Trauma and Acute Care Surgery

Missing expectations: Windlass tourniquet use without formal training yields poor results Background Despite significant attempts to educate civilians in hemorrhage control, the majority remain untrained. We sought to determine if laypersons can successfully apply one of three commercially available tourniquets; including those endorsed by the United States Military and the American College of Surgeons. Methods Pre-clinical graduate health science students were randomly assigned a commercially-available windless tourniquet: SAM® XT, Combat Application Tourniquet® (CAT), or Special Operation Forces® Tactical Tourniquet (SOFT-T). Each was given up to one minute to read package instructions and asked to apply it to the HapMed® Leg Tourniquet Trainer. Estimated blood loss was measured until successful hemostatic pressure was achieved or simulated death occurred from exsanguination. Simulation survival, time to read instructions and stop bleeding, tourniquet pressure, and blood loss were analyzed. Results Of the 150 students recruited, 55, 46, and 49 were randomized to the SAM XT, CAT, SOFT-T, respectively. Mean overall simulation survival was less than 66% (61%, 72%, 65%; p=0.55). Of survivors, all three tourniquets performed similarly in median pressure applied (319 mmHg, 315 mmHg, and 329 mmHg; p=0.54) and median time to stop bleeding (91 sec, 70 sec, 77 sec; p=0.28). There was a statistical difference in median blood loss volume favoring SOFT-T (SAM XT 686 ml, CAT 624 ml, SOFT-T 433 ml; p=0.03). All 16 participants with previous experience were able to successfully place the tourniquet compared to 81 of 131 (62%) first-time users (p=0.008). Conclusion No one should die of extremity hemorrhage, and civilians are our first line of defense. We demonstrate that when an untrained layperson is handed a commonly accepted tourniquet, failure is unacceptably high. Current devices are not intuitive and require training beyond the enclosed instructions. Plans to further evaluate this cohort after formal "Stop the Bleed" training are underway. Level of Evidence Level II; Therapeutic study type First and Corresponding Authors: Andrew Dennis, DO, Department of Trauma and Burn Surgery, Cook County Health, Rush University, Midwestern University, adennis@cookcountytrauma.org Conflicts of Interest Statement: All authors have no conflicts of interest to disclose. Meetings at which paper presented: 49th Annual Meeting of the Western Trauma Association, March 3-8, 2019 in Snowmass, Colorado Funding Statement: No funding was received for this work from the National Institutes of Health (NIH); Wellcome Trust; or the Howard Hughes Medical Institute (HHMI). © 2019 Lippincott Williams & Wilkins, Inc.

Hypoxia/reoxygenation decreases endothelial glycocalyx via reactive oxygen species and calcium signaling in a cellular model for shock Background Ischemia/reperfusion injury (IRI) has been shown to cause endothelial glycocalyx (EG) damage. Whether the hypoxic/ischemic insult or the oxidative and inflammatory stress of reperfusion plays a greater part in glycocalyx damage is not known. Furthermore, the mechanisms by which IRI causes EG damage have not been fully elucidated. The aims of this study were to determine if hypoxia alone or hypoxia/reoxygenation (H/R) caused greater damage to the glycocalyx, and if this damage was mediated by reactive oxygen species (ROS) and Ca2+ signaling. Methods Human umbilical vein endothelial cells (HUVECs) were cultured to confluence and exposed to either normoxia (30 minutes), hypoxia (2% O2 for 30 minutes), or H/R (30 minutes hypoxia followed by 30 minutes normoxia). Some cells were pretreated with ROS-scavengers TEMPOL, MitoTEMPOL, Febuxostat, or Apocynin, or with the Ca2+ chelator BAPTA or Ca2+ channel blockers 2-APB, A967079, Pyr3, or ML204. Intracellular ROS was quantified for all groups. EG was measured using fluorescently-tagged wheat germ agglutinin and imaged with fluorescence microscopy. Results Glycocalyx thickness was decreased in both hypoxia and H/R groups, with the decrease being greater in the H/R group. TEMPOL, MitoTEMPOL, BAPTA, and 2-APB prevented loss of glycocalyx in H/R.ROS levels were likewise elevated compared to normoxia in both groups, but were increased in the H/R group compared to hypoxia alone. BAPTA did not prevent ROS production in either group. Conclusions In our cellular model for shock, we demonstrate that while hypoxia alone is sufficient to produce glycocalyx loss, hypoxia/reoxygenation causes a greater decrease in glycocalyx thickness. Under both conditions damage is dependent on ROS and Ca2+ signaling. Notably, we found that ROS are generated upstream of Ca2+, but that ROS-mediated damage to the glycocalyx is dependent on Ca2+. Study Type Basic science Level of Evidence Not applicable Author contribution statement: O.J.W. Conceived the study design, performed experiments, analyzed data, and wrote the manuscript. J.K.F. Conceived the study design, analyzed and interpreted data, and wrote the manuscript. L.A.R. aided in data acquisition. M.A.H. analyzed data. R.H.D. analyzed data. J.T.P. analyzed data. A.S. analyzed and interpreted data. C.G. conceived the study design and interpreted data. J.C.D. conceived the study design and interpreted data. Corresponding author: Olan Jackson-Weaver, Ph.D., Tulane School of Medicine, 1430 Tulane Ave, Dept. of Surgery, SL-22, New Orleans, LA 70112, Email: ojacksonweaver@tulane.edu, Phone: 504-988-2306, Fax: 504-988-3683 Conflicts of interest: No conflicts of interest are declared. This manuscript was presented at the 49th Annual Meeting of the Western Trauma Association, March 3-8, 2019, in Snowmass, CO, Scientific Session 3, March 5th. © 2019 Lippincott Williams & Wilkins, Inc.

Transition from Abdominal Aortic and Junctional Tourniquet (AAJT) to Zone 3 Resuscitative Endovascular Balloon Occlusion of the Aorta (REBOA) is feasible with hemodynamic support after porcine class IV hemorrhage BACKGROUND Traumatic hemorrhage remains a major cause of death in rural civilian and combat environments. Potential interventions to control hemorrhage from the pelvis and lower junctional regions include the Abdominal Aortic and Junctional Tourniquet (AAJT) and Resuscitative Endovascular Balloon Occlusion of the Aorta (REBOA). The AAJT requires low technical skills and may thus be used by non-medical professionals, but is associated with time dependent ischemic complications. In combination with delayed patient evacuation, it may therefore be deleterious. Transition to zone 3 REBOA in higher levels of care may be a possibility to maintain hemostasis, mitigate adverse effects and enable surgery in patients resuscitated with the AAJT. It is possible that a transition between the interventions could lead to hemodynamic penalties. Therefore, we investigated the feasibility of replacing the AAJT with zone 3 REBOA in a porcine model of uncontrolled femoral hemorrhage. METHODS Domestic pigs (n=12) averaging 57 kg were exposed to a class IV uncontrolled hemorrhage from the common femoral artery. The animals were randomized to 60 min AAJT (n=6) or 30 min AAJT with transition to 30 min zone 3 REBOA. Hemodynamic-, and metabolic parameters and ultra-sonographic measurements of the common femoral artery were collected. RESULTS Transition from AAJT to zone 3 REBOA caused a significant decrease in mean arterial pressure (25 mm Hg). Hemostasis was maintained. The common femoral artery diameter decreased by 1,8 mm (38%) after hemorrhage and further 0,7 mm (23%) after aortic occlusion. CONCLUSION Transition from AAJT to zone 3 REBOA after a class IV bleeding is feasible with hemodynamic support. Vascular access to the femoral artery for REBOA insertion poses a technical challenge after hemorrhage and AAJT application. LEVEL OF EVIDENCE level IV, Laboratory animal study. Correspondence: Dr Andreas Brännström, Department of Clinical Science and Education, Södersjukhuset, Karolinska Institutet, Sjukhusbacken 10, S1, SE-118 83 Stockholm, Sweden, Phone: +46 735 411 875, E-mail: andreas.brannstrom@ki.se Conflicts of interests: None © 2019 Lippincott Williams & Wilkins, Inc.

Big Problems in Little Patients: Nationwide Blunt Cerebrovascular Injury Outcomes in the Pediatric Population Background Blunt cerebrovascular injuries (BCVI) are uncommon but potentially devastating. The epidemiology, outcomes, and screening criteria are well described in adults, but data in pediatric patients are extremely limited. The purpose of this study was to characterize pediatric BCVI in a large nationwide sample. We hypothesized that outcomes of BCVI in the pediatric blunt trauma population will vary by age. Methods We conducted a retrospective cohort study of the Kids' Inpatient Database for pediatric BCVI from 2000-2012. Epidemiology, associated injuries, outcomes (including stroke and mortality), and the utility of standard screening criteria were analyzed. Results 1182 cases of BCVI were identified, yielding an incidence of 0.21%. Patients were predominately male (69%), mean age 15±5years. Injuries were 59% carotid, 13% vertebral, and 28% unspecified, with 15% having bilateral or multivessel BCVI. Although younger patients (<11y) had significantly lower ISS and decreased severe associated injuries (all p<0.01), they had a similar mortality rate (10%) versus the older cohort. Additionally, the stroke rate was significantly higher among the younger patients versus their older peers (29% mortality for <11y vs. 15% for ≥11y, p<0.01). Only 4 of 7 commonly utilized risk factors were associated with BCVI overall, but none were significantly associated with BCVI in younger children (<11y). Conclusion This represents the first nationwide assessment of BCVI in the pediatric population. Pediatric BCVI carry considerable mortality and stroke risk. Despite being less severely injured, younger children (<11y) had similar a mortality rate and a significantly higher stroke rate compared to older pediatric patients. Furthermore, commonly utilized adult screening criteria had limited utility in the younger cohorts. These findings suggest pediatric BCVI may require screening and treatment protocols that are significantly different than currently utilized adult-based programs. Level of Evidence Level III, Prognostic/Epidemiological Study Name and Address for Correspondence: Matthew J. Martin, MD, FACS, Trauma and Emergency Surgery Service, Scripps Mercy Medical Center, 550 Washington Street, Suite 641, San Diego, CA 92103, (619) 299-2600, traumadoc22@gmail.com There are no conflicts of interest to declare for any author as regards to this manuscript. This paper was presented at the 49th Annual Meeting of the Western Trauma Association in Snowmass, CO on Friday, March 8, 2019. There are no further disclosures. © 2019 Lippincott Williams & Wilkins, Inc.

Blunt Rupture of Two Cardiac Chambers Following a Motor Vehicle Collision No abstract available

Short-Term vs. Long-Term Trauma Mortality: A Systematic Review STRUCTURED ABSTRACT Background Trauma is the leading cause of death in the United States for persons under 44 years and the 4th leading cause of death in the elderly. Advancements in clinical care and standardization of treatment protocols have reduced 30-day trauma mortality to less than 4%. However, these improvements do not seem to correlate with long-term outcomes. Some reports have shown a greater-than-20% mortality rate when looking at long-term outcomes. The aim of this study was to systematically review the incongruence between short- and long-term mortality for trauma patients. Methods For this systematic review, we searched the Cochrane Library, EMBASE, Ovid Medline, Google Scholar, and Web of Science database to obtain relevant English, German, French, and Portuguese articles from 1965 to 2018. Results Trauma patients have decreased long-term survival when compared to the general population and when compared to age-matched cohorts. Post-discharge trauma mortality is significantly higher (mean 4.6% at 3-6 months, 15.8% at 2-3 years, 26.3% at 5-25 years) compared to controls (mean 1.3%, 2.2% and 15.6%, respectively). Patient comorbidities likely contribute to long-term trauma deaths. Trauma patients discharged to a skilled nursing facility have worse mortality compared to those discharged either to home or a rehabilitation center. In contrast to data available which illustrate that short-term mortality has improved, quality of evidence was not sufficient to determine if any improvements in long-term trauma mortality outcomes have also occurred. Conclusions The decreased short-term mortality observed in trauma patients does not appear correlated with decreased long-term mortality. The extent to which increased long-term trauma mortality is related to the initial traumatic insult – versus rising population age and comorbidity burden as well as sub-optimal discharge location – requires further study. Level of Evidence Level IV Study Type Systematic Review These authors contributed equally to this work, Lynn M. Frydrych, Toby P. Keeney-Bonthrone Conflict of Interest and Sources of Funding: All authors declare no conflicts of interest. LMF would like to acknowledge T32 HL007517, which supported her during her research fellowship. TPKB would like to acknowledge TL1TR000435 and TL1TR002242, which supported him during his research year. MJD would like to acknowledge the 2015 Research and Education Foundation Scholarship from the American Association for the Surgery of Trauma, the 2016 Research Scholarship from the Shock Society, and the 2017 Faculty Early Career Investigator Research Fellowship from the American Surgical Association Foundation which funded this research. Correspondence should be directed to: Matthew J. Delano, M.D., Ph.D., Assistant Professor of Surgery, University of Michigan, Department of Surgery, Division of Acute Care Surgery, University Hospital, 1C340D, 1500 E. Medical Center Dr, SPC 5033, Ann Arbor, Michigan 48109-5033, (734) 936-3662, (734) 936-9657, Email:mjdelano@med.umich.edu © 2019 Lippincott Williams & Wilkins, Inc.

LESSER SAC FLUID AFTER BLUNT TRAUMA No abstract available

Execute on the Vision: Pyramids and Mirages in Shifting Sands No abstract available

Patients with Acute Cholecystitis Should be Admitted to a Surgical Service Background In bowel obstruction and biliary pancreatitis, patients receive more expedient surgical care when admitted to surgical compared with medical services. This has not been studied in acute cholecystitis. Methods Retrospective analysis of clinical and cost data from July 2013 to September 2015 for patients with cholecystitis who underwent laparoscopic cholecystectomy in a tertiary care inpatient hospital. 190 lower-risk (Charlson-Deyo) patients were included. We assessed admitting service, length of stay, time from admission to surgery, time from surgery to discharge, number of imaging studies, and total cost. Results Patients admitted to surgical (n=106) versus medical (n=84) service had shorter mean LOS (1.4 vs 2.6 days), shorter time from admission to surgery (0.4 vs 0.8 days), and shorter time from surgery to discharge (0.8 vs 1.1 days). Surgical service patients had fewer CT (38% vs 56%) and MRI (5% vs 16%) studies. Cholangiography (30 vs 25%) and ERCP (3 vs 8%) rates were similar. Surgical service patients had 39% lower median total costs ($7787 vs $12572). Conclusions Nonsurgical admissions of patients with cholecystitis are common, even among lower-risk patients. Routine admission to the surgical service should decrease LOS, resource utilization and costs. This is a retrospective comparative study without negative criterion and thus Level III evidence. The study type is "Therapeutic/Care Management." Presented at the 88th Annual Meeting of the Pacific Coast Surgical Association, February 17-20, 2017 in Indian Wells, California Ning Lu, Present address: Ryder Trauma Center, Jackson Memorial Hospital, 1800 NW 10th Ave, Miami, FL, 33136 USA Walter L. Biffl, Present address: Scripps Memorial Hospital La Jolla, 9888 Genesee Ave., La Jolla, CA, 92037, USA No conflicts of interest. Funding: There are no sources of funding. Correspondence: Walter L. Biffl, MD, 9888 Genesee Ave., MC LJ601, La Jolla, CA 92037, 858-626-6362, 858-626-6354, Biffl.walter@scrippshealth.org © 2019 Lippincott Williams & Wilkins, Inc.

Evaluation and Management of Abdominal Gunshot Wounds: A Western Trauma Association Critical Decisions Algorithm No abstract available

Alexandros Sfakianakis
Anapafseos 5 . Agios Nikolaos
Crete.Greece.72100
2841026182

6948891480

alsfakia@gmail.com