The Oregon District Shooting: Reviewing the Pre-Hospital Protocols and the Role of the Resident During a Multiple Casualty Event

Background: Review of multiple casualty events (MCEs) protocols in an academic trauma center and more importantly role of residents in management of MCEs has not been discussed. Also, no real-world examples have been described. This study reviews utilization of multiple casualty protocols by the area hospitals and EMS along with role of residents in one such real-world MCEMethods: A mass shooting event in the Oregon District in Dayton, Ohio from 2019 was reviewed. MCE protocols from a Level I trauma center were reviewed as well as patient outcomes and role of residents.Results: A total of 10 casualties were observed and 38 patients presented to hospitals throughout the city. There were 25 patients presented to the Level I trauma center, 1 to the Level II trauma center, and 12 to the Level III trauma centers in the community. Surgical and Emergency residents performed initial triage upon arrival to the ED, managed resuscitation, and performed various procedures under supervision of attending staff. A total of 5 patients required emergent surgery and 4 patients required tourniquets. All patients that were presented to the hospitals survived.Conclusion: MCEs are going to continue, and healthcare systems should have protocols in place. Residents are a valuable resource to hospital systems that provide trauma services. Creation of a protocol with the assistance of EMS will allow first responders to utilize resources available. We recommend testing of this protocol, as an MCE in your area may not be a matter of if, but when.

An initiative to assess and improve the resources and patient care processes used among Chest Wall Injury Society collaborative centers (CWIS-CC2)

BACKGROUND

Over the last two decades, the acute management of rib fractures has changed significantly. In 2021, the Chest Wall injury Society (CWIS) began recognizing centers who epitomize their mission as CWIS Collaborative Centers (CWIS-CC). The primary aim of this study was to determine the resources, surgical expertise, access to care, and institutional support that are present among centers.

METHODS

A survey was performed including all CWIS-CC evaluating the resources available at their hospital for the treatment of patients with chest wall injury. Data about each Chest Wall Injury Center (CWIC) care process, availability of resources, institutional support, research support, and educational offerings were recorded.

RESULTS

Data was collected from 20 trauma centers resulting in an 80% response rate. These trauma centers were made up of 5 international and 15 US based trauma centers. Eighty percent (16/20) have dedicated care team members for the evaluation and management of rib fractures. Twenty-five percent (5/20) have a dedicated rib fracture service with a separate call schedule. Staffing for chest wall injury clinics consists of a multidisciplinary team: with attending surgeons in all clinics, 80%(8/10) with APPs and 70%(7/10) with care coordinators. Forty percent(8/20) of centers have dedicated rib fracture research support and 35%(7/20) have SSRF-related grants. Forty percent (8/20) of centers have marketing support and 30%(8/20) have a web page support to bring awareness to their center. At these trauma centers, a median of 4(1-9) surgeons perform surgical stabilization of rib fractures (SSRF). In the majority of trauma centers the trauma surgeons perform SSRF.

CONCLUSIONS

Considerable similarities and differences exist within these CWIS collaborative centers. These differences in resources are hypothesis generating in determining the optimal CWIC. These findings may generate several patient care and team process questions to optimize patient care, patient experience, provider satisfaction, research productivity, education, and outreach.

LEVEL OF EVIDENCE

IV Economic & Value-Based Evaluations.

Management of Penetrating Traumatic Brain Injury: Operative versus Non-Operative Intervention

BACKGROUND

Penetrating traumatic brain injury (pTBI) is the most lethal form of TBI, with mortality rates as high as 90%. This high mortality rate leads many providers to feel that the treatment of pTBI is futile. Contrary to this point of view, several studies have shown that victims of pTBI who present with a Glasgow Coma Scale (GCS) ≥6 have a reasonable chance of a meaningful outcome. This study sought to investigate outcomes of pTBI patients based on GCS score who underwent neurosurgical intervention (craniotomy or craniectomy) and compare them with patients who did not undergo surgical intervention.

MATERIALS AND METHODS

The study represents a secondary analysis of the data that were collected from 2006 to 2016 from 17 institutions as part of a multi-center study, investigating clinical outcomes for adult patients sustaining pTBI and surviving >72 h. Patients were divided into those with GCS 3-5 and those with GCS ≥6. Within these groups, patients were stratified by whether they received surgical intervention, compared with standard non-surgical care. Patient level data (age and gender), clinical data (Injury Severity Score and Abbreviated Injury Score), GCS on admission, post-op infection rates, and outcomes data (mortality, length of stay [LOS], intensive care unit LOS) were collected. Both groups were compared using independent sample t-test or chi-squared test.

RESULTS

Seven hundred twenty patients with pTBI were identified over 11 y, out of which 336 (46.7%) underwent surgery. The mean Injury Severity Score and Abbreviated Injury Score on admission were higher in the surgical intervention group than their non-surgical counterpart in patients with a GCS ≥6 (P < 0.0001). Patients with GCS of 3-5 with surgical intervention demonstrated a higher survival rate than non-surgical patients (P < 0.0001). In the GCS ≥6 group, surgical intervention did not impact near-term mortality. Intensive care unit LOS was significantly longer in the surgical intervention group in patients with GCS ≥ 6 (P < 0.0001) and GCS of 3-5 (P < 0.0001), as was total hospital LOS (P < 0.0001). Patients with a GCS 3-5 and ≥6 who underwent surgical intervention were more likely to develop a central nervous system infection (P = 0.016; P = 0.017).

CONCLUSIONS

Surgical intervention in pTBI patients with GCS 3-5 results in improved mortality but comes at a cost of increased resource utilization in the form of longer LOS and higher infection rate. On the other hand, in patients with GCS ≥6, surgery does not provide significant benefits in patient survival. Future prospective studies providing insight as to the impact of surgery on the resource utilization and quality of survival would be beneficial in determining the need for surgical intervention in this population.

Infection after penetrating brain injury-An Eastern Association for the Surgery of Trauma multicenter study oral presentation at the 32nd annual meeting of the Eastern Association for the Surgery of Trauma, January 15-19, 2019, in Austin, Texas

BACKGROUND

Fatality rates following penetrating traumatic brain injury (pTBI) are extremely high and survivors are often left with significant disability. Infection following pTBI is associated with worse morbidity. The modern rates of central nervous system infections (INF) in civilian survivors are unknown. This study sought to determine the rate of and risk factors for INF following pTBI and to determine the impact of antibiotic prophylaxis.

METHODS

Seventeen institutions submitted adult patients with pTBI and survival of more than 72 hours from 2006 to 2016. Patients were stratified by the presence or absence of infection and the use or omission of prophylactic antibiotics. Study was powered at 85% to detect a difference in infection rate of 5%. Primary endpoint was the impact of prophylactic antibiotics on INF. Mantel-Haenszel χ and Wilcoxon's rank-sum tests were used to compare categorical and nonparametric variables. Significance greater than p = 0.2 was included in a logistic regression adjusted for center.

RESULTS

Seven hundred sixty-three patients with pTBI were identified over 11 years. 7% (n = 51) of patients developed an INF. Sixty-six percent of INF patients received prophylactic antibiotics. Sixty-two percent of all patients received one dose or greater of prophylactic antibiotics and 50% of patients received extended antibiotics. Degree of dural penetration did not appear to impact the incidence of INF (p = 0.8) nor did trajectory through the oropharynx (p = 0.18). Controlling for other variables, there was no statistically significant difference in INF with the use of prophylactic antibiotics (p = 0.5). Infection was higher in patients with intracerebral pressure monitors (4% vs. 12%; p = <0.001) and in patients with surgical intervention (10% vs. 3%; p < 0.001).

CONCLUSION

There is no reduction in INF with prophylactic antibiotics in pTBI. Surgical intervention and invasive intracerebral pressure monitoring appear to be risk factors for INF regardless of prophylactic use.

LEVEL OF EVIDENCE

Therapeutic, level IV.