Securing the Emergency Department During Terrorism Incidents: Lessons Learned From the Boston Marathon Bombings

Terrorist incidents that target hospitals magnify morbidity and mortality. Before a real or perceived terrorist mass casualty incident threatens a hospital and its providers, it is essential to have protocols in place to minimize damage to the infrastructure, morbidity, and mortality. In the years following the Boston Marathon bombings, much has been written about the heroic efforts of survivors and responders. Far less has been published about near misses due to lack of experience responding to a mass casualty incident resulting from terrorism. After an extensive review of the medical literature and published media in English, Spanish, and Hebrew, we were unable to identify a similar event. To the best of our knowledge, this is the first reported experience of a bomb threat caused evacuation of an emergency department in the United States while actively responding to multiple casualty terrorist incidents. We summarized the chronology of the events that led to a bomb threat being identified and the subsequent evacuation of the emergency department. We then reviewed the problematic nature of our response and described evidence-based policy changes based on data from health care, law enforcement, and counterterrorism. (Disaster Med Public Health Preparedness. 2019;13:791–798

Readmission Following Surgical Stabilization of Rib Fractures

BACKGROUND: Surgical stabilization of rib fractures (SSRF) has become increasingly common for the treatment of traumatic rib fractures; however, little is known about related postoperative readmissions. The aims of this study were to determine the rate, and cost of readmissions as well as to identify patient, hospital, and injury characteristics that are associated with risk of readmission in patients who underwent SSRF. The null hypotheses were that readmissions following rib fixation were rare and unrelated to the SSRF complications. METHODS: This is a retrospective analysis of the 2015–2017 Nationwide Readmission Database. Adult patients with rib fractures treated by SSRF were included. Univariate and multivariate analyses were used to compare patients readmitted within 30 days to those who were not, based on demographics, comorbidities, and hospital characteristics. Financial information examined included average visit costs and national extrapolations. RESULTS: 2,522 patients who underwent SSRF were included, of whom 276 (10.9%) were readmitted within 30 days. In 36.2% of patients the reasons for readmissions were related to complications of rib fractures or SSRF. The rest of the patients (63.8%) were readmitted due to mostly non-trauma reasons (32.2%) and new traumatic injuries (21.1%) among other reasons. Multivariate analysis demonstrated that ventilator use, discharge other than home, smaller hospital size, and medical comorbidities were significantly associated with risk of readmission. Nationally, an estimated 2,498 patients undergo SSRF each year, with costs of $176 million for initial admissions and$5.9 million for readmissions. CONCLUSIONS: Readmissions after SSRF are rare and mostly attributed to the reasons not directly related to sequelae of rib fractures or SSRF complications. Interventions aimed at optimizing patients’ pre-existing medical conditions prior to discharge should be further investigated as a potential way to decrease rates of readmission after SSRF. LEVEL OF EVIDENCE: Epidemiological study, level II

Duration of Antimicrobial Treatment for Complicated Intra-abdominal Infections after Definitive Source Control: A Systematic Review, Meta-Analysis, and Practice Management Guideline from the Eastern Association for the Surgery of Trauma

BACKGROUNDRecent studies have evaluated outcomes associated with duration of antimicrobial treatment for complicated intra-abdominal infections (cIAI). The goal of this guideline was to help clinicians better define appropriate antimicrobial duration in patients who have undergone definitive source control for cIAI. METHODSA working group of Eastern Association for the Surgery of Trauma (EAST) performed a systematic review and meta-analyses of the available data pertaining to the duration of antibiotics after definitive source control of cIAI in adult patients. Only studies that compared patients treated with short vs long duration antibiotic regimens were included. The critical outcomes of interest were selected by the group. Non-inferiority of short compared to long duration of antimicrobial treatment was defined as an indicator for a potential recommendation in favor of shorter antibiotics course. The Grading of Recommendations Assessment, Development and Evaluation (GRADE) methodology was utilized to assess the quality of the evidence and to formulate recommendations. RESULTSSixteen studies were included. The short duration ranged from 1 dose to ≤10 days, with an average of 4 days, and the long duration ranged >1-28 days, with an average of 8 days. There were no differences between short and long duration of antibiotics in terms of mortality (odd ratio (OR) .90; 95% confidence interval (CI) 0.56-1.44), rate of surgical site infection (OR 0.88; 95% CI 0.56 to 1.38); persistent/recurrent abscess (OR 0.76, CI 0.45, 1.29); unplanned interventions (OR 0.53, CI 0.12, 2.26); hospital length of stay (mean difference -2.62 days, CI -7.08, 1.83); or readmissions (OR 0.92, CI 0.50, 1.69). The level of evidence was assessed as very low. CONCLUSIONThe group made a recommendation for shorter (four or less days) versus longer duration (eight or more days) of antimicrobial treatment in adult patients with cIAIs who had definitive source control.Level of Evidence: Systematic Review and Meta-Analysis, III

Experimental and theoretical study of hydrogen desorption process from Mn(BH4)2

The thermal decomposition of manganese borohydride Mn(BH4)2 was studied by means of synchrotron-based X-ray absorption spectroscopy (XAS), X-ray powder diffraction (XRPD) and theoretical density functional (DFT) modeling aiming to elucidate changes of the local atomic structure upon hydrogen desorption and to determine possible decomposition reaction products. XRPD patterns indicate profound structural changes in the material above 120 °C with subsequent amorphization. DFT simulations predict the collapse of the highly porous framework structure upon hydrogen desorption and significant reduction of Mn-B and Mn-Mn interatomic distances by 19% and 41% respectively. These estimations are in a good agreement with the quantitative analysis of the X-ray absorption spectra above Mn K-edge. Based on XAS we derive possible decomposition products and reaction path. In particular, the amount of Mn metallic phase was estimated to be less than 5% after the heating up to 200 °C. Several structural models for the final state of manganese borohydride in a heating process are constructed by means of energy minimization in conjunction with evolutionary algorithms

Role of Vena Cava Filter in the Prophylaxis and Treatment of Venous Thromboembolism in Injured Adult Patients: A Systematic Review, Meta-Analysis, and Practice Management Guideline from the Eastern Association for the Surgery of Trauma

Injured patients are at an increased risk of developing deep vein thrombosis (DVT) and pulmonary embolism (PE). Inferior vena cava (IVC) filters have been used in injured patients to prevent venous thromboembolism (VTE), but current evidence-based guidelines are lacking. Questions regarding IVC filter use in injured patients with clearly defined Population(s), Intervention(s), Comparison(s), and appropriately selected Outcomes (PICO) were formulated. The study sought to understand the evidence behind use of ultra short term IVC filters and use of IVC filters in injured patients with and without known VTE who are unable to receive therapeutic anticoagulation and chemoprophylaxis, respectively. A literature search and review was conducted, followed by meta-analysis. The quality of evidence was assessed per Grading of Recommendations Assessment, Development and Evaluation (GRADE) methodology. There were twenty-one studies that were analyzed. Three studies were randomized controlled trials (RCTs), three were observational studies, and fifteen studies were retrospective studies. In injured patients without known acute VTE who cannot receive chemoprophylaxis, we recommend against placement of an IVC filter due to associated higher rate of mortality, DVT, PE, and length of stay. The quality of evidence was assessed to be low. In injured patients with known DVT who cannot receive chemoprophylaxis we conditionally recommend against placement of an IVC filter. The quality of evidence was assessed to be very low. No recommendations can be made with respect to placement of ultra short term IVC filters based upon available data. IVC filters should not be placed routinely for prophylaxis in injured adult patients without known VTE who cannot receive chemoprophylaxis. The taskforce conditionally recommends against the placement of IVC filter in injured adult patients with known DVT who cannot receive chemoprophylaxis. Guideline; Systematic review/meta-analysis, level IV