Trauma and Acute Care Surgery

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

Reply to Letter: Observing Pneumothoraces: The 35 Millimeter Rule Is Safe for Both Blunt and Penetrating Chest Trauma No abstract available

A Preliminary Analysis of Level IV Trauma Centers within an Organized Trauma System Background The effect of Level IV trauma center (TC) accreditation within an existing trauma network remains understudied. This study compared pre- to post-accreditation data from Level IV TCs within a mature trauma system in Pennsylvania to determine whether TC designation affected time to and/or rate of transfer to definitive care. Level IV TCs were hypothesized to have a decreased time to transfer following accreditation and improved mortality. Methods The Pennsylvania Trauma Systems Foundation (PTSF) collects pre- and post-designation data from hospitals pursuing accreditation. Data from PTSF between 2012 and 2017 was analyzed. Variables of interest included patient demographics, injury severity, mortality and incidence of surgical interventions pre- to post-credentialing. A multilevel mixed-effects logistic regression model assessed the adjusted impact of Level IV TC accreditation on transfer rate. ArcGIS Desktop was used for geospatial mapping of lives and geographic area covered by the addition of Level IV TCs in Pennsylvania Results Five hospitals underwent Level IV credentialing from 2012-2017, providing data on 5,076 cases (Pre: 2,395 [47.2%]; Post: 2,681 [52.8%]). No significant difference in age, admission Glasgow Coma Scale score, or shock index was observed pre to post-accreditation. A difference in transfer rate was observed after credentialing in unadjusted (62.7% vs. 63.3%; p<0.014) and adjusted analyses (AOR: 1.13, p=0.389). There was a trend toward reduced odds of mortality post-credentialing (AOR: 0.59, p=0.261). Major surgical intervention decreased (Pre: 0.42%, Post: 0.04%; p=0.004). Conclusion Level IV TC accreditation has beneficial effects on increased transfer rates and may improve mortality. It is important to continue to observe the impact of Level IV TCs on patient outcomes within a mature trauma system. Level of Evidence III; prognostic and epidemiological Corresponding Author: Frederick B. Rogers, MD, MS, MA, FACS; Frederick.Rogers@pennmedicine.upenn.edu, 555 N. Duke St., Lancaster, PA 17602, 717-544-5945 (tel), 717-544-5944 (fax) All authors have neither conflict of interest nor disclosure of funding or proprietary interest to declare on the materials or subject matter discussed herein. This study was accepted for a Quick Shot presentation at the 32nd Annual Scientific Assembly of the Eastern Association for the Surgery of Trauma held in Austin, Texas from January 15-19, 2019. © 2019 Lippincott Williams & Wilkins, Inc.

Cholecystitis Complicated by Intrathoracic Gallbladder No abstract available

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

TITRATE TO EQUILIBRATE AND NOT EXSANGUINATE!: CHARACTERIZATION AND VALIDATION OF A NOVEL PARTIAL RESUSCITATIVE ENDOVASCULAR BALLOON OCCLUSION OF THE AORTA CATHETER IN NORMAL AND HEMORRHAGIC SHOCK CONDITIONS Background Resuscitative Endovascular Balloon Occlusion of the Aorta (REBOA) is a significant advancement in the control of non-compressible truncal hemorrhage. However, its ischemic burden and reperfusion injury following balloon deflation limits its utilization. Partial restoration of aortic flow during REBOA has the potential to balance hemorrhage control and ischemia. This study validates the mechanics, physiology, and optimal partial flow rates using a prototype partial REBOA (pREBOA) device. Methods 25 swine underwent placement of aortic flow probes and zone 1 pREBOA. Experiment 1(N=5) animals were not injured and assessed the tested the catheters ability to titrate and control flow. Experiment 2 (N=10) added 20% hemorrhage and either solid organ, or abdominal vascular injury to compare flow rate and re-bleeding from injuries. Experiment 3 (N=10) swine were similarly prepared, hemorrhaged, and underwent pREBOA at set partial flow rates for 2hr followed by complete deflation for 30min. Results Balloon volume at minimum flow (mean .09 L/min) was 3.5-6.0mL. Half maximal flow was achieved with 56.5% of maximum balloon inflation. pREBOA allowed very fine titration of flow rates. Rebleeding occurred at 0.45-0.83 L/min. Distal flow of 0.7 L/min had 50% survival, 0.5 had 100% survival, and 0.3L had 50% survival with mean end lactates of 9.6, 12.6, and 13.3 respectively. There was a trend towards hyperkalemia and hypocalcemia in non-survivors. Conclusions The pREBOA device demonstrated a high level of titratability for restoration of aortic flow. An optimal partial flow of 0.5L/min was effective at hemorrhage control while limiting the burden of ischemic injury, and extending the tolerable duration of zone 1 occlusion. Aggressive calcium supplementation prior to and during partial occlusion and reperfusion may be warranted to prevent hyperkalemic arrest. Level of Evidence III Study Type Therapeutic Presented at the 49th Annual Meeting of the Western Trauma Association, March 03-08, 2019 in Snowmass, CO This work was supported by a Department of Defense Medical Research and Development Program (DMRDP) research grant under the DHP 6.7 program: Proposal D6.7 16 C2 I 16 J9 1490, "Intermittent Resuscitative Endovascular Balloon Occlusion of the Aorta (REBOA) for Severe Non-compressible Truncal Hemorrhage" Conflicts of Interest: The authors have no conflicts of interest to declare and have received no financial or material support related to this manuscript Disclaimer: The results and opinions expressed in this article are those of the authors, and do not reflect the opinions or official policy of the United States Army or the Department of Defense. Corresponding Author: Matthew J. Martin, MD, FACS, Trauma and Emergency Surgery Service, Scripps Mercy Hospital, 550 Washington Avenue, Suite 641, San Diego, CA 92127, (619) 299-2600, traumadoc22@gmail.com © 2019 Lippincott Williams & Wilkins, Inc.

Pre-injury Palliative Performance Scale (PPS) predicts functional outcomes at 6 months in older trauma patients Background Older trauma patients have increased risk of adverse in-hospital outcomes. We previously demonstrated that low pre-injury Palliative Performance Scale (PPS) independently predicted poor discharge outcomes. We hypothesized that low PPS would predict long-term outcomes in older trauma patients. Methods Prospective observational study of trauma patients aged > 55 admitted between 7/2016-4/2018. Pre-injury PPS was assessed at admission; low PPS was defined as <70. Primary outcomes were mortality and functional outcomes, measured by GOSE, at discharge and 6 months. Poor functional outcomes were defined as GOSE < 4. Secondary outcomes were patient-reported outcomes at 6 months: EQ-5D and SF-36. Adjusted relative risks (aRRs) were obtained for each primary outcome using multivariable modified Poisson regression, adjusting for PPS, age, race/ethnicity, gender, and injury severity. Results In-hospital data were available for 516 patients; mean age 70 years and median ISS 13. 30% had low PPS. 6% (n=32) died in hospital, and half of survivors (n=248) had severe disability at discharge. Low PPS predicted hospital mortality (aRR 2.6, 95% CI 1.2-5.3) and poor outcomes at discharge (aRR 2.0, 95% CI 1.7-2.3). Six-month data were available for 176/203 (87%) patients who were due for follow-up. Functional outcomes improved in 64% at 6 months. However, 63% had moderate to severe pain, and 42% moderate to severe anxiety/depression. Mean GOSE improved less over time in low-PPS patients (7% vs. 24%; p<0.01). Low PPS predicted poor functional outcomes at 6 months (aRR 3.1, 95% CI 1.8-5.3) while age and ISS did not. Conclusions Pre-injury PPS predicts mortality and poor outcomes at discharge and 6 months. Despite improvement in function, persistent pain and anxiety/depression were common. Low-PPS patients fail to improve over time compared to high-PPS patients. Pre-injury PPS can be used on admission for prognostication of short- and long-term outcomes and is a potential trigger for palliative care in older trauma patients. Level of Evidence Prognostic study – level II Corresponding Author: Anne C. Mosenthal, MD, FACS, Professor and Chair, Department of Surgery, Rutgers – New Jersey Medical School, Medical Sciences Building G-506, 185 South Orange Avenue, Newark, NJ 07103, Email: mosentac@njms.rutgers.edu, Office: 973-972-5045 Meetings: This work was presented as a full oral presentation at the 77th Annual Meeting of the American Association for the Surgery of Trauma and 4th World Trauma Congress on September 28th, 2018 in San Diego, CA under the same title. Conflicts of Interest and Source of Funding: None of the authors have any personal conflicts of interest with the material. Support for this publication was provided by the Patient Centered Outcomes Research Institute through Grant PCORI-1502-27462 (Dr. Mosenthal) and by the Auen Foundation (Dr. Hwang). © 2019 Lippincott Williams & Wilkins, Inc.

Commentary on a Case Report, JT-D-19-09465 No abstract available

Screening and Treating Hospitalized Trauma Survivors for PTSD and Depression Traumatic injury affects over 2.6 million U.S. adults annually and elevates risk for a number of negative health consequences. This includes substantial psychological harm, the most prominent being posttraumatic stress disorder (PTSD), with approximately 21% of traumatic injury survivors developing the disorder within the first year after injury. PTSD is associated with deficits in physical recovery, social functioning, and quality of life. Depression is diagnosed in approximately 6% in the year after injury and is also a predictor of poor quality of life. The American College of Surgeons Committee on Trauma suggests screening for and treatment of PTSD and depression, reflecting a growing awareness of the critical need to address patients' mental health needs after trauma. While some trauma centers have implemented screening and treatment or referral for treatment programs, the majority are evaluating how to best address this recommendation and no standard approach for screening and treatment currently exists. Further, guidelines are not yet available with respect to resources that may be used to effectively screen and treat these disorders in trauma survivors, as well as who is going to bear the costs. The purpose of this review is: 1) to evaluate the current state of the literature regarding evidence-based screens for PTSD and depression in the hospitalized trauma patient, and 2) summarize the literature to date regarding the treatments that have empirical support in treating PTSD and depression acutely after injury. This review also includes structural and funding information regarding existing post-injury mental health programs. Screening of injured patients and timely intervention to prevent or treat PTSD and depression could substantially improve health outcomes and improve quality of life for this high-risk population. Level of Evidence Review, level IV Conflicts of Interest and Source of Funding: There are no conflicts of interest to declare and no sources of funding to declare. Corresponding Author: Terri deRoon-Cassini, Ph.D., M.S. (AAST Member) 1Medical College of Wisconsin Department of Surgery Division of Trauma & Acute Care Surgery 8701 Watertown Plank Road Milwaukee, WI 53226 tcassini@mcw.edu © 2019 Lippincott Williams & Wilkins, Inc.

Authors' Response. "Changes in US Mass Shooting Deaths Associated With the 1994-2004 Federal Assault Weapon Ban: Analysis of Open-Source Data." No abstract available

Alexandros Sfakianakis
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