Attempting to validate the over/under triage matrix at a level I trauma center.

The Optimal Resources Document (ORD) mandates trauma activation based on injury mechanism, physiologic and anatomic criteria and recommends using the over/undertriage matrix (Matrix) to evaluate the appropriateness of trauma team activation. The purpose of this study was to assess the effectiveness of the Matrix method by comparing patients appropriately triaged with those undertriaged. We hypothesized that these two groups are different and Matrix does not discriminate the needs or outcomes of these different groups of patients.Trauma registry data, from 1/2013-12/2015, at a Level I trauma center were reviewed. Over and undertriage rates were calculated by Matrix. Patients with ISS ≥16 were classified by activation level (full, limited, consultation), and triage category by Matrix. Patients in the limited activation and consultation groups were compared to patients with full activation by demographics, injuries, initial vital signs, procedures, delays to procedure, ICU admission, length of stay, and mortality.7031 patients met activation criteria. Compliance with ACS tiered activation criteria was 99%. The Matrix overtriage rate was 45% and undertriage was 24%. Of 2282 patients with an ISS ≥16, 1026 were appropriately triaged (full activation), and 1256 were under triaged. Undertriaged patients had better GCS, blood pressure, and BD than patients with full activation. ICU admission, hospital stays, and mortality were lower in the undertriaged group. The under triaged group required fewer operative interventions with fewer delays to procedure.Despite having an ISS ≥ 16, patients with limited activations were dissimilar to patients with full activation. Level of activation and triage are not equivalent. The ACS-COT full and tiered activation criteria are a robust means to have the appropriate personnel present based on available pre-hospital information. Evaluation of the process of care, regardless of level of activation should be used to evaluate trauma center performance.Level III Therapeutic and Care managementThis 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

Current outcomes of blunt open pelvic fractures: how modern advances in trauma care may decrease mortality.

Background:Open pelvic fracture, caused by a blunt mechanism, is an uncommon injury with a high mortality rate. In 2008, evidence-based algorithm for managing pelvic fractures in unstable patients was published by the Western Trauma Association (WTA). The use of massive transfusion protocols has become widespread as has the availability and use of pelvic angiography. The purpose of this study was to evaluate the outcome of open pelvic fractures in association with related advances in trauma care. Methods:A retrospective review was performed, at an American College of Surgeon verified level I trauma center, of patients with blunt open pelvic fractures from January 2010 to April 2016. The WTA algorithm, including massive transfusion protocol, and pelvic angiography were uniformly used. Data collected included injury severity score, demographic data, transfusion requirements, use of pelvic angiography, length of stay, and disposition. Data were compared with a similar study from 2005. Results:During the study period, 1505 patients with pelvic fractures were analyzed; 87 (6%) patients had open pelvic fractures. Of these, 25 were from blunt mechanisms and made up the study population. Patients in both studies had similar injury severity scores, ages, Glasgow Coma Scale, and gender distributions. Use of angiography was higher (44% vs. 16%; P=0.011) and mortality was lower (16% vs. 45%; P=0.014) than in the 2005 study. Conclusions:Changes in trauma care for patients with open blunt pelvic fracture include the use of an evidence-based algorithm, massive transfusion protocols and increased use of angioembolization. Mortality for open pelvic fractures has decreased with these advances. Level of evidence:Level IV

Patients with gunshot wounds to the head do not require cervical spine immobilization and evaluation.

Abstract Objective: The purpose of this study was to determine the incidence of indirect spinal column injury in patients sustaining gunshot wounds to the head. Methods: A retrospective review of patient records and autopsy reports was conducted of patients admitted with gunshot wounds to the head between July of 1990 and September of 1995 were included. Those with gunshot wounds to the neck and those who were dead on arrival were excluded. Results: A total of 215 patients were included in the study. Cervical spine clearance in 202 patients (93%) was Conclusions: Indirect spinal injury does not occur in patients with gunshot wounds to the head. Airway management was compromised by cervical spine immobilization. Protocols mandating cervical spine immobilization after a gunshot wound to the head are unnecessary and may complicate airway management. Key Words: Gunshot wound to head, Cervical spine immobilization, Cervical spine injury. The risk of cervical spine injury associated with head injury has been reported to be from 3.5% up to 10% of cases. The occurrence of cervical spine injury in patients sustaining penetrating trauma to the head is essentially unknown. Despite this lack of knowledge, these patients routinely are immobilized in rigid collars and are treated with cervical spine precautions. These interventions have implications for airway management and necessitate diagnostic intervention (i.e., cervical spine clearance), accordingly, their utility should be determined. This study was performed to test the hypothesis that cervical spine injury, other than from direct bullet injury, does not occur in patients who sustain gunshot wounds (GSW) to the head and that these patients do not require cervical spine immobilization or clearance. MATERIALS AND METHODS The trauma registry records of all patients admitted to University Medical Center, a Level I trauma center, between July 1, 1990, and September 30, 1995, were reviewed, and patients with GSW to the head were identified. Hospital records were reviewed and data were abstracted, including age, sex, Glasgow Coma Scale score at emergency department (ED) presentation, other injuries, the use of cervical spine immobilization, cervical spine radiographs, and survival or autopsy results. The presence of cervical spine injury and direct (penetrating) or indirect (from associated blast injury of fall) mechanism was also recorded. Cervical spine clearance was by clinical or radiologic criteria in survivors; in nonsurvivors, clearance was by radiologic o

Attempting to validate the overtriage/undertriage matrix at a Level I trauma center.

BackgroundThe Optimal Resources Document mandates trauma activation based on injury mechanism, physiologic and anatomic criteria and recommends using the overtriage/undertriage matrix (Matrix) to evaluate the appropriateness of trauma team activation. The purpose of this study was to assess the effectiveness of the Matrix method by comparing patients appropriately triaged with those undertriaged. We hypothesized that these two groups are different, and Matrix does not discriminate the needs or outcomes of these different groups of patients.MethodsTrauma registry data, from January 2013 to December 2015, at a Level I trauma center, were reviewed. Overtriage and undertriage rates were calculated by Matrix. Patients with Injury Severity Score (ISS) of 16 or greater were classified by activation level (full, limited, consultation), and triage category by Matrix. Patients in the limited activation and consultation groups were compared with patients with full activation by demographics, injuries, initial vital signs, procedures, delays to procedure, intensive care unit admission, length of stay, and mortality.ResultsSeven thousand thirty-one patients met activation criteria. Compliance with American College of Surgeons tiered activation criteria was 99%. The Matrix overtriage rate was 45% and undertriage was 24%. Of 2,282 patients with an ISS of 16 or greater, 1,026 were appropriately triaged (full activation), and 1,256 were undertriaged. Undertriaged patients had better Glasgow Coma Scale score, blood pressure, and base deficit than patients with full activation. Intensive care unit admission, hospital stays, and mortality were lower in the undertriaged group. The undertriaged group required fewer operative interventions with fewer delays to procedure.ConclusionDespite having an ISS of 16 or greater, patients with limited activations were dissimilar to patients with full activation. Level of activation and triage are not equivalent. The American College of Surgeons Committee on Trauma full and tiered activation criteria are a robust means to have the appropriate personnel present based on the available prehospital information. Evaluation of the process of care, regardless of level of activation, should be used to evaluate trauma center performance.Level of evidenceTherapeutic and care management, level III

Attempting to validate the overtriage/undertriage matrix at a Level I trauma center.

BackgroundThe Optimal Resources Document mandates trauma activation based on injury mechanism, physiologic and anatomic criteria and recommends using the overtriage/undertriage matrix (Matrix) to evaluate the appropriateness of trauma team activation. The purpose of this study was to assess the effectiveness of the Matrix method by comparing patients appropriately triaged with those undertriaged. We hypothesized that these two groups are different, and Matrix does not discriminate the needs or outcomes of these different groups of patients.MethodsTrauma registry data, from January 2013 to December 2015, at a Level I trauma center, were reviewed. Overtriage and undertriage rates were calculated by Matrix. Patients with Injury Severity Score (ISS) of 16 or greater were classified by activation level (full, limited, consultation), and triage category by Matrix. Patients in the limited activation and consultation groups were compared with patients with full activation by demographics, injuries, initial vital signs, procedures, delays to procedure, intensive care unit admission, length of stay, and mortality.ResultsSeven thousand thirty-one patients met activation criteria. Compliance with American College of Surgeons tiered activation criteria was 99%. The Matrix overtriage rate was 45% and undertriage was 24%. Of 2,282 patients with an ISS of 16 or greater, 1,026 were appropriately triaged (full activation), and 1,256 were undertriaged. Undertriaged patients had better Glasgow Coma Scale score, blood pressure, and base deficit than patients with full activation. Intensive care unit admission, hospital stays, and mortality were lower in the undertriaged group. The undertriaged group required fewer operative interventions with fewer delays to procedure.ConclusionDespite having an ISS of 16 or greater, patients with limited activations were dissimilar to patients with full activation. Level of activation and triage are not equivalent. The American College of Surgeons Committee on Trauma full and tiered activation criteria are a robust means to have the appropriate personnel present based on the available prehospital information. Evaluation of the process of care, regardless of level of activation, should be used to evaluate trauma center performance.Level of evidenceTherapeutic and care management, level III

Attempting to validate the over/under triage matrix at a level I trauma center.

The Optimal Resources Document (ORD) mandates trauma activation based on injury mechanism, physiologic and anatomic criteria and recommends using the over/undertriage matrix (Matrix) to evaluate the appropriateness of trauma team activation. The purpose of this study was to assess the effectiveness of the Matrix method by comparing patients appropriately triaged with those undertriaged. We hypothesized that these two groups are different and Matrix does not discriminate the needs or outcomes of these different groups of patients.Trauma registry data, from 1/2013-12/2015, at a Level I trauma center were reviewed. Over and undertriage rates were calculated by Matrix. Patients with ISS ≥16 were classified by activation level (full, limited, consultation), and triage category by Matrix. Patients in the limited activation and consultation groups were compared to patients with full activation by demographics, injuries, initial vital signs, procedures, delays to procedure, ICU admission, length of stay, and mortality.7031 patients met activation criteria. Compliance with ACS tiered activation criteria was 99%. The Matrix overtriage rate was 45% and undertriage was 24%. Of 2282 patients with an ISS ≥16, 1026 were appropriately triaged (full activation), and 1256 were under triaged. Undertriaged patients had better GCS, blood pressure, and BD than patients with full activation. ICU admission, hospital stays, and mortality were lower in the undertriaged group. The under triaged group required fewer operative interventions with fewer delays to procedure.Despite having an ISS ≥ 16, patients with limited activations were dissimilar to patients with full activation. Level of activation and triage are not equivalent. The ACS-COT full and tiered activation criteria are a robust means to have the appropriate personnel present based on available pre-hospital information. Evaluation of the process of care, regardless of level of activation should be used to evaluate trauma center performance.Level III Therapeutic and Care managementThis 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

After the embo: predicting non-hemorrhagic indications for splenectomy after angioembolization in patients with blunt trauma.

BackgroundSuccessful non-operative management (NOM) of blunt splenic trauma is enhanced with splenic angioembolization (SAE). Patients may still require splenectomy post-SAE for splenic infarction/necrosis. Prior studies have used white blood cell count (WBC), platelet count (PLT), and PLT:WBC ratio after splenectomy to predict complications, but none have evaluated these findings prior to splenectomy in patients who have undergone SAE. Changes in these values may indicate clinically significant splenic infarction, facilitating management of these patients.MethodsPatients admitted to an American College of Surgeons verified level 1 trauma center from January 2007 to August 2017 who underwent SAE were identified. Patients with successful NOM after SAE (SAE/NOM) were compared with those requiring splenectomy (SAE/SPLEN). Data included demographics, splenic injury grade, Injury Severity Score (ISS), time to SAE and splenectomy, intensive care unit and hospital length of stay (LOS), and complete blood count. Lab values were analyzed immediately post-SAE (time 1) and day 5 post-SAE (or day of discharge) for SAE/NOM patients and day of SPLEN for SAE/SPLEN patients (time 2). Data were analyzed using Mann-Whitney U, χ2 tests, and receiver operating characteristic (ROC) curves with significance attributed to P<0.05.ResultsOf 124 patients undergoing SAE, 16 (13%) later required SPLEN for infarction/necrosis at a median of 5 days post-SAE (IQR: 3-10 days). SAE/SPLEN and SAE/NOM patients did not differ by age, gender, ISS, or grade of splenic injury. SAE/SPLEN patients had longer hospital LOS (23 vs. 10 days, P<0.001). WBC, PLT, and PLT:WBC ratio did not differ between the groups at time 1. At time 2, WBC was higher and PLT:WBC ratio was lower in SAE/SPLEN patients. Using ROC curves at time 2, the area under the curve was 0.90 (P<0.001) for WBC and 0.71 (P<0.007) for PLT:WBC ratio.DiscussionPatients requiring splenectomy for clinically significant infarction/necrosis after SAE develop leukocytosis and decreased PLT:WBC ratio when compared with SAE/NOM patients. Monitoring these parameters allows more prompt diagnosis and operative intervention.Level of evidenceTherapeutic/care management, level III

Survey of surgical critical care applicant and program director views on virtual interviews for fellowship training: a Surgical Critical Care Program Directors Society sponsored study

Background: The COVID-19 pandemic forced postgraduate interview processes to move to a virtual platform. There are no studies on the opinions of faculty and applicants regarding this format. The aim of this study was to assess the opinions of surgical critical care (SCC) applicants and program directors regarding the virtual versus in-person interview process. Methods: An anonymous survey of the SCC Program Director\u27s Society members and applicants to the 2019 (in-person) and 2020 (virtual) interview cycles was done. Demographic data and Likert scale based responses were collected using Research Electronic Data Capture. Results: Fellowship and program director responses rates were 25% (137/550) and 58% (83/143), respectively. Applicants in the 2020 application cycle attended more interviews. The majority of applicants (57%) and program faculty (67%) strongly liked/liked the virtual interview format but felt an in-person format allows better assessment of the curriculum and culture of the program. Both groups felt that an in-person format allows applicants and faculty to establish rapport better. Only 9% and 16% of SCC program directors wanted a purely virtual or purely in-person interview process, respectively. Applicants were nearly evenly split between preferring a purely in-person versus virtual interviews in the future. Discussion: The virtual interview format allows applicants and program directors to screen a larger number of programs and applications. However, the virtual format is less useful than an in-person interview format for describing unique aspects of a training program and for allowing faculty and applicants to establish rapport. Future strategies using both formats may be optimal, but such an approach requires further study. Level of evidence: Epidemiologic level IV

Management of Decompensated Cirrhosis in the Surgical ICU: an American Association for the Surgery of Trauma Critical Care Committee Clinical Consensus Document

Management of decompensated cirrhosis (DC) can be challenging for the surgical intensivist. Management of DC is often complicated by ascites, coagulopathy, hepatic encephalopathy, gastrointestinal bleeding, hepatorenal syndrome, and difficulty assessing volume status. This Clinical Consensus Document created by the American Association for the Surgery of Trauma Critical Care Committee reviews practical clinical questions about the critical care management of patients with DC to facilitate best practices by the bedside provider