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

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.

Contemporary management and outcomes of penetrating colon injuries: Validation of the 2020 AAST Colon Organ Injury Scale

INTRODUCTION

The American Association for the Surgery of Trauma Colon Organ Injury Scale (OIS) was updated in 2020 to include a separate OIS for penetrating colon injuries and included imaging criteria. In this multicenter study, we describe the contemporary management and outcomes of penetrating colon injuries and hypothesize that the 2020 OIS system correlates with operative management, complications, and outcomes.

METHODS

This was a retrospective study of patients presenting to 12 Level 1 trauma centers between 2016 and 2020 with penetrating colon injuries and Abbreviated Injury Scale score of <3 in other body regions. We assessed the association of the new OIS with surgical management and clinical outcomes and the association of OIS imaging criteria with operative criteria. Bivariate analysis was done with χ 2 , analysis of variance, and Kruskal-Wallis, where appropriate. Multivariable models were constructed in a stepwise selection fashion.

RESULTS

We identified 573 patients with penetrating colon injuries. Patients were young and predominantly male; 79% suffered a gunshot injury, 11% had a grade V destructive injury, 19% required ≥6 U of transfusion, 24% had an Injury Severity Score of >15, and 42% had moderate-to-large contamination. Higher OIS was independently associated with a lower likelihood of primary repair, higher likelihood of resection with anastomosis and/or diversion, need for damage-control laparotomy, and higher incidence of abscess, wound infection, extra-abdominal infections, acute kidney injury, and lung injury. Damage control was independently associated with diversion and intra-abdominal and extra-abdominal infections. Preoperative imaging in 152 (27%) cases had a low correlation with operative findings ( κ coefficient, 0.13).

CONCLUSION

This is the largest study to date of penetrating colon injuries and the first multicenter validation of the new OIS specific to these injuries. While imaging criteria alone lacked strong predictive value, operative American Association for the Surgery of Trauma OIS colon grade strongly predicted type of interventions and outcomes, supporting use of this grading scale for research and clinical practice.

LEVEL OF EVIDENCE

Prognostic and Epidemiological; Level III.

Revision of the AAST grading scale for acute cholecystitis with comparison to physiologic measures of severity

BACKGROUND

Grading systems for acute cholecystitis are essential to compare outcomes, improve quality, and advance research. The American Association for the Surgery of Trauma (AAST) grading system for acute cholecystitis was only moderately discriminant when predicting multiple outcomes and underperformed the Tokyo guidelines and Parkland grade. We hypothesized that through additional expert consensus, the predictive capacity of the AAST anatomic grading system could be improved.

METHODS

A modified Delphi approach was used to revise the AAST grading system. Changes were made to improve distribution of patients across grades, and additional key clinical variables were introduced. The revised version was assessed using prospectively collected data from an AAST multicenter study. Patient distribution across grades was assessed, and the revised grading system was evaluated based on predictive capacity using area under receiver operating characteristic curves for conversion from laparoscopic to an open procedure, use of a surgical "bail-out" procedure, bile leak, major complications, and discharge home. A preoperative AAST grade was defined based on preoperative, clinical, and radiologic data, and the Parkland grade was also substituted for the operative component of the AAST grade.

RESULTS

Using prospectively collected data on 861 patients with acute cholecystitis the revised version of the AAST grade has an improved distribution across all grades, both the overall grade and across each subscale. A higher AAST grade predicted each of the outcomes assessed (all p ≤ 0.01). The revised AAST grade outperformed the original AAST grade for predicting operative outcomes and discharge disposition. Despite this improvement, the AAST grade did not outperform the Parkland grade or the Emergency Surgery Score.

CONCLUSION

The revised AAST grade and the preoperative AAST grade demonstrated improved discrimination; however, a purely anatomic grade based on chart review is unlikely to predict outcomes without addition of physiologic variables. Follow-up validation will be necessary.

LEVEL OF EVIDENCE

Diagnostic Test or Criteria, Level IV.

Crisis Standards of Care Guidelines for the COVID-19 Pandemic: Fresno Resource Allocation Guide (FRAG)

The coronavirus disease 2019 (COVID-19) pandemic has forced healthcare providers and policymakers to look candidly at the possibility that critical care resources, such as ventilators, medical staff, extracorporeal membrane oxygenation (ECMO), bilevel positive airway pressure (BiPAP) machines, and high-flow oxygen, may become scarce or depleted if the virus continues to move throughout the United States unabated. With hospitalizations and ICU occupancy rates rapidly increasing all over the US, we must face the uncomfortable truth that a triage system, much like on the battlefields of war, will need to be implemented. Ethical concerns abound, but the process for addressing limited resources must continue to be explored.

Multiple frameworks have previously been developed to address the use of limited medical resources during catastrophic public health emergencies. Many crisis care guidelines and protocols address the maximizing of surge capabilities and allocation of resource use (specifically, ventilators). While overwhelming scenarios unfolded in Europe and then on the East Coast of the United States in March of 2020, our hospital system in central California was obligated to consider previously unimaginable scenarios. In an effort to pro-actively address these, an expert group, consisting of intensivists (adult and pediatric), trauma surgery, palliative care, and ethicists was organized to develop guidelines for resource allocation to be utilized for our medical system in the event of a public health emergency. As part of this process, existing guidelines and consensus documents were reviewed. A novel system for ventilator allocation was developed, termed the Fresno Resource Allocation Guide (FRAG). As the pandemic continued to surge into 2021, we began to look at other resources, such as oxygen delivery systems other than ventilators, as well as healthcare team members.

This resource allocation guide takes into account a depletion in critical care supplies for adults and children. It employs ethical principles and evidence-based tools for critical care.

Outcomes of major lower extremity amputations n dysvascular patients: Room for improvement

OBJECTIVES

Dysvascular patients account for >80% of major amputations in the US. We sought to determine if early mobilization and discharge disposition decreased post-operative hospital length of stay (PO-LOS) and expedited independent ambulation.

METHODS

A retrospective review of dysvascular patients undergoing major amputations was performed. Primary outcomes included PO-LOS, discharge disposition, and days to ambulation.

RESULTS

130 patients were included. Patients evaluated by Physical Therapy (PT) within 1 day of formal amputation had decreased PO-LOS (5.6 vs 6.5 days, p = 0.029). Patients discharged to rehab had a shorter PO-LOS (4 days) than those discharged to SNF or home (8 and 5 days, respectively; p = 0.008). Time to ambulation was shorter for patients discharged to rehab (109 days vs home = 153 days; SNF = 175 days; p = 0.033).

CONCLUSION

Modifiable factors, including early PT and rehab placement, decreased PO-LOS and expedited time to ambulation. A need exists for a standardized multidisciplinary team approach to improve outcomes.

Prospective evaluation of admission cortisol in trauma

Background

A low cortisol level has been shown to occur soon after trauma, and is associated with increased mortality. The purpose of this study was to investigate the impact of low cortisol levels in acute critically ill trauma patients. We hypothesized that patients would require increase vasopressor use, have a greater blood product administration, and increased mortality rate.

Methods

A blinded, prospective observational study was performed at an American College of Surgeons verified Level I trauma center. Adult patients who met trauma activation criteria, received initial treatment at Community Regional Medical Center and were admitted to the intensive care unit were included. Total serum cortisol levels were measured from the initial blood draw in the emergency department. Patients were categorized according to cortisol ≤15 µg/dL (severe low cortisol, SLC), 15.01–25 µg/dL (relative low cortisol, RLC), or >25 µg/dL (normal cortisol, NC) and compared on demographics, injury severity score, initial vital signs, blood product usage, vasopressor requirements, and mortality.

Results

Cortisol levels were ordered for 280 patients; 91 were excluded and 189 were included. Penetrating trauma accounted for 19% of injuries and blunt trauma for 81%. 22 patients (12%) had SLC, 83 (44%) had RLC, and 84 (44%) had NC. This study found patients with admission SLC had higher rates of vasopressor requirements, required more units of blood, and had a higher mortality rate than both the RLC and NC groups.

Conclusion

Low cortisol level can be identified acutely after severe trauma. Trauma patients with SLC had larger blood product requirements, vasopressor use, and increase mortality. Initial cortisol levels are useful in identifying these high-risk patients.

Level of evidence

Prognostic/epidemiologic study, level III

Clinical use of resuscitative endovascular balloon occlusion of the aorta (REBOA) in civilian trauma systems in the USA, 2019: a joint statement from the American College of Surgeons Committee on Trauma, the American College of Emergency Physicians, the National Association of Emergency Medical Services Physicians and the National Association of Emergency Medical Technicians

This is a joint statement from the American College of Surgeons Committee on Trauma, the American College of Emergency Physicians, the National Association of Emergency Medical Services Physicians and the National Association of Emergency Medical Technicians regarding the clinical use of resuscitative endovascular balloon occlusion of the aorta (REBOA) in civilian trauma systems in the USA. This statement addresses the system of care needed to manage trauma patients requiring the use of REBOA, in light of the current evidence available in this patient population. This statement was developed by an expert panel following a comprehensive review of the literature with representation from all sponsoring organizations and the US Military. This is an update to the previous statement published in 2018. It has been formally endorsed by the four sponsoring organizations.

Delayed splenic hemorrhage: Myth or mystery? A Western Trauma Association multicenter study

BACKGROUND

Multi-detector computed tomography imaging is now the reference standard for identifying solid organ injuries, with a high sensitivity and specificity. However, delayed splenic hemorrhage (DSH), defined as no identified injury to the spleen on the index scan but delayed bleeding from a splenic injury, has been reported. We hypothesized that the occurrence of DSH would be minimized by utilization of modern imaging techniques.

METHODS

Data was retrospectively collected from 2006 to 2016 in 12 adult Level I and II trauma centers. All patients had an initial CT scan demonstrating no splenic injury but subsequently were diagnosed with splenic bleeding. Demographic, injury characteristics, imaging parameters and results, interventions and outcomes were collected.

RESULTS

Of 6867 patients with splenic injuries, 32 cases (0.4%) of blunt splenic hemorrage were identified. Patients were primarily male, had blunt trauma, severely injured (ISS 32 (9-57) and with associated injuries. Injuries of all grades were identified up to 16 days following admission. Overall, half of patients required splenectomy. All index images were obtained using multi-detector CT (16-320 slice). Secondary review of imaging by two trauma radiologists judged 72% (n = 23) of scans as suboptimal. This was due to poor scan quality primary from artifact(23), single phase contrast imaging (16), and/or poor contrast bolus timing or volume (6). Notably, only 28% of scans in patients with DSH were performed with optimal scanning techniques.

CONCLUSION

This is the largest reported series of DSH in the era of modern imaging. Although the incidence of DSH is low, it still occurs despite the use of multi-detector imaging and when present, is associated with a high rate of splenectomy. Most cases of DSH can be attributed to missed diagnosis from suboptimal index imaging and ultimately be avoided.

Single-dose etomidate for intubation in the trauma patient

BACKGROUND

Concerns over adrenal suppression caused by a single dose of etomidate for intubation led to limiting its use in trauma patients in 2006.

OBJECTIVE

The purpose of this study was to compare mortality, hypotension, and intensive care unit (ICU) and hospital length of stay (LOS) for trauma patients requiring intubation during periods of liberal vs. limited etomidate use.

METHODS

A retrospective review of trauma patients requiring emergent intubation who presented between August 2004 and December 2008, before and after we decided to limit the use of etomidate. Data were collected on patient demographics, induction agents used, episodes of hypotension in the first 24h, ICU and total hospital LOS, and survival.

RESULTS

Of 1325 trauma patients intubated in the Emergency Department during the study period, 443 occurred during the 23 months before July 2006 (liberal etomidate use) and 882 in the 30 months after July 2006 (limited etomidate use). During the liberal use period, 258/443 (58%) were intubated using etomidate, compared to 205/882 (23%, p<0.0001) during the period of limited use. We found no significant differences in mortality (30% vs. 29%, p=0.70), mean ICU days (8.2 vs. 8.8, p=0.356), or mean hospital LOS (13.8 vs. 14.4 days, p=0.55). Episodes of hypotension were more common in the limited etomidate use group (45% vs. 33%, p<0.0001).

CONCLUSIONS

A significant reduction in the use of etomidate in trauma patients was not associated with differences in mortality, ICU days, or hospital LOS, but was associated with an increase in episodes of hypotension within 24h of presentation.

Routine Chest Radiograph is not Indicated after Open Tracheostomy: A Multicenter Perspective

Obtaining a chest radiograph (CXR) after open tracheostomy has been standard practice for many surgeons. We hypothesized that routine CXR after uncomplicated open tracheostomy is unnecessary. A prospective multicenter protocol was carried out on adult surgical patients undergoing uncomplicated tracheostomy. CXR was not routinely ordered in the immediate postoperative period but was obtained only for clinical indications. Preoperative and subsequent postoperative CXRs were reviewed for evidence of complications. Twenty-two surgeons at four institutions performed 151 tracheostomies. Posttracheostomy CXR was not diagnostic in four patients with potential tracheostomy-related complications (i.e., tachypnea, tachycardia, desaturation, and elevated peak airway pressure). In the 147 patients without clinical indications for CXR subsequent CXR revealed no significant new findings. In this era of cost containment the need for CXR after tracheostomy must be questioned. Routine CXR is not indicated or cost effective after uncomplicated open tracheostomy in adults.

Routine chest radiograph is not indicated after open tracheostomy: a multicenter perspective

Obtaining a chest radiograph (CXR) after open tracheostomy has been standard practice for many surgeons. We hypothesized that routine CXR after uncomplicated open tracheostomy is unnecessary. A prospective multicenter protocol was carried out on adult surgical patients undergoing uncomplicated tracheostomy. CXR was not routinely ordered in the immediate postoperative period but was obtained only for clinical indications. Preoperative and subsequent postoperative CXRs were reviewed for evidence of complications. Twenty-two surgeons at four institutions performed 151 tracheostomies. Posttracheostomy CXR was not diagnostic in four patients with potential tracheostomy-related complications (i.e., tachypnea, tachycardia, desaturation, and elevated peak airway pressure). In the 147 patients without clinical indications for CXR subsequent CXR revealed no significant new findings. In this era of cost containment the need for CXR after tracheostomy must be questioned. Routine CXR is not indicated or cost effective after uncomplicated open tracheostomy in adults.

Can Ringer's lactate be used safely with blood transfusions?

BACKGROUND

Blood bank recommendations specify that Ringer's lactate solution (LR) should be avoided while transfusing blood. However, there are few studies either evaluating or quantifying increased coagulation during rapid infusion of LR and blood.

DESIGN AND METHODS

Whole blood (WB, n = 25) and packed red blood cells (PRBC, n = 26) were rapidly admixed with normal saline (NS), Lactate solution and LR with 1 g (LR-1), 2 g (LR-2), and 5 g (LR-5) CaCl2/L solutions for assessment of infusion time, filter weight, and clot formation.

RESULTS

No significant differences in infusion time or filter weight using WB or PRBC with NS or LR were seen. No significant difference in clot formation between NS and LR with WB or PRBC was found, but the presence of visible clot was increased in the LR-5 group (P = 0.013, WB, and P = 0.002, PRBC).

CONCLUSION

A comparison of LR and NS with rapid infusion rates of blood showed no significant difference between infusion time, filter weight and clot formation. Blood bank guidelines should be revised to allow the use of LR in the rapid transfusion of PRBC.