Publications by authors named "Ernest E Moore"

668 Publications

Predicting Success of REBOA: Timing supersedes variable techniques in predicting patient survival.

J Trauma Acute Care Surg 2021 Jun 4. Epub 2021 Jun 4.

Denver Health Medical Center, Department of Surgery, Denver, Colorado University of Maryland School of Medicine, Department of Surgery, Baltimore, Maryland University of Southern California, Department of Surgery, Los Angeles, CA, USA. University of Washington School of Medicine, Department of Surgery, Seattle, WA Texas Health Science Center's McGovern Medical School, Department of Surgery at the University, Houston, Texas Colorado School of Public Health, Aurora, Colorado.

Background: REBOA is used for temporary aortic occlusion of trauma patients in the management of non-compressible hemorrhage. Previous studies have focused on how to properly perform REBOA in the trauma environment to improve survival rates, but high grade evidence defining the ideal patient population does not yet exist. This posthoc analysis of the Emergent Truncal Hemorrhage Control Study seeks to identify the most important clinical factors for physicians to consider when selecting for REBOA candidates and their potential survival following REBOA.

Methods: Post hoc analysis of a large multicenter, prospective observational study conducted at six Level 1 Trauma centers, 2017-2018. An onsite data collector documented all timepoints for REBOA patients since admission. Candidate predictors were: demographics, injury severity, physiology pre, during and post procedure, CPR, REBOA-specific variables (time to procedure, procedure-related time intervals, access site, technique, sheath size, catheter length, balloon volume, deployment zone). Predictive models for survival at three different timepoints along the trauma triage and REBOA process timeline ("Admission", "REBOA Initiation" and "Postaortic Occlusion") were devised by logistic regression.

Results: 88 patients had REBOA placement. The "Admission" model selected age, GCS, and admission SBP as significant predictors of survival (AUC 0.86; 95% CI 0.77-0.94). The "REBOA Initiation" and "After Aortic Occlusion" models selected age, GCS, and the SBP measured just prior to balloon inflation as predictors for survival (AUC 0.87 with 95% CI 0.78-0.97 and AUC as 0.90 with 95% CI 0.81-0.99, respectively). No REBOA procedural variables were identified as predictors of patient survival.

Conclusions: Only patient-specific criteria of age, neurologic status, and severity of shock predicted survival. The hemodynamic stability of the patient at the time REBOA is initiated is more important than how REBOA is initiated. These findings suggest that earlier preparation for REBOA placement may be a key to improved survival.

Level Of Evidence: Level III Prospective Observational Study.
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http://dx.doi.org/10.1097/TA.0000000000003307DOI Listing
June 2021

Getting hit by the bus around the world - a global perspective on goal directed treatment of massive hemorrhage in trauma.

Curr Opin Anaesthesiol 2021 Jun 1. Epub 2021 Jun 1.

Department of Anaesthesiology, Intensive Care, Emergency and Pain Medicine, University Hospital Wuerzburg, Wuerzburg, Germany Centre for Trauma Sciences, Blizard Institute, Barts and the London School of Medicine and Dentistry, Queen Mary University of London, London, UK Section for Transfusion Medicine, Capital Region Blood Bank, Rigshospitalet, Copenhagen University Hospital, Copenhagen, Denmark Department of Surgery, Ernest E Moore Shock Trauma Center at Denver Health, University of Colorado, Denver, Colorado, USA Department of Anaesthesiology and Intensive Care Medicine, AUVA Trauma Centre Salzburg, Academic Teaching Hospital of the Paracelsus Medical University, Salzburg Ludwig Boltzmann Institute for Experimental and Clinical Traumatology, AUVA Trauma Research Centre, Vienna, Austria Department of Anaesthesia and Acute Pain Medicine, Melbourne Medical School, The University of Melbourne, Melbourne, Australia Department of Anesthesia and Trauma Center, Centre of Head and Orthopaedics, Rigshospitalet, Copenhagen University Hospital, Copenhagen, Denmark Department of Anaesthesiology, Intensive Care and Pain Therapy, University Hospital Frankfurt, Frankfurt/Main, Germany.

Purpose Of Review: Major trauma remains one of the leading causes of death worldwide with traumatic brain injury and uncontrolled traumatic bleeding as the main determinants of fatal outcome. Interestingly, the therapeutic approach to trauma-associated bleeding and coagulopathy shows differences between geographic regions, that are reflected in different guidelines and protocols.

Recent Findings: This article summarizes main principles in coagulation diagnostics and compares different strategies for treatment of massive hemorrhage after trauma in different regions of the world. How would a bleeding trauma patient be managed if they got hit by the bus in the United States, United Kingdom, Germany, Switzerland, Austria, Denmark, Australia, or in Japan?

Summary: There are multiple coexistent treatment standards for trauma-induced coagulopathy in different countries and different trauma centers. Most of them initially follow a protocol-based approach and subsequently focus on predefined clinical and laboratory targets.
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http://dx.doi.org/10.1097/ACO.0000000000001025DOI Listing
June 2021

Don't Mess with the Pancreas! A Multicenter Analysis of the Management of Low-Grade Pancreatic Injuries.

J Trauma Acute Care Surg 2021 May 25. Epub 2021 May 25.

Introduction: Current guidelines recommend nonoperative management (NOM) of low-grade (AAST-OIS grade I-II) pancreatic injuries (LGPIs), and drainage rather than resection for those undergoing operative management, but they are based on low quality evidence. The purpose of this study was to review the contemporary management and outcomes of LGPIs and identify risk factors for morbidity.

Methods: Multicenter retrospective review of diagnosis, management, and outcomes of adult pancreatic injuries from 2010-2018. The primary outcome was pancreas-related complications (PRCs). Predictors of PRCs were analyzed using multivariate logistic regression.

Results: 29 centers submitted data on 728 patients with LGPI (76% male; mean age 38; 37% penetrating; 51% grade I; median ISS 24). Among 24-hour survivors, definitive management was NOM in 31%, surgical drainage alone in 54%, resection in 10%, and pancreatic debridement or suturing in 5%. The incidence of PRCs was 21% overall, and was 42% after resection, 26% after drainage, and 4% after NOM. On multivariate analysis, independent risk factors for PRC were other intra-abdominal injury (OR 2.30; 1.16, 15.28), low volume (OR 2.88; 1.65, 5.06), and penetrating injury (OR 3.42; 1.80, 6.58). Resection was very close to significance (OR 2.06; 0.97, 4.34) (p = 0.0584).

Conclusion: The incidence of PRCs is significant after LGPIs. Patients who undergo pancreatic resection have PRC rates equivalent to patients resected for HGPIs. Those who underwent surgical drainage had slightly lower PRC rate, but only 4% of those who underwent NOM had PRCs. In patients with LGPIs, resection should be avoided. The NOM strategy should be employed whenever possible and studied prospectively, particularly in penetrating trauma.

Level Of Evidence: Level III, Retrospective Diagnostic/Therapeutic Study.
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http://dx.doi.org/10.1097/TA.0000000000003293DOI Listing
May 2021

Recommended Primary Outcomes for Clinical Trials Evaluating Hemostatic Blood Products and Agents in Patients with Bleeding: Proceedings of a National Heart Lung and Blood Institute and United States Department of Defense Consensus Conference.

J Trauma Acute Care Surg 2021 May 26. Epub 2021 May 26.

Division of Critical Care, Department of Pediatrics, Washington University School of Medicine, St. Louis, MO, USA National Heart Lung and Blood Institute, NIH, Bethesda, MD US Army Institute of Surgical Research, Ft Sam Houston, TX Division of Gastroenterology, McGill University and the McGill University Health Centre Montréal, Québec, Canada Division of Hematology, University of Washington, Seattle WA 98195 USA Department of Emergency Medicine, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA Department of Surgery, Center for Injury Science, Division of Acute Care Surgery, University of Alabama at Birmingham, Birmingham, AL Division of Hematology and Thromboembolism, Department of Medicine and Department of Health Research Methods, Evidence, and Impact, McMaster University, Hamilton Ontario L8S 4K Canada Division of Gastroenterology, Department of Medicine, David Geffen School of Medicine at UCLA, Los Angeles, CA 90095 Division of Hematology and Blood Research Center, Department of Medicine, University of North Carolina, Chapel Hill, NC 27599 Department of Anesthesiology and Critical Care, Duke University Medical Center, Durham, NC 27710 USA Departments of Neurology and Neurosurgery, Westchester Medical Center, New York Medical College, Valhalla NY 10595 Ernest E Moore Shock Trauma Center at Denver Health, Department of Surgery, University of Colorado Denver, Denver, Colorado 80204 USA Oxford University, Oxford, United Kingdom, The John Radcliffe Hospital, Oxford, GBR NHSBT, Oxford, United Kingdom Berry Consultants LLC, Austin TX 78746 Department of Emergency Medicine, David Geffen School of Medicine at UCLA, Los Angeles California 90095 USA Department of Pediatrics, Division of Pediatric Hematology and Oncology, Division of Pediatric Critical Care Medicine, University of Minnesota Medical School, Minneapolis, MN 55455 USA.

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http://dx.doi.org/10.1097/TA.0000000000003300DOI Listing
May 2021

WSES-AAST guidelines: management of inflammatory bowel disease in the emergency setting.

World J Emerg Surg 2021 May 11;16(1):23. Epub 2021 May 11.

Department of Surgical Sciences, Policlinico Sant'Orsola Malpighi, Bologna, Italy.

Background: Despite the current therapeutic options for the treatment of inflammatory bowel disease, surgery is still frequently required in the emergency setting, although the number of cases performed seems to have decreased in recent years. The World Society of Emergency Surgery decided to debate in a consensus conference of experts, the main pertinent issues around the management of inflammatory bowel disease in the emergent situation, with the need to provide focused guidelines for acute care and emergency surgeons.

Method: A group of experienced surgeons and gastroenterologists were nominated to develop the topics assigned and answer the questions addressed by the Steering Committee of the project. Each expert followed a precise analysis and grading of the studies selected for review. Statements and recommendations were discussed and voted at the Consensus Conference of the 6th World Society of Emergency Surgery held in Nijmegen (The Netherlands) in June 2019.

Conclusions: Complicated inflammatory bowel disease requires a multidisciplinary approach because of the complexity of this patient group and disease spectrum in the emergency setting, with the aim of obtaining safe surgery with good functional outcomes and a decreasing stoma rate where appropriate.
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http://dx.doi.org/10.1186/s13017-021-00362-3DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8111988PMC
May 2021

A randomized clinical trial of single dose liposomal bupivacaine versus indwelling analgesic catheter in patients undergoing surgical stabilization of rib fractures.

J Trauma Acute Care Surg 2021 May 5. Epub 2021 May 5.

Department of Surgery, Denver Health & Hospital Authority Department of Anesthesiology, Denver Health & Hospital Authority Department of Pharmacy, Denver Health & Hospital Authority.

Introduction: Loco-regional analgesia (LRA) remains underutilized in patients with chest wall injuries. Surgical stabilization of rib fractures (SSRF) offers an opportunity to deliver surgeon-directed LRA under direct visualization at the site of surgical intervention. We hypothesized that a single-dose liposomal bupivacaine (LB) intercostal nerve block provides comparable analgesia to an indwelling, peripheral nerve plane analgesic catheter with continuous bupivacaine infusion (IC), each placed during SSRF.

Methods: Non-inferiority, single center, randomized clinical trial (2017-2020). Patients were randomized to receive either IC or LB during SSRF. The IC was tunneled into the surgical field (subscapular space) and LB involved thoracoscopic intercostal blocks of ribs 3-8. The primary outcome was the Sequential Clinical Assessment of Respiratory Function (SCARF) score, measured daily for 5 days post-operatively. Secondary outcomes included daily narcotic equivalents and failure of primary LRA, defined as requiring a second LRA modality.

Results: Thirty-four patients were enrolled; 16 IC and 18 LB. Age, injury severity score, RibScore, Blunt Pulmonary Contusion Score, and use of non-narcotic analgesics was similar between groups. Duration of IC was 4.5 days. There were three failures in the IC group versus one in the LB group (p=0.23). There was no significant difference in SCARF score between the IC and LB groups. On post-operative days 2-4, narcotic requirements were less than half in the LB, as compared to the IC group; however, this difference was not statistically significant. Average wholesale price was $605 for IC and $434 for LB.

Conclusions: In this non-inferiority trial, LB provided at least comparable, and potentially superior LRA as compared to IC among patients undergoing SSRF.

Level Of Evidence: Level II, Therapeutic.
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http://dx.doi.org/10.1097/TA.0000000000003264DOI Listing
May 2021

Beyond the tube: Can we reduce chest tube complications in trauma patients?

Am J Surg 2021 Apr 20. Epub 2021 Apr 20.

Denver Health and Hospital Authority, 777 Bannock Street, Denver, CO 80204, USA.

Background: We sought to identify opportunities for interventions to mitigate complications of tube thoracostomy (TT).

Methods: Retrospective review of all trauma patients undergoing TT from 6/30/2016-6/30/2019. Multivariable logistic regression identified independent predictors of complications.

Results: Out of 451 patients, 171 (37.9%) had at least one TT malpositioning or complication. Placement in the emergency department, placement by emergency medicine physicians, and body mass index >30 kg/m were independent predictors of complication. Malpositioning increased the likelihood of early complication (6.5%-53.5%), and early complication increased the likelihood of late complication (4.3%-13.6%). Patients with a late complication had, on average, a 7.56 day longer hospital stay than patients without a late complication.

Conclusion: TT complications were associated with placement in the emergency department, placement by emergency medicine physicians, and BMI>30 kg/m. We identified associations between malpositioning, early complications, and late complications, and demonstrated that TT complications impact patient outcomes.
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http://dx.doi.org/10.1016/j.amjsurg.2021.04.008DOI Listing
April 2021

Trauma-induced coagulopathy.

Nat Rev Dis Primers 2021 04 29;7(1):30. Epub 2021 Apr 29.

Department of Surgery, University of Colorado Denver, Aurora, CO, USA.

Uncontrolled haemorrhage is a major preventable cause of death in patients with traumatic injury. Trauma-induced coagulopathy (TIC) describes abnormal coagulation processes that are attributable to trauma. In the early hours of TIC development, hypocoagulability is typically present, resulting in bleeding, whereas later TIC is characterized by a hypercoagulable state associated with venous thromboembolism and multiple organ failure. Several pathophysiological mechanisms underlie TIC; tissue injury and shock synergistically provoke endothelial, immune system, platelet and clotting activation, which are accentuated by the 'lethal triad' (coagulopathy, hypothermia and acidosis). Traumatic brain injury also has a distinct role in TIC. Haemostatic abnormalities include fibrinogen depletion, inadequate thrombin generation, impaired platelet function and dysregulated fibrinolysis. Laboratory diagnosis is based on coagulation abnormalities detected by conventional or viscoelastic haemostatic assays; however, it does not always match the clinical condition. Management priorities are stopping blood loss and reversing shock by restoring circulating blood volume, to prevent or reduce the risk of worsening TIC. Various blood products can be used in resuscitation; however, there is no international agreement on the optimal composition of transfusion components. Tranexamic acid is used in pre-hospital settings selectively in the USA and more widely in Europe and other locations. Survivors of TIC experience high rates of morbidity, which affects short-term and long-term quality of life and functional outcome.
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http://dx.doi.org/10.1038/s41572-021-00264-3DOI Listing
April 2021

Current practices and challenges in assessing traumatic hemorrhage: An international survey of trauma care providers.

J Trauma Acute Care Surg 2021 May;90(5):e95-e100

From the Department of Surgery (A.T., T.L., J.L.), The Ottawa Hospital, School of Epidemiology and Public Health (A.T., T.L., M.T.), and Division of Critical Care, Department of Medicine (A.T., S.M.F.), University of Ottawa; Clinical Epidemiology Program (M.T., C.V.), Ottawa Hospital Research Institute; Department of Emergency Medicine (S.M.F., C.V.), University of Ottawa, Ottawa, ON, Canada; Department of Surgery (K.I., D.D.), University of Southern California, Los Angeles, California; Department of Surgery (E.E.M.), University of Denver, Denver, Colorado; Division of Acute Care Surgery, Department of Surgery (E.R.H.), and Department of Anesthesiology and Critical Care, Department of Emergency Medicine (E.R.H.), The Johns Hopkins University School of Medicine; Department of Health Policy and Management (E.R.H.), The Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland.

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http://dx.doi.org/10.1097/TA.0000000000003081DOI Listing
May 2021

A multicenter trial of current trends in the diagnosis and management of high-grade pancreatic injuries.

J Trauma Acute Care Surg 2021 05;90(5):776-786

From the Scripps Memorial Hospital La Jolla (WLB, FZZ, MC, KBS), La Jolla, CA; Maine Medical Center (BM), Portland, ME; Memorial Hermann Hospital (MM), Houston, TX; University of Oklahoma (JL), Oklahoma City, OK; Ryder Trauma Center (SB), Miami, FL; University of California-San Diego (JW), San Diego, CA; San Francisco General Hospital (RC, LK), San Francisco, CA; University of Calgary (CCGB), Calgary, Alberta, Canada; University of California-Irvine (JN), Irvine, CA; North Memorial Health Hospital (MW), Robbinsdale, MN; University of California-Davis (GJJ), Sacramento, CA; Grady Memorial Hospital (SRT), Atlanta, GA; Hadassah- Hebrew University Medical Center (MB), Jerusalem, Israel; Grant Medical Center (CS), Columbus, OH; Ernest E. Moore Shock Trauma Center at Denver Health (EEM), Denver, CO.

Background: Outcomes following pancreatic trauma have not improved significantly over the past two decades. A 2013 Western Trauma Association algorithm highlighted emerging data that might improve the diagnosis and management of high-grade pancreatic injuries (HGPIs; grades III-V). We hypothesized that the use of magnetic resonance cholangiopancreatography, pancreatic duct stenting, operative drainage versus resection, and nonoperative management of HGPIs increased over time.

Methods: Multicenter retrospective review of diagnosis, management, and outcomes of adult pancreatic injuries from 2010 to 2018 was performed. Data were analyzed by grade and time period (PRE, 2010-2013; POST, 2014-2018) using various statistical tests where appropriate.

Results: Thirty-two centers reported data on 515 HGPI patients. A total of 270 (53%) had penetrating trauma, and 58% went directly to the operating room without imaging. Eighty-nine (17%) died within 24 hours. Management and outcomes of 426 24-hour survivors were evaluated. Agreement between computed tomography and operating room grading was 38%. Magnetic resonance cholangiopancreatography use doubled in grade IV/V injuries over time but was still low.Overall HGPI treatment and outcomes did not change over time. Resection was performed in 78% of grade III injuries and remained stable over time, while resection of grade IV/V injuries trended downward (56% to 39%, p = 0.11). Pancreas-related complications (PRCs) occurred more frequently in grade IV/V injuries managed with drainage versus resection (61% vs. 32%, p = 0.0051), but there was no difference in PRCs for grade III injuries between resection and drainage.Pancreatectomy closure had no impact on PRCs. Pancreatic duct stenting increased over time in grade IV/V injuries, with 76% used to treat PRCs.

Conclusion: Intraoperative and computed tomography grading are different in the majority of HGPI cases. Resection is still used for most patients with grade III injuries; however, drainage may be a noninferior alternative. Drainage trended upward for grade IV/V injuries, but the higher rate of PRCs calls for caution in this practice.

Level Of Evidence: Retrospective diagnostic/therapeutic study, level III.
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http://dx.doi.org/10.1097/TA.0000000000003080DOI Listing
May 2021

Hemodynamically unstable pelvic fracture: A damage control surgical algorithm that fits your reality.

Colomb Med (Cali) 2020 Dec 30;51(4):e4214510. Epub 2020 Dec 30.

University of Colorado, Denver Health Medical Center, Department of Surgery, Denver, CO USA.

Pelvic fractures occur in up to 25% of all severely injured trauma patients and its mortality is markedly high despite advances in resuscitation and modernization of surgical techniques due to its inherent blood loss and associated extra-pelvic injuries. Pelvic ring volume increases significantly from fractures and/or ligament disruptions which precludes its inherent ability to self-tamponade resulting in accumulation of hemorrhage in the retroperitoneal space which inevitably leads to hemodynamic instability and the lethal diamond. Pelvic hemorrhage is mainly venous (80%) from the pre-sacral/pre-peritoneal plexus and the remaining 20% is of arterial origin (branches of the internal iliac artery). This reality can be altered via a sequential management approach that is tailored to the specific reality of the treating facility which involves a collaborative effort between orthopedic, trauma and intensive care surgeons. We propose two different management algorithms that specifically address the availability of qualified staff and existing infrastructure: one for the fully equipped trauma center and another for the very common limited resource center.
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http://dx.doi.org/10.25100/cm.v51i4.4510DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7968423PMC
December 2020

WSES-AAST Guidelines for Management of Clostridioides (Clostridium) difficile infection in Surgical Patients: an executive summary.

J Trauma Acute Care Surg 2021 Mar 27. Epub 2021 Mar 27.

Department of Surgery, Macerata Hospital, Macerata, Italy. General, Emergency and Trauma Surgery Department, Bufalini Hospital, Cesena, Italy. Trauma and Acute Care Surgery, Scripps Memorial Hospital, La Jolla, CA, USA. General, Emergency and Trauma Surgery Department, Pisa University Hospital, Pisa, Italy. Department of General and Metabolic Surgery, Poissy and Saint Germain en Laye Hospitals, Poissy, France. Abdominal Center, Helsinki University Hospital Meilahti, Finland. Division of General Surgery, Rambam Health Care Campus, Haifa, Israel. Ernest E. Moore Shock Trauma Center at Denver Health, Colorado, USA. Department of Emergency Surgery, Parma Maggiore Hospital, Parma, Italy.

Abstract: In the last three decades, the dramatic worldwide increase in incidence and severity of Clostridioides difficile infection (CDI) (formerly Clostridium difficile infection) has made CDI a global public health challenge. Surgery is a known risk factor for development of CDI yet surgery is also a treatment option in severe cases of CDI. The World Society of Emergency Surgery (WSES) guidelines for management of CDI in surgical patients were published in 2015(1). In 2019(2) the guidelines were revised and updated according to the GRADE methodology.This executive summary is intended to consolidate knowledge on the management of CDI focusing on aspects that a general and emergency surgeon should know about the prevention and the management of CDI, by providing a practical and concise version of the original guidelines.
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http://dx.doi.org/10.1097/TA.0000000000003196DOI Listing
March 2021

Strategies for successful implementation of resuscitative endovascular balloon occlusion of the aorta (REBOA) in an urban Level I trauma center.

J Trauma Acute Care Surg 2021 Mar 27. Epub 2021 Mar 27.

University of Colorado School of Medicine University of Colorado School of Medicine Denver Health Medical Center, University of Colorado School of Medicine Denver Health Medical Center, University of Colorado School of Medicine Denver Health Medical Center, University of Colorado School of Medicine Denver Health Medical Center, University of Colorado School of Medicine Denver Health Medical Center, University of Colorado School of Medicine Denver Health Medical Center, University of Colorado School of Medicine Denver Health Medical Center, University of Colorado School of Medicine Denver Health Medical Center, University of Colorado School of Medicine Denver Health Medical Center, University of Colorado School of Medicine Denver Health Medical Center University of Colorado School of Medicine University of Colorado School of Medicine University of Colorado School of Medicine Denver Health Medical Center, University of Colorado School of Medicine.

Background: The rationale for Resuscitative Endovascular Balloon Occlusion of the Aorta (REBOA) is to control life-threatening sub-diaphragmatic bleeding and facilitate resuscitation, however, incorporating this into the resuscitative practices of a trauma service remains challenging. The objective of this study is to describe the process of successful implementation of REBOA use in an academic urban level I trauma center. All REBOA procedures from April 2014 through December 2019 were evaluated; REBOA was implemented after surgical faculty attended a required and internally developed Advanced Endovascular Strategies for Trauma Surgeons course (AESTS). Success was defined by sustained early adoption rates.

Methods: An institutional protocol was published, and a REBOA supply cart was placed in the emergency department(ED) with posters attached to depict technical and procedural details. A focused professional practice evaluation was utilized for the first three REBOA procedures performed by each faculty member, leading to internal privileging.

Results: REBOA was performed in 97 patients by 9 trauma surgeons, which is 1% of the total trauma admissions during this time. Each surgeon performed a median of 12 REBOAs (IQR: 5,14). Blunt (77/97, 81%) or penetrating abdominopelvic injuries (15/97, 15%) comprised the main injury mechanisms; 4% were placed for other reasons (4/97) including ruptured abdominal aortic aneurysms (AAA, n=3) and pre-operatively for a surgical oncologic resection (n=1). Overall survival was 65% (63/97) with a steady early adoption trend that resulted in participation in a Department of Defense (DoD) multicenter trial.

Conclusions: Strategies for how departments adopt new procedures require clinical guidelines, a training program focused on competence, and a hospital education and privileging process for those acquiring new skills.

Level Of Evidence: Level V.

Study Type: Original Article, Diagnostic.
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http://dx.doi.org/10.1097/TA.0000000000003198DOI Listing
March 2021

Fibrinolysis Shutdown in COVID-19: Clinical Manifestations, Molecular Mechanisms, and Therapeutic Implications.

J Am Coll Surg 2021 06 22;232(6):995-1003. Epub 2021 Mar 22.

Ernest E Moore Shock Trauma Center, Denver Health Medical Center, University of Colorado, Denver, CO.

The COVID-19 pandemic has introduced a global public health threat unparalleled in our history. The most severe cases are marked by ARDS attributed to microvascular thrombosis. Hypercoagulability, resulting in a profoundly prothrombotic state, is a distinct feature of COVID-19 and is accentuated by a high incidence of fibrinolysis shutdown. The aims of this review were to describe the manifestations of fibrinolysis shutdown in COVID-19 and its associated outcomes, review the molecular mechanisms of dysregulated fibrinolysis associated with COVID-19, and discuss potential implications and therapeutic targets for patients with severe COVID-19.
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http://dx.doi.org/10.1016/j.jamcollsurg.2021.02.019DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7982779PMC
June 2021

The management of surgical patients in the emergency setting during COVID-19 pandemic: the WSES position paper.

World J Emerg Surg 2021 03 22;16(1):14. Epub 2021 Mar 22.

Department of Emergency and Trauma Surgery, Parma University Hospital, Parma, Italy.

Background: Since the COVID-19 pandemic has occurred, nations showed their unpreparedness to deal with a mass casualty incident of this proportion and severity, which resulted in a tremendous number of deaths even among healthcare workers. The World Society of Emergency Surgery conceived this position paper with the purpose of providing evidence-based recommendations for the management of emergency surgical patients under COVID-19 pandemic for the safety of the patient and healthcare workers.

Method: A systematic review was conducted in accordance with the Preferred Reporting Items for Systematic Review and Meta-analysis Protocols (PRISMA-P) through the MEDLINE (PubMed), Embase and SCOPUS databases. Synthesis of evidence, statements and recommendations were developed in accordance with the GRADE methodology.

Results: Given the limitation of the evidence, the current document represents an effort to join selected high-quality articles and experts' opinion.

Conclusions: The aim of this position paper is to provide an exhaustive guidelines to perform emergency surgery in a safe and protected environment for surgical patients and for healthcare workers under COVID-19 and to offer the best management of COVID-19 patients needing for an emergency surgical treatment. We recommend screening for COVID-19 infection at the emergency department all acute surgical patients who are waiting for hospital admission and urgent surgery. The screening work-up provides a RT-PCR nasopharyngeal swab test and a baseline (non-contrast) chest CT or a chest X-ray or a lungs US, depending on skills and availability. If the COVID-19 screening is not completed we recommend keeping the patient in isolation until RT-PCR swab test result is not available, and to manage him/she such as an overt COVID patient. The management of COVID-19 surgical patients is multidisciplinary. If an immediate surgical procedure is mandatory, whether laparoscopic or via open approach, we recommend doing every effort to protect the operating room staff for the safety of the patient.
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http://dx.doi.org/10.1186/s13017-021-00349-0DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7983964PMC
March 2021

The WSES: what do we see in the future?

World J Emerg Surg 2021 03 20;16(1):13. Epub 2021 Mar 20.

Department of Emergency and Trauma Surgery, University Hospital of Parma, Parma, Italy.

We present the New Year letter from the WSES board to wish everyone a new year full of positive surprises and good news, despite COVID-19 pandemic.We confirm the WSES primary aim: to promote education in emergency surgery putting together all the world experts on emergency surgery without restrictions or boundaries, in inclusivity, equality, and equal opportunities. This will be the year of innovations and WSES will assess the application of artificial intelligence technologies in emergency and trauma surgery.Thank you All for trusting us with your collaboration.
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http://dx.doi.org/10.1186/s13017-021-00358-zDOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7980739PMC
March 2021

The Association of Surgical Timing and Injury Severity With Systemic Complications in Severely Injured Patients With Pelvic Ring Injuries.

J Orthop Trauma 2021 04;35(4):171-174

Department of Orthopaedics, Denver Health Medical Center, Denver, CO.

Objectives: To evaluate the relationship between timing of definitive fixation, injury severity, and the development of systemic complications in severely injured patients with pelvic ring injuries.

Design: Retrospective review.

Settings: Level 1 trauma center.

Patients: One hundred eighteen severely injured [Injury Severity Score (ISS) ≥ 16] adult patients with pelvic ring injuries undergoing definitive fixation, excluding patients treated with external fixation for hemodynamic instability.

Intervention: Early fixation (≤36 hours) in 37 patients and delayed fixation (>36 hours) in 81 patients.

Main Outcome Measurements: Systemic complications (acute respiratory distress syndrome, pulmonary embolism, deep venous thrombosis, sepsis, multi-organ failure, and death).

Results: The delayed fixation group had a higher ISS and had more patients with chest injuries. There was no detectable difference in the number of patients with systemic complications between early versus delayed fixation groups [8 (22%) vs. 29 (35%), P = 0.1]. The only difference detected in specific complications was a higher incidence of pneumonia with delayed fixation [16 (20%) vs. 0 (0%), P = 0.004] with 11 of the 16 cases being associated with chest injury. Univariate analysis showed an association between complication and time to fixation, ISS, Glasgow Coma Scale, pH, base excess, and injuries to the head, chest, and abdomen. On multivariate analysis, only ISS remained significantly associated with the development of complications [Odds ratio 2.6 per 10 point increase, 95% confidence interval (CI), 1.4-4.4].

Conclusions: These data suggest that the severity of injury is most highly associated with systemic complications after definitive fixation of pelvic ring injuries.

Level Of Evidence: Therapeutic Level III. See Instructions for Authors for a complete description of levels of evidence.
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http://dx.doi.org/10.1097/BOT.0000000000001946DOI Listing
April 2021

Determination of optimal deployment strategy for REBOA in patients with non-compressible hemorrhage below the diaphragm.

Trauma Surg Acute Care Open 2021 23;6(1):e000660. Epub 2021 Feb 23.

Department of Surgery, University of Texas McGovern Medical School, Houston, Texas, USA.

Background: Non-compressible truncal hemorrhage (NCTH) is the leading cause of preventable death after trauma. Resuscitative endovascular balloon occlusion of the aorta (REBOA) achieves temporary hemorrhage control, supporting cardiac and cerebral perfusion prior to definitive hemostasis. Aortic zone selection algorithms vary among institutions. We evaluated the efficacy of an algorithm for REBOA use.

Methods: A multicenter prospective, observational study conducted at six level 1 trauma centers over 12 months. Inclusion criteria were age >15 years with evidence of infradiaphragmatic NCTH needing emergent hemorrhage control within 60 min of ED arrival. An algorithm characterized by the results of focused assessment with sonography in trauma and pelvic X-ray was assessed post hoc for efficacy in a cohort of patients receiving REBOA.

Results: Of the 8166 patients screened, 78 patients had a REBOA placed. 21 patients were excluded, leaving 57 patients for analysis. The algorithm ensures REBOA deployment proximal to hemorrhage source to control bleeding in 98.2% of cases and accurately predicts the optimal REBOA zone in 78.9% of cases. If the algorithm was violated, bleeding was optimally controlled in only 43.8% (p=0.01). Three (75.0%) of the patients that received an inappropriate zone 1 REBOA died, two from multiple organ failure (MOF). All three patients that died with an inappropriate zone 3 REBOA died from exsanguination.

Discussion: This algorithm ensures proximal hemorrhage control and accurately predicts the primary source of hemorrhage. We propose a new algorithm that will be more inclusive. A zone 3 REBOA should not be performed when a zone 1 is indicated by the algorithm as 100% of these patients exsanguinated. MOF, perhaps from visceral ischemia in patients with an inappropriate zone 1 REBOA, may have been prevented with zone 3 placement or limited zone 1 occlusion time.

Level Of Evidence: Level III.
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http://dx.doi.org/10.1136/tsaco-2020-000660DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7907878PMC
February 2021

"Death Diamond" Tracing on Thromboelastography as a Marker of Poor Survival After Trauma.

Am Surg 2021 Feb 25:3134821998684. Epub 2021 Feb 25.

Departments of Trauma, Surgery, and Critical Care Medicine, 5973Christiana Care Health Services, Wilmington, DE, USA.

Background: Improvements in health care innovations have resulted in an enhanced ability to extend patient viability. As a consequence, resources are being increasingly utilized at an unsustainable level. As we implement novel treatments, identifying futility should be a focus. The "death diamond" (DD) is a unique thrombelastography (TEG) tracing that is indicative of failure of the coagulation system, with a mortality rate exceeding 90%. The purpose of this study was to determine if the DD was a consistent marker of poor survival in a multicenter study population. We hypothesize that the DD, while an infrequent occurrence, predicts poor survival and can be used to stratify patients in whom resuscitation efforts are futile.

Methods: A retrospective multi-institutional study of trauma patients presenting with TEG DDs between 8/2008 and 12/2018 at four American College of Surgeons trauma centers was completed. Demographics, injury mechanisms, TEG results, management, and survival were examined.

Results: A total of 50 trauma patients presented with DD tracings, with a 94% (n = 47) mortality rate. Twenty-six (52%) patients received a repeat TEG with 10 patients re-demonstrating the DD tracing. There was 100% mortality in patients with serial DD tracings. The median use of total blood products was 18 units (interquartile range 6, 34.25) per patient.

Discussion: The DD is highly predictive of trauma-associated mortality. This multicenter study highlights that serial DDs may represent a possible biomarker of futility.
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http://dx.doi.org/10.1177/0003134821998684DOI Listing
February 2021

Trauma quality indicators: internationally approved core factors for trauma management quality evaluation.

World J Emerg Surg 2021 Feb 23;16(1). Epub 2021 Feb 23.

General Surgery, Brescia University Hospital, Brescia, Italy.

Introduction: Quality in medical care must be measured in order to be improved. Trauma management is part of health care, and by definition, it must be checked constantly. The only way to measure quality and outcomes is to systematically accrue data and analyze them.

Material And Methods: A systematic revision of the literature about quality indicators in trauma associated to an international consensus conference RESULTS: An internationally approved base core set of 82 trauma quality indicators was obtained: Indicators were divided into 6 fields: prevention, structure, process, outcome, post-traumatic management, and society integrational effects.

Conclusion: Present trauma quality indicator core set represents the result of an international effort aiming to provide a useful tool in quality evaluation and improvement. Further improvement may only be possible through international trauma registry development. This will allow for huge international data accrual permitting to evaluate results and compare outcomes.
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http://dx.doi.org/10.1186/s13017-021-00350-7DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7901006PMC
February 2021

Whole Blood Thrombin Generation in Severely Injured Patients Requiring Massive Transfusion.

J Am Coll Surg 2021 May 4;232(5):709-716. Epub 2021 Feb 4.

Department of Biochemistry, University of Vermont, Burlington, VT.

Background: Despite the prevalence of hypocoagulability after injury, the majority of trauma patients paradoxically present with elevated thrombin generation (TG). Although several studies have examined plasma TG post injury, this has not been assessed in whole blood. We hypothesize that whole blood TG is lower in hypocoagulopathy, and TG effectively predicts massive transfusion (MT).

Study Design: Blood was collected from trauma activation patients at an urban Level I trauma center. Whole blood TG was performed with a prototype point-of-care device. Whole blood TG values in healthy volunteers were compared with trauma patients, and TG values were examined in trauma patients with shock and MT requirement.

Results: Overall, 118 patients were included. Compared with healthy volunteers, trauma patients overall presented with more robust TG; however, those arriving in shock (n = 23) had a depressed TG, with significantly lower peak thrombin (88.3 vs 133.0 nM; p = 0.01) and slower maximum rate of TG (27.4 vs 48.3 nM/min; p = 0.04). Patients who required MT (n = 26) had significantly decreased TG, with a longer lag time (median 4.8 vs 3.9 minutes, p = 0.04), decreased peak thrombin (median 71.4 vs 124.2 nM; p = 0.0003), and lower maximum rate of TG (median 15.8 vs 39.4 nM/min; p = 0.01). Area under the receiver operating characteristics (AUROC) analysis revealed lag time (AUROC 0.6), peak thrombin (AUROC 0.7), and maximum rate of TG (AUROC 0.7) predict early MT.

Conclusions: These data challenge the prevailing bias that all trauma patients present with elevated TG and highlight that deficient thrombin contributes to the hypocoagulopathic phenotype of trauma-induced coagulopathy. In addition, whole blood TG predicts MT, suggesting point-of-care whole blood TG can be a useful tool for diagnostic and therapeutic strategies in trauma.
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http://dx.doi.org/10.1016/j.jamcollsurg.2020.12.058DOI Listing
May 2021

Do young patients with high clinical suspicion of appendicitis really need cross-sectional imaging? Proceedings from a highly controversial debate among the experts' panel of 2020 WSES Jerusalem guidelines.

J Trauma Acute Care Surg 2021 05;90(5):e101-e107

From the Department of Emergency Surgery (M.P., A.P.), Azienda Ospedaliero-Universitaria di Cagliari, University Hospital Policlinico Duilio Casula, Cagliari, Italy; Department of Surgery (R.A.), Linkoping University, Linkoping, Sweden; Department of Surgery (M.B.), University of Amsterdam, Amsterdam, The Netherlands; General, Emergency and Trauma Surgery (F.C.), Pisa University Hospital, Pisa, Italy; Department of Surgery (M.S.), Macerata Hospital, Macerata, Italy; Denver Health System-Denver Health Medical Center (E.E.M.), Denver, Colorado; Department of Surgery (M.S.), Letterkenny Hospital, Donegal, Ireland; Department of Surgery (F.A.-Z.), College of Medicine and Health Sciences, UAE University, Al-Ain, United Arab Emirates; Department of Abdominal Surgery (M.T., A.L.), Abdominal Center, University of Helsinki and Helsinki University Central Hospital, Helsinki, Finland; Department of Upper GI Surgery (D.D.), Royal Infirmary of Edinburgh, Edinburgh, Scotland, United Kingdom; Division of General Surgery (Y.K.), Rambam Health Care Campus, Haifa, Israel; Department of Gastrointestinal Surgery (K.S.), Stavanger University Hospital, Stavanger, Norway; Department of Surgery (G.A.), University Hospital Centre of Zagreb, Zagreb, Croatia; Section of Acute Care Surgery, Westchester Medical Center, Department of Surgery (R.L.), New York Medical College, Valhalla, New York; Acute Surgical Unit (M.K.), Canberra Hospital, ACT, Canberra, Australia; Faculdade de Ciências Médicas (FCM)-Unicamp, Campinas (G.P.F.), SP, Brazil; Department of Surgery (R.T.B., E.T., H.V.G.), Radboud University Medical Center, Nijmegen, The Netherlands; Niguarda Hospital Trauma Center (O.C.), Milan, Italy; Department of Surgery (R.V.M.), University of Washington, Harborview Medical Center, Seattle, Washington; Department of Surgery (F.P.), Nicola Giannettasio Hospital, Corigliano-Rossano, and La Sapienza University o Rome, Rome, Italy; Department of Visceral Surgery (B.D.S.), Centre Hospitalier Intercommunal Poissy/Saint-Germain-en-Laye, Poissy, France; Division of Trauma and Acute Care Surgery, Department of General Surgery (C.A.O.), Fundación Valle del Lili, Cali, Colombia; Department of General Surgery and Trauma (L.A.), Bufalini Hospital, Cesena, Italy; Emergency and Trauma Surgery Department (F.C.), Maggiore Hospital of Parma, Parma, Italy; and Department of General Surgery (S.D.S.), University of Insubria, University Hospital of Varese, ASST Sette Laghi, Regione Lombardia, Varese, Italy.

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http://dx.doi.org/10.1097/TA.0000000000003097DOI Listing
May 2021

Whole Blood, Fixed Ratio, or Goal-Directed Blood Component Therapy for the Initial Resuscitation of Severely Hemorrhaging Trauma Patients: A Narrative Review.

J Clin Med 2021 Jan 17;10(2). Epub 2021 Jan 17.

The R Adams Cowley Shock Trauma Center, University of Maryland School of Medicine, Baltimore, MD 21201, USA.

This narrative review explores the pathophysiology, geographic variation, and historical developments underlying the selection of fixed ratio versus whole blood resuscitation for hemorrhaging trauma patients. We also detail a physiologically driven and goal-directed alternative to fixed ratio and whole blood, whereby viscoelastic testing guides the administration of blood components and factor concentrates to the severely bleeding trauma patient. The major studies of each resuscitation method are highlighted, and upcoming comparative trials are detailed.
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http://dx.doi.org/10.3390/jcm10020320DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7830337PMC
January 2021

Child physical abuse trauma evaluation and management: A Western Trauma Association and Pediatric Trauma Society critical decisions algorithm.

J Trauma Acute Care Surg 2021 04;90(4):641-651

From the Division of General and Thoracic Surgery, Cincinnati Children's Hospital Medical Center (N.G.R., R.A.F.), Cincinnati, Ohio; Department of Surgery, Mary Bridge Children's Hospital (M.A.E.), Tacoma, Washington; Division of Acute Care Surgery, Dell Medical School (C.V.B.), Austin, Texas; Department of Surgery, University of Colorado School of Medicine (E.E.M.), Denver, Colorado; Division of Trauma, MedStar Hospital Center (J.A.S.), Washington, DC; Department of Surgery, Scripps Mercy (K.P.), San Diego, California; Acute Care Surgery Division, Morsani College of Medicine (D.J.C.), Tampa, Florida; Division of Trauma Surgery, University of Pittsburgh (J.L.S.), Pittsburgh, Pennsylvania; Department of Surgery, Inova Trauma Center (A.G.R.), Falls Church, Virginia; Cedars-Sinai Medical Center (E.J.L.), Los Angeles, California; Division of Trauma, Critical Care, and Acute Care Surgery, Oregon Health/Science University (K.J.B.), Portland, Oregon; Department of Surgery, University of Maryland School of Medicine (R.K.), Baltimore, Maryland; Division of Trauma, Emergency Surgery, and Surgical Critical Care, Keck School of Medicine (K.I.), Los Angeles, California; Department of Pediatrics, Albert Einstein College of Medicine (J.L.H.-R.), Bronx, New York; Division of Pediatric Surgery, Phoenix Children's Hospital (D.M.N., L.W.S., T.N.), Phoenix, Arizona; Department of Surgery, Nemours Children's Specialty Care (R.W.L.), Jacksonville, Florida; Departments of Surgery, UT Health San Antonio and Baylor College of Medicine (I.C.M.), San Antonio, Texas; and the Department of Surgery, Scripps Mercy Hospital (M.J.M.), San Diego, California.

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http://dx.doi.org/10.1097/TA.0000000000003076DOI Listing
April 2021

A scoping review of worldwide studies evaluating the effects of prehospital time on trauma outcomes.

Int J Emerg Med 2020 Dec 9;13(1):64. Epub 2020 Dec 9.

University of Colorado, Anschutz Medical Campus, 13001 E 17th Place, Aurora, CO, 80045, USA.

Background: Annually, over 1 billion people sustain traumatic injuries, resulting in over 900,000 deaths in Africa and 6 million deaths globally. Timely response, intervention, and transportation in the prehospital setting reduce morbidity and mortality of trauma victims. Our objective was to describe the existing literature evaluating trauma morbidity and mortality outcomes as a function of prehospital care time to identify gaps in literature and inform future investigation.

Main Body: We performed a scoping review of published literature in MEDLINE. Results were limited to English language publications from 2009 to 2020. Included articles reported trauma outcomes and prehospital time. We excluded case reports, reviews, systematic reviews, meta-analyses, comments, editorials, letters, and conference proceedings. In total, 808 articles were identified for title and abstract review. Of those, 96 articles met all inclusion criteria and were fully reviewed. Higher quality studies used data derived from trauma registries. There was a paucity of literature from studies in low- and middle-income countries (LMIC), with only 3 (3%) of articles explicitly including African populations. Mortality was an outcome measure in 93% of articles, predominantly defined as "in-hospital mortality" as opposed to mortality within a specified time frame. Prehospital time was most commonly assessed as crude time from EMS dispatch to arrival at a tertiary trauma center. Few studies evaluated physiologic morbidity outcomes such as multi-organ failure.

Conclusion: The existing literature disproportionately represents high-income settings and most commonly assessed in-hospital mortality as a function of crude prehospital time. Future studies should focus on how specific prehospital intervals impact morbidity outcomes (e.g., organ failure) and mortality at earlier time points (e.g., 3 or 7 days) to better reflect the effect of early prehospital resuscitation and transport. Trauma registries may be a tool to facilitate such research and may promote higher quality investigations in Africa and LMICs.
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http://dx.doi.org/10.1186/s12245-020-00324-7DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7724615PMC
December 2020

Effects of Blood Components and Whole Blood in a Model of Severe Trauma-Induced Coagulopathy.

J Surg Res 2021 03 2;259:55-61. Epub 2020 Dec 2.

Department of Surgery, University of Colorado, Aurora, Colorado; Vitalant Research Institute, Vitalant Mountain Division, Denver, Colorado; Department of Pediatrics, University of Colorado, Aurora, Colorado.

Background: Plasma resuscitation ameliorates hyperfibrinolysis (HF) and trauma-induced coagulopathy (TIC). However, the use of other blood components to reduce HF has not been evaluated. Therefore, our aim was to determine the effect of individual blood components and whole blood (WB) on an in vitro model of severe HF/TIC.

Methods: A "TIC" solution was made with 1:1 dilution of WB with saline and exacerbated with tissue plasminogen activator (tPA). Components were added in proportions equivalent to the thromboelastography (TEG) based goal-directed resuscitation used at our institution. Whole blood was added at proportions equal to what has been transfused in injured patients. Samples (n = 9) underwent citrated native and tPA-challenge (75 ng/mL) TEG with analysis of R-time, angle, MA, and LY30. Statistical analyses were completed employing the nonparametric Kruskal-Wallis and Dunn's multiple comparisons tests.

Results: TIC solution, when compared to control, had a decrease in clot strength (MA 41 mm versus 51.5 mm, P < 0.01). The addition of tPA resulted in a severe coagulopathy (MA 24.5 mm versus 41 mm and LY30 52.8% versus 2.4%, P < 0.03 for all). The addition of 4U of WB improved clot strength compared to TIC + tPA (P = 0.03). No individual blood component resulted in improved fibrinolysis (P > 0.7). Cryoprecipitate improved R-time (7.5 versus 11.9 min, P < 0.01), angle (56.8 versus 30.2°) and MA (49 mm versus 36.25 mm), while platelets improved MA (44 mm versus 36.25 mm) compared to TIC + tPA (P < 0.03 for all).

Conclusions: No single blood component or volume of whole blood led to attenuation of tPA-mediated fibrinolysis in an in vitro model of TIC. Cryoprecipitate was the most effective at improving coagulation function.
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http://dx.doi.org/10.1016/j.jss.2020.10.022DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7897253PMC
March 2021

Challenges in Acute Care Surgery: Zone II Neck Gun Shot Wound at a Remote Rural Hospital.

J Trauma Acute Care Surg 2020 Nov 20. Epub 2020 Nov 20.

Department of Surgery, University of Colorado School of Medicine, Aurora, Colorado.

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http://dx.doi.org/10.1097/TA.0000000000003038DOI Listing
November 2020

American Association for the Surgery of Trauma-World Society of Emergency Surgery guidelines on diagnosis and management of abdominal vascular injuries.

J Trauma Acute Care Surg 2020 12;89(6):1197-1211

From the Division of Trauma (L.K., J.S.), Surgical Critical Care, Burns, and Acute Care Surgery, University of California San Diego, San Diego; Comparative Effectiveness and Clinical Outcomes Research Center (R.C.), Riverside University Health System Medical Center, Loma Linda University School of Medicine, Riverside, California; Vascular and Trauma Surgery (A.M.O.G. Jr.), Universidade Federal do Pará/Centro Universitário do Estado do Pará, Belém, PA, Brazil; Department of War Surgery (V.R.), Kirov Military Medical Academy, Saint Petersburg, Russia; Department of Surgery (E.E.M.), Ernest E. Moore Shock Trauma Center at Denver Health, University of Colorado, Denver, Colorado; Division Chief Trauma and Acute Care Surgery (J.M.G.), Department of Surgery, University of California Davis, Sacramento, California; Department of Surgery, College of Medicine and Health Sciences, UAE University, Al-Ain, United Arab Emirates; Division of Trauma and Acute Care Surgery, Department of Surgery (A.B.P.), University of Pittsburgh School of Medicine, Pittsburg, Pennsylvania; Division of Trauma and Acute Care Surgery, Department of Surgery (C.A.O.), Fundación Valle del Lili, Universidad del Valle, Cali, Colombia; Department of Surgery (R.V.M.), University of Washington, Seattle, Washington; Department of Surgery (S.D.S.), University Hospital of Varese, University of Insubria, Italy; Division of Acute Care Surgery, Department of Surgery (R.I.), Virginia Commonwealth University Richmond, Virginia; Unit of Digestive and HPB Surgery (N.D.A.), CARE Department, Henri Mondor University Hospital (AP-HP) and Faculty of Medicine, University of Paris Est, UPEC, Creteil, France; R. Adams Cowley Shock Trauma Center (T.S.), University of Maryland, Baltimore, Maryland; Emergency Surgery Department (F.C.), Parma University Hospital, Parma, Italy; Department of Surgery and Critical Care Medicine (A.K.), University of Calgary, Calgary, Alberta, Canada; Department of Emergency Surgery (V.K.), City Hospital, Mozyr, Belarus; Departments of Surgery and Medicine (N.P.), Schulich School of Medicine and Dentistry, Western University London Health Sciences Centre, London, Ontario, Canada; Trauma Services (I.C.), Auckland City Hospital, Faculty of Medical and Health Sciences, University of Auckland, Auckland, New Zealand; Abdominal Center, Department of Surgery (A.L., M.S.), University Hospital Meilahti, Helsinki, Finland; Department of Digestive Surgery (M. Chirica), Grenoble University Hospital, Grenoble, France; 3rd Department of Surgery (E.P.), Attikon General Hospital, National and Kapodistrian University of Athens, Athens, Greece; Division of Trauma/Acute Care Surgery and Surgical Critical Care (G.P.F.), University of Campinas, Campinas, Brazil; General, Emergency Surgery, and Trauma Center (M. Chiarugi), University of Pisa, Pisa, Italy; Department of General and Upper GI Surgery (D.D.), Royal Infirmary of Edinburgh, Edinburgh, United Kingdom; Dipartimento di Scienze Clinico Chirurgiche (E.C.), Diagnostiche e Pediatriche, University of Pavia, Pavia; General and Emergency Surgery Department (M. Ceresoli), School of Medicine and Surgery, Milano-Bicocca University, Monza, Italy; Service de Chirurgie Generale, Digestive, Metabolique Centre Hospitalier de Poissy (B.D.S.), St Germain en Laye, France; Departamento de Cirugía (F.V.-R.), Hospital Angeles Lomas, Curso Universitario Posgrado de Cirugía, Universidad Nacional Autónoma de México, Mexico, Mexico; Department of Surgery (M.S.), Macerata Hospital (ASUR Marche), Macerata, Italy; Trauma Surgery Department (W.B.), Scripps Memorial Hospital, La Jolla, California; General Surgery Department (L.A.), Bufalini Hospital, Cesena, Italy; and Trauma Service, Department of General Surgery (D.G.W.), Royal Perth Hospital, The University of Western Australia, Perth, Australia.

Abdominal vascular trauma accounts for a small percentage of military and a moderate percentage of civilian trauma, affecting all age ranges and impacting young adult men most frequently. Penetrating causes are more frequent than blunt in adults, while blunt mechanisms are more common among pediatric populations. High rates of associated injuries, bleeding, and hemorrhagic shock ensure that, despite advances in both diagnostic and therapeutic technologies, immediate open surgical repair remains the mainstay of treatment for traumatic abdominal vascular injuries. Because of their devastating nature, abdominal vascular injuries remain a significant source of morbidity and mortality among trauma patients. The American Association for the Surgery of Trauma in conjunction with the World Society of Emergency Surgery seek to summarize the literature to date and provide guidelines on the presentation, diagnosis, and treatment of abdominal vascular injuries. LEVEL OF EVIDENCE: Review study, level IV.
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http://dx.doi.org/10.1097/TA.0000000000002968DOI Listing
December 2020