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Ritondale J, Piehl M, Caputo S, Broome J, McLafferty B, Anderson A, Belding C, Tatum D, Duchesne J. Impact of Prehospital Exsanguinating Airway-Breathing-Circulation Resuscitation Sequence on Patients with Severe Hemorrhage. J Am Coll Surg 2024; 238:367-373. [PMID: 38197435 DOI: 10.1097/xcs.0000000000000956] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/11/2024]
Abstract
BACKGROUND At the 2023 ATLS symposium, the priority of circulation was emphasized through the "x-airway-breathing-circulation (ABC)" sequence, where "x" stands for exsanguinating hemorrhage control. With growing evidence from military and civilian studies supporting an x-ABC approach to trauma care, a prehospital advanced resuscitative care (ARC) bundle emphasizing early transfusion was developed in our emergency medical services (EMS) system. We hypothesized that prioritization of prehospital x-ABC through ARC would reduce in-hospital mortality. STUDY DESIGN This was a single-year prospective analysis of patients with severe hemorrhage. These patients were combined with our institution's historic controls before prehospital blood implementation. Included were patients with systolic blood pressure (SBP) less than 90 mmHg. Excluded were patients with penetrating head trauma or prehospital cardiac arrest. Two-to-one propensity matching for x-ABC to ABC groups was conducted, and the primary outcome, in-hospital mortality, was compared between groups. RESULTS A total of 93 patients (x-ABC = 62, ABC = 31) met the inclusion criteria. There was no difference in patient age, sex, initial SBP, initial Glasgow Coma Score, and initial shock index between groups. When compared with the ABC group, x-ABC patients had significant improvement in vitals at emergency department admission. Overall mortality was lower in the x-ABC group (13% vs 47%, p < 0.001). Multivariable regression revealed that prehospital circulation-first prioritization was independently associated with decreased in-hospital mortality (odds ratio 0.15, 95% CI 0.04 to 0.54, p = 0.004). CONCLUSIONS This is the first analysis to demonstrate a prehospital survival benefit of x-ABC in this subset of patient with severe injury and hemorrhagic shock. Standardization of prehospital x-ABC management in this patient population warrants special consideration.
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Affiliation(s)
- Joseph Ritondale
- From the Department of Surgery, Tulane University School of Medicine, New Orleans, LA (Ritondale, Caputo, McLafferty, Anderson, Belding, Tatum, Duchesne)
| | - Mark Piehl
- Department of Pediatrics, University of North Carolina at Chapel Hill, Chapel Hill, NC (Piehl)
- Department of Pediatrics, WakeMed Health and Hospitals, Raleigh, NC (Piehl)
| | - Sydney Caputo
- From the Department of Surgery, Tulane University School of Medicine, New Orleans, LA (Ritondale, Caputo, McLafferty, Anderson, Belding, Tatum, Duchesne)
| | - Jacob Broome
- Department of Surgery, MedStar Georgetown Washington Hospital Center, Washington DC (Broome)
| | - Bryant McLafferty
- From the Department of Surgery, Tulane University School of Medicine, New Orleans, LA (Ritondale, Caputo, McLafferty, Anderson, Belding, Tatum, Duchesne)
| | - Augustus Anderson
- From the Department of Surgery, Tulane University School of Medicine, New Orleans, LA (Ritondale, Caputo, McLafferty, Anderson, Belding, Tatum, Duchesne)
| | - Cameron Belding
- From the Department of Surgery, Tulane University School of Medicine, New Orleans, LA (Ritondale, Caputo, McLafferty, Anderson, Belding, Tatum, Duchesne)
| | - Danielle Tatum
- From the Department of Surgery, Tulane University School of Medicine, New Orleans, LA (Ritondale, Caputo, McLafferty, Anderson, Belding, Tatum, Duchesne)
| | - Juan Duchesne
- From the Department of Surgery, Tulane University School of Medicine, New Orleans, LA (Ritondale, Caputo, McLafferty, Anderson, Belding, Tatum, Duchesne)
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Bradford JM, Teixeira PG, DuBose J, Trust MD, Cardenas TC, Golestani S, Efird J, Kempema J, Zimmerman J, Czysz C, Robert M, Ali S, Brown LH, Brown CV. Temporal changes in the prehospital management of trauma patients: 2014-2021. Am J Surg 2024; 228:88-93. [PMID: 37567816 DOI: 10.1016/j.amjsurg.2023.08.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/25/2023] [Revised: 07/24/2023] [Accepted: 08/01/2023] [Indexed: 08/13/2023]
Abstract
INTRODUCTION Aggressive prehospital interventions (PHI) in trauma may not improve outcomes compared to prioritizing rapid transport. The aim of this study was to quantify temporal changes in the frequency of PHI performed by EMS. METHODS Retrospective chart review of adult patients transported by EMS to our trauma center from January 1, 2014 to 12/31/2021. PHI were recorded and annual changes in their frequency were assessed via year-by-year trend analysis and multivariate regression. RESULTS Between the first and last year of the study period, the frequency of thoracostomy (6% vs. 9%, p = 0.001), TXA administration (0.3% vs. 33%, p < 0.001), and whole blood administration (0% vs. 20%, p < 0.001) increased. Advanced airway procedures (21% vs. 12%, p < 0.001) and IV fluid administration (57% vs. 36%, p < 0.001) decreased. ED mortality decreased from 8% to 5% (p = 0.001) over the study period. On multivariate regression, no PHI were independently associated with increased or decreased ED mortality. CONCLUSION PHI have changed significantly over the past eight years. However, no PHI were independently associated with increased or decreased ED mortality.
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Affiliation(s)
- James M Bradford
- Department of Surgery and Perioperative Care, Dell Medical School, University of Texas at Austin, United States.
| | - Pedro G Teixeira
- Department of Surgery and Perioperative Care, Dell Medical School, University of Texas at Austin, United States.
| | - Joseph DuBose
- Department of Surgery and Perioperative Care, Dell Medical School, University of Texas at Austin, United States.
| | - Marc D Trust
- Department of Surgery and Perioperative Care, Dell Medical School, University of Texas at Austin, United States.
| | - Tatiana Cp Cardenas
- Department of Surgery and Perioperative Care, Dell Medical School, University of Texas at Austin, United States.
| | - Simin Golestani
- Department of Surgery and Perioperative Care, Dell Medical School, University of Texas at Austin, United States.
| | - Jessica Efird
- Department of Surgery and Perioperative Care, Dell Medical School, University of Texas at Austin, United States.
| | - James Kempema
- Department of Surgery and Perioperative Care, Dell Medical School, University of Texas at Austin, United States.
| | - Jessica Zimmerman
- Department of Surgery and Perioperative Care, Dell Medical School, University of Texas at Austin, United States.
| | - Clea Czysz
- Department of Surgery and Perioperative Care, Dell Medical School, University of Texas at Austin, United States.
| | - Michelle Robert
- Department of Surgery and Perioperative Care, Dell Medical School, University of Texas at Austin, United States.
| | - Sadia Ali
- Department of Surgery and Perioperative Care, Dell Medical School, University of Texas at Austin, United States.
| | - Lawrence H Brown
- Department of Surgery and Perioperative Care, Dell Medical School, University of Texas at Austin, United States.
| | - Carlos Vr Brown
- Department of Surgery and Perioperative Care, Dell Medical School, University of Texas at Austin, United States.
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Radulovic N, Hillier M, Nisenbaum R, Turner L, Nolan B. The Impact of Out-of-Hospital Time and Prehospital Intubation on Return of Spontaneous Circulation following Resuscitative Thoracotomy in Traumatic Cardiac Arrest. PREHOSP EMERG CARE 2023; 28:580-588. [PMID: 38015060 DOI: 10.1080/10903127.2023.2285390] [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: 06/27/2023] [Accepted: 10/16/2023] [Indexed: 11/29/2023]
Abstract
INTRODUCTION Resuscitative thoracotomy (RT) is a critical procedure performed in certain trauma patients in extremis, with extremely low survival rates. Currently, there is a paucity of data pertaining to prehospital variables and their predictive role in survival outcomes in traumatic cardiac arrest (TCA) patients requiring RT. The aim of the study was to determine the impact of prehospital intubation and out-of-hospital time (OOHT) on return of spontaneous circulation (ROSC) and survival in TCA requiring RT. METHODS This was a retrospective cohort study of trauma patients presenting to two level-1 trauma centers, St. Michael's Hospital and Sunnybrook Health Sciences Center, in Toronto, Canada (January 1, 2005-December 31, 2020). Our exposures of interest were any prehospital intubation attempt and OOHT. Primary and secondary outcome measures were ROSC post-RT and survival to hospital discharge, respectively, and data analysis was performed using univariate logistic regression. RESULTS A total of 195 patients were included, of which 86% were male, and the mean age was 33 years. ROSC and survival to hospital discharge were achieved in 30% and 5% of patients, respectively. Of those who survived to discharge, 89% sustained penetrating trauma. There was no association between OOHT and ROSC (OR = 1.00, 95% CI 0.97-1.03) or survival (OR = 0.99, 95% CI 0.94-1.05). The odds of ROSC were lower in penetrating trauma in the presence of any prehospital intubation attempt (OR = 0.39, 95% CI 0.19-0.82, p = 0.01). ROSC was less likely among all patients with no prehospital signs of life (SOL) compared to those who had prehospital SOL (OR = 0.30, 95% CI 0.13-0.69, p < 0.01). CONCLUSIONS There was a significant association between prehospital intubation and lower likelihoods of ROSC in the penetrating TCA population requiring RT, as well as with the absence of prehospital SOL in all patients. OOHT did not appear to significantly impact ROSC or survival.
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Affiliation(s)
- Nada Radulovic
- Department of Medicine, Division of Emergency Medicine, University of Toronto, Toronto, Canada
| | - Morgan Hillier
- Department of Medicine, Division of Emergency Medicine, University of Toronto, Toronto, Canada
- Department of Emergency Medicine, Sunnybrook Health Sciences Center, Toronto, Canada
| | - Rosane Nisenbaum
- Li Ka Shing Knowledge Institute, St. Michael's Hospital, Toronto, Canada
- Division of Biostatistics, Dalla Lana School of Public Health, University of Toronto, Toronto, Canada
| | - Linda Turner
- Sunnybrook Center for Prehospital Medicine, Sunnybrook Health Sciences Center, Toronto, Canada
| | - Brodie Nolan
- Department of Medicine, Division of Emergency Medicine, University of Toronto, Toronto, Canada
- Li Ka Shing Knowledge Institute, St. Michael's Hospital, Toronto, Canada
- Department of Emergency Medicine, St. Michael's Hospital, Toronto, Canada
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Popp D, Zimmermann M, Kerschbaum M, Matzke M, Judemann K, Alt V. [Prehospital treatment of polytrauma : Ongoing challenge in prehospital emergency services]. UNFALLCHIRURGIE (HEIDELBERG, GERMANY) 2023; 126:975-984. [PMID: 37943322 PMCID: PMC10682197 DOI: 10.1007/s00113-023-01383-0] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Accepted: 10/05/2023] [Indexed: 11/10/2023]
Abstract
Tscherne was the first to define the term polytrauma in 1966 as "multiple injuries to different regions of the body sustained simultaneously, with at least one injury or the combination of these injuries being life-threatening". This definition highlights the essential pathophysiological paradigm of polytrauma, with the life-threating characteristics resulting from injuries to multiple organ systems. The treatment of polytrauma patients begins at the scene of the accident. Important life-saving initial interventions can already be carried out on site through targeted measures and expertise of the emergency medical service team, thus improving patient survival. The advanced trauma life support/prehospital trauma life support (ATLS/PHTLS) concept is the worldwide gold standard. As prehospital treatment of severely injured patients is not routine for most emergency teams, concepts and emergency interventions must be regularly trained. This is the prerequisite for safe and effective emergency treatment in this time-critical situation.
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Affiliation(s)
- Daniel Popp
- Uniklinik Regensburg, Klinik und Poliklinik für Unfallchirurgie, Franz-Josef-Strauß Allee 11, 93053, Regensburg, Deutschland.
| | - Markus Zimmermann
- Interdisziplinäre Notaufnahme, Universitätsklinik Regensburg, Regensburg, Deutschland
| | - Maximilian Kerschbaum
- Klinik und Poliklinik für Unfallchirurgie, Universitätsklinik Regensburg, Regensburg, Deutschland
| | - Magdalena Matzke
- Uniklinik Regensburg, Klinik und Poliklinik für Unfallchirurgie, Franz-Josef-Strauß Allee 11, 93053, Regensburg, Deutschland
| | - Katrin Judemann
- Klinik für Anästhesiologie, Universitätsklinik Regensburg, Regensburg, Deutschland
| | - Volker Alt
- Uniklinik Regensburg, Klinik und Poliklinik für Unfallchirurgie, Franz-Josef-Strauß Allee 11, 93053, Regensburg, Deutschland
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Atkins K, Schneider A, Gallaher J, Charles A. The effect of transport mode on mortality following isolated penetrating torso Trauma. Am J Surg 2023; 226:542-547. [PMID: 37453802 PMCID: PMC10528673 DOI: 10.1016/j.amjsurg.2023.06.033] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/10/2023] [Revised: 06/12/2023] [Accepted: 06/26/2023] [Indexed: 07/18/2023]
Abstract
BACKGROUND Prehospital interventions may increase the time to definitive care. Compared to ground ambulance, we hypothesize improved mortality for patients with isolated, penetrating torso injuries transported via private vehicle. METHODS We reviewed the National Trauma Data Bank (2017-2021) for adults with isolated, penetrating torso injuries stratified by mechanism (stabbing vs. firearm) and transport mode (private vehicle vs. ground ambulance). We performed a multivariable logistic regression to estimate the effect of transport mode on mortality. RESULTS 48,444 patients met our inclusion criteria. Patients transported by ambulance, injured by stabbing (n = 26,633) and by firearm (n = 21,811) had adjusted odds ratios of 1.81 (95%CI 1.05-3.14, p = 0.03) and 1.66 (95%CI 1.32-2.09,p < 0.001) respectively for mortality compared to private vehicle transport. CONCLUSION Patients with penetrating torso injuries have nearly twice the odds of mortality when transported by ground ambulance than private vehicles, despite injury severity. The "scoop and run" strategy may confer a survival benefit in this population.
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Affiliation(s)
- Kathryn Atkins
- Department of Surgery, University of North Carolina at Chapel Hill, United States
| | - Andrew Schneider
- Department of Surgery, University of North Carolina at Chapel Hill, United States
| | - Jared Gallaher
- Department of Surgery, University of North Carolina at Chapel Hill, United States
| | - Anthony Charles
- Department of Surgery, University of North Carolina at Chapel Hill, United States.
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Salhi RA, Iyengar S, da Silva Bhatia B, Smith GC, Heisler M. How do current police practices impact trauma care in the prehospital setting? A scoping review. J Am Coll Emerg Physicians Open 2023; 4:e12974. [PMID: 37229183 PMCID: PMC10204184 DOI: 10.1002/emp2.12974] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/23/2022] [Revised: 04/08/2023] [Accepted: 04/27/2023] [Indexed: 05/27/2023] Open
Abstract
Objective In the United States, police are often important co-responders to 911 calls with emergency medical services for medical emergencies. To date, there remains a lack of a comprehensive understanding of the mechanisms by which police response modifies time to in-hospital medical care for traumatically injured patients. Further, it remains unclear if differentials exist within or between communities. A scoping review was performed to identify studies evaluating prehospital transport of traumatically injured patients and the role or impact of police involvement. Methods PubMed, SCOPUS, and Criminal Justice Abstracts databases were utilized to identify articles. English-language, US-based, peer-reviewed articles published on or prior to March 30, 2022 were eligible for inclusion. Results Of 19,437 articles initially identified, 70 articles were selected for full review and 17 for final inclusion. Key findings included (1) current law enforcement practices involving scene clearance introduce the potential for delayed patient transport but to date there is little research quantifying delays; (2) police transport protocols may decrease transport times; and (3) there are no studies examining the potential impact of scene clearance practices at the patient or community level. Conclusions Our results highlight that police are often the first on scene when responding to traumatic injuries and have an active role via scene clearance or, in some systems, patient transport. Despite the significant potential for impact on patient well-being, there remains a paucity of data examining and driving current practices.
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Affiliation(s)
- Rama A. Salhi
- Department of Emergency MedicineMassachusetts General HospitalBostonMassachusettsUSA
| | - Sonia Iyengar
- University of Michigan Medical SchoolAnn ArborMichiganUSA
| | | | - Graham C. Smith
- Department of Emergency MedicineUniversity of MichiganAnn ArborMichiganUSA
- Washtenaw/Livingston Medical Control AuthorityAnn ArborMichiganUSA
| | - Michele Heisler
- Department of Internal MedicineUniversity of MichiganAnn ArborMichiganUSA
- Institute for Healthcare Policy and InnovationUniversity of MichiganAnn ArborMichiganUSA
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Gupta B, Singh Y, Bagaria D, Nagarajappa A. Comprehensive Management of the Patient With Traumatic Cardiac Injury. Anesth Analg 2023; 136:877-893. [PMID: 37058724 DOI: 10.1213/ane.0000000000006380] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 04/16/2023]
Abstract
Cardiac injuries are rare but potentially life-threatening, with a significant proportion of victims dying before arrival at the hospital. The in-hospital mortality among patients who arrive in-hospital alive also remains significantly high, despite major advancements in trauma care including the continuous updating of the Advanced Trauma Life Support (ATLS) program. Stab and gunshot wounds due to assault or self-inflicted injuries are the common causes of penetrating cardiac injuries, while motor vehicular accidents and fall from height are attributable causes of blunt cardiac injury. Rapid transport of victim to trauma care facility, prompt recognition of cardiac trauma by clinical evaluation and focused assessment with sonography for trauma (FAST) examination, quick decision-making to perform emergency department thoracotomy, and/or shifting the patient expeditiously to the operating room for operative intervention with ongoing resuscitation are the key components for a successful outcome in cardiac injury victims with cardiac tamponade or exsanguinating hemorrhage. Blunt cardiac injury with arrhythmias, myocardial dysfunction, or cardiac failure may need continuous cardiac monitoring or anesthetic care for operative procedure of other associated injuries. This mandates a multidisciplinary approach working in concert with agreed local protocols and shared goals. An anesthesiologist has a pivotal role to play as a team leader or member in the trauma pathway of severely injured patients. They are not only involved in in-hospital care as a perioperative physician but also participate in the organizational aspects of prehospital trauma systems and training of prehospital care providers/paramedics. There is sparse literature available on the anesthetic management of cardiac injury (penetrating as well as blunt) patients. This narrative review discusses the comprehensive management of cardiac injury patients, focusing on the anesthetic concerns and is guided by our experience in managing cardiac injury cases at Jai Prakash Narayan Apex Trauma Center (JPNATC), All India Institute of Medical Sciences, New Delhi. JPNATC is the only level 1 trauma center in north India, providing services to a population of approximately 30 million with around 9000 operations being performed annually.
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Affiliation(s)
- Babita Gupta
- From the Department of Anaesthesiology, Pain Medicine and Critical Care, Jai Prakash Narayan Apex Trauma Center, All India Institute of Medical Sciences, New Delhi, India
| | - Yudhyavir Singh
- From the Department of Anaesthesiology, Pain Medicine and Critical Care, Jai Prakash Narayan Apex Trauma Center, All India Institute of Medical Sciences, New Delhi, India
| | - Dinesh Bagaria
- Division of Trauma Surgery and Critical Care, Jai Prakash Narayan Apex Trauma Center, All India Institute of Medical Sciences, New Delhi, India
| | - Abhishek Nagarajappa
- Department of Anaesthesiology, Pain Medicine and Critical Care, All India Institute of Medical Sciences, New Delhi, India
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Lier H, Gooßen K, Trentzsch H. [The chapters "Stop the bleed-prehospital" and "Coagulation management and volume therapy (emergency departement)" in the new S3 guideline "Polytrauma/severe injury treatment"]. Notf Rett Med 2023; 26:259-268. [PMID: 37261335 PMCID: PMC10117256 DOI: 10.1007/s10049-023-01147-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 02/15/2023] [Indexed: 06/02/2023]
Abstract
The S3 guideline on the treatment of patients with severe/multiple injuries by the German Association of the Scientific Medical Societies was updated between 2020 and 2022. This article describes the essence of the new chapter "Stop the bleed-prehospital" and the revised chapter "Coagulation management and volume therapy".
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Affiliation(s)
- H. Lier
- Medizinische Fakultät und Uniklinik Köln, Klinik für Anästhesiologie und Operative Intensivmedizin, Universität zu Köln, Kerpener Straße 62, 50937 Köln, Deutschland
- Sektion „Klinische Hämotherapie und Hämostasemanagement“ der Deutschen Gesellschaft für Intensiv- und Notfallmedizin (DIVI), Schumannstr. 2, 10117, Berlin, Deutschland
| | - K. Gooßen
- Institut für Forschung in der Operativen Medizin (IFOM), Universität Witten/Herdecke, Ostmerheimer Straße 200, 51109 Köln, Deutschland
| | - H. Trentzsch
- Institut für Notfallmedizin und Medizinmanagement (INM), Klinikum der Universität München, LMU München, Schillerstr. 53, 80336 München, Deutschland
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Breeding T, Martinez B, Katz J, Kim J, Havron W, Hoops H, Elkbuli A. CAB versus ABC approach for resuscitation of patients following traumatic injury: Toward improving patient safety and survival. Am J Emerg Med 2023; 68:28-32. [PMID: 36905883 DOI: 10.1016/j.ajem.2023.02.034] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/19/2023] [Revised: 02/19/2023] [Accepted: 02/24/2023] [Indexed: 03/05/2023] Open
Abstract
INTRODUCTION Though a circulation-airway-breathing (CAB) resuscitation sequence is now widely accepted in administering CPR over the airway-breathing-circulation (ABC) sequence following cardiac arrest, current evidence and guidelines vary considerably for complex polytraumas, with some prioritizing management of the airway and others advocating for initial treatment of hemorrhage. This review aims to evaluate existing literature comparing ABC and CAB resuscitation sequences in adult trauma patients in-hospital to direct future research and guide evidence-based recommendations for management. METHODS A literature search was conducted on PubMed, Embase, and Google Scholar until September 29, 2022. Articles were assessed for comparison between CAB and ABC resuscitation sequences, adult trauma patients, in-hospital treatment, patient volume status, and clinical outcomes. RESULTS Four studies met the inclusion criteria. Two studies compared the CAB and ABC sequences specifically in hypotensive trauma patients, one study evaluated the sequences in trauma patients with hypovolemic shock, and one study in patients with all types of shock. Hypotensive trauma patients who underwent rapid sequence intubation before blood transfusion had a significantly higher mortality rate than those who had blood transfusion initiated first (50 vs 78% P < 0.05) and a significant drop in blood pressure. Patients who subsequently experienced post-intubation hypotension (PIH) had increased mortality over those without PIH. overall mortality was higher in patients that developed PIH (mortality, n (%): PIH = 250/753 (33.2%) vs 253/1291 (19.6%), p < 0.001). CONCLUSION This study found that hypotensive trauma patients, especially those with active hemorrhage, may benefit more from a CAB approach to resuscitation, as early intubation may increase mortality secondary to PIH. However, patients with critical hypoxia or airway injury may still benefit more from the ABC sequence and prioritization of the airway. Future prospective studies are needed to understand the benefits of CAB with trauma patients and identify which patient subgroups are most affected by prioritizing circulation before airway management.
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Affiliation(s)
- Tessa Breeding
- NOVA Southeastern University, Dr. Kiran C. Patel College of Allopathic Medicine, Fort Lauderdale, FL, USA
| | - Brian Martinez
- NOVA Southeastern University, Dr. Kiran C. Patel College of Allopathic Medicine, Fort Lauderdale, FL, USA
| | - Joshua Katz
- NOVA Southeastern University, Dr. Kiran C. Patel College of Allopathic Medicine, Fort Lauderdale, FL, USA
| | - Jason Kim
- NOVA Southeastern University, Dr. Kiran C. Patel College of Allopathic Medicine, Fort Lauderdale, FL, USA
| | - Will Havron
- Department of Surgery, Division of Trauma and Surgical Critical Care, Orlando Regional Medical Center, Orlando, FL, USA; Department of Surgical Education, Orlando Regional Medical Center, Orlando, FL, USA
| | - Heather Hoops
- Department of Surgery, Division of Trauma, Critical Care, and Acute Care Surgery, Oregon Health & Sciences University, Portland, OR, USA
| | - Adel Elkbuli
- Department of Surgery, Division of Trauma and Surgical Critical Care, Orlando Regional Medical Center, Orlando, FL, USA; Department of Surgical Education, Orlando Regional Medical Center, Orlando, FL, USA.
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When it comes to urban penetrating trauma in America: "Start your engines". J Trauma Acute Care Surg 2023; 94:e23-e24. [PMID: 36694338 DOI: 10.1097/ta.0000000000003814] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/26/2023]
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ter Avest E, Carenzo L, Lendrum RA, Christian MD, Lyon RM, Coniglio C, Rehn M, Lockey DJ, Perkins ZB. Advanced interventions in the pre-hospital resuscitation of patients with non-compressible haemorrhage after penetrating injuries. Crit Care 2022; 26:184. [PMID: 35725641 PMCID: PMC9210796 DOI: 10.1186/s13054-022-04052-7] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/14/2022] [Accepted: 06/02/2022] [Indexed: 11/10/2022] Open
Abstract
Abstract Early haemorrhage control and minimizing the time to definitive care have long been the cornerstones of therapy for patients exsanguinating from non-compressible haemorrhage (NCH) after penetrating injuries, as only basic treatment could be provided on scene. However, more recently, advanced on-scene treatments such as the transfusion of blood products, resuscitative thoracotomy (RT) and resuscitative endovascular balloon occlusion of the aorta (REBOA) have become available in a small number of pre-hospital critical care teams. Although these advanced techniques are included in the current traumatic cardiac arrest algorithm of the European Resuscitation Council (ERC), published in 2021, clear guidance on the practical application of these techniques in the pre-hospital setting is scarce. This paper provides a scoping review on how these advanced techniques can be incorporated into practice for the resuscitation of patients exsanguinating from NCH after penetrating injuries, based on available literature and the collective experience of several helicopter emergency medical services (HEMS) across Europe who have introduced these advanced resuscitation interventions into routine practice.
Graphical Abstract ![]()
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12
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Coming in hot: Police transport and prehospital time after firearm injury. J Trauma Acute Care Surg 2022; 93:656-663. [DOI: 10.1097/ta.0000000000003689] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
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Muchnok D, Vargo A, Deeb AP, Guyette FX, Brown JB. Association of Prehospital Needle Decompression With Mortality Among Injured Patients Requiring Emergency Chest Decompression. JAMA Surg 2022; 157:934-940. [PMID: 35976642 PMCID: PMC9386601 DOI: 10.1001/jamasurg.2022.3552] [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: 03/24/2022] [Accepted: 05/30/2022] [Indexed: 11/14/2022]
Abstract
Importance Prehospital needle decompression (PHND) is a rare but potentially life-saving procedure. Prior studies on chest decompression in trauma patients have been small, limited to single institutions or emergency medical services (EMS) agencies, and lacked appropriate comparator groups, making the effectiveness of this intervention uncertain. Objective To determine the association of PHND with early mortality in patients requiring emergent chest decompression. Design, Setting, and Participants This was a retrospective cohort study conducted from January 1, 2000, to March 18, 2020, using the Pennsylvania Trauma Outcomes Study database. Patients older than 15 years who were transported from the scene of injury were included in the analysis. Data were analyzed between April 28, 2021, and September 18, 2021. Exposures Patients without PHND but undergoing tube thoracostomy within 15 minutes of arrival at the trauma center were the comparison group that may have benefited from PHND. Main Outcomes and Measures Mixed-effect logistic regression was used to determine the variability in PHND between patient and EMS agency factors, as well as the association between risk-adjusted 24-hour mortality and PHND, accounting for clustering by center and year. Propensity score matching, instrumental variable analysis using EMS agency-level PHND proportion, and several sensitivity analyses were performed to address potential bias. Results A total of 8469 patients were included in this study; 1337 patients (11%) had PHND (median [IQR] age, 37 [25-52] years; 1096 male patients [82.0%]), and 7132 patients (84.2%) had emergent tube thoracostomy (median [IQR] age, 32 [23-48] years; 6083 male patients [85.3%]). PHND rates were stable over the study period between 0.2% and 0.5%. Patient factors accounted for 43% of the variation in PHND rates, whereas EMS agency accounted for 57% of the variation. PHND was associated with a 25% decrease in odds of 24-hour mortality (odds ratio [OR], 0.75; 95% CI, 0.61-0.94; P = .01). Similar results were found in patients who survived their ED stay (OR, 0.68; 95% CI, 0.52-0.89; P < .01), excluding severe traumatic brain injury (OR, 0.65; 95% CI, 0.45-0.95; P = .03), and restricted to patients with severe chest injury (OR, 0.72; 95% CI, 0.55-0.93; P = .01). PHND was also associated with lower odds of 24-hour mortality after propensity matching (OR, 0.79; 95% CI, 0.62-0.98; P = .04) when restricting matches to the same EMS agency (OR, 0.74; 95% CI, 0.56-0.99; P = .04) and in instrumental variable probit regression (coefficient, -0.60; 95% CI, -1.04 to -0.16; P < .01). Conclusions and Relevance In this cohort study, PHND was associated with lower 24-hour mortality compared with emergent trauma center chest tube placement in trauma patients. Although performed rarely, PHND can be a life-saving intervention and should be reinforced in EMS education for appropriately selected trauma patients.
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Affiliation(s)
- Daniel Muchnok
- Division of General/Trauma Surgery, Department of Surgery, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania
| | - Allison Vargo
- Division of General/Trauma Surgery, Department of Surgery, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania
| | - Andrew-Paul Deeb
- Division of General/Trauma Surgery, Department of Surgery, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania
| | - Francis X. Guyette
- Department of Emergency Medicine, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania
| | - Joshua B. Brown
- Division of General/Trauma Surgery, Department of Surgery, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania
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14
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Airway management in self-inflicted gunshot wounds to the face. SURGERY IN PRACTICE AND SCIENCE 2022. [DOI: 10.1016/j.sipas.2022.100118] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
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15
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An analysis of police transport in an Eastern Association for the Surgery of Trauma multicenter trial examining prehospital procedures in penetrating trauma patients. J Trauma Acute Care Surg 2022; 93:265-272. [PMID: 35121705 DOI: 10.1097/ta.0000000000003563] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
BACKGROUND Police transport (PT) of penetrating trauma patients in urban locations has become routine in certain metropolitan areas; however, whether it results in improved outcomes over prehospital Advanced life support (ALS) transport has not been determined in a multicenter study. We hypothesized that PT would not result in improved outcomes. METHODS This was a multicenter, prospective, observational study of adults (18+ years) with penetrating trauma to the torso and/or proximal extremity presenting at 25 urban trauma centers. Police transport and ALS patients were allocated via nearest neighbor, propensity matching. Transport mode also examined by Cox regression. RESULTS Of 1,618 total patients, 294 (18.2%) had PT and 1,324 (81.8%) were by ALS. After matching, 588 (294/cohort) remained. The patients were primarily Black (n = 497, 84.5%), males (n = 525, 89.3%, injured by gunshot wound (n = 494, 84.0%) with 34.5% (n = 203) having Injury Severity Score of 16 or higher. Overall mortality by propensity matching was not different between cohorts (15.6% ALS vs. 15.0% PT, p = 0.82). In severely injured patients (Injury Severity Score ≥16), mortality did not differ between PT and ALS transport (38.8% vs. 36.0%, respectively; p = 0.68). Cox regression analysis controlled for relevant factors revealed no association with a mortality benefit in patients transported by ALS. CONCLUSION Police transport of penetrating trauma patients in urban locations results in similar outcomes compared with ALS. Immediate transport to definitive trauma care should be emphasized in this patient population. LEVEL OF EVIDENCE Prognostic and Epidemiologic; Level III.
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16
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Duchesne J, Slaughter K, Puente I, Berne JD, Yorkgitis B, Mull J, Sperry J, Tessmer M, Costantini T, Berndtson AE, Kai T, Rokvic G, Norwood S, Meadows K, Chang G, Lemon BM, Jacome T, Van Sant L, Paul J, Maher Z, Goldberg AJ, Madayag RM, Pinson G, Lieser MJ, Haan J, Marshall G, Carrick M, Tatum D. Impact of time to surgery on mortality in hypotensive patients with noncompressible torso hemorrhage: An AAST multicenter, prospective study. J Trauma Acute Care Surg 2022; 92:801-811. [PMID: 35468112 DOI: 10.1097/ta.0000000000003544] [Citation(s) in RCA: 7] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
BACKGROUND Death from noncompressible torso hemorrhage (NCTH) may be preventable with improved prehospital care and shorter in-hospital times to hemorrhage control. We hypothesized that shorter times to surgical intervention for hemorrhage control would decrease mortality in hypotensive patients with NCTH. METHODS This was an AAST-sponsored multicenter, prospective analysis of hypotensive patients aged 15+ years who presented with NCTH from May 2018 to December 2020. Hypotension was defined as an initial systolic blood pressure (SBP) ≤ 90 mm Hg. Primary outcomes of interest were time to surgical intervention and in-hospital mortality. RESULTS There were 242 hypotensive patients, of which 48 died (19.8%). Nonsurvivors had higher mean age (47.3 vs. 38.8; p = 0.02), higher mean New Injury Severity Score (38 vs. 29; p < 0.001), lower admit systolic blood pressure (68 vs. 79 mm Hg; p < 0.01), higher incidence of vascular injury (41.7% vs. 21.1%; p = 0.02), and shorter median (interquartile range, 25-75) time from injury to operating room start (74 minutes [48-98 minutes] vs. 88 minutes [61-128 minutes]; p = 0.03) than did survivors. Multivariable Cox regression showed shorter time from emergency department arrival to operating room start was not associated with improved survival (p = 0.04). CONCLUSION Patients who died arrived to a trauma center in a similar time frame as did survivors but presented in greater physiological distress and had significantly shorter times to surgical hemorrhage intervention than did survivors. This suggests that even expediting a critically ill patient through the current trauma system is not sufficient time to save lives from NCTH. Civilian prehospital advance resuscitative care starting from the patient first contact needs special consideration. LEVEL OF EVIDENCE Prognostic/Epidemiologic, Level III.
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Affiliation(s)
- Juan Duchesne
- From the Tulane University School of Medicine (J.D., K.S., D.T.), New Orleans, Louisiana; Broward Health Medical Center (I.P., J.D.B.), Fort Lauderdale; University of Florida-Jacksonville (B.Y., J.M.), Jacksonville, Florida; University of Pittsburgh (J.S., M.T.), Pittsburgh, Pennsylvania; UC San Diego Medical Center (T.C., A.E.B.), San Diego, California; University of Kentucky Chandler Medical Center (T.K., G.R.), Lexington, Kentucky; University of Texas Health Tyler (S.N., K.M.), Tyler, Texas; Mount Sinai Hospital (G.C., B.M.L.), Chicago, Illinois; Our Lady of the Lake Regional Medical Center (T.J.), Baton Rouge, Louisiana; University of New Mexico Hospital (L.V.S., J.P.), Albuquerque, New Mexico; Temple University Hospital (Z.M., A.J.G.), Philadelphia, Pennsylvania; St. Anthony Hospital (R.M.M., G.P.), Lakewood, Colorado; Research Medical Center (M.J.L.), Kansas City, Missouri; Ascension Via Christi Hospital St. Francis (J.H.), Wichita, Kansas; and Medical City Plano (G.M., M.C.), Plano, Texas
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17
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Tatebe LC, Schlanser V, Hampton D, Chang G, Hanson I, Doherty J, Issa N, Ghandour H, Kingsley S, Stewart A, Anstadt M, Dennis A. The tight rope act: A multicenter regional experience of tourniquets in acute trauma resuscitation. J Trauma Acute Care Surg 2022; 92:890-896. [PMID: 34882594 DOI: 10.1097/ta.0000000000003491] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Abstract
BACKGROUND As tourniquets have become more prevalent, device use has been questioned. This study sought to characterize the incidence, indication, and efficacy of tourniquet placement in acute trauma resuscitation. METHODS Nine regional level 1 trauma centers prospectively enrolled for 12 months adult patients (18 years or older) who had a tourniquet placed. Age, sex, mechanism, tourniquet type, indication, applying personnel, location placed, level of occlusion, and degree of hemostasis were collected. Major vascular injury, imaging and operations performed, and outcomes were assessed. Analyses were performed with significance at p < 0.05. RESULTS A total of 216 tourniquet applications were reported on 209 patients. There were significantly more male patients (183 [88%]) and penetrating injuries (186 [89%]) with gunshots being most common (127 [61%]). Commercial tourniquets were most often used (205 [95%]). Ninety-two percent were placed in the prehospital setting (by fire/paramedics, 56%; police, 33%; bystanders, 2%). The most common indications were pooling (47%) and pulsatile (32%) hemorrhage. Only 2% were for amputation. The most frequent location was high proximal extremity (70%). Four percent were placed over the wound, and 0.5% were distal to the wound. Only 61% of applications were arterial occlusive. Median application time was 30 minutes (interquartile range, 20-40 minutes). Imaging was performed in 54% of patients. Overall, 36% had a named arterial injury. Tourniquet application failed to achieve hemostasis in 22% of patients with a named vascular injury. There was no difference in hemostasis between those with and without vascular injury (p = 0.12) or between who placed the tourniquet (p = 0.07). Seventy patients (34%) required vascular operations. Thirty-four percent of patients were discharged home without admission. CONCLUSION Discerning which injuries require tourniquets over pressure dressings remains elusive. Trained responders had high rates of superfluous and inadequate deployments. As tourniquets continue to be disseminated, emphasis should be placed on improving education, device development, and quality control. LEVEL OF EVIDENCE Prognostic/Epidemiologic, Level III.
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Affiliation(s)
- Leah Carey Tatebe
- From the Department of Trauma and Burn Surgery (L.C.T., V.S., A.D.), Cook County Health, Rush University, Midwestern University, Chicago, Illinois; Department of Surgery (D.H.), University of Chicago, Chicago, Illinois; Department of Surgery (G.C., I.H.), Mount Sinai Hospital, Chicago, Illinois; Department of Surgery (J.D.), Advocate Christ Medical Center, Oak Lawn, Illinois; Department of Surgery (N.I.), Northwestern University, Chicago, Illinois; Department of Surgery (H.G., S.K.), Advocate Illinois Masonic Medical Center, Chicago, Illinois; Department of Surgery (A.S.), Advocate Lutheran General Hospital, Park Ridge, Illinois; and Department of Surgery (M.A.), Loyola University, Maywood, Illinois
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18
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Ono Y, Iwasaki Y, Hirano T, Hashimoto K, Kakamu T, Inoue S, Kotani J, Shinohara K. Impact of emergency physician-staffed ambulances on preoperative time course and survival among injured patients requiring emergency surgery or transarterial embolization: A retrospective cohort study at a community emergency department in Japan. PLoS One 2021; 16:e0259733. [PMID: 34748604 PMCID: PMC8575187 DOI: 10.1371/journal.pone.0259733] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/27/2021] [Accepted: 10/25/2021] [Indexed: 11/18/2022] Open
Abstract
Injured patients requiring definitive intervention, such as surgery or transarterial embolization (TAE), are an extremely time-sensitive population. The effect of an emergency physician (EP) patient care delivery system in this important trauma subset remains unclear. We aimed to clarify whether the preoperative time course and mortality among injured patients differ between ambulances staffed by EPs and those staffed by emergency life-saving technicians (ELST). This was a retrospective cohort study at a community emergency department (ED) in Japan. We included all injured patients requiring emergency surgery or TAE who were transported directly from the ED to the operating room from January 2002 to December 2019. The primary exposure was dispatch of an EP-staffed ambulance to the prehospital scene. The primary outcome measures were preoperative time course including prehospital length of stay (LOS), ED LOS, and total time to definitive intervention. The other outcome of interest was in-hospital mortality. One-to-one propensity score matching was performed to compare these outcomes between the groups. Of the 1,020 eligible patients, 353 (34.6%) were transported to the ED by an EP-staffed ambulance. In the propensity score-matched analysis with 295 pairs, the EP group showed a significant increase in median prehospital LOS (71.0 min vs. 41.0 min, P < 0.001) and total time to definitive intervention (189.0 min vs. 177.0 min, P = 0.002) in comparison with the ELST group. Conversely, ED LOS was significantly shorter in the EP group than in the ELST group (120.0 min vs. 131.0 min, P = 0.043). There was no significant difference in mortality between the two groups (8.8% vs.9.8%, P = 0.671). At a community hospital in Japan, EP-staffed ambulances were found to be associated with prolonged prehospital time, delay in definitive treatment, and did not improve survival among injured patients needing definitive hemostatic procedures compared with ELST-staffed ambulances.
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Affiliation(s)
- Yuko Ono
- Department of Disaster and Emergency Medicine, Graduate School of Medicine, Kobe University, Kobe, Japan
- Department of Anesthesiology, Ohta General Hospital Foundation, Ohta Nishinouchi Hospital, Koriyama, Japan
| | - Yudai Iwasaki
- Department of Anesthesiology, Ohta General Hospital Foundation, Ohta Nishinouchi Hospital, Koriyama, Japan
- Department of Anesthesiology and Perioperative Medicine, Tohoku University, Graduate School of Medicine, Sendai, Japan
| | - Takaki Hirano
- Department of Anesthesiology, Ohta General Hospital Foundation, Ohta Nishinouchi Hospital, Koriyama, Japan
| | - Katsuhiko Hashimoto
- Department of Anesthesiology, Ohta General Hospital Foundation, Ohta Nishinouchi Hospital, Koriyama, Japan
- Department of Minimally Invasive Surgical and Medical Oncology, Fukushima Medical University, Fukushima, Japan
| | - Takeyasu Kakamu
- Department of Hygiene and Preventive Medicine, School of Medicine, Fukushima Medical University, Fukushima, Japan
| | - Shigeaki Inoue
- Department of Disaster and Emergency Medicine, Graduate School of Medicine, Kobe University, Kobe, Japan
| | - Joji Kotani
- Department of Disaster and Emergency Medicine, Graduate School of Medicine, Kobe University, Kobe, Japan
| | - Kazuaki Shinohara
- Department of Anesthesiology, Ohta General Hospital Foundation, Ohta Nishinouchi Hospital, Koriyama, Japan
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19
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Neeki MM, Cheung C, Dong F, Pham N, Shafer D, Neeki A, Hajjafar K, Borger R, Woodward B, Tran L. Emergent needle thoracostomy in prehospital trauma patients: a review of procedural execution through computed tomography scans. Trauma Surg Acute Care Open 2021; 6:e000752. [PMID: 34527813 PMCID: PMC8404440 DOI: 10.1136/tsaco-2021-000752] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/01/2021] [Accepted: 08/08/2021] [Indexed: 11/04/2022] Open
Abstract
Background Traumatic tension pneumothoraces (TPT) are among the most serious causes of death in traumatic injuries, requiring immediate treatment with a needle thoracostomy (NT). Improperly placed NT insertion into the pleural cavity may fail to treat a life-threatening TPT. This study aimed to assess the accuracy of prehospital NT placements by paramedics in adult trauma patients. Methods A retrospective chart review was performed on 84 consecutive trauma patients who had received NT by prehospital personnel. The primary outcome was the accuracy of NT placement by prehospital personnel. Comparisons of various variables were conducted between those who survived and those who died, and proper versus improper needle insertion separately. Results Proper NT placement into the pleural cavity was noted in 27.4% of adult trauma patients. In addition, more than 19% of the procedures performed by the prehospital providers appeared to have not been medically indicated. Discussion Long-term strategies may be needed to improve the capabilities and performance of prehospital providers' capabilities in this delicate life-saving procedure. Level of evidence IV.
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Affiliation(s)
- Michael M Neeki
- Department of Emergency Medicine, Arrowhead Regional Medical Center, Colton, California, USA.,Department of Emergency Medicine, California University of Science and Medicine, San Bernardino, California, USA.,Department of General Surgery, Arrowhead Regional Medical Center, Colton, California, USA
| | - Christina Cheung
- Department of Emergency Medicine, Arrowhead Regional Medical Center, Colton, California, USA
| | - Fanglong Dong
- Department of Emergency Medicine, Arrowhead Regional Medical Center, Colton, California, USA
| | - Nam Pham
- Department of Emergency Medicine, Arrowhead Regional Medical Center, Colton, California, USA
| | - Dylan Shafer
- Department of Emergency Medicine, Arrowhead Regional Medical Center, Colton, California, USA
| | - Arianna Neeki
- Department of Emergency Medicine, Arrowhead Regional Medical Center, Colton, California, USA
| | - Keeyon Hajjafar
- Department of Emergency Medicine, Arrowhead Regional Medical Center, Colton, California, USA
| | - Rodney Borger
- Department of Emergency Medicine, Arrowhead Regional Medical Center, Colton, California, USA.,Department of Emergency Medicine, California University of Science and Medicine, San Bernardino, California, USA
| | - Brandon Woodward
- Department of General Surgery, Arrowhead Regional Medical Center, Colton, California, USA.,Department of General Surgery, California University of Science and Medicine, San Bernardino, California, USA
| | - Louis Tran
- Department of Emergency Medicine, Arrowhead Regional Medical Center, Colton, California, USA.,Department of Emergency Medicine, California University of Science and Medicine, San Bernardino, California, USA
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