Flying with a Safety Net: Use of REBOA to Enable Safe Transfer to a Level 1 Trauma Center

Background: Using Resuscitative Endovascular Balloon Occlusion of the Aorta (REBOA) during air and ground transport requires coordination among the responding clinical team, transport team, and receiving surgical team. Here, we describe the development of a REBOA transport program in a civilian medical system that demonstrates the value of REBOA as part of the toolkit for safe casualty transport. Methods: The regional REBOA program was developed at St. Anthony Summit Medical Center in a multi-step planning and training process to ensure coordination among the facilities and transport resources during trauma patient care. Retrospective record review was performed on all patients (n=5) that received REBOA for transport from the Level 3 Trauma Center to the Level 1 Trauma Center, since inception of the program in March 2019. Data were gathered from hospital electronic medical records. Results: SASMC has transported five trauma patients under the REBOA program; all successfully arrived at the Level 1 Trauma Center to receive definitive care. The integrated arterial blood pressure monitoring capability in the REBOA catheter provided robust physiologic data to enable data-driven interventions during transport. Conclusion: The REBOA program described here is a model of how REBOA can be used to enable safe transport between levels of care, when, without REBOA, such transport might not be possible. The model is applicable during care of civilian trauma patients and combat casualties, where injured patients are initially treated in a prehospital or Role1/2 environment but require transport to a Level 1 Trauma Center or Role 3+ for definitive care. Keywords: REBOA, non-compressible hemorrhage, patient transport

How Did the COVID-19 Pandemic Affect Trauma Volume at an Urban Level I Trauma Center?

Introduction The COVID-19 pandemic changed the face of health care worldwide. While the impacts from this catastrophe are still being measured, it is important to understand how this pandemic impacted existing health care systems. As such, the objective of this study was to quantify its effects on trauma volume at an urban Level 1 trauma center in one of the earliest and most significantly affected US cities. Methods A retrospective chart review of consecutive trauma patients admitted to a Level 1 trauma center from January 1, 2017 to December 31, 2020 was completed. The total trauma volume in the years prior to the pandemic (2017-2019) was compared to the volume in 2020. These data were then further stratified to compare quarterly volume across all 4 years. Results A total of 4138 trauma patients were treated in the emergency room throughout 2020 with 4124 seen during 2019, 3774 during 2018, and 3505 during 2017 in the pre-COVID-19 time period. No significant difference in the volume of minor trauma or trauma transfers was observed ( P < .05). However, there was a significant increase in the number of major traumas in 2020 as compared to prior years (38.5% vs 35.6%, P < .01) and in the volume of penetrating trauma (29.1% vs 24.0%, P < .01). Discussion During the COVID-19 outbreak, trauma remained a significant health care concern. This study found an increase in volume of penetrating trauma, specifically gunshot wounds throughout 2020. It remains important to continue to devote resources to trauma patients during the ongoing COVID-19 pandemic.

Crotalidae Polyvalent Immune Fab and Cost-Effective Management of Hospital Admissions for Snakebites

Background Venomous snakebites are a common clinical scenario in the Southeastern United States. CroFab® (Crotalidae Polyvalent Immune Fab (Ovine), BTG, Wales, UK) antivenom is indicated in cases involving pit vipers and is known to be expensive. The treatment protocol for snakebites is based on clinically subjective measures triggering the application, or escalation of, antivenom administration. The purpose of this study is to characterize the use of CroFab at our institution and to evaluate the impact of its use regarding cost and overall outcomes. We suspect that it is often used but potentially less often needed. We hypothesized that CroFab use was associated with increased length of stay (LOS) without an observed difference in patient outcomes. Materials and Methods A retrospective chart review of snakebite patients at our level-1 trauma center from 2000 to 2016 was performed. Snakebite location, snake species, number of vials of CroFab administered, hospital LOS, intensive care unit (ICU) LOS, and complications were identified for each patient. Patients were divided into CroFab (C) and no CroFab (NC) groups. Results One hundred ninety patients with venomous snakebites were included. 53.7% of patients received CroFab. There was no difference in the complication rate of C versus NC groups, ( P = .1118). CroFab use was associated with longer hospital LOS ( P < .0001) and ICU LOS ( P < .0001). Discussion CroFab use was associated with increased LOS in our patient population. There was no difference in observed outcomes between the C and NC groups. These findings imply that CroFab is potentially over-used in our patient population.

Bronchoscopy Decreases Ventilator-Associated Pneumonia in Trauma Patients

Health care-associated pneumonias (HAPs) are a significant comorbidity seen in hospitalized patients. Traumatic injury is a known independent risk factor for the development of HAP. Trauma-related injuries also contribute to an increase in the rate of pneumonia in mechanically ventilated patients requiring intensive care unit (ICU) treatment. In 2011, the ventilator-associated pneumonia (VAP) rate among ICU patients at our institution (CMMC) increased dramatically. As a result, our infection control specialists performed a focused review of these patients and found a likely association between these infections and patients requiring pre-hospital intubation. Their determination prompted a July 2012 revision of the CMMC Trauma/Surgery Admission ICU protocol for ventilated patients to include bronchoscopy for all patients who have been intubated pre-hospital providing no contraindications were present. Our aim was to ascertain any influence of the protocol change on the rate of VAP. We conducted a retrospective medical record review of trauma patients who were intubated in the field or ED and seen at our institution (an accredited Level 1 trauma center) from 2012 to 2018. Applying the current definition of VAP from the Centers for Disease Control and Prevention (CDC) to data collected from the CMMC trauma registry, we observed a 13% lower VAP rate in the bronchoscopy group ( YB) as compared to the group that did not receive bronchoscopy (NB) ( P < .025). Based on our results, we determined that bronchoscopy performed in this setting does support a statistically significant decrease in the rate of ventilator-associated pneumonia.

Video-Assisted Thoracoscopic Internal Rib Fixation

Rib fractures result in serious morbidity and mortality after trauma. Although there is ongoing debate about surgical rib fixation, it is increasingly important for some patients. Minimally invasive techniques for rib fixation are gaining traction within the trauma community. We present an observational experience at our level 1 trauma center with our first 10 cases of video-assisted thoracoscopic surgery (VATS) internal rib fixation. Video-assisted thoracoscopic surgery internal plates are especially helpful for rib fractures under the scapula, which are difficult to access traditionally. This technique is also excellent at reducing complex segmental fractures as the bridge can span across multiple fractures with a single post on either side. They also work well for posterior fractures where multiple screws cannot be placed. Video-assisted thoracoscopic surgery internal rib fixation is a viable and exciting option for surgical fixation. The plates work particularly well for certain fracture patterns.

Computed tomography angiography is associated with low added utility for detecting clinically relevant vascular injuries among patients with extremity trauma

BackgroundExtremity CT angiography (CTA) is frequently used to assess for vascular injury among patients with extremity trauma. The injured extremity index (IEI), defined as the ratio of systolic occlusion pressure between injured and uninjured extremities, has been implemented to screen patients being considered for CTA. Physical examination together with IEI is extremely sensitive for significant extremity vascular injury. Unfortunately, IEI cannot always be calculated. This study aimed to determine whether patients with normal pulse examinations and no hard signs of vascular injury benefitted from further imaging with CTA. We hypothesized that CTA has become overused among patients with extremity trauma, as determined by the outcome of vascular abnormalities that underwent vascular intervention but were missed by physical examination.MethodsThe charts of traumatically injured patients who underwent extremity CTA were retrospectively reviewed. This study was performed at a level 1 trauma center for patients who presented as trauma activations from September 1, 2019 to September 1, 2020.ResultsOne hundred and thirty-six patients with 167 injured limbs were included. Eight limbs (4.8%) underwent an open vascular operation, whereas five limbs (3.0%) underwent an endovascular procedure. One of the 167 limbs (0.6%) had a vascular injury seen on CTA and underwent intervention that was not associated with a pulse abnormality or hard signs of vascular injury. This patient presented in a delayed fashion after an initially normal IEI and examination. Proximity injuries and fractures alone were not highly associated with vascular injuries.DiscussionMany patients with normal pulse examination and no hard signs of vascular injury underwent CTA; the vast majority of these patients did not then have a vascular intervention. Given the consequences of missed vascular injuries, further work is required to prospectively assess the utility of CTA among patients with extremity trauma.Level of evidenceIII.