Raquel M. Forsythe

INTRODUCTION: Whole blood resuscitation is associated with survival benefits in observational cohort studies. The mechanisms responsible for outcome benefits have not been adequately determined. We sought to characterize the achievement of hemostasis across patients receiving early whole blood versus component resuscitation. We hypothesized that achieving hemostasis would be associated with outcome benefits and patients receiving whole blood would be more likely to achieve hemostasis. METHODS: We performed a post hoc retrospective secondary analysis of data from a recent prospective observational cohort study comparing early whole blood and component resuscitation in patients at risk of hemorrhagic shock. Achievement of hemostasis was defined by receiving a single unit of blood or less, including whole blood or red cells, in any 60-minute period, over the first 4 hours from the time of arrival. Time-to-event analysis with log-rank comparison and regression modeling were used to determine the independent benefits of achieving hemostasis and whether achieving hemostasis was associated with whole blood resuscitation. RESULTS: For the current analysis, 1,047 patients met the inclusion criteria for the study. When we compared patients who achieved hemostasis versus those who did not, achievement of hemostasis had significantly more hemostatic coagulation parameters, had lower transfusion requirements, and was independently associated with 4-hour, 24-hour and 28-day survival. Whole blood patients were significantly more likely to achieve hemostasis (88.9% vs. 81.1%, p < 0.001). Whole blood patients achieved hemostasis earlier (log-rank χ² = 8.2, p < 0.01) and were independently associated with over twofold greater odds of achieving hemostasis (odds ratio, 2.4; 95% confidence interval, 1.6–3.7; p < 0.001). CONCLUSION: Achievement of hemostasis is associated with significant outcome benefits. Early whole blood resuscitation is associated with a greater independent odds of achieving hemostasis and at an earlier time point. Reaching a nadir transfusion rate early following injury represents a possible mechanism of whole blood resuscitation and its attributable outcome benefits. LEVEL OF EVIDENCE: Therapeutic/Care Management; Level III.

Objective: To determine the feasibility, efficacy, and safety of cold storage compared with room temperature (RT) platelet transfusion in patients with traumatic brain injury (TBI). Background: Data demonstrating the safety and efficacy of cold-stored platelet (CSP) transfusion are lacking after TBI. Methods: A phase 2, randomized, open-label clinical trial was performed at a single U.S. trauma center. Traumatic brain-injured patients with positive brain imaging and a need for platelet transfusion received up to 2 apheresis units of CSPs stored out to 14 days versus standard care RT platelet transfusion. The primary outcome was feasibility and the principal clinical outcome for efficacy and safety was the 6-month Glasgow Coma Scale–extended score. Results: The 6-month Glasgow Outcome Scale–extended score distributions were not different across cold stored and RT platelet arms (odds ratio: 1.58, 95% CI: 0.71 to 3.54, P = 0.27). A lower rate of neurosurgical craniotomy/craniectomy was found for those receiving CSPs (difference: -14.4%, 95% CI: -26.5% to -2.3%, P = 0.03). Adverse event rates did not differ across groups. The storage age of the cold-stored product was not associated with outcome differences. Conclusions: In brain-injured patients requiring platelet transfusion, early CSP transfusion is feasible and did not result in improved 6-month Glasgow Coma Scale–extended scores. Early CSP transfusion was associated with a lower rate of neurosurgical operative intervention without an increase in adverse events. The storage age of the CSP product was not associated with outcome differences. Future phase 3 clinical trials are required to determine clinical outcome differences and safety attributable to CSP transfusion after TBI.

Advanced practice providers (APPs) have become essential to trauma teams in the United States during the last few decades. The optimal utilization of APPs is not yet known and is likely highly variable secondary to many factors. We discuss three aspects of the multidisciplinary approach to caring for trauma patients. First, a review of the literature demonstrates that APPs in trauma improve quality of care, patient throughput, and decrease cost. We then report on models of APP utilization by comparing five trauma centers across the country, concluding that utilization remains highly variable due to several system and provider factors. The final portion of this review highlights current billing and coding practices in integrated teams considering recent changes to Centers for Medicare and Medicaid rules in 2024.

BACKGROUND AND OBJECTIVES: Nearly 30% of older adults presenting with isolated spine fractures will die within 1 year. Attempts to ameliorate this alarming statistic are hindered by our inability to identify relevant risk factors. The primary objective of this study was to develop a prediction model that identifies feasible targets to limit 1-year mortality. METHODS: This retrospective cohort study included 703 older adults (65 years or older) admitted to a level I trauma center with isolated spine fractures, without neural deficit, from January 2013 to January 2018. Multivariable analysis was used to select for independently significant patient demographics, frailty variables, injury metrics, and management decisions to incorporate into distinct logistic regression models predicting 1-year mortality. Variables were considered significant, if P < .05. RESULTS: Of the 703 older adults, 199 (28.3%) died after hospital discharge, but within 1 year of index trauma. Risk Analysis Index (RAI; odds ratio [OR]: 1.116; 95% CI: 1.087-1.149; P < .001) and ambulation requiring a cane (OR: 2.601; 95% CI: 1.151-5.799; P = .02) or walker (OR: 4.942; 95% CI: 2.698-9.196; P < .001), ie, frailty variables, were associated with increased odds of 1-year mortality. Spine trauma scales were not associated with 1-year mortality. Longer hospital stays (OR: 1.112; 95% CI: 1.034-1.196; P = .004) and nursing home discharge (OR: 3.881; 95% CI: 2.070-7.378; P < .001) were associated with increased odds, while discharge to rehab (OR: 0.361; 95% CI: 0.155-0.799; P = .014) decreased 1-year mortality odds. A “preinjury” regression model incorporating Risk Analysis Index and ambulation status resulted in an area under receiver operating characteristic curve (AUROCC) of 0.914 (95% CI: 0.863-0.965). A “postinjury” model incorporating Glasgow Coma Scale, hospital stay duration, and discharge disposition resulted in AUROCC of 0.746 (95% CI: 0.642-0.849). Combining elements of the preinjury and postinjury models into an “integrated model” produced an AUROCC of 0.908 (95% CI: 0.852-0.965). CONCLUSION: Preinjury frailty measures are most strongly associated with 1-year mortality outcomes in older adults with isolated spine fractures. Incorporating injury metrics or management decisions did not enhance predictive accuracy. Further work is needed to understand how targeting frailty may reduce mortality.

Blunt cerebrovascular injuries (BCVI) are generally associated with high-energy injury mechanisms. Less is known regarding lower-energy injuries in elderly patients. We sought to determine the incidence of BCVI and characterize current BCVI screening practices and associated complications in elderly ground-level fall patients (EGLF, ≥ 65 years). We hypothesized that BCVI in EGLF patients would be clinically significant and screening would be less common. A retrospective study was performed utilizing the National Trauma Data Bank (NTDB, 2007–2014) and single institutional data. BCVI risk factors and diagnosis were determined by ICD-9 codes. Presenting patient characteristics and clinical course were obtained by chart review. The NTDB dataset was used to determine the incidence of BCVI, risk factors for BCVI, and outcomes in the EGLF cohort. Local chart review focused on screening rates and complications. The incidence of BCVI in EGLF patients was 0.15% overall and 0.86% in those with at least one BCVI risk factor in the NTDB. Upper cervical spine fractures were the most common risk factor for BCVI in EGLF patients. In EGLF patients, the diagnosis of BCVI was an independent risk factor for mortality (OR1.8, 95% C.I. 1.5–2.1). The local institutional data (2007–2014) had a BCVI incidence of 0.37% (n = 6487) and 1.47% in those with at least one risk factor (n = 1429). EGLF patients with a risk factor for BCVI had a very low rate of screening (44%). Only 8% of EGLF patients not screened had documented contraindications. The incidence of renal injury was 9% irrespective of BCVI screening. The incidence of BCVI is clinically significant in EGLF patients and an independent predictor of mortality. Screening is less common in EGLF patients despite few contraindications. This data suggests that using age and injury mechanism to omit BCVI screening in EGLF patients may exclude an at-risk population. IRB approval number: PRO15020269. Retrospective trial not registered

BACKGROUND The evolving field of acute care surgery (ACS) traditionally includes trauma, emergency general surgery, and critical care. However, the critical role of ACS in the rescue of patients with a surgical complication has not been explored. We here describe the role of “surgical rescue” in the practice of ACS. METHODS A prospective, electronic medical record-based ACS registry spanning January 2013 to May 2014 at a large urban academic medical center was screened by ICD-9 codes for acute surgical complications of an operative or interventional procedure. Long-term outcomes were derived from the Social Security Death Index. RESULTS Of 2,410 ACS patients, 320 (13%) required “surgical rescue”: most commonly, from wound complications (32%), uncontrolled sepsis (19%), and acute obstruction (15%). The majority of complications (85%) were related to an operation; 15% were related to interventional procedures. The most common rescue interventions required were bowel resection (23%), wound debridement (18%), and source control of infection (17%); 63% of patients required operative intervention, and 22% required surgical critical care. Thirty-six percent of complications occurred in ACS primary patients (“local”), whereas 38% were referred from another surgical service (“institutional”) and 26% referred from another institution (“regional”). Hospital length of stay was longer, and in-hospital and 1-year mortalities were higher in rescue patients compared with those without a complication. Outcomes were equivalent between “local” and “institutional” patients, but hospital length of stay and discharge to home were significantly worse in “institutional” referrals. CONCLUSION We here describe the distinct role of the acute care surgeon in the surgical management of complications; this is an additional pillar of ACS. In this vital role, the acute care surgeon provides crucial support to other providers as well as direct patient care in the “surgical rescue” of surgical and procedural complications. LEVEL OF EVIDENCE Epidemiological study, level III; therapeutic/care management study, level IV.

BACKGROUND The Air Medical Prehospital Triage (AMPT) score was developed to identify injured patients who may benefit from scene helicopter emergency medical services (HEMS) transport. External validation using a different data set is essential to ensure reliable performance. The study objective was to validate the effectiveness of the AMPT score to identify patients with a survival benefit from HEMS using the Pennsylvania Trauma Outcomes Study registry. METHODS Patients 16 years or older undergoing scene HEMS or ground EMS (GEMS) transport in the Pennsylvania Trauma Outcomes Study registry 2000–2013 were included. Patients with 2 or higher AMPT score points were triaged to HEMS, while those with less than 2 points were triaged to GEMS. Multilevel Poisson regression determined the association of survival with actual transport mode across AMPT score triage assignments, adjusting for demographics, mechanism, vital signs, interventions, and injury severity. Successful validation was defined as no survival benefit for actual HEMS transport in patients triaged to GEMS by the AMPT score, with a survival benefit for actual HEMS transport in patients triaged to HEMS by the AMPT score. Subgroup analyses were performed in patients treated by advanced life support providers and patients with transport times longer than 10 minutes. RESULTS There were 222,827 patients included. For patients triaged to GEMS by the AMPT score, actual transport mode was not associated with survival (adjusted relative risk, 1.004; 95% confidence interval, 0.999–1.009; p = 0.08). For patients triaged to HEMS by the AMPT score, actual HEMS transport was associated with a 6.7% increase in the relative probability of survival (adjusted relative risk, 1.067; 95% confidence interval, 1.040–1.083, p < 0.001). Similar results were seen in all subgroups. CONCLUSIONS This study is the first to externally validate the AMPT score, demonstrating the ability of this tool to reliably identify trauma patients most likely to benefit from HEMS transport. The AMPT score should be considered when protocols for HEMS scene transport are developed and reviewed. LEVEL OF EVIDENCE Epidemiologic/prognostic study, level III; therapeutic/care management study, level IV.

Objective: The aim of this study was to develop and internally validate a triage score that can identify trauma patients at the scene who would potentially benefit from helicopter emergency medical services (HEMS). Summary Background Data: Although survival benefits have been shown at the population level, identification of patients most likely to benefit from HEMS transport is imperative to justify the risks and cost of this intervention. Methods: Retrospective cohort study of subjects undergoing scene HEMS or ground emergency medical services (GEMS) in the National Trauma Databank (2007–2012). Data were split into training and validation sets. Subjects were grouped by triage criteria in the training set and regression used to determine which criteria had a survival benefit associated with HEMS. Points were assigned to these criteria to develop the Air Medical Prehospital Triage (AMPT) score. The score was applied in the validation set to determine whether subjects triaged to HEMS had a survival benefit when actually transported by helicopter. Results: There were 2,086,137 subjects included. Criteria identified for inclusion in the AMPT score included GCS P < 0.01). In subjects triaged to GEMS, actual transport mode was not associated with survival (AOR 1.04; 95% CI 0.97–1.11, P = 0.20). Conclusions: The AMPT score identifies patients with improved survival following HEMS transport and should be considered in air medical triage protocols.

BACKGROUND Trauma is time sensitive, and minimizing prehospital (PH) time is appealing. However, most studies have not linked increasing PH time with worse outcomes because raw PH times are highly variable. It is unclear whether specific PH time patterns affect outcomes. Our objective was to evaluate the association of PH time interval distribution with mortality. METHODS Patients transported by emergency medical services in the Pennsylvania trauma registry from 2000 to 2013 with a total PH time (TPT) of 20 minutes or longer were included. TPT was divided into three PH time intervals: response, scene, and transport time. The number of minutes in each PH time interval was divided by TPT to determine the relative proportion each interval contributed to TPT. A prolonged interval was defined as any one PH interval contributing equal to or greater than 50% of TPT. Patients were classified by prolonged PH interval or no prolonged PH interval (all intervals < 50% of TPT). Patients were matched for TPT, and conditional logistic regression determined the association of mortality with PH time pattern, controlling for confounders. PH interventions were explored as potential mediators, and PH triage criteria used identify patients with time-sensitive injuries. RESULTS There were 164,471 patients included. Patients with prolonged scene time had increased odds of mortality (odds ratio, 1.21; 95% confidence interval, 1.02–1.44; p = 0.03). Prolonged response, transport, and no prolonged interval were not associated with mortality. When adjusting for mediators including extrication and PH intubation, prolonged scene time was no longer associated with mortality (odds ratio, 1.06; 95% confidence interval, 0.90–1.25; p = 0.50). Together, these factors mediated 61% of the effect between prolonged scene time and mortality. Mortality remained associated with prolonged scene time in patients with hypotension, penetrating injury, and flail chest. CONCLUSION Prolonged scene time is associated with increased mortality. PH interventions partially mediate this association. Further study should evaluate whether these interventions drive increased mortality because they prolong scene time or by another mechanism, as reducing scene time may be a target for intervention. LEVEL OF EVIDENCE Prognostic/epidemiologic study, level III.