Weight-based enoxaparin thromboprophylaxis in young trauma patients: analysis of the CLOTT-1 registry.

Introduction: Optimal venous thromboembolism (VTE) enoxaparin prophylaxis dosing remains elusive. Weight-based (WB) dosing safely increases anti-factor Xa levels without the need for routine monitoring but it is unclear if it leads to lower VTE risk. We hypothesized that WB dosing would decrease VTE risk compared with standard fixed dosing (SFD).

Developing a National Trauma Research Action Plan: Results from the postadmission critical care research gap Delphi survey.

Introduction: The 2016 National Academies of Science, Engineering and Medicine report included a proposal to establish a National Trauma Research Action Plan. In response, the Department of Defense funded the Coalition for National Trauma Research to generate a comprehensive research agenda spanning the continuum of trauma and burn care from prehospital care to rehabilitation as part of an overall strategy to achieve zero preventable deaths and disability after injury. The Postadmission Critical Care Research panel was 1 of 11 panels constituted to develop this research agenda.

Challenging Traditional Paradigms in Posttraumatic Pulmonary Thromboembolism.

Importance: Pulmonary clots are seen frequently on chest computed tomography performed after trauma, but recent studies suggest that pulmonary thrombosis (PT) and pulmonary embolism (PE) after trauma are independent clinical events.

Objective: To assess whether posttraumatic PT represents a distinct clinical entity associated with the nature of the injury, different from the traditional venous thromboembolic paradigm of deep venous thrombosis (DVT) and PE.

Design, Setting, And Participants: This prospective, observational, multicenter cohort study was conducted by the Consortium of Leaders in the Study of Traumatic Thromboembolism (CLOTT) study group.

Ultrasonographic inferior vena cava diameter response to trauma resuscitation after 1 hour predicts 24-hour fluid requirement.

Background: Identification of occult hypovolemia in trauma patients is difficult. We hypothesized that in acute trauma patients, the response of ultrasound-measured minimum inferior vena cava diameter (IVCDMIN), IVC Collapsibility Index (IVCCI), minimum internal jugular diameter (IJVDMIN) or IJV Collapsibility Index (IJVCI) after up to 1 hour of fluid resuscitation would predict 24-hour resuscitation intravenous fluid requirements (24FR).

Methods: An NTI-funded, American Association for the Surgery of Trauma Multi-Institutional Trials Committee prospective, cohort trial was conducted at four Level I Trauma Centers.

An AAST-MITC analysis of pancreatic trauma: Staple or sew? Resect or drain?

Introduction: Pancreatic trauma results in high morbidity and mortality, in part caused by the delay in diagnosis and subsequent organ dysfunction. Optimal operative management strategies remain unclear. We therefore sought to determine CT accuracy in diagnosing pancreatic injury and the morbidity and mortality associated with varying operative strategies.

Factor VIIa administration in traumatic brain injury: an AAST-MITC propensity score analysis.

Background: Recombinant factor VIIa (rFVIIa) has been used off-label as an adjunct in the reversal of warfarin therapy and management of hemorrhage after trauma. Only a handful of these reports are rigorous studies, from which results regarding safety and effectiveness have been mixed. There remains no clear consensus as to the role of rFVIIa in traumatic brain injury (TBI).

Open abdomen critical care management principles: resuscitation, fluid balance, nutrition, and ventilator management.

The term "open abdomen" refers to a surgically created defect in the abdominal wall that exposes abdominal viscera. Leaving an abdominal cavity temporarily open has been well described for several indications, including damage control surgery and abdominal compartment syndrome. Although beneficial in certain patients, the act of keeping an abdominal cavity open has physiologic repercussions that must be recognized and managed during postoperative care.

Rib fixation: Who, What, When?

Rib fractures are among the most common traumatic injury found in ∼20% of all patients who suffer thoracic trauma. The majority of these are a result of a blunt mechanism and are often associated with other traumatic injuries. The most common associated injury is lung contusion.

Anti-Factor Xa measurements in acute care surgery patients to examine enoxaparin dose.

Background: The purpose of this study was to determine if fixed dose enoxaparin prophylaxis provided effective anticoagulation for acute care surgery patients and to examine whether a real-time enoxaparin dose adjustment algorithm optimized anticoagulation.

Methods: Acute care surgical patients placed on enoxaparin prophylaxis 30 mg twice daily were recruited prospectively. Peak steady state aFXa levels were drawn with a goal peak aFXa range of 0.

Development and Implementation of a Comprehensive, Multidisciplinary Emergency Department Extracorporeal Membrane Oxygenation Program.

Despite advances in the medical and surgical management of cardiovascular disease, greater than 350,000 patients experience out-of-hospital cardiac arrest in the United States annually, with only a 12% neurologically favorable survival rate. Of these patients, 23% have an initial shockable rhythm of ventricular fibrillation/pulseless ventricular tachycardia (VF/VT), a marker of high probability of acute coronary ischemia (80%) as the precipitating factor. However, few patients (22%) will experience return of spontaneous circulation and sufficient hemodynamic stability to undergo cardiac catheterization and revascularization.

Decompressive craniectomy or medical management for refractory intracranial hypertension: an AAST-MIT propensity score analysis.

Background: Moderate/severe traumatic brain injury (TBI) management involves minimizing cerebral edema to maintain brain oxygen delivery. While medical therapy (MT) consisting of diuresis, hyperosmolar therapy, ventriculostomy, and barbiturate coma is the standard of care, decompressive craniectomy (DC) for refractory intracranial hypertension (ICH) has gained renewed interest. Since TBI treatment guidelines consider DC a second-tier intervention after MT failure, we sought to determine if early DC (<48 hours) was associated with improved survival in patients with refractory ICH.

Should adhesive small bowel obstruction be managed laparoscopically? A National Surgical Quality Improvement Program propensity score analysis.

Background: Celiotomy is the most common approach for refractory small bowel obstruction (SBO). Small reviews suggest that a laparoscopic approach is associated with shorter stay and less morbidity. Given the limitations of previous studies, we sought to evaluate outcomes of laparoscopic (L) compared with open (O) adhesiolysis for SBO, using the National Surgical Quality Improvement Program data set.

Two case studies of cardiopulmonary effects of intra-abdominal hypertension.

Intra-abdominal hypertension falsely elevates the pulmonary artery pressure. Volumetric pulmonary artery catheter monitoring is an optionfor estimating preload in this condition. Treatment of intra-abdominal hypertension begins with medical therapy but once abdominal compartment syndrome develops it requires decompressive laparotomy for definitive management.

Who should we feed? Western Trauma Association multi-institutional study of enteral nutrition in the open abdomen after injury.

Background: The open abdomen is a requisite component of a damage control operation and treatment of abdominal compartment syndrome.Enteral nutrition (EN) has proven beneficial for patients with critical injury, but its application in those with an open abdomen has not been defined. The purpose of this study was to analyze the use of EN for patients with an open abdomen after trauma and the effect of EN on fascial closure rates and nosocomial infections.

Rib fracture fixation for flail chest: what is the benefit?

Background: Recently, rib fracture fixation for flail chest has been used increasingly at both academic and nonacademic trauma centers. Although a few small non-US studies have demonstrated a clinical benefit, it is unclear whether this benefit outweighs the added expense and potential perioperative complications related to the procedure. We therefore sought to determine if open reduction and internal fixation of ribs for flail chest (ORIF-FC) represents a cost-effective means for managing these patients.

Resection and primary anastomosis with proximal diversion instead of Hartmann's: evolving the management of diverticulitis using NSQIP data.

Background: The emergency surgical treatment of acute diverticulitis with feculent or purulent peritonitis has traditionally been the Hartmann's procedure (HP). Debate continues over whether primary resection with anastomosis and proximal diversion may be performed in the setting of a high-risk anastomosis in complicated diverticular disease. In contrast to a loop ileostomy takedown, the morbidity of a Hartmann's reversal is preventative for many patients, leaving them with a permanent stoma.

Sew it up! A Western Trauma Association multi-institutional study of enteric injury management in the postinjury open abdomen.

Background: Use of damage control surgery techniques has reduced mortality in critically injured patients but at the cost of the open abdomen. With the option of delayed definitive management of enteric injuries, the question of intestinal repair/anastomosis or definitive stoma creation has been posed with no clear consensus. The purpose of this study was to determine outcomes on the basis of management of enteric injuries in patients relegated to the postinjury open abdomen.

Effects of a localized high-flow anastomosis between the aorta and left lower lobe pulmonary artery on great vessel flow and pulmonary arterial reactivity in the contralateral lung.

Objectives: We sought to assess the effects of a localized anastomosis between the aorta and left lower lobe pulmonary artery on flows through central vessels and on the vascular reactivity of small pulmonary arteries distal or contralateral to the shunt.

Methods: Flow rates in major vessels and tensions from small pulmonary arteries from the left and right lower lobes were determined 48 hours after creation of an end-to-side anastomosis of the left lower lobe pulmonary artery to the aorta.

Results: Anastomoses increased flow through the left lower lobe pulmonary artery from 194±6 to 452±18 mL/min immediately after anastomosis to 756±19 mL/min by the time of harvest (n=88, P<.

Scoop and run to the trauma center or stay and play at the local hospital: hospital transfer's effect on mortality.

Background: Triage attempts to ensure that severely injured patients are transported to a high-level trauma facility to reduce mortality. However, some patients are triaged to the nearest medical facility before transport to a final destination trauma center (TC). We sought to analyze whether initial triage of critically injured patients to a nontrauma center (NTC) is associated with increased mortality.

Injury thresholds after motor vehicle crash--important factors for patient triage and vehicle design.

Introduction: The Committee on Trauma recommends that older motor vehicle crash (MVC) victims or victims of crashes with significant vehicle intrusion of more than 12 in. be transferred to a trauma center since those older than 55 have an increased risk of death after injury. Yet, the precise injury thresholds as they relate to age, gender and velocity remain ill-defined.

Inequity of rehabilitation services after traumatic injury.

Background: The delivery of optimal trauma care involves identification and repair of injuries as well as rehabilitation of patients to return them to their preinjury functional status. This requires access to appropriate rehabilitation services; however, such services may be disproportionately allocated to insured individuals leaving lower income individuals without the means to achieve optimal functional status. We hypothesized that a lack of insurance is associated with a reduced likelihood of being transferred to a rehabilitation facility after trauma.

Early use of vasopressors after injury: caution before constriction.

Objective: Recent evidence suggests that overly aggressive crystalloid resuscitation is associated with poor outcome. This has led to a renewed interest in the use of vasopressors for hemodynamic support during resuscitation after injury. We sought to characterize early vasopressor (EV) use and aggressive early crystalloid resuscitation (ECR) and their association with mortality in severely injured patients.

Length of stay: an appropriate quality measure?

Hypothesis: Although demographic and clinical information are known to affect hospital length of stay (LOS), we hypothesized that LOS after traumatic injury would be significantly influenced by nonclinical factors.

Design: Retrospective database analysis.

Patients: Trauma patients treated at hospitals participating in data submission to the National Trauma Data Bank.

Heart rate: is it truly a vital sign?

Background: Tachycardia, often defined as heart rate >100 bpm, has been utilized as a physical sign of hypovolemic shock among the injured for decades without evidence to support its use as a predictor of injury or significant hypovolemia. We sought to determine whether admission heart rate is a valid predictor of hemodynamically significant injuries.

Methods: Trauma registry data from 1998 to 2004 were analyzed with logistic regression to determine whether heart rate was associated with need for emergent intervention for bleeding (laparotomy, thoracotomy, or angiography), need for packed red blood cell (pRBC) transfusion in the first 24 hours, or severe injury (ISS >25) after blunt or penetrating trauma.