2018 Pediatric Trauma Society Presidential Address: Another Point of View No abstract available

Prevention of Firearm Injuries: It all Begins with a Conversation No abstract available

CONCOMITANT BLADDER AND RECTAL INJURIES: RESULTS FROM THE AMERICAN ASSOCIATION FOR THE SURGERY OF TRAUMA (AAST) MULTI-CENTER RECTAL INJURY STUDY GROUP Background Combined traumatic injuries to the rectum and bladder are rare. We hypothesized that the combination of bladder and rectal injures would have worse outcomes than rectal injury alone. Methods This is an American Association for the Surgery of Trauma multi-institutional retrospective study from 2004-2015 traumatic rectal injury patients who were admitted to one of 22 participating centers. Demographics, mechanism, and management of rectal injury were collected. Patients who sustained a rectal injury alone were compared to patients who sustained a combined injury to the bladder and rectum. Multivariable logistic regression was used to determine if abdominal complications, mortality, and length of stay were impacted by a concomitant bladder injury after adjusting for cofounders. Results There were 424 patients who sustained a traumatic rectal injury, of which 117 (28%) had a combined injury to the bladder. When comparing the patients with a combined bladder/rectal injury to the rectal alone group there was no difference in admission demographics admission physiology, or injury severity score. There was also no differences in management of the rectal injury and no difference in abdominal complications (13% vs. 16%, p=0.38), mortality (3% vs. 2%, p=0.68), or length of stay (17 days vs. 21 days, p=0.10). When looking at only the 117 patients with a combined injury, the addition of a colostomy did not significantly decrease the rate of abdominal complications (14% vs. 8%, p=0.42), mortality (3% vs. 0%, p=0.99), or length of stay (17 days vs. 17 days, p=0.94). After adjusting for cofounders (AAST rectal injury grade, gender, damage control surgery, diverting colostomy, and length of stay) the presence of a bladder injury did not impact outcomes. Conclusion For patients with traumatic rectal injury, a concomitant bladder injury does not increase the rates of abdominal complications, mortality, or length of stay. Furthermore, the addition of a diverting colostomy for management of traumatic bladder and rectal injury does not change outcomes. Level of Evidence IV; prognostic Corresponding Author: E. Charles Osterberg, MD, Assistant Professor of Surgery and Perioperative Care, Dell Medical School at the University of Texas at Austin, Charles.osterberg@austin.utexas.edu, Dell Seton Medical Center at The University of Texas at Austin, 1500 Red River St, Brackenridge Annex 301, Austin, TX 78701, Phone: (512) 324 – 8470, Fax: (512) 324 – 8471 Presented at the South Central Section of the American Urological Association on September 27th 2018 Conflict of Interest: Dr Holcomb has received honoraria from CMO of Prytime Medical, a founder and on the Board of Directors of Decisio Health, a Co-inventor of the Junctional Emergency Tourniquet Tool, an advisor to Terumo BCT and Arsenal Medical. For the remaining authors, no conflicts were declared. Disclosure of Funding: none © 2019 Lippincott Williams & Wilkins, Inc.

Critical Call for Hospital-Based Domestic Violence Intervention: The Davis Challenge BACKGROUND 50% of women killed in intimate partner violence (IPV) were seen by a health care provider within a year of their death. As guest speaker to Virginia Commonwealth University Trauma Center (VCU-TC), Dr. James Davis (Western Trauma Association - past president) challenged VCU-TC to develop a hospital-based IPV program. This research examines the development and impact of an integrated hospital/VCU-TC based IPV program. METHODS IPV survey was carried out to determine need for training and screening. Hospital forensic nurse examiners (FNE) case logs were evaluated to determine IPV prevalence. An integrated IPV program – Project Empower was developed, consisting of staff education, patient screening, victim crisis fund, and interdisciplinary sexual assault/domestic violence intervention team. Between 2014-2018, patients admitted with an IPV consult to Project Empower were entered into a secure database capturing demographics, mechanisms, income data, and social determinants of risk. Program feasibility was evaluated on patient engagement via screening and case management. Program impact was evaluated on crisis intervention, safety planning, and community referral. RESULTS FNE data and IPV survey evaluation noted 20% IPV prevalence and lack of IPV screening and training. IPV patients (N=799) were women (90%), unmarried (79%) and African-American (60%). Primary mechanisms were firearm (44%) or stabbing (34%). Survivors were perpetrated by a cohabiting (42%) or dating partner (18%). Monthly income averaged $622. 40% had no health insurance. Advocates provided 62% case management. Survivors received victim crisis funds (16%), safety planning (68%), crisis intervention (78%), sexual and domestic violence education (83%), and community referral (83%). Within five years, 35 (4 %) were re-injured and seen in the ED. 31 (4%) were readmitted for IPV related injuries. Two deaths were attributed to IPV. CONCLUSION Critical call for hospital-based IPV intervention programs as a priority for trauma centers to adopt cannot be underestimated but can be answered in a comprehensive integrated model. Level of Evidence III Study Type Original Article, Therapeutic Corresponding Author: Michel B. Aboutanos, MD, MPH, FACS, Division of Acute Care Surgical Services, Department of Surgery, Virginia Commonwealth University Medical Center, 1200 East Broad Street, P.O. Box 980454, Richmond Virginia 23298, Telephone: (804) 827-1207, Fax: (804) 827-0285, michel.aboutanos@vcuhealth.org Conflict of Interest: All authors on this manuscript declare no conflict of interest. The research was approved by the Institutional Review Boards of the Virginia Commonwealth University. Meeting: Our study was presented as a podium presentation at the Western Trauma Association 49th Annual Meeting on March 7, 2019 at the Westin Snowmass Resort, Snowmass, Colorado. Support: This study was supported by VA DCJS Victims of Crime Act -VOCA FP4537/17, the Richmond Memorial Health Foundation grant, the VCU Auxiliary Funds, and the MCV Foundation Hospital - Trauma Fund –881425 Index. © 2019 Lippincott Williams & Wilkins, Inc.

Antimotility Agents For The Treatment Of Acute Non-Infectious Diarrhea In Critically Ill Patients: A Practice Management Guideline From The Eastern Association For The Surgery Of Trauma Background Acute non-infectious diarrhea is a common phenomenon in ICU patients. Multiple treatments are suggested but the most effective management is unknown. A working group of the Eastern Association for the Surgery of Trauma (EAST), aimed to evaluate the effectiveness of loperamide, diphenoxylate/atropine, and elemental diet on acute non-infectious diarrhea in critically ill adults and to develop recommendations applicable to daily clinical practice. Methods The literature search identified 11 randomized controlled trials (RCT) appropriate for inclusion. The Grading of Recommendations Assessment, Development and Evaluation (GRADE) methodology was applied to evaluate the effect of loperamide, diphenoxylate/atropine, and elemental diet on the resolution of non-infectious diarrhea in critically ill adults based on selected outcomes: improvement in clinical diarrhea, fecal frequency, time to the diarrhea resolution, and hospital length of stay. Results The level of evidence was assessed as very low. Analyses of 10 RCTs showed that loperamide facilitates resolution of diarrhea. Diphenoxylate/atropine was evaluated in three RCTs and was as effective as loperamide and more effective than placebo. No studies evaluating elemental diet as an intervention in patients with diarrhea were found. Conclusion Loperamide and diphenoxylate/atropine are conditionally recommended to be used in critically ill patients with acute non-infectious diarrhea. Level of Evidence Level II Type of Study Therapeutic Corresponding Author: Nikolay Bugaev, MD, Division of Trauma & Acute Care Surgery, Tufts Medical Center, Tufts University School of Medicine, Boston, MA. nbugaev@tuftsmedicalcenter.org. 800 Washington St, #4488, Boston, MA, 02111, Tel. 617-636-4488, Fax 617-636-8172 Conflict of Interests: no conflicts to disclose The manuscript was presented as a podium presentation at the 32nd EAST Annual Scientific Assembly on January 15-19, 2019 at the JW Marriott Austin in Austin, Texas. Disclosures of Funding: nothing to disclose. © 2019 Lippincott Williams & Wilkins, Inc.

Helmet Use is Associated with Higher Injury Severity Scores in Alpine Skiers and Snowboarders Evaluated at a Level 1 Trauma Center Background There is uncertainty regarding the efficacy of ski helmets in preventing traumatic injury. We investigated the relationship between helmet use, injury types and injury severity among skiers and snowboarders. Methods The trauma registry at a Northeast ACS Level 1 trauma center was queried by ICD 9/10-code for skiing and snowboarding injury between 2010 and 2018. The primary exposure was helmet use and primary outcome was severe injury (injury severity score >15). We performed univariate and multivariable logistic regression to assess for injury types and severity associated with helmet use. Results 721 patients (65% helmeted, 35% unhelmeted) met inclusion criteria. Helmet use doubled during the study period (43% to 81%, p<0.001), but the rate of any head injury did not significantly change (49% to 43%, p=0.499). On multivariable regression, helmeted patients were significantly more likely to suffer severe injury (OR:2.01, CI:1.30-3.11), intracranial hemorrhage (OR:1.81, CI:1.10-2.96), chest injury (OR:1.66, CI:1.05-2.61), and/or lumbosacral spine injury (OR:1.84, CI:1.04-3.25) than unhelmeted patients. Helmeted patients were half as likely to suffer cervical spine injury (OR:0.51, CI:0.30-0.89) and a third as likely to sustain skull fracture and/or scalp laceration (OR:0.30, CI:0.14-0.64). More patients who hit a stationary object were helmeted compared to those who fell from standing height onto snow (70% vs. 56% respectively, p<0.001). After adjustment, hitting a stationary object was the injury mechanism most significantly associated with severe injury (OR:2.80, CI:1.79-4.38). Conclusion Helmeted skiers and snowboarders evaluated at a Level 1 trauma center were more likely to suffer severe injury, including intracranial hemorrhage, as compared to unhelmeted participants. However, they were less likely to sustain skull fractures or cervical spine injuries. Helmeted patients were also more likely to hit a stationary object. Our findings reinforce the importance of safe skiing practices and trauma evaluation after high impact injury, regardless of helmet use. Level of Evidence III, prognostic and epidemiological 49th Annual Meeting Western Trauma Association Earl G. Young Clinical Research Competition March 3rd - 8th, 2019 Aspen, CO Correspondence: Andrew O. Crockett, MD, Assistant Professor of Surgery, Division of Trauma and Acute Care Surgery, Dartmouth-Hitchcock Medical Center, 1 Medical Center Dr.Lebanon, NH 03756. T: (603)650-5000, F: (603)650-8030 Conflict of Interest Statement: The authors of this manuscript have nothing to declare. © 2019 Lippincott Williams & Wilkins, Inc.

Influence of prehospital physician presence on survival after severe trauma: Systematic review and meta-analysis Background As trauma is one of the leading causes of death worldwide, there is great potential for reducing mortality in trauma patients. However, there is continuing controversy over the benefit of deploying EMS physicians in the prehospital setting. The objective of this systematic review and meta-analysis is to assess how out-of-hospital hospital management of severely injured patients by EMS teams with and without physicians affects mortality. Methods PubMed and Google Scholar were searched for relevant articles and the search was supplemented by a hand search. Injury severity in the group of patients treated by an EMS team including a physician had to be comparable to the group treated without a physician. Primary outcome parameter was mortality. Helicopter transport as a confounder was accounted for by sub-group analyses including only the studies with comparable modes of transport. Quality of all included studies was assessed according to the Cochrane handbook. Results 2,249 publications were found, 71 full-text articles assessed and 22 studies included. Nine of these studies were matched or adjusted for injury severity. The odds ratio (OR) of mortality was significantly lower in the EMS physician-treated group of patients: 0.81; 95% confidence interval (CI): 0.71-0.92. When analysis was limited to the studies that were adjusted or matched for injury severity, the OR was 0.86 (95% CI: 0.73-1.01). Analysing only studies published after 2005 yielded an OR for mortality of 0.75 (95% CI: 0.64-0.88) in the overall analysis and 0.81 (95% CI: 0.67-0.97) in the analysis of adjusted or matched studies. The OR was 0.80 (95% CI: 0.65-1.00) in the sub-group of studies with comparable modes of transport and 0.74 (95% CI: 0.53-1.03) in the more recent studies. Conclusion Prehospital management of severely injured patients by EMS teams including a physician seems to be associated with lower mortality. After excluding the confounder of helicopter transport we have shown a non-significant trend toward lower mortality. Level of evidence level III Type of study Systematic review and meta-analysis Corresponding author: Dr. Jürgen Knapp, MD, Department of Anaesthesiology and Pain Medicine, Inselspital, Bern University Hospital, University of Bern, Freiburgstrasse, 3010 Bern, Switzerland, Phone: +41 31 632 04 96, Mobile: +49 176 20 370 299. E-mail: juergen.knapp@insel.ch Funding: None Conflicts of interest: None © 2019 Lippincott Williams & Wilkins, Inc.

KEtaminE/ProPofol Admixture vs Etomidate for Intubation in the Critically-Ill: KEEP PACE Randomized Clinical Trial Background Peri-intubation hypotension is associated with poor outcomes in the critically-ill. We aimed to determine if an admixture of ketamine and propofol for emergent endotracheal intubation in critically-ill patients was superior to etomidate. Primary endpoint was the change in mean arterial pressure from baseline to 5 minutes post-drug administration. Methods Emergent-use, stratified (shock status and unit type), multi-unit, randomized, parallel-group superiority clinical trial was conducted at a tertiary academic medical center. Adult medical/surgical and transplant/oncologic intensive care unit patients undergoing emergent intubation were assigned randomly to receive either ketamine/propofol admixture [0.5 mg/kg of ketamine and propofol each] or reduced dose etomidate [0.15 mg/kg] for emergent intubation. Results One hundred and sixty participants were randomized and 152 (79 ketamine/propofol admixture, 73 etomidate) were included in the intention-to-treat analysis. There was no statistically significant difference in mean arterial pressure change from baseline to 5 minutes post-drug administration [treatment difference (ketamine/propofol admixture – etomidate): -2.1 mmHg 95% C.I. (-6.9 mmHg, +2.7 mmHg); P=0.385]. In addition, no statistically significant difference was demonstrated in the change of mean arterial pressure from baseline at 10 and 15 minutes post-drug administration, no statistical difference in the use of new-onset vasoactive agents or difficulty of intubation between groups. More patients in the etomidate group required non-red blood cell transfusions [16 (22%) vs. 8 (10%), P=0.046]. For patients who had adrenal testing performed, more patients in the etomidate group developed immediate adrenal insufficiency [13/16 (81%) vs. 5/13 (38%), P=0.027]. Serious adverse events were rare, 2 (3%) [cardiac arrest, hypotension] in ketamine/propofol admixture and 4 (5%) [hypertension, hypotension] in etomidate (P=0.430). Conclusions In a heterogeneous critically-ill population, ketamine/propofol admixture was not superior to a reduced dose of etomidate at preserving per-intubation hemodynamics and appears to be a safe alternative induction agent in the critically-ill. Level of Evidence Level 1, Therapeutic Trial Registry ClinicalTrials.gov, # NCT02105415, Ketamine / Propofol Admixture "Ketofol" at Induction in the Critically Ill Against Etomidate: KEEP PACE Trial, IRB# 13-000506, Trial Registration: 03/31/2014 Correspondence/Reprints: Nathan J. Smischney, MD, Department of Anesthesiology, Mayo Clinic, 200 First St SW, Rochester, MN 55905. Tel: 507-255-6051/Fax: 507-255-4267. Email: smischney.nathan@mayo.edu. No reprints will be ordered. Conflict of Interest: Drs. Smischney and Nicholson have a provisional patent filed for ketamine/propofol admixture: Serial #:62/487,330; Filing Date: 04/19/17. The other authors have nothing to disclose. Meetings: 2018 Military Health System Research Symposium, August 20-23, 2018 in Kissimmee, Florida; 2018 Georgia Society of Anesthesiologists Summer Meeting, July 13-15, 2018 in Lake Oconee, Greensboro, Georgia. Financial Support: Funded by the Department of Anesthesiology and Perioperative Medicine and the Critical Care Independent Multidisciplinary Practice at Mayo Clinic Rochester. This publication was made possible by CTSA Grant Number UL1 TR002377 from the National Center for Advancing Translational Sciences (NCATS), a component of the National Institutes of Health (NIH). Its contents are solely the responsibility of the authors and do not necessarily represent the official view of NIH. © 2019 Lippincott Williams & Wilkins, Inc.

My Dad the Renaissance Man No abstract available

One Year Mortality in Geriatric Trauma Patients: Improving Upon the Geriatric Trauma Outcomes Score Utilizing the Social Security Death Index Background GTOS predicts in-patient mortality in geriatric trauma patients and has been validated in a prospective multicenter trial and expanded to predict adverse discharge (GTOS II). We hypothesized that these formulations actually underestimate the downstream sequelae of injury and sought to predict longer-term mortality in geriatric trauma patients. Methods The Parkland Memorial Hospital Trauma registry was queried for patients age ≥65 years from 2001–2013. Patients were then matched to the SSDI. The primary outcome was one-year mortality. The original GTOS formula (variables of age, ISS, 24-hour transfusion) was tested to predict 1-year mortality using receiver operator curves. Significant variables on univariate analysis were used to build an optimal multivariate model to predict 1-year mortality (GTOS III). Results There were 3,262 patients who met inclusion. Inpatient mortality was 10.0% (324) and increased each year: 15.8% one, 17.8% two, and 22.6% five years. The original GTOS equation had an area under the curve (AUC) of 0.742 for 1-year mortality. Univariate analysis showed that patients with 1-year mortality had on average increased age (75.7 vs. 79.5 years), ISS (11.1 vs. 19.1), lower GCS (14.3 vs. 10.5), more likely to require transfusion within 24 hours (11.5% vs. 31.3%), and adverse discharge (19.5% vs. 78.2%; p<0.0001 for all). Multivariate logistic regression was used to create the optimal equation to predict one-year mortality: [GTOSIII = Age + (0.806 x ISS) + 5.55 (if transfusion in first 24 hours) + 21.69 (if low GCS) + 34.36 (if adverse discharge)]; AUC of 0.878. Conclusions Traumatic injury in geriatric patients is associated with high mortality rates at 1–5 years. GTOS III has robust test characteristics to predict death at one year and can be used to guide patient centered goals discussions with objective data. Study Type Original Article Level of Evidence III Evidence Level III: Retrospective cohort study Presented at the 49th Annual Meeting of Western Trauma Association, March 4, 2019 in Snowmass, Colorado, Earl G. Young Clinical Research Competition Award Nomination Paper No funding was received for this study The authors have no conflicts of interest to report Senior Author Contact: Herbert Phelan, MD, MSCS, FACS, Associate Professor of Surgery, Division of General and Acute Care Surgery, UT Southwestern Medical Center, 5323 Harry Hines Blvd. – Mail Code 9158, Dallas, TX 75390-9158, Email: Herbert.Phelan@utsouthwestern.edu, Phone: 214-648-7548 © 2019 Lippincott Williams & Wilkins, Inc.