A Comparison Between the TEG® 6s and TEG® 5000 Analyzers to Assess Coagulation in Trauma Patients Background Trauma-induced coagulopathy is a major driver of mortality following severe injury. Viscoelastic goal-directed resuscitation can reduce mortality after injury. The TEG® 5000 system is widely used for viscoelastic testing. However, the TEG® 6s system incorporates newer technology, with encouraging results in cardiovascular interventions. The purpose of this study was to validate the TEG® 6s system for use in trauma patients. Methods Multicenter noninvasive observational study for method comparison conducted at 12 US Level I and II trauma centers. Agreement between the TEG® 6s and TEG® 5000 systems was examined using CK.R, CFF.MA, CK.LY30, CRT.MA and CK.MA parameters in adults meeting full or limited trauma team criteria. Blood was drawn ≤1hr after admission. Assays were repeated in duplicate. Reliability (TEG® 5000 vs. TEG® 6s analyzers) and repeatability (inter-device comparison) was quantified. Linear regression was used to define the relationship between TEG® 6s and TEG® 5000 devices. Results A total of 475 patients were enrolled. The cohort was predominantly male (68.6%) with a median age of 49 years. Regression line slope estimates (ß) and linear correlation estimates (p) were as follows: CK.R (ß=1.05,p=0.9), CFF.MA (ß=0.99,p=0.95), CK.LY30 (ß=1.01,p=0.91), CRT.MA (TEG® 6s) vs. CK.MA (TEG® 5000) (ß=1.06,p=0.86) as well as vs. CRT.MA (TEG® 5000) (ß=0.93,p=0.93), indicating strong reliability between the devices. Overall, within-device repeatability was better for TEG® 6s vs. TEG® 5000, particularly for CFF.MA and CK.LY30. Conclusions The TEG® 6s device appears to be highly reliable for use in trauma patients, with close correlation to the TEG® 5000 device and equivalent/improved within-device reliability. Given the potential advantages of using the TEG® 6s device at the site of care, confirmation of agreement between the devices represents an important advance in diagnostic testing. Level of evidence Level II-Diagnostic test Corresponding Author: Matthew D. Neal, MD, Assistant Professor of Surgery and Critical Care Medicine, Department of Surgery, University of Pittsburgh School of Medicine, F1271.2 Presbyterian Hospital, 200 Lothrop St, Pittsburgh, PA 15213, Phone: 412-647-0635, Fax: 412-647-3389, nealm2@upmc.edu Conflicts of Interest and Source of Funding: This study was funded by Haemonetics Corporation, Braintree, USA. MDN receives research support from the NIH and the United States Department of Defense. He receives research support from Janssen Pharmaceuticals, Haemonetics, Accriva Diagnostics, Instrument Laboratories, and Noveome Therapeutics. He has served as a paid scientific advisory board member to Janssen Pharmaceuticals and CSL Behring. EEM received research support from Haemonetics for consumable supplies. MW and ST received research grants from Haemonetics for equipment, reagents and logistical and statistical support for research. RAC received funding from Haemonetics for this research and receives funding for research from the NIH and DOD. LZK received funding from Haemonetics for this research and receives research support from the NIH. MS received consultancy payments from Haemonetics, Arsenal Medical and Velico Medical to his University. His university received funding from Haemonetics for this research. AJS is on the speakers bureau for BMS, Pfizer, Janssen, and AstraZeneca. LL was previously a speaker for Haemonetics. RDW is on the Editorial Board, Journal of Trauma and Acute Care Surgery (board service, no compensation) and the Editorial Board, SURGERY (honorarium for serving as Associate Editor for Social Media). NS received funding from Haemonetics for this research. JH and HEA are or were employees of Haemonetics Corporation, Braintree, USA. For the remaining authors, no relevant conflicts were declared. This is an open-access article distributed under the terms of the Creative Commons Attribution-Non Commercial-No Derivatives License 4.0 (CCBY-NC-ND), where it is permissible to download and share the work provided it is properly cited. The work cannot be changed in any way or used commercially without permission from the journal. © 2019 Lippincott Williams & Wilkins, Inc.

Desmopressin Is A Transfusion Sparing Option To Reverse Platelet Dysfunction In Patients With Severe Traumatic Brain Injury Background Platelet dysfunction (PD) is an independent predictor of mortality in patients with severe traumatic brain injury (sTBI). Platelet transfusions have been shown to be an effective treatment strategy to reverse platelet inhibition. Their use is contingent on availability and may be associated with increased cost and transfusion related complications making desmopressin (DDAVP) an attractive. We hypothesized that DDAVP would correct PD similarly to platelet transfusions in patients with sTBI. Methods This retrospective study evaluated all blunt trauma patients admitted to an urban, level one trauma center from July 2015 to October 2016 with sTBI (defined as Head AIS ≥ 3) and PD (defined as adenosine diphosphate [ADP] inhibition ≥60% on thromboelastography [TEG]) and subsequently received treatment. Per our institutional practice patients with sTBI and PD are transfused one unit of apheresis platelets to reverse inhibition. During a platelet shortage, we interchanged DDAVP for the initial treatment. Patients were classified as receiving DDAVP or platelet transfusion (PLT) based on the initial treatment. Results A total of 57 patients were included (DDAVP n=23; PLT n=34). Patients who received DDAVP were more severely injured (ISS: 29 vs. 23, p=0.045) but there was no difference in Head AIS (4 vs. 4, p=0.16). There was no difference between the two groups in admission platelet count (244 ± 68 ×103/uL vs. 265 ± 66 ×103/uL, p =0.24), or other coagulation parameters such at PT, PTT or INR. Prior to treatment both groups had similar ADP inhibition as measured by TEG (ADP 86% vs. 89%, p=0.34). After treatment both the DDAVP and PLT groups had similar correction of platelet ADP inhibition (p=0.28). Conclusion In patients with severe TBI and PD, DDAVP may be an alternative to platelet transfusions to correct PD. LEVEL OF EVIDENCE IV, therapeutic Corresponding Author: Elisa J. Furay, MD, Dell Seton Medical Center at the University of Texas Attn: General Surgery, 1500 Red River Street, Austin, Texas 78701. Email: Efuray@ascension.org There are no conflicts of interest to disclose and no funding for this study. This study will be a podium presentation at the 77th Annual Meeting of the American Association for the Surgery of Trauma, September 28, 2018. San Diego, CA. © 2019 Lippincott Williams & Wilkins, Inc.

Is all plasma created equal? A pilot study of the effect of interdonor variability BACKGROUND Clinical benefits of plasma as an adjunct for treatment of hemorrhagic shock (HS) have been well established. However, its use is not without risk. Little is understood regarding the clinical implications of plasma variability. We hypothesized there to be interdonor variability in plasma that would impact endothelial and organ function post injury. METHODS Pulmonary endothelial cells (EC) were incubated with plasma from 24 random donors and transendothelial electrical resistance (TEER) was measured. Plasma units with a more or less protective effect on reducing EC permeability were selected for testing in vivo. Syndecan-1 and cytokines were measured. Mice underwent laparotomy then HS followed by resuscitation with the selected plasma units and were compared to mice receiving no resuscitation and shams. Lung tissue was sectioned and stained for myeloperoxidase, pulmonary syndecan-1 and scored for lung histopathologic injury. RESULTS Plasma from 24 donors revealed variability in the reversal of EC monolayer hyperpermeability; TEER for the more protective plasma was significantly higher than for the less protective plasma (0.801±0.022 vs. 0.744±0.035; p=.002). Syndecan-1 was also markedly increased in the less protective compared to the more protective plasma (38427±1257 vs. 231±172pg/mL, p<.001), while cytokines varied. In vivo, the more protective plasma mitigated lung histopathologic injury compared to the less protective plasma (1.56±0.27 vs. 2.33±0.47, respectively, p=.005). Similarly, myeloperoxidase was significantly reduced in the more protective compared to the less protective plasma group (2.590±0.559 vs. 6.045±1.885; p=0.02). Lastly, pulmonary syndecan-1 immunostaining was significantly increased in the more protective compared to the less protective plasma group (20.909±8.202 vs. 9.325±3.412; p=0.018). CONCLUSIONS These data demonstrate significant interdonor variability in plasma that can adversely influence the protective effects of plasma-based resuscitation on HS-induced lung injury. This may have important implications for patient safety and clinical outcomes. Study type: Basic science Level of Evidence not applicable The authors have no conflicts of interest. This work was presented at the 49th Annual Meeting of the Western Trauma Association, March 3-8, 2019 in Snowmass, Colorado. This manuscript was funded in part by the National Institutes of Health grant RO1GM107482 and Department of Defense grant W81XWH-17-2-0054. © 2019 Lippincott Williams & Wilkins, Inc.

Re: End Tidal Carbon Dioxide Underestimates Plasma Carbon Dioxide During Emergent Trauma Laparotomy Leading to Hypoventilation and Misguided Resuscitation: . No abstract available

Traumatic Tricuspid Valve Rupture Associated with Pericardial Rupture and Cardiac Herniation No abstract available

DEFINING THE SURGICAL CRITICAL CARE RESEARCH AGENDA: RESULTS OF A GAPS ANALYSIS FROM THE CRITICAL CARE COMMITTEE OF THE AMERICAN ASSOCIATION FOR THE SURGERY OF TRAUMA BACKGROUND There has been an unprecedented increase in critical care research recently and there is a need for an organized and systematic approach to surgical critical care research planning. The purpose of this paper was to establish a surgical critical care research agenda via a systematic review of the literature and needs assessment. METHODS A systematic review of the literature was performed to identify high-impact critical care articles since 1999 on the basis of citation data. Using a standardized data abstraction tool, surgical representation in the literature was analyzed. A needs assessment was performed using a modified Delphi approach in three rounds to obtain consensus among members of the Critical Care Committee of the American Association for the Surgery of Trauma (n=30) regarding research priorities in surgical critical care. RESULTS Of 1,019 articles screened, 645 underwent full-text review, and 276 papers were included in the final analysis. Surgical patients were identified in 177 studies (64.1%), whereas trauma patients were identified in 82 (31.7%). Key categories identified during the first round of the Delphi included end of life care, traumatic brain injury (TBI), delirium, post-ICU syndrome, hemodynamic monitoring, and volume/fluid balance. During the second and third rounds, 10 topics were classified as high priority. The three highest ranked topics were: addressing goals of care in the acute care setting (4.44 ± 0.70); improving prognostic indicators in patients with severe TBI (4.38 ± 0.85); and interventions to mitigate the post-ICU syndrome (4.22 ± 0.65). There was a strong positive correlation in ratings (Rs value = 0.90, p = 0.001) between rounds 2 and 3. CONCLUSIONS The results of this study highlight the recent surgical critical care research literature and may serve as a platform for future research endeavors in surgical critical care. LEVEL OF EVIDENCE: IV STUDY DESIGN: Original article Sources of Funding and Conflicts of Interest: No authors have any financial disclosures or any conflict of interests to report relative to this publication. Corresponding Author: Karen J. Brasel, MD, MPH, Department of Surgery, Oregon Health and Science University, Mailcode L223, 3181 Sam Jackson Park Rd, Portland, OR 97239 © 2019 Lippincott Williams & Wilkins, Inc.

Altered Mental Status and Hypercalcemia with a Splenic Mass No abstract available

Letter to the Editor – Author Response: Re Article: The effect of hemorrhage control adjuncts on outcome in severe pelvic fracture: A multi-institutional study No abstract available

Jejunal Phytobezoar Complicated by Small Bowel Perforation No abstract available

Rotational Thromboelastometry (ROTEM) Predicts Transfusion and Disability in Pediatric Trauma BACKGROUND Trauma-induced coagulopathy seen on rotational thromboelastometry (ROTEM) is associated with poor outcomes in adults, however this relationship is poorly understood in the pediatric population. We sought to define thresholds for product-specific transfusion and evaluate the prognostic efficacy of ROTEM in injured children. METHODS Demographics, ROTEM, and clinical outcomes from severely injured children (age < 18 years) admitted to a level 1 trauma center between 2014 and 2018 were retrospectively analyzed. Receiver operating characteristic curves were plotted and Youden indexes were calculated against the endpoint of packed red blood cell (PRBC) transfusion to identify thresholds for intervention. ROTEM parameters were compared against the clinical outcomes of mortality or disability at discharge. RESULTS Ninety subjects were reviewed. Increased EXTEM (tissue factor-triggered extrinsic pathway) clotting time (CT) >84.5 sec (p=0.049), decreased EXTEM amplitude at 10 minutes (A10) <43.5 mm (p=0.025), and decreased EXTEM maximal clot firmness (MCF) <64.5 mm (p=0.026) were associated with need for blood product transfusion. Additionally, EXTEM CT >68.5 seconds was associated with mortality or disability at discharge. CONCLUSION Coagulation dysregulation on thromboelastometry is associated with disability and mortality in children. Based on our findings, we propose ROTEM thresholds: plasma transfusion for EXTEM CT>84.5 seconds, fibrinogen replacement for EXTEM A10<43.5 mm, and platelet transfusion for EXTEM MCF<68.5 mm. Level of Evidence III – Retrospective cohort prognostic study Presented at the 2019 Annual Meeting & Conference of the Trauma Association of Canada on February 28 - March 1, 2019, in Calgary, AB, Canada Correspondence: Aaron J. Cunningham, MD, 3181 SW Sam Jackson Park Rd., CDW7, Oregon Health & Science University, Portland, OR, 97239, USA, (503) 494-7764. cunninaa@ohsu.edu Funding Sources: This research did not receive any specific grant from funding agencies in the public, commercial, or not-for-profit sectors. Declarations of Interest: None. © 2019 Lippincott Williams & Wilkins, Inc.