Direct to operating room trauma resuscitation: Optimizing patient selection and time-critical outcomes when minutes count

eFAST to OR: Determining the Quality of Paramedic Conduction and Interpretation of eFAST Exams in Prehospital Settings

Traumatic injuries are a leading cause of morbidity and mortality, particularly among young adults. Direct transport to the operating room has been associated with reduced mortality by minimizing treatment delays. The extended Focused Assessment with Sonography for Trauma (eFAST) is a critical diagnostic tool in trauma care, identifying life-threatening conditions that may require urgent surgical intervention. This study aims to assess the diagnostic accuracy of eFAST performed by paramedics in a prehospital environment, comparing their interpretations to those of expert physicians. A retrospective observational cohort analysis was conducted on trauma cases (n = 64) attended by South Metro Fire Rescue from January to December 2022. Paramedics underwent comprehensive training in ultrasound use and interpretation before performing eFAST exams in transit to medical facilities. Exam findings were compared to interpretations by an expert ultrasonographer, with sensitivity, specificity, and predictive values calculated. The cohort consisted primarily of males (63%), with a mean age of 46 years. The most common injury mechanism was motor vehicle crash (n = 20). Paramedic-conducted eFAST exams demonstrated a sensitivity of 80.0% and specificity of 95.8%. Positive and negative predictive values were 50% and 95.8%, respectively. False positives were largely due to difficulty in interpreting normal anatomy or identifying pathologies. Paramedics can reliably perform eFAST exams with high diagnostic accuracy, suggesting that prehospital eFAST could enhance trauma care by reducing time to surgical intervention. Future research should explore the integration of eFAST into prehospital protocols across diverse settings to improve trauma outcomes.

Penetrating cardiac injuries: What you need to know

ABSTRACT

Despite significant advances in trauma surgery in recent years, patients sustaining penetrating cardiac injuries still have an overall survival rate of 19%. A substantial number of deaths occur at the scene, while approximately 40% of those reaching trauma centers survive. To increase survival, the key factor is timely intervention for bleeding control, pericardial tamponade release, and definitive repair. Asymptomatic patients sustaining precordial wounds or mediastinal gunshot wounds should be assessed with chest ultrasound to rule out cardiac injuries. Shock on admission is an immediate indication of surgery repair. Patients admitted in posttraumatic cardiac arrest may benefit from resuscitative thoracotomy. The surgical team must be assured that appropriate personnel, equipment, instruments, and blood are immediately available in the operating room. A left anterolateral thoracotomy, which can be extended to a clamshell incision, and sternotomy are the most common surgical incisions. Identification of cardiac anatomical landmarks during surgery is vital to avoid complications. There are several technical options for bleeding control, and the surgeon must be trained to use them to obtain optimal results. Ultimately, prioritizing surgical intervention and using effective resuscitation strategies are essential for improving survival rates and outcomes.

Cardiac Trauma: A Review of Penetrating and Blunt Cardiac Injuries

Cardiac injuries pose challenging diagnostic and management dilemmas. Cardiac trauma can be classified by mechanism into blunt and penetrating injuries. Penetrating trauma has an overall higher mortality and is more likely to require operative intervention. Due to the lethality of any cardiac injury, prompt diagnosis and treatment is critical for survival. The initial management of suspected cardiac injury should start with Advanced Trauma Life Support (ATLS) protocols followed shortly by directed diagnosis and management, which usually begins with a focused assessment with sonography in trauma (FAST) examination. In contrast to traditional ATLS protocols, some centers have adopted an assessment of "circulation before "airway" and "breathing"; however, this is an evolving concept. In this article, we provide an overview on the management of penetrating and blunt cardiac injuries, including use of physical exam, laboratory tests, imaging, and surgery.

Real-time attending trauma surgeon assessment of direct-to-operating room trauma resuscitations: Results from a prospective observational study

BACKGROUND

Direct-to-operating room (DOR) resuscitation expedites interventions for trauma patients. Perceived benefit from the surgeon's perspective is not well known. This study assesses the integration of a real-time surgeon assessment tool into a DOR protocol.

METHODS

Surgeon assessment tool results from a prospective study of DOR cases were analyzed. Analysis assessed patient factors and surgeon perception for appropriateness and benefit of DOR. Multivariate analysis identified independent factors associated with perceived DOR benefit.

RESULTS

A total of 104 trauma patients underwent DOR resuscitation; 84% were perceived as appropriate triage, and 48% as beneficial. Patients with Injury Severity Score of >15 (50% vs. 28%), systolic blood pressure of <90 mm Hg (24% vs. 9%), and severe abdominal injury (28% vs. 9%) had higher perceived DOR benefits (all p < 0.05). Patients deemed to benefit from DOR underwent more emergent interventions or truncal surgery (44% vs. 92%, p < 0.01). No difference in benefit was seen based on age, sex, Glasgow Coma Scale score of <9, or injury mechanism. Forty-four percent had perceived benefit from DOR resuscitation despite requiring imaging after initial evaluation. Patients with perceived benefit had a higher rate of unplanned return to the operating room (16% vs. 2%, p < 0.05), but no differences in complication rates, Glasgow Outcome Score, or mortality. Injury Severity Score of >15 was the only independently associated variable with a perceived benefit on surgeon assessment tool (odds ratio, 3.5; p < 0.05).

CONCLUSION

The majority of DOR resuscitations were deemed as appropriately triaged, and approximately half had a perceived benefit. Benefit was associated with higher injury severity and the need for urgent interventions but was not predicted by injury mechanism or other triage variables.

LEVEL OF EVIDENCE

Prognostic and Epidemiological; Level IV.

Platinum Hour: Emergency Department Length of Stay and Trauma Patients' Outcomes

INTRODUCTION

Trauma bay and emergency department (ED) length of stay (LOS) are important time measures in patient care. The data on this subject are inconclusive or specific to one condition. Our goal was to determine the relationship between ED LOS and outcomes or mortality of trauma patients. We sought to investigate certain cofactors which influence this relationship. We hypothesized that ED LOS will be correlated with negative patient outcomes and mortality for moderately and severely injured trauma patients.

METHODS

A retrospective study was conducted from June 2018 to June 2022 at our level 1 Trauma center. Patients ≥18 y that arrived as a trauma activation were included. Patients were excluded if they were transfers in or out, expired before arrival, or were discharged from the ED. Univariate and multivariable statistical analysis based on disposition time were performed. The primary outcome was mortality.

RESULTS

Six thousand seven hundred eighty-one patients met the inclusion criteria. Patients were stratified based on time to disposition ≤60 (n = 521) and >60 min (n = 6260). The ≤60-min group was younger than the >60-min group (53 (interquartile range (IQR) 30-73) versus 68 (IQR 48-82), P < 0.001), and was more often male (69.48% (n = 362) versus 50.32% (n = 3150), P < 0.001). The ≤60-min group had a lower Glasgow Coma Scale (14 (IQR 8-15) versus 15 (IQR 15-15), P < 0.001), a longer intensive care unit LOS (2 (IQR 1-5) versus 1 (IQR 1-3), P < 0.001), a longer hospital LOS (4 (IQR 1-10) versus 3 (IQR 2-6), P < 0.001), and a greater Injury Severity Score (13 (IQR 5-22) versus 5 (IQR 4-10), P < 0.001) compared to the >60-min group. The ≤60-min group was also more likely to receive blood products (39.92% (n = 208) versus 13.15% (n = 823), P < 0.001) compared to the >60-min group. A greater risk of mortality was found in the ≤60-min versus >60-min group (17.47% (n = 91) versus 2.75% (172), P < 0.001). The ≤60-min group had a shorter transport time (14 (IQR 8-21) versus 17 (IQR 11-24), P < 0.001). On multivariable analysis, there was an association between a disposition time of 60 min or less and a decreased risk of mortality. However, men had a greater risk of mortality compared to women. Patients that received blood products and patients with more severe injuries had a higher likelihood of mortality.

CONCLUSIONS

Trauma patients with a decreased ED LOS had a higher rate of mortality, contrary to our hypothesis. The patients with a decreased ED LOS were also more severely injured. It may be reasonable that trauma patients can receive the same level of care regardless of location in the hospital.

Challenging Dogma by Skipping the Emergency Department Thoracotomy: A Propensity Score Matched Analysis of the Trauma Quality Improvement Database

INTRODUCTION

Survival following emergency department thoracotomy (EDT) for patients in extremis is poor. Whether intervention in the operating room instead of EDT in select patients could lead to improved outcomes is unknown. We hypothesized that patients who underwent intervention in the operating room would have improved outcomes compared to those who underwent EDT.

METHODS

We conducted a retrospective review of the Trauma Quality Improvement Program database from 2017 to 2021. All adult patients who underwent EDT, operating room thoracotomy (ORT), or sternotomy as the first form of surgical intervention within 1 h of arrival were included. Of patients without prehospital cardiac arrest, propensity score matching was utilized to create three comparable groups. The primary outcome was survival. Secondary outcomes included time to procedure.

RESULTS

There were 1865 EDT patients, 835 ORT patients, and 456 sternotomy patients who met the inclusion criteria. There were 349 EDT, 344 ORT, and 408 sternotomy patients in the matched analysis. On Cox multivariate regression, there was an increased risk of mortality with EDT versus sternotomy (HR 4.64, P < 0.0001), EDT versus ORT (HR 1.65, P < 0.0001), and ORT versus sternotomy (HR 2.81, P < 0.0001). Time to procedure was shorter with EDT versus sternotomy (22 min versus 34 min, P < 0.0001) and versus ORT (22 min versus 37 min, P < 0.0001).

CONCLUSIONS

There was an association between sternotomy and ORT versus EDT and improved mortality. In select patients, operative approaches rather than the traditional EDT could be considered.

State of the art of trauma teams in Italy: A nationwide study

Trauma teams play a vital role in providing prompt and specialized care to trauma patients. This study aims to provide a comprehensive description of the presence and organization of trauma teams in Italy. A nationwide cross-sectional epidemiological study was conducted between July and October 2022, involving interviews with 137 designated trauma centers. Centers were stratified based on level: higher specialized trauma centers (CTS), intermediate level trauma centers (CTZ + N) and district general hospital with trauma capacity (CTZ). A standardized structured interview questionnaire was used to gather information on hospital characteristics, trauma team prevalence, activation pathways, structure, components, leadership, education, and governance. Descriptive statistics were used for analysis. Results showed that 53 % of the centers had a formally defined trauma team, with higher percentages in CTS (73 %) compared to CTZ + N (49 %) and CTZ (39 %). The trauma team activation pathway varied among centers, with pre-alerts predominantly received from emergency medical services. The study also highlighted the lack of formally defined massive transfusion protocols in many centers. The composition of trauma teams typically included airway and procedure doctors, nurses, and healthcare assistants. Trauma team leadership was predetermined in 59 % of the centers, with anesthesiologists/intensive care physicians often assuming this role. The study revealed gaps in trauma team education and governance, with a lack of specific training for trauma team leaders and low utilization of simulation-based training. These findings emphasize the need for improvements in trauma management education, governance, and the formalization of trauma teams. This study provides valuable insights that can guide discussions and interventions aimed at enhancing trauma care at both local and national levels in Italy.

Efficacy of direct-to-operating room trauma resuscitation: a systematic review

BACKGROUND

Hemorrhage control is a time-critical task, and recent studies have demonstrated that a shorter time to definitive care is positively associated with patient survival and functional outcomes. The concept of direct transport to the operating room was proposed in the 1960s to reduce treatment time. Some trauma centers have developed protocols for direct-to-operating room resuscitation (DOR) programs. Moreover, few studies have reported the clinical outcomes of DOR in patients with trauma; however, their clinical effect in improving the efficiency and quality of care remains unclear. In this systematic review, we aimed to consolidate all published studies reporting the effect of DOR on severe trauma and evaluate its utility.

METHODS

The PubMed, EMBASE, and Cochrane databases were searched from inception to April 2023, to identify all articles published in English that reported the effect of direct-to-operating room trauma resuscitation for severe trauma. The articles were reviewed as references of interest.

RESULTS

We reviewed six studies reporting the clinical effect of operating room trauma resuscitation. A total of 3232 patients were identified. Five studies compared the actual mortality with the predicted mortality using the trauma score and injury severity score, while one study compared mortality using propensity matching. Four studies reported that the actual survival rate for overall injuries was better than the predicted survival rate, whereas two studies reported no difference. Some studies performed subgroup analyses. Two studies showed that the survival rate for penetrating injuries was better than the predicted survival rate, and one showed that the survival rate for blunt injuries was better than the predicted survival rate. Five studies reported the time to surgical intervention, which was within 30 min. Two studies time-compared surgical intervention, which was shorter in patients who underwent DOR.

CONCLUSION

Implementing DOR is likely to have a beneficial effect on mortality and can facilitate rapid intervention in patients with severe shock. Future studies, possibly clinical trials, are needed to ensure a proper comparison of the efficiency.

Direct to Operating Room for Decompressive Craniotomy/Craniectomy in Patients With Traumatic Brain Injury

BACKGROUND

Emergent decompressive craniotomy/craniectomy can be a lifesaving surgical intervention for select patients with traumatic brain injury. Prompt management is critical as early decompression can impact traumatic brain injury outcomes.

OBJECTIVE

This study aims to describe the feasibility and clinical impact of a new pathway for transporting patients with severe traumatic brain injury directly to the operating room from the trauma bay for decompressive craniotomy/craniectomy.

METHODS

This is a retrospective cohort preintervention and postintervention study of severe traumatic brain injury patients undergoing decompressive craniectomy/craniotomy at a Midwestern U.S. Level I trauma center between 2016 and 2022. In the new pathway, the in-house trauma surgeon takes the patient directly to the operating room with the neurosurgery advanced practice provider to drape and prepare the patient for surgery while the neurosurgeon is en route to the hospital.

RESULTS

A total of 44 patients were studied, five (5/44, 11.4%) of which were in the preintervention group and 39 (39/44, 88.6%) in the postintervention group. The median arrival-to-operating room time was shorter in the postintervention cohort (1.4 hr) than in the preintervention cohort (1.5 hr). In examining night shifts only, the preintervention cohort had shorter arrival-to-operating room times (1.2 hr) than the postintervention cohort (1.5 hr).

CONCLUSION

The study demonstrated that the new pathway is feasible and expedites patient transport to the operating room while awaiting the arrival of the on-call neurosurgeon.

Retrospective value assessment of a dedicated, trauma hybrid operating room

BACKGROUND

In traumatic hemorrhage, hybrid operating rooms offer near simultaneous performance of endovascular and open techniques, with correlations to earlier hemorrhage control, fewer transfusions, and possible decreased mortality. However, hybrid operating rooms are resource intensive. This study quantifies and describes a single-center experience with the complications, cost-utility, and value of a dedicated trauma hybrid operating room.

METHODS

This retrospective cohort study evaluated 292 consecutive adult trauma patients who underwent immediate (<4 hours) operative intervention at a Level I trauma center. A total of 106 patients treated before the construction of a hybrid operating room served as historical controls to the 186 patients treated thereafter. Demographics, hemorrhage-control procedures, and financial data as well as postoperative complications and outcomes were collected via electronic medical records. Value and incremental cost-utility ratio were calculated.

RESULTS

Demographics and severity of illness were similar between cohorts. Resuscitative endovascular occlusion of the aorta was more frequently used in the hybrid operating room. Hemorrhage control occurred faster (60 vs. 49 minutes, p = 0.005) and, in the 4- to 24-hour postadmission period, required less red blood cell (mean, 1.0 vs. 0 U, p = 0.001) and plasma (mean, 1.0 vs. 0 U, p < 0.001) transfusions. Complications were similar except for a significant decrease in pneumonia (7% vs. 4%, p = 0.008). Severe complications (Clavien-Dindo classification, ≥3) were similar. Across the patient admission, costs were not significantly different ($50,023 vs. $54,740, p = 0.637). There was no change in overall value (1.00 vs. 1.07, p = 0.778).

CONCLUSION

The conversion of our standard trauma operating room to an endovascular hybrid operating room provided measurable improvements in hemorrhage control, red blood cell and plasma transfusions, and postoperative pneumonia without significant increase in cost. Value was unchanged.

LEVEL OF EVIDENCE

Economic/Value-Based Evaluations; Level III.

Comprehensive Management of the Patient With Traumatic Cardiac Injury

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.

Diagnostic accuracy for hemoperitoneum, influence on prehospital times and time-to-definitive treatment of prehospital FAST: A systematic review and individual participant data meta-analysis

BACKGROUND

Focused assessment sonography for trauma (FAST) performed in the prehospital setting may improve trauma care by influencing treatment decisions and reducing time to definitive care, but its accuracy and benefits remain uncertain. This systematic review evaluated the diagnostic accuracy of prehospital FAST in detecting hemoperitoneum and its effects on prehospital time and time to definitive diagnosis or treatment.

METHODS

We systematically searched PubMed, Embase, and Cochrane library up to November 11th, 2022. Studies investigating prehospital FAST and reporting at least one outcome of interest for this review were considered eligible. The primary outcome was prehospital FAST diagnostic accuracy for hemoperitoneum. A random-effect meta-analysis, including individual patient data, was performed to calculate the pooled outcomes with 95% confidence intervals (CI). Quality of studies was assessed using the QUADAS-2 tool for diagnostic accuracy.

RESULTS

We included 21 studies enrolling 5790 patients. The pooled sensitivity and specificity of prehospital FAST for hemoperitoneum were 0.630 (0.454 - 0.777) and 0.970 (0.957-0.979), respectively. Prehospital FAST was performed in a median of 2.72 (2.12 - 3.31) minutes without increasing prehospital times (pooled median difference of 2.44 min [95% CI: -3.93 - 8.81]) compared to standard management. Prehospital FAST findings changed on-scene trauma care in 12-48% of cases, the choice of admitting hospital in 13-71%, the communication with the receiving hospital in 45-52%, and the transfer management in 52-86%. Patients with a positive prehospital FAST achieved definitive diagnosis or treatment more rapidly (severity-adjusted pooled time ratio = 0.63 [95% CI: 0.41 - 0.95]) compared with patients with a negative or not performed prehospital FAST.

CONCLUSIONS

Prehospital FAST had a low sensitivity but a very high specificity to identify hemoperitoneum and reduced time-to-diagnostics or interventions, without increasing prehospital times, in patients with a high probability of abdominal bleeding. Its effect on mortality is still under-investigated.

The European guideline on management of major bleeding and coagulopathy following trauma: sixth edition

BACKGROUND

Severe trauma represents a major global public health burden and the management of post-traumatic bleeding continues to challenge healthcare systems around the world. Post-traumatic bleeding and associated traumatic coagulopathy remain leading causes of potentially preventable multiorgan failure and death if not diagnosed and managed in an appropriate and timely manner. This sixth edition of the European guideline on the management of major bleeding and coagulopathy following traumatic injury aims to advise clinicians who care for the bleeding trauma patient during the initial diagnostic and therapeutic phases of patient management.

METHODS

The pan-European, multidisciplinary Task Force for Advanced Bleeding Care in Trauma included representatives from six European professional societies and convened to assess and update the previous version of this guideline using a structured, evidence-based consensus approach. Structured literature searches covered the period since the last edition of the guideline, but considered evidence cited previously. The format of this edition has been adjusted to reflect the trend towards concise guideline documents that cite only the highest-quality studies and most relevant literature rather than attempting to provide a comprehensive literature review to accompany each recommendation.

RESULTS

This guideline comprises 39 clinical practice recommendations that follow an approximate temporal path for management of the bleeding trauma patient, with recommendations grouped behind key decision points. While approximately one-third of patients who have experienced severe trauma arrive in hospital in a coagulopathic state, a systematic diagnostic and therapeutic approach has been shown to reduce the number of preventable deaths attributable to traumatic injury.

CONCLUSION

A multidisciplinary approach and adherence to evidence-based guidelines are pillars of best practice in the management of severely injured trauma patients. Further improvement in outcomes will be achieved by optimising and standardising trauma care in line with the available evidence across Europe and beyond.

Early management of isolated severe traumatic brain injury patients in a hospital without neurosurgical capabilities: a consensus and clinical recommendations of the World Society of Emergency Surgery (WSES)

BACKGROUND

Severe traumatic brain-injured (TBI) patients should be primarily admitted to a hub trauma center (hospital with neurosurgical capabilities) to allow immediate delivery of appropriate care in a specialized environment. Sometimes, severe TBI patients are admitted to a spoke hospital (hospital without neurosurgical capabilities), and scarce data are available regarding the optimal management of severe isolated TBI patients who do not have immediate access to neurosurgical care.

METHODS

A multidisciplinary consensus panel composed of 41 physicians selected for their established clinical and scientific expertise in the acute management of TBI patients with different specializations (anesthesia/intensive care, neurocritical care, acute care surgery, neurosurgery and neuroradiology) was established. The consensus was endorsed by the World Society of Emergency Surgery, and a modified Delphi approach was adopted.

RESULTS

A total of 28 statements were proposed and discussed. Consensus was reached on 22 strong recommendations and 3 weak recommendations. In three cases, where consensus was not reached, no recommendation was provided.

CONCLUSIONS

This consensus provides practical recommendations to support clinician's decision making in the management of isolated severe TBI patients in centers without neurosurgical capabilities and during transfer to a hub center.

Streamlining orthopaedic trauma surgical care: do all patients need medical clearance?

INTRODUCTION

Preoperative medical optimization is necessary for safe and efficient care of the orthopaedic trauma patient. To improve care quality and value, a preoperative matrix was created to more appropriately utilize subspecialty consultation and avoid unnecessary consults, testing, and operating room delays. Our study compares surgical variables before and after implementation of the matrix to assess its utility.

METHODS

A retrospective review of all orthopaedic trauma cases 6 months before and after the use of the matrix (2/2021-8/2021) was conducted an urban, level one trauma centre in collaboration with internal medicine, cardiology, anaesthesia, and orthopaedics. Patients were separated into two cohorts based on use of the matrix during the initial orthopaedic consultation. Logistic regressions were performed to limit significant differences in comorbidities. Independent samples t-tests and Chi-squared tests were used to compare means and proportions, respectively, between the two cohorts.

RESULTS

In total, 576 patients were included in this study (281 pre- and 295 post-matrix implementation). Use of the matrix resulted in no significant difference in time to OR, LOS, readmissions, or ER visits; however, it resulted in 18% fewer overall preoperative consults for general trauma, and 25% fewer pre-operative consults for hip fractures. Older patients were more likely to require a consult regardless of matrix use. When controlling for comorbidities, patients with renal disease were at higher risk for increased LOS.

CONCLUSION

Use of an orthopaedic surgical matrix to predict preoperative subspecialty consultation is easy to implement and allows for better care utilization without a corresponding increase in complications and readmissions. Follow-up studies are needed to reassess the relationships between matrix use and a potential decrease in ER to OR time, and validate its use.

Advances in the Management of Coagulopathy in Trauma: The Role of Viscoelastic Hemostatic Assays across All Phases of Trauma Care

Uncontrolled bleeding is the leading cause of preventable death following injury. Trauma-induced coagulopathy can manifest as diverse phenotypes ranging from hypocoagulability to hypercoagulability, which can change quickly during the acute phase of trauma care. The major advances in understanding coagulation over the past 25 years have resulted from the cell-based concept, emphasizing the key role of platelets and their interaction with the damaged endothelium. Consequently, conventional plasma-based coagulation testing is not accurate in predicting bleeding and does not provide an assessment of which blood products are indicated. Viscoelastic hemostatic assays (VHA), conducted in whole blood, have emerged as a superior method to guide goal-directed transfusion. The major change in resuscitation has been the shift from unbridled crystalloid loading to judicious balanced blood product administration. Furthermore, the recognition of the rapid changes from hypocoagulability to hypercoagulability has underscored the importance of ongoing surveillance beyond emergent surgery. While the benefits of VHA testing are maximized when used as early as possible, current technology limits use in the pre-hospital setting and the time to results compromises its utility in the emergency department. Thus, most of the reported experience with VHA in trauma is in the operating room and intensive care unit, where there is compelling data to support its value. This overview will address the current and potential role of VHA in the seriously injured patient, throughout the continuum of trauma management.

Treatment of a gunshot wound (birdshot) patient with traumatic shock in a hybrid emergency room

Background

Although the Hybrid Emergency Room System (HERS) is a relatively novel method for treating severe trauma patients, there have been few reported cases of gunshot wound patients treated in HERS. Here we report our treatment of a unique gunshot wound case, with shock, in a HERS setting.

Case presentation

A 72-year-old male was transferred to our hospital due to a gunshot wound (GSW). He presented with left chest injuries and vital signs consistent with shock. While resuscitating the patient, including massive blood transfusion and surgery to control the damage, a subsequent computed tomography in HERS revealed the internal distribution of the birdshot and damage to the abdominal organs. Lower lobectomy of the left lung and laparotomy for gastrointestinal repair were performed. After a planned repeat operation and reconstruction of the left chest wall, he was discharged uneventfully.

Conclusions

HERS during resuscitation was useful for helping clinicians not only to find the bullets' distribution and judge the severity of injury caused by the gunshot, but also to develop subsequent therapeutic strategies for rescuing the gunshot wound patient from a life-threatening situation.

A Case Series of Trauma Resuscitation in the Intensive Care Unit Bypassing the Emergency Room During the Conversion to a COVID-19 Only Hospital

When a patient with severe trauma is admitted to the emergency room (ER), they are evaluated before transfer to either the intensive care unit (ICU) or operating room. To minimize the time until a definitive treatment can be provided, direct operating room resuscitation can be performed. In this hospital the ER was closed during the hospital’s transition to a coronavirus disease 2019-dedicated hospital, and direct ICU resuscitation for patients with trauma was performed for a short period. To perform effective trauma resuscitation, all ICU beds were reorganized to achieve a modified, experienced nurse: patient ratio (1:2-3) and 2 beds were assigned for trauma ICU resuscitation alone. The equipment for initial resuscitation was installed and ICU nurses received training. Consultations with the hospital administration, nursing, and pharmaceutical departments were completed in advance to avoid formal problems. Conversion of the ICU for direct resuscitation procedures was performed in 4 patients.

Analysis of the Effect of Holistic Nursing in the Operating Room Based on PDCA and Evidence-Based Nursing in the Otorhinolaryngology Operating Room: Based on a Retrospective Case-Control Study

Objective

Based on a retrospective case-control study, this study aims to explore the effect of holistic nursing in operating room based on PDCA (plan, do, check, and action) process and evidence-based nursing (EBN) in a ear, nose, and throat operating room.

Methods

About 200 patients who underwent otorhinolaryngology surgery in our hospital from January 2019 to September 2021 were enrolled. According to the difference of nursing mode, patients were assigned into a control group and study group; holistic nursing in operating room was included in control group, and holistic nursing in the operating room based on PDCA and EBN was included in study group. Nursing satisfaction, hypothermia, chills, restlessness, related indexes of operating room, nursing quality scores of operating room, and individual quality control scores were compared.

Results

First of all, we compared the nursing satisfaction, the study group was very satisfied in 69 cases, satisfactory in 30 cases, general in 1 case, the satisfaction rate was 100.00%, while in the control group, 46 cases were very satisfied, 34 cases were satisfied, 13 cases were general, and 7 cases were dissatisfied, the satisfaction rate was 93.00%. The nursing satisfaction of the study group was higher compared to the control group (P < 0.05). Second, we compared the incidence of hypothermia, chills and restlessness. The incidence of hypothermia, chills, and restlessness in the study group was lower compared to the control group (P < 0.05). The time of tracheal tube extubation, PACU stay time, postoperative hospitalization time, hospitalization cost, and operation time in the study group was significantly lower compared to the control group (P < 0.05). In terms of the scores of nursing quality in the operating room, the instruments and equipment management, equipment preparation, nurses' cooperation skills, disinfection and isolation quality, and total score in the study group were higher compared to the control group (P < 0.05). Finally, we compared the scores of individual quality control examination. The scores of ward management, rescue, therapeutic articles, drug management, first-level nursing, nursing documents, and head nurse management in the study group were higher compared to the control group (P < 0.05).

Conclusion

Incorporating the concepts of PDCA and EBN into the overall care of the operating theatre is effective for patients in the ENT operating theatre. Our results show that this care can be effective in improving patients' surgical indicators, reducing the incidence of postoperative infections, shortening postoperative resuscitation and length of stay, reducing hospital costs, and promoting surgical patient satisfaction. While further multicenter studies are necessary, this series of nursing interventions remains worthy of replication in the clinical setting.

The role of prehospital ultrasound in reducing time to definitive care in abdominal trauma patients with moderate to severe liver and spleen injuries

BACKGROUND

The role of prehospital focused assessment sonography for trauma (FAST) is still under debate and no definitive recommendations are available in actual guidelines, moreover, the availability of ultrasound machines in emergency medical services (EMS) is still inhomogeneous. On the other hand, time to definitive care is strictly related to survival in bleeding trauma patients. This study aimed at investigating if a positive prehospital FAST in abdominal trauma patients could have a role in reducing door-to-CT scan or door-to-operating room (OR) time.

METHODS

This retrospective observational study included all the patients affected by an abdominal trauma with an abdominal abbreviated injury score ≥ 2 and a spleen or liver injury admitted to Maggiore Hospital Carlo Alberto Pizzardi, a level 1 trauma centre between 2014 and 2019. Prehospital and emergency department (ED) clinical and laboratory variables were collected, as well as in-hospital times during the diagnostic and therapeutic pathways of these patients.

RESULTS

199 patients were included in the final analysis. Of these, 44 had a prehospital FAST performed and in 27 of them, peritoneal free fluid was detected in the prehospital setting, while 128 out of 199 patients had a positive ED-FAST. Sensitivity was 62.9% (95% CI: 42.4%-80.6%) and specificity 100% (95% CI: 80.5% - 100%). Patients with a positive prehospital FAST reported a significantly lower door-to-CT or door-to-OR median time (46 vs 69 min, p < 0.001). Prehospital hypotension and Glasgow coma scale, first arterial blood lactate, ISS, age, positive prehospital and ED FAST were inserted in a stepwise selection for a multivariable Cox proportional regression hazards model. Only ISS and prehospital FAST resulted significantly associated with a reduction in the door-to-CT scan or door-to-operating theatre time in the multivariable model.

CONCLUSION

Prehospital FAST information of intraperitoneal free fluid could significantly hasten door-to-CT scan or door-to-operating theatre time in abdominal trauma patients if established hospital response protocols are available.

LEVEL OF EVIDENCE

III, (Therapeutic / Care Management).

Direct to OR resuscitation of abdominal trauma: An NTDB propensity matched outcomes study

BACKGROUND

Direct to operating room resuscitation (DOR) is used by some trauma centers for severely injured trauma patients as an approach to minimize time to hemorrhage control. It is unknown whether this strategy results in favorable outcomes. We hypothesized that utilization of an emergency department operating room (EDOR) for resuscitation of patients with abdominal trauma at an urban Level I trauma center would be associated with decreased time to laparotomy and improved outcomes.

METHODS

We included patients 15 years or older with abdominal trauma who underwent emergent laparotomy within 120 minutes of arrival both at our institution and within a National Trauma Data Bank sample between 2007 to 2019 and 2013 to 2016, respectively. Our institutional sample was matched 1:1 to an American College of Surgeons National Trauma Databank sample using propensity score matching based on age, sex, mechanism of injury, and abdominal Abbreviated Injury Scale score. The primary outcome was time to laparotomy incision. Secondary outcomes included blood transfusion requirement, intensive care unit (ICU) length of stay (LOS), ventilator days, hospital LOS, and in-hospital mortality.

RESULTS

Two hundred forty patients were included (120 institutional, 120 national). Both samples were well balanced, and 83.3% sustained penetrating trauma. There were 84.2% young adults between the ages of 15 and 47, 91.7% were male, 47.5% Black/African American, with a median Injury Severity Score of 14 (interquartile range [IQR], 8-29), Glasgow Coma Scale score of 15 (IQR, 13-15), 71.7% had an systolic blood pressure of >90 mm Hg, and had a shock index of 0.9 (IQR, 0.7-1.1) which did not differ between groups (p > 0.05). Treatment in the EDOR was associated with decreased time to incision (25.5 minutes vs. 40 minutes; p ≤ 0.001), ICU LOS (1 vs. 3.1 days; p < 0.001), transfusion requirement within 24 hours (3 units vs. 5.8 units packed red blood cells; p = 0.025), hospital LOS (5 days vs. 8.5 days, p = 0.014), and ventilator days (1 day vs. 2 days; p ≤ 0.001). There were no significant differences in in-hospital mortality (22.5% vs. 15.0%; p = 0.14) or outcome-free days (4.9 days vs. 4.5 days, p = 0.55).

CONCLUSION

The use of an EDOR is associated with decreased time to hemorrhage control as evidenced by the decreased time to incision, blood transfusion requirement, ICU LOS, hospital LOS, and ventilator days. These findings support DOR for patients sustaining operative abdominal trauma.

LEVEL OF EVIDENCE

Therapeutic/Care Management, Level III.

Management of Complex Transmediastinal Stab Wound With Cardiac, Esophageal, and Arterial Injury

Penetrating transmediastinal traumatic injuries often carry a high mortality given the vital structures this type of injury often involves. Here, we describe a case of 24-year-old man who suffered multiple stab wounds to the chest and back with associated cardiac, esophageal, and arterial injury, requiring immediate operative intervention. He underwent sternotomy and left thoracotomy with pericardiotomy, repair of 2 right ventricular lacerations, and ligation of internal mammary artery. The esophageal injury was repaired with endoscopic clips. Patient had an uncomplicated recovery. Despite high mortality often associated with transmediastinal penetrating injuries, good outcomes are achievable with rapid identification of injuries and appropriate operative intervention alongside adequate resuscitation.

Selective Prehospital Advanced Resuscitative Care - Developing a Strategy to Prevent Prehospital Deaths From Noncompressible Torso Hemorrhage

Hemorrhage, and particularly noncompressible torso hemorrhage remains a leading cause of potentially preventable prehospital death from trauma in the United States and globally. A subset of severely injured patients either die in the field or develop irreversible hemorrhagic shock before they can receive hospital definitive care, resulting in poor outcomes. The focus of this opinion paper is to delineate (a) the need for existing trauma systems to adapt so that potentially life-saving advanced resuscitation and truncal hemorrhage control interventions can be delivered closer to the point-of-injury in select patients, and (b) a possible mechanism through which some trauma systems can train and incorporate select prehospital advanced resuscitative care teams to deliver those interventions.

Systematic review of the efficacy of a hybrid operating theatre in the management of severe trauma

Background

Hybrid operating theatres (OT) allow for simultaneous interventional radiology and operative procedures, serving as a one-stop facility for the treatment of severely injured patients. Several countries have adopted the use of the hybrid OT however their clinical impact in improving efficiency and quality of care remains unclear. This study systematically reviews the clinical impact of the hybrid OT for treatment of the severely injured.

Methods

A literature review of the PubMed, Embase and Cochrane databases was performed to identify all published articles in English, from 1st January 2000 to 31st December 2020, reporting on the impact of a hybrid OT for severe trauma. Articles were also reviewed for references of interest.

Results

Five studies reporting the clinical impact of the hybrid OT, in a total of 951 patients, were shortlisted. All were cohort studies that compared patient outcomes in the hybrid OT versus a conventional group. Out of 3 studies that assessed timeliness to intervention, one reported shorter time associated with the hybrid OT, while the other two reported no difference. Mortality outcomes were reported in 4 studies and showed no significant difference associated with treatment in the hybrid OT. Two studies revealed shorter total procedure times associated with the hybrid OT. Two out of 3 studies that evaluated blood transfusion requirements reported decreased transfusion rates in the hybrid OT group. Only 1 study examined complication rates and demonstrated morbidity benefits associated with the hybrid OT.

Conclusion

Establishment of a hybrid OT requires a significant capital investment as well as a highly functioning multi-disciplinary team. The cost–benefit ratio remains unclear. Future studies, preferably in the form of clinical trials, are required to evaluate its usefulness in improving timeliness to definitive haemorrhage control and outcomes in severe trauma.

Choosing wisely: A prospective study of direct to operating room trauma resuscitation including real-time trauma surgeon after-action review

INTRODUCTION

Although several centers have direct to operating room (DOR) resuscitation programs, there are no published prospective studies on optimal patient selection, interventions, outcomes, or real-time surgeon assessments.

METHODS

Direct to operating room cases for 1 year were prospectively enrolled. Demographics, injury types/severity, triage criteria, interventions, and outcomes including Glasgow Outcome Scale score were collected. Detailed time-to-event and sequence data on initial lifesaving interventions (LSIs) or emergent surgeries were analyzed. A structured real-time attending surgeon assessment tool for each case was collected. Direct to operating room activation criteria were grouped into categories: mechanism, physiology, injury pattern, or emergency medical services (EMS) suspicion.

RESULTS

There were 104 DOR cases: male, 84%; penetrating, 80%; and severely injured (Injury Severity Score, >15), 39%. The majority (65%) required at least one LSI (median of 7 minutes from arrival), and 41% underwent immediate emergent surgery (median, 26 minutes). Blunt patients were more severely injured and more likely to undergo LSI (86% vs. 59%) but less likely to require emergent surgery (19% vs. 47%, all p < 0.05). Analysis of DOR criteria categories showed unique patterns in each group for interventions and outcomes, with EMS suspicion associated with the lowest need for DOR. Surgeon assessment tool results found that DOR was indicated in 84% and improved care in 63%, with a small subset identified (9%) where DOR had a negative impact.

CONCLUSION

Direct to operating room resuscitation facilitated timely emergent interventions in penetrating truncal trauma and a select subset of critically ill blunt patients. Unique intervention/outcome profiles were identified by activation criteria groups, with little utility among activations for EMS suspicion. Real-time surgeon assessment tool identified high- and low-yield DOR groups.

LEVEL OF EVIDENCE

Prospective observational study, level III.

Time to surgery: Is it truly crucial in initially stable patients with penetrating injury?

BACKGROUND

Treatment recommendations for patients with penetrating abdominal injury are well established. Trauma victims with clear indications for surgery, should undergo immediate operative intervention without any delay or additional imaging. However, the optimal time for surgery remains unclear. There are some significant advantages in preoperative abdominal CT, including gathering essential information regarding a few difficult to reach anatomical areas, avoiding unnecessary explorations associated with increased morbidity and assessing the existence of extra-abdominal injuries that may have non-expectable impact on initial therapeutic plan. The aim of this study was to determine the impact of "time-to-surgery" on final medical outcomes in patients with penetrating abdominal trauma with normal blood pressure on admission.

METHODS

A retrospective cohort study using the Israeli National Trauma Registry was conducted from 2000- 2018. This study included trauma patients with penetrating injuries and a systolic blood pressure of 90mmHg or above on admission. All patients included in the study were divided into three groups according to the time that lapsed from their admission to surgery: half an hour, an hour, and two hours. We assessed the outcome for each patient, including length of hospital stay, need for intensive care and mortality. Statistical analysis was performed using the Chi-square test, ANOVA test. A p-value of less than 0.05 was considered statistically significant.

RESULTS

The study included 1,136 penetrating trauma patients. Among these, 78.0% (886) had sustained low-energy penetrating injury (SWPI) and 22.0% (250) had sustained high-energy penetrating injury (FAPI). Males accounted for 93.5% (1,062) of the patients. Mean age was 30.4. About 29% (327) of all the patients underwent surgery within 30 minutes from admission, 42% (475) within 30-60 min, and 29% (334) patients were operated within one to two hours. Patients who underwent surgery within 30 minutes, had worse ISS and GCS scores and were, therefore, more likely to have worse clinical outcomes. No other differences in outcomes were found in patients who were operated upon within 2 hours.

CONCLUSIONS

Time to surgery within two hours from admission has no impact on final outcomes in trauma patients with penetrating injury and normal blood pressure on admission.