Moose-Motor Vehicle Collision: A Continuing Hazard in Northern New England.

BACKGROUND: Moose-motor vehicle collisions (MMVC) are especially dangerous to vehicle occupants because of the height and mass of the animal, which often collapses the roof and has a direct impact into the passenger compartment. STUDY DESIGN: Public data on MMVC were obtained from the states of New England (NE), and trauma registry data from centers in NH and ME. RESULTS: For all of NE, the annual incidence of reported MMVC has declined from a peak of \u3e1,200 in 1998, but has still averaged \u3e500 over the last 5 years, predominantly in ME, NH, and VT. Public education may have contributed to the decline, but the moose population has also apparently decreased due to environmental changes. In NE, MMVCs are most frequent in the summer months and evening hours. Maine data on crashes involving wild ungulates from 2003 to 2017 document 50,281 collisions with deer and 7,061 collisions with moose; 26 of the latter (0.37%) resulted in a human fatality. Logistic regression models demonstrate that vehicle occupant mortality, after controlling for multiple factors related to vehicle speed, is greatly increased when striking a moose rather than a deer (odds ratio [OR] 13.4, 95% CI 6.3, 28.7). In these data, there were no fatalities among occupants of Swedish cars, which are specifically engineered to tolerate MMVC. Three NH/ME trauma centers registered 124 cases of MMVC: median Injury Severity Score was 9; 5 patients died (4%); and 76 patients (61%) had injuries of the head, face, and/or cervical spine. CONCLUSIONS: Moose-motor vehicle collisions remain a frequent and serious hazard to motor vehicle occupants in northern NE. Trauma services should recognize characteristic injury patterns. Continuing public education, cautious driving, and moose herd management are warranted

\u27Step Up\u27 approach to the application of REBOA technology in a rural

Our group has developed a \u27Step Up\u27 approach to the application of Resuscitative Endovascular Balloon Occlusion of the Aorta (REBOA) in a rural trauma system. This incorporates viewing REBOA as a spectrum of technology. Examples of REBOA technology use to improve outcomes and provision of our system\u27s clinical practice guideline for the Step-Up application of REBOA technology in the care of trauma patients are presented

American College of Surgeons Committee on Trauma Stop the Bleed Program : Quantifying the Impact of Training Upon Public School Educators Readiness

BACKGROUND: School violence continues to afflict our educational institutions. In response, an institutional initiative was launched to train educators and school support staff in life-saving skills aimed at hemorrhage control. METHODS: The American College of Surgeons Committee on Trauma Stop the Bleed (STB) Program was promoted as a quality improvement initiative to schools within the geographic catchment area of this Level I Trauma Center. Participants were given the opportunity to take precourse, and postcourse confidence inventories using a Likert Scale. Statistical analysis of the 324 precourse to postcourse evaluations measuring change in confidence was used to evaluate improvement in readiness of school systems to respond in mass casualty incidents. RESULTS: Students enrolled in the STB Program were offered the opportunity to assess their confidence precourse and postcourse in reference to 7 questions. Precourse and postcourse Likert Scale inventories were compared and analyzed to assess the strength of the improvement in confidence using Student\u27s -test, where \u3c .05 is statistically significant. Students demonstrated improvement ( \u3c .006) that was statistically significant across all 7-question relating to enhance confidence postcourse compared with the precourse. DISCUSSION: This STB quality initiative has demonstrated a statistically significant improvement in the confidence of teachers and school personnel to render lifesaving care in the event of a mass casualty or isolated incident of life-threatening hemorrhage. These results support the validity of the training in making a difference in this subpopulation of responders

Biometric Analysis of Surgeons\u27 Physiologic Responses During Surgery

BACKGROUND: Much has been written from the social science perspective surrounding surgeons\u27 stress and burn out. The literature is sparse in reference to scientific investigations of the hemodynamic effect of that stress. This prospective clinical study quantifies the physiologic impact of performing surgery upon the acute care surgeon. METHODS: Over 2.5 years, monitoring devices were affixed to surgeons prior to entering the operating room, and physiologic variables were documented every 30 minutes. Qualifying cases were projected as being greater than 2 hours with a baseline preoperative measurement obtained. Variables recorded included blood pressure (BP), heart rate (HR), rate pressure product (RPP), oxygen saturation (O sat), and end-tidal carbon dioxide (ET CO). RESULTS: Statistically significant differences ( \u3c .05) were found between baseline data to the maximum recording during the surgical operation for: BP (min 101 ± 6.6 (mmHg)-max 117 ± 5.1 (mmHg)), HR (min 70.5 ± 6.2 (bpm)-max 83.7 ± 9.0 (bpm)), O sat (min 97 ± 2.0 (%)-max 100 ± 0.22(%)), and ET CO (min 34.1 ± 1.15 mmHg-max 38 ± 1.7 mmHg) ( \u3c .0001). The RPP ranged from 10.49 mmHg/min to 15.88 mmHg/min with a mean of 14.00 mmHg/min. DISCUSSION: The practice of surgery is considered demanding in training and lifestyle in comparison to other medical specialties. This data is among the first to demonstrate the negative physiological impact of surgery upon the metabolic demand of the surgeon. The longitudinal implications of increased physiologic demand over time may have cardiovascular and cerebrovascular consequences

Outcomes of Protocol-Driven Venous Thromboembolic Chemo-Prophylaxis in Trauma Patients: A Trauma Quality Improvement Project Analysis

INTRODUCTION: Low molecular weight heparin (LMWH) is the standard for venous thromboembolic (VTE) chemo-prophylaxis in trauma patients; however, inconsistencies in the use of LMWH exist. The objective of this study was to assess VTE outcomes in response to a chemo-prophylaxis protocol guided by patient physiology (eg, creatinine clearance) and comorbidities. METHODS: ACS TQIP Benchmark Reports at a level 1 trauma center using a patient physiology and comorbidity directed VTE chemo-prophylaxis protocol were analyzed for Spring 2019 to Fall 2021. Patient demographics, VTE rates and pharmacologic VTE prophylaxis type were collected for All Patients and Elderly (TQIP: age ≥ 55 years) cohorts. RESULTS: Data was analyzed for 1919183 All Hospitals (AH) and 5843 patients single institution (SI) using the physiologic and comorbidity guided VTE chemo-prophylaxis protocol. Elderly subgroup had 701965 (AH) and 2939 (SI) patients. Use of non-LMWH chemo-prophylaxis was significantly higher at SI: All patients = 62.6% SI vs 22.1% ( \u3c .01); Elderly = 68.8% SI vs 28.1% AH ( \u3c .01). VTE, DVT, and PE rates for All Patients and Elderly subgroup were significantly reduced at SI, except Elderly PE which was statistically equivalent. CONCLUSIONS: Protocol-driven VTE chemo-prophylaxis was associated with significantly lower LMWH use accompanied by significant reductions in All VTE, DVT, PE, and Elderly VTE and DVT with no difference in Elderly PE rates. These results may imply that adherence to a physiologic and comorbidity directed chemo-prophylaxis protocol, rather than LMWH, reduces VTE events in trauma patients. Further investigation to elucidate best practice is warranted

Outcomes after ultramassive transfusion in the modern era: An Eastern Association for the Surgery of Trauma multicenter study.

BackgroundDespite the widespread institution of modern massive transfusion protocols with balanced blood product ratios, survival for patients with traumatic hemorrhage receiving ultramassive transfusion (UMT) (defined as ≥20 U of packed red blood cells [RBCs]) in 24 hours) remains low and resource consumption remains high. Therefore, we aimed to identify factors associated with mortality in trauma patients receiving UMT in the modern resuscitation era.MethodsAn Eastern Association for the Surgery of Trauma multicenter retrospective study of 461 trauma patients from 17 trauma centers who received ≥20 U of RBCs in 24 hours was performed (2014-2019). Multivariable logistic regression and Classification and Regression Tree analysis were used to identify clinical characteristics associated with mortality.ResultsThe 461 patients were young (median age, 35 years), male (82%), severely injured (median Injury Severity Score, 33), in shock (median shock index, 1.2; base excess, -9), and transfused a median of 29 U of RBCs, 22 U of fresh frozen plasma (FFP), and 24 U of platelets (PLT). Mortality was 46% at 24 hours and 65% at discharge. Transfusion of RBC/FFP ≥1.5:1 or RBC/PLT ≥1.5:1 was significantly associated with mortality, most pronounced for the 18% of patients who received both RBC/PLT and RBC/FFP ≥1.5:1 (odds ratios, 3.11 and 2.81 for mortality at 24 hours and discharge; both p < 0.01). Classification and Regression Tree identified that age older than 50 years, low initial Glasgow Coma Scale, thrombocytopenia, and resuscitative thoracotomy were associated with low likelihood of survival (14-26%), while absence of these factors was associated with the highest survival (71%).ConclusionDespite modern massive transfusion protocols, one half of trauma patients receiving UMT are transfused with either RBC/FFP or RBC/PLT in unbalanced ratios ≥1.5:1, with increased associated mortality. Maintaining focus on balanced ratios during UMT is critical, and consideration of advanced age, poor initial mental status, thrombocytopenia, and resuscitative thoracotomy can aid in prognostication.Level of evidencePrognostic, level III

Outcomes after ultramassive transfusion in the modern era: An Eastern Association for the Surgery of Trauma multicenter study

BACKGROUND Despite the widespread institution of modern massive transfusion protocols with balanced blood product ratios, survival for patients with traumatic hemorrhage receiving ultramassive transfusion (UMT) (defined as >= 20 U of packed red blood cells [RBCs]) in 24 hours) remains low and resource consumption remains high. Therefore, we aimed to identify factors associated with mortality in trauma patients receiving UMT in the modern resuscitation era. METHODS An Eastern Association for the Surgery of Trauma multicenter retrospective study of 461 trauma patients from 17 trauma centers who received >= 20 U of RBCs in 24 hours was performed (2014-2019). Multivariable logistic regression and Classification and Regression Tree analysis were used to identify clinical characteristics associated with mortality. RESULTS The 461 patients were young (median age, 35 years), male (82%), severely injured (median Injury Severity Score, 33), in shock (median shock index, 1.2; base excess, -9), and transfused a median of 29 U of RBCs, 22 U of fresh frozen plasma (FFP), and 24 U of platelets (PLT). Mortality was 46% at 24 hours and 65% at discharge. Transfusion of RBC/FFP >= 1.5:1 or RBC/PLT >= 1.5:1 was significantly associated with mortality, most pronounced for the 18% of patients who received both RBC/PLT and RBC/FFP >= 1.5:1 (odds ratios, 3.11 and 2.81 for mortality at 24 hours and discharge; both p = 1.5:1, with increased associated mortality. Maintaining focus on balanced ratios during UMT is critical, and consideration of advanced age, poor initial mental status, thrombocytopenia, and resuscitative thoracotomy can aid in prognostication