could lead to a shift in both operative and nonoperative management of patients with TBI.

Terzian, Hillman WT MD; Hoey, Brian A. MD, FACS; Hoff, William S. MD, FACS; Thomas, Peter DO; Wojda, Thomas R. MD; Cipolla, James MD, FACS; Stawicki, Stanislaw P. MD, FACS Author Information

Both traumatic and nontraumatic hemorrhagic shock continues to be associated with unacceptably high mortality and morbidity. Although significant progress has been made within the transfusion science in terms of research and subsequent implementation of life-saving massive transfusion protocols, controversies persist regarding the optimal fresh frozen plasma-to-packed red blood cell (FFP-to-PRBC) ratios in the setting of hemorrhagic shock resuscitation, especially in the context of postresuscitation sequelae. To further compound the problem, there continues to be a paucity of prospective and high-quality retrospective data in this important clinical area. The goal of this hypothesis-generating, meta-analytic study was to combine data from all available high-quality literature sources in order to enhance our understanding of the relationship between FFP-to-PRBC ratios and associated morbidity/mortality across the entire reported spectrum of transfusion component combinations. Major findings of this analysis include the significant association between increasing FFP-to-PRBC ratios and decreasing mortality, as well as the concurrent increase in morbidity among survivors. More specifically, mortality odds were significantly lower with "higher" versus "lower" FFP-to-PRBC ratios (odds ratio [OR] 0.569; 95% confidence interval [CI] 0.463–0.700) in a combined cohort of 10,610 patients. At the same time, multi-organ failure was more likely to occur in the "higher" FFP-to-PRBC ratio group (OR 1.417, 95% CI 1.243–1.616). Formal studies that focus on risk-benefit aspects of higher FFP-to-PRBC ratios are needed. Research efforts should be directed at continued mortality reduction following massive transfusion while focusing on strategies designed to minimize the incidence and severity of complications among survivors of hemorrhagic shock. The current study provides a potentially useful platform for planning and implementation of future research efforts in the area of damage control resuscitation. The following core competencies are addressed in this article: Patient care, practice-based learning and improvement, systems based practice, medical knowledge

Traditional injury severity assessment is insufficient in estimating the morbidity and mortality risk for older (≥45 years) trauma patients. Commonly used tools involve complex calculations or tables, do not consider all comorbidities, and often rely on data that are not available early in the trauma patient’s hospitalization. The comorbidity–polypharmacy score (CPS), a sum of all pre-injury medications and comorbidities, was found in previous studies to independently predict morbidity and mortality in this older patient population. However, these studies are limited by relatively small sample sizes. Consequently, we sought to validate previous research findings in a large, administrative dataset.

Wernick, Brian MD; MacBean, Ulunna MD; Mubang, Ronnie N. MD; Wojda, Thomas R. MD; Liu, Suzanne C.; Evans, David C. MD; Hoey, Brian A. MD, FACS; Hoff, William S. MD, FACS; Thomas, Peter DO; Stawicki, Stanislaw P. MD Author Information

Because of multiple changes in the health care environment, the use of services of physician assistants (PAs) and nurse practitioners (NPs) in trauma and critical care has expanded. Appropriate training and ongoing professional development for these providers are essential to optimize clinical outcomes. This study offers a baseline assessment of the academic and professional needs of the contemporary trauma PAs/NPs in the United States. A 14-question electronic survey, using SurveyMonkey, was distributed to PAs/NPs at trauma centers identified through the American College of Surgeons Web site and other online resources. Demographic questions included trauma center level, provider type, level of education, and professional affiliations. Likert scale questions were incorporated to assess level of mentorship, comfort level with training, and individual perceived needs for academic and professional development. There were 120 survey respondents: 60 NPs and 60 PAs. Sixty-two respondents (52%) worked at level I trauma centers and 95 (79%) were hospital-employed. Nearly half (49%) reported working in trauma centers for 3 years or less. One hundred nineteen respondents (99%) acknowledged the importance of trauma-specific education; 98 (82%) were required by their institution to obtain such training. Thirty-five respondents (32%) reported receiving $1000 per year or less as a continuing medical education benefit. Insufficient mentorship, professional development, and academic development were identified by 22 (18%), 16 (13%), and 30 (25%) respondents, respectively. Opportunities to network with trauma PAs/NPs outside their home institution were identified as insufficient by 79 (66%). While PAs/NPs in trauma centers recognize the importance of continued contemporary trauma care and evidence-based practices, attending trauma-related education is not universally required by their employers. Financial restrictions may pose an additional impediment to academic development. Therefore, resource-efficient opportunities should be a prime consideration for advanced practitioners education, especially since half of the reported workforce has 3 years or less experience. The Eastern Association of Trauma and other organizations can provide an ideal venue for mentorship, academic development, and networking that is vital to PA/NP professional development and, ultimately, quality patient care.

Distracted driving, a significant public safety issue, is typically categorized as cell phone use and texting. The increase of distracted driving behavior (DDB) has resulted in an increase in injury and death. The purpose of this study was to identify the frequency and perception of DDB in adults. A 7-question SurveyMonkey questionnaire was distributed to a convenience sample of adults. Standard demographics included age, gender, and highest levels of education. Primary outcome questions were related to frequency of DDB, and overall perceptions specific to distracted driving. Results were compared on the basis of demographics. Chi-square testing and the Kruskal-Wallis analysis of variance were applied, with statistical significance defined as P <= .05. There were 1857 respondents to the survey: 1721 were aged 23-64 years (93%); 1511 were women (81%); 1461 had high school education or greater (79%). A total of 168 respondents (9%) reported being involved in a car accident while distracted. The highest reported frequency of DDB included cell phone use (69%), eating/drinking (67%), and reaching for an object in the care (49%). Younger age (18-34 years) and higher level of education (bachelor's degree or greater) were statistically associated with these DDB; gender demonstrated no statistical significance. Text messaging was reported by 538 respondents (29%), with a statistically significant association with age (18-34 years), higher education (bachelor's degree or greater), and gender (males). A total of 1143 respondents (63%) believed that they could drive safely while distracted. This study demonstrates that DDB in adults is not restricted to reading and sending text messages. Moreover, these results indicated that people fail to perceive the dangers inherent in distracted driving. Prevention and outreach education should not be limited to texting and cell phone use but should target all forms of DDB. The age group 18-34 years should be the primary target in the adult population.

BACKGROUND:Occult pneumothorax (OPTX) represents air within the pleural space not visible on conventional chest radiographs. Increased use of computed tomography has led to a rise in the detection of OPTX. Optimal management remains undefined.METHODS:A pediatric subgroup analysis (age <18 years) from a multicenter, observational study evaluating OPTX management. Data analyzed were pneumothorax size, management outcome, and associated risk factors to characterize those that may be safely observed.RESULTS:Fifty-two OPTX (7.3 ± 6.2 mm) in 51 patients were identified. None were greater than 27 mm; all those under 16.5 mm (n = 48) were successfully managed without intervention. Two patients underwent initial tube thoracostomy (one [21 mm] and the other with bilateral OPTX [24 mm, 27 mm]). Among patients under observation (n = 49), OPTX size progressed in 2; one (6.4mm) required no treatment, while one (16.5 mm) received elective intervention. Respiratory distress occurred in one patient (10.7 mm) who did not require tube thoracostomy. Nine received positive pressure ventilation; 8 did not have a tube thoracostomy. Twenty-four patients (51%) had one or more rib fractures; 3 required tube thoracostomy.CONCLUSION:No pediatric OPTX initially observed developed a tension pneumothorax or adverse event related to observation. Pediatric patients with OPTX less than 16 mm may be safely observed. Neither the presence of rib fractures nor need for PPV alone necessitates intervention.

Background: An occult pneumothorax (OPTX) is found incidentally in 2% to 10% of all blunt trauma patients. Indications for intervention remain controversial. We sought to determine which factors predicted failed observation in blunt trauma patients.Methods: A prospective, observational, multicenter study was undertaken to identify patients with OPTX. Successfully observed patients and patients who failed observation were compared. Multivariate logistic regression was used to identify predictors of failure of observation. OPTX size was calculated by measuring the largest air collection along a line perpendicular from the chest wall to the lung or mediastinum.Results: Sixteen trauma centers identified 588 OPTXs in 569 blunt trauma patients. One hundred twenty-one patients (21%) underwent immediate tube thoracostomy and 448 (79%) were observed. Twenty-seven patients (6%) failed observation and required tube thoracostomy for OPTX progression, respiratory distress, or subsequent hemothorax. Fourteen percent (10 of 73) failed observation during positive pressure ventilation. Hospital and intensive care unit lengths of stay, and ventilator days were longer in the failed observation group. OPTX progression and respiratory distress were significant predictors of failed observation. Most patient deaths were from traumatic brain injury. Fifteen percentage of patients in the failed observation group developed complications. No patient who failed observation developed a tension PTX, or experienced adverse events by delaying tube thoracostomy.Conclusion: Most blunt trauma patients with OPTX can be carefully monitored without tube thoracostomy; however, OPTX progression and respiratory distress are independently associated with observation failure.

OBJECTIVE:This study analyzes the impact of midlevel practitioners (MLPs) on patient care and resource utilization at a level I trauma center.METHODS:A retrospective review of trauma patients admitted during two periods was performed: PRE-MLP, during which limited MLP coverage was available; and POST-MLP, when MLP coverage was expanded. Demographics, injury severity scores (ISS), and preexisting medical conditions (PEC) were recorded. Trauma service activity was measured by daily admissions, inpatient census, and daily discharges. Outcome variables included hospital mortality, total length of stay (HLOS), ICU length of stay (ICU-LOS), and incidence of the three most prevalent complications: deep vein thrombosis (DVT), major arrhythmia (MA), urinary tract infection (UTI).RESULTS:PRE-MLP and POST-MLP groups were similar with respect to age, gender, and ISS. Mean daily admissions were 3.05 during the PRE-MLP period and 4.01 during the POST-MLP period (P = .0001). Reduced incidence of UTI was demonstrated in the POST-MLP period: 0.9% versus 2.6% (P = .0001). Incidence of DVT and MA were unchanged. HLOS decreased from 5.09 days to 4.84 days (P = .092). ICU-LOS was reduced from 4.08 days to 3.28 days (P = .019).CONCLUSION:Use of MLPs led to a significant reduction in ICU-LOS with no increased incidence of complications. MLPs offer a clinically effective and resource-efficient alternative to residents on a trauma service.