Emergency Trauma Surgery Research Articles

Anesthetic approach to trauma patients in the city hospital after the 2023 Maraş earthquake.

The February 6, 2023, Kahramanmaraş earthquake caused significant destruction across our country. More than 50,000 people lost their lives, thousands were injured, and health facilities were damaged. Victims were transferred to hospitals in other provinces for treatment. This study evaluates the anesthesia approach applied to the injured who were transferred to our tertiary hospital. We retrospectively reviewed the data of patients who underwent surgery between February 6 and February 20, 2023. The study included earthquake victims who underwent emergency trauma surgery, aged 10 years and above. We recorded the date of admission to the hospital, demographic information, type of surgery, surgical site, anesthesia technique, preference for peripheral block, laboratory values, dialysis and intensive care needs, and survival rates. Data analysis was performed using the IBM® Statistical Package for the Social Sciences (SPSS®) Version 26.0. A total of 375 cases were included in the study. Of these, 323 patients underwent surgery for extremity injuries, and 35 for vertebral injuries. Among the extremity injuries, 61.6% were to the lower extremities, and 17.1% to the upper extremities. Debridement was performed on 147 patients, fasciotomy on 49 patients, and amputation on 33 patients. General anesthesia was applied to 352 patients, spinal anesthesia to 19 patients, and sedoanalgesia to four patients. Peripheral nerve block was performed on 33 patients. Dialysis treatment was administered to 105 patients. Twenty-six patients were lost during the treatment process. There were no intraoperative patient deaths. The predominance of extremity injuries among earthquake victims increases the inclination towards regional anesthesia. Incorporating Plan A blocks into basic anesthesia skills could enhance the preference for regional anesthesia in disaster situations. Furthermore, transferring the injured to advanced centers may reduce morbidity.

EGS P13 Adherence to Guidelines for Post-Splenectomy Patients in a Primary Care Practice in North West England

Abstract Background Splenectomy is indicated in haematological, oncological disorders and occasionally during emergency (trauma) surgery. Given the spleens role in the immunological response, overwhelming infection remains an area of concern for post-splenectomy patients with low prevalence (0.1-0.5%) but high mortality (∼50%). Strep pneumoniae, H influenzae Type B and Neisseria meningitidis are common bacterial perpetrators. At present, Public Health England and the British Society for Haematology recommends regular influenza, pneumococcal and meningococcal vaccinations for patients with asplenia or hyposplenism. They should also be on lifelong prophylactic antibiotics. This audit aimed to assess the adherence to vaccination and antibiotic prophylaxis guidelines for post-splenectomy patients. Methods 19 patients post splenectomy patients were identified at a primary care practice in North West England. Data was retrospectively collected from the last 10 years with two researchers manually searching through their GP records. Parameters collected included both compliance and timeliness with vaccinations and antibiotic prophylaxis as per national guidance. Where there was a deviation from the guidance, the records were again searched to identify any cause. Results 109/162 (67.3%) ‘vaccination opportunities’ for the recommended yearly influenza vaccination were successfully delivered. 17/19 (89.4%) patients had no documented initial pneumococcal vaccination at time of splenectomy. 23/162 (14.2%) influenza and 22/37 (56.4%) pneumococcal vaccination opportunities were missed with no documentation explaining why. Only 1 patient received the recommended MenACWY/MenB vaccination at diagnosis, 5 received delayed vaccinations and 13/19 (68.4%) patients received no meningitis vaccination. 7/19 (37%) patients were not on prophylactic antibiotics as recommended with no documented explanation. 2 of those patients were issued one-off antibiotic prescriptions and 1 had their prescription stopped due to non-compliance. Conclusions Significant improvement is needed with regards to antibiotic prophylaxis, pneumococcal and meningococcal vaccinations with over 50% of vaccinations being missed. Poor documentation and a shift to electronic health records are possible factors that have affected data collection, particularly as a significant number of the splenectomies performed were prior to 2000. Recommendations include routine reviews for asplenic patients, encouragement for opportunistic vaccination and increasing awareness of the risks of post-splenectomy sepsis and the benefits of vaccinations. Future scope could include looking at the same guidelines for other hyposplenic/asplenic conditions.

Leave No One Behind: Invited Commentary on Association of Time From Injury to Initial Hospital Arrival, Emergency Trauma Surgery, and Survival in U.S. Military Casualties.

Leave No One Behind: Invited Commentary on Association of Time From Injury to Initial Hospital Arrival, Emergency Trauma Surgery, and Survival in U.S. Military Casualties.

Definition of factor Xa inhibitor-related, life-threatening gastrointestinal bleeding and guidance on when to use reversal therapy: A Delphi panel.

To define and contextualize life-threatening gastrointestinal (GI) bleeding in the setting of factor Xa (FXa) inhibitor therapy and to derive a consensus-based, clinically oriented approach to the administration of FXa inhibitor reversal therapy. We convened an expert panel of clinicians representing specialties in emergency medicine, gastroenterology, vascular medicine, and trauma surgery. Consensus was reached among the clinician panelists using the Delphi technique, which consisted of 2 survey questionnaires followed by virtual, real-time consensus-building exercises. Hypovolemia and hemodynamic instability were considered the most important clinical signs of FXa inhibitor-related, life-threatening GI bleeds. Clinician panelists agreed that potentially life-threatening GI bleeding should be determined on the basis of hemodynamic instability, signs of shock, individual patient characteristics, and clinical judgment. Last, the panel agreed that all patients with life-threatening, FXa inhibitor-associated GI bleeding should be considered for FXa inhibitor reversal therapy; the decision to reverse FXa inhibition should be individualized, weighing the risks and benefits of reversal; and when reversal is elected, therapy should be administered within 1h after initial emergency department evaluation, when possible. Consensus-based definitions of life-threatening GI bleeding and approaches to FXa inhibitor reversal centered on hemodynamic instability, signs of shock, individual patient characteristics, and clinical judgment. The results from this Delphi panel may inform clinical decision-making for the treatment of patients experiencing GI bleeding associated with FXa inhibitor use in the emergency department setting.

Focused Assessment with Sonography for Trauma (FAST) Exam: Image Acquisition.

Over the past twenty years, the Focused Assessment with Sonography for Trauma (FAST) exam has transformed the care of patients presenting with a combination of trauma (blunt or penetrating) and hypotension. In these hemodynamically unstable trauma patients, the FAST exam permits rapid and noninvasive screening for free pericardial or peritoneal fluid, the latter of which implicates intra-abdominal injury as a likely contributor to the hypotension and justifies emergent abdominal surgical exploration. Further, the abdominal portion of the FAST exam can also be used outside of the trauma setting to screen for free peritoneal fluid in patients who become hemodynamically unstable in any context, including after procedures that may inadvertently injure abdominal organs. These "non-trauma" situations of hemodynamic instability are often triaged by providers from specialties other than emergency medicine or trauma surgery who are not familiar with the FAST exam. Therefore, there is a need to promulgate knowledge about the FAST exam to all clinicians caring for critically ill patients. Toward this end, this article describes FAST exam image acquisition: patient positioning, transducer selection, image optimization, and exam limitations. Since the free fluid is likely to be found in specific anatomic locations that are unique for each canonical FAST exam view, this work centers on the unique image acquisition considerations for each window: subcostal, right upper quadrant, left upper quadrant, and pelvis.

Using multiple indicators to predict the risk of surgical site infection after ORIF of tibia fractures: a machine learning based study.

Surgical site infection (SSI) are a serious complication that can occur after open reduction and internal fixation (ORIF) of tibial fractures, leading to severe consequences. This study aimed to develop a machine learning (ML)-based predictive model to screen high-risk patients of SSI following ORIF of tibial fractures, thereby aiding in personalized prevention and treatment. Patients who underwent ORIF of tibial fractures between January 2018 and October 2022 at the Department of Emergency Trauma Surgery at Ganzhou People's Hospital were retrospectively included. The demographic characteristics, surgery-related variables and laboratory indicators of patients were collected in the inpatient electronic medical records. Ten different machine learning algorithms were employed to develop the prediction model, and the performance of the models was evaluated to select the best predictive model. Ten-fold cross validation for the training set and ROC curves for the test set were used to evaluate model performance. The decision curve and calibration curve analysis were used to verify the clinical value of the model, and the relative importance of features in the model was analyzed. A total of 351 patients who underwent ORIF of tibia fractures were included in this study, among whom 51 (14.53%) had SSI and 300 (85.47%) did not. Of the patients with SSI, 15 cases were of deep infection, and 36 cases were of superficial infection. Given the initial parameters, the ET, LR and RF are the top three algorithms with excellent performance. Ten-fold cross-validation on the training set and ROC curves on the test set revealed that the ET model had the best performance, with AUC values of 0.853 and 0.866, respectively. The decision curve analysis and calibration curves also showed that the ET model had the best clinical utility. Finally, the performance of the ET model was further tested, and the relative importance of features in the model was analyzed. In this study, we constructed a multivariate prediction model for SSI after ORIF of tibial fracture through ML, and the strength of this study was the use of multiple indicators to establish an infection prediction model, which can better reflect the real situation of patients, and the model show great clinical prediction performance.

Effect of Dexmedetomidine on Posttraumatic Stress Disorder in Patients Undergoing Emergency Trauma Surgery

Posttraumatic stress disorder (PTSD) is common in people who have experienced trauma, especially those hospitalized for surgery. Dexmedetomidine may reduce or reverse the early consolidation and formation of conditioned fear memory and prevent the occurrence of postoperative PTSD. To evaluate the effects of intraoperative and postoperative low-dose intravenous pumping dexmedetomidine on PTSD among patients with trauma undergoing emergency surgery. This double-blind, randomized clinical trial was conducted from January 22 to October 20, 2022, with follow-up 1 month postoperatively, in patients with trauma undergoing emergency surgery at 4 hospital centers in Jiangsu Province, China. A total of 477 participants were screened. The observers were blinded to patient groupings, particularly for subjective measurements. Dexmedetomidine or placebo (normal saline) was administered at a maintenance dose of 0.1 μg/kg hourly from the start of anesthesia until the end of surgery and at the same rate after surgery from 9 pm to 7 am on days 1 to 3. The primary outcome was the difference in the incidence of PTSD 1 month after surgery in the 2 groups. This outcome was assessed with the Clinician-Administered PTSD Scale for Diagnostic and Statistical Manual of Mental Disorders (Fifth Edition) (CAPS-5). The secondary outcomes were the pain score within 48 hours and 1 month postoperatively; incidence of postoperative delirium, nausea, and pruritus; subjective sleep quality; anxiety; and occurrence of adverse events. A total of 310 patients (154 in the normal saline group and 156 in the dexmedetomidine group) were included in the modified intention-to-treat analysis (mean [SD] age, 40.2 [10.3] years; 179 men [57.7%]). The incidence of PTSD was significantly lower in the dexmedetomidine group than in the control group 1 month postoperatively (14.1% vs 24.0%; P = .03). The participants in the dexmedetomidine group had a significantly lower CAPS-5 score than those in the control group (17.3 [5.3] vs 18.9 [6.6]; mean difference, 1.65; 95% CI, 0.31-2.99; P = .02). After adjusting for potential confounders, the patients in the dexmedetomidine group were less likely to develop PTSD than those in the control group 1 month postoperatively (adjusted odds ratio, 0.51; 95% CI, 0.27-0.94; P = .03). In this randomized clinical trial, the administration of intraoperative and postoperative dexmedetomidine reduced the incidence of PTSD among patients with trauma. The findings of this trial support the use of dexmedetomidine in emergency trauma surgery. Chinese Clinical Trial Register Identifier: ChiCTR2200056162.

A retrospective evaluation of characterization, clinical course and anaesthesia management of emergency trauma surgical patients during first wave of COVID-19 pandemic at a tertiary care center in India

: The COVID-19 pandemic resulted in nationwide lockdown followed by phased unlock to break the chain of transmission of the SARS-CoV-2 virus in India. Management of emergency trauma patients has been particularly challenging for anaesthesiologists in order to treat these high risk group of patients and preventing cross infection to healthy patients as well as health care personnel. : It is a single centre retrospective observational cohort study conducted at tertiary care hospital in North India in the patients who underwent emergency trauma surgeries during 31 March 2020-31 May 2020(Lockdown) and compared with data from 1 June 2020-31 July 2020(Unlock). To compare the effect of lockdown and unlock during first wave of Covid-19 pandemic on the volume of emergency trauma surgical patients operated within 24 hours of admission.: To evaluate the difference between the two periods of lockdown and unlock a) in the mortality rates b) covid status c) the length of hospital stay d) the mechanism of injury e)severity of injury f)proportion of aerosol generating procedures (AGP) utilized and g)demographics of the patients. Our anaesthesia experience of managing the patients differently in the pandemic, identify areas for improvement, particularly in terms of minimising exposure and optimising resource usage in the management of such emergency patients in the event of a future healthcare crisis is also discussed. Over the 2 periods of lockdown and unlock there was no statistical difference in number, age or sex distribution of the patients presenting for emergency trauma surgery. Number of covid positive patients were slightly higher during unlock but it was statistically insignificant (p=0.07) and the number of patients died during unlock was also higher during unlock as compared to lockdown but statistically insignificant(p=0.3). The median injury severity score and length of stay was also not statistically significant between two periods. Road traffic accidents were most common type of injury in both the groups, self-inflicted injury occurred in 5 patients during lockdown and zero during unlock, none of these showed a significant difference (p > 0.06). General anaesthesia was the most common anaesthesia technique used in both the periods.Emergency trauma surgeries will continue to occur even in different phases of pandemics, anaesthesiologists should plan and prepare appropriately to provide anaesthesia and emergency care to these patients and prevent cross infection in healthy patients and health care workers.

Nonfatal Injuries Sustained in Mass Shootings in the US, 2012-2019: Injury Diagnosis Matrix, Incident Context, and Public Health Considerations.

The epidemic of gun violence in the United States (US) is exacerbated by frequent mass shootings. In 2021, there were 698 mass shootings in the US, resulting in 705 deaths and 2,830 injuries. This is a companion paper to a publication in JAMA Network Open, in which the nonfatal outcomes of victims of mass shootings have been only partially described. We gathered clinical and logistic information from 31 hospitals in the US about 403 survivors of 13 mass shootings, each event involving greater than 10 injuries, from 2012-19. Local champions in emergency medicine and trauma surgery provided clinical data from electronic health records within 24 hours of a mass shooting. We organized descriptive statistics of individual-level diagnoses recorded in medical records using International Classification of Diseases codes, according to the Barell Injury Diagnosis Matrix (BIDM), a standardized tool that classifies 12 types of injuries within 36 body regions. Of the 403 patients who were evaluated at a hospital, 364 sustained physical injuries-252 by gunshot wound (GSW) and 112 by non-ballistic trauma-and 39 were uninjured. Fifty patients had 75 psychiatric diagnoses. Nearly 10% of victims came to the hospital for symptoms triggered by, but not directly related to, the shooting, or for exacerbations of underlying conditions. There were 362 gunshot wounds recorded in the Barell Matrix (1.44 per patient). The Emergency Severity Index (ESI) distribution was skewed toward higher acuity than typical for an emergency department (ED), with 15.1% ESI 1 and 17.6% ESI 2 patients. Semi-automatic firearms were used in 100% of these civilian public mass shootings, with 50 total weapons for 13 shootings (Route 91 Harvest Festival, Las Vegas. 24). Assailant motivations were reported to be associated with hate crimes in 23.1%. Survivors of mass shootings have substantial morbidity and characteristic injury distribution, but 37% of victims had no GSW. Law enforcement, emergency medical systems, and hospital and ED disaster planners can use this information for injury mitigation and public policy planning. The BIDM is useful to organize data regarding gun violence injuries. We call for additional research funding to prevent and mitigate interpersonal firearm injuries, and for the National Violent Death Reporting System to expand tracking of injuries, their sequelae, complications, and societal costs.

Competency in trauma surgery: a national survey of trainees and consultants

BackgroundThe current sparsity of surgical trainees’ exposure to training in operative trauma surgery is multifactorial. This concern has been addressed in the revised Intercollegiate Surgical Curriculum Programme (ISCP) for general and vascular surgery (2021). In the lead up to its implementation, we aimed to assess both trainee and consultant confidence levels as a surrogate reflection in the core competency operative skills in general emergency trauma surgery, identify individual experience in commonly performed trauma procedures and gauge interest in a career in trauma surgery.MethodAn online survey was circulated to general surgery and vascular surgery trainees and consultants. Self-reported competencies were assessed using a 1–10 confidence rating scale. Most questions were based on competencies in emergency trauma surgery as set out by the ISCP.ResultsOut of 251 surgical trainees and consultants, 119 responded to our survey (47.4% response rate). Less than half (44.1%; n = 52) of respondents had experienced a trauma thoracotomy. Respondents scored ‘somewhat’ or ‘not at all’ competent in the majority of competencies assessed.ConclusionSelf-reported competencies in operative trauma skills across all subgroups were sub-standard with incremental levels of perceived competence proportional to years of surgical training. Our data supports the necessity of the new curriculum, in addition to modern training pathways with direct exposure to operative trauma surgery involving dedicated trauma centres and networks, and responsibility of training pathways in the provision of training trauma surgery.

Position of trauma surgery in emergency medicine

The decision of the Federal Joint Committee has resulted in the further development of in-hospital emergency medicine through the establishment of central emergency departments and staged emergency care. In addition, the additional training in clinical acute and emergency medicine was established. The aim of this work is on the one hand to make trauma surgeons aware of these structural changes. On the other hand, we would like to evaluate an opinion and discuss the position of trauma surgery in emergency medicine. Aweb-based online survey was conducted at the Trauma Network and Trauma Registry Congress to collect participants' opinions on the position of trauma surgery in emergency medicine. Of 143 congress participants, 98 (67%) responded to the survey. The majority of participants were male (n = 78, 80%), over 40years of age (n = 62, 63%), and in aprofessional position with staff responsibility (n = 73, 75%). Emergency medicine (mean: 84.8; SD: 18.7) and intensive care medicine (mean: 78.3; SD: 20.4) training appears important. On the other hand, subsequent work in these areas appears less important (prehospital emergency medicine: mean: 65.1; SD: 28.0; ICU: mean: 53.7, SD: 30.3); however, activity in an emergency department is rated higher (MW: 87.0; SD: 18.7). There is high agreement that the trauma leader should be atrauma surgeon (mean 87.9; SD: 19.7). Ahigh volume of emergency trauma surgery patients and the care of severely injured patients in designated trauma centers show that trauma surgery expertise is mandatory in acentral emergency department. Senior positions should also be sought to ensure high quality standards.

Emergency Teleradiology-Past, Present, and, Is There a Future?

Emergency radiology has evolved into a distinct radiology subspecialty requiring a specialized skillset to make a timely and accurate diagnosis of acutely and critically ill or traumatized patients. The need for emergency and odd hour radiology coverage fuelled the growth of internal and external teleradiology and the "nighthawk" services to meet the increasing demands from all stakeholders and support the changing trends in emergency medicine and trauma surgery inclined toward increased reliance on imaging. However, the basic issues of increased imaging workload, radiologist demand-supply mismatch, complex imaging protocols are only partially addressed by teleradiology with the promise of workload balancing by operations to scale. Incorporation of artificially intelligent tools helps scale manifold by the promise of streamlining the workflow, improved detection and quantification as well as prediction. The future of emergency teleradiologists and teleradiology groups is entwined with their ability to incorporate such tools at scale and adapt to newer workflows and different roles. This agility to adopt and adapt would determine their future.

Difference between delayed anastomosis and early anastomosis in damage control laparotomy affecting the infusion volume and NPWT output volume: is infusion restriction necessary in delayed anastomosis? A single-center retrospective analysis

ObjectivesDuring temporary abdominal closure (TAC) with damage control laparotomy (DCL), infusion volume and negative-pressure wound therapy (NPWT) output volume are associated with the success and prognosis of primary fascial closure....

Educating and Empowering Inner-City High School Students in Bleeding Control

IntroductionUnintentional bleeding is the leading cause of death in people 1–44 years of age in the United States. The Stop the Bleed (STB) campaign is a nationwide course that teaches the public to ensure their own safety, call 911, find the bleeding injury, and achieve temporary hemorrhage control by several techniques. Although the national campaign for the training course was inspired by active shooter events, the training can be applied to motor vehicle accidents and small-scale penetrating and gunshot wounds. Extending the audience to inner-city high school students in a violence-prone neighborhood has the potential to save lives if they are first on the scene.ObjectivesWe hypothesized that students would have a greater degree of comfort, willingness, and preparedness to intervene in acute bleeding after taking the course.MethodsThis was a prospective, interventional pilot study in one inner-city high school in Brooklyn, New York. Students were given the option to participate in the STB course with pre- and post-surveys. We recruited 286 students from physical education or health education class to take a 50-minute bleeding control training course. Mean age was 15.7 years old. Students were divided into groups of 20–25 and taught by 2–3 emergency medicine, pediatric, or trauma surgery STB instructors. Each course included 2–3 skills stations for placing a tourniquet, wound packing, and pressure control.ResultsPrior to the course, only 43.8% of the students reported being somewhat likely or very likely to help an injured person who was bleeding. After the course, this increased to 80.8% of students even if no bleeding control kit was available. Additionally, there were significant improvements in self-rated comfort level from pre- to post-course 45.4% to 76.5%, and in self-rated preparedness from 25.1% to 83.8%. All three measures showed statistically significant improvement, P <.0001.ConclusionTeaching the STB course to high school students from a community with high levels of violence resulted in increased comfort level, willingness, and preparedness to act to control bleeding. If these opinions translate into action, students’ willingness to act could decrease pre-hospital blood loss and empower youth to perform life-saving interventions.

Epidemiology of pelvic fracture in the emergency room at Dr. Soetomo General Hospital between 2016-2018

ABSTRACT Pelvic fracture is a rare case. The incidence is about 3% to 8% of the whole kind of fractures. The most common cause is high energy trauma and is associated with multi-trauma. The amount of pelvic trauma patients is 63,000 and is associated with increased mortality rates. The scientific data is needed because it is helpful for trauma prevention and management. This research is a descriptive observational study that examines the epidemiology of pelvic trauma. The population was patients with pelvic trauma who came to the ER RSUD Dr. Soetomo in 2016-2018. The total sample was 229 patients. A total of 149 patients (65.1%) were male, and 80 patients (34.9%) were female. Traffic accidents caused 173 patients (76%) cases. Tile A classification was most frequent in 117 patients (51.1%). There were 178 patients (77.7%) who were multi-trauma patients. The most common treatment was pelvic bandage with 95 patients (41.5%). There were 178 multi-trauma patients, 109 patients (61.2%) who underwent emergency surgery for trauma, and 69 patients (38.8%) who did not. The most common cause of pelvic fracture in Dr. Soetomo general hospital during 2016-2018 was trauma with high energy due to traffic accidents. The most common type of pelvic fracture was Tile A. The more severe the pelvic trauma, the treatment should be more aggressive.

Effect of systematic graded rewarming measures on body temperature and prognosis of patients undergoing emergency trauma surgery

To observe the effect of systematic graded rewarming measures on body temperature and prognosis of patients with moderate and severe trauma [revised trauma score (RTS) < 12] requiring emergency operation. A prospective randomized double-blind controlled study was conducted. From January 2020 to January 2021, 104 patients who underwent emergency trauma surgery in the Second Affiliated Hospital of Wenzhou Medical University were selected as the research object. According to random number table method, the patients were divided into traditional rewarming group and systematic graded rewarming group, with 52 cases in each group. Patients in traditional rewarming group (only record the body temperature without intervention, and start the rewarming process when the body temperature at any time was less than 36 centigrade); the patients in the system graded rewarming group start the preventive measures as soon as they were admitted to the hospital, and record the body temperature. When the body temperature at any time was less than 36 centigrade, start the graded rewarming process. Observe the rewarming effect, coagulation function, blood gas analysis and postoperative anesthesia recovery time of the two groups and final outcome. With the extension of time, the body temperature of the two groups increased gradually. The body temperature of the systematic grade rewarming group was significantly higher than that of the traditional rewarming group at 2 hours after rewarming and at discharge (centigrade: 36.23±0.77 vs. 35.84±0.93 at 2 hours after rewarming, 36.54±0.87 vs. 35.82±0.92 at discharge, both P < 0.05). The incidence of subsequent hypothermia was significantly lower than that in the traditional rewarming group [7.7% (4/52) vs. 25.0% (13/52), P < 0.05]. The postoperative activated partial thromboplastin time (APTT) of the two groups was significantly shorter than that at admission (s: 35.74±8.05 vs. 45.55±28.02 in the systematic rewarming group, P < 0.05; 38.35±6.48 vs. 42.40±13.18 in the traditional rewarming group, P < 0.05); the intraoperative and postoperative pH values in the systematic rewarming group were significantly higher than those at admission (7.33±0.05, 7.36±0.06 vs. 7.30±0.07, both P < 0.05), while there was no significant difference between the intraoperative and postoperative pH values in the traditional rewarming group and those at admission (7.31±0.06, 7.33±0.06 vs. 7.31±0.05, both P > 0.05). The postoperative prothrombin time (PT) and anesthesia recovery time in the systematic graded rewarming group were significantly shorter than those in the traditional rewarming group [PT (s): 15.05±2.44 vs. 17.94±3.48, anesthesia recovery time (hours): 14.40±11.76 vs. 17.35±10.51, all P < 0.05], and the pH value was significantly higher than that in the traditional rewarming group (7.36±0.06 vs. 7.33±0.06, P < 0.05). The systematic graded rewarming group had higher improvement rate and lower disability rate than the traditional rewarming group (76.9% vs. 65.4% and 17.3% vs. 25.0%, both P < 0.05). Systematic graded rewarming measures can improve the hypothermia of emergency trauma patients who received surgery, reduce the incidence of subsequent hypothermia of trauma patients, shorten the time of postoperative resuscitation, improve the coagulation function and blood gas indexes, improve the treatment rate, and reduce the incidence of disability.

L’épidémie de fractures de l’extrémité proximale du fémur n’a pas diminué pendant la pandémie COVID-19 : résultats d’une étude observationnelle

IntroductionL’objectif de cette étude était de comparer le volume et les caractéristiques des chirurgies urgentes traumatologiques réalisées dans notre institution entre le 20 mars et le 20 avril 2020, correspondant au premier mois de confinement, et de les comparer aux données de la période équivalente de 2019. Notre hypothèse de travail reposait sur le fait qu’il existe une part de traumatologie non évitable pour laquelle des mesures de prévention spécifique pourraient être nécessaires.MéthodesIl s’agit d’une étude continue mono-centrique observationnelle. Tous les patients ayant nécessités une prise en charge chirurgicale traumatologique entre le 20 mars et le 20 avril 2020 ont été inclus, et les données de la même période de 2019 étaient récupérées. L’ensemble des chirurgies était réalisé dans notre institution qui est un centre de traumatologie de niveau 2 de notre région.RésultatsPendant le premier mois de confinement, 70 patients ont été pris en charge chirurgicalement pour une urgence traumatologique, contre 109 patients sur la période de 2019, représentant une baisse d’activité globale de 36 %. Sur l’ensemble des patients, l’âge moyen était significativement plus élevé en 2020 (68,4 SD = 22 vs 60,3 SD = 24 p = 0,0210). Les accidents de loisirs et les accidents de la circulation étaient moins nombreux en 2020 (34 vs. 10), ainsi que les accidents liés au travail (7vs. 2) alors que les accidents domestiques restaient globalement stables (65 vs. 55).ConclusionEn période d’urgence sanitaire, la poursuite des activités de traumatologie est essentielle, même si elle nécessite une organisation spécifique pour la prise en charge des patients. La période de confinement et les modifications de comportements associées ont changé le spectre global de la traumatologie. La réduction majeure de la traumatologie routière, de loisirs et celle liée au travail constitue une part évitable de cette activité chirurgicale justifiant d’une prévention spécifique en période crise sanitaire. À l’inverse, les traumatismes gériatriques et notamment les fractures de l’extrémité proximale du fémur n’étaient globalement que peu modifiées traduisant la nécessité de mesures de prévention supplémentaires pour ces patients.Niveau de preuveV ; étude observationnelle.

The proximal femur fracture epidemic continued during the COVID-19 pandemic: Results of an observational study

IntroductionThe aim of this study was to compare the volume and characteristics of emergency trauma surgery procedures done at our hospital between March 20 and April 20, 2020 (the first month of the national lockdown in France) and to compare these data to the same period in 2019. We hypothesized that a portion of fractures are unavoidable, thus specific preventative measures will be needed to reduce their incidence. MethodsThis was a continuous, observational and single center study. All patients who required urgent surgery for a fracture between March 20 and April 20, 2020, were included. Data for the same period in 2019 was retrieved. All the procedures were done at our hospital, which is a regional level II trauma center. ResultsDuring the first month of the lockdown, 70 patients underwent emergency surgery because of a fracture, versus 109 patients in the same period in 2019, thus an overall 36% drop. The mean age of the patients was higher in 2020 (68.4 years SD=22) than in 2019 (60.3 years SD=24, p=0.0210). There were fewer recreational and motor vehicle accidents in 2020 (34 vs. 10) and fewer work-related accidents (7 vs. 2) although the number of accidents at home were similar (65 vs. 55). ConclusionDuring a public health emergency, it is vital to continue doing trauma surgery procedures, even though it requires a specific care pathway. The lockdown and associated behavioral changes have altered the spectrum of trauma surgery. A major decrease in motor vehicle, recreation and work-related accidents is the avoidable portion of this surgical activity, justifying specific preventative measures during a public health crisis. Conversely, the incidence of geriatric fractures – particularly of the proximal femur – did not change much overall, thus there is need for additional preventative measures in these patients. Level of evidenceV, observational study.

Small-Scale High-Fidelity Simulation for Mass Casualty Incident Readiness.

This content can be used for trauma centers, emergency medicine residency programs, and emergency nursing. Mass casualty incidents (MCI) are becoming increasingly common and are occurring in locations that have not experienced them previously which adds to the challenge of readiness for emergency departments (EDs). Sporadic occurrences and limited resources add to the complexity of preparing for such an event. In advance of a large gathering in our metropolitan area, we developed and conducted a simulation to better prepare not only our residents, but our MCI planning committee, registered nurses (RNs) and emergency room technicians (ERTs) for an MCI.Emergency medicine is at the forefront of any hospital's response to an MCI. These events stretch the resources and force EDs to function differently than usual.1 Responding effectively is crucial to minimizing the morbidity and mortality of our patients while maximizing use of available resources. We can improve our level-headedness, efficiency, and department and hospital-level planning through simulation. This has particular implications for residency training with effects on education, preparedness, and wellness. The learners will (1) recognize state of mass casualty exercise as evidenced by verbalization or triaging by START (Simple Triage and Rapid Treatment) criteria, (2) triage several patients, including critically ill or peri-arrest acuities, according to START criteria, (3) recognize the need to limit care based on available resources, as evidenced by verbal orders or communication of priorities to team, and (4) limit emergency resuscitation, given limited resources, by only providing treatments and employing diagnostics that do not deplete limited time, staffing, and space inappropriately. A small-scale, high-fidelity simulation was created to replicate the pace and acuity of patients presenting in an MCI. Three critically injured patients with multiple gunshot wounds, represented by high-fidelity manikins with moulaged wounds, were presented over a 6-minute span. The team was allowed 10 minutes total to conduct life-saving measures, targeted evaluation, and disposition of the patients. The simulation was then adapted for use in a second institution's simulation center to replicate and validate the objectives given a different system. The learners were immediately verbally debriefed and feedback of the simulation, fidelity and appropriateness of the experience solicited. Unprompted, several of the learners volunteered that the efficacy of the experience was highly educational and valuable. Anonymized digital feedback was requested in the form of an online survey and was generally positive.The educational content was created by experts in simulation medicine and validated by content experts in the fields of Emergency Medicine, Trauma Surgery and Emergency Nursing. After the scenario ended, the learners were taken to a second room for debriefing by a trauma surgeon, an emergency medicine attending, and the nurse trauma educator. The actors were able to participate as secondary learners and were rotated out of simulation duties to participate in the debriefing. After this twenty-minute educational debrief, the learners were brought back to the simulation bay and were given a similar scenario. After this iteration, the team debriefed a second time. This hour schedule of cases and debrief was repeated a total of four times with a total of twelve individual learners. Suggestions and verbal feedback were noted for incorporation into appropriate committees or hospital departments. No formal assessment was done and inclusion was strictly on a voluntary basis. An evaluation of the session (on a Likert scale of 1-5) had six respondents which showed an average of 5 on how educational the session was, 4.8 on how realistic the session was, and 4.8 on how effective the session was. Simulation allows participants to safely gain practical experience in MCI management. The experience was well-received, and the learners verbalized increased confidence should they encounter an MCI in the future. We developed this simulation to give residents and nurses first-hand experience performing under high-stress, resource-limited conditions. We also had other learners observing the process which allowed for productive debriefing and planning for improvement. The ideas generated from this ultimately became part of the hospital's MCI response plan. The main takeaways were triage strategy and limited resource management. Mass casualty incident, mass gathering, penetrating trauma, high-fidelity simulation, team-based simulation, trauma center, hospital response planning.

Management of Minor Traumatic Brain Injury in an ED Observation Unit.

IntroductionTraumatic intracranial hemorrhages (TIH) have traditionally been managed in the intensive care unit (ICU) setting with neurosurgery consultation and repeat head CT (HCT) for each patient. Recent publications indicate patients with small TIH and normal neurological examinations who are not on anticoagulation do not require ICU-level care, repeat HCT, or neurosurgical consultation. It has been suggested that these patients can be safely discharged home after a short period of observation in emergency department observation units (EDOU) provided their symptoms do not progress.MethodsThis study is a retrospective cross-sectional evaluation of an EDOU protocol for minor traumatic brain injury (mTBI). It was conducted at a Level I trauma center. The protocol was developed by emergency medicine, neurosurgery and trauma surgery and modeled after the Brain Injury Guidelines (BIG). All patients were managed by attendings in the ED with discretionary neurosurgery and trauma surgery consultations. Patients were eligible for the mTBI protocol if they met BIG 1 or BIG 2 criteria (no intoxication, no anticoagulation, normal neurological examination, no or non-displaced skull fracture, subdural or intraparenchymal hematoma up to 7 millimeters, trace to localized subarachnoid hemorrhage), and had no other injuries or medical co-morbidities requiring admission. Protocol in the EDOU included routine neurological checks, symptom management, and repeat HCT for progression of symptoms. The EDOU group was compared with historical controls admitted with primary diagnosis of TIH over the 12 months prior to the initiation of the mTBI protocols. Primary outcome was reduction in EDOU length of stay (LOS) as compared to inpatient LOS. Secondary outcomes included rates of neurosurgical consultation, repeat HCT, conversion to inpatient admission, and need for emergent neurosurgical intervention.ResultsThere were 169 patients placed on the mTBI protocol between September 1, 2016 and August 31, 2019. The control group consisted of 53 inpatients. Median LOS (interquartile range [IQR]) for EDOU patients was 24.8 (IQR: 18.8 – 29.9) hours compared with a median LOS for the comparison group of 60.2 (IQR: 45.1 – 85.0) hours (P < .001). In the EDOU group 47 (27.8%) patients got a repeat HCT compared with 40 (75.5%) inpatients, and 106 (62.7%) had a neurosurgical consultation compared with 53 (100%) inpatients. Subdural hematoma was the most common type of hemorrhage. It was found in 60 (35.5%) patients, and subarachnoid hemorrhage was found in 56 cases (33.1%). Eleven patients had multicompartment hemorrhage of various classifications. Twelve (7.1%) patients required hospital admission from the EDOU. None of the EDOU patients required emergent neurosurgical intervention.ConclusionPatients with minor TIH can be managed in an EDOU using an mTBI protocol and discretionary neurosurgical consults and repeat HCT. This is associated with a significant reduction in length of stay.