Factors associated with organ donation by trauma patients in Nova Scotia Background Trauma patients represent a significant pool of potential organ donors (PODs), and previous research suggests that this population is underutilized for organ donation (OD). Our objective was to assess factors associated with OD in the trauma population. Methods We retrospectively analyzed OD in Nova Scotia over a 7-year period (2009-2016) using data from the Nova Scotia Trauma Registry (NSTR) and Nova Scotia Legacy of Life Donor Registry (LLDR). All trauma patients who died in hospital were included. Multiple logistic regression was used to assess factors associated with donation. We also evaluated characteristics, donation types, and reasons for non-donation among trauma PODs. Results There were 689 trauma-related deaths in all hospitals in NS during the study period, of which 39.8% (274/689) met the NSTR definition of a POD. Data on OD was available for 108 of these patients who were referred to the Legacy of Life Program. The conversion rate was 84%. Compared to non-donors, organ donors were significantly younger, had a higher Abbreviated Injury Scale head score and a lower scene Glasgow Coma Scale (GCS) score, were more likely to suffer ischemia from drowning or asphyxia and to require air transport, and were less likely to have comorbidities. Regression analysis showed donation was associated with younger age (OR 0.97, 95% CI 0.95-0.99) and lower GCS score at the scene (OR 0.76, 95% CI 0.66-0.88). Odds of donation were increased with air transport compared to land ambulance (OR 8.27, 95% CI 2.07-33.08) and injury within Halifax Regional Municipality (HRM) compared to injury outside HRM (OR 4.64, 95% CI 1.42-15.10). Among the 60 referred PODs who did not donate, family refusal of consent was the most common reason (28/60; 46.7%). Conclusions Younger age, greater severity of injury, and shorter time to tertiary care were associated with OD in trauma patients. Level of Evidence Level III, Prognostic and Epidemiological. Corresponding author: Robert S. Green, Room 377 Bethune Building, 1276 South Park Street, Halifax, NS, Canada, B3H 2Y9. Phone: (902) 473-7157. Fax: (902) 473-5835. Email: greenrs@dal.ca Presentations at conferences: Annual Meeting of the Trauma Association of Canada, February 22-23, 2018 in Toronto, Ontario. Conflicts of interest: None declared Financial support: Alexandra Hetherington and Sara Lanteigne were supported by a Trustees of the Ross Stewart Smith Studentship from the Research in Medicine Program, Faculty of Medicine, Dalhousie University. Adam Cameron was supported by the Canadian Department of National Defence. Robert Green was supported by a Clinician Scientist Award from the Faculty of Medicine, Dalhousie University. © 2019 Lippincott Williams & Wilkins, Inc.

Memories of Donald Dean Trunkey, MD, FACS No abstract available

Life-Saving Interventions in Pediatric Trauma: A National Trauma Data Bank Experience Background Emergent procedures infrequent in pediatric trauma. We sought determine the frequency and efficacy of life-saving interventions (LSI) performed for pediatric trauma patients within the first hour of care at a trauma center. Methods The National Trauma Data Bank (2010 – 2014) was queried for patients age ≤ 19 who underwent LSIs within 1 hour of arrival to the emergency department (ED). LSI included ED thoracotomy (EDT) and emergent airway procedures (EAP). Multivariable logistic regression was used to evaluate the influence of patient and hospital characteristics on mortality. Results Out of 725,284 recorded traumatic encounters, only 1,488 (0.2%) of pediatric patients underwent at least one of the defined LSI during the five-year study period (EDT 1,323; EAP 187). Most patients were ≥ 15 years old (85.6%). Mortality was high but varied by procedure type (EDT 64.3%; EAP 28.3%). Mortality for patients less than 1-year old undergoing EDT was 100%, decreasing to 62.6% in patients aged 15- to 19-years. For EAP, mortality ranged from 66.7% for infants to 27.2% in 15 to 19-year-old patients. Lower Glasgow Coma Scale score, higher Injury Severity Score, presence of shock, and a blunt mechanism of injury were independently associated with mortality in the EDT cohort. On average, trauma centers in this study performed approximately 1 LSI per year, with only 13.8% of cases occurring at a verified pediatric trauma center. Conclusion LSIs in the pediatric trauma population are uncommon and outcomes variable. Novel solutions to keep proficient at such interventions should be sought, especially for younger children. Guidelines to improve identification of appropriate candidates for LSI are critical given their rare occurrence. Level of Evidence III – Retrospective cohort study Address correspondence to: Michael L. Nance, MD, Department of Surgery, Children’s Hospital of Philadelphia, 3401 Civic Center Boulevard, Philadelphia, PA 19104. Telephone: 215-590-5932; Email: nance@email.chop.edu. Conflicts of Interest and Sources of Funding: The authors have no conflicts of interest relevant to this article to disclose. This research did not receive any specific grant from funding agencies in the public, commercial, or not-for-profit sectors. Presentations: This research was presented as an oral abstract at the 19th annual Templeton Trauma Symposium on March 1, 2019 in Pittsburgh, PA. © 2019 Lippincott Williams & Wilkins, Inc.

Endothelial cell dysfunction during Anoxia-Reoxygenation is associated with a decrease in ATP levels, rearrangement in lipid bilayer phosphatidylserine asymmetry, and an increase in endothelial cell permeability Background Phosphatidylserine (PS) is normally confined in an energy-dependent manner to the inner leaflet of the lipid cell membrane. During cellular stress PS is exteriorized to the outer layer, initiating a cascade of events. Because cellular stress is often accompanied by decreased energy levels and because maintaining PS asymmetry is an energy-dependent process, it would make sense that cellular stress associated with decreased energy levels is also associated with PS exteriorization that ultimately leads to endothelial cell dysfunction. Our hypothesis was that anoxia-reoxygenation (A-R) is associated with decreased ATP levels, increased PS exteriorization on endothelial cell membranes, and increased endothelial cell membrane permeability. Methods The effect on ATP levels during anoxia-reoxygenation was measured via colorimetric assay in cultured cells. To measure the effect of A-R on PS levels, cultured cells underwent A-R and exteriorized PS levels and also total cell PS were measured via biofluorescence assay. Finally, we measured endothelial cell monolayer permeability to albumin after A-R. Results ATP levels in cell culture decreased 27% from baseline after A-R (p<0.02). There was over a 2-fold increase in exteriorized PS as compared to controls (p<0.01). Interestingly, we found that during A-R, the total amount of cellular PS increased (p<0.01). The finding that total PS changed 2-fold over normal cells suggested that not only is there a change in the distribution of PS across the cell membrane, but there may also be an increase in the amount of PS inside the cell. Finally, A-R increased endothelial cell monolayer permeability (p<0.01). Conclusions We found that endothelial cell dysfunction during A-R is associated with decreased ATP levels, increased PS exteriorization, and increased in monolayer permeability. This supports the idea that phosphatidylserine exteriorization may a key event during clinical scenarios involving oxygen lack and may one day lead to novel therapies in these situations. Level of Evidence Basic Science Paper Correspondence: Gregory Victorino, MD, 1411 E 31st St, Dept of Surgery—UCSF East Bay, QIC 22134, Oakland, CA 94602, T 5104378370, F 5104375127. Gregory.victorino@ucsf.edu There are no conflicts of interest to report. Manuscript presented at the 77th Annual Meeting of the American Association for the Surgery of Trauma, Sep 26-29, 2018 in San Diego, CA Funding support from NIH KO8 GMO81361 © 2019 Lippincott Williams & Wilkins, Inc.

Prehospital Resuscitation In Adult Patients Following Injury: A Western Trauma Association Critical Decisions Algorithm Level of Evidence III Presented at the 49th Annual Western Trauma Association Meeting, Snowmass, CO, March 3-8, 2019 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 any of the listed affiliated institutions, the United States Army, or the Department of Defense (if military co-authors). Corresponding Author: Jason L. Sperry MD, MPH, University of Pittsburgh Medical Center, 200 Lothrop St., Pittsburgh, Pennsylvania 15213, office 412-802 8270, fax 412-647-1448. sperryjl@upmc.edu © 2019 Lippincott Williams & Wilkins, Inc.

Role of TNF-α in vascular hyporeactivity following endotoxic shock and its mechanism Background Vascular hyporeactivity plays an important role in organ dysfunction induced by endotoxic shock. Given that cytokine such as TNF-α plays an important role in endotoxic shock, the aim of the present study is to investigate the role of TNF-α in vascular hyporeactivity following endotoxic shock and the mechanisms. Methods Lipopolysaccharide (LPS, 1mg/Kg) injection was used for replicating the endotoxic shock model in the rabbit. The changes in the level of TNF-α in plasma in the rabbits model and the contractile response of superior mesenteric arteries (SMA) to norepinephrine (NE) and Ca2+ were observed. The mechanisms in TNF-α-induced vascular hyporeactivity were further explored. Results The levels of TNF-α in plasma were gradually increased after 1h of LPS administration and reached the peak at 6 h. The contractile responses of SMA to NE were decreased at 1h of LPS and lowest at 6h. TNF-α (200ng/ml) incubation decreased contractile response of SMA to NE significantly. The further studies found that calcium desensitization participated in the occurrence of TNF-α-induced vascular hyporeactivity, the changes were consistent with the changes of vascular reactivity, calcium sensitivities were decreased significantly at 1h, 2h, 4h, and 6h after LPS injection. TNF-α (200ng/ml) incubation could significantly reduce the contractile response of SMA to Ca2+. The activity of Rho-kinase and the changes of MLC20 phosphorylation level were significantly decreased at 6h following LPS administration, and TNF-α (200ng/ml) incubation led to decrease of Rho-kinase and MLC20 phosphorylation. Arginine vasopressin (AVP) significantly antagonized TNF-α (200ng/ml)-induced the decrease of the vascular reactivity and calcium sensitivity. Conclusions TNF-α is involved in vascular hyporeactivity after endotoxic shock. Calcium desensitization plays an important role in TNF-α-induced vascular hyporeactivity after endotoxic shock. Rho-kinase/MLC20 phosphorylation pathway takes part in the regulation of calcium desensitization and vascular hyporeactivity induced by TNF-α. AVP is beneficial to endotoxic shock in TNF-α-induced vascular hyporeactivity. Study type therapeutic/care management Level of evidence Level I CORRESPONDING AUTHORS: LiangMing Liu and Tao Li, Second Department of Research Institute of Surgery, Daping Hospital, Third Military Medical University (Army Medical University), Daping, Chongqing 400042, People’s Republic of China, Tel: +86-23-68757421, Fax: +86-23-68757421. E-mail: liangmingliu@yahoo.com, lt200132@163.com Tao Li and LiangMing Liu Equally contributed to this work. Address for reprints: LiangMing Liu, MD, PhD, Tao Li, PhD, Second Department of Research Institute of Surgery, Daping Hospital, Third Military Medical University (Army Medical University), Chongqing 400042, P.R.China; E-mail: liangmingliu@yahoo.com, lt200132@163.com Interest No conflict of interest exists in the submission of this manuscript. Disclosure This work was supported by a grant from Key Projects and Innovation Group of National Natural Science Foundation of China (grant No.81830065, 81721001) and the National Key R&D Program of China (grant No.2017YFC1103302). The sponsor had no involvement in study design; in the collection, analysis and interpretation of data; in the writing of the report; and in the decision to submit the article for publication. This study was approved by the Research Council and Animal Care and Use Committee of Research Institute of Surgery, Third Military Medical University. Our methods conformed to the Guide for the Care and Use of Laboratory Animals published by the US National Institutes of Health (NIH Publication, 8th edition, 2011). © 2019 Lippincott Williams & Wilkins, Inc.

ELDERLY ADULTS WITH ISOLATED HIP FRACTURES - ORTHOGERIATRIC CARE VERSUS STANDARD CARE: A PRACTICE MANAGEMENT GUIDELINE FROM THE EASTERN ASSOCIATION FOR THE SURGERY OF TRAUMA Background Elderly patients commonly suffer isolated hip fractures, causing significant morbidity and mortality. The use of orthogeriatrics (OG) management services, in which geriatric specialists primarily manage or co-manage patients after admission, may improve outcomes. We sought to provide recommendations regarding the role of OG services. Methods Using GRADE methodology with meta-analyses, the Practice Management Guidelines Committee of the Eastern Association for the Surgery of Trauma conducted a systematic review of the literature from January 1, 1900 to August 31, 2017. A single PICO question was generated with multiple outcomes: Should geriatric trauma patients aged 65+ with isolated hip fracture receive routine OG management, compared to no routine OG management, to decrease mortality, improve discharge disposition, improve functional outcomes, decrease in-hospital medical complications, and decrease hospital length of stay. Results Forty-five manuscripts were evaluated. Six randomized controlled trials and seven retrospective case-control studies (RCCS) met criteria for quantitative analysis. For critical outcomes, RCCS demonstrated a 30-day mortality benefit with OG (OR 0.78[0.67, 0.90]), but this was not demonstrated prospectively or at one year. Functional outcomes were superior with OG, specifically improved score on the Short Physical Performance Battery at four months (MD 0.78 [0.28, 1.29]), and improved score on the Mini Mental Status Exam with OG at 12 months (MD 1.57 [0.40, 2.73]). Execution of activities of daily living was improved with OG as measured by two separate tests at four and twelve months. There was no difference in discharge disposition. Among important outcomes, the OG group had fewer hospital-acquired pressure ulcers (OR 0.30 [0.15, 0.60]). There was no difference in other complications or length of stay. Overall quality of evidence was low. Conclusions In geriatric patients with isolated hip fracture, we conditionally recommend an OG care model to improve patient outcomes. Level of Evidence Level III evidence Study Type Systematic Review/Meta-Analysis Funding Source: None Conflicts of Interests: None Presented at: Eastern Association for the Surgery of Trauma 32nd Annual Scientific Assembly, January 15-19, 2019, Austin, Texas. Corresponding Author Information: Marie E. Crandall, MD, MPH, FACS, Professor of Surgery, Associate Chair for Research, Department of Surgery, Associate Program Director, General Surgery Residency, University of Florida College of Medicine Jacksonville, 655 W. 8th Street, Jacksonville, FL 32209, 904 244 6631. marie.crandall@jax.ufl.edu © 2019 Lippincott Williams & Wilkins, Inc.

Vancomycin dosing in critically ill trauma patients: The VANCTIC Study Background Current guidelines from the Infectious Diseases Society of America (IDSA) and the American Society of Health-System Pharmacists (ASHP) recommend vancomycin troughs of 15 – 20mg/L for serious MRSA infections. The pharmacokinetics of vancomycin are altered in critically ill patients, leading to inadequate serum levels. Rates of initial therapeutic vancomycin troughs have ranged from 17.6–33% using intermittent infusions (i.e. 15–20mg/L) and approximately 60% using continuous infusions (i.e. 15–25mg/L) in critically ill trauma patients (1-4). We hypothesized that our dosing protocol would achieve higher rates of initial therapeutic troughs compared to previously published reports due to more aggressive loading doses than those seen in previously published reports. Methods This was a retrospective study of all critically ill trauma patients admitted to a Level I trauma ICU over a 39-month period who had a suspected serious infection, who were treated with empiric vancomycin per the “pharmacy to dose” protocol, and who had an appropriately drawn steady state trough level. The primary outcome was the rate of initial therapeutic troughs, which was defined as 14.5–20.5 mg/L. Results 197 patients were screened. 70 patients met inclusion criteria. The study cohort had a median age 47.5 years and a median Injury Severity Score (ISS) of 28. Augmented renal clearances were observed, with a median creatinine clearance of 159.1 ml/min and a median ARCTIC score of seven. The median vancomycin loading dose was 24.6 mg/kg with an initial maintenance dose of 17.71 mg/kg. A q8hr dosing interval was initiated on 47.14% of the patients, and 45.71% of the patients were initially started on a q12hr dosing interval. Only 15.71% of the study patients achieved an initial therapeutic trough; 42.86% were <10 mg/L and 8.57% were >20.5 mg/L. Acute kidney injury (AKI) occurred in 10% based on the IDSA/ASHP vancomycin guidelines and in 11.4% based on the Acute Kidney Injury Network (AKIN) criteria. Conclusion Our incidence of initial therapeutic troughs were slightly below previously reported studies. Based on our results, which are consistent with previous literature, it would appear that our guideline-adherent protocol of intermittent vancomycin is insufficient to achieve troughs of 15 – 20 mg/L. Level of evidence III Therapeutic Correspondence: Ruben D. Villanueva, 110 N. Stonewall Ave. CPB 205, Oklahoma City, OK 73117, 405.271.6878 x47257. No conflicts of interest noted per authors Presented at the 49th Annual Western Trauma Association Meeting, March 3rd – 8th, 2019 in Snowmass, CO © 2019 Lippincott Williams & Wilkins, Inc.

Blame it on the Injury: Trauma is a Risk Factor for Pancreatic Fistula Following Distal Pancreatectomy Compared to Elective Resection Introduction Postoperative pancreatic fistula (POPF) remains a significant source of morbidity following distal pancreatectomy (DP). There is a lack of information regarding the impact of trauma on POPF rates when compared to elective resection. We hypothesize that trauma will be a significant risk factor for the development of POPF following DP. Methods A retrospective, single-institution review of all patients undergoing DP from 1999-2017 was performed. Outcomes were compared between patients undergoing DP for traumatic injury to those undergoing elective resection. Univariate and multivariable analysis were performed using SAS (version 9.4). Results Of the 372 patients who underwent DP during the study period, 298 met inclusion criteria: 38 DPs for trauma (TDP), 260 elective DPs (EDP). Clinically significant grade B or C POPFs occurred in 17/38 or 44.7% of TDPs compared to 41/260 or 15.8% of EDPs (p<0.0001). On multivariable analysis, traumatic injury was found to be independently predictive of developing a grade B or C POPF (OR=4.3, 95% CI: 2.10-8.89). Age, gender, and wound infection were highly correlated with traumatic etiology and therefore were not retained in the multivariable model. When analyzing risk factors for each group (trauma vs elective) separately, we found that TDP patients who developed POPFs had less sutured closure of their duct, higher infectious complications, and longer hospital stays, while EDP patients that suffered POPFs were more likely to be male, younger in age, and at a greater risk for infectious complications. Lastly, in a subgroup analysis involving only patients with drains left postoperatively, trauma was an independent predictor of any grade of fistula (A, B, or C) compared to elective DP (OR=8.6, 95% CI: 3.09-24.15), suggesting that traumatic injury is risk factor for pancreatic stump closure disruption following DP. Conclusion To our knowledge, this study represents the largest cohort of patients comparing pancreatic leak rates in traumatic vs elective DP, and demonstrates that traumatic injury is an independent risk factor for developing an ISGPF grade B or C pancreatic fistula following DP. Level of Evidence III, prognostic study Corresponding Author: Noah S. Rozich, MD, University of Oklahoma Health Sciences Center. Email: noah-rozich@ouhsc.edu 800 Stanton L. Young BLVD, Suite 9000, Oklahoma City, OK 73126-0901 Phone: (405) 271-6308 Fax: (405) 271-3919 Conflicts of interest: none of the authors for this manuscript have any conflicts of interest to declare. Sources of funding: no funding was received in support of this project. This work was presented at the 77th annual meeting of The American Association for the Surgery of Trauma in San Diego, California, on September 18th, 2018. © 2019 Lippincott Williams & Wilkins, Inc.

PATHway to success: implementation of a multiprofessional acute trauma healthcare team decreased length of stay and cost in patients with neurological injury requiring tracheostomy Background The aim of this study was to determine whether the implementation of a dedicated multiprofessional acute trauma healthcare (mPATH) team would decrease length of stay without adversely impacting outcomes of patients with severe traumatic brain and spinal cord injuries. The mPATH team was comprised of a physical, occupational, speech, and respiratory therapist, nurse navigator, social worker, advanced care provider, and physician who performed rounds on the subset of trauma patients with these injuries from the Intensive Care Unit to discharge. Methods Following the formation and implementation of the mPATH team at our Level I trauma center, a retrospective cohort study was performed comparing patients in the year immediately prior to the introduction of the mPATH team (n=60) to those in the first full year following implementation (n=70). Demographics were collected for both groups. Inclusion criteria were Glasgow Coma Score less than 8 on post-injury day two, all paraplegic and quadriplegic patients, and patients over age 55 with central cord syndrome who underwent tracheostomy. The primary endpoint was length of stay; secondary endpoints were time to tracheostomy, days to evaluation by occupational, physical, and speech therapy, 30-day readmission, and 30-day mortality. Results The median time to evaluation by occupational, physical, and speech therapy was universally decreased. Injury Severity Score was 27 in both cohorts. Time to tracheostomy and length of stay were both decreased. 30-day readmission and mortality rates remained unchanged (Table 2). A cost savings of $11,238 per index hospitalization was observed. Conclusions In the year following the initiation of the mPATH team we observed earlier time to occupational, physical, and speech therapist evaluation, decreased length of stay, and cost savings in severe traumatic brain and spinal cord injury patients requiring tracheostomy compared to our historical control. These benefits were observed without adversely impacting 30-day readmission or mortality. Level of Evidence therapeutic/care management Correspondence: Bradley W. Thomas, MD FACS, PO Box 32861 c/o Cherry Strickland, Charlotte, NC 28232, Bradley.thomas@atriumhealth.org, 704-355-5619 (fax), 704-355-3176 (office) Presented at the 32nd Annual Eastern Association for the Surgery of Trauma Scientific Assembly on January 17, 2019 in Austin, Texas No disclosures, conflicts of interest, other presentations of this work. © 2019 Lippincott Williams & Wilkins, Inc.