Extracorporeal life support in pediatric trauma: a systematic review

Introduction Extracorporeal membrane oxygenation (ECMO) was once thought to be contraindicated in trauma patients, however ECMO is now used in adult patients with post-traumatic acute respiratory distress syndrome (ARDS) and multisystem trauma. Despite acceptance as a therapy for the severely injured adult, there is a paucity of evidence supporting ECMO use in pediatric trauma patients. Methods An electronic literature search of PubMed, MEDLINE, and the Cochrane Database of Collected Reviews from 1972 to 2018 was performed. Included studies reported on ECMO use after trauma in patients ≤18 years of age and reported outcome data. The Institute of Health Economics quality appraisal tool for case series was used to assess study quality. Results From 745 studies, four met inclusion criteria, reporting on 58 pediatric trauma patients. The age range was <1–18 years. Overall study quality was poor with only a single article of adequate quality. Twenty-nine percent of patients were cannulated at adult centers, the remaining at pediatric centers. Ninety-one percent were cannulated for ARDS and the remaining for cardiovascular collapse. Overall 60% of patients survived and the survival rate ranged from 50% to 100%. Seventy-seven percent underwent venoarterial cannulation and the remaining underwent veno-venous cannulation. Conclusion ECMO may be a therapeutic option in critically ill pediatric trauma patients. Consideration should be made for the expansion of ECMO utilization in pediatric trauma patients including its application for pediatric patients at adult trauma centers with ECMO capabilities

Handover Practices in Trauma and Acute Care Surgery: A Multicenter Survey Study

BACKGROUND: The handover period has been identified as a particularly vulnerable period for communication breakdown leading to patient safety events. Clear and concise handover is especially critical in high-acuity care settings such as trauma, emergency general surgery, and surgical critical care. There is no consensus for the most effective and efficient means of evaluating or performing handover in this population. We aimed to characterize the current handover practices and perceptions in trauma and acute care surgery. METHODS: A survey was sent to 2265 members of the Eastern Association for the Surgery of Trauma via email regarding handoff practices at their institution. Respondents were queried regarding their practice setting, average census, level of trauma center, and patients (trauma, emergency general surgery, and/or intensive care). Data regarding handover practices were gathered including frequency of handover, attendees, duration, timing, and formality. Finally, perceptions of handover including provider satisfaction, desire for improvement, and effectiveness were collected. RESULTS: Three hundred eighty surveys (17.1%) were completed. The majority (73.4%) of respondents practiced at level 1 trauma centers (58.9%) and were trauma/emergency general surgeons (86.5%). Thirty-five percent of respondents reported a formalized handover and 52% used a standardized tool for handover. Only 18% of respondents had ever received formal training, but most (51.6%) thought this training would be helpful. Eighty-one percent of all providers felt handover was essential for patient care, and 77% felt it prevented harm. Seventy-two percent thought their handover practice needed improvement, and this was more common as the average patient census increased. The most common suggestions for improvement were shorter and more concise handover (41.6%), different handover medium (24.5%), and adding verbal communication (13.9%). CONCLUSION: Trauma and emergency general surgeons perceive handover as essential for patient care and the majority desire improvement of their current handover practices. Methods identified to improve the handover process include standardization, simplification, and verbal interaction, which allows for shared understanding. Formal education and best practice guidelines should be developed

Futility in acute care surgery: first do no harm.

The consequences of the delivery of futile or potentially ineffective medical care and interventions are devastating on the healthcare system, our patients and their families, and healthcare providers. In emergency situations in particular, determining if escalating invasive interventions will benefit a frail and/or severely critically ill patient can be exceedingly difficult. In this review, our objective is to define the problem of potentially ineffective care within the specialty of acute care surgery and describe strategies for improving the care of our patients in these difficult situations

Dysphagia is associated with worse clinical outcomes in geriatric trauma patients

Introduction Dysphagia is associated with increased morbidity, mortality, and resource utilization in hospitalized patients, but studies on outcomes in geriatric trauma patients with dysphagia are limited. We hypothesized that geriatric trauma patients with dysphagia would have worse clinical outcomes compared with those without dysphagia.Methods Patients with and without dysphagia were compared in a single-center retrospective cohort study of trauma patients aged ≥65 years admitted in 2019. The primary outcome was mortality. Secondary outcomes included intensive care unit (ICU) length of stay (LOS), hospital LOS, discharge destination, and unplanned ICU admission. Multivariable regression analyses and Bayesian analyses adjusted for age, Injury Severity Score, mechanism of injury, and gender were performed to determine the association between dysphagia and clinical outcomes.Results Of 1706 geriatric patients, 69 patients (4%) were diagnosed with dysphagia. Patients with dysphagia were older with a higher Injury Severity Score. Increased odds of mortality did not reach statistical significance (OR 1.6, 95% CI 0.6 to 3.4, p=0.30). Dysphagia was associated with increased odds of unplanned ICU admission (OR 4.6, 95% CI 2.0 to 9.6, p≤0.001) and non-home discharge (OR 5.2, 95% CI 2.4 to 13.9, p≤0.001), as well as increased ICU LOS (OR 4.9, 95% CI 3.1 to 8.1, p≤0.001), and hospital LOS (OR 2.1, 95% CI 1.7 to 2.6, p≤0.001). On Bayesian analysis, dysphagia was associated with an increased probability of longer hospital and ICU LOS, unplanned ICU admission, and non-home discharge.Conclusions Clinically apparent dysphagia is associated with poor outcomes, but it remains unclear if dysphagia represents a modifiable risk factor or a marker of underlying frailty, leading to poor outcomes. This study highlights the importance of screening protocols for dysphagia in geriatric trauma patients to possibly mitigate adverse outcomes.Level of evidence Level III

Futility in acute care surgery: first do no harm

The consequences of the delivery of futile or potentially ineffective medical care and interventions are devastating on the healthcare system, our patients and their families, and healthcare providers. In emergency situations in particular, determining if escalating invasive interventions will benefit a frail and/or severely critically ill patient can be exceedingly difficult. In this review, our objective is to define the problem of potentially ineffective care within the specialty of acute care surgery and describe strategies for improving the care of our patients in these difficult situations