An assessment of nationwide trends in emergency department (ED) resuscitative endovascular balloon occlusion of the aorta (REBOA) use - A trauma quality improvement program registry analysis

BACKGROUND

Use of resuscitative endovascular balloon occlusion of the aorta (REBOA) for temporary hemorrhage control in severe non-compressible torso trauma remains controversial, with limited data on patient selection and outcomes. This study aims to analyze the nationwide trends of its use in the emergency department (EDs).

METHODS

A retrospective analysis of the American College of Surgeons Trauma Quality Improvement Program (ACS-TQIP) from 2017 to 2022 was performed, focusing on REBOA placements in EDs.

RESULTS

The analysis included 3398 REBOA procedures. Majority patients were male (76 ​%) with a median age of 40 years (27-58) and injury severity score of 20 (20-41). The most common mechanism was collision (64 ​%), with emergency surgeries most frequently performed for pelvic trauma (14 ​%). Level 1 trauma centers performed 82 ​% of these procedures, with consistent low annual utilization (<200 facilities). Survival rates were 85 ​% at 1-h post-placement, decreasing significantly to 42 ​% by discharge.

CONCLUSIONS

REBOA usage in remains limited but steady, primarily occurring at level 1 trauma center EDs. While short-term survival rates are favorable, they drop significantly by the time of discharge.

Venous thromboembolic events associated with blood product administration in an era of whole blood use

BACKGROUND

The risks associated with blood product administration and venous thromboembolic events remains unclear. We sought to determine which blood products were associated with the development of deep vein thrombosis (DVT) and pulmonary embolism (PE).

METHODS

We analyzed data from patients ≥18 years of age in the Trauma Quality Improvement Program (TQIP) database that received ≥1 blood product and survived ≥24 ​h.

RESULTS

There were 42,399 that met inclusion, of whom, 2086 had at least one VTE event. In our multivariable logistic regression model, we found that WB had a unit odds ratio (uOR) of 1.05 (95 ​% CI 1.02-1.08) for DVT and 1.08 (1.05-1.12) for PE. Compared to WB, platelets had a higher uOR for DVT of 1.09 (1.04-1.13) but similar uOR for PE of 1.08 (1.03-1.14).

CONCLUSIONS

We found an association of both DVT and PE with early whole blood and platelets.

Precursors to oliguria during major burn resuscitation: An analysis of a prospective observational trial at 5 major US burn centers

Currently, urine output is the leading variable used to tailor fluid resuscitation in patients with large TBSA burns. However, this metric often lags with respect to resuscitation. Our group sought to identify derangements in variables that precede development of oliguria (<30 cc/hr) that we hypothesize will aid in more efficient resuscitation. We performed a retrospective analysis of 146 adult patients admitted within 4 h of a large TBSA (>20%) burn. We then divided them into two cohorts: those who developed oliguria within 6 h of admission and those who did not. Patients who experienced early oliguria had a higher incidence of invasive SBP < 90 (p = 0.02) or DBP < 40 (p = 0.009), lower minimum bicarbonate level (p = 0.04), more full thickness burns (p = 0.004), and higher TBSA (p = 0.01). More female patients were found in the oliguric group (p = 0.003). Multivariate analysis was used to develop a model to predict development of oliguria. When evaluated together, minimum DBP, sex, TBSA (or percent full thickness burn), and maximum base deficit constituted the most parsimonious model that significantly predicted oliguria (AUC = 0.92). Interestingly, the model lost significance when DBP was omitted, highlighting the importance of diastolic pressure in the development of oliguria.

An Assessment of Clinical Accuracy of Vital Sign-based Triage Tools Among U.S. and Coalition Forces

INTRODUCTION

Early appropriate allocation of resources for critically injured combat casualties is essential. This is especially important when inundated with an overwhelming number of casualties where limited resources must be efficiently allocated, such as during mass casualty events. There are multiple scoring systems utilized in the prehospital combat setting, including the shock index (SI), modified shock index (MSI), simple triage and rapid treatment (START), revised trauma score (RTS), new trauma score (NTS), Glasgow Coma Scale + age + pressure (GAP), and the mechanism + GAP (MGAP) score. The optimal score for application to the combat trauma population remains unclear.

MATERIALS AND METHODS

This is a secondary analysis of a previously described dataset from the Department of Defense Trauma Registry from January 1, 2007 through March 17, 2020. We constructed univariable analyses to determine the area under the receiving operator characteristic (AUROC) for the scoring systems of interest. Our primary outcomes were early death (within 24 hours) or early massive transfusion, as defined by ≥3 units.

RESULTS

There were 12,268 casualties that met inclusion criteria. There were 168 (1%) who died within the first 24 hours and 2082 (17%) that underwent significant transfusion within the first 24 hours. When assessing the predictive capabilities for death within 24 hours, the AUROCs were 0.72 (SI), 0.69 (MSI), 0.89 (START), 0.90 (RTS), 0.83 (NTS), 0.90 (GAP), and 0.91 (MGAP). The AUROCs for massive transfusion were 0.89 (SI), 0.89 (MSI), 0.82 (START), 0.81 (RTS), 0.83 (NTS), 0.85 (MGAP), and 0.86 (GAP).

CONCLUSIONS

This study retrospectively applied seven triage tools to a database of 12,268 cases from the Department of Defense Trauma Registry to evaluate their performance in predicting early death or massive transfusion in combat. All scoring systems performed well with an AUROC >0.8 for both outcomes. Although the SI and MSI performed best for predicting massive transfusion (both had an AUROC of 0.89), they ranked last for assessment of mortality within 24 hours, with the other tools performing well. START, RTS, NTS, MGAP and GAP reliably identified early death and need for massive transfusion, with MGAP and GAP performing the best overall. These findings highlight the importance of assessing triage tools to best manage resources and ultimately preserve lives of traumatically wounded warfighters. Further studies are needed to explain the surprising performance discrepancy of the SI and MSI in predicting early death and massive transfusion.

Incidence of Coagulopathy After Resuscitation at a Role 1 Facility: The Prehospital Trauma Registry Experience

BACKGROUND

The development of acute traumatic coagulopathy is associated with increased mortality and morbidity in patients with battlefield traumatic injuries. Currently, the incidence of acute traumatic coagulopathy in the Role 1 setting is unclear.

METHODS

We queried the Prehospital Trauma Registry (PHTR) module of the Department of Defense Trauma Registry (DoDTR) for all encounters from inception through May 2019. The PHTR captures data on Role 1 prehospital care. Data from the PHTR was linked to the DoDTR to analyze laboratory data and patient outcomes using descriptive statistics. We defined coagulopathy as an international normalized ratio (INR) of ≥1.5 or platelet count ≤150×109/L.

RESULTS

A total of 595 patients met the inclusion criteria; 36% (212) met our definition for coagulopathy, with 31% (185) carrying low platelet numbers, 11% (68) showing an elevated INR, and 7% (41) with both. The baseline (no coagulopathy) cohort had a mean INR of 1.10 (95% CI 1.09-1.12) versus 1.38 (95% CI 1.33-1.43) in the coagulopathic cohort. The mean platelet count was 218 (95% CI 213-223) ×109/L in the baseline cohort versus 117 (95% CI 110-125) ×109/L in the coagulopathic cohort.

CONCLUSIONS

Our findings indicate a high incidence of coagulopathy in trauma patients. Approximately one-third of wounded patients had laboratory evidence of coagulopathy upon presentation to a forward medical care facility. Advanced diagnostic facilities are therefore needed to facilitate early diagnosis of acute traumatic coagulopathy. Blood products with a long shelf life can aid in early correction.

Incidence of Traumatic Brain Injuries within the Prehospital Trauma Registry System

BACKGROUND

Traumatic brain injury (TBI) is often underreported or undetected in prehospital civilian and military settings. This study evaluated the incidence of TBI within the Prehospital Trauma Registry (PHTR) system.

METHODS

We reviewed PHTR and the linked Department of Defense Trauma Registry (DoDTR) records of casualties from January 2003 through May 2019 for diagnostic data and surgical reports.

RESULTS

A total of 709 casualties met inclusion criteria. The most common mechanism was blast, including 328 (51%) in the non-TBI and 45 (63%) in the TBI cohorts. The median injury severity scores in the non-TBI and TBI cohorts were 5 and 14, respectively. The survival scores in the non-TBI and TBI cohorts were 98% and 92%, respectively. Subdural hematomas, followed by subarachnoid hemorrhages were the most common classifiable brain injuries. Other nonspecific TBIs occurred in 85% of the TBI cohort casualties. Seventy-two cases (10%) were documented by the Role 1 clinician. Based on coding or operative data, 15 of the 72 (21%) were identified as TBIs. Of the 637 cases, which could not be decided based on coding or operative data, TBI was suspected in 42 (7%) cases based on Role 1 records.

CONCLUSIONS

Over 1 in 10 casualties presenting to a Role 1 facility had a TBI requiring transfer to a higher level of care. Our findings suggest the need for improved diagnostic technologies and documentation systems at Role 1 facilities for accurate TBI diagnosis and reporting.

A Narrative Review of Existing and Developing Biomarkers in Acute Traumatic Brain Injury for Potential Military Deployed Use

INTRODUCTION

Traumatic brain injury (TBI) is a leading cause of morbidity and mortality in both adult civilian and military populations. Currently, diagnostic and prognostic methods are limited to imaging and clinical findings. Biomarker measurements offer a potential method to assess head injuries and help predict outcomes, which has a potential benefit to the military, particularly in the deployed setting where imaging modalities are limited. We determine how biomarkers such as ubiquitin C-terminal hydrolase-L1 (UCH-L1), glial fibrillary acidic protein (GFAP), S100B, neurofilament light chain (NFL), and tau proteins can offer important information to guide the diagnosis, acute management, and prognosis of TBI, specifically in military personnel.

MATERIALS AND METHODS

We performed a narrative review of peer-reviewed literature using online databases of Google Scholar and PubMed. We included articles published between 1988 and 2022.

RESULTS

We screened a total of 73 sources finding a total of 39 original research studies that met inclusion for this review. We found five studies that focused on GFAP, four studies that focused on UCH-L1, eight studies that focused on tau proteins, six studies that focused on NFL, and eight studies that focused on S100B. The remainder of the studies included more than one of the biomarkers of interest.

CONCLUSIONS

TBI occurs frequently in the military and civilian settings with limited methods to diagnose and prognosticate outcomes. We highlighted several promising biomarkers for these purposes including S100B, UCH-L1, NFL, GFAP, and tau proteins. S100B and UCH-L1 appear to have the strongest data to date, but further research is necessary. The robust data that explain the optimal timing and, more importantly, trending of these biomarker measurements are necessary before widespread application.

Frequency of deployed emergency donor panel use prior to implementation of the low titre group O whole blood program

INTRODUCTION

The US military has frequently used a 'walking blood bank', formally known as an 'emergency donor panel' (EDP) to obtain warm fresh whole blood (WFWB) which is then immediately transfused into the casualty. We describe the frequency of EDP activation by the US military.

METHODS

We analysed data from 2007 to 2015 within the Department of Defense Trauma Registry for US, Coalition and US contractor casualties that received at least 1 unit of blood product within the first 24 hours and described the frequency of WFWB use.

RESULTS

There were 3474 casualties that met inclusion, of which, 290 casualties (8%) required activation of the EDP. The highest proportion of EDP events was in 2014, whereas the highest number of EDP events was in 2011. Median injury severity scores were higher in the recipients, compared with non-EDP recipients (29 vs 20), as were proportions with serious injuries to the abdomen (43% vs 19%) and extremities (77% vs 65%). The median number of units of all blood products, except for packed red blood cells, was higher for WFWB recipients. Of the WFWB recipients, the median was 5 units (IQR 2-10) with a maximum documented 144 units. There were four documented cases of EDP recipients receiving >100 units of WFWB with only one surviving to hospital discharge. During the study period, there were a total of 3102 (3%) units of WFWB transfused among a total of 104 288 total units.

CONCLUSIONS

We found nearly 1 in 11 casualties who received blood required activation of the EDP. Blood from the EDP accounted for 3% of all units transfused. These findings will enable future mission planning and medical training, especially for units with smaller, limited blood supplies. The lessons learned here can also enable mass casualty planning in civilian settings.

American Burn Association Clinical Practice Guidelines on Burn Shock Resuscitation

This Clinical Practice Guideline (CPG) addresses the topic of acute fluid resuscitation during the first 48 hours following a burn injury for adults with burns ≥20% of the total body surface area (%TBSA). The listed authors formed an investigation panel and developed clinically relevant PICO (Population, Intervention, Comparator, Outcome) questions. A systematic literature search returned 5978 titles related to this topic and after 3 levels of screening, 24 studies met criteria to address the PICO questions and were critically reviewed. We recommend that clinicians consider the use of human albumin solution, especially in patients with larger burns, to lower resuscitation volumes and improve urine output. We recommend initiating resuscitation based on providing 2 mL/kg/% TBSA burn in order to reduce resuscitation fluid volumes. We recommend selective monitoring of intra-abdominal and intraocular pressure during burn shock resuscitation. We make a weak recommendation for clinicians to consider the use of computer decision support software to guide fluid titration and lower resuscitation fluid volumes. We do not recommend the use of transpulmonary thermodilution-derived variables to guide burn shock resuscitation. We are unable to make any recommendations on the use of high-dose vitamin C (ascorbic acid), fresh frozen plasma (FFP), early continuous renal replacement therapy, or vasopressors as adjuncts during acute burn shock resuscitation. Mortality is an important outcome in burn shock resuscitation, but it was not formally included as a PICO outcome because the available scientific literature is missing studies of sufficient population size and quality to allow us to confidently make recommendations related to the outcome of survival at this time.

The employment of resuscitative endovascular balloon occlusion of the aorta in deployed settings

BACKGROUND

Resuscitative endovascular balloon occlusion of the aorta (REBOA) has been often used in place of open aortic occlusion for management of hemorrhagic shock in trauma. There is a paucity of data evaluating REBOA usage in military settings.

STUDY DESIGN AND METHODS

We queried the Department of Defense Trauma Registry (DODTR) for all cases with at least one intervention or assessment available within the first 72 h after injury between 2007 and 2023. We used relevant procedural codes to identify the use of REBOA within the DODTR, and we used descriptive statistics to characterize its use.

RESULTS

We identified 17 cases of REBOA placed in combat settings from 2017 to 2019. The majority of these were placed in the operating room (76%) and in civilian patients (70%). A penetrating mechanism caused the injury in 94% of cases with predominantly the abdomen and extremities having serious injuries. All patients subsequently underwent an exploratory laparotomy after REBOA placement, with moderate numbers of patients having spleen, liver, and small bowel injuries. The majority (82%) of included patients survived to hospital discharge.

DISCUSSION

We describe 17 cases of REBOA within the DODTR from 2007 to 2023, adding to the limited documentation of patients undergoing REBOA in military settings. We identified patterns of injury in line with previous studies of patients undergoing REBOA in military settings. In this small sample of military casualties, we observed a high survival rate.

A survey of low titer O whole blood use within the trauma quality improvement program registry

INTRODUCTION

The use of low titer O whole blood (LTOWB) has expanded although it remains unclear how many civilian trauma centers are using LTOWB.

METHODS

We analyzed data on civilian LTOWB recipients in the American College of Surgeons Trauma Quality Improvement Program (TQIP) database 2020-2021. Unique facility keys were used to determine the number of centers that used LTOWB in that period.

RESULTS

A total of 16,603 patients received LTOWB in the TQIP database between 2020 and 2021; 6600 in 2020, and 10,003 in 2021. The total number of facilities that reported LTOWB use went from 287/779 (37%) in 2020 to 302/795 (38%) in 2021. Between 2020 and 2021, among all level 1-3 designated trauma facilities that report to TQIP LTOWB use increased at level-1 centers (118 to 129), and level-2 centers (81 to 86), but decreased in level-3 facilities (9 to 4). Among pediatric and dual pediatric-adult designated hospitals there was a decrease in the number of pediatric level-1 centers (29 to 28) capable of administering LTOWB. Among centers with either single or dual level-1 trauma center designation with adult centers, the number that administered LTOWB to injured pediatric patients also decreased from 17 to 10, respectively.

CONCLUSIONS

There was an increase in the number of facilities transfusing LTOWB between 2020 and 2021. The use of LTOWB is underutilized in children at centers that have it available. These findings inform the expansion of LTOWB use in trauma.

Blood consumption in the Role 2 setting: A Department of Defense Trauma Registry analysis

BACKGROUND

The Role 2 setting represents the most far-forward military treatment facility with limited surgical and holding capabilities. There are limited data to guide recommendations on blood product utilization at the Role 2. We describe the consumption of blood products in this setting.

STUDY DESIGN AND METHODS

We analyzed data from 2007 to 2023 from the Department of Defense Trauma Registry (DODTR) that received care at a Role 2. We used descriptive and inferential statistics to characterize the volumes of blood products consumed in this setting. We also performed a secondary analysis of US military, Coalition, and US contractor personnel.

RESULTS

Within our initial cohort analysis of 15,581 encounters, 17% (2636) received at least one unit of PRBCs or whole blood, of which 11% received a submassive transfusion, 4% received a massive transfusion, and 1% received a supermassive transfusion. There were 6402 encounters that met inclusion for our secondary analysis. With this group, 5% received a submassive transfusion, 2% received a massive transfusion, and 1% received a supermassive transfusion.

CONCLUSIONS

We described volumes of blood products consumed at the Role 2 during recent conflicts. The maximum number of units consumed among survivors exceeds currently recommended available blood supply. Our findings suggest that rapid resupply and cold-stored chain demands may be higher than anticipated in future conflicts.

Early Vital Sign Thresholds Associated with 24-Hour Mortality among Trauma Patients: A Trauma Quality Improvement Program (TQIP) Study

BACKGROUND

Identifying patients at imminent risk of death is critical in the management of trauma patients. This study measures the vital sign thresholds associated with death among trauma patients.

METHODS

This study included data from patients ≥15 years of age in the American College of Surgeons Trauma Quality Improvement Program (TQIP) database. Patients with vital signs of zero were excluded. Documented prehospital and emergency department (ED) vital signs included systolic pressure, heart rate, respiratory rate, and calculated shock index (SI). The area under the receiver operator curves (AUROC) was used to assess the accuracy of these variables for predicting 24-hour survival. Optimal thresholds to predict mortality were identified using Youden's Index, 90% specificity, and 90% sensitivity. Additional analyses examined patients 70+ years of age.

RESULTS

There were 1,439,221 subjects in the 2019-2020 datasets that met inclusion for this analysis with <0.1% (10,270) who died within 24 hours. The optimal threshold for prehospital systolic pressure was 110, pulse rate was 110, SI was 0.9, and respiratory rate was 15. The optimal threshold for the ED systolic was 112, pulse rate was 107, SI was 0.9, and respiratory rate was 21. Among the elderly sub-analysis, the optimal threshold for prehospital systolic was 116, pulse rate was 100, SI was 0.8, and respiratory rate was 21. The optimal threshold for ED systolic was 121, pulse rate was 95, SI was 0.8, and respiratory rate was 0.8.

CONCLUSIONS

Systolic blood pressure (SBP) and SI offered the best predictor of mortality among trauma patients. The SBP values predictive of mortality were significantly higher than the traditional 90mmHg threshold. This dataset highlights the need for better methods to guide resuscitation as initial vital signs have limited accuracy in predicting subsequent mortality.

Effectiveness of Mobile Applications for Trauma Care in Combat Casualty Simulations Throughout the Continuum

INTRODUCTION

The U.S. Military uses handwritten documentation throughout the continuum of combat casualty care to document from point-of-injury, during transport and at facilities that provide damage control resuscitation and surgery. Proven impractical due to lack of durability and legibility in arduous tactical environments, we hypothesized that mobile applications would increase accuracy and completeness of documentation in combat casualty simulations.

METHODS

We conducted simulations across this continuum utilizing 10 two-person teams consisting of a Medic and an Emergency or Critical Care Nurse. Participants were randomized to either the paper group or BATDOK and T6 Health Systems mobile application group. Simulations were completed in both the classroom and simulated field environments. All documentation was assessed for speed, completeness, and accuracy.

RESULTS

Participant demographics averaged 10.8 ± 5.2 y of military service and 3.9 ± 0.6 h of training on both platforms. Classroom testing showed a significant increase in completeness (84.2 ± 8.1% versus 77.2 ± 6.9%; P = 0.02) and accuracy (77.6 ± 8.1% versus 68.9 ± 7.5%; P = 0.01) for mobile applications versus paper with no significant difference in overall time to completion (P = 0.19). Field testing again showed a significant increase in completeness (91.6 ± 5.8 % versus 70.0 ± 14.1%; P < 0.01) and accuracy (87.7 ± 7.6% versus 64.1 ± 14.4%; P < 0.01) with no significant difference in overall time to completion (P = 0.44).

CONCLUSIONS

In deployed environments, mobile applications have the potential to improve casualty care documentation completeness and accuracy with minimal additional training. These efforts will assist in meeting an urgent operational need to enable our providers.

Epidemiology and clinical significance of persistent bacteremia in severely burned patients

BACKGROUND

The utility of follow-up blood cultures (FUBC) for gram-negative bloodstream infections (BSIs) are controversial due to low rates of positivity. However, recent studies suggest higher rates of positivity in critically ill patients. The utility of FUBC in gram-negative BSI in patients with severe burn injuries is unknown.

METHODS

Patients ≥ 18 years old admitted to the US Army Institute of Surgical Research Burn Center for combat-related thermal burns from 1/2003-6/2014 with a monomicrobial BSI were included. FUBC were defined as repeat cultures 1-5 days from index BSI. Persistent BSI (pBSI) was defined as isolation of the same organism from initial and FUBC. The primary endpoint was all-cause in-hospital mortality in patients with gram-negative pBSI.

RESULTS

Of 126 patients meeting inclusion criteria with BSI, 53 (42%) had pBSI. Compared to patients without persistence, patients with pBSI had more severe burns with median total body surface area (TBSA) burns of 47% ([IQR 34-63] vs. 35.3% [IQR 23.3-56.6], p = 0.02), increased mortality (38 vs. 11%, p = 0.001) compared to those with non-persistent BSI. On multivariate analysis, pBSI was associated with an odds ratio for mortality of 5.3 [95% CI 1.8-15.8, p = 0.003). Amongst gram-negative pathogens, persistence rates were high and associated with increased mortality (41% vs. 11%, p = 0.001) compared to patients without pBSI.

CONCLUSION

In this cohort of military patients with combat-related severe burns, pBSI was more common than in other hospitalized populations and associated with increased mortality. Given this high frequency of persistence in patients with burn injuries and associated mortality, FUBC are an important diagnostic and prognostic study in this population.

A Retrospective Cohort Study of Burn Casualties Transported by the US Army Burn Flight Team and US Air Force Critical Care Air Transport Teams

INTRODUCTION

The US Army Burn Center, the only burn center in the Department of Defense provides comprehensive burn care. The Burn Flight Team (BFT) provides specialized burn care during transcontinental evacuation. During Operations Iraqi and Enduring Freedom, burn injuries accounted for approximately 5% of all injuries in military personnel. To augment BFT capacity, US Air Force Critical Care Air Transport Teams (CCATTs) mobilized to transport burn patients. The purpose of this study was to describe critically ill, burn injured patients transported to the US Army Burn Center by BFT or CCATT, to compare and contrast characteristics, evacuation procedures, in-flight treatments, patient injuries/illnesses, and outcomes between the two groups.

MATERIALS AND METHODS

We conducted a retrospective cohort study of CCATT and BFT patients, admitted to the burn ICU between January 1, 2001 and September 30, 2018. Patients with total body surface area burned (TBSA) >30% were evacuated by BFT, while CCATT evacuated patients with ≤ 30% TBSA.

RESULTS

Ninety-seven patients met inclusion criteria for this study. Of these, 40 (41%) were transported by the BFT and 57 (59%) were transported by CCATTs. Compared with patients transported by CCATTs, patients transferred by the BFT had higher median TBSA and full-thickness burn size, higher prevalence of chest, back and groin burns, and higher prevalence of inhalation injury. BFT patients had increased hospital days (62 vs. 37; P = .08), ICU days (29 vs. 12; P = .003) and ventilator days (14 vs. 6; P  < .001). TBSA was the only variable significantly associated with ARDS (aOR = 1.04; 95% CI: 1.01, 1.08; P = 0.04), renal failure (aOR = 1.07; 95% CI: 1.03, 1.11; P = .002), and mortality (aOR = 1.08; 95% CI: 1.03, 1.13; P = .001).

CONCLUSIONS

Evacuation by the BFT was associated with increased ICU and ventilator days, increased mortality, and a greater risk for developing renal failure. The severity of injury/TBSA likely accounted for most of these differences.

A Review of Electrolyte, Mineral, and Vitamin Changes After Traumatic Brain Injury

INTRODUCTION

Despite the prevalence of traumatic brain injury (TBI) in both civilian and military populations, the management guidelines developed by the Joint Trauma System involve minimal recommendations for electrolyte physiology optimization during the acute phase of TBI recovery. This narrative review aims to assess the current state of the science for electrolyte and mineral derangements found after TBI.

MATERIALS AND METHODS

We used Google Scholar and PubMed to identify literature on electrolyte derangements caused by TBI and supplements that may mitigate secondary injuries after TBI between 1991 and 2022.

RESULTS

We screened 94 sources, of which 26 met all inclusion criteria. Most were retrospective studies (n = 9), followed by clinical trials (n = 7), observational studies (n = 7), and case reports (n = 2). Of those, 29% covered the use of some type of supplement to support recovery after TBI, 28% covered electrolyte or mineral derangements after TBI, 16% covered the mechanisms of secondary injury after TBI and how they are related to mineral and electrolyte derangements, 14% covered current management of TBI, and 13% covered the potential toxic effects of the supplements during TBI recovery.

CONCLUSIONS

Knowledge of mechanisms and subsequent derangements of electrolyte, mineral, and vitamin physiology after TBI remains incomplete. Sodium and potassium tended to be the most well-studied derangements after TBI. Overall, data involving human subjects were limited and mostly involved observational studies. The data on vitamin and mineral effects were limited, and targeted research is needed before further recommendations can be made. Data on electrolyte derangements were stronger, but interventional studies are needed to assess causation.

Seasonal Association With Hypothermia in Combat Trauma

INTRODUCTION

Hypothermia increases mortality in trauma populations and frequently occurs in military casualties due to the nature of combat environments. The association between hypothermia and the time of year when injured remains unclear. We sought to determine the association between seasonal changes in temperature and hypothermia among combat casualties.

MATERIALS AND METHODS

This observational study was a secondary analysis of a previously described Department of Defense Trauma Registry dataset which included U.S. military and Coalition casualties who received prehospital care from January 2007 to March 2020 in Afghanistan and Iraq. We tested for associations between hypothermia (<36.2°C) and seasonal ambient temperatures by constructing multivariable logistic regression models. Summer was defined as June through August and winter as December through February. We assumed that the combat operations occurred in the area near the point of first contact with the deployed military treatment facilities. This study was determined to be exempt from Institutional Review Board oversight.

RESULTS

There were 5,821 that met inclusion for this study. Within the multivariable logistic regression model, we adjusted for injury severity score, mechanism of injury, and imputed transport time, finding that combat casualties were 2.28 (odds ratio, 95% confidence interval 1.93-2.69) times more likely to develop hypothermia in the winter versus summer. When using temperature as a continuous outcome, casualties had a lower emergency department temperature during the winter (parameter estimate -0.133°C, P < 0.001) after adjusting for confounders. In casualties experiencing hypothermia, mortality was higher (4% versus 1%, P < 0.001), and composite median injury severity score values were higher (10 versus 5, P < 0.001). Among hypothermic casualties, serious injuries were significantly more common (all P < 0.001) to the head (15% versus 7%), thorax (15% versus 7%), abdomen (9% versus 6%), extremities (35% versus 22%), and skin (4% versus 2%).

CONCLUSIONS

We found a seasonal variation in the occurrence of hypothermia in a large cohort of trauma casualties. Despite adjustment for multiple known confounders, our findings substantiate probable ambient temperature variations to trauma-induced hypothermia. Furthermore, our findings, when taken in the context of other studies on the efficacy of current hypothermia prevention and treatment strategies, support the need for better methods to mitigate hypothermia in future cold-weather operations.

Inhalation Injury Severity Score on Admission Predicts Overall Survival in Burn Patients

Inhalation injury is diagnosed in up to one-third of burn patients and is associated with increased morbidity and mortality. There are multiple scoring systems to grade inhalation injury, but no study has evaluated the ability of these scoring systems to predict outcomes of interest such as overall survival. We conducted a prospective, observational study of 99 intubated burn patients who underwent fiberoptic bronchoscopy within 24 hr of admission and graded inhalation injury using three scoring systems: abbreviated injury score (AIS), inhalation injury severity score (I-ISS), and mucosal score (MS). Agreement between scoring systems was assessed with Krippendorff's alpha (KA). Multivariable analyses were conducted to determine if variables were associated with overall survival. At admission, median AIS, I-ISS, and MS scores were 2 for all scoring systems. Patients who died had higher overall injury burden than those who survived and had similar median admission AIS and MS scores, but higher I-ISS scores. There was strong correlation between the inhalation injury grade at admission using the three scoring systems (KA = 0.85). On regression analysis, the only scoring system independently associated with overall survival was I-ISS (score 3 compared to scores 1-2: OR 13.16, 95% CI 1.65-105.07; P = .02). Progression of injury after initial assessment may contribute to the poor correlation between admission score and overall survival for injuries graded with AIS and MS. Repeated assessment may more accurately identify patients at increased risk for mortality.

Higher Initial Formula for Resuscitation After Severe Burn Injury Means Higher 24-Hour Volumes

Initial fluid infusion rates for resuscitation of burn injuries typically use formulas based on patient weight and total body surface area (TBSA) burned. However, the impact of this rate on overall resuscitation volumes and outcomes have not been extensively studied. The purpose of this study was to determine the impact of initial fluid rates on 24-hour volumes and outcomes using the Burn Navigator (BN). The BN database is composed of 300 patients with ≥20% TBSA, >40 kg that were resuscitated utilizing the BN. Four study arms were analyzed based on the initial formula-2 ml/kg/TBSA, 3 ml/kg/TBSA, 4 ml/kg/TBSA or the Rule of Ten. Total fluids infused at 24 hours after admission were compared as well as resuscitation-related outcomes. A total of 296 patients were eligible for analysis. Higher starting rates (4 ml/kg/TBSA) resulted in significantly higher volumes at 24 hours (5.2 ± 2.2 ml/kg/TBSA) than lower rates (2 ml/kg/TBSA resulted in 3.9 ± 1.4 ml/kg/TBSA). No shock was observed in the high resuscitation cohort, whereas the lowest starting rate exhibited a 12% incidence, lower than both the Rule of Ten and 3 ml/kg/TBSA arms. There was no difference in 7-day mortality across groups. Higher initial fluid rates resulted in higher 24-hour fluid volumes. The choice of 2ml/kg/TBSA as initial rate did not result in increased mortality or more complications. An initial rate of 2ml/kg/TBSA is a safe strategy.

Understanding the burden of traumatic injuries at the United States-Mexico border: A scoping review of the literature

ABSTRACT

The US-Mexico border is the busiest land crossing in the world and faces continuously increasing numbers of undocumented border crossers. Significant barriers to crossing are present in many regions of the border, including walls, bridges, rivers, canals, and the desert, each with unique features that can cause traumatic injury. The number of patients injured attempting to cross the border is also increasing, but significant knowledge gaps regarding these injuries and their impacts remain. The purpose of this scoping literature review is to describe the current state of trauma related to the US-Mexico border to draw attention to the problem, identify knowledge gaps in the existing literature, and introduce the creation of a consortium made up of representatives from border trauma centers in the Southwestern United States, the Border Region Doing Research on Trauma Consortium. Consortium members will collaborate to produce multicenter up-to-date data on the medical impact of the US-Mexico border, helping to elucidate the true magnitude of the problem and shed light on the impact cross-border trauma has on migrants, their families, and the US health care system. Only once the problem is fully described can meaningful solutions be provided.

Impact of Alcohol and Methamphetamine Use on Burn Resuscitation

Mortality associated with burn injuries is declining with improved critical care. However, patients admitted with concurrent substance use have increased risk of complications and poor outcomes. The impact of alcohol and methamphetamine use on acute burn resuscitation has been described in single center studies, however, has not been studied since implementation of computerized decision support for resuscitation. Patients were evaluated based presence of alcohol, with a minimum blood alcohol level of 0.10, or positive methamphetamines on urine drug screen. Fluid volumes and urine output were examined over 48 hours. A total of 296 patients were analyzed. 37 (12.5%) were positive for methamphetamine use, 50 (16.9%) were positive for alcohol use, and 209 (70.1%) with negative for both. Patients positive for methamphetamine received a mean of 5.30 ±2.63 cc/kg/TBSA, patients positive for alcohol received a mean of 5.41 ±2.49 cc/kg/TBSA, and patients with neither received a mean of 4.33 ±1.79 cc/kg/TBSA. Patients with methamphetamine or alcohol use had significantly higher fluid requirements. In the first 6 hours patients with alcohol use had significantly higher urinary output in comparison to patients with methamphetamine use which had similar output to patients negative for both substances. This study demonstrated that patients with alcohol and methamphetamine use had statistically significantly greater fluid resuscitation requirements compared to patients without. The effects of alcohol as a diuretic align with previous literature. However, patients with methamphetamine lack the increased urinary output as a cause for their increased fluid requirements.