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LaGrone LN, Stein D, Cribari C, Kaups K, Harris C, Miller AN, Smith B, Dutton R, Bulger E, Napolitano LM. American Association for the Surgery of Trauma/American College of Surgeons Committee on Trauma: Clinical protocol for damage-control resuscitation for the adult trauma patient. J Trauma Acute Care Surg 2024; 96:510-520. [PMID: 37697470 DOI: 10.1097/ta.0000000000004088] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 09/13/2023]
Abstract
ABSTRACT Damage-control resuscitation in the care of critically injured trauma patients aims to limit blood loss and prevent and treat coagulopathy by combining early definitive hemorrhage control, hypotensive resuscitation, and early and balanced use of blood products (hemostatic resuscitation) and the use of other hemostatic agents. This clinical protocol has been developed to provide evidence-based recommendations for optimal damage-control resuscitation in the care of trauma patients with hemorrhage.
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Affiliation(s)
- Lacey N LaGrone
- From the Department of Surgery (D.S.), University of Maryland, Baltimore, Maryland; Department of Surgery (L.N.L., C.C.), UCHealth, Loveland, Colorado; Department of Surgery (K.K), University of California San Francisco Fresno, San Francisco, California; Department of Surgery (C.H.), Tulane University, New Orleans, Louisiana; Orthopedic Surgery (A.N.M.), Washington University in St. Louis, St. Louis, Missouri; Department of Surgery (B.S.), University of Pennsylvania, Philadelphia, Pennsylvania; American Society of Anesthesiologists (R.D.), Anesthesia, Waco, Texas; Department of Surgery (E.B.), University of Washington, Seattle, Washington; and Department of Surgery (L.M.N.), University of Michigan, Ann Arbor, Michigan
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2
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Roberts DJ, Leppäniemi A, Tolonen M, Mentula P, Björck M, Kirkpatrick AW, Sugrue M, Pereira BM, Petersson U, Coccolini F, Latifi R. The open abdomen in trauma, acute care, and vascular and endovascular surgery: comprehensive, expert, narrative review. BJS Open 2023; 7:zrad084. [PMID: 37882630 PMCID: PMC10601091 DOI: 10.1093/bjsopen/zrad084] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/10/2023] [Revised: 07/28/2023] [Accepted: 07/28/2023] [Indexed: 10/27/2023] Open
Abstract
BACKGROUND The open abdomen is an innovation that greatly improved surgical understanding of damage control, temporary abdominal closure, staged abdominal reconstruction, viscera and enteric fistula care, and abdominal wall reconstruction. This article provides an evidence-informed, expert, comprehensive narrative review of the open abdomen in trauma, acute care, and vascular and endovascular surgery. METHODS A group of 12 international trauma, acute care, and vascular and endovascular surgery experts were invited to review current literature and important concepts surrounding the open abdomen. RESULTS The open abdomen may be classified using validated systems developed by a working group in 2009 and modified by the World Society of the Abdominal Compartment Syndrome-The Abdominal Compartment Society in 2013. It may be indicated in major trauma, intra-abdominal sepsis, vascular surgical emergencies, and severe acute pancreatitis; to facilitate second look laparotomy or avoid or treat abdominal compartment syndrome; and when the abdominal wall cannot be safely closed. Temporary abdominal closure and staged abdominal reconstruction methods include a mesh/sheet, transabdominal wall dynamic fascial traction, negative pressure wound therapy, and hybrid negative pressure wound therapy and dynamic fascial traction. This last method likely has the highest primary fascial closure rates. Direct peritoneal resuscitation is currently an experimental strategy developed to improve primary fascial closure rates and reduce complications in those with an open abdomen. Primary fascial closure rates may be improved by early return to the operating room; limiting use of crystalloid fluids during the surgical interval; and preventing and/or treating intra-abdominal hypertension, enteric fistulae, and intra-abdominal collections after surgery. The majority of failures of primary fascial closure and enteroatmospheric fistula formation may be prevented using effective temporary abdominal closure techniques, providing appropriate resuscitation fluids and nutritional support, and closing the abdomen as early as possible. CONCLUSION Subsequent stages of the innovation of the open abdomen will likely involve the design and conduct of prospective studies to evaluate appropriate indications for its use and effectiveness and safety of the above components of open abdomen management.
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Affiliation(s)
- Derek J Roberts
- Division of Vascular and Endovascular Surgery, Department of Surgery, University of Ottawa and The Ottawa Hospital, Ottawa, Ontario, Canada
- School of Epidemiology and Public Health, University of Ottawa, Ottawa, Ontario, Canada
- Clinical Epidemiology Program, The Ottawa Hospital Research Institute, The Ottawa Hospital, Ottawa, Ontario, Canada
| | - Ari Leppäniemi
- Abdominal Center, Department of Abdominal Surgery, Helsinki University Hospital and University of Helsinki, Helsinki, Finland
| | - Matti Tolonen
- Abdominal Center, Department of Abdominal Surgery, Helsinki University Hospital and University of Helsinki, Helsinki, Finland
| | - Panu Mentula
- Abdominal Center, Department of Abdominal Surgery, Helsinki University Hospital and University of Helsinki, Helsinki, Finland
| | - Martin Björck
- Department of Surgical Sciences, Vascular Surgery, Uppsala University, Uppsala, Sweden
| | - Andrew W Kirkpatrick
- TeleMentored Ultrasound Supported Medical Interventions (TMUSMI) Research Group, Calgary, Alberta, Canada
- Departments of Surgery and Critical Care Medicine, University of Calgary, Calgary, Alberta, Canada
| | - Michael Sugrue
- Department of Surgery Letterkenny, University Hospital Donegal, Donegal, Ireland
| | - Bruno M Pereira
- Department of Surgery, Masters Program in Health Applied Sciences, Vassouras University, Vassouras, Rio de Janeiro, Brazil
- Department of Surgery, Campinas Holy House General Surgery Residency Program Director, Campinas, Sao Paulo, Brazil
| | - Ulf Petersson
- Department of Surgery, Skane University Hospital, Malmö, Sweden
- Department of Clinical Sciences, Lund University, Lund, Sweden
| | - Federico Coccolini
- Department of General, Emergency and Trauma Surgery, Pisa University Hospital, Pisa, Italy
| | - Rifat Latifi
- Department of Surgery, Westchester Medical Center, Valhalla, New York, USA
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Dobson GP, Morris JL, Biros E, Davenport LM, Letson HL. Major surgery leads to a proinflammatory phenotype: Differential gene expression following a laparotomy. Ann Med Surg (Lond) 2021; 71:102970. [PMID: 34745602 PMCID: PMC8554464 DOI: 10.1016/j.amsu.2021.102970] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/16/2021] [Accepted: 10/17/2021] [Indexed: 11/30/2022] Open
Abstract
BACKGROUND The trauma of surgery is a neglected area of research. Our aim was to examine the differential expression of genes of stress, metabolism and inflammation in the major organs of a rat following a laparotomy. MATERIALS AND METHODS Anaesthetised Sprague-Dawley rats were randomised into baseline, 6-hr and 3-day groups (n = 6 each), catheterised and laparotomy performed. Animals were sacrificed at each timepoint and tissues collected for gene and protein analysis. Blood stress hormones, cytokines, endothelial injury markers and coagulation were measured. RESULTS Stress hormone corticosterone significantly increased and was accompanied by significant increases in inflammatory cytokines, endothelial markers, increased neutrophils (6-hr), higher lactate (3-days), and coagulopathy. In brain, there were significant increases in M1 muscarinic (31-fold) and α-1A-adrenergic (39-fold) receptor expression. Cortical expression of metabolic genes increased ∼3-fold, and IL-1β by 6-fold at 3-days. Cardiac β-1-adrenergic receptor expression increased up to 8.4-fold, and M2 and M1 muscarinic receptors by 2 to 4-fold (6-hr). At 3-days, cardiac mitochondrial gene expression (Tfam, Mtco3) and inflammation (IL-1α, IL-4, IL-6, MIP-1α, MCP-1) were significantly elevated. Haemodynamics remained stable. In liver, there was a dramatic suppression of adrenergic and muscarinic receptor expression (up to 90%) and increased inflammation. Gut also underwent autonomic suppression with 140-fold increase in IL-1β expression (3-days). CONCLUSIONS A single laparotomy led to a surgical-induced proinflammatory phenotype involving neuroendocrine stress, cortical excitability, immune activation, metabolic changes and coagulopathy. The pervasive nature of systemic and tissue inflammation was noteworthy. There is an urgent need for new therapies to prevent hyper-inflammation and restore homeostasis following major surgery.
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Affiliation(s)
- Geoffrey P. Dobson
- Heart and Trauma Research Laboratory, College of Medicine and Dentistry, James Cook University, Townsville, 4811, Australia
| | - Jodie L. Morris
- Heart and Trauma Research Laboratory, College of Medicine and Dentistry, James Cook University, Townsville, 4811, Australia
| | - Erik Biros
- Heart and Trauma Research Laboratory, College of Medicine and Dentistry, James Cook University, Townsville, 4811, Australia
| | - Lisa M. Davenport
- Heart and Trauma Research Laboratory, College of Medicine and Dentistry, James Cook University, Townsville, 4811, Australia
| | - Hayley L. Letson
- Heart and Trauma Research Laboratory, College of Medicine and Dentistry, James Cook University, Townsville, 4811, Australia
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Roberts DJ, Faris PD, Ball CG, Kirkpatrick AW, Moore EE, Feliciano DV, Rhee P, D'Amours S, Stelfox HT. Variation in use of damage control laparotomy for trauma by trauma centers in the United States, Canada, and Australasia. World J Emerg Surg 2021; 16:53. [PMID: 34649583 PMCID: PMC8515656 DOI: 10.1186/s13017-021-00396-7] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/17/2021] [Accepted: 09/19/2021] [Indexed: 11/10/2022] Open
Abstract
Background It is unknown how frequently damage control (DC) laparotomy is used across trauma centers in different countries. We conducted a cross-sectional survey of trauma centers in the United States, Canada, and Australasia to study variations in use of the procedure and predictors of more frequent use of DC laparotomy. Methods A self-administered, electronic, cross-sectional survey of trauma centers in the United States, Canada, and Australasia was conducted. The survey collected information about trauma center and program characteristics. It also asked how often the trauma program director estimated DC laparotomy was performed on injured patients at that center on average over the last year. Multivariable logistic regression was used to identify predictors of a higher reported frequency of use of DC laparotomy. Results Of the 366 potentially eligible trauma centers sent the survey, 199 (51.8%) trauma program directors or leaders responded [United States = 156 (78.4%), Canada = 26 (13.1%), and Australasia = 17 (8.5%)]. The reported frequency of use of DC laparotomy was highly variable across trauma centers. DC laparotomy was used more frequently in level-1 than level-2 or -3 trauma centers. Further, high-volume level-1 centers used DC laparotomy significantly more often than lower volume level-1 centers (p = 0.02). Nearly half (48.4%) of high-volume volume level-1 trauma centers reported using the procedure at least once weekly. Significant adjusted predictors of more frequent use of DC laparotomy included country of origin [odds ratio (OR) for the United States vs. Canada = 7.49; 95% confidence interval (CI) 1.39–40.27], level-1 verification status (OR = 6.02; 95% CI 2.01–18.06), and the assessment of a higher number of severely injured (Injury Severity Scale score > 15) patients (OR per-100 patients = 1.62; 95% CI 1.20–2.18) and patients with penetrating injuries (OR per-5% increase = 1.27; 95% CI 1.01–1.58) in the last year. Conclusions The reported frequency of use of DC laparotomy was highly variable across trauma centers. Those centers that most need to evaluate the benefit-to-risk ratio of using DC laparotomy in different scenarios may include high-volume, level-1 trauma centers, particularly those that often manage penetrating injuries. Supplementary Information The online version contains supplementary material available at 10.1186/s13017-021-00396-7.
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Affiliation(s)
- Derek J Roberts
- Division of Vascular and Endovascular Surgery, Department of Surgery, University of Ottawa, Room A-280, 1053 Carling Avenue, Ottawa, ON, K1Y 4E9, Canada. .,The Ottawa Hospital Trauma Program, The Ottawa Hospital, Ottawa, ON, Canada. .,School of Epidemiology and Public Health, Faculty of Medicine, University of Ottawa, Ottawa, ON, Canada. .,Clinical Epidemiology Program, The Ottawa Hospital Research Institute, The Ottawa Hospital, Ottawa, ON, Canada. .,The O'Brien Institute for Public Health, University of Calgary, Calgary, AB, Canada.
| | - Peter D Faris
- The O'Brien Institute for Public Health, University of Calgary, Calgary, AB, Canada.,Health Services Statistical and Analytic Methods, Data and Analytics (DIMR), Alberta Health Services, Foothills Medical Centre, Calgary, AB, Canada
| | - Chad G Ball
- The O'Brien Institute for Public Health, University of Calgary, Calgary, AB, Canada.,Department of Surgery, University of Calgary and the Foothills Medical Centre, Calgary, AB, Canada.,Department of Oncology, University of Calgary and the Foothills Medical Centre, Calgary, AB, Canada.,Regional Trauma Services, Foothills Medical Centre, Calgary, AB, Canada
| | - Andrew W Kirkpatrick
- Department of Surgery, University of Calgary and the Foothills Medical Centre, Calgary, AB, Canada.,Regional Trauma Services, Foothills Medical Centre, Calgary, AB, Canada.,Department of Critical Care Medicine, University of Calgary and Alberta Health Services, Calgary, AB, Canada
| | - Ernest E Moore
- Department of Surgery, School of Medicine and the Ernest E. Moore Shock Trauma Center at Denver Health, University of Colorado, Denver, CO, USA
| | - David V Feliciano
- Department of Surgery and Shock Trauma Center, University of Maryland Medical Center, Baltimore, MD, USA
| | - Peter Rhee
- Department of Surgery, Westchester Medical Center, Section of Trauma and Acute Care Surgery, New York Medical College, Valhalla, NY, USA
| | - Scott D'Amours
- South Western Sydney Clinical School, UNSW, Sydney, NSW, Australia.,Acute Care Surgery Unit, Liverpool Hospital, Liverpool, NSW, Australia
| | - Henry T Stelfox
- The O'Brien Institute for Public Health, University of Calgary, Calgary, AB, Canada.,Department of Critical Care Medicine, University of Calgary and Alberta Health Services, Calgary, AB, Canada.,Department of Community Health Sciences, Faculty of Medicine, University of Calgary, Calgary, AB, Canada
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Ordoñez CA, Parra MW, Caicedo Y, Padilla N, Angamarca E, Serna JJ, Rodríguez-Holguín F, García A, Salcedo A, Pino LF, González-Hadad A, Herrera MA, Quintero L, Hernández F, Franco MJ, Aristizábal G, Toro LE, Guzmán-Rodríguez M, Coccolini F, Ferrada R, Ivatury R. Damage control surgical management of combined small and large bowel injuries in penetrating trauma: Are ostomies still pertinent? Colomb Med (Cali) 2021; 52:e4114425. [PMID: 34188327 PMCID: PMC8216049 DOI: 10.25100/cm.v52i2.4425] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022] Open
Abstract
Hollow viscus injuries represent a significant portion of overall lesions sustained during penetrating trauma. Currently, isolated small or large bowel injuries are commonly managed via primary anastomosis in patients undergoing definitive laparotomy or deferred anastomosis in patients requiring damage control surgery. The traditional surgical dogma of ostomy has proven to be unnecessary and, in many instances, actually increases morbidity. The aim of this article is to delineate the experience obtained in the management of combined hollow viscus injuries of patients suffering from penetrating trauma. We sought out to determine if primary and/or deferred bowel injury repair via anastomosis is the preferred surgical course in patients suffering from combined small and large bowel penetrating injuries. Our experience shows that more than 90% of all combined penetrating bowel injuries can be managed via primary or deferred anastomosis, even in the most severe cases requiring the application of damage control principles. Applying this strategy, the overall need for an ostomy (primary or deferred) could be reduced to less than 10%.
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Affiliation(s)
- Carlos A Ordoñez
- Fundación Valle del Lili, Department of Surgery, Division of Trauma and Acute Care Surgery. Cali, Colombia.,Universidad del Valle, Facultad de Salud, Escuela de Medicina, Division of Trauma and Acute Care Surgery, Department of Surgery. Cali, Colombia.,Universidad Icesi, Cali, Colombia
| | - Michael W Parra
- Broward General Level I Trauma Center, Department of Trauma Critical Care, Fort Lauderdale, FL - USA
| | - Yaset Caicedo
- Fundación Valle del Lili, Centro de Investigaciones Clínicas (CIC), Cali, Colombia
| | - Natalia Padilla
- Fundación Valle del Lili, Centro de Investigaciones Clínicas (CIC), Cali, Colombia
| | | | - José Julián Serna
- Fundación Valle del Lili, Department of Surgery, Division of Trauma and Acute Care Surgery. Cali, Colombia.,Universidad del Valle, Facultad de Salud, Escuela de Medicina, Division of Trauma and Acute Care Surgery, Department of Surgery. Cali, Colombia.,Universidad Icesi, Cali, Colombia.,Hospital Universitario del Valle, Department of Surgery, Division of Trauma and Acute Care Surgery, Cali, Colombia
| | - Fernando Rodríguez-Holguín
- Fundación Valle del Lili, Department of Surgery, Division of Trauma and Acute Care Surgery. Cali, Colombia
| | - Alberto García
- Fundación Valle del Lili, Department of Surgery, Division of Trauma and Acute Care Surgery. Cali, Colombia.,Universidad del Valle, Facultad de Salud, Escuela de Medicina, Division of Trauma and Acute Care Surgery, Department of Surgery. Cali, Colombia.,Universidad Icesi, Cali, Colombia
| | - Alexander Salcedo
- Fundación Valle del Lili, Department of Surgery, Division of Trauma and Acute Care Surgery. Cali, Colombia.,Universidad del Valle, Facultad de Salud, Escuela de Medicina, Division of Trauma and Acute Care Surgery, Department of Surgery. Cali, Colombia.,Universidad Icesi, Cali, Colombia.,Hospital Universitario del Valle, Department of Surgery, Division of Trauma and Acute Care Surgery, Cali, Colombia
| | - Luis Fernando Pino
- Universidad del Valle, Facultad de Salud, Escuela de Medicina, Division of Trauma and Acute Care Surgery, Department of Surgery. Cali, Colombia.,Hospital Universitario del Valle, Department of Surgery, Division of Trauma and Acute Care Surgery, Cali, Colombia
| | - Adolfo González-Hadad
- Universidad del Valle, Facultad de Salud, Escuela de Medicina, Division of Trauma and Acute Care Surgery, Department of Surgery. Cali, Colombia.,Hospital Universitario del Valle, Department of Surgery, Division of Trauma and Acute Care Surgery, Cali, Colombia.,Centro Médico Imbanaco, Cali, Colombia
| | - Mario Alain Herrera
- Universidad del Valle, Facultad de Salud, Escuela de Medicina, Division of Trauma and Acute Care Surgery, Department of Surgery. Cali, Colombia.,Hospital Universitario del Valle, Department of Surgery, Division of Trauma and Acute Care Surgery, Cali, Colombia
| | - Laureano Quintero
- Universidad del Valle, Facultad de Salud, Escuela de Medicina, Division of Trauma and Acute Care Surgery, Department of Surgery. Cali, Colombia.,Centro Médico Imbanaco, Cali, Colombia
| | - Fabian Hernández
- Universidad del Valle, Facultad de Salud, Escuela de Medicina, Division of Trauma and Acute Care Surgery, Department of Surgery. Cali, Colombia.,Hospital Universitario del Valle, Department of Surgery, Division of Trauma and Acute Care Surgery, Cali, Colombia
| | - María Josefa Franco
- Fundación Valle del Lili, Department of Surgery, Division of Trauma and Acute Care Surgery. Cali, Colombia
| | - Gonzalo Aristizábal
- Fundación Valle del Lili, Department of Surgery, Division of Trauma and Acute Care Surgery. Cali, Colombia
| | - Luis Eduardo Toro
- Fundación Valle del Lili, Department of Surgery, Division of Trauma and Acute Care Surgery. Cali, Colombia
| | - Mónica Guzmán-Rodríguez
- Universidad de Chile, Facultad de Medicina, Instituto de Ciencias Biomédicas, Santiago de Chile, Chile
| | - Federico Coccolini
- Pisa University Hospital, Emergency and Trauma Surgery, Department of General, Pisa, Italy
| | - Ricardo Ferrada
- Universidad del Valle, Facultad de Salud, Escuela de Medicina, Division of Trauma and Acute Care Surgery, Department of Surgery. Cali, Colombia.,Centro Médico Imbanaco, Cali, Colombia
| | - Rao Ivatury
- Professor Emeritus Virginia Commonwealth University, Richmond, VA, USA
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Roberts DJ, Bobrovitz N, Zygun DA, Kirkpatrick AW, Ball CG, Faris PD, Stelfox HT. Evidence for use of damage control surgery and damage control interventions in civilian trauma patients: a systematic review. World J Emerg Surg 2021; 16:10. [PMID: 33706763 PMCID: PMC7951941 DOI: 10.1186/s13017-021-00352-5] [Citation(s) in RCA: 20] [Impact Index Per Article: 6.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/28/2020] [Accepted: 02/11/2021] [Indexed: 12/18/2022] Open
Abstract
BACKGROUND Although damage control (DC) surgery is widely assumed to reduce mortality in critically injured patients, survivors often suffer substantial morbidity, suggesting that it should only be used when indicated. The purpose of this systematic review was to determine which indications for DC have evidence that they are reliable and/or valid (and therefore in which clinical situations evidence supports use of DC or that DC improves outcomes). METHODS We searched 11 databases (1950-April 1, 2019) for studies that enrolled exclusively civilian trauma patients and reported data on the reliability (consistency of surgical decisions in a given clinical scenario) or content (surgeons would perform DC in that clinical scenario or the indication predicted use of DC in practice), construct (were associated with poor outcomes), or criterion (were associated with improved outcomes when DC was conducted instead of definitive surgery) validity for suggested indications for DC surgery or DC interventions. RESULTS Among 34,979 citations identified, we included 36 cohort studies and three cross-sectional surveys in the systematic review. Of the 59 unique indications for DC identified, 10 had evidence of content validity [e.g., a major abdominal vascular injury or a packed red blood cell (PRBC) volume exceeding the critical administration threshold], nine had evidence of construct validity (e.g., unstable patients with combined abdominal vascular and pancreas gunshot injuries or an iliac vessel injury and intraoperative acidosis), and six had evidence of criterion validity (e.g., penetrating trauma patients requiring > 10 U PRBCs with an abdominal vascular and multiple abdominal visceral injuries or intraoperative hypothermia, acidosis, or coagulopathy). No studies evaluated the reliability of indications. CONCLUSIONS Few indications for DC surgery or DC interventions have evidence supporting that they are reliable and/or valid. DC should be used with respect for the uncertainty regarding its effectiveness, and only in circumstances where definitive surgery cannot be entertained.
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Affiliation(s)
- Derek J Roberts
- Division of Vascular and Endovascular Surgery, University of Ottawa, Ottawa, ON, Canada. .,Clinical Epidemiology Program, Ottawa Hospital Research Institute, The Ottawa Hospital, Ottawa, ON, Canada.
| | - Niklas Bobrovitz
- Nuffield Department of Primary Care Health Sciences, University of Oxford, Oxford, UK
| | - David A Zygun
- Division of Critical Care Medicine, University of Alberta, Edmonton, AB, Canada
| | - Andrew W Kirkpatrick
- Department of Surgery, University of Calgary, Calgary, AB, Canada.,Department of Critical Care Medicine, University of Calgary and Alberta Health Services, Calgary, AB, Canada.,The Regional Trauma Program, University of Calgary and the Foothills Medical Center, Calgary, AB, Canada
| | - Chad G Ball
- Department of Surgery, University of Calgary, Calgary, AB, Canada.,The Regional Trauma Program, University of Calgary and the Foothills Medical Center, Calgary, AB, Canada.,Department of Oncology, University of Calgary and the Foothills Medical Centre, Calgary, AB, Canada
| | - Peter D Faris
- Alberta Health Sciences Research-Research Analytics, University of Calgary and the Foothills Medical Centre, Calgary, AB, Canada
| | - Henry T Stelfox
- Department of Critical Care Medicine, University of Calgary and Alberta Health Services, Calgary, AB, Canada.,O'Brien Institute for Public Health, University of Calgary, Calgary, AB, Canada.,Department of Community Health Sciences, University of Calgary, Calgary, AB, Canada
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