77th Annual Meeting of the

American Association for the

Surgery of Trauma and Clinical
Congress of Acute Care Surgery
• September 26-29• & 4th World Trauma Congress

2018 Manchester Grand Hyatt

• San Diego, CA •
 HISTORICAL BACKGROUND

AAST
The American Association for the Surgery of Trauma started with
conversations at the meetings of the Western Surgical Association
and Southern Surgical Association in December, 1937. The 14
founders, who were present at one or both of these meetings, sub-
sequently invited another 68 surgeons to a Founding Members
meeting in San Francisco on June 14, 1938. The first meeting of
the AAST was held in Hot Springs, Virginia, in May, 1939, and
Dr. Kellogg Speed’s first Presidential Address was published in
The American Journal of Surgery 47:261-264, 1940. Today, the
Association holds an annual scientific meeting, owns and publish-
es The Journal of Trauma and Acute Care Surgery, which was
initiated in 1961, and has approximately 1,300 members from 30
countries.

WCTC
The World Coalition for Trauma Care was created during the 1st
World Trauma Congress in Rio de Janeiro, Brazil in August
2012. The WCTC is a coalition of professional trauma
organizations from across the world. The goals of the WCTC are
to increase awareness of the importance of trauma as a disease
worldwide, spread trauma education at all levels worldwide,
develop trauma systems worldwide, and the continuation of the
World Trauma Congress. These organizations (and their
members) have the opportunity to exert international influence,
help less developed nations to improve care by means of better
education and knowledge, critical thinking towards systems
development, data collection (trauma registries and injury
surveillance), and implementation of quality improvement
processes.
 American Association for the Surgery of Trauma
(AAST)

Annual Meeting of AAST and Clinical Congress of Acute Care Surgery

Learning Objectives and Outcomes
This activity is designed for surgeons. Upon completion of this course, participants will be able
to:
• Exchange knowledge pertaining to current research practices and training in the surgery
of trauma.
• Design research studies to investigate new methods of preventing, correcting, and
treating acute care surgery (trauma, surgical critical care, and emergency surgery)
injuries.

CONTINUING MEDICAL EDUCATION CREDIT INFORMATION

Accreditation
This activity has been planned and implemented in accordance with the Essential Areas and
Policies of the Accreditation Council for Continuing Medical Education (ACCME) through the
joint providership of the American College of Surgeons and American Association for the
Surgery of Trauma. The American College of Surgeons is accredited by the ACCME to provide
continuing medical education for physicians.

AMA PRA Category 1 Credits™ - Annual Meeting

The American College of Surgeons designates this live activity for a maximum of 40.00 AMA
PRA Category 1 Credits™. Physicians should claim only the credit commensurate with the extent
of their participation in the activity.
Of the AMA PRA Category 1 Credits™ listed above, a maximum of 12.50 credits meet the
requirements for Self-Assessment.

Of the AMA PRA Category 1 Credits™ listed above, a maximum of 37.75 credits may qualify as
Trauma.*

Of the AMA PRA Category 1 Credits™ listed above, a maximum of 5.25 credits may qualify as
Surgical Critical Care.*

Of the AMA PRA Category 1 Credits™ listed above, a maximum of 2.00 credits may qualify as
Pediatric Trauma.*

* The content of this activity may meet certain mandates of regulatory bodies. ACS has not and does not verify the content for such
mandates with any regulatory body. Individual physicians are responsible for verifying the content satisfies such requirements.
 Society of Trauma Nurses

This year, the Society of Trauma Nurses is offering CNE for its nursing track at the annual
meeting. To claim CNE, participants will complete session evaluations electronically using the
instructions provided during the sessions. On-site faculty of the courses will provide handouts
with the link to claim CNE.

The Society of Trauma Nurses is accredited as a provider of continuing nursing education by the
American Nurses Credentialing Center's Commission on Accreditation. This activity has been
awarded a maximum of 11 contact hours.

Educational Grants
The American Association for the Surgery of Trauma wishes to recognize and thank the following
companies for their ongoing support through educational grants:
• Karl Storz
• Cook Medical, LLC
 AMERICAN COLLEGE OF SURGEONS | DIVISION OF EDUCATION
Blended Surgical Education and Training for Life
JOINT SPONSORSHIP PROGRAM

Disclosure Information
77th Annual Meeting of the AAST and Clinical Congress of Acute Care Surgery
September 26-29, 2018
San Diego, CA
In accordance with the ACCME Accreditation Criteria, the American College of Surgeons, as the accredited provider of this activity, must
ensure that anyone in a position to control the content of the educational activity has disclosed all relevant financial relationships with any
commercial interest. Therefore, it is mandatory that both the program planning committee and speakers complete disclosure forms.
Members of the program committee were required to disclose all financial relationships and speakers were required to disclose any
financial relationship as it pertains to the content of the presentations. The ACCME defines a ‘commercial interest’ as “any entity
producing, marketing, re-selling, or distributing health care goods or services consumed by, or used on, patients”. It does not consider
providers of clinical service directly to patients to be commercial interests. The ACCME considers “relevant” financial relationships as
financial transactions (in any amount) that may create a conflict of interest and occur within the 12 months preceding the time that the
individual is being asked to assume a role controlling content of the educational activity.

ACS is also required, through our joint sponsorship partners, to manage any reported conflict and eliminate the potential for bias during
the activity. All program committee members and speakers were contacted and the conflicts listed below have been managed to our
satisfaction. However, if you perceive a bias during a session, please report the circumstances on the session evaluation form.

Please note we have advised the speakers that it is their responsibility to disclose at the start of their presentation if they will be
describing the use of a device, product, or drug that is not FDA approved or the off-label use of an approved device, product, or
drug or unapproved usage.

The requirement for disclosure is not intended to imply any impropriety of such relationships, but simply to identify such relationships
through full disclosure and to allow the audience to form its own judgments regarding the presentation.

Disclosure
Presenter Nothing to Disclose
Company Role Received

Michael Aboutanos No
Sasha Adams No
Tessa Adzemovic No
John Agapian No
Suresh Agarwal No
Rebecka Ahl No
Nasim Ahmed No
Taku Akashi No
Abdul Alarhayem No

Roxie Albrecht No
Daniel Alfson No
Fahd Ali No
Muhammad Ali
Chaudhary No
Georgina Alizo No
Jamie Anderson No
Sam Arbabi No
Dennis Ashley No
Emily Ashworth No
Steven Baddour No
Jeff Bailey No
Eirc Ballon-Landa No
Zsolt Balogh No
Brittany Bankhead-
Kendall No
James Bardes No
Galinos Barmparas No
Stephen Barnes No
Erik Barquist No
Ronit Bassa No
Robert Becher No
Ramy Behman No
Presented
findings of
study at
Brandon Behrens Yes Grifols symposium Presenter
Omar Bekdache No
Theresa Bell No
Elizabeth Benjamin No
Matthew Benns No
Andrew Bernard No
Allison Berndtson No
Maunil Bhatt No
Walter Biffl No
David Blake No
Matthew Bloom No
Grant Bochicchio No

Ken Boffard No
Alicia Bonanno No
Stephanie Bonne No
Raquel Bono No
Bertil Bouillon No
Jason Bowie No
Mark Bowyer No
Kelly Boyle No
Scott Brakenridge No
Karen Brasel No
Clinical
Advisory
Prytime Board
Megan Brenner Yes Medical, Inc. Stock Options Member
Alexandra Briggs No
William Bromberg No
Adam Brooks No
Carlos Brown No
Zachary Brown No
Joshua Brown No
AIG Insurance Honorarium –
Limited November
Susan Brundage Yes Europe/UK 2017 Consultant
Brandon Bruns No
Eileen Bulger No

Jessica Burgess No
Karen Burtt No
Karyn Butler No
William Butler No
Rachael Callcut No
Andre Campbell No
Brendan Campbell No
Tercio Campos No

Jeremy Cannon No
Bryan Carr No
Shannon Carroll No
Damien Carter No
Thomas Carver No
David Carver No
Theresa Chan No
Felix Chang No
Stephanie Chao No
Jose Charry No
Li-Chien Chien No
William Chiu No
S. Ariane Christie No
Christine Chung No
Mark Cipolle No
Ian Civil No

Keith Clancy No
DSMB
Expenses and Committee
Octapharma, payment for Member,
Christine Cocanour Yes ATO Bio time Site PI
Federico Coccolini No
Panna Codner No
Mitchell Cohen No
Nina Cohen No
Raul Coimbra No
Jamie Coleman No
Julia Coleman No
John Como No
Jorge Con No
Heitor Consani No
R. Consunji No
John Cook-Jong Lee No
Zara Cooper No
John Cordero No
Todd Costantini No
Clay Cothren
Burlew No
Scientific
Advisory
Haemonetics Council
CORP Consultant Board
Bryan Cotton Yes (Braintree, MA) Fees Member
Jessica Cox No
Marie Crandall No
Chris Cremona No
Michael Cripps No

Matrin Croce No
Bruce Crookes No
Jose Cruvinel No
Bruno Jose Da
Costa Medeiros No
Jose Mauro da Silva
Rodrigues No
Scott D'Amours No

Imad Dandan No
Omar Danner No
Elizabeth Dauer No

Kimberly Davis No
James Davis No
Leonie De Munter No

Ana Del Valle No

Marc deMoya No
Christopher Dente No
Michael DeWane No
Salmone Di Saverio No
Jose Diaz No
Rochelle Dicker No
Lawrence Diebel No
Jody DiGiacomo No
Charles DiMaggio No
Woo Do No
Alcir Dorigatti No
Jay Doucet No
Jeremy Dressler No
Michael Dubick No
Joseph DuBose No

Juan Duchesne No
Lauren Dudas No
Thomas Duncan No
Cecily DuPree No
Oscar Dussan No
Alexander Eastman No
Brian Eastridge No
Catherine Eaton
Sharoky No
David Efron No
Teunis van Egmond No
Adel Elkbuli No
Eric Elster No
Akira Endo No
Thomas Esposito No
Alicia Eubanks No
Susan Evans No
Tala F Kana'an No

Timothy Fabian No
Samir Fakhry No
Richard Falcone No
Michael Farrell No
Vitor Favali Kruger No
David Feliciano No
Maria Fernanda
Oliva Detanico No
Forrest Fernandez No
Paula Ferrada No
John Fildes No
Caitlin Fitzgerald No
Erika Flashburg No

Matthew Fleming No
Neal Foley No
Joseph Forrester No
Nicole Fox No
Gustava Fraga No
Jessica Friedman No
Chih-Yuan Fu No
Xizo-bing Fu No
Takashi Fujita No
Tomohiro Funabiki No
Elisa Furay No

Christina Gaarder No
Joseph Galante No
Stephen Gale No
Alberto Garcia No
Diogo Garcia No
Ben Gardiner No
Tabitha Garwe No
Mitchell George No
Mark Gestring No
Laura Godat No
Amy Goldberg No
Johanna Gomez-
Builes No
Adolfo Gonzalez No
Roberto Gonzalez No
Dan Grabo No
Areg Grigorian No
Ronald Gross No
Jessica Gross No
Jacopo Guerrini No
Oscar
Guillamondegui No
Oliver Gunter No
Amit Gupta No
Rajan Gupta No
Jennifer Gurney No
Jennifer Gurney No
Barbara Haas No
Adil Haider No
Ansab Haider No
Krista Haines No
Sascha
Halvahizadeh No
Mohammad
Hamidi No

Ahram Han No
Laura Harmon No
John Harvin No
Zain Hashmi No
Carlos Hauser No
Elliott Haut No
Felco Heitbrink No
Sharon Henry No
Matthew
Hernandez No
Juan Herrera-
Escobar No
Lillian Hesselink No
Falco Hietbrink No
William Hoff No
CMO,
Decisio Health, founder and
Prytime Shares, salary BoD,
Medical, and options, consultant,
Terumo BCT, UT reinbursement, co-inventor
John Holcomb Yes System royalty of JETT
Daniel Holena No
Kenichiro Hondo No
Heather Hoops Yes Resusitech, Inc. Inventor On None
 Patents For
Selective Aortic
Arch Perfusion.
Co-Founder Of
Resusitech,
Inc., A Medical
Device
Company
Developing
Resuscitation
Devices,
Including
Selective Aortic
Arch Perfusion
J. Jason Hoth No
Erin Howell No
David Hoyt No
Li Hsee No
Chi-Hsun Hsieh No
Ruo-Yi Huang No
Jennifer Hubbard No
Eric Hungness Yes Baxter Honorarium Conjultin 6
Franchesca Hwang No
Prytime Speaking Speaking
Joseph Ibrahim Yes Medical Consultant Consultant
Chan Ik Park No
Kenji Inaba No
Angela Ingraham No
Kaori Ito No
Christina Jacovides No
Vinod Jain No
Molly Jarman No
David Jeffcoach No
Faisal Jehan No
Jan Jensen No
Kai Jensen No
Aaron Jensen No
Elan Jeremitsky No
Maria Jimenez No
Younggoun Jo No
Jay Johannigman No
D’Andrea Joseph No
Kimberly Joseph No
Bellal Joseph No
Christopher Josten No

Anamaria Joyce
Robles No
Catherine Julliard No
Kyoungwong Jung No
Gregory Jurkovich No
Fabiana Kain De
Moura No
Kyle Kalkwarf No
Wuseong Kang No
Section
Lillian Kao Yes UpToDate Royalties Editor
Yusuke Katayama No
Morihiro Katsura No
Taku Kazamaki No
Marius Keel No
Sorena Keihani No

Bijan Keirabadi No
Katherine Kelley No
Abid Khan No
Takeyuki Kiguchi No
Fernando Kim No
Dennis Kim No
Jungchui Kim No
Jennie Kim No
Maru Kim No
Kihoon Kim No
Patrick Kim No
Jae Hun Kim No
Akio Kimura No
Takahiro Kinoshita No
Heidi Kippers
Mullen No
I Have
Consulted
For The
Acelity,
Innovative
Acelity, Trauma
Innovative Care, And
Trauma Care, Cook
And Cook Medical
Andrew Kirkpatrick Yes Medical Corps Consultant Corporations
Orlando Kirton No
Ariel Knight No
Lisa Knowlton No
Margaret Knudson No
Mitsuaki Kojima No
Radko Komadina No
Victor Kong No
Manasnun
Kongwibulwut No
Rosemary Kozar No
Laura Kreiner No
Deborah Kuhls No
Vignesh Kumar No
Eric Kuncir No
Ling-Wei Kuo No
Hayato Kurihara No
Scientific
Advisory
Shigeki Kushimoto Yes CSL Behring Honorarium Committee
Dorian Lamis No
Mary Lancake No
Margaret
Lauerman No
Adam Laytin No
Hak-Jae Lee No
Luke Leenen No
Ari Leppaniemi No
Robert Letton No
Richard Lewis No
Zhanfei Li No
Lei Li No
Chien-Huang Liao No
Sean Liebscher No
Robert Lim Yes UpToDate, Inc. Honorarium Consultant
Tzu-hsin Lin No
Brittany LisJak No
David Livingston No
Tyler Loftus No
Haemonetics,
synthesis, KLS
Larry Lottenberg Yes Martin N/A Speaker
Stephanie Lueckel No
Jeffrey Luke Ban
Eps No
Douglas Lundy Yes Depuy Synthes Payment Speaker
Neal Lynch No
Kasey Lynne
Hamrick No
David Machado-
Aranda No
Robert Mackersie No
Jana MacLeod No
Richard Maduka No

Ronald Maier No
Rebecca Maine No
Ajai Malhotra No
Sean Maloney No
Ramiro Manzano
Nunez No
Daniel Margulies No
Matthew M Martin No
Niels Martin No
Grace Martin No
Ingo Marzi No
Peter Masiakos No
Shokei Matsumoto No
Yosuke Matsumura No
Kazuhide
Matsushima No

Hiroshi Matsuura No
Adrian Maung No
Todd Maxson No
Local PI for
industry
sponsored
clinical trial,
Consultant,
Research adjudication
funding to my panel for
institution, trial,
consulting principle
Atox Bio, LTD., fees, research investigator,
Atod Bio. LTD, funding to my sponsored
Addison May Yes Fresenius Kabi institution research
Michael Mazzei No
Maryann Mbaka No
Allison McNickle No
Christopher
McNicoll No
Michelle McNutt No
Ashley Meagher No
Amber Mehmood No
Ambar Mehta No
Carlos Menegozzo No
Carlos Mesquita No
Christopher
Michetti No
Preston Miller No
Keith Miller No
Joseph Minei No
Biplab Mishra No
Samir Misra No
Alicia Mohr No
Consulting
Fees, Research
Stryker Trauma, Support,
DJO, Bone Research Consultant,
Charles Moon Yes Support Support PI, PI
Jae Moo Lee No
 1. Haemonetics 1. Research
2. Support
Instrumentation 2. Research 1. PI
Laboratories Support 2. PI
3. Prytime 3. Research 3. Co-PI
4. Thrombo Support 4. Co-
Ernest Moore Yes Therapeutics 4. Stock Founder
Lynne Moore No
Kerry Moore No
Shusuke Mori No
Koji Morishita No
David Morris No
Anne Mosenthal No
Rachel Moses No
Nathan Mowery No
Seongpyo Mun No
Yahinori Murao No
Patrick Murphy No
Sara Myers No
Paal Naess No
Tsuyoshi Nagao No
Celina Nahanni No

Nicholas Namias No
Lena Napolitano No
Mayur Narayan No
Employee of
American
College of Medical
Avery Nathens Yes Surgeons Salary Director
Deppika Nehra No
Mariana Neves
Fernandes No
Paige Newell No
Susannah
Nicholson No
Raminder Nirula No
Takeshi Nishimura No
Charles Noon No
David Nortica No
Geoffrey Nunns No
Takayuki Ogura No
Bryant Oliphant No

Erik Olson No
Alexander Olson No
Alessandro Orlando No
Per Ortenwall No
Yasuhiro Otomo No
Yuta Oyama No
Orkun Ozkurtul No
Maranda
Pahlkotter No
Yu Pan No
Pauline Park No
Michael Parr No
Jose Parreira No
Neil Parry No
Jose Pascual No
Pascual Pascual No
Mayur Patel No
Shibani Pati No
Andrew Peitzman No

Xu-Xiang Peng No
Rueben Peralta No
Bruno Pereira No
Gennaro Perrone No
Jennifer Philip No
Peter Philip Olivieri No
Vanessa Phillis Ho No
DePuy Synthes Research Research
Funding Funding,
Paid
Fredric Pieracci Yes Consultant
Joost Plate No
Travis Polk No
Morgan Pomeranz No
Carina Pothmann No
Dustin Price No
TA Pritts No
Paul Puchwein No

Ashok Puranik No
Leonard Rael No
Stephen Ranney No
Joseph Rappold No
Rishi Rattan No
Deviney Rattigan No
Lawrence Reed No
Patrick Reilly No
Peter Rhee No
Acelity KCI Honorarium Speaker
Marcelo Ribeiro Yes
Daniel Ricaurte No
Christopher Rice No
Robert Riggs No
Lisbi Rivas No
Rachel Rivero No
Sandro Rizoli No
Bryce Robinson No
Bobby Robinson No
Jacob Roden-
Foreman No
Carlos Rodriguez No
Frederick Rogers No
Linda Roney No
Graeme Rosenberg No
Michael Rotondo No
Susan Rowell No
Noah Rozich No
Grace Rozycki No
Jerry Rubano No
Sten Saar No
Javid Sadjadi No
Joseph Sakran No
Ali Salim No
Burapat Sangthong No

Riley Santiago No
Cook Medical Consulting Consultant,
fees, research investigator-
support initiated
(donated research
Fernando Santos Yes supplies) grant
Heena Santry No
Babak Sarani No
Angela Sauaia No
Stephanie Savage No
Merck N/A N/A
Robert Sawyer Yes
Thomas Scalea No
Morgan
Schellenberg No
Henry Schiller No
Nathan Schmoekel No
Haemonetics Payments to Consultant
Martin Schreiber Yes University
Thomas Schroeppel No
Susan Schultz No
Kevin Schuster No
Linda Schutzman No
William Schwab No
Alexander Schwartz No

John Scott No
Lara Senekjian No
Steven Shackford No
Shahid Shafi No
John Sharpe No
Atsushi Shiraishi No
Francisco
EduardoSilva No
Carrie Sims No
Michael Sise No
Robert Sise No
David Skarupa No

Jason Smith No
Steven Smith No
Alison Smith No
Kira Smith No
Lindsay Smith No
Jeffrey Smith No
Alexander Smolyar No
Hahn Soe-Lin No
Andrew Sorah No
David Spain No
Jason Sperry No
Roy Spijkerman No
Nicole Stassen No
Kristan
Staudenmayer No
Deborah Stein No
Ronald Stewart No
Doug Stoddard No
Lance Stuke No
Joshua
Sumislawski No
Takaaki Suzuki No
Vivacitas
Oncology, CEO/CMO,
Mamta Swaroop Yes Infusion SIA Shares CMO
Todd Swenning No
Yuji Takahashi No
Peep Talving No
Luis Taveras No
Bryce Taylor No
Cook Medical, Educational
Boston Honorarium, speaker,
Ezra Teitelbaum Yes Scientific, Consulting Fee Consultant
Dana Telem No
Robert Tessler No
John Tierney No
Christopher
Tiganelli No
Samuel Tisherman No
Sandeep Tiwari No

Gail Tominaga No
Eric Toschlog No
Joshua Tseng No
Taichiro
Tsunoyama No
Lily Tung No
Hiroshi Uasumatsu No
Kenichiro Uchida No
Hayaki Uchino No
Pasca lUdekwu No
Rindi Uhlich No
Tadashi Umehara No
Selman Uranus No
Nao Urushibata No
Ryosuke Usui No
Michael Vella No
Catherine
Velopulos No
Gary Vercruysse No
Wouter Vints No

Eva Visser No
Rebecca Vogel No
Phoenix Vuong No
Ming-Li Wang No
Kai Wang No
Shang-Yu Wang No
Elizabeth Warnack No
Ross Weale No
Tay Wee Ming No
Shuyan Wei No
Jordan Weinberg No
Lyndsey Wessels No
Karlijn Wessem No
Sonlee West No
Michaela West No
Niluka
Wickramaratne No
Brittney Williams No
Elliott Williams No
Aaron Williams No
Robert Willis No
Consulting fee,
Robert Winchell Yes Stryker expenses Consultant
James Winearls No
Robert Winfield No
Philip Woilinsky No
Daniel Wu No
Sun Xingwei No
Paige Xu No
Masayuki Yagi No
Jay Yelon No
Ibrahim Yilmaz No
Carlos Yonez No
Jungchul Yun Park No
Mauro Zago No

Tanya Zakrison No
Ben Zarzaur No
Muhammad
Zeeshan No
Savo Bou Zein
Eddine No
Lianyang Zhang No
Guixi Zhang No
Caroline Zhu No
Nukhba Zia No
Martin Zielinski No
Cheryl Zogg No
David Zonies No

Nothing To Disclosure
Presenter
Disclose Company Role Received
Planning Committee
Christopher Michetti No
Patrick Reilly No
Lena Napolitano No
Robert Winchell No
Haemonetics, Research
Instrumentatio Support,
n Laboratories, Research
Prytime, Support,
Thrombo Research PI, PI, Co-PI,
Ernest Moore Yes Therapeutics Support, Stock Co-Founder
Clay Cothren Burlew No
Martin Croce No
Michael Rotondo No
Eileen Bulger No
Jason Smith No
Ben Zarzaur No
Karen Brasel No
Rosemary Kozar No
Timothy Fabian No
David Spain No
Raul Coimbra No
 AAST
SCHEDULE
 77th Annual Meeting of the
American Association for General &
the Surgery of Trauma and
Clinical Congress of Acute Scientific
Care Surgery
Program
4th World Trauma Schedule
Congress

September 26-29, 2018 • San Diego, CA

*Meeting room locations are subject to change. Please check the Annual Meeting App for the most up to
date room assignments.

Tuesday 7:00 am-12:00 pm AAST Board of Managers Meeting

Location: Coronado DR, Fourth Level (Harbor Tower)
9/25 11:00 am-7:00 pm Satellite Registration
Location: Manchester Grand Hyatt Lobby (Near Market One)
1:00-5:30 pm PreSession: AAST ACS-MOC Session
Location: Coronado AB, Fourth Level (Harbor Tower)
1:00-5:00 pm PreSession: Military/International Session
Location: Coronado C, Fourth Level (Harbor Tower)
1:00-5:00 pm PreSession: Pediatric/Prevention Session
Location: Torrey Hill, Third Level (Seaport Tower)
1:00-5:00 pm PreSession: Acute Care Surgery Clinical Outcomes Research
Location: Golden Hill, Third Level (Seaport Tower)
2:00-5:00 pm PreSession: SAGES/ACS Session
Location: Hillcrest, Third Level (Seaport Tower)
5:00-6:30 pm PreSession: Networking Reception
(must be registered for a PreSession to attend)
Location: Seaport Foyer, Second Level
 Wednesday 6:30 am-5:30 pm Registration
Location: Seaport Foyer - Second Level
9/26 6:15-7:15 am International Breakfast (registration required)
Speaker: Ingo Marzi, MD, Local and Systemic Inflammation After
Severe Trauma-Current Understanding and Clinical Implications
Panelists: International Panel of Experts
Location: Coronado DE, Fourth Level (Harbor Tower)
6:15-7:15 am Committee Meetings - Session I
Critical Care Committee Vista A, 32nd Level (Seaport Tower)
Geriatric/ACS Trauma Committee Cityview B, 32nd Level (Seaport Tower)
Journals Oversight Committee Vista B, 32nd Level (Seaport Tower)
Patient Assessment Committee Skyline, 32nd Level (Seaport Tower)
Research and Education Fund Committee Cityview A, 32nd Level (Seaport Tower)

7:00-8:30 am Continental Breakfast

Location: Seaport Foyer, Second Level
7:30-8:00 am Opening Session
Location: Seaport D-H, Second Level (Seaport Tower)
Session I:
Plenary Papers
Papers 1-8
Paper 1 8:00-8:20 am
ACS-COT VERIFICATION LEVEL AFFECTS TRAUMA CENTER MANAGEMENT OF PELVIC RING
Moderator: INJURIES AND PATIENT MORTALITY
Michael Rotondo, MD Presenter: Bryant Oliphant, MD, MBA Discussant: Todd Costantini, MD

Paper 2 8:20-8:40 am
Recorder: KETAMINE INFUSION FOR PAIN CONTROL IN ADULT PATIENTS WITH MULTIPLE RIB
Patrick Reilly, MD FRACTURES: RESULTS OF A RANDOMIZED CONTROLLED TRIAL
Presenter: Thomas Carver, MD Discussant: David Spain, MD

Location: Paper 3 8:40-9:00 am

Seaport D-H, Second CLEARING THE CERVICAL SPINE FOR PATIENTS WITH DISTRACTING INJURIES: AN AAST
Level (Seaport Tower) MULTI-INSTITUTIONAL TRIAL
Presenter: Abid Khan, MD Discussant: Kenji Inaba, MD

Paper 4 9:00-9:20 am
THE EFFECTIVENESS OF THE 1994-2004 FEDERAL ASSAULT WEAPONS BAN IN
CONTROLLING MASS SHOOTING DEATHS: ANALYSIS OF OPEN-SOURCE DATA
Presenter: Charles DiMaggio, MPH, PhD Discussant: Ernest Moore, MD

Paper 5 9:20-9:40 am
NATIONWIDE ANALYSIS OF RESUSCITATIVE ENDOVASCULAR BALLOON OCCLUSION OF THE
AORTA (REBOA) IN CIVILIAN TRAUMA.
Presenter: Bellal Joseph, MD Discussant: Megan Brenner, MD, MSc

Paper 6 9:40-10:00 am
MORTALITY OUTLIER HOSPITALS AND IMPROVING THE QUALITY OF CARE IN EMERGENCY
GENERAL SURGERY
Presenter: Robert Becher, MD Discussant: Shahid Shafi, MD, MPH, MBA
 Paper 7 10:00-10:20 am
VARIATION IN MISSED READMISSIONS AFTER APPENDICITIS: NATIONAL ANALYSIS
INCLUDING READMISSION TO A DIFFERENT HOSPITAL
Presenter: Rishi Rattan, MD Discussant: Christopher Dente, MD

Paper 8 10:20-10:40 am
MANAGEMENT OF ADHESIVE SMALL BOWEL OBSTRUCTION: A DISTINCT PARADIGM SHIFT
IN THE UNITED STATES
Presenter: Kazuhide Matsushima, MD Discussant: Martin Zielinski, MD

10:40-11:40 am Hemorrhage Control for Complex Pelvic Fractures

Session II: Location: Seaport D-H, Second Level (Seaport Tower)
Ingo Marzi, MD & Clay Cothren Burlew, MD
WTC Panel I Moderator:
Panelists: Ingo Marzi, MD, Role of Fixation; Clay Cothren Burlew, MD, Role of Pelvic
Packing; Ryosuke Usui, MD, Role of Endovascular Techniques

11:40-11:50 am Break
11:50 am-12:50 pm Execute on the Vision: Pyramids and Mirages in Shifting Sands
Session III: Location: Seaport D-H, Second Level (Seaport Tower)
AAST’s Presidential Michael F. Rotondo, MD
University of Rochester Medical Center
Address

1:00-2:15 pm
Session IV: LS I How to Plan a Successful Peer-Reviewed Manuscript: Avoiding Errors Before
AAST Lunch Submission
Sessions Location: Harbor A, Second Level (Harbor Tower)

LS II SBO: OR Before Sunset or Let the Sun Set?

Location: Harbor C, Second Level (Harbor Tower)

LS III Simulation Training for Civilian and Military Trauma: Advances and
Challenges
Location: Coronado DE, Fourth Level (Harbor Tower)

LS IV Controversy or Common-Sense? Regionalization of Emergency General

Surgery
Location: Harbor B, Second Level (Harbor Tower)

LS V Grassroots Legislative Advocacy: A Story is Worth 181 Votes or “The World is

Run by Those Who Show Up”
Location: Coronado B, Fourth Level (Harbor Tower)

LS VI Post Intensive Care Syndrome (PICS), The Underappreciated ICU Morbidity

Location: Coronado A, Fourth Level (Harbor Tower)

2:00-2:15 pm Break
Location: Seaport Foyer
 Session V:
Trauma
Systems
Papers 9-16
Paper 9 2:15-2:35 pm
SHOULD THEY STAY OR SHOULD THEY GO? WHO BENEFITS FROM INTERFACILITY TRANSFER
Moderator: TO A HIGHER LEVEL TRAUMA CENTER FOLLOWING INITIAL PRESENTATION FROM A LOWER
Martin Croce, MD LEVEL TRAUMA CENTER
Presenter: Christopher Tignanelli, MD Discussant: Jason Sperry, MD, MPH

Recorder: Paper 10 2:35-2:55 pm

Robert Winchell, MD DEVELOPMENT OF A GIS-BASED APPROACH FOR THE QUANTITATIVE ANALYSIS OF TRAUMA
CENTER ACCESS
Presenter: Robert Winchell, MD Discussant: Frederick Rogers, MD
Location:
Seaport D-H, Second Paper 11 2:55-3:15 pm
Level (Seaport Tower) AVOIDING CRIBARI GRIDLOCK 2: THE STANDARDIZED TRIAGE ASSESSMENT TOOL (STAT)
OUTPERFORMS THE CRIBARI MATRIX METHOD (CMM) - A REPLICATION STUDY IN 35 ADULT
AND PEDIATRIC TRAUMA CENTERS.
Presenter: Jacob Roden-Foreman, BA Discussant: James Davis, MD

Paper 12 3:15-3:35 pm
EFFECT OF DAMAGE CONTROL LAPAROTOMY ON MAJOR ABDOMINAL COMPLICATIONS
AND LENGTHS OF STAY: A PROPENSITY SCORE MATCHING AND BAYESIAN
ANALYSIS
Presenter: John Harvin, MD Discussant: Peter Rhee, MD, MPH

Paper 13 3:35-3:55 pm
TRAUMA SYSTEM RESOURCE PRESERVATION: A SIMPLE SCENE TRIAGE TOOL CAN REDUCE
HELICOPTER EMERGENCY MEDICAL SERVICES (HEMS) OVER-UTILIZATION IN A STATE
TRAUMA SYSTEM
Presenter: Pascal Udekwu, MD, MBA Discussant: Mark Gestring, MD

Paper 14 3:55-4:15 pm
LONG-TERM OUTCOMES AFTER SINGLE-LOOK TRAUMA LAPAROTOMY: A LARGE
POPULATION-BASED STUDY
Presenter: Jason Bowie, MD Discussant: Adil Haider, MD, MPH

Paper 15 4:15-4:35 pm
PRE-HOSPITAL TOURNIQUET USE IN PENETRATING EXTREMITY TRAUMA: DECREASED
BLOOD TRANSFUSIONS AND LIMB COMPLICATIONS
Presenter: Alison Smith, MD, PhD Discussant: Joseph DuBose, MD

Paper 16 4:35-4:55 pm
WHAT IS THE BEST SURGICAL MANAGEMENT FOR DUODENAL TRAUMA? A PANAMERICAN
TRAUMA SOCIETY (PTS) MULTI-CENTERTRIAL
Presenter: Paula Ferrada, MD Discussant: Gregory Jurkovich, MD
 5:00-6:00 pm Traumatic Coagulopathy: Is It All the Same?
Session VI: Location: Seaport D-H, Second Level (Seaport Tower)
Yasuhiro Otomo, MD, PhD and Mitchell Cohen, MD
WTC Panel II Moderator:
Panelists: Radko Komadina, MD, European Bleeding Guidelines
DIC or Trauma-Induced Coagulopathy:
Western Perspectives: Bryan Cotton, MD Eastern Perspective: Yasuhiro Otomo, MD,
PhD
Exhibit Hall Open
Location: Harbor D-I, Second Level (Harbor Tower)
6:00-7:30 pm
Session VII:
AAST/WTC
Posters
Location: Session I
Trauma Systems
Harbor D-I, Second Poster Professors: Brian Eastridge, MD and Joseph Rappold, MD
Level (Harbor Tower) Session II
Neurotrauma
Poster Professors: Jose Pascual Lopez, MD and William Chiu, MD
Session III
REBOA
Poster Professors: Erik Barquist, MD and Joseph DuBose, MD
Session IV
Pediatric Trauma
Poster Professors: Richard Falcone, Jr., MD and David Nortrica, MD
Session V
Imaging
Poster Professors: Stephen Barnes, MD and Jay Doucet, MD, MSc
Session VI
Critical Care
Poster Professors: Pauline Park, MD and Christopher Michetti, MD
Session VII
Military
Poster Professors: Joseph Galante, MD and Jennifer Gurney, MD
Session VIII
Coagulation
Poster Professors: Grant Bochicchio, MD, MPH and Jay Johannigman, MD
Session IX
Geriatric
Poster Professors: Anne Mosenthal, MD and Jay Yelon, DO
Session X
Firearm/Prevention
Poster Professors: Kimberly Joseph, MD and Keith Clancy, MD, MBA
Session XI
EGS
Poster Professors: Marie Crandall, MD, MPH and Ajai Malhotra, MD
Session XII
Abdominal Injury
Poster Professors: Juan Duchesne, MD and Robert Mackersie, MD
Session XIII
Outcomes
Poster Professors: Daniel Holena, MD and Michel Aboutanos, MD
Session XIV
Torso Trauma
Poster Professors: David Livingston, MD and David Blake, MD, MPH
WTC Session I
International Trauma Care
Poster Professors: Peep Talving, MD and Walter Biffl, MD
WTC Session II
Challenging Cases from Around the World
Poster Professors: Marcelo Ribeiro, MD and Mayur Narayan, MD, MPH, MBA

7:00-8:15 pm JTACS Editorial Board Meeting

Location: Harbor A, Second Level (Harbor Tower)
8:15-10:00 pm JTACS Reception
(Invitation Only)
Location: Harbor Foyer and Terrace, Second Level (Harbor Tower)
 Thursday 6:15-7:15 am Medical Student/Resident/In-Training Fellow Breakfast
(registration required)

9/27 Speaker: Martin Croce, MD

Location: Coronado DE, Fourth Level (Harbor Tower)
6:15-7:15 am Committee Meetings II
Acute Care Surgery Committee Cortez Hill, Third Level (Seaport Tower)
Communications Committee Vista C, 32nd Level (Seaport Tower)
Disaster Committee Cityview A, 32nd Level (Seaport Tower)
Healthcare Economics Committee Cityview B, 32nd Level (Seaport Tower)
International Relations Committee Vista A, 32nd Level (Seaport Tower)
Pallative Care Ad Hoc Committee Skyline (32nd Floor, Seaport Tower)
Pediatric Trauma Surgery Committee Vista B, 32nd Level (Seaport Tower)

6:15-7:15 am
Session VIII:
WTC I Sessions
Location: WTC 1: Resuscitation Australasian Trauma Society
Coronado A, Fourth Level Moderators: John Cook-Jong Lee, MD, PhD and Michael Parr, MD
(Harbor Tower) Keynote: Michael Parr, MD
Management of Traumatic Cardiac Arrest

Location: WTC 2: Quality Eastern Association for the Surgery of Trauma

Seaport A-C, Second Level Moderators: Michel Aboutanos, MD and Bruce Crookes, MD
(Seaport Tower) Keynote: Bruce Crookes, MD
Quality in Trauma Care: Navigating the Perfect Storm

Location: WTC 3: Innovative Care Japanese Association for the Surgery of Trauma (JAST)
Hillcrest, Third Level (Seaport Moderators: Hayato Kurihara, MD and Takahiro Kinoshita, MD
Tower) Keynote: Takahiro Kinoshita, MD
Hybrid ER

Location: WTC 4: Critical Care PanAmerican Trauma Society

Harbor C, Second Level Moderators: Ajai Malhotra, MD and Akio Kimura, MD
(Harbor Tower) Keynote: Thomas Scalea, MD
Acute Resuscitation Unit: Added Value Over ICU?

Location: WTC 5: Polytrauma/Ortho German Trauma Society (DGU)

Harbor B, Second Level Moderators: Marius Keel, MD and Bertil Bouillon, MD
(Harbor Tower) Keynote: Bertil Bouillon, MD
S3 Polytrauma Guideline Germany

Location: WTC 6: Geriatrics European Society for Trauma and Emergency Surgery (ESTES)
Harbor A, Second Level Moderators: Ingo Marzi, MD and Christoph Josten, MD
(Harbor Tower) Keynote: Christoph Josten, MD
The New Classification of Fragility Fractures of the Pelvis

Location: WTC 7: Emergency General Surgery World Society of Emergency Surgery (WSES)
Coronado B, Fourth Level Moderators: Mauro Zago, MD and Salomone Di Saverio, MD
Keynote: Salomone Di Saverio, MD
(Harbor Tower) Acute Appendicitis GL
 7:00 am-3:00 pm Exhibits Open
Location: Harbor D-I, Second Level (Harbor Tower)

7:00-8:30 am Continental Breakfast in Exhibit Hall

Location: Harbor Ballroom, Second Level (Harbor Tower)

7:00 am-4:00 pm Registration Open

Seaport Foyer - Second Level
7:00 am-5:00 pm Donor Lounge Open
Location: Harbor Foyer, Second Level (Harbor Tower)
Session IX:
Plenary Session
Papers 17-20 Paper 17 7:30-7:50 am
THE ECONOMIC FOOTPRINT OF ACUTE CARE SURGERY IN THE UNITED STATES:
Moderator: IMPLICATIONS FOR SYSTEMS DEVELOPMENT
Presenter: Kristan Staudenmayer, MD, MSc Discussant: David Hoyt, MD
R. Lawrence Reed, MD
Paper 18 7:50-8:10 am
Recorder: HOW MUCH GREEN DOES IT TAKE TO BE ORANGE? DETERMINING COST ASSOCIATED WITH
Preston Miller, MD TRAUMA CENTER READINESS
Presenter: Dennis Ashley, MD Discussant: John Fildes, MD

Location: Paper 19 8:10-8:30 am

Seaport D-H, Second MEDICAID EXPANSION ASSOCIATED WITH INCREASED ACCESS TO POST-DISCHARGE CARE
FOR TRAUMA PATIENTS
Level (Seaport Tower) Presenter: John Scott, MD, MPH Discussant: Andrew Bernard, MD

Paper 20 8:30-8:50 am
ASSOCIATION BETWEEN LENGTH OF STAY AND ACCESS TO POST-ACUTE CARE:
CHALLENGES WITH DISPOSITION AND THE IMPACT ON INPATIENT COSTS
Presenter: Lisa Knowlton, MD, MPH Discussant: Jay Doucet, MD, MSc

8:50-10:00 am How Should We Position Acute Care Surgery in the Landscape of Healthcare
Session X: Economics?
AAST Panel Location: Seaport D-H, Second Level (Seaport Tower)
Moderator: Joseph Minei, MD, MBA and Kristan Staudenmayer, MD, MSc
Panelists: Kristan Staudenmayer, MD, MSc; Joseph Minei, MD, MBA; Andrew Bernard, MD;
Jay Doucet, MD, MSc
Topics: Setting the Stage - US Economics Trends
The Devil is in the Details
What is Affecting Our Practice Now
Local Economics- Advocating Value and Meeting Local Need

10:00-10:30 am Moderator: Michael F. Rotondo, MD

Session XI: Location: Seaport D-H, Second Level (Seaport Tower)
Scholarship
Presentations
10:30-10:45 am Break in Exhibit Hall
Location: Harbor D-I, Second Level (Harbor Tower)
 10:45-11:15 am A Long Run for a Short Slide: A Story of Trauma Care in New Zealand
Session XII: Location: Seaport D-H, Second Level (Seaport Tower)
Master Surgeon Presenter: Ian Civil, MD
Lecture I

11:15 am-12:15 pm Pro/Con Debate

Session XIII: Location: Seaport D-H, Second Level
Ari Leppaniemi, MD, PhD and Zsolt Balogh, MD,
WTC Panel III Moderators:
PhD
Laparoscopy in Trauma
Pro: Selman Uranus, MD Con: David Feliciano, MD
Grade IV Splenic Injury with Brush
Splenectomy: Andrew Peitzman, MD Angio/Embolization: Federico Coccolini, MD

12:15-1:30 pm Lunch in Exhibit Hall/Break

(Lunch available for purchase in Exhibit Hall)
12:30-1:30 pm
Location: Harbor D-I, Second Level (Harbor Tower)
Session XIV:
WTC Power
Sessions
Location: WTC PS1 How Good Can Highly Performing Trauma Systems Get?
Coronado A, Fourth Level Sponsored by Australasian Trauma Society
(Harbor Tower) Panelists:
• Michael Parr, MD
• Ian Civil, MD
• Zsolt Balogh, MD, PhD
• Li Hsee, MD

Location: WTC PS2 Understanding EAST Practice Management Guidelines and Practical
Coronado DE, Fourth Level, Tips to Adapting at your Hospital
(Harbor Tower) Moderator: Elliot Haut, MD, PhD
Sponsored by Eastern Association for the Surgery of Trauma
Panelists:
• Elliott Haut, MD, PhD, A 20-year history of EAST’s Practice Management Guidelines
• John Como, MD, Current Role of EAST’s Practice Management Guidelines
• Nicole Fox, MD, MPH, Evaluation and Management of Blunt Trauma Aortic Injury: An
EAST PMG
• Mayur Patel, MD, MPH, Cervical Spine Collar Clearance in the Obtunded Adult Blunt
Trauma Patient: An EAST PMG
Location:
Coronado B, Fourth Level WTC PS3 DCIR and REBOA
(Harbor Tower) Sponsored by Japanese Association for the Surgery of Trauma (JAST)
Panelists:
• Tomohiro Funabiki, MD, PhD, What is DCIR? (Damage Control Interventional
Radiology)
• Yosuke Matsumura, MD, PhD, Small profile, partial occlusion, undelayed but short
occlusion: REBOA registry in Japan
• Taichiro Tsunoyama, MD, PhD, Review of all cases using REBOA: A single-center
expericne from Tokyo for five years
• Takayuki Ogura, MD, PhD, Traumatic bleeding severity score (TBSS) guided initiation
of REBOA as a Damage Control Strategy; for the right patient, at the right timing,
and in the right way
Location: WTC PS4 ACS Education Program in Asia (JSACS/KSACS)
Golden Hill, Third Level Sponsored by the Japanese Society for Acute Care Surgery/The Korean Society for Acute
(Seaport Tower) Care Surgery
Panelists:
• Jae Hun Kim, MD, ACS Resident Program in Korea
• Yashurio Otomo, MD, PhD, ACS Board Certified Surgeon in Japan
• Tay Wee Ming, MD, ACS Training program in Singapore
• LI-Chien Chien, MD, ACS Program in Taiwan

Location: WTC PS5 Hot Topics in Trauma

Harbor B, Second Level Sponsored by SBAIT - Brazilian Trauma Society
(Harbor Tower) Panelists:
• Marcelo Ribeiro,MD, Enteroatmospheric Fistula Management
• Diogo Garcia, MD, Rib Fixation
• Carlos Menegozzo, MD, Laparoscopy in Trauma
• Jose Cruvinel, MD, Thoracoscopy in Trauma

Location: WTC PS6 How to Organize Trauma Care in the ICU

Harbor A, Second Level Sponsored by ESTES/IATSIC Moderator: Kenneth Boffard, MD
(Harbor Tower) Panelists:
• Felco Hietbrink, MD, Intermediate care, cost effective alternative for ICU care
in Selected Patients
• Karen Brasel, MD, MPH, Trauma ICU in the USA - the role of the surgeon
• Christine Gaarder, MD, PhD, Is There A Role for the Trauma Surgeon in ICU in
European Closed ICU?
• Kenneth Boffard, MD, Is ICU Viable in a Developing Country? Best for the
most?

Location: WTC PS7 Did You Think You Had Seen It All? Unusual Cases and Discussions
Harbor C, Second Level with Panel (You May Be On It)
(Harbor Tower) Sponsored by ESTES/IATSIC Moderator: Scott D'Amours, MD
Panelists:
• Steven Moeng, MD
• Scott D’Amours, MD
• Peep Talving, MD

Location: WTC PS8 Short Clinical Updates by the Experts: What is New and Important
Seaport A-C, Second Level Sponsored by ESTES/IATSIC Moderator: Luke Leenen, MD, PhD
(Seaport Tower) Panelists:
• Paal Naess, MD, PhD, Pelvic Injuries - the role for EPP?
• Adam Brooks, MD, Pancreatic Injuries - to resect or not?
• Luke Leenen, MD, PhD, Chest Injuries - to fixate or not?
• Rajan Gupta, MD, DCS in Trauma - Under vs Overuse?
• David Zonies, MD,MPH, Role of ECMO in Trauma in the Future
• Martin Schreiber, MD, Thromboprophylaxis In Trauma - Drug, Dosing, Do We Know
What We Are Doing?

Location: The Impact of Big Data and Artificial Intelligence on Trauma

Hillcrest, Third Level (Seaport Care
Tower) Sponsored by Chang Gung Memorial Hospital Moderator: Chi-Hsun Hsieh, MD, PhD
Panelists:
 Session XVA:
Parallel Session
Papers 21-29
Paper 21 1:30-1:50 pm
PEDIATRIC FIREARM INCIDENTS: IT’S TIME TO DECREASE ON-SCENE MORTALITY
Moderator: Presenter: Jessica Friedman, MD Discussant: L.R. Tres Scherer, MD
Deborah Kuhls, MD
Paper 22 1:50-2:10 pm
EFFECT OF MASS SHOOTINGS ON GUN SALES – A 20 YEAR PERSPECTIVE
Recorder: Presenter: Rachael Callcut, MD, MSPH Discussant: Ronald Stewart, MD
Christine Cocanour,
Paper 23 2:10-2:30 pm
MD INCREASINGLY PERMISSIVE FIREARM CARRY LEGISLATION IS ASSOCIATED WITH
INCREASED FIREARM-RELATED SUICIDE RATES
Location: Presenter: Matthew Hernandez, MD Discussant: Zara Cooper, MD, MSc
Seaport D-H, Second Paper 24 2:30-2:50 pm
Level (Seaport Tower) COMPARISON OF MALE AND FEMALE VICTIMS OF INTIMATE PARTNER HOMICIDE
IN OPPOSITE SEX RELATIONSHIPS - AN ANALYSIS OF THE NATIONAL VIOLENT DEATH
REPORTING SYSTEM
Presenter: Catherine Velopulos, MD, MHS Discussant: D’Andrea Joseph, MD

Paper 25 2:50-3:10 pm
ESSENTIAL VIOLENCE INTERVENTION RESOURCES: AN UPDATE USING THE NATIONAL
NETWORK OF HOSPITAL-BASED VIOLENCE INTERVENTION PROGRAM’S MULTI-
INSTITUTIONAL DATABASE
Presenter: Rochelle Dicker, MD Discussant: Amy Goldberg, MD

Paper 26 3:10-3:30 pm
THE GATE PROGRAM: A MULTIDISCIPLINARY INTERVENTION TO REDUCE JUVENILE GUN
VIOLENCE RECIDIVISM AND POTENTIAL MODEL FOR NATIONWIDE EXPANSION
Presenter: Hahn Soe-Lin, MD, MS Discussant: Rochelle Dicker, MD

Paper 27 3:30-3:50 pm
USE OF SHOTSPOTTERTM DETECTION TECHNOLOGY DECREASES TRANSPORT TIME FOR
PATIENTS SUSTAINING GUNSHOT WOUNDS
Presenter: Deviney Rattigan, MD Discussant: Alexander Eastman, MD, MPH

Paper 28 3:50-4:10 pm
OBSERVING PNEUMOTHORACES: THE 35 MM RULE IS SAFE FOR BOTH BLUNT AND
PENETRATING CHEST TRAUMA
Presenter: Savo Bou Zein Eddine, MD Discussant: Andrew Kirkpatrick, MD

Paper 29 4:10-4:30 pm
TO SLEEP, PERCHANCE TO DREAM: ACUTE AND CHRONIC SLEEP DEPRIVATION IN ACUTE
CARE SURGEONS
Presenter: Jamie Coleman, MD Discussant: Nicole Stassen, MD
 Session XVB:
Basic Science
Papers 30-38
Paper 30 1:30-1:50 pm
DOES A LUNG INFECTION AFTER BRAIN INJURY WORSEN EARLY BRAIN INFLAMMATION
Moderator: AND SUBSEQUENT NEUROLOGICAL RECOVERY?
Suresh Agarwal, MD Presenter: Christina Jacovides, MD Discussant: Deborah Stein, MD, MPH

Paper 31 1:50-2:10 pm
Recorder: ELECTROPORATION-MEDIATED LUNG GENE TRANSFER OF HUMAN FELINE SARCOMA
Marc deMoya, MD RELATED (FER) TYROSINE-KINASE MOBILIZES TOLL-LIKE RECEPTOR-4 GRANULO-
MONOCYTES AND IMPROVES SURVIVAL IN MURINE MODEL OF PSEUDOMONAS
AERUGINOSA PNEUMONIA
Location: Presenter: David Machado-Aranda, MD Discussant: James Hoth, MD
Seaport A-C, Second
Paper 32 2:10-2:30 pm
Level (Seaport Tower) RED BLOOD CELL STORAGE AND ADHESION TO VASCULAR ENDOTHELIUM UNDER NORMAL
OR STRESS CONDITIONS: AN IN VITRO MICROFLUIDIC STUDY
Presenter: Lawrence Diebel, MD Discussant: Rosemary Kozar, MD, PhD

Paper 33 2:30-2:50 pm
TRANEXAMIC ACID SUPPRESSES THE RELEASE OF MITOCHONDRIAL DAMPS AND REDUCES
LUNG INFLAMMATION IN A MURINE BURN MODEL
Presenter: Damien Carter, MD Discussant: Carl Hauser, MD

Paper 34 2:50-3:10 pm
ENDOTHELIAL CELL DYSFUNCTION DURING ANOXIA-REOXYGENATION IS ASSOCIATED WITH
A DECREASE IN ATP LEVELS, REARRANGEMENT IN LIPID BILAYER PHOSPHATIDYLSERINE
ASYMMETRY, AND AN INCREASE IN ENDOTHELIAL CELL PERMEABILITY
Presenter: Javid Sadjadi, MD Discussant: Timothy Pritts, MD

Paper 35 3:10-3:30 pm
SELECTIVE AORTIC ARCH PERFUSION WITH FRESH WHOLE BLOOD OR HBOC-201
EFFECTIVELY REVERSES HEMORRHAGE-INDUCED TRAUMATIC CARDIAC ARREST IN A
LETHAL MODEL OF NON-COMPRESSIBLE TORSO HEMORRHAGE
Presenter: Heather Hoops, MD Discussant: Samuel Tisherman, MD

Paper 36 3:30-3:50 pm
DOES BLOOD TRANSFUSION PRESERVE THE GUT MICROBIOME (GM) AFTER TRAUMA? A
PROSPECTIVE, CLINICAL STUDY IN SEVERELY INJURED PATIENTS
Presenter: Susannah Nicholson, MD, Msci Discussant: Mitchell Cohen, MD

Paper 37 3:50-4:10 pm
PRECIOUS CARGO: NEURO-ENTERIC MODULATION OF THE MESENTERIC LYMPH EXOSOME
PAYLOAD AFTER HEMORRHAGIC SHOCK
Presenter: Elliott Williams, MD Discussant: Jason Smith, MD

Paper 38 4:10-4:30 pm
ACUTE RESUSCITATION WITH POLYETHYLENE GLYCOL-20K: A THROMBOELASTOGRAPHIC
ANALYSIS
Presenter: Niluka Wickramaratne, MD, BS Discussant: Jeremy Cannon, MD
 4:45-5:45 pm
Session XVI:
WTC II Sessions
Location: WTC 8: Research Sponsored by European Society for Trauma and Emergency Surgery
Seaport A-C, Second Level (ESTES)
Moderators: Ronald Maier, MD and Ingo Marzi, MD
(Seaport Tower)
Keynote: Bertil Bouillon, MD
Influence of Trauma Registry Data on Basic Research
Location: WTC 9: Shock/Transfusion Sponsored by The Japanese Society for Acute Care
Coronado A, Fourth Level Surgery (JSACS)
(Harbor Tower) Moderators: Ernest Moore, MD and Yasuhiro Otomo, MD, PhD
Keynote: Yasuhiro Otomo, MD, PhD
Traumatic Coagulopathy
Location: WTC 10:Prevention/Outcomes Sponsored by SBAIT - Brazilian Trauma Society
Harbor B, Fourth Level (Harbor Moderators: Rochelle Dicker, MD and Gustavo Fraga, MD, PhD
Tower) Keynote: Gustavo Fraga, MD, PhD
“Yellow May” - Trauma Prevention Program

Location: WTC 11: Trauma Systems Sponsored by Chinese Medical Doctor Association
Coronado B, Fourth Level Trauma Committee (CMDATC)
(Harbor Tower) Moderators: Marc deMoya, MD and Xiao-Bing Fu, MD
Keynote: Zhanfei Li, MD, PhD
Trauma System Development in China

Location: WTC 12: Thoracic/Vascular Sponsored by Austrian Council for Emergency Medicine
Coronado DE, Fourth Level (AGN)
(Harbor Tower) Moderators: Luke Leenen, MD, PhD and Paul Puchwein, MD
Keynote: Paul Puchwein, MD
Emergency Thoracotomy in Preclinical Setting- An Advantage of
Physician Based EMS

Location: WTC 13: Emergency General Surgery Sponsored by WSES

Harbor A, Fourth Level (Harbor Moderators: Carlos Mesquita, MD and Federico Coccolini, MD
Tower) Keynote: Federico Coccolini, MD
Acute Cholecystsitis GL

6:30 pm-9:30 pm San Diego Night (USS Midway) - Ticketed Event

Location: USS Midway (910 N Harbor Dr, San Diego, CA)
 Friday 6:15-7:15 am Committee Meetings - Session III
ACS Program Directors Committee Meeting Vista A, 32nd Level (Seaport Tower)
9/28 Education/CME Committee
Military Liaison Committee
Vista B, 32nd Level (Seaport Tower)
Skyline, 32nd Level (Seaport Tower)
Multi-Institutional Trials Committee Cityview B, 32nd Level (Seaport Tower)
Prevention Committee Cityview A, 32nd Level (Seaport Tower)
Reimbursement/Coding Committee Vista C, 32nd Level (Seaport Tower)

6:15-7:15 am
Session XVII:
WTC III Sessions
Location: WTC 14: Critical Care Sponsored by Australasian Trauma Society
Harbor A, Second Level Moderators: Koji Morishita, MD and Zsolt Balogh, MD, PhD
(Harbor Tower) Keynote: Zsolt Balogh, MD, PhD
Understanding Post Injury Inflammation for Better Timing of
Definitive Surgical Intervention in Polytrauma

Location: WTC 15: Prevention Sponsored by Eastern Association for the Surgery of Trauma (EAST)
Harbor C, Second Level Moderators: Jose Mauro da Silva Rodrigues, MD and Nicole Stassen, MD
(Harbor Tower) Keynote: Nicole Stassen, MD
A New Frontier in Firearm Injury

Location: WTC 16: Abdominal Trauma Sponsored by European Society for Trauma
Seaport A-C, Second Level and Emergency Surgery (ESTES)
(Seaport Tower) Moderators: Jungchui Kim, MD and Ari Leppaniemi, MD, PhD
Keynote: Ari Leppaniemi, MD, PhD
Nonoperative Management of Solid Abdominal Organ
Injuries

Location: WTC 17: Guidelines/Outcomes Sponsored by European Society for Trauma

Coronado DE, Fourth Level and Emergency Surgery (ESTES)
(Harbor Tower) Moderators: Yoshinori Murao, MD and Rado Komadina, MD
Keynote: Radko Komadina, MD
European Bleeding Guidelines

Location:
WTC 18: Education Sponsored by SBAIT - Brazil Trauma Society
Harbor B, Second Level
Moderators: Mamta Swaroop, MD and Gustavo Fraga, MD, PhD
(Harbor Tower)
Keynote: Gustavo Fraga, MD, PhD
Trauma Leagues: A Novel Option to Attract Medical Students to a
Surgical Career
Location:
Coronado A, Fourth Level WTC 19: Geriatrics/Outcomes Sponsored by Japanese Association for the Surgery of
(Harbor Tower) Trauma (JAST)
Moderators: Amit Gupta, MD, and Takashi Fujita, MD
Keynote: Takashi Fujita, MD
Geriatric Trauma in Japan
Location: WTC 20: Shock Resuscitation Sponsored by The Japanese Society for Acute Care
Coronado B, Fourth Level Surgery (JSACS)
(Harbor Tower) Moderators: Sandro Rizoli, MD, PhD, and Shigeki Kushimoto, MD
Keynote: Shigeki Kushimoto, MD
Traumatic Coagulopathy

7:00-8:30 am Continental Breakfast

Location: Harbor D-I, Second Level (Harbor Tower)
7:00 am-2:00 pm Exhibits Open
Location: Harbor D-I, Second Level (Harbor Tower)
7:00 am-3:00 pm Registration Open
Location: Seaport Foyer, Second Level (Seaport Tower)
7:00 am-4:00 pm Donor Lounge Open
Location: Harbor Foyer, Second Level (Harbor Tower)

Session XVIII:
Coagulation
Session
Papers 39-44
Paper 39 7:30-7:50 am
MICROVESICLES GENERATED FOLLOWING TRAUMATIC BRAIN INJURY INDUCE PLATELET
Moderator: DYSFUNCTION VIA ADP RECEPTOR
Martin Schreiber, MD Presenter: Grace Martin, MD Discussant: John Holcomb, MD

Recorder: Paper 40 7:50-8:10 am

GUIDELINE-BASED CORRECTION OF PLATELET INHIBITION IN TBI PATIENTS IS
Sharon Henry, MD
ASSOCIATED WITH IMPROVED MORTALITY
Presenter: Andrew Sorah, MD Discussant: Michael Cripps, MD
Location:
Seaport D-H, Second Paper 41 8:10-8:30 am
Level (Seaport Tower) PLATELET DERIVED EXTRACELLULAR VESICLES ARE EQUIVALENT TO PLATELETS WITH
RESPECT TO HEMOSTASIS AND VASCULAR PERMEABILITY
Presenter: Shibani Pati, MD, PhD Discussant: Susan Evans, MD

Paper 42 8:30-8:50 am
TRANEXAMIC ACID AS A RISK FACTOR FOR POST-TRAUMATIC VENOUS
THROMBOEMBOLISM: RESULTS FROM A PROPENSITY MATCHED COHORT STUDY
Presenter: Sara Myers, MD, MA, MS Discussant: Adrian Maung, MD

Paper 43 8:50-9:10 am
4-FACTOR PROTHROMBIN COMPLEX CONCENTRATE IMPROVES SURVIVAL IN TRAUMA: A
NATIONWIDE PROPENSITY MATCHED ANALYSIS
Presenter: Muhammad Zeeshan, MD Discussant: Matthew Martin, MD
 Paper 44 9:10-9:30 am
DESMOPRESSIN IS A TRANSFUSION SPARING OPTION TO REVERESE PLATELET
DYSFUNCTION IN PATIENTS WITH SEVERE TRAUMATIC BRAIN INJURY
Presenter: Elisa Furay, MD Discussant: Susan Rowell, MD

9:30-9:45 am Break
Session XIX: Location: Harbor D-I, Second Level (Harbor Tower)
Coagulation
Papers 45-47
Paper 45 9:45-10:05 am
A NOVEL PLATELET FUNCTION ASSAY FOR TRAUMA
Moderator: Presenter: Mitchell George, MD Discussant: Jordan Weinberg, MD
Raminder Nirula, MD,
PhD Paper 46 10:05-10:25 am
TRANEXAMIC ACID CAUSES A ROBUST AND PROLONGED FIBRINOLYTIC
SHUTDOWN
Recorder:
Presenter: Julia Coleman, MD, MPH Discussant: Nicholas Namias, MD, MBA
Oscar
Guillamondegui, MD, Paper 47 10:25-10:45 am
MPH EARLY FIBRINOLYSIS SHUTDOWN IS ASSOCIATED WITH INCREASED NEUROSURGICAL
INTERVENTIONS AFTER TRAUMATIC BRAIN INJURY: IS SHUTDOWN AN EARLY MARKER OF
HYPOCOAGULABILITY RATHER THAN HYPOFIBRINOLYSIS?
Location:
Presenter: Johana Gomez-Builes, MD Discussant: Martin Schreiber, MD
Seaport D-H, Second
Level (Seaport Tower)
10:55-11:55 am Damage Control and Firearm Deaths: “A Tale of Two Cities!”
Session XX: Location: Seaport D-H, Second Level (Seaport Tower)
Fitts Lecture Pesenter: C. William Schwab, MD
12:00-1:15 pm LS VII Establishing a Translational Research Career in Acute Care Surgery: Early,
Session XXI: Mid-, and Late Career Milestones
Location: Coronado A, Fourth Level (Harbor Tower)
AAST Lunch
Sessions LS VIII The Opioid Epidemic: Challenges for Acute Care Surgeons
Location: Coronado B, Fourth Level (Harbor Tower)
LS IX TXA Beyond CRASH2 - Controversies and the Global Perspective
Location: Coronado DE, Fourth Level (Harbor Tower)
LS X Physician Resilience, Burnout and the Work Life Balance
Location: Harbor A, Second Level (Harbor Tower)
LS XI Palliative Care 2018: Implementing the TQIP Best Practice Guideline
Location: Harbor B, Second Level (Harbor Tower)
LS XII The Difficult Cholexystectomy
Location: Harbor C, Second Level (Harbor Tower)

1:15-1:30 pm Break in Exhibit Hall

Location: Harbor D-I, Second Level (Harbor Tower)
 1:30-2:00 pm Advise, Advance, Support, Teach - the True Meaning of AAST to Me
Session XXII: Location: Seaport D-H, Second Level (Seaport Tower)
Master Surgeon Presenter: Christine Gaarder, MD, PhD
Lecture II
Session XXIIIA:
Plenary Papers
Papers 48-56
Paper 48 2:00-2:20 pm
A NOMOGRAM PREDICTING THE NEED FOR BLEEDING INTERVENTIONS AFTER HIGH-
Moderator: GRADE RENAL TRAUMA: RESULTS FROM THE AMERICAN ASSOCIATION FOR THE SURGERY
Christoph Josten, MD OF TRAUMA (AAST) GENITOURINARY TRAUMA STUDY
Presenter: Sorena Keihani, MD Discussant: Neil Perry, MD
Recorder:
Paper 49 2:20-2:40 pm
Andre Campbell, MD PRESUMPTIVE ANTIBIOTICS FOR TUBE THORACOSTOMY FOR TRAUMATIC
HEMOPNEUMOTHORAX
Location: Presenter: Susan Schultz, MD Discussant: Timothy Fabian, MD
Seaport D-H, Second
Level (Seaport Tower) Paper 50 2:40-3:00 pm
VASOPRESSOR USE IN SPINAL CORD INJURY INCREASES MORTALITY AND COMPLICATIONS
WITHOUT IMPROVING SHORT TERM NEUROLOGIC FUNCTION
Presenter: Caitlin Fitzgerald, MD Discussant: David Zonies, MD, MPH

Paper 51 3:00-3:20 pm
PREHOSPITAL END TIDAL CO2: A SUPERIOR MARKER FOR MORTALITY RISK IN THE ACUTELY
INJURED PATIENT
Presenter: Robert Willis, MD, MS Discussant: Saman Arbabi, MD, MPH

Paper 52 3:20-3:40 pm
PRE-INJURY PALLIATIVE PERFORMANCE SCALE (PPS) PREDICTS FUNCTIONAL OUTCOMES
AT 6 MONTHS IN OLDER TRAUMA PATIENTS
Presenter: Franchesca Hwang, MD Discussant: Karen Brasel, MD, MPH

Paper 53 3:40-4:00 pm
USING PERFORMANCE FRONTIERS TO DIFFERENTIATE ELECTIVE AND CAPACITY-BASED
SURGICAL SERVICES
Presenter: Stephen Ranney, MD Discussant: Kimberly Davis, MD, MBA

Paper 54 4:00-4:20 pm
MINIMALLY INVASIVE PREPERITONEAL BALLOON TAMPONADE AND ABDOMINAL AORTIC
JUNCTIONAL TOURNIQUET VERSUS OPEN PACKING FOR PELVIC FRACTURE-ASSOCIATED
HEMORRHAGE: NOT ALL EXTRINSIC COMPRESSION IS EQUAL
Presenter: Woo Do, MD Discussant: Clay Cothren Burlew, MD

Paper 55 4:20-4:40 pm
OUTCOMES FOR POPLITEAL ARTERY INJURY REPAIR AFTER DISCHARGE: A LARGE-SCALE
POPULATION-BASED ANALYSIS
Presenter: William Butler, MD Discussant: David Feliciano, MD
 Paper 56 4:40-5:00 pm
WITHDRAWN

Session XXIIIB:
Plenary Papers
Papers 57-65
Paper 57 2:00-2:20 pm
APPLICATION OF EMR-DERIVED ANALYTICS IN CRITICAL CARE: ROTHMAN INDEX PREDICTS
Moderator: MORTALITY AND READMISSIONS IN SURGICAL ICU PATIENTS
M. Margaret Knudson, Presenter: Abdul Alarhaeym, MD Discussant: Sonlee West, MD
MD
Paper 58 2:20-2:40 pm
PREDISPOSED TO FAILURE? THE CHALLENGE OF RESCUE IN THE MEDICAL INTENSIVE CARE
Recorder:
UNIT
Addison May, MD Presenter: Alexandra Briggs, MD Discussant: Lena Napolitano, MD, MPH

Location: Paper 59 2:40-3:00 pm

Seaport A-C, Second ULTRASONGRAPHIC IVC DIAMETER RESPONSE AFTER ONE HOUR OF TRAUMA
RESUSCITATION PREDICTS 24 HOUR FLUID REQUIREMENT
Level (Seaport Tower)
Presenter: Jay Doucet, MD, MSc Discussant: Grace Rozycki, MD, MBA

Paper 60 3:00-3:20 pm
VENTILATOR ASSOCIATED EVENT, NOT VENTILATOR ASSOCIATED PNEUMONIA, IS A TRUE
QUALITY INDICATOR
Presenter: Ashley Meagher, MD, MPH Discussant: Martin Croce, MD

Paper 61 3:20-3:40 pm
TRAUMA ICU PREVALENCE PROJECT (TRIPP): THE PHENOTYPE OF A TRAUMA ICU. AN AAST
MULTI-INSTITUTIONAL STUDY
Presenter: Christopher Michetti, MD Discussant: Bryce Robinson, MD, MSc

Paper 62 3:40-4:00 pm
TWENTY-FOUR HOUR VERSUS EXTENDED ANTIBIOTIC ADMINISTRATION AFTER SURGERY IN
COMPLICATED APPENDICITIS: A RANDOMIZED CONTROLLED TRIAL
Presenter: Sten Saar, MD Discussant: Robert Sawyer, MD

Paper 63 4:00-4:20 pm
P-SELECTIN IS CRITICAL FOR DE NOVO PULMONARY ARTERIAL THROMBOSIS FOLLOWING
BLUNT THORACIC TRAUMA
Presenter: Linda Schutzman, MD Discussant: Alicia Mohr, MD

Paper 64 4:20-4:40 pm
HIGH PERFORMANCE EMERGENCY GENERAL SURGERY HOSPITALS: GOOD AT ONE
OPERATION, GOOD AT THEM ALL
Presenter: Michael DeWane, MD Discussant: Avery Nathens, MD, PhD, MPH
 Paper 65 4:40-5:00 pm
THE EGS GRADING SCALE FOR SKIN AND SOFT TISSUE INFECTIONS IS PREDICTIVE OF POOR
OUTCOMES : AN AAST MULTI-CENTER VALIDATION STUDY
Presenter: Stephanie Savage, MD, MS Discussant: Eileen Bulger, MD

5:00-6:30 pm AAST Business Meeting (AAST Members Only)

Location: Seaport A-C, Second Level (Seaport Tower)
5:00-6:30 pm
Session XXIV:
WTC IV Sessions
Location: WTC 21: Abdominal Trauma Sponsored by SBAIT - Brazilian Trauma Society
Golden Hill, Third Level Moderators: Gennaro Perrone, MD and Tercio Campos, MD
(Seaport Tower) Keynote: Tercio Campos, MD
Pancreatic Trauma

Location: WTC 22: Shock/Resuscitation Sponsored by The Japanese Society for Acute Care
Torrey Hill, Third Level Surgery (JSACS)
(Seaport Tower) Moderators: Christine Gaarder, MD, PhD and Atsushi Shiraishi, MD
Keynote: Atsushi Shiraishi, MD
The Effects of TXA on Trauma

Location: WTC 23: Trauma Education Sponsored by Chinese Medical Doctor Association
La Jolla, Second Level Trauma Committee (CMDATC)
(Seaport Tower) Moderators: Ashok Puranik, MD and Lian-Yang Zhang, MD
Keynote: Guixi Zhang, MD, MBBS, MHSM, MSc
Trauma Education in China

Location: WTC 24: Prehospital Sponsored by JSACS/KSACS

Old Town, Second Level Moderators: Susan Brundage, MD and John Cook-Jong Lee, MD, PhD
(Seaport Tower) Keynote: John Cook-Jong Lee, MD, PhD
Invasive Prehospital Care

7:30-11:00 pm Reception and Banquet

Location: Seaport Foyer and Seaport D-H, Second Level (Seaport Tower)
 Saturday 7:00-8:00 am New Member Breakfast
Location: La Jolla, Second Level (Seaport Tower)
9/29 Continental Breakfast
Location: Seaport Foyer, Second Level (Seaport Tower)
Registration Open (if needed)
Session XXV: Location: Seaport Foyer, Second Level (Seaport Tower)
Plenary Papers
Papers 66-68
Paper 66 8:00-8:20 am
RESILIENCE AND LONG-TERM OUTCOMES AFTER TRAUMA: AN OPPORTUNITY FOR EARLY
Moderator:
INTERVENTION?
Eric Toschlog, MD Presenter: Deepika Nehra, MD Discussant: Ben Zarzaur, Jr., MD

Recorder: Paper 67 8:20-8:40 am

Thomas Esposito, MD, CORRELATION OF ON-CALL TRAUMA SURGEON FATIGUE FLUCTUATIONS WITH BURNOUT
RISK AND SURGICAL SKILL PERFORMANCE
MPH
Moderator: Brittany Lisjak, PA-C Discussant: Heena Santry, MD

Location: Paper 68 8:40-9:00 am

Seaport A-C, Second STOP FLAILING: THE IMPACT OF BICORTICALLY DISPLACED RIB FRACTURES ON
Level (Seaport Tower) PULMONARY OUTCOMES IN PATIENTS WITH CHEST TRAUMA - AN AAST MITC STUDY
Presenter: Lara Senekjian, MD, Msci Discussant: Frederic Pieracci, MD, MPH

Session XXVI: Quickshot 1 9:00-9:06 am

Quickshot I THE ACA AND EMERGENCY GENERAL SURGERY CHOLECYSTECTOMIES
1-13 Presenter: Laura Godat, MD Discussant: Lance Stuke, MD, MPH

Quickshot 2 9:06-9:12 am
Moderator:
EMERGENCY GENERAL SURGERY IN GERIATRIC PATIENTS: HOW SHOULD WE EVALUATE
Roxie Albrecht, MD HOSPITAL EXPERIENCE?
Presenter: Ambar Mehta, MPH Discussant: Jody DiGiacomo, MD
Location:
Seaport A-C, Second Quickshot 3 9:12-9:18 am
THE ACUTE ABDOMEN: FASTER AND SAFER WITH ACUTE CARE SURGERY
Level (Seaport Tower)
Presenter: David Jeffcoach, MD Discussant: Brandon Bruns, MD

Quickshot 4 9:18-9:24 am
OUTCOMES IN ADHESIVE SMALL BOWEL OBSTRUCTION FROM A LARGE STATEWIDE
DATABASE: WHAT TO EXPECT AFTER NON-OPERATIVE MANAGEMENT
Presenter: Lyndsey Wessels, MD Discussant: Jose Diaz, MD

Quickshot 5 9:24-9:30 am
EGS PRESENTS GREATER FINANCIAL RISK THAN TRAUMA
Presenter: Andrew Bernard, MD Discussant: Oliver Gunter, MD
Quickshot 6 9:30-9:36 am
QUANTIFYING THE THOUSANDS OF LIVES LOST DUE TO POOR EMERGENCY GENERAL
SURGERY (EGS) OUTCOMES: WHY WE NEED A NATIONAL EGS QUALITY IMPROVEMENT
PROGRAM
Presenter: Zain Hashmi, MBBS Discussant: Angela Ingraham, MD

Quickshot 7 9:36-9:42 am
IMPACT OF A SIMPLIFIED MANAGEMENT ALGORITHM ON OUTCOME FOLLOWING
EXSANGUINATING PELVIC FRACTURES: A 10-YEAR EXPERIENCE
Presenter: Richard Lewis, MD, MA Discussant: David Morris, MD

Quickshot 8 9:42-9:48 am
BLUNT SMALL BOWEL PERFORATION (SBP): A MULTICENTER UPDATE 15 YEARS
LATER
Presenter: Samir Fakhry, MD Discussant: Stephen Gale, MD

Quickshot 9 9:48-9:54 am
THE NEED FOR TRAUMA INTERVENTION (NFTI) DEFINES MAJOR TRAUMA MORE
ACCURATELY THAN INJURY SEVERITY SCORE (ISS) AND REVISED TRAUMA SCORE (RTS):
DATA FROM A COLLABORATION OF 35 ADULT AND PEDIATRIC TRAUMA CENTERS.
Discussant: William Hoff, MD

Quickshot 10 9:54-10:00 am
DIAGNOSIS OF DIAPHRAGM INJURIES USING MODERN 256 SLICE CT SCANNERS: TOO
EARLY TO ABANDON OPERATIVE EXPLORATION
Presenter: Rindi Uhlich, MD Discussant: David Skarupa, MD

Quickshot 11 10:00-10:06 am
HOW SAFE AND EFFECTIVE ARE SMALL-BORE CHEST TUBES AT MANAGING DELAYED
HEMOTHORACES COMPARED TO LARGE-BORE CHEST TUBES?
Presenter: John Cordero, MD Discussant: Ali Salim, MD

Quickshot 12 10:06-10:12 am
COMPARISON OF 7 AND 11-12 FRENCH ACCESS FOR REBOA: RESULTS FROM THE AAST
AORTIC OCCLUSION FOR RESUSCITATION IN TRAUMA AND ACUTE CARE SURGERY (AORTA)
REGISTRY
Presenter: Joseph DuBose, MD Discussant: Michael Sise, MD

Quickshot 13 10:12-10:18 am
THE IMPACT OF IN-HOSPITAL COMPLICATIONS ON THE LONG-TERM FUNCTIONAL
OUTCOMES OF TRAUMA PATIENTS: A MULTICENTER STUDY.
Presenter: Jae Moo Lee, BA Discussant: David Efron, MD

10:18-10:30 am Break
Location: Seaport Foyer, Second Level (Seaport Tower)
 Session XXVII: Quickshot 14 10:30-10:36 am
Quickshot I ARE YOU KIDDING? PEDIATRIC TRAUMA CENTER VERIFICATION IMPROVES OUTCOMES AT
AN ADULT CENTER
14-26 Presenter: Sean Maloney, MD Discussant: Daniel Margulies, MD
Moderator:
Elliott Haut, MD, PhD Quickshot 15 10:36-10:42 am
TRAUMA OVER-TRIAGE, CONCURRENT TRAUMA ACTIVATION AND OVERLAPPING EGS
SURGERY ARE NOT ASSOCIATED WITH SHORT OR LONG TERM MORTALITY IN EGS
Location: PATIENTS
Seaport A-C, Second Presenter: Ariel Knight, MD Discussant: Sasha Adams, MD
Level (Seaport Tower) Quickshot 16 10:42-10:48 am
BETA-ADRENERGIC BLOCKADE FOR TREATMENT OF TRAUMATIC BRAIN INJURY: A
RANDOMIZED CONTROLLED TRIAL
Presenter: Thomas Schroeppel, MD, MS Discussant: Bryan Cotton, MD

Quickshot 17 10:48-10:54 am
PHYSIOLOGIC IMPACT OF XSTAT 30 USE IN THE MANAGEMENT OF NON-COMPRESSIBLE
TORSO HEMORRHAGE
Presenter: Alicia Bonanno, MD Discussant: Travis Polk, MD

Quickshot 18 10:54-11:00 am
PERCENT CHANGE FROM PRE-INJURY BLOOD PRESSURE IS AN INDEPENDENT PREDICTOR
OF MORTALITY IN ELDERLY TRAUMA
Presenter: Kelly Boyle, MD Discussant: Jennifer Hubbard, MD

Quickshot 19 11:00-11:06 am
THE NLRP3 INFLAMMASOME PATHWAY LEADS TO THE LOSS OF BLOOD-BRAIN BARRIER
INTEGRITY IN TRAUMATIC BRAIN INJURY
Presenter: Bobby Robinson, MD Discussant: Mayur Patel, MD, MPH

Quickshot 20 11:06-11:12 am
OBESITY IS NOT ASSOCIATED WITH MICROVASCULAR INFLAMMATION FOLLOWING INJURY
Presenter: Robert Winfield, MD Discussant: Carlos Brown, MD

Quickshot 21 11:12-11:18 am
THE DIVERSITY OF SURGICAL CRITICAL CARE: A REPORT OF THE TRAUMA ICU PREVALENCE
PROJECT (TRIPP), AN AAST MULTI-INSTITUTIONAL STUDY
Presenter: Christopher Michetti, MD Discussant: Panna Codner, MD

Quickshot 22 11:18-11:24 am
TEACHING HOW TO STOP THE BLEED: DOES IT WORK? A PROSPECTIVE EVALUATION OF
TOURNIQUET APPLICATION IN SECURITY AND LAW ENFORCEMENT PERSONNEL
Presenter: Fahd Ali, MD Discussant: Babak Sarani, MD

Quickshot 23 11:24-11:30 am
WHEN IS IT SAFE TO START VTE PROPHYLAXIS AFTER BLUNT SOLID ORGAN INJURY? A
PROSPECTIVE STUDY FROM A LEVEL I TRAUMA CENTER
Presenter: Morgan Schellenberg, MD, MPH Discussant: Forrest Fernandez, MD
Quickshot 24 11:30-11:36 am
THROMBOPROPHYLAXIS WITH NOVEL ORAL ANTICOAGULANTS IS ASSOCIATED WITH
LOWER VENOUS THROMBOEMBOLIC EVENTS IN OPERATIVE SPINE TRAUMA
Presenter: Mohammad Hamidi, MD Discussant: Mark Cipolle, MD, PhD

Quickshot 25 11:36-11:42 am
AMERICAN FIREARM HOMICIDES: THE IMPACT OF YOUR NEIGHBORS
Presenter: Erik Olson, MD Discussant: Omar Danner, MD

Quickshot 26 11:42-11:48 am
IMPACT OF LICENSED FEDEvRAL FIREARM SUPPLIERS ON FIREARM-RELATED MORTALITY
Presenter: Stephanie Chao, MD Discussant: Sherry Sixta, MD

12:00-2:00 pm TSACO Editorial Board Meeting

Location: La Jolla, Second Level (Seaport Tower)
 WTC
SCHEDULE &
ABSTRACTS
 SA
VE
TH
E
DA
TE
!

HOSTED BY

For further information please contact:

The Australasian Trauma Society
ATS Secretariat
PO Box 576
Crows Nest NSW Australia 1585
P: Intnl +61 2 9431 8668
Local/National 02 9431 8668
E: wtc2020@[Link]
[Link]
 77th Annual Meeting of the
American Association for World
the Surgery of Trauma and
Clinical Congress of Acute Trauma
Care Surgery
Congress
4th World Trauma Schedule
Congress

September 26-29, 2018 • San Diego, CA

*Meeting room locations are subject to change. Please check the Annual Meeting App
for the most up to date room assignments.

WTC Thursday Sessions

WTC Friday Sessions

OTA Schedule

STN Schedule
 77th Annual Meeting of the
American Association for World
the Surgery of Trauma and
Clinical Congress of Acute Trauma
Care Surgery
Congress
4th World Trauma Schedule
Congress

September 26-29, 2018 • San Diego, CA

Thursday
*Meeting room locations are subject to change. Please check the Annual Meeting App
9/27 for the most up to date room assignments.

6:15-7:15 A.M.
6:15-7:15 am WTC 1: Resuscitation Sponsored by Australasian Trauma Society
Session VIII: Location: Coronado A, Fourth Level (Harbor Tower)
WTC I Sessions Moderators: John Cook-Jong Lee, MD, South Korea and Michael Parr, MD, Australia
Keynote: Michael Parr, MD, Management of Traumatic Cardiac Arrest
FEISTY - Fibrinogen Early In Severe Trauma studY: Fibrinogen Concentrate Vs.
Cryoprecipitate In Severe Traumatic Haemorrhage: A Pilot Randomised Controlled
Trial
Presenter: James Winearls, MD, BS, Australia

ORGAN FAILURES FOLLOWING RESUSCITATIVE ENDOVASCULAR OCCLUSION OF THE

AORTA: A PROPENSITY SCORE MATCHING ANALYSIS
Presenter: Atsushi Shiraishi, MD, PhD, Japan

PREDICTING MORTALITY AFTER TRAUMATIC BRAIN INJURY: PROGNOSTIC MODEL

BASED ON ADMISSION CHARACTERISTICS
Presenter: Jose D. Charry, MD, PhD, Colombia

ATLS® PROTOCOL ADHERENCE BY GENERAL SURGERY RESIDENTS IN THE

EMERGENCY ROOM: A SIMULATION-BASED APPRAISAL
Presenter: Gustavo Fraga, MD, PhD, Brazil

PENETRATING INJURY TO THE CARDIAC BOX

Presenter: Jennie SoMang Kim, MD, USA
 Session VIII: WTC I Resuscitation
Paper 1: 6:15am - 7:15am
FEISTY - Fibrinogen Early In Severe Trauma Study: Fibrinogen Concentrate Vs.
Cryoprecipitate In Severe Traumatic Haemorrhage: A Pilot Randomised
Controlled Trial
James Winearls BS,MD, Martin Wullschleger MD,Ph.D., Elizabeth Wake BS,RN,
Catherine Hurn MD, Anthony Holley MD, Glen Ryan MD, Jeremy Furyk MD, Gerben
Keijzers MD,Ph.D., Wayne Dyer Ph.D., John Fraser MD,Ph.D., Jeff Presneill MD,Ph.D.,
Don Campbell MD, Gold Coast University Hospital

Introduction: Trauma is a leading cause of death worldwide and represents a global

health concern. Major haemorrhage in the setting of severe trauma is associated with
significant morbidity and mortality. Hypofibrinogenaemia plays a significant role in
traumatic haemorrhage and is associated with worse outcomes. It is postulated that early
fibrinogen replacement may reduce haemorrhage and improve outcomes. This study
assessed the effects of a targeted dose of Fibrinogen Concentrate (FC) vs Cryoprecipitate
(Cryo) in traumatic haemorrhage. It was hypothesised that fibrinogen replacement can be
achieved quicker with a more predictable dose response using FC compared to Cryo.
Methods: A multi-centre, randomised controlled, un-blinded, feasibility pilot study.
Primary study aims: 1) Investigate the feasibility of early targeted fibrinogen
replacement in traumatic haemorrhage 2) Compare time to administration of fibrinogen
replacement between FC and Cryo 3) Investigate feasibility of study protocol in a pilot
multicentre study. Inclusion Criteria: 1) Adult affected by Trauma 2) Judged to have
significant haemorrhage 3) Predicted to require significant transfusion with ABC score ≥
2 or by treating clinician judgement. Intervention: 100 patients were randomised into FC
(Intervention) or Cryo (Comparator) arms with requirement for fibrinogen replacement
triggered by pre-specified ROTEM values – FIBTEM A5 ≤ 10 mm. Primary outcome
measures: 1) Time to administration of Fibrinogen Replacement 2) Feasibility of
administering FC within 30 mins 3) Effects on Fibrinogen levels during traumatic
haemorrhage. Secondary outcome measures: 1) Transfusion requirements 2) Duration
of bleeding episode 3) ICU and Hospital LOS 3) Thromobembolic events 4) Mortality.
Results: Full primary outcome data was available for 94 patients. FC Arm FIBTEM A5
(n=47): Median 8 mm (IQR 7 – 10) Cryo Arm (n=47): 10 mm (8 – 14). FC Arm 36/47
(77%) had a FIBTEM A5 ≤ 10 mm - median transfusion of 3g FC. Cryo Arm 26/47
(55%) had a FIBTEM A5 ≤ 10 mm - median transfusion of 8 Units Cryo. Time to
administration was for FC 29 min (IQR 23 – 40) [Range 10 - 125] compared to Cryo 60
min (40 – 80) [30 - 170]. The mean time to first treatment advantage for FC over Cryo
was 33 min (95% CI 17 to 48 min). The HR for commencement of treatment was 2.8
(95% CI 1.7 to 4.9) in favour of FC relative to Cryoprecipitate. Full data analysis for
remaining outcome measures will be available by June 2018.
Conclusions: FC therapy commenced a median of 31 minutes
before Cryo. Assessed using a time to event method, patients
in the FC arm were on average almost three times more likely
to have commenced treatment compared to those in Cryo arm.
These results suggest that FC may have a substantial advantage
in time to administration relative to Cryo. There is currently
insufficient evidence to support one means of fibrinogen replacement over another;
resulting in non-uniform practices within facilities and diverse transfusion guidelines.
This study will add to the evidence base and inform the planning of a definitive
multi-centre study with patient centred outcomes as primary outcomes.
 Session VIII: WTC I Session: Resuscitation
Paper 2: 6:15am - 7:15am
ORGAN FAILURES FOLLOWING RESUSCITATIVE ENDOVASCULAR
OCCLUSION OF THE AORTA: A PROPENSITY SCORE MATCHING
ANALYSIS
Atsushi Shiraishi MD,Ph.D., Yasuhiro Otomo MD,Ph.D., Junichi Inoue MD,Ph.D.,
Toshinao Suzuki MD, Kameda Medical Center
Introduction: Despite the growing importance of resuscitative endovascular balloon
occlusion of the aorta (REBOA) in critically bleeding trauma patients, reports on benefits
and drawbacks regarding mortality and organ failure following REBOA have been
heterogeneous and inconclusive in previous studies. This study aimed to compare and
assess not only mortality, but also organ failure, in critically bleeding trauma patients who
did and did not undergo REBOA.
Method: From the Japan Trauma Databank, a retrospective, observational, nationwide,
registry-based, and propensity score-matched cohort study included adult (≥16 years old)
trauma patients who underwent torso emergency surgery. Patients whose systolic blood
pressure was 0 mmHg at the baseline were excluded. After multiple imputation for all the
study variables, propensity scores to predict the use of REBOA were generated from 54
covariates at the baseline as fixed-effect and hospital as random-effect by the logistic
regression mixed effect model, and were used for 1:1 within-cluster (hospital) matching
for patients who underwent REBOA with those who did not. The study outcomes included
in-hospital mortality, organ failure including supra-diaphragmatic organ failure (brain,
heart, and lung dysfunction), infra-diaphragmatic organ failure (abdominal organ
dysfunction and pulmonary embolism following deep vein thrombosis), systemic organ
failure (sepsis and coagulopathy), and a combination of in-hospital mortality and any kind
of organ failure.
Results: Within-cluster propensity score-matching included 607 patients each who did
and did not undergo REBOA. Baseline covariates were adequately matched (absolute
standardized mean difference [ASMD] <0.1) between patients who did or did not undergo
REBOA, including age (54 versus 53 years [median], respectively, ASMD 0.019), sex
(68% male versus 68% male, respectively, ASMD 0.007), systolic blood pressure (84
versus 80 mmHg [median], respectively, ASMD 0.062), and the Injury Severity Score (34
versus 34 [median], respectively, ASMD 0.026). Undergoing REBOA was associated
with higher in-hospital mortality (57% versus 37%, respectively, difference +20% [95%
confidence interval (CI) +15%, +26%], P<0.001). Supra-diaphragmatic (13% versus 14%,
difference -1% [95% CI -5%, +3%], P=0.737) and infra-diaphragmatic (2% versus 3%,
difference -0% [95% CI -2%, +1%], P=0.712) organ failures did not differ in patients who
did and did not undergo REBOA, respectively; however, excess prevalence in systemic
organ failures was observed in association with REBOA (24% versus 18%, respectively,
difference +6% [95% CI +1%,+11%], P=0.011). REBOA was also associated with the
combined outcome including in-hospital death or any organ failure (68% versus 52%,
respectively, difference +17%[95% CI +11%, +22%]).
Conclusion: In this retrospective, observational, propensity score-matched study,
undergoing REBOA was associated with higher mortality, higher prevalence of systemic
organ failures including coagulopathy and sepsis, and fewer organ failure-free survival.
 Session VIII: WTC I Session: Resuscitation
Paper 3: 6:15am - 7:15am
PREDICTING MORTALITY AFTER TRAUMATIC BRAIN INJURY:
PROGNOSTIC MODEL BASED ON ADMISSION CHARACTERISTICS
Jose D. Charry MD,Ph.D., Juan P. Solano MD, Jorman H. Tejada MD, FUNDACIÓN
UNIVERSITARIA NAVATTA
Introduction: Traumatic Brain Injury (TBI) is a public health problem. It is a
pathology that causes significant mortality and disability. Different models have been
developed in order to predict the neurological outcomes. Marshall computed
tomographic (CT) classification is widely used as a predictor of outcome. However,
this grading system lacks useful variables to predict the outcome of the patient, which
are subarachnoid/intraventricular hemorrhage, extradural haematoma, and extent of
basal cistern compression. We aimed to develop and validate a practical prognostic
model that include all the variables above and predict death at six months after
TBI.
Methods: Prospectively collected individual patient data were analyzed. The CT model
included midline shift over 5 mm, normal, compressed or absent basal cisterns,
subarachnoid bleeding, basal bleeding, intraventricular bleeding, contusion and
epidural, subdural or intracerebral haematoma. We considered predictors available at
admission in logistic regression models to predict mortality at 6 months after TBI. The
performance and accuracy of several model was assessment using the Spearman's rank
correlation coefficient and the area under the receiver operating characteristic curve
(AUC).
Results: A total of 145 patients were recruited for study, median age 33 (15-85) years,
and 86.89% were male. The overall mortality was 24.82%. The median GCS of patients
was 6 (3-12). The Marshall CT classification discrimination was AUC= 0.646, Helsinki
CT Score discrimination was AUC= 0.724, Rotterdam grading discrimination was
AUC= 0.735, all these with a low correlation with the outcome (Spearman's rho <0.40).
Our model showed the best performance and correlation with 6-month mortality:
AUC= 0.7755, Spearman's rho 0,4201, p= 0.000.

Conclusion:Our prognostic mortality CT model showed a great performance and

accuracy and can be used to obtain valid predictions of relevant outcomes in patients
with TBI.
 Session VIII: WTC I Session: Resuscitation
Paper 4: 6:15am - 7:15am

ATLS® PROTOCOL ADHERENCE BY GENERAL SURGERY RESIDENTS IN

THE EMERGENCY ROOM: A SIMULATION-BASED APPRAISAL
Bruno M. Pereira MD,Ph.D., Cristiane P. Lopes MD, Juliany L. Silva Thiago R.
Calderan MD, Bruno De Jorge Alcir E. Dorigatti MD, Jose B. Bortoto MD, Elcio S.
Hirano MD,Ph.D., Gustavo P. Fraga MD,Ph.D., University of Campinas

Introduction: Decision-making process has been insufficiently discussed in medical

teaching. Recently, more importance has being given to the study of critical
decision-making capacity in simulation-based scenarios. This study aim to evaluate
adherence to the Advanced Trauma Life Support (ATLS ®) protocol by general surgery
residents when exposed to clinical simulation scenario as well as their ability to take
critical life saving decisions in a stressfull scenario.

Methods: 44 general surgery residents from a unique university teaching hospital were
exposed to 23 identical trauma simulation scenarios between 2013 – 2016. A score has
been given according to Resident’s performance and adherence to ATLS® protocol. All
simulation case scenarios were also recorded and reviewed by a different evaluator of the
live case-scenario. Performance scores were confronted and discussed all together in order
to lower any possible bias. Here, this group of authors studied the adherence of 44
residents to the ATLS ® protocol as well as their decision-making capacity in a critical
scenario.

Results: Unconformities factors were identified on general surgery residents adherence to

the ATLS® protocol. Lack of attention, failure to comply with rapid sequence intubation
protocol with adequate pre-oxygenation, conceptual lapse in volume ressucitation and
neglection of hypothermia prevention were the most important observed points. There
were also identified failures in the process of critical decision-making.

Conclusion: Current protocols despite of objectifying a clear and logical method of

attending trauma victims at the emergency room, are unable to exclude personal decision-
making process. Focus by tutors and teachers should be given to physicians in training for
general surgery in the pre-oxygenation, measures of confirmation of the process of
intubation in the emergency room, massive transfusion protocol and hypothermia
prevention.
 Session VIII: WTC I Session: Resuscitation
Paper 5: 6:15am - 7:15am
PENETRATING INJURY TO THE CARDIAC BOX
Jennie S. Kim MD, Kenji Inaba* MD, FRCSC, FACS, Luis Alejandro De Leon MD,
Cyrus Rais BA, John B. Holcomb* MD, FACS, Jean Stephane David MD, Demetrios
Demetriades* MD,Ph.D., FACS LAC+USC Medical Center
Introduction: Classically, a penetrating injury to the “cardiac box” has been thought to be
predictive of an injury to the heart, however, there is very little evidence available to
support this association. This study aims to further evaluate the relationship between
penetrating trauma to the cardiac box and a clinically significant injury.
Methods: All patients 18 years and older presenting to a Level 1 trauma center from
01/2009 – 06/2015 who sustained a penetrating injury isolated to the thorax were
retrospectively identified. Patients were categorized according to the location of their
injury: within or outside the historical cardiac box defined by the sternal notch superiorly,
the xiphoid process inferiorly, and the nipples laterally. Patients with concurrent injuries
both inside and outside the cardiac box were excluded. Clinical demographics, injuries,
procedures, and outcomes were compared.
Results: During this 7-year period, 330 patients (92% male; median age, 28 years)
sustained penetrating injuries isolated to the thorax: 138 patients (42%) within the cardiac
box and 192 patients (58%) outside the cardiac box. By mechanism, 105 (76%) were stab
wounds (SW) and 33 (24%) were gunshot wounds (GSW) inside the cardiac box, and 125
(65%) SW and 67 (35%) GSW outside the cardiac box. The overall rate of thoracotomy or
sternotomy was significantly higher in patients with penetrating trauma within the cardiac
box [35/138 (25.4%) vs. 15/192 (7.8%), p<0.001]. These patients also had a higher
incidence of cardiac injury compared to patients with wounds outside the box
[18/138 (13%) vs. 5/192 (5%), p<0.001]. There was no difference in overall mortality
[9/138 (6.5%) vs. 6/192 (3.1%), p=0.144]. On multivariate logistic regression, a
penetrating injury within the cardiac box was an independent risk factor for undergoing a
thoracotomy or sternotomy (adj p=0.008, OR 3.255, 95% CI 1.353-7.832) and for cardiac
injury (adj p=0.008, OR 6.845, 95% CI 1.636-28.636).
Conclusion: Penetrating trauma within the cardiac box is associated with a higher risk of
cardiac injury and need for thoracotomy or sternotomy than injuries outside the cardiac
box. Injuries outside the cardiac box still warrant rapid assessment as they have a one in
twenty chance of an associated cardiac injury.
WTC 2: Quality Sponsored by the Eastern Association for the
Surgery of Trauma
Location: Seaport A-C, Second Level (Seaport Tower)
Moderators: Michel Aboutanos, MD and Bruce Crookes, MD USA
Keynote: Bruce Crookes, MD, Quality in Trauma: Navigating the Perfect Storm
LOW VALUE SURGICAL PRACTICES IN TRAUMA CARE: A SCOPING REVIEW AND
EXPERT CONSULTATION STUDY
Presenter: Lynne Moore, PhD, Canada

EFFECTS OF THE FULLY ENFORCED AFFORDABLE CARE ACT

Presenter: Krista Haines, DO, USA

PREDICTION MODELS FOR HEALTH STATUS 6-MONTHS AND 1-YEAR AFTER INJURY:
A PROSPECTIVE COHORT STUDY
Presenter: Leonie De Munter, MSc, Netherlands

CAUSES OF PREVENTABLE AND POTENTIALLY PREVENTABLE DEATH IN TRAUMA

PATIENTS IN A COMPREHENSIVE TRAUMA CENTER IN CHINA
Presenter: Zhanfei Li, MD, PhD, China

TRAUMA TERTIARY SURVEY: IMPROVING COMPLIANCE IN FOUR STEPS

Presenter: Juan Herrera-Escobar, MD, USA
 Session VIII: WTC I Session: Quality
Paper 1: 6:15am - 7:15am
LOW VALUE SURGICAL PRACTICES IN TRAUMA CARE: A SCOPING
REVIEW AND EXPERT CONSULTATION STUDY
Lynne Moore Ph.D., Khadidja M. Boukar PhD candidate, Howard Champion MD,
Pier-Alexandre Tardif MSc, Natalie Yanchar MD,MPH, John Kortbeek MD, Julien
Clément MD, David Evans MD, Morad Hameed MD,MPH, Radoslav Krouchev
MD,MPH, Laval University
Introduction: Injuries lead to 200,000 hospital stays, 60,000 disabilities, and 13,000
deaths per year in Canada with direct costs of $16 billion. Low-value medical
interventions are estimated to consume up to 30% of healthcare resources and may expose
patients to avoidable harm. However, little is known about healthcare overuse in trauma
populations. We aimed to identify low-value clinical practices in trauma surgery.
Methods: We conducted a scoping review of peer- and non-peer-reviewed literature
followed by a consultation with experts. We identified research articles, reviews,
recommendations and guidelines that identified at least one low-value clinical practice
specific to hospitalized injury populations. We searched Medline, Embase, Cochrane
CENTRAL, and Web of Science databases, websites of government agencies,
professional societies and patient advocacy organizations, thesis holdings and conference
proceedings. Pairs of independent reviewers evaluated studies for eligibility and extracted
data from included articles using a pre-piloted and standardized electronic data abstraction
form. We documented the level of evidence by the number and type of studies reporting
on each clinical practice. We then consulted experts in two phases: to classify, group and
standardize identified surgical practices and to rate them according to their potential to be
low-value.
Results: The systematic scoping review revealed 72,226 citations of which 1,486 were
deemed eligible and led to the identification of 113 surgical practices. Following the first
phase of consultation, 24 surgical practices were retained. Of these, 11 were considered
clearly or potentially low value by experts (see Table 1 for examples).
Conclusion: This review contributes new knowledge on low-value surgical practices in
acute injury care. This is the first study of the Canadian Program for Monitoring Low
Value Clinical Practices in Injury Care, funded by the Canadian Institutes of Health
Research and conducted in collaboration with Choosing Wisely. In addition to surgical
care, the program targets injury care in the emergency department, the intensive care unit,
and orthopedics. This review represents a first step towards developing valid and reliable
metrics to monitor potentially unnecessary or harmful practices in acute injury care. These
metrics will provide a solid basis for the development of interventions targeting de-
adoption such as shared decision-making tools. Such interventions have the potential to
reduce costs, delays and unnecessary hospital days and increase resource availability.
They may also improve patient outcomes through a reduction in exposure to adverse
events.
 Session VIII: WTC I Session: Quality
Paper 2: 6:15am - 7:15am
Effects of the Fully Enforced Affordable Care Act
Krista Haines DO, Suresh Agarwal MD, Duke University

Introduction: The Affordable Care Act (ACA) of 2010 was created to expand insurance
coverage for all Americans. This analysis was done to determine if the ACA, once it was
fully enforced, expanded coverage and improved outcomes for trauma patients.

Methods: Trauma patient’s ages 15-65 years who presented between 2007 and 2015 were
identified in the National Trauma Data Bank (NTDB). Those patients with unknown
disposition where excluded from analysis as well as patients who would have qualified for
social security secondary to age. Patients were grouped by years: 2007-2009
pre-ACA, 2011-2013 post-ACA, and 2014-2015, once the ACA was fully enforced.
Patient outcomes of interest included hospital length of stay (LOS), in-hospital mortality,
and discharge disposition. Multivariate regression models for mortality and LOS were
built controlling for injury severity (ISS), age, gender, race, patient comorbidities, and
insurance status to determine if these grouped years affected outcomes.

Results: There were 10,830,716 patients included in this analysis. Patients were 40 ±15
years old and 72% were male. Mean ISS was 9.9±9 and LOS was 6.0±9 days. Prior to the
ACA patients were significantly more likely to die controlling for all above covariates
(p<0.001, CI 0.0018-0.0023). Patients from 2011-2013 were less likely to die, while
patients who presented from 2014-2015 once the act was fully enforced had the lowest
mortality of all groups (p<0.001). In the same regression model, patients with insurance
other than private and minorities were more likely to die as compared to their Caucasian
privately insured counterparts (p<0.0001). Regression for LOS controlling for same
covariates including comorbidities found patients from 2014-2015, despite having better
outcomes, had the lowest LOS (p<0.001). Furthermore, patients from 2011-2013 had a
significantly shorter hospital LOS than those patients prior to the enactment of ACA
(p<0.001). Uninsured patients, excluding AMA, had significantly lower LOS than all
other patients controlling for all years (p<0.001).

Conclusion: This analysis demonstrates that once the ACA was fully enforced, the group
of Americans trauma patients with the highest rate of uninsured patients had better
outcomes. Not only did their outcomes improve immediately following implementation of
the ACA from 2011 to 2013, but improved significantly more once the act was entirely
engrained within the US healthcare system.
 Session VIII: WTC I Session: Quality
Paper 3: 6:15am - 7:15am
PREDICTION MODELS FOR HEALTH STATUS 6-MONTHS AND 1-YEAR
AFTER INJURY: A PROSPECTIVE COHORT STUDY
Leonie De Munter MSc, Suzanne Polinder Ph.D., Nena Kruithof MSc, Cornelis L. Van
De Ree MD, Ewout W. Steyerberg Ph.D., Mariska A. De Jongh Ph.D., Elisabeth-Twee
Steden Hospital

Introduction: Trauma patients often perceive an impaired health related quality of life
after trauma. This study aims to develop a prediction model for health status in the general
trauma population, based on 6-months and 12-months outcome. The model should
incorporate easily accessible predictors.
Methods: A total of 9774 adult trauma patients were included from August 2015 through
November 2016 if they were admitted to one of the ten hospitals in the county. Outcome
measures were the EuroQol-5 dimensions (EQ-5D) and the Health Utilities Index (HUI) 6
months and 1 year after trauma. Summary scores were calculated for all outcome
measures. Possible predictors were pre-injury health status, injury severity, patient
characteristics and frailty pre-injury (measured with the Groningen Frailty Index). All
potential predictors were assessed with univariable linear regression. Predictors were
included in the multivariable model if p<0,2. The model performances were assessed with
Nagelkerke R-square (R 2).
Results:. A total of 2,106 patients and 1,938 patients were used to develop a prediction
model for functional outcome, respectively 6 months and 1 year after injury. Pre-injury
health status and frailty pre-injury were the strongest predictors for functional outcome in
the general trauma population. Age, comorbidity, social economic status, functional
capacity index, injury severity score, length of stay in hospital were also included in the
multivariable prediction models. The model explained 50% of the variance for
EQ5D-utility score (R2=0.5) and 40% of the variance was explained for HUI 2 or HUI 3
index scores (R2=0.4).
Conclusion:To our knowledge, these are the first models to predict health status 6 months
and 1 year after trauma. The models seem promising for predicting health status of trauma
patients in the western society. However, future research is recommended to externally
validate the models.
 Session VIII: WTC I Session: Quality
Paper 4: 6:15am - 7:15am
Causes of preventable and potentially preventable death in trauma patients in a
comprehensive trauma center in China
Zhanfei Li MD,Ph.D., Xi-er Xu BS, Xiangjun Bai MD,Ph.D., Tongji Hospital

Introduction:Trauma and accidental death account for the five common causes of
mortality in China as well as worldwide. Introduction of trauma centers improves severely
injured patients care. Since the trauma centers are established in China, there are advances
in trauma care management. In this retrospective study, we analyzed the causes of
preventable and potentially preventable early in-hospital death in a comprehensive trauma
center in China. the purpose of this study was to analyze the deficits in medical care for
injured patients, and to provide clue of how to improve the trauma care system in the
future.
Methods: The clinical data of early in-hospital mortality from 2000 to 2014 in the Trauma
Center of Tongji Hospital were collected. The demographic data, causes and mechanisms
of injury, anatomy of injury, as well as pre-hospital care of these patients were assessed.
The medical deficits were also studied. The data were acquired from medical records. The
classification of inevitable or potentially avoidable death was determined on the basis of
available data, mainly by clinical consideration. We analyzed data by GraphPad Prism 5,
P<0.05 was set statistically significant.
Results: Seventy-four percent of our patients were males and the median of age was 42.
Traffic injury was the leading cause of trauma death in 49%. The site of injury was cranio-
cerebral in 72% of our patients. From 2010 to 2014 the number of deaths increased with a
rate of 33%. In all groups, the number of deaths was increased in less than one hour from
the time of injury in 54% ( P<0.05). Most of deaths were inevitable in all groups in 79%
(P<0.05). Among deaths considered as potentially avoidable or avoidable, a total of 182
deficits are noticed. The inappropriate transfer is the leading deficit encountered. Other
deficits are: inadequate resuscitation, inappropriate airway management, inadequate
bleeding control and missed diagnosis.
Conclusion:Inappropriate transfer, inadequate fluid resuscitation, airway management
and bleeding control, and missed diagnosis are major deficits of medical care for severely
injured patients. More training for trauma management and better patient-doctor
relationship will help to improve the outcome of severely injured patients.
 Session VIII: WTC I Session: Quality
Paper 5: 6:15am - 7:15am
Trauma Tertiary Survey: Improving Compliance in Four Steps
Juan P. Herrera-Escobar MD, Arturo J. Rios-Diaz MD, Amy Bulger MPH,RN, Meghan
McDonald RN, Samir Shah BS, Barbara U. Okafor BS, Katherine Armstrong MPH,
Ramsis Ramsis BS, Edward J. Caterson MD,Ph.D., Ali Salim MD, Deepika Nehra MD,
Brigham and Womens Hospital

Introduction: Missed injury rate is a commonly used quality indicator of trauma care
performance. The routine completion of trauma tertiary surveys (TTS) has been
recommended to minimize the rate of missed injuries amongst hospitalized trauma
patients. However, poor compliance in the routine documentation of TTS is commonly
reported. In this study, we sought to determine whether the implementation of a
standardized TTS template increases the compliance of TTS completion and
documentation.

Methods: The current project was developed in four steps: 1) development of a

standardized TTS template in collaboration with multiple stakeholders at a Level I
Trauma Center; 2) education campaign and dissemination of TTS documentation
guidelines; 3) project launch in March 2016; and 4) data collection and analysis. For the
last phase, we retrospectively reviewed the medical charts of all patients admitted under
the care of the trauma surgery service over the 6 month period from September
2015-February 2016 (pre-implementation group) and from September 2016-February
2017 (post-implementation group). Compliance and timeliness of completion of TTS in
the charts was compared for the pre- and post-implementation groups.

Results: A total of 918 records were reviewed: 495 pre- and 423 post-implementation of
a standardized TTS template. Patients in the pre-implementation group were more likely
to be male and have longer length of stay compared to patients in the
post-implementation group (p<0.05). Other demographics, clinical, and injury-related
characteristics of patients were comparable between pre- and post-implementation groups
(p>0.05). Compliance in documenting TTS in the medical charts was 58% before and
79% after implementation of the template (p<0.001). Furthermore, 96% of TTS were
documented within the first 48 hours of admission in the post-implementation group,
compared to 85% in the pre-implementation group (p<0.001). After implementing the
template, the TTS template was used to document TTS in 85% of patients with a
completed TTS.

Conclusion: The introduction of a standardized TTS template significantly improved

compliance and timeliness in TTS documentation in medical charts. A standardized
template for TTS completion and documentation and the regular education of health care
providers on TTS guidelines may improve compliance with TTS documentation.
WTC 3: Innovative Care Sponsored by Japanese Association for the
Surgery of Trauma (JAST)
Location: Hillcrest, Third Level (Seaport Tower)
Moderators: Hayato Kurihara, MD and Takahiro Kinoshita, MD, Japan
Keynote: Takahiro Kinoshita, MD, Hybrid ER
PROPENSITY-SCORE MATCHED ANALYSIS OF ENDOVASCULAR VS. OPEN REPAIR OF
ISOLATED SUPERFICIAL FEMORAL AND POPLITEAL ARTERY INJURIES
Presenter: Daniel Alfson, MD, USA

THE EFFICACY OF A NOVEL TWO-ROOM TYPE ALL-IN-ONE TRAUMA RESUSCITATION

SUITE: THE RETROSPECTIVE EVALUATION OF THE BENEFITS OF TIME-SAVING AND
COST-EFFECTIVENESS.
Presenter: Taku Kazamaki, MD, Japan

RESUSCITATIVE ENDOVASCULAR OCCLUSION OF THE AORTA ‘REBOA’: INDICATIONS-

ADVANTAGES AND CHALLENGES OF IMPLEMENTATION IN TRAUMATIC NON-
COMPRESSIBLE TORSO HEMORRHAGE - A SCOPING REVIEW
Presenter: Omar Bekdache, MD, Canada

THE ROLE AND AVAILABILITY OF TEVAR WITH DEBRANCHING TECHUNIQUE FOR

BLUNT TRAUMATIC AORTIC INJURY IN THE SEVERE MULTIPLE TRAUMA PATIENTS.
Presenter: Kenichiro Uchida, MD, PhD, Japan

ENDOVASCULAR MANAGEMENT IN TRAUMATIZED PATIENTS: EXPERIENCE AT A

LEVEL 1 TRAUMA CENTER IN AN UPPER-MIDDLE INCOME COUNTRY.
Presenter: Ana Del Valle, MD, Colombia
 Session VIII: WTC I Session: Innovative Care
Paper 1: 6:15am - 7:15am
Propensity-score matched analysis of endovascular vs. open repair of isolated
superficial femoral and popliteal artery injuries
Daniel B. Alfson MD, Vincent L. Rowe MD, Niquelle B. Wade MS, Kenji Inaba MD,
Gregory A. Magee MD, MSc University Of Southern California

Introduction: Endovascular therapy of traumatic vascular injuries has increased

dramatically during the past decade. No large studies have reported the outcomes for
endovascular versus open repair of isolated superficial femoral (SFA) and popliteal artery
(PA) injuries.
Methods: Analysis of the National Trauma Data Bank (NTDB: 2007-2014) was performed
to identify all patients with a superficial femoral or popliteal artery injury. Isolated SFA and
PA injuries were defined as cases with abbreviated injury scale (AIS) severity score <4 for
non-lower extremity injuries. Nearest neighbor propensity score matching was used to
account for pre-surgery differences in patients’ demographic and clinical characteristics.
Variables were selected for matching based on evidence of association with the exposure
(repair type) and at least one patient outcome. Logistic regression models were used to
assess associations between repair type and patient outcomes.
Results: A total of 11,395 patients with SFA or PA injuries were identified, of which 2,873
were defined as isolated SFA/PA injuries (163 endovascular repair and 2,710 open repair)
and were included in the full analysis dataset. A propensity-matched dataset was derived
from the full dataset using pre-treatment characteristics (gender, age, systolic blood pressure,
pulse, ISS, SFA injury, PA injury, femur fracture/knee dislocation) and a 1:4 matching ratio
(157 endovascular, 628 open). In the full analysis dataset, the percentage of patients who
underwent endovascular repair increased from 3.2% in 2007 to 7.6% in 2014. Patients with
isolated SFA/PA injuries had morbidity rates of: deep venous thrombosis (DVT) (endo
7.4%, open 4.2%, p=0.06), fasciotomy (endo 12.3%, open 49.7%, p<0.001), amputation
(endo 4.3%, open 9.5%, p=0.025), acute kidney injury (AKI) (endo 3.1%, open 2.1%,
p=0.403). In the propensity-matched dataset, endovascular repair was not associated with
improved amputation-free survival (OR 1.16, 95% CI [0.60-2.10], p=0.65). However, there
was a higher mortality (OR 3.69, p=0.008) and decreased fasciotomy risk (OR 0.23,
p<0.001) among endovascular repair patients compared to open repair patients.
Conclusion: In patients with isolated SFA/PA injuries, endovascular repair was not
associated with improved amputation-free survival. Mortality was higher in the
endovascular repair group and the rate of fasciotomy was higher in the open group.
 Session VIII: WTC I Session: Innovative Care
Paper 2: 6:15am - 7:15am
THE EFFICACY OF A NOVEL TWO-ROOM TYPE ALL-IN-ONE TRAUMA
RESUSCITATION SUITE: THE RETROSPECTIVE EVALUATION OF THE
BENEFITS OF TIME-SAVING AND COST-EFFECTIVENESS.
Taku Kazamaki MD, Nao Hiroe MD, Shokei Matsumoto* MD, Masayuki Shimizu MD,
Tomohiko Orita MD, Tomohiro Funabiki MD,Ph.D., Motoyasu Yamazaki MD,Ph.D.,
Mitsuhide Kitano MD,Ph.D., Saiseikai Yokohamashi Tobu Hospital
Invited Discussant:

Introduction: Recently, an all-in-one trauma

resuscitation unit, comprised of computed tomography
(CT) scanner, intervention radiology (IVR) system,
and operation room (OR), known as a “Hybrid
emergency room (ER)” was developed and the survival
benefit of using that type of facility in severe trauma has been shown. This is assumed to
reflect the shortened times to CT scan, subsequent diagnosis and decision making, and
definitive therapies. From an economic aspect, however, the Hybrid ER could be too
resource-intensive for many trauma patients. In October 2017, we installed a novel
“two-room type” Hybrid ER in our shock trauma center. This facility combines a
resuscitation room with an OR/IVR system and a standard CT examination room. The
gantry of the CT is shared by both rooms, so the facility can be used as a standard CT
room for scheduled examinations when the resuscitation room is not in use. We
hypothesized that this type of hybrid ER could be as effective for trauma resuscitation as
the conventional, one-room type Hybrid ER and resolve the concern about cost recovery.
Methods: This was a single center, retrospective, historically controlled observational
study. (A) To evaluate the benefit of time-saving, we selected consecutive trauma patients
with an Injury Severity Score (ISS) ≥16 who were admitted at a tertiary care hospital
before and after the installation of the Hybrid ER. Patients who were dead on arrival or
needed immediate ER thoracotomy were excluded. The time to CT scan was calculated
for each case. (B) We evaluated costs for all patients, both trauma and non-trauma, who
used the Hybrid ER for resuscitation after its installation. The stay time in the
resuscitation room was also recorded, and the occupancy rate of the resuscitation room
was calculated. The number of scheduled CT examinations performed within the Hybrid
ER was also counted and the profit from them was estimated.
Results: (A) 106 patients were included in the study population. 50 patients were
admitted before the Hybrid ER was installed, whereas 36 and 20 patients were admitted
into the Hybrid ER or a conventional trauma bay after the installation, respectively. By
using the Hybrid ER, the mean time to CT scanning was significantly decreased from
24.8 ±1.1 [min] to 10.4 ±0.8 [min] (mean ±standard error, p <0.0001). (B) Including
non-trauma cases, there were 193 patients who used the Hybrid ER for their
resuscitation. Their mean stay time in the resuscitation room was 74.4 ±5.7 [min] and the
average number of cases per day was 1.6, therefore the total room occupancy rate was
8.1% of the day. While not in use for resuscitation, an average of 14.1 scheduled CT
scans were done within the facility earning at least an estimated $1,355 per day.
Conclusion: The time to CT scan was significantly shortened in the Hybrid ER. This
result is similar to that of a previous study, and the shortened time is expected to
contribute to better survival. Meanwhile, the occupancy rate of the resuscitation room
was less than one-tenth. Low operation rates might be a common characteristic of Hybrid
ERs, leaving the potential for improved efficacy in its operation. The two-room type
Hybrid ER would be one possible solution to the problem, contributing to the hospital’s
profits by enabling scheduled CT examinations.
 Session VIII: WTC I Session: Innovative Care
Paper 3: 6:15am - 7:15am
RESUSCITATIVE ENDOVASCULAR OCCLUSION OF THE AORTA 'REBOA':
INDICATIONS-ADVANTAGES AND CHALLENGES OF IMPLEMENTATION
IN TRAUMATIC NON-COMPRESSIBLE TORSO HEMORRHAGE - A
SCOPING REVIEW
Omar Bekdache MD, Tiffany Paradis Yu B. He Shen Aly Elbahrawy MD, Mohammed
Alamoudi MD, Tarek Razek MD, Andrew Beckett MD, McGill University

Introduction: Resuscitative Endovascular Balloon Occlusion of the Aorta‘REBOA’ is

recently gaining popularity in the treatment of traumatic non-compressible torso bleeding.
Refinement of the technique supported by advances gained from the invasive radiology
experience, endovascular treatment of AAA, added to other damage control measures
nonavailable previously, helped in bringing back the technique with very promising
outcomes. The literature is still having substantial heterogeneity about the clear
indications of the procedure, the population that will benefit the most from its use, and the
challenges faced while implementing the technique in a level I trauma center. Scoping
reviews are excellent platforms to assess the diverse literature of a new technique. It is for
the first time that a Scoping review is adopted for this topic.
Methods: Critical search from MEDLINE, EMBASE, BIOSIS, COCHRANE CENTRAL,
PUBMED and SCOPUS was conducted from the earliest available dates till January
15,2018. Evidence-based papers as well as grey literature at large were analyzed
regardless of the quality of manuscripts.
Results: Identification of 1176 articles related to the topic. Retrieval of 128 full papers for
assessment. Quantitative and Qualitative measures included Demographics, Study design,
Study Objectives, Methods of data collection, Indications, REBOA protocol used, time to
deployment, Zone of deployment, Occlusion time, Complications, amount of blood used,
Outcome, and level of expertise at the concerned Trauma Centers.
Conclusion: Growing levels of evidence are supporting the use of REBOA in selected
indications. Analysis showed advantage for its use in terms of morbidities and physiologic
derangement as compared to other methods. Challenges in implementation, competency
assessment and credentialing are areas to be addressed. Recommended systematic reviews
to identify proper indications, terms of use and possible advantage of pre-hospital and
partial REBOA are topics for further researches.
 Session VIII: WTC I Session: Innovative Care
Paper 4: 6:15am - 7:15am
THE ROLE AND AVAILABILITY OF TEVAR WITH DEBRANCHING
TECHUNIQUE FOR BLUNT TRAUMATIC AORTIC INJURY IN THE SEVERE
MULTIPLE TRAUMA PATIENTS.
KENICHIRO UCHIDA MD,Ph.D., YASUMITSU MIZOBATA MD,Ph.D., HIROMASA
YAMAMOTO MD,Ph.D., TETSURO NISHIMURA MD,Ph.D., Osaka City University
Graduate School Of Medicine
Introduction: The multiple trauma patients concomitant with blunt traumatic aortic
injury (BTAI) tend to be severe and have high mortality and morbidity. The evaluation
and treatment for BTAI needs accurate and immediate cooperation with many
departments as trauma, radiology, and also cardiovascular surgery. We strive to perform
thoracic endovascular aortic repair (TEVAR) ± debranching technique for thoracic BTAI
and retrospectively reviewed the roles and short-term results of emergent TEVAR for
BTAI.
Methods: The records of the BTAI patients were retrospectively reviewed for the vital
signs on arrival, mechanism of injury, characteristics, time flow, concomitant injuries,
injury description, operation procedures, and the outcomes. The patients arrived under
cardiopulmonary arrest were excluded. All statistical data are described as median
(25-75% interquartile range [IQR]) or number.
Results: From January 2015 to February 2018, 15 patients administrated as BTAI and 7
patients were treated by TEVAR. The median age was 44 (28-57) years old and 57.1 %
was male. The grade of injury was all 3 or 4 and the time from admission to operation
was 171 (127-216) minutes. One patient was hemodynamically unstable on arrival. The
ISS was 34 (29-34) and Ps was 0.82 (0.16-0.94). Three were performed simple TEVAR
(LSCA occlusion:1) and four were performed debranching TEVAR (LSCA occlusion
+ LCCA-LSCA bypass) because of detected anomary of vertebral artery. Two were
performed under unheparinization. The concomitant injuries were one intracranial
hemorrhage, three intra-abdominal injuries, three pneumo or hemothoraxes and six
pelvic / extremities fractures. The other emergent interventions which performed
concurrently or within 24 h after TEVAR were two transcatheter arterial embolizations,
one external fixation of pelvis and three indirect tractions for fractures of extremities.
There was no intraoperative complication or delay for interventions for other injuries and
hospital death.
Conclusion: The short-term results of TEVAR with debranching technique for BTAI in
multiple trauma patients were acceptable and no complications or delay of intervention
for other injuries in the multiple trauma patients.
 Session VIII: WTC I Session: Innovative Care
Paper 5: 6:15am - 7:15am
Endovascular management in traumatized patients: Experience at a Level 1 Trauma
Center in an Upper-Middle Income Country.
Ana M. Del Valle MD, Hernan E. Munevar MD, Alberto F. Garcia MD, MSC, Ricardo
Ferrada MD, FACS, Constanza Navarro MD, Juan C. Herrera MD, Juan P. Herrera MD,
Juan C. Puyana MD, Juan P. Carbonell MD, Fundación Valle Del Lili
Introduction: Endovascular and hybrid therapy is a new treatment for complex trauma.
We describe a case series of trauma patients with endovascular management at a Level I
Trauma Center in an upper-middle income country.
Methods: Retrospective study of patients who received endovascular therapy from 2010
to 2017. Patients were divided in two groups (With single endovascular therapy (SET) and
those with hybrid therapy (HT: endovascular and surgery management). Demographic
data, injury details and treatment were registered.
Results: Were included 74 patients. 21 patients with SET and 44 with HT. In SET group,
median age was 35 (IQR 22-56), ISS 16. The mechanism of trauma by gunshot was
53.3%. 26.7% arrived in shock. 43.3% the vascular trauma was subclavia artery. 46.7%
were managed with covered stent. There were no deaths. HT group median age was 25
(IQR 20-42), ISS 25. 51.4% of trauma mechanism was penetrating by gunshot. 34 patients
arrived in shock. In 84.1% the surgery was prior to endovascular procedure. In 50% were
due to vascular trauma in areas of complex surgical approach (25% subclavian, 18%
hypogastric and 10.8% hepatic arteries).5 patients with non-compressible torso
hemorrhage needed REBOA. 47.7% presented active hemorrhage at angiography. 39.2%
underwent Coil embolization. There were 6 deaths, none attributable to endovascular
management.

Conclusion: Endovascular and hybrid trauma management are still evolving. They seem
to be a safe option and may be able to reduce mortality in penetrating trauma.
WTC 4: Critical Care Sponsored by PanAmerican Trauma Society
Location: Harbor C, Second Level (Harbor Tower)
Moderator: Ajai Malhotra, MD and Akio Kimura, MD, USA and Japan
Keynote: Thomas Scalea, MD, Acute Resuscitation Unit: Added Value Over ICU?

CLINICAL, LABORATORY AND VENTILATORY PREDICTORS FOR INTRA-ABDOMINAL

HYPERTENSION IN SEPTIC SHOCK ICU PATIENTS
Presnter: Vitor Favali Krugar, MD, Brazil

EXTERNAL VALIDATION OF THE HELSINKI COMPUTED TOMOGRAPHY SCORE IN THE

PREDICTION OF MORTALITY IN SEVERE TRAUMATIC BRAIN INJURY
Presenter: Jose Charry, MD, PhD, Colombia

OPTIMIZING CRITICAL CARE OF THE TRAUMA PATIENT IN A COST-EFFICIENT WAY: THE

INTERMEDIATE CARE UNIT
Presenter: Joost Plate, MD, Netherlands

INTRODUCTION AND EVALUATION OF THE ACS “B-CON BASICS” COURSE IN

ZARAGOZA, SPAIN
Presenter: Carlos Yanez, MD, Spain

VOLUME-OUTCOME RELATIONSHIP IN BURN CARE: ANALYSIS OF NATIONWIDE

ADMINISTRATIVE DATABASE
Presenter: Akira Endo, MD, PhD, Japan
 Session VIII: WTC I Session: Critical Care
Paper 1: 6:15am - 7:15am
CLINICAL, LABORATORY AND VENTILATORY PREDICTORS FOR
INTRA-ABDOMINAL HYPERTENSION IN SEPTIC SHOCK ICU PATIENTS
Alcir E. Dorigatti MD, Bruno M. Pereira MD,Ph.D., Marina Z. Melek MD, Vitor F.
Kruger MD, Jennifer L. Dos Santos Fernanda D. Teramoto Haline S. Batistoti MD,
Fernanda V. De Freitas MD, Marcos A. Boes Roberta N. Aoki Cesar V. Carmona MD,
Thiago M. Santos MD,Ph.D., Gustavo P. Fraga MD,Ph.D., University of Campinas
Introduction: Intra-Abdominal Hypertension (IAH) is a frequent complication in
critically ill patients. According to the World Sociey of the Abdominal Compartment,
physical examination is not an accurate diagnosis method and there are no predictive
factors whatsoever. The objective of this study is to search for IAH predictors in ICU
septic shock patients.
Methods: This is a prospective, single institution, observational study involving all septic
shock patients admitted at the ICU between April and October 2016. Sepsis criteria was
determined either by SEPSIS-3 and Surviving Sepsis Campaign concomitantly. Patients
with primary abdominal pathologies were excluded. Intra-Abdominal Pressure (IAP) was
assessed following WSACS protocols every 6 hours. Statistical analysis was performed
using Generalized Estimation Equations (GEE) method. Level of significance was 5%.
Results: Twenty-five patients were followed up for 10 days of hospitalization. The mean
age was 51.13 ± 16.52 years, 64% males. The pulmonary sepsis was present in 76% of
the cases. The increase in IAP correlated with the increase in CVP (p=0.0421); PEEP
(p=0.0056); ventilatory support pressure (p=0.0015); accumulated water balance (AWB)
(p=0.0273) and SOFA (p=0.0393). Acidosis reduction (p=0.0096) and increase in
bicarbonate (p=0.0247) in blood gas analysis were associated with lower IAP values. Cut
points values for AWB, PEEP, SOFA, pH and bicarbonate were found.
Conclusion: Clinical, ventilatory and gasometric parameters can be used as predictors for
IAH. Patients with values ​above the cut points should be actively monitored for IAH.
 Session VIII: WTC I Session: Critical Care
Paper 2: 6:15am - 7:15am
EXTERNAL VALIDATION OF THE HELSINKI COMPUTED TOMOGRAPHY
SCORE IN THE PREDICTION OF MORTALITY IN SEVERE TRAUMATIC
BRAIN INJURY
Jose D. Charry MD,Ph.D., Juan P. Solano MD, Fundación Universitaria Navarra

Introduction:Traumatic Brain Injury (TBI) is a public health problem. It is a pathology

that causes significant mortality and disability in Colombia. Different calculators and
prognostic models have been developed in order to predict the neurological outcomes of
these patients. The Helsinki computed tomography (CT) score was developed for
prognostic purposes in TBI. We aimed to examine the accuracy of the prognostic
discrimination and prediction of mortality of the Helsinki CT score in a cohort of trauma
patients with severe TBI in a university Hospital in Colombia.
Methods:We analyzed 145 patients with severe TBI treated in a regional trauma center in
Colombia over a 2 year period. Bivariate and Multivariate analyses were used. The
discriminatory power of the score, its accuracy and precision was assessed by logistic
regression and as the area under the receiver operating characteristic curve. Shapiro
Wilks, chi2 and Wilcoxon test were used to compare the real outcomes in the cohort
against the predicted outcomes.
Results:The median age of the patient cohort was 37 years, and 86.9% were male. The
median injury severity score (ISS) was 27, the median GCS motor score was 3, the basal
cisterns were closed in 37.93% of the patients and a midline shift of >5mm was seen in
41.98%. The six-month mortality was 24.8%, and the Helsinki CT score predicted a
mortality of 26% p <0,0001 (AUC 0,724 IC 95% 0,628-0,820).
Conclusion:The Helsinki CT score predicted mortality at 6 months in patients with
severe head trauma in a university hospital in Colombia. The Helsinki CT score is useful
for predicting early death and the prognosis of patients with TBI.
 Session VIII: WTC I Session: Critical Care
Paper 3: 6:15am - 7:15am
OPTIMIZING CRITICAL CARE OF THE TRAUMA PATIENT IN A
COST-EFFICIENT WAY: THE INTERMEDIATE CARE UNIT
Joost Plate MD, Linda M. Peelen Ph.D., Luke P. Leenen* MD,Ph.D., Falco Hietbrink
MD,Ph.D., UMC Utrecht
Introduction: The organization of specialized trauma care is an ongoing topic of debate,
especially with regard to the critical care facilities needed to optimize patient outcome.
The aim of this study was to describe the caseload, safety and cost-efficiency of critical
care of the trauma patient provided at the surgical Intermediate Care Unit (IMCU).
Methods: This cohort study included all trauma admissions between 01.01.2011 and
01.07.2015 at the general ICU, stand-alone neurosurgical IMCU and stand-alone surgical
IMCU of a level I trauma centre. Trauma mechanism, abbreviated injury scale (AIS) and
injury severity scores (ISS), vital signs, laboratory parameters, admission duration,
intubation duration, ICU transfer rate, and in-hospital mortality were prospectively
collected. Expected cost savings were calculated using the cost price per IMCU ($1,500)
and ICU ($2,500) admission day.
Results: A total of 1320 admissions were included, of which 645 (48.9%) at the ICU and
675 (51.1%) at the IMCU. Nearly all (n=620, 96.3%) ICU admissions were mechanically
ventilated. The IMCU admissions had a mean age of 54.2 (CI 53.1, 55.3) and median ISS
of 17 [IQR 11, 22]. The median duration of IMCU admission was 32.8 hours [IQR 18.8,
62.5]. At the IMCU one patient died due to a neurogenic shock. A subsequent ICU
transfer was required in 38 (5.6%) IMCU admissions, after a median admission time of
28.1 [IQR 16.3, 51.0] hours. Of these transfers, 4 patients died due to neurological
deterioration (cerebral herniation). Expected total cost savings due to the presence of the
IMCU were $1,772,785.
Conclusions: A substantial amount of trauma patients in need of critical care can safely
be admitted at the stand-alone specialist driven IMCU, without the need for further
mechanical ventilation. Thereby, the IMCU fulfils an essential and cost-effective role in
the management of severely injured trauma patients.
 Session VIII: WTC I Session: Critical Care
Paper 4: 6:15am - 7:15am
INTRODUCTION AND EVALUATION OF THE ACS “B-CON BASICS”
COURSE IN ZARAGOZA, SPAIN
Carlos Yanez MD, Antonio Guemes MD, Ana Navarro MD, Alberto Moreno MD,
Jacqueline Vazquez MD, Lozano Blesa Clinical University Hospital

Introduction: Our commitment as fellows of the ACS is to spread and promote the
principles of basic life saving techniques in massive bleeding patients using the
methodology of the “B-Con Basics” course. This course in new in Spain and we consider
it a very useful teaching tool for our society and for the public in general. Our objective
was the introduction, development and evaluation of the Bleeding Control “B-Con
Basics” course of the ACS among the college students and medical employees of the
public health system of Aragon in the city of Zaragoza, Spain. We also set out to assess
the degree of usefulness, relevance and applicability of the course content, as well as the
overall satisfaction of the course valued among the study population of city of Zaragoza
from December 2017 to March 2018.
Methods: To achieve our objectives we first had to obtain the official instructor
accreditation for the “B-Con Basics” course in the US. We accomplished it by doing the
regular course in October of 2018 in a level 1 Trauma Center in the state of California.
Having obtained instructor accreditation, we organized in a public university hospital in
Zaragoza and in the main university of the city an awareness campaign of the importance
of the stop the bleeding. Subsequently we conducted from December 2017 to March
2018, 4 free access courses. Of the four courses 2 were done in the university hospital
among nurses and physicians and 2 in the university for students. The methodology used
for the evaluation of the activity among participants was to conduct an anonymous survey
at the end of each course. The survey evaluated the variables of sex, age, occupation and
personal opinion of the participants regarding the relevance, usefulness and applicability
of the course content as well as the overall satisfaction. The surveys course content
variables were classified with a quantitative scale from 0 to 10 and converting them to a
qualitative scale of poor when graded from 0 to 3, fair from 4 to 6 and good from 7 to 10
for each of the four variables studied (relevance, usefulness, applicability and overall
satisfaction), the rest of the variables were analyzed in percentages.
Results: From December of 2017 until March of 2018 we organized 4 courses in total
with 83 assistants with an average of 20 participants per course. Most of the attendees
were female 51(61%) vs. 32(39%) males and the age ranged from 21 to 52 with an
average of 26 years. In the study population there were 46(56%) university students,
25(30%) hospital nurses and 12(14%) physicians. The results of the surveys for the
course contents were broken down by category for each of the variables. Overall
satisfaction and usefulness were the best valued with a good result by 70(84%) and
61(73%) of the participants respectively, followed by applicability and relevance with a
good evaluation in 58(70%) and 55(66%). There were no poor results in any of the course
content variables studied. In general, the attitude during the development of the courses
was friendly and of interest to the trainees.
Conclusions: The ACS “B-Con Basics Course” is a good valued course for teaching the
Basic techniques of hemorrhage control in the bleeding patient among university students
and public health employees of Aragon, Spain. Its content was considered as good for
relevance, usefulness and applicability by most of the studied population. The overall
satisfaction was good for the population to witch it was taught in Zaragoza.
 Session VIII: WTC I Session: Critical Care
Paper 5: 6:15am - 7:15am
VOLUME-OUTCOME RELATIONSHIP IN BURN CARE: ANALYSIS OF
NATIONWIDE ADMINISTRATIVE DATABASE
Akira Endo MD,Ph.D., Atsushi Shiraishi MD,Ph.D., Kiyohide Fushimi MD,Ph.D.,
Yasuhiro Otomo* MD,Ph.D., Trauma And Acute Critical Care Medical Center, Tokyo
Medical And Dental University Hospital Of Medicine
Introduction: Although hospital patient volume has been suggested to affect patient
outcomes in several diseases, it has been still under debate whether this association could
be observed in burn care. Assessment of healthcare costs based on burn patient volume
has been scarce.
Methods: We conducted retrospective observational study
including burn patients, using a Japanese national
administrative database between 2010–2015. We
established a case-mix adjustment model using burn
index, patient demographic, and interventions in acute
phase. A nonlinear generalized additive model (GAM)
was used to evaluate the associations between hospital
volume and the outcomes (in-hospital mortality and total
healthcare costs per admission). Logistic or linear
generalized estimating equation (GEE) models, adjusting
for patient severity and hospital characteristics
simultaneously, were also performed.
Results: Of 48,112 burn patients, 26,779 eligible patients
from 1,316 hospitals (maximum of 58 burn patients
annually) were analyzed. The case-mix adjustment model
established had well accuracy with the area under receiver
operating characteristics curve of 0.89. The GAM plots
suggested little association between hospital volume and
in-hospital mortality; however, the higher hospital
volume was associated with the higher healthcare costs
(Figure). While GEE models showed no significant
association for in-hospital mortality [adjusted odds ratio (95% CI) = 1.00 (0.99–1.00), p
= 0.336], a significant association was observed for healthcare costs [adjusted difference
(95% CI) for each patient increase = $332 ($297–$368), p <0.001].
Conclusion: HHigh hospital volume was not associated with in-hospital mortality but
significantly associated with high healthcare costs. Further study is needed with a range
of higher hospital volume than this study.
WTC 5: Polytrauma/Ortho Sponsored by German Trauma Society (DGU)
Location: Harbor B, Second Level (Harbor Tower)
Moderators: Marius Keel, MD and Bertil Bouillon, MD, Switzerland and Germany
Keynote: Bertil Bouillon, MD, S3 Polytrauma Guideline Germany
ADMISSION OF ISOLATED HIP FRACTURE PATIENTS TO A TRAUMA SERVICE
IMPROVES OUTCOMES
Presenter: Jerry Rubano, MD, USA

WHICH IS THE BEST TREATMENT FOR DISPLACED INTRA-ARTICULAR CALCANEAL

FRACTURES: A SYSTEMATIC REVIEW AND NETWORK META-ANALYSIS
Presenter: Xu-Xiang Peng, BS, MS,China

WITHDRAWN

COMPARISON OF OUTCOMES IN SEVERE PELVIC FRACTURES BETWEEN A SOUTH

KOREAN TRAUMA CENTER AND MATCHED PATIENTS TREATED IN THE UNITED STATES
Presenter: Kyoungwon Jung, MD, PhD, South Korea

HIP FRACTURE TIME-TO-SURGERY AND COMPLICATION/ MORTALITY RATE: IS THERE

A SIGNIFICANT DIFFERENCE?
Presenter: Adel Elkbuli, MD, MPH, USA
 Session VIII: WTC I Session: Polytrauma/Ortho
Paper 1: 6:15am - 7:15am
ADMISSION OF ISOLATED HIP FRACTURE PATIENTS TO A TRAUMA
SERVICE IMPROVES OUTCOMES
Jerry Rubano MD, Marc Shapiro MD, Daniel N. Rutigliano MD, Jane E. McCormack
RN, Emily C. Huang MS,James A. Vosswinkel MD, Randeep S. Jawa MD, Stony
Brook University Hospital
Introduction: Isolated hip fracture (IHF) is a common injury in the elderly. In late
2014, in preparation for ACS verification, our trauma center changed admission
practices for this group of patients so that they are largely admitted to the trauma
service. Previously, IHF patients were most often admitted to a medical service. In
this before-after quality assurance study, we evaluated the effects of this change on
outcomes.
Methods: A retrospective review of the trauma registry at an ACS level I trauma
center was performed for all elderly (age ≥65 years) blunt trauma patients discharged
between 2013 and 2016, with a focus on patients with IHF. IHF was defined as a
fracture of the femoral head, neck, and/or trochanteric region with no other injuries
other than minor skin or soft tissue injuries, occurring after a fall. Comorbidities and
complications were recorded concurrently, and as defined by the annually revised
National Trauma Data Standard data dictionary.
Results: There were 3437 geriatric blunt trauma admissions. Of these, 656 (19.1%)
had an isolated hip fracture, 264 were admitted before change and 298 were admitted
after the change in admission practice. The patients were generally female, had
comparable median age and comorbid conditions (Table). Both had ISS of 9. After
the change, hospital length of stay (LOS) remained similar (7 [IQR 5-9] vs 7 days
[IQR 6-10], p=0.27), but more patients were admitted to the stepdown unit (68.2% vs
19.8%, p<0.001) and to the ICU (5.1% vs 0.4%, p<0.001) than before the change.
Fewer patients were admitted to the floor (after 8.9% vs 75.9% before, p<0.001) .
After this change in our practice, fewer patients developed a complication (10.7% vs
17.4%, p=0.02) than before. Discharge disposition was not significantly different,
with the majority of patients in both groups being discharged to rehabilitation facilities
(80.5% after vs 79.5% before, p=0.77). While the percentage of patients with in-
hospital mortality decreased to 0.7% after the change from 1.5% before, this did not
reach statistical significance (p=0.33).
Conclusion: Nearly 20% of our elderly blunt trauma admissions, excluding ED deaths
and burns, were for IHF. After implementing a practice change of admitting elderly
isolated hip fracture patients to the trauma service, fewer patients developed
complications. This reduction in complications corresponds to an increase in the
intensity of care provided, as measured by increased step-down and ICU utilization.
Likely, patient admission to a single unified trauma service with protocols and a
unified qualified assurance process contributed.
 Session VIII: WTC I Session: Polytrauma/Ortho
Paper 2: 6:15am - 7:15am
WHICH IS THE BEST TREATMENT FOR DISPLACED INTRA-ARTICULAR
CALCANEAL FRACTURES: A SYSTEMATIC REVIEW AND NETWORK
META-ANALYSIS
Xu-Xiang PENG BS, Master of Surgery, Xiao-Min WU BS, Master of Surgery, Yu PAN
MD, Chun-Ye LI MD, Bao-An People's Hospital, Affiliated To Southern Medical
University & Affiliated To Guangdong Medical University
Introduction: Displaced Intra-Articular Calcaneus Fractures (DIACFs) represent a
source of tremendous disability to the patient, economic burden to the society and a
treatment challenge to the average orthopaedic surgeon. Open reduction and internal
fixation (ORIF), minimally invasive surgery (MIS), external fixator (EF), external fixator
combined with limited internal fixation (EFLIF) and non-surgical treatment (NST) are
mostly used for the treatment of DIACFs. However, no single approach is universally
applicable to all calcaneus fractures. More over, previous studies was still unclear and
have offered conflicting recommendations. The purpose of this study is to
comprehensively review the literature and ascertain the relative efficacy and safety of
ORIF, MIS, EF, EFLIF and NST for patients with DIACFs using a Bayesian network
meta-analysis.
Methods: We will comprehensively search PubMed, EMBASE, Cochrane Library,
Medline, Science Direct, CBM and CNKI from the inception dates to January 01, 2018,
to include potentially relevant randomized controlled trials (RCTs) and cohort studies
(CSs) that evaluated interventions for treating adults with DIACFs. The quality of
included studies was assessed using the Newcastle-Ottawa Scale and the risk of bias
according to the Cochrane Handbook. After independent study selection by 2 authors,
data were extracted and collected independently. The primary outcome measures were
anatomical measures, functional measures, and complications. The data of RCTs and CSs
were pooled respectively using the fixed-effect model or random-effect model. Mean
differences (MDs) with 95% confidence intervals (CIs) were calculated for continuous
data, and relative risks (RRs) with 95% CIs were calculated for dichotomous data.
Statistical heterogeneity was assessed with the Q test and I2. Sensitivity analysis was
developed to assess the reliability of pooled results.
Results: Seventeen trials (5 RCTs and 12 CSs) including 2369 patients were considered
in the study. EFLIF had significantly the highest AOFAS Ankle Hindfoot Scale (MD,
9.54 [95% CI, 5.97 to 17.42]) and lower total incidence of complications (RR, 1.65 [95%
CI, 1.27 to 2.54]) than ORIF, MIS, EF and NST. Moreover, EFLIF resulted in a lower
incidence of additional surgery (RR, 3.47 [95% CI, 2.28 to 6.95]) than ORIF and NST.
The rank of anatomical recovery was: EFLIF, ORIF, EF, MIS and NST. The rank of
functional recovery was: EFLIF, ORIF, MIS, EF and NST. For reduction in total
incidence of complications, the rank was: EFLIF, NST, EF, MIS and ORIF.
Conclusion: EFLIF has the highest probability of improving the functional outcome and
reducing the total incidence of complications and additional surgery among the five
interventions for treating adults with DIACFs.
PAPER 3 - WITHDRAWN
 Session VIII: WTC I Session: Polytrauma/Ortho
Paper 4: 6:15am - 7:15am
Comparison of outcomes in severe pelvic fractures between a South Korean trauma
center and matched patients treated in the United States.
Kyoungwon Jung MD,Ph.D., Shokei Matsumoto* MD, Alan Smith Ph.D., Kyungjin
Hwang MPH,RN, John Cook-Jong Lee MD,Ph.D., Ajou University School Of Medicine
Introduction: This study aimed to compare treatment outcomes between patients with
severe pelvic fractures at a representative trauma center which was established in Korea
since 2015 and matched cases in the United States.
Methods: Two cohorts were selected from a single institution trauma database in South
Korea (ATDB) and the National Trauma Data Bank (NTDB) in the United States (US).
Adult blunt trauma patients with a pelvic Abbreviated Injury Scale >3 were included.
Patients were matched based on covariates that affect mortality rate using a 1:1 propensity
score matching (PSM)

approach. We compared differences in outcomes between the two groups, performed

survival analysis for the cohort after PSM, and identified factors associated with
mortality. Lastly, we analyzed factors related to outcomes in the ATDB dataset
comparing a period prior to the implementation of the trauma center according to US
standards, an interim period, and a post-implementation period.
Results: After PSM, a total of 320 patients (160 in each cohort) were identified for
comparison. In-hospital mortality was significantly higher in the ATDB cohort using chi-
square test, but it was not statistically significant when using Kaplan-Meier survival
curves and Cox regression analysis. Moreover, the mortality rate was similar comparing
the NTDB cohort to ATDB data reflecting the post-trauma center establishment period.
Older age, lower SBP and GCS on admission were factors associated with mortality.
Conclusion: Mortality rate following severe pelvic fractures was significantly associated
with older age, lower SBP and GCS scores on admission. Efforts to establish a trauma
center in South Korea led to improvement in outcomes, which are comparable to those in
US centers.
 Session VIII: WTC I Session: Polytrauma/Ortho
Paper 5: 6:15am - 7:15am
HIP FRACTURE TIME-TO-SURGERY AND COMPLICATION/ MORTALITY
RATE: IS THERE A SIGNIFICANT DIFFERENCE?
Adel Elkbuli MD,MPH, Alyssa Ely BS, [Link], Valerie Polcz BS, MS, Brenda Benson RN,
Eileen Bernal MD, Mark McKenney MBA,MD, Shaikh Hai MD, FACS, Dessy Boneva
MD, Kendall Regional Medical Center

Introduction: Post-operative complications impose a significant burden on patient

outcomes and cost of medical care. Our aim was to determine the relationship between time
to surgery and post-operative complications/mortality in patients with hip fracture.
Methods: A retrospective review of data collected from our institution’s trauma registry for
adult patients with hip fracture and subsequent repair from 2015-2017. Patients were
stratified into two groups based on time to surgery after admission 24-48 hours (Group 1) vs
>48 hours (Group 2). Demographic variables included age, gender, race, and Injury Severity
Score (ISS). Outcome variables included Intensive Care Unit Length of Stay (ICU-LOS),
DVT/PE rate, mortality, and readmission status. ANOVA was used for data analysis with
statistical significance defined as p-value <0.05.
Results: A total of 485 patients with hip fracture required surgical intervention. Of those,
460 had surgery at <24-48 hours, and 25 had surgery >48 hours
post-admission. Average ISS was the same in both groups. The average ICU-LOS was
statistically significant higher in >48 hours group compared to <24-48 hour group (4 vs 2)
(p-value <0.0002). There was no statistically significant difference between groups when
comparing DVT/PE rate, 30-day readmission, or mortality.
Conclusion: Time to surgery may affect overall ICU-LOS in patients with hip fracture
requiring surgical intervention. Time to surgery does not affect complication rates or
mortality. Future research should investigate long-term outcomes such as functional status
and Disability-Adjusted Life Years.
WTC 6: Geriatrics Sponsored by ESTES
Location: Harbor A, Second Level (Harbor Tower)
Moderators: Ingo Marzi, MD and Christoph Josten, MD, Germany
Keynote: Christoph Josten, MD, The New Classifications of Fragility Fractures of the
IMPLEMENTATION OF NEW STANDARD OPERATING PROCEDURES: WHAT ARE THE
BENEFITS FOR GERIATRIC TRAUMA PATIENTS WITH MULTIPLE INJURIES.
Presenter: Kai Jensen, MD, Switzerland

CHARACTERISTICS OF TRAUMA MECHANISMS AND ANATOMICAL DISTRIBUTION

OF INJURY IN GERIATRIC PATIENTS; A DESCRIPTIVE ANALYSIS OF THE NATIONWIDE
TRAUMA REGISTRY OF THE WORLD’S FASTEST AGING COUNTRY
Presenter: Mitsuaki Kojima, MD, PhD, Japan

EMERGENCY/TRAUMA SURGEONS REPORT PRESCRIBING LESS OPIOIDS OVER TIME

Jamie Anderson, MD, MPH, USA

TRAFFIC ACCIDENTS FOR GERIATRIC CYCLIST IN JAPAN

Presenter: Yuta Oyama, MD, Japan

PREDICTION OF MORTALITY AND MORBIDITY EVALUATING WITH SARCOPENIA IN

JAPANESE GERIATRIC TRAUMA PATIENTS
Presenter: Takeshi Nishimura, MD, Japan
 Session VIII: WTC I Session: Geriatrics
Paper 1: 6:15am - 7:15am
Implementation Of New Standard Operating Procedures: What Are The Benefits
For Geriatric Trauma Patients With Multiple Injuries.
Kai O. Jensen MD, Lorenz Peterer MD, Georg Osterhoff MD, Ladislav Mica MD, Hans
P. Simmen MD, Hans C. Pape MD, Kai Sprengel MD, University Hospital Zurich

Introduction: The demographic changes towards ageing of the populations in developed

countries imposes a challenge to trauma centers, as geriatric trauma patients require
specific diagnostic and therapeutic procedures. This study investigated whether the
integration of new standard operating procedures (SOPs) for the resuscitation room (ER)
has an impact on the clinical course in geriatric patients. The new SOPs were designed for
severely injured adult trauma patients, based on the Advanced Trauma Life Support
(ATLS) and imply early whole-body computed tomography, damage control surgery, and
the use of goal-directed coagulation management. We investigated whether there were
changes in the in-hospital mortality, infection rate, and rate of palliative care after the
implementation of new SOPs.
Methods: Single-center cohort study. We included all patients >= 65 years of age with an
Injury Severity Score (ISS) >= 9 who were admitted to our hospital primarily via ER. A
historic cohort was compared to a cohort after the implementation of the new SOPs.
Person’s chi-square, Fisher’s exact and Mann–Whitney U test were used to compare the
treatments. Binary logistic regression analysis was conducted to measure the strengths of
associations and to identify possible risk factors.
Results: We enrolled 311 patients who met the inclusion criteria between 2000–2006
(group PreSOP) and 2010–2012 (group SOP). In group SOP, the mortality rate was
significant lower (64.1% vs. 44.4%; standardized mortality ratio 0.90 vs. 0.70, P = .001)
whereas the rate of infections (21.4% vs. 21.9%) and palliative care (23.7% vs. 28.3%)
was comparable and not significant different with group PreSOP. TBIs were the leading
cause of death in both time periods (60.2% vs. 72.5%). However, the rate of
exsanguinating patients decreased from 26.5% to 7.5%. This benefit was seen only for
severely injured patients (ISS ≥ 16), but not for moderately injured patients (ISS 9–15).

Conclusion: Our findings suggest that the implementation of new SOPs comprising early
whole-body CT, damage control surgery, and the use of goal-directed coagulation
management significantly reduced the mortality rate in severely injured geriatric trauma
patients, whereas moderately injured patients seemed not obtain the same benefit and
with no influence on the infection rate. Further research is needed to improve the
outcomes for this fast-growing population.
 Session VIII: WTC I Session: Geriatrics
Paper 2: 6:15am - 7:15am
CHARACTERISTICS OF TRAUMA MECHANISMS AND ANATOMICAL
DISTRIBUTION OF INJURY IN GERIATRIC PATIENTS; A DESCRIPTIVE
ANALYSIS OF THE NATIONWIDE TRAUMA REGISTRY OF THE WORLD'S
FASTEST AGING COUNTRY
Mitsuaki Kojima MD,Ph.D., Akira Endo MD,Ph.D., Atsushi Shiraishi MD,Ph.D.,
Yasuhiro Otomo MD,Ph.D., Tokyo Medical and Dental University
Introduction: The burden of trauma among elderly patients has been increasing in
developed countries and is characterized by a higher prevalence of post-injury mortality
and requirement of more substantial healthcare resources. People aged 65 years and older
comprised 26.7% of the entire Japanese population in 2015 and were nearly twice that of
the United States. We performed a comprehensive analysis of Japan’s nationwide trauma
registry that may include the highest proportion of the aged population to study the
age-related changes in characteristics of trauma patients.
Method: We performed a retrospective observational study of the Japan Trauma Data
Bank between 2004 and 2015 to evaluate the age-related changes in mechanisms,
anatomical distribution of injury and injury severity, physiological status, and outcomes of
trauma patients. Characteristics of the trauma patients were assessed according to age,
which was categorized into 10-year intervals. The nonlinear correlation between age and
in-hospital mortality of trauma patients were assessed using a generalized additive model
(GAM) where the model was adjusted for both anatomy- and physiology-based trauma
severity (Injury Severity Score [ISS] and Revised Trauma Score), and age was
incorporated into the model as a continuous variable.
Results: Of a total of 128,036 severe trauma patients (ISS ≥9) included in the analysis,
67,279 (52.5%) patients were 60 years or older. The proportion of the elderly patients
aged ≥ 60 years increased from 31.4% to 59.1% over the observation period. The majority
of trauma in the older groups was caused by ground-level falls, while younger groups
experienced high-energy mechanisms such as traffic accidents (Figure 1). The proportions
of lower extremity injuries were higher among those aged 70 years and older (31.6%,
50.1%, and 70.5% corresponded to the 70-79, 80-89 and 90+ year age groups,
respectively) in comparison to the younger groups (26.1% among those younger than 60
years). The GAM plot revealed that the adjusted odds ratio for in-hospital mortality
increased monotonically with increasing age (Figure 2).

Conclusion: Here, we described the unique mechanism of injury and pattern among
elderly trauma patients, as well as age-related increase in risk for in-hospital mortality.
These results may provide valuable information to societies faced with aging to recognize
the specialty of geriatric trauma care.
 Session VIII: WTC I Session: Geriatrics
Paper 3: 6:15am - 7:15am
EMERGENCY/TRAUMA SURGEONS REPORT PRESCRIBING LESS OPIOIDS
OVER TIME
Jamie E. Anderson MD,MPH, Christine S. Cocanour MD, Joseph M. Galante MD,
University Of California, Davis
Introduction: Confronted with the opioid epidemic, surgeons must play a larger role to
reduce risk of opioid abuse while managing acute pain. Having a better understanding of
the beliefs and practices of emergency/trauma surgeons regarding discharge pain
management may offer potential targets for interventions beyond fixed legal mandates.
Methods: An IRB-approved electronic survey was sent to emergency/trauma surgeons
who are members of AAST, and separately, emergency/trauma surgeons and nurse
practitioners at a Level I Trauma Center in February 2018. The survey included 4
case-based scenarios and questions about discharge prescription practices and beliefs.
Results: Of 66 respondents, most (88.1%) were at academic institutions. Mean number of
opioid tablets prescribed was 20-30 (range 5-90), with the fewest tablets prescribed for
elective laparoscopic cholecystectomy and the most for rib fractures. Few prescribed both
opioid and non-opioid medications (22.4-31.4%). Most would not change the amount,
dose, or type of medication prescribed at discharge (53.9%-83.1%) if patients used
opioids regularly prior to their hospitalization. The most common factors that made
providers more likely to prescribe opioids were high opioid use in the hospital (32.4%),
history of opioid use/abuse (24.5%), and if the patient lives far from the hospital
(12.9%). The most common factors that made providers less likely to prescribe opioids
were frailty (24.4%), older age (23.3%), low body-mass index (7.6%), and history of
drug/alcohol abuse (7.6%). Most providers (56.9%) give patients detailed instructions on
how to wean off opioids. Less than half (47.0%) reported their hospital has prescriptive
opioid practice guidelines. For providers in practice >5 years, most reported a decrease in
opioids (71.9%) and an increase in non-opioids prescribed (76.6%) at discharge.
Conclusion: Emergency/trauma surgeons and nurse practitioners reported decreasing the
number/amount of opioids prescribed over their practice. Patients with high opioid use in
the hospital, history of opioid use/abuse, or who live far from the provider may be
prescribed more opioids at discharge. Offering detailed instructions for weaning opioids
and hospital-based practice guidelines are potential interventions to help decrease risk of
opioid abuse.
 Session VIII: WTC I Session: Geriatrics
Paper 4: 6:15am - 7:15am
TRAFFIC ACCIDENTS FOR GERIATRIC CYCLIST IN JAPAN
Yuta OYAMA MD, Takashi FUJITA MD,Ph.D., FACS, Shinji NAKAHARA MD,Ph.D.,
Yasufumi MIYAKE MD,Ph.D., Tetsuya SAKAMOTO MD,Ph.D., Teikyo University
School of Medicine

Introduction: Traffic injuries among the elderly are increasing in Japan. A bicycle is an
important transportation for elderly people who are not able to walk long distance or drive a
car. The purpose of this study was to describe injured body regions among the elderly
cyclists compared with young population and the fatal injuries among them with the sample
of Japan Trauma Data Bank (JTDB).
Methods: We extracted data of cyclist injuries from the JTDB2016. Those with complete
data of Age, ISS, Max AIS of 9 body region, and mortality were analyzed. The subjects
were divided into two groups by age. Yong group(YG) was defined as the age from15 to 64
and old group(OG) was done as more than 65. We also conducted subgroup analysis for old
group between the survived and dead. Mann-Whitney’s U test was used for non-
parametrical analysis.
Results: In YG, 120037 subjects were extracted and median ISS(IQR) was 13(9-21). In
OG, for 4618 subjects, median ISS(IQR) was 16(9-25) (p<0.001). Median Max AISs(IQR)
for head, abdomen and spine by YG vs. OG were 3(2-4) vs.4(3-4) (p<0.001), 2(2-3)
vs.2(2-3) (pΩ 0.001), 2(2-4) vs.3(2-4) (p<0.001) respectively. Subgroup analysis for OG
revealed that Median(IQR)of Max AISs compared death to survive were 5(4-5) vs.3(3-4)
(p<0.001) in head, 4(3-4) vs.3(2-4) (p<0.001) in chest, 3(2-4) vs. 2(2-3) (p<0.001) in
abdomen.
Conclusion: Geriatric cyclists tended to sustain severe injuries in their head, abdomen and
spine. For 65 and over population, severe injuries in head, chest and abdomen were
associated with mortality. We must advocate more strongly about helmet wearing for
geriatric cyclist. Prevention for chest injury and abdominal injury is the next target of
intervention by medicine-engineering collaboration.
 Session VIII: WTC I Session: Geriatrics
Paper 5: 6:15am - 7:15am
Prediction of Mortality and Morbidity evaluating with Sarcopenia in Japanese
Geriatric Trauma Patients
Takeshi Nishimura MD, Shigenari Matsuyama MD, Satoshi Ishihara Ph.D., Shinichi
Nakayama Ph.D., Hyogo Emergency Medical Center
Introduction: Sarcopenia is assumed as a predictor of the poor outcome after surgery.
However, an association between a prognosis of trauma and sarcopenia has not been
documented well. The purpose of this study was to evaluate the outcome of trauma with
sarcopenia, by comparing it with non-sarcopenia in the Japanese elderly patients. We
hypothesized that sarcopenia had a great influence on the outcome of geriatric trauma.
Methods: Medical records of over 65-year-old trauma patients, who were transported to
our center from 2010 to 2017, were retrospectively reviewed. Psoas muscle index (PMI),
where total psoas muscle area at L3 level on computed tomography on arrival divided by
body surface area, was measured in each case. Sarcopenia was defined that PMI was less
than lower inter quartile range in each gender. Patient’s background, Injury Severity Score
(ISS), mortality, and morbidity were analyzed. Via a questionnaire mailed to the patients,
1-year survival and activity of daily living (Barthel index) were obtained.
Results: Overall, 405 patients were included in this study. There were 101 in Sarcopenia
group (S) and 304 in Non-sarcopenia group (NS). Patients’ background and ISS were not
significantly different. Concerning morbidity, more pneumonia tended to occur in S (S;
17.5% vs NS; 23.8%, p=0.065), but numbers of cases, complicating urinary tract infection
and venous thromboembolism, were similar in both groups. It was noted that mortality
was higher in S than NS (S; 15.8% vs NS; 7.9%, p=0.032). Although 169 patients
answered the questionnaires, the results had no significant difference between groups.[1-
year survival: 34/37 (91.9%) in S vs 118/132 (89.4%) in NS. Barthel index; 100
(63.5-100) in S vs 100 (75-100) in NS].
Conclusion: Sarcopenia, defined by PMI, can be a trusted predictor in mortality among
geriatric trauma patients.
WTC 7: Emergency General Surgery Sponsored by WSES
Location: Coronado B, Fourth Level (Harbor Tower)
Moderators: Mauro Zago, MD and Salomone Di Saverio, MD, FRCS (Eng), Italy and United
Kingdom
Keynote: Salomone Di Saverio, MD, FRCS (Eng), Acute Appendicitis GL
MATCHING THREE CLINICAL SCORES WITH SURGEON-PERFORMED ULTRASOUND
IN THE DIAGNOSIS OF ACUTE APPENDICITIS: PRELIMINARY RESULTS OF A
PROSPECTIVE STUDY
Presenter: Mauro Zago, MD, Italy

PROGNOSTIC VALUE OF P-POSSUM AND OSTEOPENIA FOR PREDICTING MORTALITY

AFTER EMERGENCY LAPAROTOMY IN GERIATRIC PATIENTS
Presenter: Rebecka Ahl, MD, Sweden

REBOA: NOT JUST FOR TRAUMATIC HEMORRHAGIC SHOCK ANYMORE

Presenter: Joseph Ibrahim, MD, USA

DAMAGE CONTROL OR DEFINITIVE REPAIR? A RETROSPECTIVE AUDIT OF

ABDOMINAL TRAUMA AT A SOUTH AFRICAN CENTRE.
Presenter: Ross Weale, MBBS, BSc, South Africa

A CHANCE TO CUT: DEFINING A NEGATIVE EXPLORATION RATE IN PATIENTS WITH

SUSPECTED NECROTIZING SOFT TISSUE INFECTION
Presenter: Erin Howell, MD, USA
 Session VIII: WTC I Session: Emergency General Surgery
Paper 1: 6:15am - 7:15am
MATCHING THREE CLINICAL SCORES WITH SURGEON-PERFORMED
ULTRASOUND IN THE DIAGNOSIS OF ACUTE APPENDICITIS:
PRELIMINARY RESULTS OF A PROSPECTIVE STUDY
Mauro Zago* MD, Samantha Bozzo MD, Alessia Malagnino MD, Claudio Gianotti MD,
Giulia Carrara MD, Maria Masutti MD, Diego Mariani MD, Matteo Zago Ph.D., BME
Policlinico San Pietro

Introduction: Clinical scores are used in clinical practice as a tool for diagnosing acute
appendicitis, such as the Alvarado, Acute Inflammatory Response Score (AIR), and the
Adult Appendicitis Score (AAS). At present, no studies integrating ultrasound (US) with
all the three clinical scores are available in literature.
Methods: Eighty-one patients (pts) with a suspicion of acute appendicitis were
prospectively enrolled (37 M, 44 F). The Alvarado and AIR scores were calculated for all
pts, the AAS for adult pts only (> 18 y/o). Stratification consisted of 3 groups for each
score: low , intermediate, and high probability of acute appendicitis. A
surgeon-performed US completed the assessment. Differences between proportions of
positive US (US+) vs. negative US (US-)/other diagnosis were tested within each score
level using "N-1" Chi-squared tests. 95% Confidence Intervals (95%CI) were also
computed. Accuracy, sensitivity and specificity of US were computed. Significance level
was set at alpha = 0.05. A phone follow-up was done on non operated pts at three months.
Results: US sensitivity, specificity and accuracy in the overall population are shown on
Table 1. US was positive in 27, negative in 41 (1 false negative in
an adult, 1 in a child), and in 13 obtained an alternative diagnosis.
Hystology confirmed appendicitis in all operated pts. The phone
follow-up excluded relapse of symptoms or appendectomy in all
US- pts. The comparison between US+ vs. US-/other diagnosis in
the overall population is shown in Table 2. The rate of pts with
US proved appendicitis in the low probability groups ranges from 17,1% (Alvarado) to
19,2% (AIR) [p<0.001]. Conversely, 23,5% in the high probability Alvarado score
had appendicitis, only 27,5% in the
intermediate [p<0.003 and 0.001,
respectively]. Among AIR intermediate
score pts, 42,8% had no appendicitis
(p=NS). Table 3 shows the comparison of
proportions in the adult population (all
scores). AAS got 81% of US+ in the
intermediate risk group.
Conclusion: Surgeon-performed US can
potentiate the accuracy of clinical decision
making. Whatever is the therapeutic strategy
(non-operative vs. surgery), US reduces both
over- and under-treatment rates. Its role
seems higher in the low probability groups
for all scores, avoiding undiagnosed
appendicitis (17-29%). AIR score seems
unreliable in the intermediate risk group (>
40% of US-). Its use in algorithms without
imaging should be questioned.
 Session VIII: WTC I Session: Emergency General Surgery
Paper 2: 6:15am - 7:15am
PROGNOSTIC VALUE OF P-POSSUM AND OSTEOPENIA FOR PREDICTING
MORTALITY AFTER EMERGENCY LAPAROTOMY IN GERIATRIC
PATIENTS
Rebecka Ahl MD, Xin Fang PhD student, Hakan Geijer MD,Ph.D., Kardo Taha MD,
Sahar Pourhossein MD, Peep Talving* MD,Ph.D., Olle Ljugqvist MD,Ph.D., Shahin
Mohseni MD,Ph.D., OREBRO University Hospital, Sweden

Introduction: Portsmouth - Physiological and Operative Severity Score for the

enumeration of Mortality and Morbidity (P-POSSUM) score is widely utilized for
operative mortality prediction. Its applicability to emergency laparotomy operations in
geriatric patients is lacking. The present study evaluates the P-POSSUM in a comparison
with other risk factors for mortality including osteopenia as an indicator for frailty in
geriatric patients subjected to emergency laparotomy.
Methods: Retrospective analysis of all consecutive patients (≥ 65 years) subjected to an
emergency laparotomy between 1/2015 and 12/2016. Data accrued included
demographics, pre-operative laboratory values, Charlson’s co-morbidity index, American
Society of Anesthesiologist (ASA) Score, indication and type of operation, osteopenia, P-
POSSUM score, post-operative complication, ICU and hospital length of stay, and 30-day
mortality. Association between prognostic markers and 30-day mortality was assessed
using log-binomial regression model. Confounding variables were selected using
backward stepwise method. Prognostic value was evaluated using receiver operating
characteristic (ROC) curve and Youden’s J statistic was used to find optimum cut-off
point.
Results: A total of 209 patients were available for analysis. The main surgical procedures
were small bowel resection, adhesiolysis, large bowel resection, diverting stoma, and
miscellaneous procedures at 15% (n=31), 18% (n=38), 21% (n=43), 16.7% (n=35), and
30% (n=62), respectively. Poor association was observed between P-POSSUM and
mortality [relative risk (RR)=1.01, 95% (CI): 1.00 - 1.02, p=0.21]. Also, a poor
prognostic value for 30-day mortality (area under ROC=0.49) was noted. According to
Youden’s optimum cut-off point on the ROC curve, the optimal sensitive and specificity
for P-POSSUM were 0.26 and 0.83 respectively. Age, systolic BP, ASA= 4, BMI, PRBC
transfusions and postoperative infections were associated with 30-day mortality.
Osteopenia was not statistically significant in multivariate analysis (adj. RR=1.05, 95%
CI: 0.67 – 1.66, p=0.82). Multivariate log-binomial regression model outperformed the P-
POSSUM (c 2=28.61, p<0.001). However, osteopenia contributed little to the prognostic
value of the regression model (area under ROC increases from 0.8087 to 0.8092).
Conclusion: The P-POSSUM and osteopenia performed poorly in prediction of 30-day
post emergency laparotomy mortality. External validation of these findings is warranted.
 Session VIII: WTC I Session: Emergency General Surgery
Paper 3: 6:15am - 7:15am
REBOA: NOT JUST FOR TRAUMATIC HEMORRHAGIC SHOCK ANYMORE
Joseph A. Ibrahim MD, Karen Safcsak RN, Michael L. Cheatham MD, Orlando Health

Introduction: Resuscitative endovascular balloon occlusion of the aorta (REBOA)

effectively improves survival among traumatically injured patients with uncontrolled
hemorrhagic shock. REBOA can also be used in non-trauma patients with similar
success. We report our experience using REBOA in obstetric, general surgery, and
cardiology patients.
Methods: REBOA has been used extensively in our Level 1 trauma center with relatively
high success (56% survival rate). As part of our hospital quality improvement process, we
identified several non-trauma indications where rapid control of hemorrhage could be
beneficial. The concept of REBOA was introduced to the non-trauma surgical services
including the 24/7 availability of trauma surgeons to perform REBOA. All non-trauma
REBOA insertions were reviewed.
Results: 6 non-trauma patients underwent REBOA for hemorrhagic or cardiogenic shock.
Two emergent and 1 elective obstetric REBOA insertions were performed for either
placenta previa or accreta. Both emergent patients were in profound hemorrhagic shock
requiring massive transfusion protocol; 1 was in cardiac arrest. REBOA was performed
without complication and all 3 patients survived to be discharged home. One elective
splenectomy patient developed profound hemorrhage intra-operatively. REBOA was
performed allowing the procedure to be completed with little additional blood loss. The
patient subsequently had care withdrawn due to their medical comorbidities. One
pancreaticoduodenectomy patient returned 3 weeks post-operatively with acute
hemorrhage from the right hepatic artery. REBOA was performed, controlling the
hemorrhage and rescuing the patient allowing them to be discharged home. One patient
presented following motor vehicle crash due to a witnessed cardiac arrest. The patient
regained perfusion through cardiopulmonary resuscitation in the field, but arrived
hypotensive in cardiogenic shock. No traumatic injuries were found. REBOA was
performed with improvement in cardiac perfusion resulting in patient survival and
discharge home.
Conclusion: While REBOA was originally intended for control of traumatic hemorrhage,
we have successfully used REBOA for several non-trauma indications with similar patient
survival. Trauma surgeons who perform REBOA can be a valuable resource to both
elective and emergent non-trauma surgical patients.
 Session VIII: WTC I Session: Emergency General Surgery
Paper 4: 6:15am - 7:15am
DAMAGE CONTROL OR DEFINITIVE REPAIR? A RETROSPECTIVE AUDIT
OF ABDOMINAL TRAUMA AT A SOUTH AFRICAN CENTRE.
Ross D. Weale MBBS, BSc, Victor Kong Ph.D., MBChB, Johan Buitendag MBChB,
Joanna Blodgett BSc, Damian L. Clarke Ph.D., MBChB Pietermaritzburg Metropolitan
Trauma Service, Department Of Surgery
Introduction: The indications for damage control surgery (DCS) rely heavily on clinical
judgement. This audit set out to assess and compare the presenting physiology and organ
injury pattern of the DCS patient vs the non-DCS patient and to use this data to assess if
any of four clinical prediction scores, namely PATI (penetrating abdominal trauma index),
ISS (injury severity score), AIS-abdomen (abbreviated injury scale-abdomen) and AIS-
chest, are predictive of the need for DCS.
Methods: All patients undergoing a laparotomy for trauma over the period from
December 2012 to December 2017 at a Major Trauma Centre in South Africa were
retrieved from the regional database. Statistical analysis was performed using STATA
15.0 ©.
Results: A total of 562 patients were included in this analysis, all of which underwent
trauma laparotomy. 99 of these (18%) had a DCS procedure vs 463 (82%) non-DCS. In a
multiple logistic regression model, the only predictive scoring system significantly
associated with the need for DCS was the PATI score (p 0.044). Neither ISS (p 0.293),
AIS-abdomen (p 0.194) nor AIS-chest (p 0.325) were statistically significant. A multiple
logistic regression model revealed a significant association with SBP <90 mmHg (systolic
blood pressure) (p 0.005), pH <7.2 (p 0.001), PATI score (p 0.019) and liver injury (p
0.004). Pancreatic-duodenal injury (p 0.586) and IAVI (p 0.156) were not significant in
this model in their prediction for DCS.
Conclusion: This comprehensive analysis proves that even aggregate anatomical scores
are not nearly as predictive as physiology when considering the need for DCS. This is in
keeping with the central tenet of damage control surgery, which focuses on the correction
of physiological rather than anatomic status.
 Session VIII: WTC I Session: Emergency General Surgery
Paper 5: 6:15am - 7:15am
A CHANCE TO CUT: DEFINING A NEGATIVE EXPLORATION RATE IN
PATIENTS WITH SUSPECTED NECROTIZING SOFT TISSUE INFECTION
Erin C. Howell MD, Jessica A. Keeley MD, Amy H. Kaji MD,Ph.D., Molly R. Deane
MD, Dennis Y. Kim* MD, Brant Putnam* MD, Steven L. Lee MD, Alexis L. Woods
BA, Angela L. Neville* MD, Harbor-UCLA Medical Center

Introduction: Multiple predictive models exist for the identification of necrotizing soft
tissue infection (NSTI), yet a subset of patients will not have NSTI at exploration. We
hypothesize non-NSTI patients are clinically similar to those patients that have an NSTI
and seek to report a rate of negative exploration for this disease process.
Methods: We conducted a retrospective review of patients (n= 295) undergoing surgery
for suspected NSTI at our county funded, academic medical center between 2008-2015.
Patients with NSTI identified surgically were compared to patients with negative
explorations.
Results: Over the 7-year study period, 232 (79%) patients were diagnosed with an NSTI
at the initial surgery and 63 (21%) were not. Of these 63 patients, 5 (7.9%) had an abscess
and 58 (92%) had cellulitis resulting in a total of 237 (80%) patients with a surgical
disease process. NSTI patients had higher white blood cell count and blood glucose levels,
but were less likely to have violaceous skin changes. Other presenting clinical variables
were similar between patients with and without NSTI (Table). Eight (14%) patients
initially diagnosed with cellulitis had an NSTI diagnosed upon return to the operating
room for failure to improve.

Median values with IQR unless otherwise specified

Conclusion: Given the known implications of delayed surgical management, we

propose a 20% negative exploration rate for suspected NSTI. Ongoing vigilance of this
cohort is warranted as a small subset may progress.
 4:45-5:45 P.M.
4:45-5:45 pm WTC 8: Research Sponsored by European Society for Trauma and Emergency
Session XVI: Surgery (ESTES)
WTC II Sessions Location: Seaport A-C, Second Level (Seaport Tower)
Moderators: Ronald Maier, MD and Ingo Marzi, MD, USA and Germany
Keynote: Bertil Bouillon, MD, Influence of Trauma Registry Data on Basic Research
A COMPARISON OF TRAUMA OUTCOMES BETWEEN JAPAN AND UNITED STATES
USING NATIONAL TRAUMA REGISTRIES
Presenter: Shokei Matsumoto, MD, Japan

THE IMPACT OF GEOCODING A TRAUMA REGISTRY

Presenter: Ben Gardiner, RN, BN, GDip Periop, Australia

CAUSES AND OUTCOMES OF UNINTENTIONAL AND INTENTIONAL TRAUMATIC BRAIN

INJURIES IN UGANDA: ANALYSIS FROM HOSPITAL-BASED REGISTRY
Presenter: Nukhba Zia, MD, MPH, USA/Uganda

REJUVENATION OF AGED BONE MARROW STEM CELLS TO IMPROVE THE POTENTIAL

OF OSTEOGENIC DIFFERENTIATION BY MICROENVIRONENTAL REGULATION
Presenter: Yu Pan, MD, BS, China

DECREASED LEUKOCYTE VIABILITY IN SURGICAL PATIENTS: A NEWLY DESCRIBED

PHENOMENON
Presenter: Lillian Hesselink, MD, Netherlands
 Session XVI: WTC II Session: Research
Paper 1: 4:45pm - 5:45pm
A comparison of trauma outcomes between Japan and United States using national
trauma registries.
Shokei Matsumoto MD, Kyoungwon Jung MD, Alan Smith Ph.D., Motoyasu Yamazaki
MD, Mitsuhide Kitano MD, Raul Coimbra MD,Ph.D., Saiseikai Yokohamashi Tobu
Hospital
Introduction: Japan has recently made concerted efforts to improve trauma outcomes
over the last decade. The United State (US) has developed advanced regional trauma
systems in the last four decades. The National Trauma Data Bank (NTDB)should serve as
a benchmark of quality of care and outcomes for international trauma registries. Here, we
compared patient characteristics, trauma management, and outcomes in Japan using the
Japanese Trauma Data Bank (JTDB) dataset to US level 1 trauma centers using the
NTDB dataset.
Method: A retrospective cohort matching study was performed to compare trauma
outcomes between the JTDB and the NTDB in order to evaluate Japanese trauma quality
using NTDB as a benchmark. Patients aged ≥16 years old, with Injury Severity Score
(ISS) ≥9, treated at level I trauma centers in 2013 were included in the analysis. Patients
who were dead on arrival or with gunshot wounds, were excluded. The primary outcome
measure was in-hospital mortality. Secondary outcome measures included hospital length
of stay (LOS) and the rate of use of radiologic diagnostic modalities. A 1:1 matching
strategy was used.
Results: During the study period, 22,535 patients in the JTDB and 112,060 patients in the
NTDB were eligible for inclusion in this study. Using one to one exact matching, 14,960
pairs were generated. Significant differences were found between the two cohorts; in
particular, the JTDB group had a higher rate of elderly patients and self-inflicted wounds.
After 1:1 matching, patient characteristics were well balanced in both the groups. Before
matching, the in-hospital mortality was higher in the JTDB group compared to the NTDB
group (7.6% vs. 6.1%; Odds ratio (OR), 1.28; 95% CI: 1.21-1.35). However, after
matching, in-hospital mortality was lower in the JTDB (4.2% vs. 5.8%; OR, 0.72; 95%CI:
0.65-0.80) (Fig. 1). After matching, the median hospital LOS was more than three times
higher in the JTDB group than in the NTDB (17.0 [7.0-32.0] vs. 5.0 [3.0-8.0], P < 0.001).
CT scans were used in more than 80% patients in the JTDB and more than 1.5 times as
often in the JTDB than in the NTDB (Fig. 2).
Conclusion: We reported marked differences of trauma care between Japan and the US.
However, the quality of the recent Japanese trauma care appears to be approaching that of
the US. These comparisons may contribute to further improvements in Japanese trauma
care.
 Session XVI: WTC II Session: Research
Paper 2: 4:45pm - 5:45pm
THE IMPACT OF GEOCODING A TRAUMA REGISTRY.
Ben Gardiner RN, BN, GDip Periop., Pheobe Brandis MD, Caitlin O'Hare MD, Don
Campbell MBBS, FACEM, Martin Wullschleger MD,Ph.D., FRACS. Gold Coast
University Hospital
Introduction: Within the current Trauma landscape, injury location by zip/postal code is
a mandated field within trauma registries such as the American National Trauma Data
Standard and the Australian Trauma Registry. Postal codes in Australia do not have a
defined geographic boundaries, these codes are for postal distribution system and are not
related to specific address. Geocoding in population health epidemiological studies is
common practice, although within trauma this has been isolated to only a few studies,
focusing on planning and design of trauma systems. The Midlands Registry (New
Zealand) has demonstrated the potential benefits of geocoding in trauma registries
identifying ‘hot-spots’ and engaging with local communities for injury prevention. The
aim of this study is to establish the viability of collating geocode of injury in a consistent
methodology and examine the difference between retrospective and prospective collection
practices.
Methods: Upon ethics approval, Gold Coast University Hospital Trauma Service
undertook a retrospective spatial review of 927 incidents ISS>12 (AIS2005(08)),
examining medical records and emergency medical services (EMS) records for 38 months
(Jan 2014 - Feb 2017) for identifiers of specific injury location, then using a standardised
Global Positioning System (GPS) address locator and collated the information within the
trauma registry. For 9 months (Mar – Dec 2017) geocoded injury location has been
collected from all trauma service patients at the bedside, where they had a presentation
time to discharge >12hours. Analysis of the information was extracted from our trauma
registry (Imagetrend®) utilising Tableau® and Qlik Sence® for spatial visualisation.
Statistical significance was calculated on injury severity to ensure both groups collected
were consistent.
Results: Retrospective GPS was collected on n=647/927 (69.8%) with an average
ISS=21.41. The remaining retrospective non GPS group of 310 with an average
ISS=23.07. The prospective (n=572) group was split for comparison into two groups
where ISS>12 (same as retrospective group) this group achieved geocode collection
n=180/232 with (77.6%) an average ISS=21.10. No significance between the groups in the
Injury Severity Score was demonstrated (p<0.01). Early results of prospective collection
identified a significant increase in data capture >80% for ISS>12, this result decreased in
the latter part of the year with a change in EMS records. The remaining group collected
prospectively (admission >12 hrs where ISS<13) n=392 had an average ISS=5.06. This
showed we were collecting prospectively injury locations (68%) that were not achieving
ISS>12.
Conclusion: We have demonstrated that injury geocode location is feasible, with
prospective collection demonstrating improved collection methodology. The source of
location derivation and quality of location information vary and impact on the
interpretation of the spatial analysis. The improved geocoded locations have improved the
specificity and heat analysis. The this study has informed our understanding of traumatic
injury eg mortality due to traumatic brain injury and insights into paediatric trauma due to
recreational activities. Geocoding is the key in the development of partnerships with
government and community agencies for trauma prevention.
 Session XVI: WTC II Session: Research
Paper 3: 4:45pm - 5:45pm
CAUSES AND OUTCOMES OF UNINTENTIONAL AND INTENTIONAL
TRAUMATIC BRAIN INJURIES IN UGANDA: ANALYSIS FROM
HOSPITAL-BASED REGISTRY
Nukhba Zia MD,MPH, Amber Mehmood MPH, Rukia Namaganda MPH, Hussein
Ssenyonjo Joel Kiryabwire John Mukasa Michael Muhumuza Olive Kobusingye Adnan
A. Hyder Ph.D., Johns Hopkins Bloomberg School Of Public Health, USA; Makerere
University School Of Public Health And Mulago Hospital, Uganda

Introduction: Traumatic brain injury (TBI) is an important cause of morbidity and

mortality especially in low-and-middle income countries. The objective was to assess
causes and outcomes of unintentional and intentional TBI among patients presenting to a
tertiary-care hospital in Uganda.
Methods: This prospective observational study was conducted at Mulago National
Referral Hospital, Kampala, Uganda for 15-months in 2016-17. Patients of all age groups,
males and females, presenting to the emergency department of the hospital with suspected
or documented TBI were enrolled. Patient demographics, TBI causes and outcomes were
recorded. TBI was grouped into mild, moderate and severe categories based on Glasgow
Coma Scale (GCS). The outcome of interest was unintentional and intentional TBI.
Ethical approval was taken from Johns Hopkins School of Public Health and Makerere
University School of Public Health.
Results: Total 3944 patients were enrolled, of these 66.2% were unintentional TBI and
30% were intentional TBI. The average age of patients in both groups was similar (28±14
years) with over 70% patients between 19–45 years age group. More than 80% were
males in both groups. The main causes of unintentional TBI were road traffic injuries
(RTIs) (89%) and falls (11%). Pedestrians (42.3%) and motorcycle drivers (28.1%) were
common road users. Only 16% of RTI patients were wearing helmet at the time of the
crash. Assault (97.1%) was the main cause of intentional TBI, however, there were 33
(2.9%) self-harm cases. Common assault methods were use of bodily force (33.7%), iron
bar (24.2%) and hammer (12%). Gun was used in 3 cases. Around 16.5% of RTI patients
and 23.3% of fall patients had GCS below 8. TBI patients with self-harm were likely to be
in severe GCS category (39.4%) compare to victims of assault (14%). Among
unintentional TBI patients, about 40.6% of the patients were admitted to ward, 32.8%were
sent home. There were 73 deaths; 63 were RTI patients and 10 had a fall. Among
intentional TBI patients, 42.6% of the patients were admitted for inpatient care and 42.6%
were sent home. There were 30 deaths; 29 were assault victims and 1 of self-harm.
Conclusion: Unintentional TBI caused by RTI and intentional TBI caused by assault are
common among young males in Kampala. This has consequences for Uganda which has a
young population contributing to a broad population pyramid. Most young males are
vulnerable road users including pedestrians and motorcycle riders. Having designated
pedestrian crossing for pedestrians and mandatory helmet use can reduce TBI caused by
RTIs. There is need for further exploration of intentional injuries among youth in the
country and to develop programs to engage youth in productive activities for contribution
towards country’s economic development.
 Session XVI: WTC II Session: Research
Paper 4: 4:45pm - 5:45pm
REJUVENATION OF AGED BONE MARROW STEM CELLS TO IMPROVE
THE POTENTIAL OF OSTEOGENIC DIFFERENTIATION BY
MICROENVIRONENTAL REGULATION
Yu PAN BS,MD, Sa CAI MD, Xiao-Ming WU BS, Master of Surgery Bao-An People's
Hospital, Affiliated To Southern Medical University & Guangdong Medical Univeristy
Introduction: The accumulation of aged adult stem cells and attenuation of tissue repair
capacity characterize the aging process of the body. The microenvironment of aged cells
is defined as senescent associated secretory phenotype (SASP), which might stress
adjacent stem cells to age and jeopardize the homeostasis of tissue repair. We tried to find
the key secretory factors to intervene the senescent microenvironment and rejuvenate the
aged stem cells.
Methods: The aged bone marrow stem cells (BMMSCs) were obtained from osteoporotic
patients over 65 years old, and young stem cells 20-35 years old health donors. The
extraction from the culture medium of young cells were collected and add to the culture
medium of aged cells. Then we detected the effects on cell proliferation, cellular
senescent protein markers and oxidative responses to assess the rejuvenation of the aged
cells. We also observed the change of potential of osteogenic differentiation after the
treatment. The young cells-derived exosome was also collected to observe its effects on
the biological functions of aged stem cells.
Results: The senescent phenotype of aged BMMSCs were reversed by the treatment of
young culture medium and exosome, demonstrated by the down-regulation of cellular
senescent markers including: SA-b-Gal activity, p16 and p53. The declined cell
proliferation of aged BMMSCs was also rescued by the secretory factors of young cells.
Similar results on the osteogenic differentiation induction assay also suggested the
function of BMMSCs increased after the young secretory factors treatment.
Conclusion: The microenvironment of aged stem cells is characterized by their secretory
factors, which are crucial to the cellular functions of BMMSCs. Rejuvenation the aged
stem cells with secretory factors provide a promising way to resist the functional
attenuation of stem cells.
 Session XVI: WTC II Session: Research
Paper 5: 4:45pm - 5:45pm
DECREASED LEUKOCYTE VIABILITY IN SURGICAL PATIENTS: A NEWLY
DESCRIBED PHENOMENON.
Lillian Hesselink MD, Albert Huisman Ph.D., PharmD, Imo Hoefer Ph.D., Maarten Ten
Berg Ph.D., Leo Koenderman Ph.D., Luke P. Leenen MD,Ph.D., FACS, FEBS (Emerg
Surg), Falco Hietbrink MD,Ph.D., University Medical Center Utrecht
Introduction: Non-viable leukocytes were incidentally found in critically ill patients after
trauma. Not much is known about this phenomenon and its implications for leukocyte
functioning. The aim of this study was to investigate the incidence of a decreased
leukocyte viability in surgical patients and reveal the mechanisms behind this decreased
leukocyte viability.
Methods: Leukocyte viability was routinely measured in every blood analysis with
propidium iodide staining and was stored in the hospital database. Propidium iodide
stains DNA of non-viable leukocytes. The incidence of a decreased leukocyte viability
among surgical patients and trauma patients was investigated. Then, the propidium iodide
signal that indicated decreased leukocyte viability, was investigated. Based on distinct
propidium iodide signals, underlying mechanisms for a decreased leukocyte viability
were simulated in vitro. A prospective analysis was carried out in surgical patients with a
leukocyte viability ≤ 95%. The analysis included reassessing leukocyte viability,
measuring leukocyte receptor expression and investigating leukocyte functioning
(phagocytosis and responsiveness to a bacterial stimulus).
Results: Decreased leukocyte viability was found in 3% of all surgical patients. The
propidium iodide signal in patients with decreased leukocyte viability (n = 10) was
suggestive for non-viable leukocytes in half of the patients and adherence of DNA to
leukocytes in the other half. Both adherence of DNA and non-viable leukocytes could be
simulated in vitro. Next, nine surgical patients were prospectively included. All 9 patients
had a diagnosed or suspected infection. Analysis of all patients showed the presence of
leukocytes with low viability characterized by either increased leukocyte
autofluorescence (n = 6) or by the presence of fragile circulating leukocytes (n = 3).
Fragile leukocytes were leukocytes that became non-viable when kept in certain tubes
(such as EDTA) or after ex vivo manipulation (such as red blood cell lysis).
Conclusion: A decreased leukocyte viability in surgical patients such as measured by
routine hematological analyzers, reflects either fragile circulating leukocytes or leukocyte
autofluorescence. Further analyses will be performed to get better insight in leukocyte
functioning in these patients and to get a better understanding of how these data can be
used in clinical practice.
WTC 9: Shock/Transfusion Sponsored by The Japanese Society for Acute Care
Surgery (JSACS)
Location: Coronado A, Fourth Level (Harbor Tower)
Moderator: Ernest E. Moore, MD and Yasuhiro Otomo, MD, PhD, USA and Japan
Keynote: Yasuhiro Otomo, MD, PhD, Traumatic Coagulopathy
ONE HUNDRED PERCENTS FATALITY RATE IN ASIANS WITH HYPERFIBRINOLYSIS
AFTER MAJOR TRAUMA: A REPORT FROM A LEVEL I TRAUMA CENTER IN ASIA
CALLING FOR AN EARLY AGGRESSIVE APPROACH
Presenter: Burapat Sangthong, MD, Thailand

CLINICAL EVALUATION OF A NOVEL COAGULOPATHY DEVICE

Presenter: Emily Ashworth, RN BNurs (hons) Mres, England

TEG IN TRAUMA PATIENTS: EVERY MINUTE COUNTS

Presenter: Alison Smith, MD, PhD, USA

EVALUATION OF FACTORS AFFECTING CLINICAL OUTCOMES IN PATIENTS WITH

PENETRATING CARDIAC INJURIES BY CORTOPUNZANTE WEAPON. 5 YEARS
EXPERIENCE IN A LEVEL 1 COMPLEXITY INSTITUTION IN COLOMBIA
Presenter: Oscar Dussan, MD, Colombia

MASS-CASUALTY IN A LEVEL 2 TRAUMA CENTER: ARE WE REALLY PREPARED?

Presenter: Morgan Pomeranz, MD, USA
 Session XVI: WTC II Session: Shock/Transfusion
Paper 1: 4:45pm - 5:45pm
ONE HUNDRED PERCENTS FATALITY RATE IN ASIANS WITH
HYPERFIBRINOLYSIS AFTER MAJOR TRAUMA: A REPORT FROM A
LEVEL I TRAUMA CENTER IN ASIA CALLING FOR AN EARLY
AGGRESSIVE APPROACH.
Burapat Sangthong MD, Chomphunut Supavita MD, Osaree Akaraborworn MD, MS,
Komet Thongkhao MD,Khanitta Kaewsaengrueang BS, Prattana Chainiramol RN, Prince
Of Songkla University
Introduction: Hemorrhage remains the leading cause of death after trauma worldwide.
Coagulopathy after severe hemorrahge is common and leads to complicated bleeding
control which increases mortality and blood transfusions. Recent studies from Western
countries have identified the coagulopathy is associated with hyperfibrinolysis (HF). This
study was designed to determine the incidence of HF after trauma in an Asian population
and its outcomes.
Methods: A case-control study was conducted. All adult trauma patients presented
directly to our institution, a level I trauma center in Thailand, and met major trauma
activation criteria were reviewed. Patients who were transferred and resusciated from
outside hospitals were excluded from the study. Blood for coagulation studies was drawn
on arrival. HF was determined by rotational thromboelastrometry (ROTEM), a
viscoelastic hemostatic test. The patient characteristics, transfusion requirements, and
mortality were reviewed.
Results: During the two-year study period, a total of 2,368 adult trauma patients were
admitted with 353 patients met severe trauma activation criteria. Forty-three patients had
full data sets of ROTEM and were the study population. The average age was 36.0 +14.0
years old. Forty-one (95.4%) of the patients were male. The median Injury Severity Score
was 25 (14-33). Blunt trauma was the majority of injury mechanism (79.1%). HF was
identified in two patients (4.7%). The overall mortality rate was 32.6%. One hundred
percent mortality rate was observed in the HF group while the group that did not exhibit
HF on arrival (non-HF group) showed 29.3%mortality rate. Blood product requirements
and mortality rate between the 2 groups was shown (Table 1).

Conclusion: Hyperfibrinolysis rarely occurred in Asian population with severe trauma.

However, patients that exhibited hyperfibrinolysis have extremely high mortality rate and
need massive amount of blood transfusion. Further study to address this coagulation
disturbance is substantially warranted.
 Session XVI: WTC II Session: Shock/Transfusion
Paper 2: 4:45pm - 5:45pm
CLINICAL EVALUATION OF A NOVEL COAGULOPATHY DEVICE
Emily R. Ashworth RN BNurs (hons) MRes, Mansoor Khan MBBS (Lond) PhD FRCS
FEBS FACS Imperial College London
Introduction: Thrombelastography (TEG) provides viscoelastic information on the
clotting processes in real-time. It is currently applied in trauma patients who are at risk of
bleeding or who are being transferred to theatres when it is vital to analyse and understand
their coagulopathy. Trauma patients, in particular, are at risk of changes to coagulopathy
due to massive haemorrhage, body temperature and infusion of blood products. TEG
analysis is not a substitute for ANTT and INR measurements, but the analysis time is
considerably quicker than comparable laboratory tests and does provide guidance and
information pre-transfusion in “at risk” patients. Current TEG instruments are large and
relatively immobile but the data the technique provides, is useful in early-trauma
resuscitation and providing information on coagulation pathways in bleeding trauma
patients. We tested a novel portable viscoelastic measuring device (CoaguScan
Biosensor) and compared it to a Haemonetics TEG 5000 analyser.
Methods: 20 Consecutive trauma patients were selected (convenience sampling) based
upon their suitability to need a TEG. A routine TEG was taken for patient care, and the
remained of this sample that would normally go to waste was used for the CoaguScan
Biosensor. All adult trauma patients were included (age 18 and above), and patients were
recruited using a nominated consultee if unable to consent at the time of the study. These
results were anonymised prior to data analysis and 12 healthy volunteers were used as a
comparator. Clinicians requesting the TEG were blinded to the Biosensor results.
Results: Results compared were: initial viscosity, blood viscosity, maximum amplitude,
R-time (time to detect the clot), and overall raw traces. The CoaguScan Biosensor showed
comparable results to that of the TEG 5000, despite the biosensor being an early pre-
production model. The positive correlation potentially demonstrates that the Biosensor
may be used to measure and observe coagulopathy, and that this could be calibrated to the
results of the TEG for Clinicians to direct care. The Biosensor showed a significant
difference in Maximum Amplitude – giving an indication that the biosensor may be more
sensitive to this measurement than the TEG 5000. It also identified a hyperfibrinolysis in
trauma patients where the TEG 5000 stated there was normal, suggesting potential for
detecting Acute Coagulopathy of Trauma. Comparison against the TEG 5000 was
challenging as the biosensor was configured to mimic the manual steps associated with the
TEG, but the biosensor had a much smaller sample size. This study was limited by a
small sample size and a device that is in early stages of development and therefore more
prone to user error.
Conclusion: Further work validation and calibrating the device on both healthy volunteers
and abnormal samples is currently being undertaken to further understand the results
produced and to show comparability to the current TEG and ROTEM devices. Following
calibration, a large multi-centre study, taking samples from trauma patients at point of
injury and throughout the patient pathway will be completed. The benefit of a portable
device, with rapid diagnosis of coagulopathy in trauma – particularly early on the in the
patient pathway is currently unknown – a device such as this indicate on how to direct care
using early coagulopathy results.
 Session XVI: WTC II Session: Shock/Transfusion
Paper 3: 4:45pm - 5:45pm
TEG IN TRAUMA PATIENTS: EVERY MINUTE COUNTS
Alison A. Smith MD,Ph.D., Lynn Hakki BS, Matthew Marturano BS, Chrissy Guidry DO,
Patrick McGrew MD, Clifton McGinness MD, Rebecca Schroll MD, Juan Duchesne MD,
Tulane School of Medicine
Introduction: Thromboelastography (TEG) has become an integral part of the management
of trauma patients. However, optimal protocols to incorporate TEG into routine trauma
protocols have not been determined. We hypothesize a correlation between early TEG use
and survival in patients with severe hemorrhage.
Methods: A retrospective review of consecutive adult patients who received massive
transfusion protocol (MTP) at a Level I Trauma Center was performed from
4/2017-2/2018. Patient demographics, Injury Severity Score (ISS), blood product usage,
and mortality were recorded. Patients were stratified into 2 groups based on length of time
before TEG was ordered (TEG-L, >120 min and TEG-S<120 min). Patient outcomes were
analyzed with a t test for univariate analysis.
Results: A total of 91 patients were identified and 56.0% of these patients had TEG level
measured. Average time for trauma surgeons to order TEG was 381.4 min with a range of
22-7226 min. There was no difference in baseline patient demographics between TEG-L
and TEG-S patients. The TEG-S group had decreased ICU LOS (8.6 +1.8 vs. 22.6+3.8,
p=0.0031) and decreased deaths (14.2% vs 47.8%, p=0.0135).

Conclusion: This analysis demonstrated a survival benefit in severe hemorrhage patients

with early use of TEG. Institutions should adopt quality measures to review proper early use
of TEG in patients with severe hemorrhage. Prospective validation is needed in order to
better understand this TEG time-survival correlation.
 Session XVI: WTC II Session: Shock/Transfusion
Paper 4: 4:45pm - 5:45pm
Evaluation of Factors Affecting Clinical Outcomes in Patients with Penetrating
Cardiac Injuries by Cortopunzante Weapon. 5 Years Experience in a Level 1
Complexity Institution in Colombia.
Oscar Dussan MD, Jose D. Charry MD, Roberto J. Rodriguez MD, Rafale Silva MD,
Francisco Ruiz MD, Hospital Universitario De Neiva
Introduction: The behavior of assault injuries with a short stabbing weapon as a cause of
death has been described from 1980 to 2016 by the Global Burden Of Disease with a
sustained trend in young population between 15 to 55 years of age, with a peak persistent
towards 25 years The injuries caused by sharps in the thorax are related to a high mortality
despite the early interventions carried out by the pre-hospital care staff and even in the
emergency room of hospitals around the world, despite the advances in the area of care in
trauma, the implementation of programs such as ATLS and the use of portable ultrasound
images, up to 90% of patients may die before reaching the emergency service. The
objective of the following study was to describe the different factors that affect clinical
outcomes in patients with wounds caused by a sharp weapon in the thorax.
Methods: Observational descriptive study of patients admitted to the emergency
department with a diagnosis or penetrating cardiac lesion, clinical, paraclinical, imaging
findings were evaluated, patients were lowered, central tendency measures were
calculated, statistical confidence tests were applied as Chi2, wilconson test, fisher test.
Results: The majority of patients belong to the male sex 86%]; the average age was 30.6 ±
9.75 years, 98% of penetrating injuries were located within the area, At the time of
admission to the emergency department, the average Systolic Blood Pressure (SBP) was
79.4 mmHg and the heart rate (HR) was 100 beats per minute; the average of the Shock
Index (IS) was 1.9, Admission to the Intensive Care Unit was required by 21 (42%) of the
patients and 36 (72%) required the use of Hemocomponents during the hospital stay. The
average hospital stay was 7.5 ± 6.1 days. The location of the cardiac lesions were 60% of
cases in the right ventricle, 18% in the left ventricle, 12% in the right atrium, 6% in the
pericardial sac and 4% in the left atrium. The left anterolateral thoracotomy was the most
frequent technique of surgical approach. The average size of the cardiac lesions was 19.2
mm. Hospital mortality was 14%. The diagnostic method of cardiac injury was by Surgery
in 62%.
Conclusion:Despite advances in pre-hospital care, diagnostic modalities and resuscitation
strategies, PCLs remain highly lethal. A clinical suspicion focused on the early recognition
of the unstable patient with lesion in the precordial area allows decision-making aimed at
imaging diagnosis or immediate surgical diagnosis.
 Session XVI: WTC II Session: Shock/Transfusion
Paper 5: 4:45pm - 5:45pm
MASS-CASUALTY IN A LEVEL 2 TRAUMA CENTER: ARE WE REALLY
PREPARED?
Morgan Pomeranz MD, Matthew Johnson MD, Sunrise Hospital And Medical Center

Introduction: On the 1st of October, 2017 in Las Vegas, Nevada, a crowd of over 22,000
people at a country music festival was fired upon by an individual using a semi-automatic
converted to automatic rifle from an elevated position at the Mandalay Bay Hotel and
Casino. This resulted in approximately 60 fatalities and over 500 injuries. The majority of
those who were injured were treated at one of two major trauma centers in the city.
Methods and Results: Sunrise Hospital and Medical Center received and treated 221 of
those patients. Of those, 16 were triaged to category black and later pronounced deceased,
over 95 underwent surgery in the first 24 hours, and an unknown number were treated for
minor injuries and left the hospital without being registered. Through the combined
efforts of the trauma surgeons, residents, and registered nurses, non-trauma surgeons,
anesthesiologists and nurse anesthetists, physician assistants, nurse practitioners, and
support staff of all levels, the above was accomplished and with only two additional
mortalities occurring after the first 24 hours.
Conclusion: Routine training for mass casualty incidents (MCI) and other disasters is part
of the curriculum for most trauma centers. However, no amount of preparation would be
considered adequate for one of such a large scale as that which occurred on October 1st.
Sunrise Hospital periodically performs mock trauma scenarios in order to keep its staff
ready in the event of such situations, but these are usually limited to motor vehicle
collisions and associated blunt trauma. Those performing their duties during the MCI at
Sunrise will attest that the patients were treated properly with remarkable speed and
efficiency, and although strained for personnel and resources at times, the compensatory
efforts made were successful. Part of this can be explained by the nature of the trauma
seen in Las Vegas routinely. In 2017, there were 408 cases of penetrating trauma treated
at Sunrise Hospital, including 316 caused by firearms. These numbers and experience
translate into familiarity, comfort, and skill in treating this type of pathology that would
make the outcomes and statistics of this MCI otherwise unachievable. There is a wide
variation in the types of trauma that are seen at different trauma centers across the United
States, with many seeing blunt trauma disproportionately. Many surgical residency
programs send their trainees to larger academic centers in order to fulfill their trauma
training requirements and gain a more broad perspective in the field. In light of recent
events and the realization of certain deficiencies, it would be of great benefit to expand on
this concept, and examine the possibility of developing further cross-program integration
or exchanges for MCI routine training and continuing medical education for all trauma
healthcare providers. This would create a network of well-prepared community trauma
centers, better prepared to serve their regions and alleviate a portion of burden on the
more high-volume academic centers.
WTC 10: Prevention/Outcomes Sponsored by SBAIT - Brazilian Trauma
Society

EDUCATION IN TRAUMA: AN EDUCATIONAL ALTERNATIVE THAT PROMOTES INJURY

PREVENTION
Presenter: Jose Charry, MD, PhD, Colombia

PSYCHOLOGICAL DISTRESS AFTER TRAUMA: A PROSPECTIVE COHORT STUDY

Presenter: Leonie De Munter, MSc, Netherlands

EFFECTS OF TRAUMA CENTER ON MORTALITY AT A REGIONAL CITY IN JAPAN: A

POPULATION BASED STUDY
Presenter: Yuji Takahashi, MD, Japan

PSYCHOLOGICAL DEVELOPMENTS 28 YEARS AFTER MULTIPLE TRAUMA

Presenter: Sascha Halvachizadeh, MD, Switzerland

TRAUMA, TREATMENT AND REHABILITATION: A PATIENTS’ PERSPECTIVE

Presenter: Eva Visser, MSc, Netherlands
 Session XVI: WTC II Session: Prevention/Outcomes
Paper 1: 4:45pm - 5:45pm
Education in trauma: An educational alternative that promotes injury prevention.
Jose D. Charry MD,Ph.D., Sandra L. Navarro-Parra Ph.D., FUNDACIÓN
UNIVERSITARIA NAVARRA
Introduction: As trauma is a public health problem, different programs have been
designed to prevent injuries. The aim of this study was to evaluate the effectiveness of an
educational model that measures the adolescents' attitudes towards the rules of road
safety, alcohol and road accidents in Colombia.
Methods: A pedagogical model evaluating the effect of road safety education and
adolescents' attitudes towards and experiences of alcohol and road accidents in Colombia
was created. After the education concluded, this educational process is analyzed by its
impact on adolescents' behavior. The educational program included 160 adolescents with
the mean age being 17.5 years.
Results: The test results indicated that before the educational program 80% of
adolescents did not use a safety element when driving, while after the educational
program the percentage of no helmet use among adolescents decreased from 72.5% to
24.3% (p = 0.0001) and driving a vehicle under the state of drunkenness from 49.3% to
8.1% (p = 0.0001).
Conclusion: An educational model aimed at preventing injuries caused by traffic
accidents is shown to be effective in generating changes in adolescents' customs of and
attitudes towards alcohol and road safety standards in Colombia
 Session XVI: WTC II Session: Prevention/Outcomes
Paper 2: 4:45pm - 5:45pm
PSYCHOLOGICAL DISTRESS AFTER TRAUMA: A PROSPECTIVE COHORT
STUDY
Leonie De Munter MSc, Suzanne Polinder Ph.D., Cornelis L. Van De Ree MD, Nena
Kruithof MSc, Juanita A. Haagsma Ph.D., Mariska A. De Jongh Ph.D., Elisabeth-Twee
Steden Hospital

Introduction: Psychological distress is a general term to describe a state of emotional

suffering that interferes with the level of functioning, and could be characterized by
symptoms of posttraumatic stress (PTSS), and symptoms of depression and anxiety. This
study aimed to (1) describe the prevalence of psychological distress within one year after
injury in a clinical trauma population (2) determine risk factors for this poor outcome and
(3) develop prediction models for poor psychological outcome 6 months and 1 year after
trauma.
Methods: This is a multicenter prospective observational cohort study. All adult trauma
patients admitted to ten hospitals (N=9774) were asked to complete a questionnaire at 1
week, and 1, 3, 6 and 12 months after injury. The Hospital Anxiety and Depression Scale
(HADS) was used to screen for anxiety and depressive disorders and the Impact of Event
Scale (IES) was used to assess symptoms of posttraumatic stress disorder (PTSD).
Potential predictors were assessed in univariable logistic regression, with psychological
distress as outcome. Psychological distress was defined as: HADS≥8 or IES≥35. All risk
factors with a p<0.2 were included in multivariable model. The model performances were
assessed with the discrimination (Area Under the Curve), Nagelkerke R-square (R 2) and
graphically with calibration curves.
Results: A total of 4883 patients (46%) completed at least one questionnaire in the
follow-up period of one year after trauma. Prevalence rates of psychological distress is
higher in women than in men. Patients with a low injury severity score also suffered from
psychological distress. Overall, the prevalence of anxiety and depressive symptoms
decreased during the follow up period. The highest prevalence of PTSS was found in
female trauma patients with low injury severity. Risk factors for poor psychological
outcome are female gender, low educational level, low injury severity, pre injury presence
of anxiety and depression, and low functional capacity index.
Conclusion: Prevalence of psychological distress is high among female trauma survivors.
This study provides possible tools for early diagnosis and screening of poor psychological
outcome after trauma. Further research is needed to externally validate these findings.
 Session XVI: WTC II Session: Prevention/Outcomes
Paper 3: 4:45pm - 5:45pm
EFFECTS OF TRAUMA CENTER ON MORTALITY AT A REGIONAL CITY IN JAPAN: A
POPULATION BASED STUDY
Yuji Takahashi MD, Kazunori Yamashita MD,Ph.D., Naoya Matsumoto MD,Ph.D., Yoshihiro Nozaki MD,Ph.D.,
Tomohito Hirao MD,Ph.D., Goro Tajima MD,Ph.D., Takamitsu Inokuma MD,Ph.D., Shuhei Yamano MD, Kensuke
Takahashi MD,Ph.D., Takashi Miyamoto MD,Ph.D., Kenichiro Inoue MD, Department Of Emergency Medicine,
Unit Of Clinical Medicine, Nagasaki University Graduate School Of Biomedical Sciences

Introduction: Although trauma centers have been reported to be effective on mortality of trauma patients, their
effects on mortality in a region have not been thoroughly investigated. In our medical district (about 500,000 of
population), emergency medical center (EMC) and trauma center (TC) was established for the first time in April
2010, and October 2011 respectively in only one university hospital (UH), and cooperated with each other for
trauma patients. The objective of this study is to clarify the effects of the centers on the mortality at a
population-level.
Methods: Standardized regional data form were used for this retrospective study. The data have been collected for
all patients taken to hospitals by ambulance, and included prehospital information, and both of diagnosis and
outcome one week after injury. The analysis was performed during fiscal years from 2009 to 2014. Trauma patients
were extracted from the codes of trauma such as “traumatic intracranial hemorrhage”, “spinal cord injury”,
“cardiovascular and lung injury”, “abdominal organ injury”, “pelvic fracture”, “proximal femur fracture”, “severe
multiple trauma”, and “other fractures”.
Results: There were total 122, 306 patients transported in the region during 6 years, and collection rate of the
records was 92.6% (n=113,254). Out of them, 11,788 (10.4%) were trauma patients directly transported from the
scene and used for analysis.
Number of trauma patients,
median a ge, and the time from
call to hospital increased during
the period(Table). Rate of
patients transported to UH
increased from 4.2% at 2009 to
7.5% at 2012 after
establishment of trauma center.
Mortality in UH decreased from
18.6% (2009) to 10.9% (2014),
and that in non-UH hospitals
also decreased from 1.9% to
0.5% (Figure). As a result, the
overall mortality in the region
improved from 2.6% to 1.2% despite of population aging and the increased time from call to hospital (Figure).
Conclusion: The establishment of EMC and TC resulted in the increase in a number of patients transported to UH,
and the improvement of mortality at a population level. The centers may have contributed to trauma care in the
region by intensification of severe trauma patients.
 Session XVI: WTC II Session: Prevention/Outcomes
Paper 4: 4:45pm - 5:45pm
PSYCHOLOGICAL DEVELOPMENTS 28 YEARS AFTER MULTIPLE
TRAUMA
Sascha Halvahizadeh MD, Henrik Teuber MD, Kai Sprengel MD, Georg Osterhoff MD,
PD MD, Valentin Neuhaus MD, PD MD, Hans-Christoph Pape* MD, Prof. Dr. med.,
Roman Pfeifer MD, PD MD University Hospital Zurich
Introduction: The impact of polytrauma on long-term quality of life is poorly
investigated. Potential effects are based on type and severity of the injury, but also on the
psychological consequences of the trauma itself as well as long-term consequences.
Trauma can decrease quality of life and increase socio-economic burden. We have
previously shown long-term development of post-traumatic stress disorder and
depression. In this study, we examined other long-term psychological developments in
multiple injured patients.
Methods: More than 20 years after trauma, 637 patients enrolled in our polytrauma
database who suffered trauma dating from January 1, 1973 to December 31, 1990
received a questionnaire that included self-assessment of posttraumatic psychological
developments. This questionnaire included questions modified from or based on: Short
Form 12 Health Survey (SF-12) Diagnostic criteria of PTSD from the Diagnostic and
Statistical Manual of Mental Disorders (DSM IV) of the American Psychiatric
Association (APA) HADS (Hospital Anxiety and Depression Scale) and the Clinical
Anxiety Scale (CAS) as found in the Present State Examination (PSE, Wing, Cooper and
Sartorius 1974) An internally devised question set to evaluate potential positive
psychological developments
Inclusion criteria: patients who were enrolled in the database and returned the
questionnaire.
Exclusion criteria: patients with severe head injuries or patients who could not fill out the
questionnaire even with assistance.
Results: This study evaluated 337 completed questionnaires from 637 patients more than
20 years after trauma. Of these patients, 34.9% experienced or witnessed additional
trauma, potentially amplifying psychological effects of the initial injury. Ten patients
(3.0%) suffer from symptoms of PTSD. Further, 4.1% of patients reported symptoms of
anxiety and nearly half (48.2%) show symptoms of depression. However, we also
identified effects that were considered as positive by this population. The most common
positive development was a sense of improved trust in others (42.0%) during times of
need. Nearly one-third of patients (31.4%) accepted or learned to cope with personal
shortcomings. More than half of patients (52.7%) developed a new appreciation for health
and vitality. Nearly one in five patients (17.8%) developed faith or strengthened their
religious beliefs.
Conclusion: Multiple injured patients risk developing multiple psychological effects
including PTSD, anxiety, or depression. However, patients can also experience different
psychological developments. As clinicians we must keep these effects in mind, offering
psychiatric consultation where needed, while fostering and supporting potential positive
developments.
 Session XVI: WTC II Session: Prevention/Outcomes
Paper 5: 4:45pm - 5:45pm
TRAUMA, TREATMENT AND REHABILITATION: A PATIENTS’
PERSPECTIVE
Eva Visser MSc., Brenda Den Oudsten Ph.D., Taco Gosens MD,Ph.D., Marjan Traa
Ph.D., Jolanda De Vries Ph.D., Elisabeth-TweeSteden Hospital
Introduction: Qualitative research that focusses on the process of treatment and
rehabilitation in relation to psychological factors after trauma is lacking. Using focus
groups, the aim was to explore patients’ experiences with the trauma, treatment and
rehabilitation.
Methods: Trauma patients, treated in the shock room of the Elisabeth-TweeSteden
Hospital, The Netherlands, participated in a focus group. Purposive sampling was used.
Exclusion criteria were younger than 18 years old, severe traumatic brain injury,
dementia, insufficient knowledge of the Dutch language. The interviews were recorded,
transcribed verbatim and analyzed using coding technique open, axial and selective
coding.
Results: Six focus groups were held before data saturation was reached. Then, no new
information was found during the discussion. In total, 134 patients were invited, 28 (21%)
agreed to participate (Age median: 59.5; min. 18 – max. 84). Main reasons to decline were
fear that the discussion would be too confronting or patients experienced no problems
regarding the trauma or treatment. Participants reported difficulties on physical (no
recovery to pre-trauma level), psychological (fear of dying or for permanent limitations,
symptoms of posttraumatic stress disorder, cognitive dysfunction), social
(impact on relatives and social support) and environmental domains (satisfaction with
care). Good communication regarding recovery is imperative, whereas clarity about the
injury and expectations regarding recovery and future perspectives needs to be explained.
Good communication seems to be related to surrendering to care and reduced feelings of
helplessness and loss of control.
Conclusion: This is the first study that explored patients’ experiences with the trauma,
treatment and rehabilitation. Our findings illustrate the need for awareness and knowledge
in health care providers about the consequences on several domains. Improvement in care
can be accomplished after awareness, improved adjustment in communication and a
multidisciplinary team is created. Professionals with the knowledge of consequences after
trauma can better anticipate on patients’ need.
WTC 11: Trauma Systems Sponsored by Chinese Medical Doctor Association
Trauma Committee (CMDATC)
Moderators: Marc deMoya, MD and Xiao-Bing Fu, MD, PhD, USA and China
Keynote: Zhanfei Li, MD, PhD, Trauma System Development in China
APPLYING THE 5-PILLAR MATRIX TO THE DECADE OF ACTION FOR ROAD SAFETY IN
QATAR: IDENTIFYING GAPS AND PRIORITIES
Presenter: Ruben Peralta, MD, Qatar

ROLE OF REVISED TRAUMA SCORE AND KAMPALA TRAUMA SCORE IN LOW AND
MIDDLE INCOME COUNTRIES - ASSESSING FEASIBILITY, ACCURACY AND UTILITY IN
RURAL INDIA
Presenter: Maunil Bhatt, MD, BS, USA

AN 18-YEAR ANALYSIS OF BORDER FENCE INJURIES

Presenter: Theresa Chan, MD, USA

“INTEGRATION” IS THE KEY FACTOR TO DEVELOP PREHOSPITAL TRAUMA CARE

SYSTEM IN THE LEAST DEVELOPING COUNTRIES
Presenter: Takaaki Suzuki, MD, Japan

THE CHALLENGING AND STRATEGIES FOR TRAUMA CARE IN CHINA

Presenter: Zhanfei Li, MD, PhD, China
 Session XVI: WTC II Session: Trauma Systems
Paper 1: 4:45pm - 5:45pm
APPLYING THE 5-PILLAR MATRIX TO THE DECADE OF ACTION FOR
ROAD SAFETY IN QATAR: IDENTIFYING GAPS AND PRIORITIES
R. Consunji MD,MPH, A. El-Menyar MD, H Al-Thani MBA,MD, Ruben Peralta MD,
FACS, FCCM Hamad General Hospital And Hamad Medical Corporation
Introduction: Road traffic injuries [RTIs] are the leading cause of death in Qatar;
consequently, the country has participated in the Decade of Action for Road Safety
[DoARS] coordinated by the United Nations Road Safety Collaboration, since 2011. Its
goal is to reduce the number of road traffic deaths and injuries by 50% by 2020, by
implementing activities, in the areas of road safety management, safer roads, safer vehicles,
safer road users and post-crash response, the 5-Pillars. This study evaluated the DoARS
initiatives and programs implemented in Qatar, to identify areas for future prioritization
and focus.
Methods: Data, on completed or ongoing road safety initiatives for the years 2011-16, was
collected from the key stakeholders, governmental and non-governmental, involved in road
safety. This data was analyzed in the 5-Pillar Matrix, created, based on the DoARS Action
Plan [Table 1].

Results: Pillars 2 [Safer Roads] and 5 [Post-Crash Response] met most of the DoARS
indicators, 100% and 86% respectively, while Pillar 3 [Safer Vehicles] complied with
none. Previously non-existent, legislative and policy indicators were the least likely to be
completed. Systems, programs and laws that were already existent in 2011 and involving
road engineering or healthcare systems were more likely to be in compliance with DoARS
indicators.
Conclusion: To build on the initial gains of DoARS, Qatar must go beyond activities and
programs that were already existent in 2011. It must prioritize proven interventions that
make vehicles and road users safer; i.e. more stringent vehicle safety standards and
graduated driver licensing for novice drivers.
 Session XVI: WTC II Session: Trauma Systems
Paper 2: 4:45pm - 5:45pm
ROLE OF REVISED TRAUMA SCORE AND KAMPALA TRAUMA SCORE IN
LOW AND MIDDLE INCOME COUNTRIES - ASSESSING FEASIBILITY,
ACCURACY AND UTILITY IN RURAL INDIA
Maunil Bhatt BS,MD, Mayur Shinde BS, Kandarp Talati BS,MPH, Ajay Phatak
BS,MPH, Karthik Vishwanathan BS, M.S, Somashekhar Nimbalkar BS,MD, Heena
Santry BS,MD, Boston University Medical Center
Introduction: Annually, trauma causes more than 5.8 million deaths worldwide, with low
and middle income countries (LMICs) accounting for the vast majority of these deaths.
While predictors of mortality have long been studied and validated in high-income
countries (HICs), risk predictors such as the Injury Severity Score (ISS) are of low utility
in resource poor settings. As a result, both the Revised Trauma Score (RTS) and Kampala
Trauma Score (KTS) have been developed and tested in LMICs, largely in urban areas.
We aimed to validate RTS and KTS as predictors of mortality as well as disposition from
a trauma department in rural western India.
Methods: Retrospective analysis of prospectively collected trauma registry data at a 550
bed tertiary care hospital serving a rural catchment area of 11,300 sq km of Gujarat, India
was conducted. Patients presenting to the emergency room with all mechanisms of injury
between September 1, 2017 to February 12, 2018 were included. Patients pronounced
‘dead on arrival’ were excluded. Primary outcome was in-hospital mortality. Secondary
outcome was disposition from the trauma department (treated and discharged vs
hospitalized). RTS and KTS were evaluated as predictors of in-hospital mortality by using
logistic regression models. The sensitivity and specificity of each score was assessed
using the area under the receiver operating curve (ROC). Pearson’s X2 goodness of fit test
was performed to assess the above mentioned associations.
Results: Of 1601 patients included in the trauma registry, 479 had enough data points
recorded to calculate both the RTS and the KTS. Missing respiratory rate was the most
common reason for inability to calculate these measures. Of these, 71% were males,
median age was 32 (IQR 19.5 - 44.5) years and the most common cause of injury was road
traffic accidents (54%, 258/479), followed by falls (23%, 110/479). 33 patients died in the
hospital. 47% patients required inpatient admission, 29% patients were treated and
discharged from the trauma department, and 20% left against medical advice. Logistic
regressions revealed that both RTS [OR 0.39, 95% CI 0.28 - 0.55, p < 0.001] and KTS
[OR 0.41, 95% CI 0.27 - 0.62, p < 0.001] were strong predictors of in-hospital mortality.
Both the scores demonstrated adequate level of fit based on the Pearson’s X 2 goodness-
of-fit test (X2 <0.0001). The area under the curve (AUC) for RTS (0.766) and KTS
(0.783) were similar (p = 0.78). For patients with RTS < 4.5, the probability of
in-hospital death was > 25% in our cohort. Additionally, both the scores were significant
predictors of requiring hospitalization (RTS: OR 0.18, 95% CI 0.04 - 0.74, p = 0.018;
KTS: OR 0.10, 95% CI 0.06 - 0.17, p < 0.0001). Only 3% (8/268) patients discharged
directly from the trauma department required readmission within 30 days.
Conclusion: In rural LMIC settings when ISS is impractical to calculate, less resource
intensive scoring systems such as RTS and KTS perform equally well as significant
predictors of mortality. Both scores can also be utilized to predict safe and successful
discharge directly from the trauma department. This can further guide the clinical practice
in LMICs where resources are sparse and need to be rationed. However, to maximize
utility of these measures in the future, it will be important to encourage full recording of
key data such as respiratory rate that preclude such calculations.
 Session XVI: WTC II Session: Trauma Systems
Paper 3: 4:45pm - 5:45pm
AN 18-YEAR ANALYSIS OF BORDER FENCE INJURIES
Theresa W. Chan MD, Todd W. Costantini MD, Laura N. Godat MD, Alan Smith
MPH,Ph.D., Jay J. Doucet MD, University of California, San Diego
Introduction: The southwest portion of the US-Mexico border remains the greatest
contributing sector to national border apprehensions. Policy increasing the length and
height of the fence has previously affected the number and severity of intentional border
jump or fall cases seen at US border trauma centers. The Secure Fence Act of 2006
which increased the height, length and reinforcement of the area border fence was more
than 99% complete by 2011. We hypothesized that policy and economic changes
significantly affected numbers and severity of intentional border jump or fall cases seen
over an 18-year period.
Methods: We performed a time-trend study using the Trauma Registry at a US Level 1
Trauma Center covering a portion of the US-Mexico border. Age, sex, injury severity
score (ISS), and injured body regions for patients admitted after a border jump or fall
from 2000 through 2017 were analyzed. The number of apprehensions in the Trauma
Center’s catchment border regions per year were obtained from US Customs and Border
Protection data.
Results: A total of 465
admissions were coded as border
jump or fall injuries. 72% were
male with an average age of 33.0
± 9.6 years. There was a
significant decrease in the number
of border jump or fall patients
admitted from 43 in 2006 to 20 in
2011. This trend correlated with a
decrease in apprehensions within
the region but also an increase in
the number of body regions affected per patient. Since 2011, the number of cases and
apprehensions has remained stable. ISS also remained stable over the 18-year analysis
with an overall average of 8.33. The highest mean ISS of 11.8 occurred in 2011, and the
lowest mean ISS of 4.7 occurred in 2015.
Conclusion: During this 18-year period, the number of border jump or fall cases at the
US-Mexico border has decreased and stabilized after completion of the Secure Fence
Act. The overall ISS of border crossing jump or fall cases has remained unchanged but
the number of body regions affected per patient has increased.
 Session XVI: WTC II Session: Trauma Systems
Paper 4: 4:45pm - 5:45pm
“INTEGRATION” IS THE KEY FACTOR TO DEVELOP PREHOSPITAL
TRAUMA CARE SYSTEM IN THE LEAST DEVELOPING COUNTRIES
Takaaki Suzuki MD, Yoshiaki Inoue MD,Ph.D., University Of Tsukuba

Introduction: Road traffic accidents (RTAs) is a global issue, and all countries are aimed
to achieve SDGs 3.6, half deaths and injuries from RTAs. In fact, in most of the
developing countries, the number of RTA deaths and injuries expected to rise. Emergency
medical service (EMS) is one of the key factor to minimize the damage of RTAs.
However, building a nationwide EMS is extremely challenging, especially in the least
developing countries (LDCs). Lao People’s Democratic Republic (Laos) is no exception.
Methods: Laos is one of the LDCs, which faces the rapid increase of RTAs. There is no
public EMS existed and little is known about the trauma care system, especially about the
prehospital settings. From January to February 2018, we have conducted an observational
study in the capital Vientiane. We focused on visualizing the current prehospital settings
and proposing the action plans for strengthening the capacity of post-crash response.
Results: In Vientiane, 8 private non-profit sectors are running the ambulance services.
Since 2007, different ambulance services have been developed one after another. Today,
due to the “disintegration” of services, the overlap calls and arrival of several ambulances
at once were observed at the injury sites. The quality gap among services are evident,
including transfer time and prehospital care treatment. We found most of the severe RTAs
occur out of the town, but most of the stations where ambulance stands were located
middle of the town. After our survey, we have set the 25 action plans to strengthen the
trauma care system, including the establishment of a universal access number and
command & control center.
Conclusion: There are many developing countries where private sectors run the
ambulance services. “Disintegrated” prehospital trauma care system could cause transfer
delay and the quality gap. Achieving a universal access number and command & control
center in the early development stage are necessary.
 Session XVI: WTC II Session: Trauma Systems
Paper 5: 4:45pm - 5:45pm
THE CHALLENGING AND STRATEGIES FOR TRAUMA CARE IN CHINA
Lianyang ZHANG MD, Professor, Xiuzhu ZHANG MD, Xiangjun BAI MD, Professor,
Mao ZHANG MD, Professor, Xiaogang ZHAO MD, Professor, Yongan XU MD, Hao
TAN MD, Yang LI MD, Third Affiliated Hospital, Army Military Medical University
Introduction: Trauma is one of the biggest public health problems in the world, as well as
in China. In order to understand the current pitfalls in dealing with trauma care in China
and to find out the solution, a survey was carried out between January 2010 and December
2014. Based on the success of the Advanced Trauma Life Support course and Primary
Trauma Care course, a trauma-training program was propelled in China.
Methods: The authors and their colleagues surveyed 30 hospitals located in different parts
of China, including 15 tertiary hospitals, 22 secondary hospitals, and 4 primary hospitals.
A Standard Operating Procedure was established in advance and was used for face-to-face
interviews and field surveys, with the primary objective of whether a trauma patient was
admitted to a specific division, such as acute surgery and trauma surgery. Field survey
covered both the hospital settings and the layout of the emergency departments, including
hospital profiles, infrastructure for trauma care, trauma care capacity and pre-hospital
response capacity.
Results: The study found that there were specialized trauma care facilities in 11 tertiary
hospitals (73.33%), 4 secondary hospitals (36.36%) and 3 primary hospitals (75.00%).
The common adverse aspects included: External factors – less desirably regulated
operation of local EMS system, lack of effective inter-hospital transfers, no mandatory
setups for trauma care required by legislation, no specialty such as the trauma surgery in
the promotion system, the time-consuming training and the expanding scope of trauma
care. Internal factors - the restrained development of trauma surgery, the less efficient
operation of trauma care facilities, the lower time-sensitive management of the multiple
trauma patients approached by intra-hospital consulting regime, the less satisfactory
spatial accessibility among different interacting functional units, and confusing standard
protocol with unnecessary patient transfers. Other findings include that the unique path for
trauma care was less taken into consideration in tertiary hospitals, the care of traumatic
brain injury or major thoracic trauma is less satisfied, traffic is poor, first-aid setups were
far behind, long distance away from emergent department and insufficient storage of
blood products, no resuscitation room for trauma patients in ED and prolonged pre-
operative time. In June 2016, a panel of trauma committee experts from the Chinese
Medical Doctor Association initiated a training course on trauma care with independent
intellectual property right. In June 2017, 21 courses were organized.
Conclusion: Strategies for improving trauma care system in China include, at the national
level - establishing and improving regulations and standards for designated trauma
centers, setting up the “trauma/acute care” as a new discipline in medical colleges or
universities, strengthening injury and trauma care capacity by certificated trauma training
program; at the hospital level – reorganizing trauma team and trauma division at different
levels of hospitals, establishing a trauma resuscitation area in ED and for improving
“hardware” for ED and pre-hospital care facilities.
Key words: Challenging and strategies; Trauma care; China
WTC 12: Thoracic/Vascular Austrian Council for Emergency Medicine (AGN)
Location: Coronado DE, Fourth Level (Harbor Tower)
Moderator: Luke Leenen, MD and Paul Puchwein, MD, Netherlands and Austria
Keynote: Paul Puchwein, MD, Emergency Thoracotomy in Preclinical Setting-An Advantage
of Physician Based EMS
A COMPARATIVE STUDY ON BOARDING OF MEDICAL STAFF OF HELICOPTER
EMERGENCY MEDICAL SERVICE (HEMS) AND THE TRAUMA DEATH RATE: FOCUSING
ON THE LOCAL REGIONAL TRAUMA CENTER
Presenter: John Lee, MD, PhD, South Korea

A QUALITY OF LIFE STUDY COMPARING PATIENT’S OUTCOME OF SURGICAL

INTERVENTION FOR RIB FRACTURES: A PRELIMINARY, PROSPECTIVE, COHORT
STUDY IN TAIWAN
Presenter: Tzu-hsin Lin, MD, Taiwan

CLINICAL SIGNIFICANCE OF ULTRASOUND IN PATIENTS WITH PENETRATING CHEST

TRAUMA
Presenter: Alexander Smolyar, PhD, Russia

PENETRATING CARDIAC INJURIES IN THE 21ST CENTURY: HAS SURVIVAL

IMPROVED?
Presenter: Christopher McNicoll, MD, USA

PREDICTORS FOR RETAINED HEMOTHORAX AMONG PATIENTS WITH PENETRATING

THORACIC INJURIES
Presenter: Adolfo Gonzalez, MD, Columbia
 Session XVI: WTC II Session: Thoracic/Vascular
Paper 1: 4:45pm - 5:45pm
A COMPARATIVE STUDY ON BOARDING OF MEDICAL STAFF OF
HELICOPTER EMERGENCY MEDICAL SERVICE (HEMS AND THE
TRAUMA DEATH RATE: FOCUSING ON THE LOCAL REGIONAL TRAUMA
CENTER
John C. Lee MD,Ph.D., Tea-Youn Kim MPH, Yo Huh MD, Hojun Lee MD, Jonghwan
Moon MD, Donghwan Choi MD, Byung Hee Kang MD, Seungwoo Chung MD,
Kyoungwon Jung MD,Ph.D., Ajou University Hospital

Introduction: The importance of rapid transfer to designated regional trauma centers for
the good outcome of severely traumatized patients cannot be emphasized enough. To this
end, helicopters for emergency medical care have been established in most developed
countries today, but there is still controversy about the proper boarding personnel to
provide professional prehospital care during the air transportation. The purpose of this
study was to compare the outcomes in traumatic patients with trauma surgeons on board
with outcomes in those with paramedics on board during transportation flights to the
regional trauma centers by helicopter.
Methods: Among the patients who were transferred to the two regional trauma centers
from January 2012 to December 2017, adult blunt patients who were referred to the 'air
transportation' as a means of transfer in the trauma database system were included. The
information on the transfer was taken from the ‘EMERGENCY MEDICAL SERVICE
REPORT’ prepared by the EMTs and the electronic medical records of the trauma center
were used. Trauma Team Staffed HEMS (TTS-HEMS) and EMT-HEMS (Emergency
Medical Technicians HEMS) were compared. The trauma and injury severity score
(TRISS), the injury severity score (ISS) and the revised trauma score (RTS) were used to
classify the trauma patients. Z statistics and W statistics were calculated to compare the
predicted survival rate with the actual survival rate of the study population.
Results: A total of 662 trauma patients were transferred to the regional trauma center
using HEMS. A total of 435 adult patients were included in the analysis except for
pediatric, penetrating, drowning, hanging, Dead on Arrival (DOA) and Dead in
Emergency Department (DIED). Of these, 327 (75.2%) were TTS-HEMS and 108
(24.8%) were EMT-HEMS. The TTS-HEMS was 266 subjects (81.3%) who exceeded the
ISS 15 compared with the EMT-HEMS 44 subjects (40.7%) were statistically significant.
During the transfer, TTS-HEMS could be treated with endotracheal intubation,
transfusion, and thoracotomy + open cardiac massage, but EMT-HEMS could only
perform basic treatment based on basic life support (BLS). When the predicted survival
rate was calculated using TRISS, the actual survival rate of overall HEMS (Z statistic =
4.40 , p < 0.001, W statistic = 3.77) and TTS-HEMS (Z statistic = 3.69, p < 0.001, W
statistic = 3.79) were statistically significantly higher than the predicted survival rate. The
actual survival rate of TTS-HEMS was statistically significantly higher than the predicted
survival rate in the subgroup of the severely injured patient(ISS ≥25)(Z statistic = 3.56, p
< 0.001, W statistic = 18.44). In the subgroup of mild (ISS <15) and moderate (16 ≤ ISS
<24), there were no statistically significant difference between actual survival and
predicted survival.
Conclusion: As a result of analyzing HEMS conducted for adult blunt trauma patients,
when trauma team staff participated in the transfer, the actual survival rate was higher
than the predicted by TRISS despite the high severity. Improvement in treatment result
was not confirmed when boarding only by EMT.
 Session XVI: WTC II Session: Thoracic/Vascular
Paper 2: 4:45pm - 5:45pm
A QUALITY OF LIFE STUDY COMPARING PATIENT'S OUTCOME OF
SURGICAL INTERVENTION FOR RIB FRACTURES: A PRELIMINARY,
PROSPECTIVE, COHORT STUDY IN TAIWAN
Tzu-hsin Lin MD, Hui-Lin C. Wang MD, Chi-Cheng Yang Ph.D., Chun-Hsiung Huuang
MD, Shien-Chi Liaw MD, NATIONAL Taiwan University Hopsital
Introduction: Traumatic rib fracture is the most common cause of chest injury. For so
many years, most of patients were treated with non-operative methods such as pain
control or rib brace. Recently, surgical intervention for rib fixation becomes more and
more adopted as a treatment modality because of its effects on lessening pain scale and
shortening length of stays (LOS). Despite all the abundant literature related to the rib
fractures, there are still very few investigations using Quality of life (QoL) measurement
to compare the outcomes of patients with rib fractures. Therefore, the goal of the present
study is to compare the subjective outcomes of these patients measured by QoL
instruments and their timing and possibility of return to work.
Methods: Since July, 2017 we started a prospective, cohort study of rib fractures in three
major hospitals of northern Taiwan using Short-form 36 (SF-36) and Work Quality Index
(WQI) to measure the quality of life among these patients after admission. Patients of rib
fractures in these three hospitals were asked their willingness to join our study and to have
surgery or not. We performed several screw-plate systems for rib fixation. For the
operative groups, we collected the results of these two questionnaires at 5 time points
(Pre-operative, Post-operative, 1 months, 3 months and 6 months). If patients chose not to
have surgery, the first two interviews will be conducted as within 3 days of admission and
1~2 day before discharge.
Results: Up to now, we have recruited 21 patients in this multi-centered QoL study.
There are slightly more patients (12/21, 57.14%) chose to have surgery. The average age
of these patients are 61.9 years old and the gender of study patients is predominantly male
(16/21, 76.2%). The majority of patients have been admitted to ICU (16/21, 76.2%) and
the average length of stay (LOS) in ICU is 4.75 days. The total LOS of these patients is
8.8 days. The average number of fractured ribs in these patients are 5.57 ribs. To show the
comparative effects of surgery, we found younger patients are more inclined to have rib
fixation (average: 55.2 years old in operative group vs 70.8 years old in non-operative
group, p< 0.001). The surgical patients have slightly longer LOS (9.25 days in operative
group vs 8.22 days in non-operative group). In terms of QoL results, the most significant
finding is except pain scale, most physical, emotional and social limitations are decreased
in operative groups and the effects become stronger until 1 ~ 3 months. The chance of
return to work, measured by WQI, showed that there are 6 patients already back to work.
Among those already back to work at 1 month of follow-up, most patients are in surgical
group (5/6, 83.36%).
Conclusion: Our study is the first study to show that rib fixation has better effects on
helping patient recovery, both in QoL and work quality. Beyond traditional pain score
measurements and physiological parameters such as pulmonary function test and lung
volume, the results of this study encourage more patients to have surgery to improve the
quality of life and their ability to return to work. Further study of larger scales should be
done to investigate the economic impacts on the society after rib fixation.
 Session XVI: WTC II Session: Thoracic/Vascular
Paper 3: 4:45pm - 5:45pm
CLINICAL SIGNIFICANCE OF ULTRASOUND IN PATIENTS WITH
PENETRATING CHEST TRAUMA
Alexander Smolyar Ph.D., Domodedovo Central City Hospital

Introduction: Treatment of patients with penetrating chest trauma depends on accuracy

and velocity of examination. Focused assessment with sonography for trauma (FAST),
computed tomography and pericardial window are used as diagnostic tools.
Methods: Patients with open wound admitted to level 1 trauma center from 1st of
January to 31st of December 2016 were included in retrospective non-randomized study.
Heart injury was suggested if the wound was located in the “precardial box”. Findings of
ultrasonography of pericardium were taken into account only in such cases. Patients in
extremes were excluded from the survey. Any amount of fluid in the pleural cavities, or
discrepancy between pericardium and heart more than 5 mm in diastole was considered as
a positive result. The results of FAST were controlled by follow-up observation, CT or
operation. Chest X-ray was also performed. Local wound exploration and suturing was
fulfilled after preoperative examinations. Depending on intensity of intrapleural bleeding
in the patients with penetratin wound, suturing with tube thoracostomy, VATS, or
thoracotomy was performed. The presence of hemothorax and hemopericardium, which
was detected by FAST preoperatively, was confirmed or disproved during surgery. All
patients were admitted to hospital for observation. Chest X-ray, ultrasound examination
of pleural cavities and echocardiography were repeated when necessary. Sensitivity,
specificity, positive and negative predictive value and their 95% confidence interval were
calculated.
Results: The relationship between FAST and intraoperative findings was explored in 547
patients with chest wound, of which 155 had one in the “precardial box”, and are
presented in the tables 1 and 2. Sensitivity, specificity, negative and positive predictive
value of ultrasound results are presented in table 3.
Table 1. The relationship between FAST of the pleural cavities and real hemothorax.

Table 2. The relationship between FAST of pericardial cavity and real hemopericardium.

Table 3. Sensitivity, specificity and predictive value of FAST.

Se*95%CI
- 95% confidence interval, NPV - negative predictive value, PPV - positive predictive
valuensitivity, specificity and predictive value of FAST.
Conclusion: Positive result of FAST in patients with open injuries clearly indicates a
penetrating character of the wounds. A negative ultrasound result does not exclude serious
internal organ injuries, and therefore such patients require further observation and
instrumental investigations.
 Session XVI: WTC II Session: Thoracic/Vascular
Paper 4: 4:45pm - 5:45pm

PENETRATING CARDIAC INJURIES IN THE 21ST CENTURY: HAS

SURVIVAL IMPROVED?
Christopher F. McNicoll MD, Paul J. Chestovich MD, Purvi P. Patel MD, Patricia
Souchon MD, Mallory Hamilton MD, Esmeralda Clark NP, Douglas R. Fraser MD,
Deborah A. Kuhls MD, John J. Fildes MD, University Of Nevada Las Vegas School Of
Medicine
Introduction: Penetrating cardiac injuries (PCI) are often fatal despite rapid pre-hospital
care. Although many studies have identified risk factors for mortality, few studies have
included non-transported field mortalities, and none published in the 21st century. This
study analyzes penetrating cardiac injuries including hospital and coroner reports in the
current era.
Methods: 17-years of records were reviewed, including trauma center (TC) registry,
medical records, and coroner reports from 2000-2016. Identified PCI was graded using
the AAST cardiac organ injury score (COIS). Subjects were divided into three groups:
field deaths, hospital deaths, and survived to hospital discharge. The primary outcome is
survival to hospital discharge overall and among those transported to the hospital.
Results: During the study period, 834 patients were identified, and after excluding 243 for
inadequate data, 591 PCI patients were analyzed. Mean age was 38.1 ± 17.5 years, and
survivors (n=66) were significantly younger than field deaths (n=359) (32.6 vs. 41.1,
p<0.001). Stab wounds (n=173) had improved survival compared to gunshot wounds
(n=470) (26.6% vs. 4.3%, p<0.001). COIS grades 4 to 6 (n=602) had lower survival than
grades 1 to 3 (n=41) (8.3% vs. 39.0%, p<0.001). Survivors (n=66) had lower median
COIS than patients who died in hospital (n=218) (4 vs. 5, p<0.001). Single chamber PCI
had higher survival than multiple chamber PCI (13% vs. 5%, p=0.004) (Table1). Of single
chamber injuries, the left ventricle is the most injured (n=177), and right ventricle PCI has
the highest survival (p<0.001). Of field deaths, left ventricular injuries had the greatest
single chamber mortality (60%), equaling multi-chamber PCI (60%). Overall and hospital
survival are similar to previous reports from Campbell et. al and Rhee et. al, who reported
overall survival of 2.9% and 19.3% and hospital survival of 50% and 42.7% (Table 2).
Conclusion: Survival to both TC evaluation and hospital discharge following PCI is
influenced by many factors including age, mechanism, anatomic site, and grade. Despite
advances in trauma care, survival has not appreciably improved.
 Session XVI: WTC II Session: Thoracic/Vascular
Paper 5: 4:45pm - 5:45pm
PREDICTORS FOR RETAINED HEMOTHORAX AMONG PATIENTS WITH
PENETRATING THORACIC INJURIES
ADOLFO GONZALEZ MD, ALBERTO F. GARCIA MD, ALEXANDER SALCEDO
MD, JOSE J. SERNA MD, ORLANDO AREVALO MD, SUSAN GUERRERO MD,
DIEGO VALDEZ MD, DIANA MARMOLEJO YEYSON MONTERO LINA
GRISALES VICTOR MORENO ALVARO I. SANCHEZ MD,Ph.D., JUAN C.
PUYANA* MD, UNIVERSIDAD DEL VALLE
Introduction: Tube thoracostomy (TT) is the most common procedure for thoracic
trauma. Retained hemothorax (RH) is a frequent complication in patients requiring a TT
after penetrating trauma. It is associated with higher risk of empyema, prolonged length
of stay and increasing costs. Risk factors of RH have been poorly studied in subjects with
TT after penetrating chest trauma (PCT). We aimed to investigate clinical predictors of
retained hemothorax among patients with penetrating thoracic injuries.
Methods: We conducted an observational study of 324 patients with PCT who required a
TT within the first 48 hours from injury. Patients admitted to the emergency department
in shock, who required an emergent or urgent thoracotomy, or those who were transferred
or died within 48 hours after the injury, were excluded. Demographics, injury
characteristics, and clinical and surgical information were prospectively collected during
hospitalization. Retained hemothorax was defined as blood in the pleural cavity observed
on X-ray or computed tomography scan that could not be drained through the TT and
required surgical intervention (thoracotomy or video-assisted thoracoscopy). Predictors
for RH were assessed using stepwise logistic regressions.
Results: Retained hemothorax was observed in 41 (12.6%) patients. The final regression
model indicated that total drainage greater than 750mL (odds ratio [OR], 2.00; 95%
confidence interval [CI], 1.41-2.81) and changing tube procedures (OR, 4.62; 95%CI,
1.68-12.7) were independent risk factor of retained hemothorax. Patients who underwent
laparotomies were at lower risk of developing retained hemothorax (OR, 0.05; 95%CI,
0.00-0.47). Injury severity, delay in the TT insertion and the requirement of two or more
chest tubes were not independent predictors of RH.
Conclusion: In patients with PCT, emphasis on continuous quantification of pleural
drainage and proper chest tube placement are important factors for reducing the risk of
RH. Improved pain management and chest physiotherapy after abdominal surgery may in
part explain the reduced risk of RH after laparotomy.
WTC 13: Emergency General Surgery Sponsored by WSES
Location: Harbor A, Fourth Level (Harbor Tower)
Moderators: Carlos Mesquita, MD and Federico Coccolini, MD, Portugal and Italy
Keynote: Federico Coccolini, MD, Acute Cholecystitis GL,
A STUDY OF POST-OPERATIVE COMPLICATIONS IN AN EMERGENCY GENERAL
SURGERY FIRM IN 2017
Presenter: Chris Cremona, MD, Brazil

COMPLICATION RATES IN EMERGENT VERSUS DELAYED SURGICAL INTERVENTION

FOR ACUTE CHOLECYSTITIS – A RETROSPECTIVE REVIEW
Presenter: Christopher Rice, BS, USA

DOES THE “HALO EFFECT” OF TRAUMA CENTER DESIGNATION EXTEND TO SEVERE

POSTPARTUM HEMORRHAGE? A FOUR YEAR RETROSPECTIVE REVIEW OF LEVEL 1
TRAUMA CENTERS IN AMERICA
Presenter: Phoenix Vuong, MD, USA

SURGICAL RESCUE IN A MAJOR HIGH VOLUME URBAN EMERGENCY GENERAL

SURGERY (EGS) SERVICE USING AN ELECTRONIC AUTOMATIC EMERGENCY GENERAL
SURGERY REGISTRY
Presenter: Maria Jimenez, MD, Colombia

ESTIMATING THE ECONOMIC BURDEN OF ENTERIC FISTULA AFTER DAMAGE-

CONTROL LAPAROTOMIES: A SYSTEMATIC REVIEW AND META-ANALYSIS
Presenter: Felix Chang, MBA, USA
 Session XVI: WTC II Session: Emergency General Surgery
Paper 1: 4:45pm - 5:45pm
A STUDY OF POST-OPERATIVE COMPLICATIONS IN AN EMERGENCY
GENERAL SURGERY FIRM IN 2017
Chris Cremona MD, Predrag Andrejevic* MD, Attila Csengeri MD, Mater Dei Hospital

Introduction: The aim of this study was to provide a basic statistical assessment of the
post-operative complications within a 30-day period of a local emergency general surgery
firm using the Clavien-Dindo classification. The data collected pertains to all surgeries
performed by this surgical firm over the course of 2017.
Methods: Trainees working in this firm were responsible for data collection. Every
patient who underwent emergency surgery during
the calendar year of 2017 had the following details
collected - the presence or absence of a
complication in the 30-day post-operative period,
the type of complication and description of
complication along with the grade of the
complication (see Fig 1.) and the total number of
complications for any given patient were documented. Patients who underwent
intermediate to major surgery were followed up at outpatients and were specifically asked
for the occurrence of complications from the point of discharge up until the outpatient
appointment. With one centralised national hospital - the people who were discharged and
subsequently experienced considerable or major complications invariably represented
back to hospital via the A&E department. Some patients kept in touch giving verbal
feedback and the rest were contacted and asked for any post-operative complications after
discharge within this 30-day period.
Results: A total of 148 emergency surgeries were
performed by this surgical firm in 2017. Of these
148 cases – 29 patients experienced post-operative
complications within the first 30 days after their
procedure. This equated to a complication rate of
19.59%. 24 of the 29 patients experienced just one
complication, whilst the other five patients
experienced two complications from the same procedure. Thus, giving a total of 34
complications for all the surgeries performed by this firm in 2017. The most common
complications were abdominal pain, nausea & vomiting, and wound infection. There
were 8 complications for each of these 3 categories. Post-operative bleeding occurred in
5 cases with fistulas or leak of an anastomosis occurring in 3 cases. Death of a patient
occurred in 3 instances once as a result of post-operative bleeding from the site of
anastomosis after a Whipple’s procedure, the 2nd occurred subsequent to post-operative
bleeding from a peptic ulcer and in the 3rd case occurred in an instance of faecal
peritonitis as a result of anastomotic failure after a Roux-en-Y bypass for a patient with
pancreatic malignancy.
Conclusion: The Davien-Clindo classification proved to be simple, efficient and useful in
analysing post-operative outcomes. The results of this study prove that despite that the
vast proportion of emergency cases in a predominantly elderly cohort at times going
laparoscopic or minimally invasive surgery – the complication rates were similar to other
foreign studies who had younger cohorts undergoing elective surgery.
 Session XVI: WTC II Session: Emergency General Surgery
Paper 2: 4:45pm - 5:45pm
COMPLICATION RATES IN EMERGENT VERSUS DELAYED SURGICAL
INTERVENTION FOR ACUTE CHOLECYSTITIS – A RETROSPECTIVE
REVIEW
Christopher P. Rice BS, Celia Chao MD, Daniel Jupiter Ph.D., Winston Chan BS,
August Schaeffer BS, Lance W. Griffin MD, Whitney R. Jenson MD, William Mileski*
MD, University of Texas Medical Branch - Galveston
Introduction: The last several years have seen considerable enthusiasm endorsing the
adoption of clinical pathways recommending early cholecystectomy for patients
presenting with complicated gallstone disease. We evaluated the differences between
“Emergent” (operation performed on the initial hospital admission) versus
“Delayed” (operation scheduled for and performed at a later date) for acute cholecystitis
over a 7.5-year period.
Methods: Patients who underwent cholecystectomy for acute cholecystitis from June
2010 to December 2017 were identified using our tertiary referral center’s acute care
surgery registry and operative logs. Their cases were reviewed retrospectively from
electronic medical records. Comparisons were analyzed with chi-square testing.
Results: Three hundred twenty-nine patients with acute cholecystitis were treated
surgically on their initial encounter. Conversely, 107 patients presenting with acute
cholecystitis were initially treated non-operatively and underwent a delayed
cholecystectomy. There were 77 (23.4%) Emergent patients that developed intra- or
post-op complications (including 7 deaths) and 13 (12.1%) complicated cases in the
Delayed group (no deaths). In addition to deaths, the complications identified include
common bile duct injuries, bile leaks, retained stones, abscesses, and reoperation for
hemorrhage. The difference in complication rates between the Emergent group (23.4%)
and the Delayed group (12.1%) was statistically significant (p=0.012, χ 2).
Conclusion: Our observations of significant surgical complications in patients
undergoing early cholecystectomy for acute cholecystitis support a selective approach to
surgery for complicated gallstone disease. Efforts should be made to identify patients at
greatest risk for perioperative complications, especially death.
 Session XVI: WTC II Session: Emergency General Surgery
Paper 3: 4:45pm - 5:45pm
DOES THE "HALO EFFECT" OF TRAUMA CENTER DESIGNATION
EXTEND TO SEVERE POSTPARTUM HEMORRHAGE? A FOUR YEAR
RETROSPECTIVE REVIEW OF LEVEL 1 TRAUMA CENTERS IN AMERICA
PHOENIX VUONG MD, Jason Sample MD, Arturo Torices-Dardon MD, Sarah
Stankiewicz BS, Daniel Skupski MD, Pierre Saldinger MD, NEW YORK
PRESBYTERIAN QUEENS
Introduction: High quality trauma services have been shown to improve outcomes of
trauma patients. This “halo effect” has been shown to extend to patients with nontrauma
surgical conditions such as ruptured abdominal aortic aneurysms. However, it remains
unclear if this benefit is generalizable to other populations. We hypothesize that
the discrepancy in outcomes in prior studies is related to the populations studied;
specifically, that the “halo effect” of trauma centers encompasses noninjured patients in
hemorrhagic shock. The aim of this study is to assess the impact of level 1 trauma center
designation on outcomes for patients with severe postpartum hemorrhage (PPH).
Methods: The Nationwide Inpatient Sample for years 2008 to 2011 was reviewed.
Patients with severe PPH were identified with a diagnosis code for postpartum
hemorrhage requiring transfusion, hysterectomy, or surgical repair of the uterus. Trauma
patients and patients transferred from other institutions were excluded. Hospitals were
dichotomized into level 1 trauma centers (TC) versus non-level 1 trauma centers (NTC)
by linking the American Hospital Association Annual Survey. Hospital and patient level
covariates were evaluated including the Obstetric Comorbidity Index (OCI), a validated
index used to predict maternal end-organ damage and mortality. Primary outcomes were
end-organ injury or death. Multivariate logistic regression analysis was performed and
potential confounders were included if univariate analysis showed p <0.10.
Results: 11,135 patients were admitted with a diagnosis of severe PPH. The majority
were hospitalized at NTC rather than TC (71.4% vs. 28.6%). Patients at NTC were
younger, more likely to be white, admitted electively, insured, and healthier at baseline
with a lower mean OCI (1.3 vs. 1.7; p <0.0001). Patients at TC had higher rates
of preeclampsia, congenital heart disease, sickle cell disease, multiple gestation, systemic
lupus erythematosus, human immunodeficiency virus, placenta previa, hypertension,
previous cesarean delivery, asthma, and diabetes mellitus. Overall inpatient mortality was
less than 1% with no statistical difference between rates at NTC and TC. There was also
no significant difference in rates of organ failure. However, after adjustment for
differences in OCI, race, emergency admission status, patients at NTC had a significantly
higher risk of respiratory failure (OR, 1.27; 95% CI, 1.01-1.59). The overall risk of either
end organ failure or death, although not significantly different, was higher at NTC (OR,
1.11; 95% CI, 0.95-1.3).
Conclusion: We have found that in the care of patients with severe postpartum
hemorrhage, level 1 trauma centers care for patients with an overall higher maternal
comorbidity index. When adjusted for this and other confounders, patients at TC had
improved respiratory outcomes. These patients also tended to have a lower, though not
statistically significant, risk of acute maternal end-organ injury when compared to patients
at NTC. These findings suggest that improvements in the care of patients at trauma
centers may be transferable to non-trauma patients, and achievement of trauma center
designation may indirectly improve the level of care provided to patients with severe PPH.
 Session XVI: WTC II Session: Emergency General Surgery
Paper 4: 4:45pm - 5:45pm
SURGICAL RESCUE IN A MAJOR HIGH VOLUME URBAN EMERGENCY
GENERAL SURGERY (EGS SERVICE USING AN ELECTRONIC
AUTOMATIC EMERGENCY GENERAL SURGERY REGISTRY
Maria F. Jimenez* MD, Andres Isaza MD, Danny Conde MD, Felipe Borda Medical
Student, Daniel Colmenares Medical Student, Alex Arroyo BS, Luis Bejarano BS, Juan
C. Puyana* MD, Hospital Universitario Mederi

Introduction: Postoperative mortality is impacted by the speed and proper interventions

implemented by an acute care surgeon to “rescue” complicated patients from death.
Failure to rescue has been recently regarded as an important indicator of patient’s safety
and quality care. In our high surgical volume and low resources institution where there is
no option to hire registrars to fed databases, an electronic Emergency General Surgery
registry was recently developed to automatically capture in-hospital information and
outcomes from the Electronic Medical Record (EMR).
Objective: The aim of this study is to describe the incidence of “surgical rescue” and
outcomes of the complicated EGS patients at an inner city 1000 beds university major
referral center.
Methods: A prospective electronic captured EGS (demographic, primary EGS coding,
surgical procedures, surgical and outcomes) was used to screen for acute EGS surgical
complications of operative procedures from June to July 2017 at a large urban academic
medical center in a tertiary care facility. During morning rounds, emergency general
surgeons prospectively identified, classified and included surgical complications in an
online application that was also automatically captured in the electronic EGS registry.
Surgical chart reviewers of complicated patients confirmed and validated the captured
data. Only surgical complications requiring surgical procedure in the operating room were
included.
Results: We identified 496 patients (55 years old ± 20; 57% female) who underwent to
524 EGS surgical procedures. Most common procedures were: laparoscopic
cholecystectomy (25.6%), appendectomy (18.5%), drainage of intraabdominal collection
(14.6%), and abdominal exploration (7%). for peritonitis or ischemia Thirteen patients of
the 496 patients (2.6%) required “surgical rescue” defined as patients who were
immediately intervened after identifying a surgical complication mainly for uncontrolled
sepsis (43%) and anastomotic leaks (30%). The most common surgical intervention was
source control of the infection (50%), bowel resection or intestinal repair (15%), and
bleeding control (15%). Surgical rescue failure rate (inability to prevent death after de
development of a surgical complication) was 15.4%.. Hospital length of stay, need for
critical care and in-hospital mortality was higher in the surgical rescue patients compared
to those without surgical complications.
Conclusion: Surgical failure to rescue rate was higher than similar high volume EGS
services recently described. The development and implementation of an electronic
automatic captured EGS registry database in our academic medical served to build best
practices for “surgical rescue” and to drive quality improvement programs.
 Session XVI: WTC II Session: Emergency General Surgery
Paper 5: 4:45pm - 5:45pm
ESTIMATING THE ECONOMIC BURDEN OF ENTERIC FISTULA AFTER
DAMAGE-CONTROL LAPAROTOMIES: A SYSTEMATIC REVIEW AND
META-ANALYSIS
Felix K. Chang MBA, Rondi B. Gelbard MD, Christopher J. Dente* MD, Allan D. Kirk
MD,Ph.D., Timothy G. Buchman* MD,Ph.D., Eric A. Elster MD, Emory University
Introduction: Enteric fistula (EF) are a known complication after damage-control
laparotomy (DCL) for severe traumatic injury. However, the total economic burden of EF
in the United States is unknown. Defining the economic burden of fistula development is
needed to provide the foundation for future research, advocacy, and education efforts.
Methods: This analysis combined a systematic review of data from the Agency for
Healthcare Research and Quality’s Healthcare Cost and Utilization Project (HCUP) with a
meta-analysis of data from a Level 1 trauma center and a literature review from the
PubMed and MEDLINE databases, covering January 1, 2000 through December 31, 2017.
We selected data from HCUP by primary diagnosis ICD-9CM codes to determine an
annual number of emergent laparotomies in the United States. Since the most recent
HCUP data available to us was collected in 2014, we updated its figures to 2017,
assuming that the proportion of laparotomy procedures to the U.S. population remained
consistent over the three-year period. We then used ratios created from our meta-analysis
of past medical studies to determine the number of specific types of laparotomies and their
complications, specifically fistula development. Intensive care unit (ICU) and hospital
lengths of stay (LOS) for DCL patients with and without fistula were analyzed to generate
baseline costs. We then conducted an 80-hospital survey of direct charges for ICU and
general ward stays, in conjunction with a ratio of professional to facility charges for
patients with an Injury Severity Score ≥18, to determine the excess per-patient charges
incurred by DCL patients with fistula. Applying those excess charges to the likely annual
nationwide number of fistula developed, we then calculated the total economic burden of
fistula development.
Results: There were between 13,526 and 19,938 emergent laparotomies in 2017. Of
these, between 4,427 and 6,525 (or 32.7%) represented DCL. A fistula complication was
likely to have arisen in 322 to 474 (or 7.3%) of these DCL cases. We estimate that the
facility and professional charges required to treat DCL patients with EF was $309,150
versus $69,929 without EF, and the excess per-patient cost for EF treatment was
$239,211. Nationally, we assess that the total economic burden of enterocutaneous and
enteroatmospheric fistula after damage-control laparotomies to be between $77 million to
$113 million.
Conclusion: This analysis fills a knowledge gap in the study of fistula development after
DCL. The economic burden of fistula is substantial and significant in the United States.
 Friday
6:15-7:15 A.M.
9/28
6:15-7:15 am WTC 14: Critical Care Sponsored by Australasian Trauma Society
Session XVII: Location: Harbor A, Second Level (Harbor Tower)
WTC III Sessions Moderators: Koji Morishita, MD and Zsolt Balogh, MD, PhD, Japan and Australia
Keynote: Zsolt Balogh, MD, PhD, Understanding Post Injury Inflammation for Better Timing
of Definitive Surgical Intervention in Polytrauma
RHABDOMYOLYSIS AND ACUTE KIDNEY INJURY IN BLUNT TRAUMA PATIENTS
Presenter: Jung Yun Park, MD, South Korea

NEUROENTERIC AXIS MODULATES THE INTESTINAL CIRCULATION AFTER TRAUMA/

HEMORRHAGIC SHOCK
Presenter: Masayuki Yagi, MD, Japan

INCIDENCE OF ACUTE RESPIRATORY DISTRESS SYNDROME AND ASSOCIATED

MORTALITY IN A POLYTRAUMA POPULATION
Presenter: Karlijn Van Wessem, MD, PhD, Netherlands

WITHDRAWN

STUDY OF SERUM COPPER LEVELS IN CONSERVATIVELY MANAGED HEAD INJURY

PATIENTS WITH SPECIAL REFERENCE TO ITS SEVERITY AND OUTCOME
Presenter: Vinod Jain, MD, India
 Session XVII: WTC III Session: Critical Care
Paper 1: 6:15am - 7:15am
Rhabdomyolysis and acute kidney injury in blunt trauma patients
Jung Yun Park MD, Yonsei University College Of Medicine

Introduction: Rhabdomyolysis (RB), which is a decomposition of skeletal muscles, is

common in blunt trauma patients. RB can result in acute kidney injury (AKI) and
sometimes it can be life-threatening. The aim of our study is to identify predictors of RB
induced AKI from the initial patient information and parameters.
Methods: We retrospectively analyzed 727 blunt trauma patients admitted to a single
tertiary hospital from January 2014 through December 2017. Patients who had chronic
kidney disease previously diagnosed were excluded from the study. RB was defined as a
creatine kinase (CK) level equal or greater than 1,000 U/L. The diagnosis of AKI was
based on RIFLE criteria.
Results: The overall incidence of RB and AKI were 30.4 % (n = 221) and 12.2 % (n =
89), respectively. According to the univariate analysis, peak CK (p = 0.045), initial
hemoglobin (p = 0.010), serum pH (p = 0.001), base excess (p = 0.001), lactate (p =
0.008), calcium (p = 0.001), magnesium (p = 0.021), ISS score (p = 0.016), and ISS of
extremity (p = 0.017) were showed to be associated with RB induced AKI. And lactate
appeared to be related to needs for RRT among RB associated AKI patients (p = 0.003).
In multivariate analysis initial base excess (Odds ratio (OR) 0.862; 95 % confidence
interval (CI) 0.775 - 0.959; p = 0.006) and initial serum calcium level (OR 0.563; 95% CI
0.373 - 0.849; p = 0.006) were shown to be associated independently with RB induced
AKI.
Conclusion: Serum CK level is used diagnose RB, but it does not predict RB induced
AKI. Low base excess and low serum calcium levels are independently associated with
RB induced AKI. And serum lactate level seems to be associated with RRT in RB
induced AKI patients.
 Session XVII: WTC III Session: Critical Care
Paper 2: 6:15am - 7:15am
NEUROENTERIC AXIS MODULATES THE INTESTINAL CIRCULATION
AFTER TRAUMA/HEMORRHAGIC SHOCK
Masayuki Yagi MD, Koji Morishita MD,Ph.D., Akinori Ueno Ph.D., Junichi Aiboshi
MD,Ph.D., Hajime Nakamura BS, Hiroya Akabori MD,Ph.D., Mitsuaki Kojima
MD,Ph.D., Atsushi Senda MD, Yasuhiro Otomo MD,Ph.D., Tokyo Medical And Dental
University
Introduction: Gut barrier breakdown causes an intestinal inflammatory response
generating the inflammatory mediators. Electrical vagus nerve stimulation (VNS) is
known to prevent gut damage in animal models of trauma/hemorrhagic shock (T/HS) by
altering the gut inflammatory response to acute injury, independent of the spleen.
However, its effect on detailed electrophysiological function of the vagus nerve (VN) to
the gut is unknown. Therefore, the aims of this study were: 1) to investigate the action
potential of VN induced by VNS, 2) to evaluate the influence of evoked neural activity on
the systemic circulation and intestinal blood flow (IBF), 3) to determine whether VNS
improve the gut damage after T/HS.
Methods: 1) Male Sprague Dawley rats were anesthetized by isoflurane, and cervical and
abdominal VN was exposed. One pair of bipolar electrodes were attached the cervical VN
to stimulate the VN (square wave, 5V, 5Hz, 20min), and other two pairs of bipolar
electrodes to the abdominal VN to measure the VN action potential. After the each VNS,
the action potential was detected by threshold processing of band-pass-filtered (200-1000
Hz) recording from the abdominal VN. The mean arterial pressure (MAP) and heart rate
(HR) were measured simultaneously. 2) Rats were randomly assigned to undergo T/HS, T/
HS+VNS, or T/HS+Vagotomy (Vx)+VNS. The rats underwent the T/HS (MAP 25 mmHg
for 30min) without fluid resuscitation and then received cervical VNS. A separate cohort
of animals was subjected to abdominal Vx to disrupt the neuroenteric axis. The IBF was
measured by laser Doppler flowmery. The gut was harvested to evaluate the gut injury.
Results: 1) The action potential was identified around the time point of 40±12 msec after
each stimulus of VN in the normal condition. 2) VNS caused an approximately 3.2-fold
increase in the IBF in comparison to shock phase (p<0.05). Abdominal Vx eliminated the
effect of VNS on the IBF (p<0.05). The BP and HR were decreased for several seconds
immediately after VNS, but the BP then rapidly increased from 25.2 mmHg to 52.1
(34.2-62.8 mmHg) and the HR showed a slight
increase. 3) Performing VNS is tend to protect
T/HS induced gut injury (MPO activity).

Conclusion: VNS causes VN action potential and

improves the T/HS-induced IBF impairment.
VNS may have a therapeutic impact on acute gut
injury after T/HS.
 Session XVII: WTC III Session: Critical Care
Paper 3: 6:15am - 7:15am
INCIDENCE OF ACUTE RESPIRATORY DISTRESS SYNDROME AND
ASSOCIATED MORTALITY IN A POLYTRAUMA POPULATION
Karlijn J. Van Wessem* MD,Ph.D., Luke P. Leenen* MD,Ph.D., Department Of Trauma
Surgery, University Medical Center Utrecht
Invited Discussant:

Introduction
The incidence of Adult Respiratory Distress Syndrome (ARDS) has decreased in the last
decades by improvement in trauma and critical care. However, it still remains a major
cause of morbidity and mortality. This study investigated the current incidence of ARDS
and its relation to mortality in polytrauma patients.
Methods
A 4-year prospective study included consecutive trauma patients admitted to a Level-1
Trauma Center ICU. Isolated head injuries, drowning, asphyxiation and burns were
excluded. Demographics, ISS, physiologic parameters, resuscitation parameters, Denver
Multiple Organ Failure (MOF) scores and ARDS data according to Berlin criteria were
prospectively collected. Only severe ARDS (PaO2 /FiO 2 ratio<100) was included in
analysis. Data are presented as median (IQR), p<0.05 was considered significant.
Results
222 patients were included. Median age was 47 (28-60) years, 169 males (76%), ISS was
29 (22-37), 212 (95%) patients had blunt injuries. Forty-two patients (19%) died, 36 due
to brain and/or spinal cord injuries (86%). Twenty-eight patients (13%) developed severe
ARDS. Median time to ARDS onset was 2 (1-4) days after injury. Median duration of
ARDS was 1 (1-2) day. Only 3 patients (11%) had ARDS for more than 3 consecutive
days. No patient died of ARDS. Four patients who developed ARDS later died of CNS
related injuries. Patients who developed ARDS had lower ISS (28 vs.29, p=0.04) lower
PaO 2 in ED (182 vs. 223 mmHg, p=0.005), and lower saturation in ICU (97 vs. 98%,
p=0.002). Further, they stayed longer on the ventilator (12 vs. 6 days, p=0.000), longer in
ICU (16 vs.7 days, p=0.000) and in hospital (31 vs. 21 days, p=0.000) and developed
more often Multiple Organ Dysfunction Syndrome (MODS 71% vs. 20%, p=0.000).
There was however no difference in mortality between both groups (14% in ARDS vs.
20% in non-ARDS, p=0.61).
Conclusion
In this polytrauma population mortality was predominantly caused by brain injury.
Although ARDS was still present in severely injured polytrauma patients, no patient died
of ARDS. Its presentation was only early onset, and during a short time period.
PAPER 4 - WITHDRAWN
 Session XVII: WTC III Session: Critical Care
Paper 5: 6:15am - 7:15am
STUDY OF SERUM COPPER LEVELS IN CONSERVATIVELY MANAGED
HEAD INJURY PATIENTS WITH SPECIAL REFERENCE TO ITS SEVERITY
AND OUTCOME.
VINOD JAIN MD, Samir Misra MD, Ankita Johary Ph.D., King George's Medical
University
Introduction: Head injury is most common cause of death and disability in mechanically
injured patients. Trace metals like copper is known to have its impact in traumatic brain
injury. This study was conducted to observe impact of serum copper levels in traumatic
brain injury and its correlation with severity and outcome.
Methods: It is a prospective cohort study. Blood samples were collected within eight
hours of injury and serum copper was estimated by atomic absorption spectrophotometer
after its complete digestion by microwave digester. Patients were subsequently followed
up clinically with repeat serum copper estimation on day 5 and day 10. Levels in cases
and controls as well as that in moderate and severe head injury patients on day 0, day 5
and day 10 were compared using paired t-test. The p-value<0.05 was considered as
significant. All analysis was carried out by using SPSS 24.0 version.
Results: The results are presented in mean±sd. Serum copper levels were found to be
significantly low in patients of severe head injury (p<0.001). Patients with persistent low
levels of serum copper had poor recovery in GCS (P<0.05)
Conclusion: Study showed primary evidence of a relationship between severity and
serum copper levels in traumatic brain injury patients. Association of persistent low level
with poor outcome opens new area of research to study recovery pattern with additive
therapy of copper in severe head injury patients.
WTC 15: Prevention Sponsored by Eastern Association for the Surgery
of Trauma (EAST)
Location: Harbor C, Second Level (Harbor Tower)
Moderators: Jose Mauro da Silva Rodrigues, MD and Nicole Stassen, MD, Brazil and USA
Keynote: Nicole Stassen, MD, A New Frontier in Firearm Injury, USA
IMPACT OF THE RESUSCITATIVE ENDOVASCULAR BALLOON OCCLUSION OF THE
AORTA (REBOA) ON MORTALITY IN PENETRATING TRAUMA PATIENTS: A PROPENSITY
SCORE ANALYSIS
Alberto Garcia, MD, Colombia

INTERPERSONAL VIOLENCE AND MORTALITY IN PEACETIME SUB-SAHARAN AFRICA

Presenter: Brittney Williams, MD, USA

THE SPECTRUM OF INJURIES RESULTING FROM GUNSHOT WOUNDS IN CAR

HIJACKING: A SOUTH AFRICAN EXPERIENCE
Presenter: Victor Kong, PhD, MBChB, South Africa

CORRELATION BETWEEN QUALITY AUDIT FILTERS AND SEVERITY OF TRAUMA

Presenter: Jose Parreira, MD, PhD, Brazil

MORBIDITY, MORTALITY AND HEALTHCARE COST DUE TO INJURY FROM VENOMOUS

AND NON-VENOMOUS ANIMALS IN THE UNITED STATES: 5-YEAR ANALYSIS OF THE
NATIONAL EMERGENCY DEPARTMENT SAMPLE
Presenter: Joseph Forrester, MD, MSc, USA
 Session XVII: WTC III Session: Prevention
Paper 1: 6:15am - 7:15am
IMPACT OF THE RESUSCITATIVE ENDOVASCULAR BALLOON
OCCLUSION OF THE AORTA (REBOA ON MORTALITY IN PENETRATING
TRAUMA PATIENTS: A PROPENSITY SCORE ANALYSIS.
ALBERTO F. GARCIA MD, RAMIRO MANZANO MD, CLAUDIA P. ORLAS MD,
ALVARO I. SANCHEZ MD,Ph.D., JUAN C. PUYANA MD, CARLOS A. ORDOÑEZ
MD, Fundacion Valle del Lili

Introduction: The use of endovascular balloon occlusion of the aorta (REBOA) as an

ancillary method in damage control resuscitation (DCR) for trauma has been reported
mostly on blunt injuries. Information on penetrating trauma is limited and the effect on
mortality is not known. We compared in-hospital mortality between penetrating trauma
patients managed with and without REBOA, adjusted by a propensity score.
Methods: In a retrospective cohort study, patients 16 years or older with penetrating
trauma, requiring DCR and emergent surgery, and treated between 2014 and 2017, were
included. The decision to use or not REBOA during emergent surgery was based on
individual surgeon opinion. A propensity score (PS) was built adjusting for age, clinical
signs on admission (systolic blood pressure, cardiac rate, Glasgow coma scale), severe
trauma in thorax and abdomen, and the presence of non-compressive torso hemorrhage.
PS attempted to approximate the conditions of random assignation of REBOA for
treatment, in patients who had a similar distribution of covariates. Main analysis
compared mortality between patients with and without REBOA. Final logistic regression
for mortality was adjusted for the number of red blood cells (RBC) transfused within the
first six hours after admission, injury severity score (ISS), and quintiles of PS.
Results: Inclusion criteria were met by 345 patients; 28 of them (8.1%) were treated with
REBOA. Crude mortality rates were 17.8% (5 patients) in REBOA group and 15.4% (49
patients) in control group (p=0.785). After controlling for RBC transfused, ISS, and PS,
the odds of death in REBOA group was 78% lower than in the control group (odds ratio
[OR] 0.22, 95% confidence interval [95%CI] 0.05-0.84, p=0.028). This regression model
demonstrated excellent discrimination (area under the curve of 0.81) and adequate
calibration (p=0.097).
Conclusion: After adjustment for an anatomic score (ISS), a physiologic indicator of
blood loss (number of RBC transfused), and quintiles of PS, the use of REBOA showed a
significant reduction in the odds of mortality, compared with no REBOA use. It suggests
that, in selected penetrating trauma patients who are suffering severe injuries and
physiologic exhaustion, the use of REBOA might add to the survival, as an adjuvant of
DCR protocols.
 Session XVII: WTC III Session: Prevention
Paper 2: 6:15am - 7:15am
INTERPERSONAL VIOLENCE AND MORTALITY IN PEACETIME
SUB-SAHARAN AFRICA
Brittney M. Williams MD, Gift Mulima MBBS, Paula Strassle MSPH, Anthony Charles
MD,MPH, Rebecca Maine MD,MPH, University of North Carolina
Introduction: Trauma is a leading cause of death and disability worldwide. Interpersonal
violence has often been overlooked as a significant cause of traumatic injury and
mortality. We hypothesized characteristics differed between victims of interpersonal
violence and unintentional injuries in Sub-Saharan. We also sought to identify factors
associated with mortality.
Methods: We compared characteristics of all injured patients in the trauma registry at
Kamuzu Central Hospital, Lilongwe, Malawi, from 2009 through 2016. Multivariable
Poisson regression was used to identify factors associated with inpatient mortality after
interpersonal violence.
Results: Of 109,422 trauma patients, 26,829 (24.5%) were victims of interpersonal
violence. Compared to unintentional injuries, alcohol was more frequently used by
assault victims (15.7% vs 2.9%, p<0.001), women comprised fewer assault victims
(20.7% vs 29.8%, p<0.001), and assaulted patients were older (median 27yrs vs 21yrs,
p<0.001). Most assaults involved penetrating injuries (45.8%). In multivariable analysis,
truncal injuries (iRR 7.14, 95%CI 3.74, 13.67) head injuries (iRR 4.36, 95%CI 2.41,
7.90), ≥3 injured body locations (iRR 2.54, 95%CI 1.71, 3.76), penetrating injuries (iRR
3.52, 95%CI 1.96, 6.34) and blunt tool injuries (iRR 2.27, 95%CI 1.23, 4.18) were
associated with increased mortality (Table). For every increased decade of age, mortality
risk increased by 17% (iRR 1.17, 95%CI 1.02, 1.33). Women had lower mortality (iRR
0.43, 95%CI 0.24, 0.78).
Conclusion: Even in peace times, interpersonal violence accounts for a large percentage
of Malawi’s trauma burden. Significant risk factors for mortality are penetrating and
blunt tool injuries to the torso, thus improving surgical capacity is essential to reducing
homicides.
 Session XVII: WTC III Session: Prevention
Paper 3: 6:15am - 7:15am
THE SPECTRUM OF INJURIES RESULTING FROM GUNSHOT WOUNDS IN
CAR HIJACKING: A SOUTH AFRICAN EXPERIENCE
Victor Kong Ph.D., MBChB, Joanna M. Blodgett BSc, Ross Weale MBBS, BSc, John L.
Bruce MBChB, Grant Laing Ph.D., MBChB, Damian Clarke Ph.D., MBChB
Pietermaritzburg Metropolitan Trauma Service, Department Of Surgery
Introduction:​ Car hijacking is aggravated robbery of a vehicle from the driver that usually
involves the use of a firearm. South Africa has the highest rate in the world. However,
there is little literature on the spectrum of GSW (gunshot wounds) sustained by victims of
car hijacking.
Methods: A retrospective review was conducted over the 8-year period from January 2010
to January 2018 at a Major Trauma Centre in South Africa. All patients who sustained
GSW following a carjacking incident were included.
Results: 101 patients were identified (74% male, mean age: 34 years). The mean time
from injury to arrival was 7 hrs (rural district: 10 hrs, urban district, 4 hrs, p < 0.001).
Seventy-five percent (75/101) of all patients sustained GSW to multiple body regions,
while the remaining 25% (25/101) were confined to a single body region. The most
common region involved was the chest (48) followed by the abdomen (46) and neck (34).
62% of patients required one or more operative intervention. The most common procedure
was laparotomy (28), followed by peripheral vascular exploration (20) and neck (14)
exploration. Eighteen percent require intensive care admission, the mean length of hospital
stay was 8 days. The overall morbidity was 13% (16/101) and the overall mortality was
18% (18/101).
Conclusion: The majority of victims sustained multi-regional GSWs and two-third require
surgery, with a high mortality. Trans-axial GSW of the torso is common and can be
challenging to manage.
 Session XVII: WTC III Session: Prevention
Paper 4: 6:15am - 7:15am
CORRELATION BETWEEN QUALITY AUDIT FILTERS AND SEVERITY OF
TRAUMA
Jose G. Parreira MD,Ph.D., Luisa C. Higa Samuel B. Melin Thalia Polgrossi Jacqueline
G. Perlingeiro MD,Ph.D., Tercio De Campos MD,Ph.D., Jose C. Assef MD,Ph.D.,
SANTA CASA SCHOOL OF MEDICAL SCIENCES

Introduction: trauma is a frequent problem, which often requires prompt diagnosis and
treatment. The stress and the complexity present in some cases create a situation in which
errors are more likely to occur. Trauma audit filters were proposed as variables able to
identify opportunities to improve patient’s care. However, the role of audit filters as
adequate tools for quality improvement programs has been recently questioned. The
objective of this study was to assess the correlation between the most frequently used
audit filters (AF) and the severity of trauma.
Methods: We carried out a retrospective analysis of the trauma registry data, including
adult patients admitted from 2014 to 2015. Severity of the trauma was assessed by
Abbreviated Injury Scale (AIS), Revised Trauma Score (RTS), Injury Severity Score
(ISS) e TRISS. We selected ten AF frequently used in quality improvement programs: F1:
Acute subdural hematoma drained after 4 hs. of admission. F2: transfer a patient with
GCS<8 without a definitive airway. F3: tracheal reintubation <48 hs. of planned
extubation. F4: time between admission and laparotomy > 60 min. in unstable patients.
F5: unplanned reoperation. F6: laparotomy after 4 hs. of admission. F7: no fixation of
femur diaphysis fracture. F8: nonoperative management of abdominal GSW. F9: time
between admission and operative treatment of open tibial fracture greater than 6 hs. F10:
operation after 24hs. of admission. We compared trauma indexes between patients with
and without AF. We used chi-square and Fisher's exact tests, considering p<0.05 as
significant.
Results: 663 patients were included, with mean age of 39 ± 9 years. Mean RTS, ISS and
TRISS were, respectively, 6.7 ± 1.4; 6.8 ± 11.3 e 0.90 ± 0.20. AF were present in 39
patients (5.9%), including 10 of the 498 patients with ISS<10 (2.0%), 3 of the 26 with ISS
between 10 and 15 (11.5%), 14 of the 63 with ISS between 16 and 25 (16.9%) and 12 of
the 43 with ISS>25 (27.9%) (p<0.05). In patients sustaining severe injuries in head,
thorax, abdomen and extremities, AF were, respectively, 21, 16, 17 and 9 times
more frequent.
Conclusion: These data show a correlation between AF and trauma severity. This might
indicate that the more severe is the trauma, the higher is the risk for mistakes.
 Session XVII: WTC III Session: Prevention
Paper 5: 6:15am - 7:15am
MORBIDITY, MORTALITY AND HEALTHCARE COST DUE TO INJURY
FROM VENOMOUS AND NON-VENOMOUS ANIMALS IN THE UNITED
STATES: 5-YEAR ANALYSIS OF THE NATIONAL EMERGENCY
DEPARTMENT SAMPLE
Joseph D. Forrester MD, MSc, Jared A. Forrester MD, Lakshika Tennakoon MPhil,
Kristan Staudenmayer* MD, MS Stanford University

Introduction: Injuries due to encounters with animals can be serious, but are often
discussed anecdotally or only for isolated types of encounters. The burden of
animal-related injuries is currently unexplored. We sought to characterize animal-related
injuries on U.S. emergency departments (ED) to determine the impact of these types of
injuries.
Methods: All ED encounters with the diagnosis code corresponding to an animal-related
injury were identified using ICD-9-CM codes from the 2010-2014 National Emergency
Department Sample (NEDS). The primary outcome was mortality; secondary outcomes
included costs and inpatient admission. Survey methodology was applied to univariate and
multivariate analyses. Weighted numbers are presented.
Results: A total of 6,457,534 ED visits resulting from animal-related injuries were
identified, averaging 1,291,507 visits annually. This corresponded to 19 animal-related
injuries per 10,000 patient-ED visits per year. Common animal-related injuries were
associated with bites from non-venomous arthropods (n=2,648,880; 41%), followed by
dogs (n=1,660,878; 26%), and envenomation from hornets, wasps or bees (n=813,649;
13%). A total of 210,516 patients (3%) were admitted. Inpatient admission was the most
common for those who sustained bites from venomous snakes or lizards (24%, N=10,332).
Death was infrequent, occurring in 1,162 patients (0.02% of all ED presentations). The
greatest number of deaths were due to bites from non-venomous arthropods (24% of
deaths, n=278). Rat bites proved the most lethal (6.5 deaths per 10,000 bites), followed by
bites from venomous snakes or lizards (6.4 deaths per 10,000 bites). Dog bites resulted in
fatality 6.1 times in 10,000 bites. Factors associated with increasing odds of death were
age>65 years (OR 7.0, P<0.001) and ISS>15 (OR 39.9, P<0.001); female sex was
associated with decreased odds of death (OR 0.6, P<0.001). Total healthcare cost due to
animal encounters was 5.7 billion dollars (95% confidence interval: 5.4-6.5 billion dollars)
over the 5-year time period.
Conclusion: The morbidity, mortality, and healthcare cost due to animal encounters in the
United States is considerable. Often overlooked, this particular mechanism of injury
warrants further public health prevention efforts.
WTC 16: Abdominal Trauma Sponsored by European Society for Trauma and
Emergency Surgery (ESTES)
Location: Seaport A-C, Second Level (Seaport Tower)
Moderators: Jungchul Kim, MD and Ari Leppaniemi, MD, PhD, South Korea and Finland
Keynote: Ari Leppaniemi, MD, PhD, Nonoperative Management of Solid Abdominal Organ
Injuries
DIAGNOSIS AND TREATMENT OF BLUNT ADRENAL GLAND TRAUMA
Presenter: Alexander Smolyar, PhD, Russia

DAMAGE CONTROL INDICATION FOR SEVERE BLUNT TRAUMA INJURIES IN JAPAN

Presenter: Nao Urushibata, MD, Japan

OUTCOMES OF BLUNT ABDOMINAL TRAUMA PATIENTS WITH A FALSE-NEGATIVE FAST

SCANNING IN A LEVEL I TRAUMA CENTER
Presenter: Ibrahim Yilmaz, MD, USA

HOLLOW VISCOUS ORGAN INJURY IN BLUNT ABDOMINAL TRAUMA- CHALLENGES

IN TRAUMA BAY
Presenter: Samir Misra, MD, India

EVALUATION OF THE SELECTIVE USE OF CONTRAST-ENHANCED COMPUTED

TOMOGRAPHY IN CLOSED ABDOMINAL TRAUMA
Presenter: Heitor Consani, MD, Brazil
 Session XVII: WTC III Session: Abdominal Trauma
Paper 1: 6:15am - 7:15am
DIAGNOSIS AND TREATMENT OF BLUNT ADRENAL GLAND TRAUMA
Alexander Smolyar Ph.D., Domodedovo City Hospital

Introduction: Frequency of blunt adrenal gland injury (AGI) is less than 1%.
Methods: 32 patients with AGI were included in a prospective study. There were 26 men
(81.3%) and 6 women (18.7%) 30±12.9 years old with ISS of 22.7±13.6. 28 (87.5%) were
delivered to the hospital through 1.3±1 hour after injury, 4 (12.5%) were transferred
from10 till 96 hours. All patients performed FAST during resuscitation. Intensive bleeding
from liver or spleen in 10 patients were the indication for urgent laparotomy. One patient
performed left thoracotomy and then laparotomy. One of the four transferred performed
laparotomy at Level 2 trauma center. Thus 12 victims (37.5%) performed urgent
laparotomy, 20 (62.5%) were treated without operation. US of the abdominal cavity and
the abdominal CT with intravenous contrast enhancement were performed. In case of
conservative treatment US and CT have been repeated.
Results: Thirty victims were found to have right AGI, 1 - left and 1 - both. The V degree
of AGI was found in 30 victims, IV and III – in one. Most often, the right kidney (10),
liver and right kidney (5), liver (3) were damaged with the adrenal gland. AGI hadn’t any
clinical picture and was found only during US or CT. No one AGI was identified during
laparotomy. AGI was found by US in 27 victims (84.4%). Direct US sign was the
appearance of oval hypoechoic mass with a clear border and size less than 50x40 mm
without blood flow. AGI suggested when injury of right kidney, liver segment VII and
right perirenal hematoma were identified. The more indirect signs had been found, the
more likely AGI was. The accuracy of US diagnosis of AGI increased with repeated trials
a day from the time of injury. An important difference of AGI from tumor was gradual
regression of US signs and return to a normal picture in the fourth week. AGI was found
by CT in 31 patients (96.9%). An oval high density mass with clear borders less than
57x31 mm was found. On the 3rd day the gland became heterogeneous due to the
appearance of low-density areas. By the 14th day adrenal gland density became normal.
Only the absence of contrast medium accumulation allowed to recognise AGI from tumor.
The AGI size decreased from the third week and the structure and size became normal to
1.5-2 months. Bleeding from the adrenal gland in all cases stopped spontaneously.
Clinical manifestations of adrenal insufficiency wasn’t observed. Thirty one victims
recovered, one died from severe traumatic brain injury.
Conclusion: Blunt adrenal gland injury had no characteristic clinical picture, however,
clearly revealed by US and CT. Conservative therapy was effective in all cases.
 Session XVII: WTC III Session: Abdominal Trauma Paper 2:
6:15am - 7:15am
Damage Control Indication for Severe Blunt Trauma Injuries in Japan
Nao Urushibata MD, Kiyoshi Murata Ph.D., Raira Nakamoto MD, Ayako Yoshiyuki MD,
Matsudo City General Hospital
Introduction: There are many arguments regarding the criteria for damage control
surgery(DCS). Previously, we analyzed the data from Japan Trauma Data Bank (JTDB)
and created a score for damage control surgery (Damage Control Indication Detecting
score; DECIDE score), comprised of body temperature, Glasgow Coma Scale(GCS) and
type of injury (blunt or penetrating). Considering trauma in Japan is mostly blunt injuries,
as gun-shot wounds are seldom in Japan, we sought for a new criterion for DCS focusing
on blunt injuries.
Methods: Retrospective data from JTDB from 2004-2014 were used to analyze blunt
trauma patients who were FAST positive and underwent emergency laparotomy. We
excluded burn victim patients and patients with ISS=75. Primarily, we performed a
baseline characteristic analysis between the DCS group and non-DCS group. Then, we
performed a logistic regression analysis and created a prediction score for damage control
surgery.
Results: Of the 159157 registered trauma patients, 1934 blunt trauma patients who were
FAST positive and underwent emergency laparotomy were extracted. We compared the
364 patients that underwent DCS (DCS group) to the 1570 patients who underwent
typical laparotomy (non-DCS group). Blood pressure, body temperature, GCS, blood
transfusion rate, Injury Severity Score, time to surgery, and mortality rate were
significantly different between the groups. Then, we performed a logistic regression
analysis, with DCS as the dependent variable, and age, gender, head AIS, ISS, GCS, body
temperature, and blood pressure as the independent variables. Blood pressure, GCS, and
body temperature were independent risk factors for DCS. Following the analysis, we
categorized the risk variables, and created the DCS prediction score comprised of body
temperature (0-2 points), blood pressure (0-1 point) and Glasgow Coma Scale (0-3 points)
with a maximum of six points. From this score, we performed a receiver operating
characteristic (ROC) analysis. Area under the ROC curve was 0.704, and cut-off value of
three points showed sensitivity of 68% and specificity of 63%. Furthermore, we used the
data from JTDB 2015 to validate our score. The proposed score showed legitimate
sensitivity and specificity for Damage Control Surgery as well as mortality.
Conclusion:Blood pressure, body temperature, and GCS could be utilized as a legitimate
indicator for damage control surgery in Japan.
 Session XVII: WTC III Session: Abdominal Trauma
Paper 3: 6:15am - 7:15am
OUTCOMES OF BLUNT ABDOMINAL TRAUMA PATIENTS WITH A
FALSE-NEGATIVE FAST SCANNING IN A LEVEL I TRAUMA CENTER
Ibrahim Yilmaz MD, Mehmet Saydam MD, Paige E. Finkelstein BS, Omar Picado
MD,MPH, University Of Miami, Jackson Memorial Hospital
Introduction: Focused assessment with sonography for trauma (FAST), is the initial
diagnostic modality of choice for the assessment of blunt abdominal trauma and was
adopted in the Advanced Trauma Life Support (ATLS) protocol by American College of
Surgeons. Despite widespread use, there are ongoing debates regarding the accuracy of
FAST and the interpretation of false-negative results. Here we determine whether negative
FAST studies can rule out abdominal injuries.
Methods: A retrospective study was carried out between October 2008 and October 2013
on 11,924 patients admitted to our Level I Trauma Center who received a FAST
examination. Free fluid in RUQ, LUQ or pelvis was considered “positive FAST.”
Abdominal CT and/or exploratory laparotomy were considered gold standard confirmation
of free fluid. True positive (TP) FAST was defined as positive FAST and presence of free
fluid with abdominal CT or surgery. False negative (FN) FAST was absence of free fluid
with FAST but presence of free fluid found during abdominal CT or surgery.
Multivariable modeling was used to compare TP and FN FAST results and outcomes of
FN FAST patients.
Results: The study population comprised 9973 patients that sustained blunt abdominal
trauma, the majority of them being male (72.4%). Mean age was 38.5 years, median
hospital LOS was 9.52 days, injury severity score (ISS) was 11.9 and 7,767 (79.47%)
cases were discharged home without any sequela. FAST positive (+), FAST negative (-),
and FAST undetermined were; 358 (3.6%), 9172 (93.8%) and 242 (2.47%), respectively.
FN FAST was 312 (3.4%) of total FAST (-) patients, and TP FAST group was 319
(89.1%) of total FAST (+) patients. Sensitivity was 50.55% (95% CI [46.58%-54.52%])
and specificity was 99.56% (95% CI [99.40%-99.69%]). True LOS was increased for FN
FAST by a factor of 2 (p<0.0001), but hospital LOS, ICU days, morbidity, and discharge
status were similar between TP and FN.
Conclusion: FAST has a low sensitivity (50.5%) for evaluation of blunt abdominal
trauma, and FN FAST results in prolonged LOS due to additional imaging methods and/or
serial abdominal examinations. Although FAST (+) predicts abdominal injury, FAST (-)
does not exclude abdominal injury.
 Session XVII: WTC III Session: Abdominal Trauma
Paper 4: 6:15am - 7:15am
HOLLOW VISCOUS ORGAN INJURY IN BLUNT ABDOMINAL TRAUMA-
CHALLENGES IN TRAUMA BAY
Samir Misra MD, Yadvendra Dheer MD, Sandeep Tiwari MD, Vaibhav Jaiswal MD,
King George's Medical University
Introduction: Trauma is fast becoming the leading cause of mortality and morbidity in
the young population of the globe. Amongst all the causes of trauma like road traffic
incidence, falls and penetrating injuries, trauma surgeons tend to broadly categorize
trauma in two broad categories – blunt injuries and penetrating injuries. Most of the
victims, who suffer from multiple injuries, experience both types of mechanism of injury
and land up in the trauma bay. But by far, blunt injuries are more common than
penetrating forces. Blunt injury abdomen are challenging in both, presentation and
management. It is also quite challenging to understand and reconstruct the event in
reference to the mechanism of injury to predict intraabdominal injuries.
Methods: Total 824 patients with blunt injury abdomen were admitted to the department
of trauma surgery, KGMU, UP, Lucknow, India. A retrospective observational study was
conducted in regard to the mechanism of injury, presentation and operative findings.
Results: 326 patients were managed by surgical intervention and 499 patients by
nonoperative measures. Out of 326 patients, who landed in OR, 96 patients of solid
visceral organ injuries were treated. 227 patients presented with hollow visceral injuries
and only 128 patients required early operative management. 99 patients with blunt
abdominal trauma presented late, either in our department or were transferred from other
hospitals.
Conclusion: We studied the basic mechanism of injuries and presentation of the patients,
and concluded that hollow viscous injuries may delay in presentation, symptomatically.
We called this delay as the lucid interval of presentation. The varied mechanism involved
in blunt abdominal trauma may obstruct the reconstruction of events. These may
masquerade or even hide symptom of intra-abdominal injuries, which may present late.
Patients may attend the trauma bay late and even land up in shock, which becomes
challenging to manage. The overuse of antibiotics and analgesics may keep an operative
patient out of OR and initial protocol management may tilt towards non-operative
management. Late bowel perforations and mesenteric tear leading to gangrene of bowel
segments may delay symptomatic presentation. Injuries to urinary bladder, gall bladder,
previously undetected ovarian cyst, mesenteric cyst, and gravid uterus etc may present
late in course of blunt abdominal trauma, and a high index of suspicion and serial clinical
and radiological examination are the keys for successful management of these patients.
The patients who presented late had a prolonged hospital stay and high incidence of
morbidity and mortality.
 Session XVII: WTC III Session: Abdominal Trauma
Paper 5: 6:15am - 7:15am
EVALUATION OF THE SELECTIVE USE OF CONTRAST-ENHANCED
COMPUTED TOMOGRAPHY IN CLOSED ABDOMINAL TRAUMA
Heitor F. Consani MD, Yasmine Rebecchi CONJUNTO HOSPITALAR DE
SOROCABA
In order to reduce the dose of radiation and contrast-induced nephropathy, we suggest the
use of contrast-free Computer Tomography (CT) as the initial evaluation form, and
selective indication of intravenous (iv) and oral contrast.
We retrospectively evaluated 86 exams of patients attended in the ER with a history of
closed abdominal trauma who underwent tomography in the current protocol, noncontrast
phase, phase with iv contrast and late phase.
We evaluated the noncontrast phase of these exams and then suggested the use of
contrast, so that we could evaluate all CTs in the following phases.
As a result we had 86 exams, 12(14%) which had indication to use contrast ev and
8(0,09%) to use oral contrast (6 (0,07%) had indication to ev and oral contrast). The main
doubt in these exams was hollow viscera lesion and pancreatic lesions.
Of the 76(88%) CT scans that did not require contrast, only one presented a discrepant
diagnosis, however did not compromise the patient's clinical follow-up.
The emergency CT plays an important role in the assessment of blunt abdominal trauma,
despite the need for prospective multicenter and randomized studies, in this retrospective
study with protocol of evaluation using contrast selectively, the evaluation without
contrast presented a great result, and safety. Although CTs with contrast can facilitate the
representation of lesions of solid and hollow viscera, CTs without contrast can detect
serious lesions effectively, also reducing radiation and possible complications of
intravenous contrast.
WTC 17: Guidelines/Outcomes Sponsored by European Society for
Trauma and Emergency Surgery (ESTES)
Location: Coronado DE, Fourth Level (Harbor Tower)
Moderators: Yoshinori Murao, MD and Radko Komadina, MD, Japan and Slovenia
Keynote: Radko Komadina, MD, European Bleeding Guidelines
DETERMINANTS OF EMERGENCY DEPARTMENT DISCHARGE DISPOSITION OF
PATIENTS WITH TRAUMATIC BRAIN INJURY IN A TERIARY CARE HOSPITAL OF
UGANDA
Presenter: Amber Mehmood, MD, MPH, USA

ROUTINE SERIAL CT OF THE HEAD AND HOURLY NEUROLOGIC EXAMINATIONS ARE

UNNECESSARY IN PATIENTS WITH MINOR TRAUMATIC BRAIN INJURY
Presenter: Kira Smith, MD, MS, USA

DEVELOPMENT OF A PSEUDO ENCRYPTION TOOL TO SHARE UNIQUE PATIENT

IDENTIFIERS BETWEEN INSTITUTIONS TO FACILITATE TRAUMA/EMERGENCY
MEDICINE EPIDEMIOLOGIC RESEARCH WITHIN METRO REGION
Presenter: Michaela West, MD, PhD, USA

A COMPARATIVE ANALYSIS OF THE FINDINGS OF POST-MORTEM CT SCAN AND

TRADITIONAL AUTOPSY IN TRAUMATIC DEATHS: IS TECHNOLOGY MUTUALLY
COMPLEMENTING OR EXCLUSIVE?
Presenter: Biplab Mishra, MS, India

TUBE THORACOSTOMY FOR THE TRAUMA PATIENT; IT’S NOT JUST ABOUT SIZE
Presenter: John Agapian, MD, USA
 Session XVII: WTC III Session: Guidelines/Outcomes
Paper 1: 6:15am - 7:15am
DETERMINANTS OF EMERGENCY DEPARTMENT DISCHARGE
DISPOSITION OF PATIENTS WITH TRAUMATIC BRAIN INJURY IN A
TERTIARY CARE HOSPITAL OF UGANDA
Amber Mehmood MD,MPH, Nukhba Zia MD,MPH, Rukia Namaganda MPH, Hussein
Ssenyonjo MD, John Mukasa MD, Joel Kiryabwire MD, Michael Muhumuza MD, Adnan
A. Hyder MD,MPH,Ph.D., Olive Kobusingye MD,MPH, Johns Hopkins Bloomberg
School Of Public Health, USA/ Makerere University School Of Public Health And
Mulago Hospital, Uganda
Introduction: Traumatic brain injuries (TBI) are common causes of emergency
department visits and hospital admissions due to trauma in Kampala, Uganda. Patients
with different causes of TBI have different clinical presentation and severity of injury.
The objective of this study was to determine the predictors of Emergency Department
(ED) discharge disposition with reference to patient and injury characteristics. The
outcome consists of four categories: Discharged home, Admitted, Died, and Others
including referred or went against medical advice.
Methods: This prospective study was conducted at Mulago National Referral Hospital,
Kampala, Uganda from May 2016-July 2017. Patients of all age groups presenting to ED
with TBI were followed-up till ED disposition or within 24 hours of ED arrival,
whichever comes first. Patient demographics, external causes of injury, TBI
characteristics, injury severity (Kampala trauma score: KTS; Revised trauma score: RTS)
and discharge disposition from ED was noted. TBI cases were grouped into mild,
moderate and severe categories based on Glasgow Coma Scale (GCS). We used
multinomial logistic regression model to calculate conditional odds ratio of admission,
death and other disposition compared to discharged home as a reference category.
Results: There were 3,944 patients were included in the study. Proportion of males was
84.7% and that of females was 15.3%. Mean age was 28.50 (SD:14.22). Patients had
closed head injury in 62.9% cases and open head injury in another 36.3% The cause of
TBI was road traffic injury in 58.8% cases, and intentional injuries in 28.7% cases. There
was no significant difference between four discharge categories with respect to age, sex,
mode of arrival, cause of TBI, area of residence, place of injury, type of head injury, and
RTS (p³0.05), but there were statistically significant differences (p< 0.05) between four
discharge categories for number of serious injuries, GCS on arrival, change in GCS, and
KTS. In multinomial logistic regression model, after adjusting for other variables—type
of head injury, GCS on arrival, KTS and change in GCS were significant predictors for
admission and death in ED, whereas mode of arrival, improvement in GCS, and KTS
were significant predictors in others category including referred or left against medical
advice.
Conclusion: The conditional odds ratios for Emergency department disposition are
differentially affected by injury characteristics and are largely dependent on KTS, and
change in Glasgow Coma Scale during ED stay. TBI patient characteristics have no
impact on ED disposition in a tertiary care hospital of Kampala.
 Session XVII: WTC III Session: Guidelines/Outcomes
Paper 2: 6:15am - 7:15am
ROUTINE SERIAL CT OF THE HEAD AND HOURLY NEUROLOGIC
EXAMINATIONS ARE UNNECESSARY IN PATIENTS WITH MINOR
TRAUMATIC BRAIN INJURY
Kira E. Smith MD, MS, Lauren E. Mount MD, Edwin Rosendo BS, Nicole E. Leahy
MPH,RN, Phillip S. Barie* MBA,MD, Mayur Narayan* MBA,MD,MPH, Anton G.
Kelly MD, Jian Shou MD, Robert J. Winchell* MD, Weill Cornell Medicine
Introduction: The clinical presentation of mild traumatic brain injury (TBI), defined as
initial GCS > 13, is frequent in patients presenting with blunt trauma, and is often
evaluated by computed tomography of the head (CTH). Positive findings on CTH can
trigger a cascade of events including serial CTH, monitoring in an ICU setting, and
prolonged hospitalization, all intended to identify patients that might require
neurosurgical intervention, although the frequency of such intervention is low. We
hypothesize that positive findings on CTH in patients with GCS > 13 portend minimal
risk, and that serial CTH and ICU-level monitoring are unnecessary, adding substantial
cost of care without benefit.
Methods: We reviewed all adult trauma patients (age > 17 years) admitted to a single
urban level I trauma center between 1/1/2016 and 12/31/16. Patients with an ICD10 code
for traumatic subarachnoid hemorrhage (SAH: chosen as a marker for positive CTH) and
initial GCS > 13 were identified as the study group, and medical records were reviewed.
Data collected included age, sex, mechanism of injury, admission GCS score, length of
stay and discharge disposition. Timing and results of CTH studies, serial evaluations of
GCS, and need for neurosurgical intervention were also collected.
Results: The study group consisted of 135 patients, who underwent a total of 311 CTH.
24 patients had one CTH, 63 patients had 2, 35 patients had 3 and 13 patients ≥ 4 CTH.
Average ICU length of stay was 2.4 days for patients having 1 or 2 CTH, and 5.6 days for
those having more than 2 CTH. Four patients (3%) required craniotomy, all of whom
had either epidural hematoma (EDH) or subdural hematoma (SDH) in addition to SAH.
One craniotomy was done immediately for a large EDH, and the other 3 were done in
delayed fashion for acute-on-chronic SDH. No patient had specific intervention driven
by findings on serial CTH, nor did any patient have specific intervention driven by
clinical neurologic deterioration over the course of a single hour.
Conclusion: In our study population of patients with GCS > 13 and positive CTH, as
identified by the presence of traumatic SAH, neurosurgical intervention was required in
only 3%, all of whom had large EDH or SDH identified on the initial CTH. No specific
interventions were driven by findings on serial CTH, or by changes in GCS over the
course of a single hour. These findings demonstrate that more than 170 repeat CTH
yielded no actionable findings, and could have been avoided. Furthermore, patients the
study group utilized a total of more than 450 ICU days, at a cost more than double that of
care in the step-down unit. Based on our data, patients with presenting GCS > 13 and
positive CTH do not require routine serial CTH or routine admission to the ICU.
Adoption of this approach will result in substantial savings while maintaining quality
care.
 Session XVII: WTC III Session: Guidelines/Outcomes
Paper 3: 6:15am - 7:15am
Development of a Pseudo Encryption Tool to Share Unique Patient Identifiers
Between Institutions to Facilitate Trauma/Emergency Medicine Epidemiologic
Research Within Metro Region
Michaela A. West MD,Ph.D., John Lyng MD, Rachle Nygaard Ph.D., Patty Reicks RN,
Barb Curran MA, Jonathan Gipson MD, North Memorial Health Care

Introduction: Local and national safeguards limit sharing of personal health information
(PHI), to protect patient privacy. We encountered challenges in attempting to study
recidivism of penetrating trauma across an urban metropolitan area secondary to HIPPA
and state privacy laws. We sought to develop an IRB-approved mechanism whereby
different trauma centers could identify patients who received care at more than one metro
area trauma center.
Methods: An Excel formula was developed to create a unique identifier for each subject.
This identifier had to be sufficiently specific to avoid duplication, incorporate
alphanumeric data, be configurable at each site, and provide a de-encryption pathway. The
Excel file stipulated columns for name (last, first, MI) and date of birth (month, dd, yyyy).
Parsing functions were used to extract one or more characters from each column. The
parsed alphanumeric terms were compiled into a shared “encrypted identifier”.
Results: The Figure shows an example of a sample input: John Smith, 22 Jan 1979 (First,
Last, Day, Month, Year) is transformed and compiled into the unique identifier JhS018Ja.
Additional elements could be added to improve specificity or further obfuscate the identity.
The approach was reviewed and approved by the IRB at all institutions and by corporate
compliance officers.

Conclusion: A simple, spreadsheet based algorithm was developed to allow disparate

trauma centers to share unique anonymous patient identifiers that allowed us to expand
the scope of trauma research across health care systems to more completely understand
injury within the entire metro area. Such a tool will help to facilitate trauma
epidemiologic studies.
 Session XVII: WTC III Session: Guidelines/Outcomes
Paper 4: 6:15am - 7:15am
A COMPARATIVE ANALYSIS OF THE FINDINGS OF POST-MORTEM CT
SCAN AND TRADITIONAL AUTOPSY IN TRAUMATIC DEATHS: IS
TECHNOLOGY MUTUALLY COMPLEMENTING OR EXCLUSIVE?
Biplab Mishra MS, Mohit K. Joshi MS, Sanjeev Lalwani MD, Adarsh Kumar MD, Atin
Kumar MD, Subodh Kumar MS, Amit Gupta MS, Sushma Sagar MS, Amulya Rattan
MS All India Institute Of Medical Sciences

Background: Postmortem examination is indispensable to ascertain the cause of an

unnatural death. The increasing use of modern-day radiology for postmortem examination
has opened a new arena in overcoming the difficulties of traditional autopsy. There are
conflicting reports regarding superiority of one modality of the postmortem over other.
Objective: To compare the findings of postmortem CT scan and traditional autopsy in the
victims of traumatic deaths and to analyze whether postmortem CT can be used to replace
traditional autopsy.
Methods: All patients with history of trauma that were declared dead on arrival in
Emergency Department were subjected to full body CT scan. An experienced Radiologist
reported the findings of CT scan. Subsequently a forensic expert subjected the patients to
traditional autopsy. The physician who performed autopsy was blinded to the findings of
CT scan and vice versa. An individual who was not part of the Radiology or Forensic
team entered the findings of CT scan and autopsy in a pre-designed Performa. An
unbiased assessor finally compared the findings of the two modalities and analyzed the
results. McNemar test was used to ascertain the level of significance between the findings
reported by the two modalities considering p value of 0.05 as significant. The agreement
or disagreement on cause of death reported by the two modalities was also assessed.
Results: 95% of the deceased were males. The mean age was 35 yrs. CT was superior in
picking up bony injuries, air containing lesions, hemothorax and hemoperitoneum.
Autopsy was more sensitive for soft tissue and solid visceral injuries. Both modalities
were equally helpful in identifying extremity fractures. There was no statistically
significant agreement on cause of death by both modalities.
Conclusion: Postmortem CT scan is promising in reporting injuries in traumatic deaths
and can significantly complement the conventional autopsy. However, at present it cannot
be considered as a replacement for traditional autopsy.
 Session XVII: WTC III Session: Guidelines/Outcomes
Paper 5: 6:15am - 7:15am
TUBE THORACOSTOMY FOR THE TRAUMA PATIENT; IT'S NOT JUST ABOUT SIZE
John V. Agapian* MD, FACS, FCCM, Sean Satey MD, Peter Edpao MD, Juan Ortiz MD, Bron J.
Finkelstein BS, David J. Eng BS, Anika Singh MD, Sydney Johnson MD, Daniel Ludi* MD, FACS,
Arnold Tabuenca MD, FACS, Afshin Molkara MD, FACS University Of California,
Riverside/RUHS; LLU

Introduction: Recent studies have challenged the dogma of using large chest tubes for trauma, and
the 10th edition of ATLS is now even suggesting against this practice. However, none of these
studies have accounted for the suction power used in the context of tube size; and, their conclusions
have focused only on long term outcomes, and not on theimmediate considerations that may
determine if the patient will live or if they will die (i.e.<24hour mortality was excluded from these
early studies) . The most decisive decision for the trauma surgeon to make under these conditions is
whether a thoracotomy is indicated or not, and is based on whether the initial chest tube output/flow
rate is higher than 20mL/kg or >200mL/hr for 4 consecutive hours. This standard of care was
established using flow rates from large tube thoracostomies connected to a pleurovac set at -20cm
H20 (14.7mmHg). Our hypothesis is that variation of suction power may affect the flow rate, and
that this deviation from established standards may have significant therapeutic ramifications.
Methods: Flow rates of a uniform volume of solution (200mL water) were measured using different
size thoracostomy tubes (10F, 20F, 40F) and different suction powers (200mmHg, 100mmHg,
40mmHg, 20mmHg).
Results: SD:200mmHg-->14.77100mmHg-->23.48 40mmHg-->42.09 20mmHg-->68.01 Tube Size
mmHg mL/Sec

Conclusion: In all cases, the entire study volume of solution was eventually evacuated irrespective
of tube size or suction power; this finding is in line with earlier studies that showed no difference in
tube size with respect to long term outcomes (ie. retained hemothorax for incomplete evacuation).
On the other hand though, the variation in flow rates between different size tubes changes
significantly, with increasing suction power; suction power is a variable that has not been accounted
for by any of the earlier studies. This variation is particularly important at the suction power that
mimics a conventional pleurovac (-20mmH 2O/14.7mmHg).Timing, and indication for a
thoracotomy can be dramatically affected by this variation in flow rate. Moreover, slower flow rates
may lead to increase viscosity of solution (hemothorax forming clot), a factor not specifically
addressed by our study. To this end, we advocate reserving caution moving away from time
honored dogma of using large chest tubes for the trauma patient.
WTC 18: Education Sponsored by SBAIT - Brazil Trauma Society
Location: Harbor B, Second Level (Harbor Tower)
Moderators: Mamta Swaroop, MD and Gustavo Fraga, MD, PhD, USA and Brazil
Keynote: Gustavo Fraga, MD, PhD, Trauma Leagues: A Novel Option to Attract Medical
Students to a Surgical Career
THE TEAM (TRAUMA EVALUATION AND MANAGEMENT) COURSE - MEDICAL STUDENT
KNOWLEDGE GAINS AND RETENTION IN THE USA VS GHANA
Presenter: Allison Berndtson, MD, USA

VARIED TRAINING EXPERIENCE AMONG 2-YEAR FELLOWSHIP CANDIDATES:

EXPERIENCE MAY NOT EQUATE TO SELF-PERCIEVED COMPETENCE
Presenter: Richard Maduka, BS, USA

COGNITIVE AND TEAM WORK RESUSCITATION SKILLS PERFORMANCE OF MEDICAL

STUDENTS WITH THE TEAM® COURSE
Presenter: Maria Jimenez, MD, Colombia

THE IMPACT OF INTERNATIONAL TRAUMA ROTATION AT TYGERBERG HOSPITAL

IN SOUTH AFRICA; COMPARISON OF SURGICAL VOLUME IN AN URBAN TRAUMA
CENTER IN TOKYO
Presenter: Tsuyoshi Nagao, MD, Japan

ATLS 20 YEARS - FROM HONG KONG TO MAINLAND CHINA

Presenter: GUIXI ZHANG, BS, MBBS MHSM MTS, Hong Kong
 Session XVII: WTC III Session: Education
Paper 1: 6:15am - 7:15am
THE TEAM (TRAUMA EVALUATION AND MANAGEMENT COURSE -
MEDICAL STUDENT KNOWLEDGE GAINS AND RETENTION IN THE USA
VS GHANA
Allison E. Berndtson MD, Martin T. Morna MB ChB, Samuel Debrah MB ChB, Raul
Coimbra MD,Ph.D., University of California, San Diego
Introduction: Trauma and injury are significant contributors to the global burden of
disease, with 5 million deaths and 250 million disability-adjusted life years lost in 2015.
This burden is disproportionally borne by low and middle income countries (LMICs).
Solutions are complex, but one area for improvement is basic trauma education. The
American College of Surgeons has developed the TEAM (Trauma Evaluation and
Management) Course as an introduction to trauma care for medical students. We
hypothesized that the TEAM course would be an effective educational program in LMICs
and result in increased knowledge gains and retention similar to students in high-income
countries (HICs).
Methods: The TEAM course was taught and students evaluated at two sites, one LMIC
and one HIC, after
obtaining approval
from the HIC
Institutional Review
Board and medical
school dean.
Participation was
optional for all
students and results
were blinded. The
course was
administered by a
single educator for
all sessions. Tests
were given before
and after the course,
and again six
months later.
Results: A total of
62 LMIC and 52 HIC students participated in the course and completed testing.
Demographics for the two groups were similar. LMIC students started with a relative
knowledge deficit, scoring lower on both pre- and post-course tests than HIC students,
but gained more knowledge during the initial teaching session. After 6 months the LMIC
students continued to improve, while the HIC students’ knowledge had regressed.
Conclusion: The TEAM course is a useful tool to provide the basic principles of trauma
care to students in LMICs, and should be expanded. Further study is needed to determine
the impact of TEAM education on patient care in LMICs.
 Session XVII: WTC III Session: Education
Paper 2: 6:15am - 7:15am
VARIED TRAINING EXPERIENCE AMONG 2-YEAR FELLOWSHIP
CANDIDATES: EXPERIENCE MAY NOT EQUATE TO SELF-PERCIEVED
COMPETENCE
Richard C. Maduka BS, Sarah A. Moore MD, Patrick M. Reilly MD, Jon Morris MD,
Mark J. Seamon MD, Daniel Holena MD, Lewis J. Kaplan MD, Niels D. Martin MD,
University of Pennsylvania
Introduction: Fundamental training in trauma & surgical critical care is an integral
component of general surgery residency and the critical base experience for the added
educational qualifications of fellowship. We hypothesize that variations in clinical
exposure exist and that perceived confidence will correlate with clinical experience.
Methods: With IRB approval and in a double-blinded fashion, all interviewees to a large,
urban, academic, level one trauma, critical care, & emergency surgery fellowship were
offered a 70-question survey. The survey focused on past clinical exposure and their
perceived confidence in key areas relevant to fellowship. Experience was assessed via
absolute numbers and confidence via a 5-point Likert scale; data is reported using
descriptive statistics and linear regression.
Results: Forty-two of 44 completed the survey (95.5% response rate). 81% had exposure
to a Level 1 trauma center during training. Experience and comfort varied greatly between
procedures (TABLE and experience did correlate with self-perceived confidence in most
procedures including resuscitative thoracotomy (FIGURE). However, the experience
necessary to result in confidence was minimal, for cricothyroidotomy, 86% of
respondents had done < 2, but only 26% were uncomfortable with the procedure.

Conclusion: Large variations in both experience and comfort within relevant training
domains exists amongst 2-year fellowship interviewees. Importantly, domains with little
experience did not impede applicants from reporting comfort with those skills. These
disparate findings may inform fellowship program directors on curriculum development
and appropriate training support structures.
 Session XVII: WTC III Session: Education
Paper 3: 6:15am - 7:15am
COGNITIVE AND TEAM WORK RESUSCITATION SKILLS PERFORMANCE
OF MEDICAL STUDENTS WITH THE TEAM® COURSE
Maria F. Jimenez* MD, Catalina Tobon MD, Andres Isaza MD, Victor Velandia MD,
Felipe Vargas MD, Karen Brasel* MD,MPH, Stephen Bush MD, Sharon Henry* MD,
Monique N. Drago edD, Ronald Stewart* MD, Hospital Universitario Mederi

Introduction: Trauma Evaluation and Management®(TEAM®) is an abbreviated version

of the American College of Surgeons (ACS) Advanced Trauma Life Support® (ATLS®)
course that introduces the concepts of trauma assessment and management. Errors in
teamwork, leadership, and communication skills have been identified as major factor in
adverse clinical events. Improvements in these areas are therefore of particular interest.
The aim of this study is to evaluate immediate retention in knowledge, communication
and team resuscitation skills performance using the team approach in medical students
taking the TEAM course in Bogota, Colombia

Methods: The TEAM (3rd edition) format used for our course was: ATLS 10th Edition
team approach initial assessment video demonstration, a 90-minute slide presentation, a
series of clinical trauma case scenarios for small-group discussion, and skills sessions in 2
trauma simulation scenarios using the team approach. We performed an observational pre-
and post- intervention comparison study of the effects the TEAM course had on cognitive
and teamwork resuscitation skills performance. Cognitive skills were assessed by a 20-
multiple-choice questionnaire with a pre and post-test assessment. Team clinical
assessment and management skills performance was evaluated using checklist rating of
critical decision making and overall performance evaluation in 2 trauma simulation
scenarios. The effectiveness of the group during these simulated scenarios in the behaviors
of assistance, communication, and situation assessment was evaluated by 2 independent
raters using the Standardized Assessment for Evaluation of Team Skills (SAFE-TeamS)
method.
Results: A TEAM course was conducted in November 2015 for 92 medical students in
Bogota, Colombia. Participants displayed a significant improvement in cognitive skills (p
< 0.001) on the post course evaluation. The 16-team groups demonstrated a significant
improvement in their checklist rating of critical decision making (p=0.01), and overall
teamwork performance evaluation (p= 0.006) between training and test trauma simulation
scenario. The group’s team performance as measured by the SAFE-TeamS method
improved, but was not statistically significant (p=0.12).
Conclusions: Trauma Evaluation and Management course improves trauma didactic
knowledge. Teamwork behaviors and resuscitation skills performance needs further study
with a larger sample size. Trauma education and teamwork training as can be done with
the ACS TEAM course is a critical component for trauma and safety care improvement
worldwide.
 Session XVII: WTC III Session: Education
Paper 4: 6:15am - 7:15am
The impact of International trauma rotation at Tygerberg hospital in South Africa;
Comparison of surgical volume in an urban trauma center in Tokyo
Tsuyoshi Nagao MD, Takashi Fujita MD,Ph.D., Taichiro Tsunoyama MD,Ph.D.,
Hirohito Chiba MD, Kahoko Nakazawa MD,MPH, Tomohide Koyama MD, Kaori Ito
MD, Yasufumi Miyake MD,Ph.D., Tetsuya Sakamoto MD,Ph.D., Teikyo University
School of Medicine

Introduction: International rotation will get a chance of operations which surgeon rarely
experienced in own country. The author has rotated in six months at Tygerberg hospital
(TB) in South [Link] purpose of this study was to compare the volume between our
trauma center in Tokyo and TB in South Africa.
Methods: We conducted the retrospective chart review at our trauma center in Tokyo and
compare the surgical volume which he experienced in TB for six months and the number
of operations which he joined in Tokyo for fifteen months.
Results: The number of operations he joined in TB for six months was 175, and 151 of
them were for trauma cases. The number of urgent trauma operations was 102 (68%), and
that of penetrating and blunt injuries, GSW and Stab injuries were 85 (83%), 17 (17%), 46
(45%) and 39 (38%) respectively. Cardiac or large vessel injuries were 40 cases including
2 cardiac, 2 aortic, 5 subclavian artery, 6 iliac vessels, and 8 inferior vena cava injuries.
The number of operations for trauma cases he joined in Tokyo for fifteen months was 49,
and the urgent operations were 27 (55%). Ten (37%) were penetrating injury and 17
(63%) as the result of blunt trauma.
The number of urgent trauma operations he could experience in South Africa for six
months was approximately same as the number for five years at the one of the biggest
trauma center in Tokyo, especially penetrating cases were for ten years.
The number of operations for trauma cases he joined in Tokyo for fifteen months was 49,
and the urgent operations were 27 (55%). Ten (37%) were penetrating injury and 17
(63%) as the result of blunt trauma.
The number of urgent trauma operations he could experience in South Africa for six
months was approximately same as the number for five years at the one of the biggest
trauma center in Tokyo, especially penetrating cases were for ten years.
Conclusion: The international rotation in South Africa has impacted on learning for
trauma surgery, especially for penetrating injuries. It has resulted in a private negotiation
but not through a systematic and sophisticated organization. The personal reference by the
surgical society should be necessary to rotate in foreign facility.
 Session XVII: WTC III Session: Education
Paper 5: 6:15am - 7:15am
ATLS 20 YEARS - FROM HONG KONG TO MAINLAND CHINA
GUIXI ZHANG BS, MBBS MHSM MTS, JOHN WONG MD,Ph.D., The University Of
Hong Kong-Shenzhen Hospital

Introduction: ATLS® was introduced into Hong Kong in 1997. In September 2016, 136
courses were given to students and 13 courses for instructors were organized, as well as

2100 doctors received ATLS® training. The setup of a new hospital managed by both
Hong Kong and Shenzhen provided the possibility and opportunity to bring ATLS ® into
mainland China. However, language barrier has previously been a major obstacle against

the promulgation of ATLS ® into mainland China. How to set up an appropriate training
area is also another big issue to deal with.

Methods: With the support and approval of the American College of Surgeons, ATLS®
textbook was allowed to be translated into Chinese by a team from Shenzhen. Since
September 2013, 20 ATLS ® Providers from Shenzhen have been approved to attend
English courses in Hong Kong, of which seven of these candidates have successfully
achieved Instructor status. These Instructors are Putonghua-speakers who are now charged
with the task of conducting the ATLS ® courses in mainland China, based on the
translated 9th Edition ATLS® Student Manual and other teaching materials. A
multi-party group was formed and regular meetings were arranged to organize things in
the future. A new surgical skills training center was designed and built to provide accurate
preparation for ATLS ® training purpose. Funding for this surgical skills training center
was donated by philanthropists from Hong Kong. The training equipment list was
purchased in Hong Kong and sent to Shenzhen. Chinese ATLS ® instructors were trained
in Hong Kong with a Singapore educator. A joint and transitional Chinese ATLS® course
was organized in Hong Kong before the first Chinese ATLS® course held in Shenzhen,
China.
Results: The Chinese ATLS® student manual was published in August 2016. The new
surgical skills training center was completed and opened for ATLS ® training. An ATLS®
instructor group with mixed doctors from Hong Kong and Shenzhen was established to

teach the first Chinese ATLS® course from September 26-28, 2016. An instructor course
was also organized in December 2016 with the same educator from Singapore. In
September 2017, a total of 6 courses were organized for students, with 80 doctors coming

from across mainland China receiving ATLS® training and another 9 doctors receiving
their instructor qualifications.

Conclusion: It is highly recommended that ATLS® courses be taught to doctors in

mainland China who are involved in the management of trauma patients, as evidenced by

the strong documented positive impact of ATLS® courses on cognitive knowledge,

practical skills and critical decision making. The introduction of ATLS® into mainland
China is, hopefully, a step to help develop a structured trauma service for the benefit of
people in China.

Key words: ATLS® training; mainland China; Trauma education

WTC 19: Geriatrics/Outcomes Sponsored by Japanese Association for the
Surgery of Trauma (JAST)
Location: Coronado A, Fourth Level (Harbor Tower)
Moderators: Amit Gupta, MD and Takashi Fujita, MD, India and Japan
Keynote: Takashi Fujita, MD, Geriatric Trauma in Japan
RIB FRACTURES IN THE ELDERLY: PHYSIOLOGY TRUMPS ANATOMY
Presenter: Nathan Schmoekel, DO, USA

TREATMENT OF SEVERELY INJURED PATIENTS - SMALL IMPACT, BIG DEAL. ELDERLY

PATIENTS AFTER LOW-ENERGY TRAUMA AND LIFE-THREATENING CONSEQUENCES
Presenter: Orkun Özkurtul, MD, Germany

TRAFFIC ACCIDENTS FOR GERIATRIC PEDESTRIAN IN JAPAN

Presenter: Tadashi UMEHARA, MD, Japan

COMPARATIVE ASSESSMENT OF IN-HOSPITAL TRAUMA MORTALITY AT AN INDIAN

TRAUMA CENTER WITH IN-HOSPITAL TRAUMA MORTALITY AT A LEVEL 1 TRAUMA
CENTER IN THE UNITED STATES
Presenter: Tessa Adzemovic, BA, USA

PREHOSPITAL CARE IN INDIA: THE NEED OF THE HOUR

Presenter: Vignesh Kumar Shanmuganathan, MBBS, DNB, India
 Session XVII: WTC III Session: Geriatrics/Outcomes
Paper 1: 6:15am - 7:15am
RIB FRACTURES IN THE ELDERLY: PHYSIOLOGY TRUMPS ANATOMY
Nathan Schmoekel DO, Jon Berguson BS, Jerry Stassinopoulos MD,MPH, Efstathios
Karamanos MD, Pat Patton MD, Jeffery Johnson MD, Henry Ford Hospital
Introduction: Rib fractures in elderly patients are associated with substantial pulmonary
morbidity and mortality; predicting which patients are at highest risk for late
complications remains a dilemma. Most existing predictive models use anatomic,
physiologic or laboratory parameters in isolation. The RibScore is an example of an
anatomic only model that uses radiographs to assess severity of the fractures. In a single
institution with a relatively young patient population, RibScore performed well. We
hypothesized that in elderly patients, where frailty is a major driver of adverse outcomes,
a purely anatomic model will underperform models that take into account physiologic and
laboratory variables.

Methods: This is a retrospective chart review of adult trauma patients admitted from
January 2014 to June 2017 at an academic level 1 trauma center. A total of 466 patients
were identified with a blunt mechanism and ≥1 rib fractures by computed tomography
scan. Patient care was driven by a protocol for initial disposition, pain management and
pulmonary hygiene. Variables indicating adverse pulmonary outcomes included
pneumonia, ventilator days, and tracheostomy. We examined three models for their
ability to predict adverse outcomes: (1) Ribscore, (2) Modified Frailty Index (mFI), and
(3) initial PaCO 2. Receiver operating characteristics (ROC) and area under the cure
(AUC) were used to compare each approach. Logistic regression was used to identify
independent predictors of adverse outcome.

Results: Fifty seven percent of the population was ≥ 55 years of age, and comprised our
elderly cohort. Thirteen percent developed one or more pulmonary complications.
Increased RibScore, mFI, and initial PaCO2 were each statistically associated with risk.
ROC AUC analysis of individual models predicted complications with the following
concordance statistic (CS): Anatomic only (RibScore) yielded a CS of 0.79 (95% CI 0.69,
0.89) p <0.001; Physiologic only (mFI) yielded a CS of 0.83 (95% CI 0.75, 0.91) p
<0.001; and Laboratory only (initial PaCO2) yielded a CS of 0.88 (95% CI 0.80, 0.95) p <
0.001. A PaCO2 threshold of 45 mm Hg yielded the highest sensitivity and specificity.
The initial PaCO 2 had the highest discriminative ability of the three individual models.
When examining independent predictors of developing complications, the initial PaCO 2
and mFI resulted in an adjusted odds ratio of 1.11 (95% CI 1.05, 1.18, p < 0.001) and
30.66 (2.35, 36.79, p 0.008) respectively. When the models were combined, a CS of 0.85
(95% CI 0.74, 0.91), p < 0.001 resulted for anatomic and physiologic; 0.88 (95% CI 0.80,
0.96) p <0.001 for anatomic and laboratory; and 0.89 (95% CI 0.82, 0.96) p <0.001 for
physiologic and laboratory. Combining all three models yielded the best performance
with a CS of 0.90 (95% CI 0.81, 0.97) p <0.001.

Conclusion: An anatomic score (RibScore) can predict adverse outcomes in elderly

patients with rib fractures. However, models based on mFI and PaCO2 individually
outperform the RibScore. A combination of all three models yields the highest
discriminative ability. This combined approach should be used in assessing the overall
severity of the injury, the prediction of complications, and the intensity of interventions in
the elderly.
 Session XVII: WTC III Session: Geriatrics/Outcomes
Paper 2: 6:15am - 7:15am
TREATMENT OF SEVERELY INJURED PATIENTS - SMALL IMPACT, BIG
DEAL. ELDERLY PATIENTS AFTER LOW-ENERGY TRAUMA AND
LIFE-THREATENING CONSEQUENCES
Orkun Özkurtul MD, Johannes K. Fakler MD, Christoph Josten MD,Ph.D., University Of
Leipzig
Introduction: Due to demographic developments, the proportion of elderly patients
among severely injured with an ISS ≥ 25 is becoming increasingly important. Their
treatment is particularly challenging for trauma surgeons, not only because of the
increased risk of mortality. The complex medication and the constantly growing mobility
of the elderly is an additional risk. Moreover, the biomechanical and physiological effects
of trauma in patients > 59 years of age differs fundamentally from those in younger
patients < 60 years. The aim of our study was to investigate the differences in the trauma
mechanism, treatment and therapy of this population compared to younger patients.

Methods:We carried out a retrospective evaluation from our own prospectively recorded
data set of the trauma register of the German Trauma Society DGU® for the years
2010-2015. Included in the study were polytrauma patients with ISS>25, over 16 years of
age and low energy trauma. A fall below 3m was defined as a low-energy trauma. All
patients who died in the trauma bay were excluded. A poor outcome was defined as a
Glasgow Outcome Scale (GOS) of 1-3 points. Descriptive data were recorded in addition
to injury severity ISS, AIS, hospital stay, outcome, ITS and ventilation duration as well as
dismissal in care facilities and domesticity. We conducted a subgroup analysis with
patients > 59 vs. < 60 years. Statistical evaluation was carried out via univariate analysis
and the significance test for subgroup analyses via t-test.

Results: Out of 1200 patients in our database, a total of 69 (6%) patients with ISS≥ 25 and
low energy trauma were included, of whom 55 ≥ 60 years were and 14 < 60 years old,
respectively. In the group of < 60-year-olds, the mean ISS was 28.27±7.5 (range 25-75)
and 29.43 ± 5 (range 25-38) in the younger group. Elderly patients had a 5 times higher
incidence of severe injuries despite minor trauma than younger patients and had a
significantly worse outcome with 54.5% to 36.4% (p=0.05). Only 9 patients ≥ 60 years of
age were discharged home, 14 (25.5%) older patients have died.

Conclusion: Patients in old age suffer 5 times more severe injuries with an ISS ≥ 25 than
younger patients, despite low kinetic energy. For the treating colleague, knowledge of the
effects of age-related physiological changes and the associated vulnerability of the
musculoskeletal system is crucial. Only then a comprehensive treatment concept can be
created and resources targeted. Despite established networks and interdisciplinary
cooperation, the severely injured is and remains a major challenge for trauma surgeons.
 Session XVII: WTC III Session: Geriatrics/Outcomes
Paper 3: 6:15am - 7:15am
TRAFFIC ACCIDENTS FOR GERIATRIC PEDESTRIAN IN JAPAN
Tadashi UMEHARA MD, Takashi FUJITA MD,Ph.D., FACS, Shinji NAKAHARA
MD,Ph.D., Yasufumi MIYAKE MD,Ph.D., Tetsuya SAKAMOTO MD,Ph.D., Teikyo
University School of Medicine

Introduction: Walking is strongly recommended as a health promotion strategy for elderly

people. Traffic accidents in geriatric population are increasing rapidly in our aging society.
The purpose of this study was to describe injured body regions among the elderly
pedestrians compared with young population and the fatal injuries among them with the
sample of Japan Trauma Data Bank (JTDB).
Methods: We extracted data of pedestrian injuries from the JTDB2016. Those with
complete data of Age, ISS, Max AIS of 9 body region, and mortality were analyzed. The
subjects were divided into two groups by age: Yong group(YG) was defined as the age
from15 to 64 and old group(OG) as more than 65. We also conducted subgroup analysis for
old group to compare between the survived and dead. Mann-Whitney’s U test was used for
non-parametrical analysis.
Results: In YG, 5883 subjects were extracted and median ISS(IQR) was 16(9-25). In OG
for 6197, median ISS(IQR) was 20(10-30) (p<0.001). Madian Max AIS in OG was greater
than that of YG in all body region except surface region. On subgroup analysis for OG,
Median(IQR)of Max AISs compared death to survive were 4(4-5) vs.3(3-4) (p<0.001) in
head, 4(3-4) vs.3(3-4) (p<0.001) in chest, 3(2-4) vs. 2(2-3) (p<0.001) in abdomen.
Conclusion: Geriatric pedestrian sustained severer injuries than young generation. For
older population, severer head, chest and abdomen were associated with death. Reducing
injury severity, possibly by pedestrian protection devices, may reduce pedestrian mortality
in the case of vehicle-pedestrian collisions. ed with death. Reducing injury severity,
possibly by pedestrian protection devices, may reduce pedestrian mortality in the case of
vehicle-pedestrian collisions.
 Session XVII: WTC III Session: Geriatrics/Outcomes
Paper 4: 6:15am - 7:15am
COMPARATIVE ASSESSMENT OF IN-HOSPITAL TRAUMA MORTALITY AT
AN INDIAN TRAUMA CENTER WITH IN-HOSPITAL TRAUMA MORTALITY
AT A LEVEL 1 TRAUMA CENTER IN THE UNITED STATES
Tessa Adzemovic BA, Ankita Sharma Ph.D., Jeffrey L. Nadel BA, Amit Gupta MBBS,
MS, Krishnan Raghavendran MD, Pauline Park MD, University of Michigan
Background: In India, a trauma-related death occurs every 1.9 minutes. While Trauma
Center infrastructures have been developed to provide definitive trauma care, formal
performance improvement initiatives remain in the early stages at both the national and
individual hospital level. As an initial benchmarking exercise, we compared registry-
based mortality data from the Jai Prakash Narayan Apex Trauma Centre (JPNATC) in
New Delhi, India and Michigan Medicine in Ann Arbor, Michigan
Methods: Retrospective data was collected over four months from September 2015 to
December 2015 as a part of the Australia–India Systems Collaborations (AITSC) project
in the JPNATC-AIIMS New Delhi, India. For comparison, consecutive admissions from
the University of Michigan’s Trauma Registry for 2015 were abstracted. Data were
managed Excel and SAS (Version 9.4, Cary NC). Univariate and bivariate descriptive
statistics were generated for the following variables: age, gender, mechanism of injury,
emergency department vital signs, GCS score, Injury Severity Score, ICU days, operative
status, and mortality. Mortality was evaluated based on gender, mechanism of injury, GCS
score, ISS, and destination. Statistical significance was considered at an alpha level of
0.05. Proportions were compared with a two sample Z-test for categorical and ordinal
variables.
Results: A total of 1,505 patients were included in this study. Differences in population
and patterns of mortality were apparent between the two systems. Patients in India were
younger and overwhelmingly male. The most common cause of injury seen at JPNATC
was motor vehicle accidents, which accounted for 56.4% of the injuries, followed by falls
at 25.4%. Falls were more commonly seen in the US. Initial overall mean GCS was lower
(12.9 vs.14.4, p<0.05), mean ISS was lower (8.96 vs 10.46, p<0.05) and RTS was lower
(7.289 v 7.59, p<0.05). As expected, the overall mortality was higher at JPNATC
compared to Michigan Medicine (3.3%, P<0.05). Mortality differences were not
distributed evenly across all categories of injury; outsized differences were identified in
minor brain injury (GCS 13-15, OR death 5.02, p <.0001) and in patients with even mild -
moderate injury (ISS 0 -15, ISS 16-24, OR death 8.12, 12.77 respectively, p<0.0001).
Conclusions: Trauma care in India is still in a fragile state of development, and the
societal burden remains high. We have shown that shared trauma performance
improvement efforts can identify areas where interventions from a mature system could
have impact in the Indian system. Specifically, further examination of potential
opportunities for improvement in moderate injury and mild TBI between institutions may
have mortality benefit. This work supports the ongoing importance of collaborative
registry and performance improvement efforts in India.
 Session XVII: WTC III Session: Geriatrics/Outcomes Paper 5:
6:15am - 7:15am
PREHOSPITAL CARE IN INDIA: THE NEED OF THE HOUR
Vignesh Kumar Shanmuganathan MBBS, DNB, Amit Gupta MBBS, MS, Harshit
Agarwal MBBS, MS, Biplab Mishra MBBS, MS, Sushma Sagar MBBS, MS, Subodh
Kumar Garg MBBS, MS JPN Apex Trauma Centre, AIIMS

Introduction: India is a developing country and although our potential as a budding

superpower seems irrefutable, we lag far behind when it comes to prehospital care. The
availability of trained personnel and prehospital ambulance services, as well as the time
taken to attend to the injured are severely compromised.
Methods: At a Level - I Trauma centre in New Delhi, We did a retrospective review of
2413 severely injured patients who presented to the hospital between January 2017 and
June 2017. We also conducted a questionnaire-based interview of ambulance drivers
(n=95).
Results: We found that majority of them were in the 3rd decade of life (24%).
Interestingly, we noticed that 22% of them were children under 10 years of age, with fall
from height contributing 84% injuries in this age group. The mechanism of injury was
predominantly RTI (42%), closely followed by fall from height (37%). The average time
to presentation was around 3 hours for these patients, with only 15% of them reaching
within the golden hour. And among the 27% referred patients, only 15% reached the
hospital within first 3 hours. Only 4% had an access to (or) preferred to use an ambulance
to get to the hospital, and 63% had made it to the hospital by themselves or with the help
of a relative via a private means of transit to the hospital. This established the fact about
the non-availability of ambulances and the long response time. Most of the ambulances in
the capital were patient transport ambulances. Very few of these ambulances had any kind
of paramedic support (n=9), and even fewer ambulance drivers received any kind of
formal pre-hospital training (n=7). An average ambulance in the country is usually a
vehicle which can accommodate a driver, the patient and at most a couple of his/her
relatives. Apart from a very few, that are part of elite hospitals or private owned hospitals,
most ambulances lack a cervical collar, backboard, intravenous cannulas, and/or
resuscitative fluids. Some even lack a proper first aid kit. When enquired about the delay,
most ambulance drivers quoted the traffic and the lack of awareness among the general
public as the reason behind the same. They also said that the “on-scene” time was
practically near zero as they had no paramedic support. We also noted that the ambulances
usually take the patient to the nearest hospital and the absence of field triage protocols
result in some patients landing in centers which are under-equipped for patient care. Most
patients had to pay for their transfer.
Conclusion: If the prehospital phase is delayed to such an extent in the capital of the
country, one has to question the availability and the time taken at peripheral centers. India
spends only 3% of its Gross Domestic Product (GDP) on healthcare. With such limited
spending and the lack of government insurance cover for the poor and the needy, the
future of healthcare in the country looks bleak. For a country which is looking to lock
horns with the super giants of the world, it is not only necessary but also prudent to
increase their outlay on healthcare services. There is a pressing need to formulate goals
and work towards bringing about a change in the healthcare system which, at the moment,
is in shambles.
WTC 20: Shock Resuscitation Sponsored by The Japanese Society for Acute Care
Surgery (JSACS)
Location: Coronado B, Fourth Level (Harbor Tower)
Moderators: Sandro Rizoli, MD, PhD and Shigeki Kushimoto, MD, Canada and Japan
Keynote: Shigeki Kushimoto, MD, Traumatic Coagulopathy, Japan
TRAUMATIC LARYNGOTRACHEAL INJURIES – 7 YEAR EXPERIENCE FROM A LEVEL I
TRAUMA CENTRE
Presenter: Vignesh Kumar Shanmuganathan, MBBS, DNB, India

INTER-HOSPITAL VARIATIONS IN RESOURCE USE INTENSITY IN INJURY DEATHS: A

MULTICENTER COHORT STUDY
Presenter: Lynne Moore, PhD, Canada

UNPRECEDENTED SURGE ON BLOOD BANK DURING LARGEST MASS SHOOTING IN

UNITED STATES’ HISTORY
Presenter: Neal Foley, DO, USA

SHOCK INDEX AS A MORTALITY PREDICTOR IN A EMERGENCY RESUSCITATION IN

TRAUMA PATIENTS
Presenter: Jose Charry, MD, PhD, Colombia

WITHDRAWN
 Session XVII: WTC III Session: Shock/Resuscitation
Paper 1: 6:15am - 7:15am
TRAUMATIC LARYNGOTRACHEAL INJURIES – 7 YEAR EXPERIENCE
FROM A LEVEL I TRAUMA CENTRE
Vignesh Kumar Shanmuganathan MBBS, DNB, Abhinav Kumar MBBS, MS, Biplab
Mishra MBBS, MS, Amit Gupta MBBS, MS, Subodh Kumar Garg MBBS, MS, Sushma
Sagar MBBS, MS JPN Apex Trauma Centre, AIIMS

Introduction: Laryngotracheal (LT) trauma is a potentially devastating injury that

requires a high index of suspicion and prompt intervention to maximize survival and
aerodigestive outcomes. Traumatic laryngotracheal injuries can be classified as external
or internal, and due to blunt or penetrating mechanisms. Due to the protection offered by
surrounding bony structures and numerous soft tissue suspensions, injuries to the
laryngotracheal apparatus are considered infrequent. Respiration, phonation, and airway
protection are all at risk following laryngeal injuries that potentially compromise the
structural or neurologic integrity of the apparatus.
Methods: The study design was of a retrospective cohort of all patients with traumatic
laryngo-tracheal injuries presenting to a level-I trauma centre in India between January
2011 and June 2017.
Results: A total of 48 patients presented to our centre with traumatic LT injuries over the
7 year time period. Majority of them were males (87.5%) and 50% patients in the 3 rd
decade of life, with mean age of 30.7 years and range between 7-70 years. Penetrating
injury accounted to 62.5% patients, out of which 40% were self-inflicted. 44% patients
were referred from other hospitals, of which 42% presented after 24 hours of injury. Of all
the primary patients, only 8 presented within the golden hour of trauma. Of the 48
patients, 13 were referred intubated, 13 needed immediate airway intervention at our
centre. 85%patients had partial LT injury. 25 patients had associated injuries, with 7
having vascular injury, 11 with aero-digestive tract injuries. 19 patients underwent
primary repair alone, 16 underwent primary repair with tracheostomy, 3 patients had a
tracheostomy done, and 8 were managed non-operatively. We had a mortality of 4%, both
patients due to other causes.
Conclusion: Although rare, blunt and penetrating trauma to the soft tissue structures of
the neck is associated with high morbidity. Many of these injuries require operative
intervention, and awareness of the injury with complete, prompt work-up and evaluation
are important in order to implement timely, appropriate management. The management of
LT traumatic injury continues to evolve, knowledge of current practices allows trauma
surgeons to help guide surgical and interventional treatments.
 Session XVII: WTC III Session: Shock/Resuscitation
Paper 2: 6:15am - 7:15am
INTER-HOSPITAL VARIATIONS IN RESOURCE USE INTENSITY IN INJURY
DEATHS: A MULTICENTER COHORT STUDY
Lynne Moore Ph.D., Alexis F. Turgeon MD, MSc, Valérie Porgo Ph.D., Imen Farhat
MSc, Coralie Assy MSc, Howard Champion* MD, Laval University
Introduction: Injury represents the first cause of life years lost and is second only to
cardiovascular diseases in terms of acute care costs. Our group has previously shown
significant variation in withdrawal of life-sustaining therapies for traumatic brain injury
across Canadian trauma centers (Turgeon et al. CMAJ 2011). The intensity of care
associated with death following injury is however, unknown. We aimed to evaluate inter-
hospital variations in resource use intensity for injury deaths across trauma centers in an
inclusive, mature Canadian trauma system.
Methods: We conducted a multicenter, retrospective cohort study including deaths
following admission for injury to any of the 57 trauma centers in a Canadian trauma
system between 2014 and 2016. We used data from a trauma registry linked to hospital
discharge and hospital costing databases. Resource use intensity was measured by activity-
based costs according to Canadian guidelines for the economic evaluation of health
technologies and GRADE recommendations, whereby units of resource use were
multiplied by unit costs. We used multilevel log-linear regression to calculate median
activity-based costs adjusted for age, comorbidities, physiological status on arrival, injury
type and severity and transfer. Inter-hospital variations in resource use intensity were
measured using intraclass correlation coefficients (ICC) with 95% confidence intervals.
Analyses were performed globally and by time to death (48h, 72h, 7 days), age (<65, ≥65
years) and injury type.
Results: We identified 2055 injury deaths among whom 12% died within 48h of arrival,
21% within 72h, and 44% within 7 days. Median activity-based costs were $4710
(quartiles 1 and 3: 1932-10,296). We observed significant inter-hospital variation in
resource use intensity (ICC=7.3% [4.1-8.8], Figure 1). Mean risk-adjusted activity-based
costs varied from $4863 to $7812 across level I trauma centers. Variations were still
significant when we restricted analyses to deaths within 48h (ICC=10.6% [3.3-17.1]),
within 72h (ICC=9.4% [5.8-12.7]) and within 7 days (ICC=7.9% [5.9-10.1]). Variation
was higher for traumatic brain injuries (ICC=9.3% [5.1-12.4]) than overall and higher for
patients aged <65 years (ICC=12.9% [3.1-19.1]) than for ≥65 years (ICC=6.2% [3.7-7.7]).
Conclusion: We observed significant variations in resource use intensity for injury deaths
across trauma centers even after adjustment for patient case mix. These variations were
greater in traumatic brain injury and younger patients. Results may reflect variations in
decisions to withdraw life-sustaining therapies. Our group is currently working on
improving the shared decision-making process in this population.
 Session XVII: WTC III Session: Shock/Resuscitation
Paper 3: 6:15am - 7:15am
UNPRECEDENTED SURGE ON BLOOD BANK DURING LARGEST MASS
SHOOTING IN UNITED STATES' HISTORY
Neal M. Foley DO, Nelly Chow DO, Cyrus Rahnema MD, Collin Stewart MD, Paul
Nelson MD, Chris Fisher MD, Stefan Chock MD, Sunrise Health GME Consortium
Introduction: The most deadly mass shooting in modern U.S. history occurred in Las
Vegas, Nevada on October 1, 2017, where 58 people were killed and 851 were injured at
an outdoor concert. Bleeding is responsible for the majority of trauma deaths occurring
within the first 24 hours, which has prompted public awareness programs like “Stop the
Bleed Campaign.” Additionally, severely injured patients experiencing hemorrhagic
shock often require massive transfusion. Earlier transfusion with higher blood products
ratios (FFP:Platelets:RBC), defined as damage control resuscitation (DCR), has been
associated with improved outcomes. (PROPPR trial). The surge for blood products at our
level 2 trauma center during this unprecedented event has prompted further investigation
into our blood product utilization. We aim to identify limiting factors in blood product
transfusion and the feasibility of balanced resuscitation during a mass casualty event
(MCE).
Methods: This is a review analysis of blood product utilization for all victims of the
MCE at our institution. After obtaining approval from our IRB, we collected data for age,
blood products administered, timing of transfusion, injury severity score (ISS), length of
stay (LOS) and mortality. The total inventory of blood product within our blood bank and
steps to transfusion were reviewed. Additionally, our team met with blood bank staff to
address barriers and successes during this unanticipated event.
Results: We identified 23 patients who presented to our institution and required blood
product transfusion. A total of 105 units of fresh frozen plasma, 174 units of platelets, 226
units of packed red blood cells, and 15 units cryoprecipitate were utilized during the
MCE. We observed the most demand on the blood bank during the first 24 hours
following admission; 100 units of FFP, 156 units of platelets, 198 units of pRBC were
used during this timeframe. This represented 95.2% of all FFP, 89.7% of all platelets, and
87.6% of all pRBC utilized during the MCE. Of the 23 patients requiring transfusion, we
further identified 11 patients who placed the highest demand on the blood bank. This
subset of patients utilized 92.2% of total blood product used during the MCE, had an
average ISS of 23.3, an average LOS of 21.25 and a transfusion ratio of 1:1.6:2. The
mortality rate was 36.4 percent.
Conclusion: Clinical knowledge, supply constraints and logistical details play crucial
roles if blood product provision is to be managed effectively. Events such as provider
recognition, patient identification, inventory, restocking, product preparation and
delivery, and teamwork impact component resuscitation during the surge for blood
product. A major difficulty in trying to learn useful lessons from past incidents is a
scarcity of clinical data. Our data suggests that balanced resuscitation is feasible and that
centers should not deviate from this practice if restocking strategies are possible.
Protocols must be developed and centers must prepare for MCE to mitigate inefficient
usage of blood components during a mass shooting event.
 Session XVII: WTC III Session: Shock/Resuscitation
Paper 4: 6:15am - 7:15am
SHOCK INDEX AS A MORTALITY PREDICTOR IN A EMERGENCY
RESUSCITATION IN TRAUMA PATIENTS
Jose D. Charry MD,Ph.D., Oscar A. Dussan MD, Roberto J. Rodriguez MD, Hospital
Universitario De Neiva
Introduction: Trauma is considered a public health problem, different scores are using
for predicting mortality. The aim of this study was to evaluate whether the shock index,
given by the formula SI = heart rate / systolic blood pressure (HR/SBP), is useful for
predicting mortality at 24 in trauma patients admitted to the emergency department of a
university hospital in Colombia.
Methods: We evaluated shock index (SI) at admission and generating a dichotomous
variable with two groups: Group A (SI < 0.9) and Group B (SI> 0.9). we evaluated the
inicial type of resuscitation used (colloids, crislatolides and blood). Bivariate
and Multivariate analyses were used. For evaluated the correlation between shock index
and the type of resuscitation the discriminatory power of the score, its accuracy and
precision was assessed by logistic regression and as the area under the receiver
operating characteristic curve. Shapiro Wilks, chi2 and Wilcoxon test were used
Results: 900 patients were analyzed, 57.22% (515) had SI < 0.9, and 42.78% (385) SI >
[Link] mean age for groups A and B was 32.4 and 35.4 respectively. Injury Severety
Score mean was 5.8 and 16.3 (p=0.001) respectively. Mortality at 24 hours after injury
for SI > 0.9 group was 24.9 % in blood resucitation and 75.09% in Crystalloid
Resuscitation (p = 0.001).
Conclusion: An initial shock index greater than 0.9 implies a worse prognosis 24 hours
afterinjury. shock index allows evaluating the effectiveness of resuscitation in emergency
department in a university hospital in Colombia, Shock index is a quick and applicable
score.
PAPER 5 - WITHDRAWN
 5:00-6:00 P.M.
5:00-6:30 pm WTC 21: Abdominal Trauma Sponsored by SBAIT - Brazil Trauma Society
Session XXIV: Location: Golden Hill, Third Level (Seaport Tower)
WTC IV Sessions Moderators: Gennaro Perrone, MD and Tercio Campos, MD, Italy and Brazil
Keynote: Tercio Campos, MD, Pancreatic Trauma
AVOIDING UNNECESSARY LAPAROTOMY IN SELECTED BLUNT AND PENETRATING
TRAUMA PATIENTS: TIME FOR A PARADIGM SHIFT TOWARDS LAPAROSCOPIC
MANAGEMENT
Presenter: Carlos Augusto Menegozzo, MD, Brazil

THE ADDITIONAL VALUE OF FOLLOW-UP TESTS IN THE ASSESSMENT OF SPLENIC

FUNCTION AFTER BLUNT SPLENIC INJURY IN PEDIATRIC TRAUMA PATIENTS
Presnter: Roy Spijkerman, MD, Netherlands

SURGICAL OUTCOMES IN PANCREATIC TRAUMA: A 10-YEAR INSTITUTIONAL

REVIEW
Presenter: Roberto Gonzalez, BS, USA

HYPOVOLEMIC SHOCK IN THE VIEW OF COMPUTED TOMOGRAPHY - IS THERE A

PLACE FOR THESE SIGNS?
Presneter: Heitor Consani, MD, Brazil

NON-OPERATIVE MANAGEMENT IN ABDOMINAL PENETRATING INJURIES - WHERE

DOES THE PROTOCOL LIE
Presenter: Sandeep Tiwari, MD, India
 Session XXIV: WTC IV Session: Abdominal Trauma
Paper 1: 5:00pm - 6:00pm
AVOIDING UNNECESSARY LAPAROTOMY IN SELECTED BLUNT AND
PENETRATING TRAUMA PATIENTS: TIME FOR A PARADIGM SHIFT
TOWARDS LAPAROSCOPIC MANAGEMENT
Carlos Augusto M. Menegozzo MD, Sérgio H. Damous MD,Ph.D., Marcelo C. Rocha
MD, Pedro H. Alves MD, Francisco S. Collet E Silva MD,Ph.D., Celso O. Bernini
MD,Ph.D., Edivaldo M. Utiyama MD,Ph.D., University of Sao Paulo
Introduction: Despite being routine in elective procedures, laparoscopy is still limited in
the emergency setting. The surgical community still struggles to incorporate laparoscopy
in the management of trauma patients due to various limitations, including lack of
technical skills, resources, and scarce evidence of safety and feasibility. However,
laparoscopy has shown benefits in selected patients. The main objective of this study is to
analyze the value of laparoscopy in avoiding unnecessary exploratory laparotomies. As a
second outcome, evaluate the safety of the procedures, measured by complication and
missed injury rates.

Methods: Retrospective chart review of consecutive blunt and penetrating trauma patients
admitted from March 2010 to March 2018. We included all patients who were initially
managed by laparoscopy. Demographic, clinical, intra and postoperative data were
analyzed. Laparoscopy was divided in negative (no injuries found), positive, and
therapeutic (injuries managed only with laparoscopy). Complications were depicted using
Clavien-Dindo classification.

Results: Complete data was obtained in 128 cases. One hundred and five were male
(82%), mean age was 32 years-old. Blunt mechanism was present In 58 cases (45%) and
the median ISS was 13 (4-50). Out of the 70 penetrating traumas, with the median ISS of
13 (1-29), 51 were due to stab wounds. Firearm injury was present in 19 (15%) of the
studied population. The most common indications for laparoscopy in blunt trauma were
free fluid with no solid organ injuries in 33 cases (57%) followed by persistent abdominal
pain (12%) and diaphragmatic hernia (10%). In penetrating trauma, thoracoabdominal
injury (49%) and suspected peritoneal violation (19%) were the main indications for
laparoscopy. Of the laparoscopic procedures, 86 were positive, of which 42 (49%) were
therapeutic. Main therapeutic procedures were diaphragmatic repair (50%), hollow viscus
suture (26%), and solid organ hemostasis (14%). Thirty-four (26%) were negative
laparoscopies. Twenty-four patients had laparotomies. Of those, 13 (54%) had small
midline incisions for intestinal suture or ressection, with no cavity re-exploration. Main
reasons for the 11 conversions to exploratory laparotomy were moderate hemoperitoneum
(45%) and technical difficulties (36%). There were 8 Clavien > 3 complications. A
single case of missed injury (main pancreatic duct) was associated with a Clavien 3a
complication (percutaneous drainage of fistula). Two patients died (1,5%) due to septic
complications. Unnecessary exploratory laparotomies were avoided in 91% of the
patients.

Conclusion: Laparoscopic management of trauma patients is feasible and safe in selected

blunt and penetrating patients. Complication and missed injury rates were low.
Unnecessary exploratory laparotomies, and their early and late complications, were
avoided in 91% of the cases.
 Session XXIV: WTC IV Session: Abdominal Trauma
Paper 2: 5:00pm - 6:00pm
THE ADDITIONAL VALUE OF FOLLOW-UP TESTS IN THE ASSESSMENT
OF SPLENIC FUNCTION AFTER BLUNT SPLENIC INJURY IN PEDIATRIC
TRAUMA PATIENTS
Roy Spijkerman MD, Marijn Kip Michel P. Teuben MD, Falco Hietbrink MD,Ph.D.,
Luke P. Leenen MD,Ph.D., UMC Utrecht

Introduction: Splenectomy used to be the main treatment modality for blunt splenic
injury (BSI). Nowadays, even patients with high grade BSI are preferably treated using
spleen preserving treatments (SPT). It is assumed that patients with low grade BSI treated
with SPT have a good splenic function after recovery. However, there is no consensus on
splenic function after high grade BSI. In several institutions, asplenic/hyposplenic
infection prevention protocol will be executed in all patients who had SPT after high
grade BSI, where other institutions evaluate splenic function first. Scintigraphy is
believed to be the best flow/activity test to approximate splenic functionality. The aim of
the study was to analyze whether spleen injury grade is associated with diminished
splenic function. Secondarily, we aimed to evaluate whether splenic function testing is
necessary in pediatric patients after BSI.
Methods: A retrospective study was performed in our level I trauma center from January
1998 to January 2018. In our institution patients with BSI grade IV of V are assumed
hyposplenic and will receive a splenic function test. We included all patients with a
minimum follow-up test period of 5 days. All tests were analyzed by the radiology
specialist. For each patient we furthermore collected clinical data, including the date of
trauma, gender, age, mechanism of injury, Abbreviated Injury Score (AIS) of splenic
injury and Injury Severity Score (ISS).
Results: During the 20 year inclusion period we included 33 patients consisted of 23 male
and 10 female, with a median (IQR) age of 11,8 (7,3 – 13,5). Median ISS was 16,0 (13 –
30,5) and the median spleen AIS was 4 (3 – 4). Non-operative management was used in
26 patients, angio-embolization in five patients and two patients were treated with
surgical mesh technique. The median follow-up time of all performed tests was 59 (22 –
75) days. A total of 20 patients (61%) had a grade IV or V splenic injury. Scintigraphy
was utilized to test most patients. After testing, a total of 32 out of 33 patients had an
adequate splenic function, including all angio-embolization patients. Only one patient
with a grade II splenic injury after surgical mesh technique showed no splenic function.
Conclusion: So in conclusion, even high grade splenic injuries show adequate splenic
function in the follow-up of pediatric trauma patients after BSI. Therefore routine
diagnostic follow-up by scintigraphy is not necessary in this specific patient group.
 Session XXIV: WTC IV Session: Abdominal Trauma
Paper 3: 5:00pm - 6:00pm
SURGICAL OUTCOMES IN PANCREATIC TRAUMA: A 10-YEAR
INSTITUTIONAL REVIEW
Roberto Gonzalez BS, Indigo Johnson BS, Janika San Roman MPH, John Gaughan
Ph.D., Steven Ross* MD, Joshua P. Hazelton* DO, Cooper University Hospital
Introduction: The use of damage control laparotomy following abdominal trauma has
been well documented, however, the clinical outcomes following damage control
laparotomy in patients with pancreatic injury has not been well studied. The aim of this
study is to compare the clinical outcomes of patients who underwent damage control
laparotomy (DCL) or single surgery (SS) for their pancreatic injury.
Methods: A retrospective review (2006-2016) of patients who presented to an urban
Level 1 Trauma Center with a diagnosis of pancreatic injury, either from a blunt or
penetrating mechanism, was performed. All patients who had operative intervention to
the pancreas (debridement, resection, or repair) were included. Non-operative patients or
patients who did not have a procedure to the pancreas were excluded. Post-surgical
outcomes were compared between groups. A p ≤0.05 was considered significant.
Results: During the study period, 111 patients were found to have a pancreatic injury
(blunt n=72; penetraing n=39); 85 (77%) had a laparotomy, and 26 (23%) were
non-operatively managed and excluded. Of the 85 patients in this series who underwent
exploratory laparotomy for intra-abdominal injury, 44 patients (52%) had operative
intervention involving the pancreas. Of these 44 patients, 24 (55%; blunt n=10;
penetrating n=14) had a damage control laparotomy procedure while the remaining 20
(45%; blunt n=12; penetrating n=8) had a single surgery with primary closure. There was
no difference between the groups in terms of age, race, mechanism of injury, grade of
injury, or anatomic location of injury (all p>0.05). The damage control surgery group had
a higher ISS (22 vs 15), abdominal AIS (3.5 vs 2.4), more ventilator days (8.4 vs 2.7),
longer ICU LOS (14.5 vs 7.4), and more blood products transfused [PRBC (22 vs 5.1),
FFP (18.1 vs 3.3), PLT (2.2 vs .4)] than the single surgery group (all p≤0.05). There was
no difference in mortality or post-surgical pancreatic complications (p>0.05) between the
damage control and single surgery groups.
Conclusion: Patients with a pancreatic injury, from either a blunt or penetrating
mechanism, who required damage control laparotomy were more severely injured than
those who did not require damage control surgery. There were no differences in mortality
or pancreas related post-surgical complication rates between these two groups. Damage
control techniques allow the management of more severely injured patients with
pancreatic trauma without increases in mortality or complications.
 Session XXIV: WTC IV Session: Abdominal Trauma
Paper 4: 5:00pm - 6:00pm
HYPOVOLEMIC SHOCK IN THE VIEW OF COMPUTED TOMOGRAPHY - IS
THERE A PLACE FOR THESE SIGNS?
Heitor F. Consani MD, YASMINE REBECCHI CONJUNTO HOSPITALAR DE
SOROCABA
Introduction: The presence of tomographic (CT) signs indicative of hypovolemic shock
(CTSH) in children has been reported in the medical literature for some time, however
these possible signs for the adult are still not well studied. In order to contribute to the
tomographic evaluation of patients with blunt abdominal trauma on the presence of shock,
we retrospectively studied the ct and hypothesized that these findings may be
representative of a clinical state of hypoperfusion.
Methods: We retrospectively reviewed 46 patients with adult blunt abdominal trauma
treated at our emergency unit (ERU) with a Severity of Injury Index (ISS) greater than 15
and a systolic blood pressure lower than 90 mm Hg and submitted to thoracoabdominal
CT during a period of 24 months, demographic and clinical data of the registered patient
were also analyzed. All the reports of the CT scans were evaluated by the radiology
service and after evaluation of the medical records a new discussion with the radiologists
was made.
Results: 32 patients (69%)of our sample had signs of hypovolemic shock, and the average
number of signs per patient was 4. The most common findings in patients with CTSH
were the presence of free peritoneal fluid, increased uptake and / or dilatation of the small
intestine, flattened inferior vena cava (IVC) and flattened renal veins. VCI and flattened
renal vein as well as active contrast extravasation were found in patients presenting with
low hemoglobin and greater need for transfusion. Another analysis identified dilatation of
the small intestine and splenic injury may be factors associated with mortality and a
greater chance of laparotomy.
Conclusion: CTSH can correlate with clinical hypoperfusion in patients with closed
trauma and still provide important prognostic and therapeutic implications. The presence
of CTSH in patients with closed trauma should call for immediate attention and may
require rapid intervention. Despite the small study with retrospective design, we can warn
that trauma surgeons should seek to understand these signs and consequently include them
in the evaluation of patients with closed abdominal trauma as to the decision making
mainly regarding the surgical conduct
 Session XXIV: WTC IV Session: Abdominal Trauma
Paper 5: 5:00pm - 6:00pm
NON-OPERATIVE MANAGEMENT IN ABDOMINAL PENETRATING
INJURIES - WHERE DOES THE PROTOCOL LIE
Sandeep Tiwari MD, Yadvendra Dheer MD, Anita Singh MD, Vaibhav Jaiswal MD,
Narendra Kumar MD, King George's Medical University
Introduction: Penetrating trauma is fast becoming the leading cause of trauma due to
intentional harm, as a result of increased use of weapons and firearm. According to WHO
report, there is increased use of firearm weapon all over the world. The war zone of the
globe is already reeling under the pressure of such patients. These patients occupy
maximum numbers of beds in the hospitals and challenge the trauma system in that part of
the world. Even the free gun licensing in the U.S.A. and other countries also have
increased the incidence of firearm injuries. India has a strict law of firearm licensing but is
still has an increasing trend in firearm and other penetrating injuries, maybe due to more
number of illegal and country-made weapons. Terrorism also is a challenge and causes
severe injuries due to penetrating injuries. Patients with abdominal penetrating injuries
occupy the maximum number of beds in trauma surgery department and OR are kept busy
with the operative intervention of these patients.
Methods: This is a retrospective observational study conducted in the department of
trauma surgery KGMU, U.P. Lucknow, India from December 2016 to February 2017.
Total 252 patients with firearm injury abdomen were admitted to trauma surgery
department. ​
Results: Out of these 252 patients, 230 patients were operated and landed in OR after
primary survey, resuscitation, and investigations. 22 patients were in grey zone and had no
positive radiological or clinical finding to justify immediate surgery. Out of 22 patients
who were initially managed by non-operative measures, 10 had stab injuries and 12 had
firearm injuries. Out of 12 firearm injuries patients, 5 had pallet (shotgun) injuries and 7
had bullet injuries. Out of the total of 22 patients of penetrating abdominal trauma 3
patients of stab wound injuries and 4 patients of firearm injuries (2 pallet injuries and 2
bullet injuries) were operated after 48 hours of the Admission and had late signs and
symptoms. While 7 patients with stab injuries and 8 patients of the firearm injury abdomen
(3 pallets and 5 bullet injuries), patients were managed by non-operative management.
Conclusion: The penetrating abdominal injuries are challenging and drama involved with
these patients, tempt the trauma surgeon to the role the patient to OR. But a good serial
clinical examination, radiological examination, and other investigations may prevent
unnecessary laparotomies and reduced mortality and morbidity. The dictum of penetrating
injuries of the abdomen are managed in OR, stays challenged for our institution.
WTC 22: Shock/Resuscitation Sponsored by The Japanese Society for Acute
Care Surgery (JSACS)
Location: Torrey Hill, Third Level (Seaport Tower)
Moderator: Christine Gaarder, MD, PhD and Atsushi Shiraishi, MD, Norway and Japan
Keynote: Atsushi Shiraishi, MD, The Effects of TXA on Trauma
IS THERE A MORTALITY DIFFERENCE IN TRAUMA PATIENTS REPATRIATED TO NON-
TRAUMA CENTERS? PILOT DATA FROM AN EAST MULTI-CENETR TRIAL
Presenter: John Agapian, MD, USA

PREDICTION OF PATIENTS WITH MAJOR TRAUMA REQUIRING MASSIVE BLOOD

TRANSFUSION : A COMPARISON OF ABC, TASH, PWH, SI SCORES
Presenter: Ahram Han, MD, South Korea

ASSOCIATION OF THE TIME INTERVAL FROM HOSPITAL ARRIVAL TO CT SCANNING

WITH MORTALITY AMONG ADULT TRAUMA PATIENTS WITH PREHOSPITAL SHOCK ON
SCENE; A NATIONWIDE HOSPITAL-BASED REGISTRY IN JAPAN
Presenter: Takeyuki Kiguchi, MD, PhD, Japan

LOOKING AT THE OTHER SIDE OF THE COIN: USING VISCOELASTIC METHODS

(ROTEM) TO HOLD BLOOD TRANSFUSIONS IN TRAUMA PATIENTS
Presenter: Jose Parreira, MD, PhD, Brazil

TRIBULATIONS OF CONDUCTING RANDOMIZED CONTROLLED TRIALS IN COLOMBIA:

THE EXPERIENCE FROM THE CELTA TRIAL (HYPERTONIC SALINE FOR EARLY
ABDOMINAL FASCIAL CLOSURE AFTER EMERGENT LAPAROTOMY IN TRAUMA
PATIENTS)
Presneter: Alberto Garcia, MD, Columbia
 Session XXIV: WTC IV Session: Shock/Resuscitation
Paper 1: 5:00pm - 6:00pm
IS THERE A MORTALITY
DIFFERENCE IN TRAUMA PATIENTS REPATRIATED TO NON-TRAUMA
CENTERS? PILOT DATA FROM AN EAST MULTI-CENETR TRIAL
John V. Agapian MD, FACS, FCCM, Pascal Bortz MD, Jonathan Vo MD, Edmund
Burke MD, Hector Ludi MD, Anthony Firek MD, Afshin Molkara MD, University Of
California, Riverside/RUHS; LLU
Introduction: The Committee on Trauma has pledged towards 'Zero Preventable Deaths'
in U.S. trauma systems. The feasibly of this mission with the trauma patient that is
repatriated to a non-trauma center is the focus of an ongoing multi-center study sponsored
by EAST (eastern association for the surgery of trauma). The impetus to transfer patients
to non-trauma centers is predicated on the Affordable Care Act; health plans require
repatriation of these patients to their assigned medical centers, many of which are not
designated trauma centers.
Methods: Multicenter data is being collected to tract 90-day mortality rates of trauma
patients transferred to non-trauma center. A 1:1 match of independent variables including
age, gender, Injury Severity Scale (ISS), Trauma Injury Severity Scale (TRISS) is used to
compare death rates to expected mortality.
Results: To date, we have 9 patients enrolled. 90 day mortality = 4.9% for transferred
patients. Expected mortality = 4.1%
Conclusion: Preliminary data does not suggest a mortality difference in repatriated
trauma patients who receive their secondary care at non-trauma centers, if they received
their initial care at a designated trauma center.
 Session XXIV: WTC IV Session: Shock/Resuscitation
Paper 2: 5:00pm - 6:00pm
PREDICTION OF PATIENTS WITH MAJOR TRAUMA REQUIRING MASSIVE
BLOOD TRANSFUSION : A COMPARISON OF ABC, TASH, PWH, SI SCORES
Ahram Han MD, Myung Jin Jang Dae Sung Ma MD, Seok Joo MD, Sung Jin Kim MD,
Sung Youl Hyun MD, Gachon University Gil Medical Center
Introduction: Several scoring systems that predict the need of massive transfusion (MT)
in trauma patients have been proposed. The aim of this single center retrospective study
was to validate the accuracy of existing scoring systems in Korean trauma patients.
Methods: Among trauma patients who were admitted to a regional trauma center between
January 1, 2014 and December 31, 2016, those who were ≥13 of age, with injury severity
score over 15, and who had received ≥ 1 RBC units during initial 24 h were included.
Previously developed scores [Assessment of Blood Consumption (ABC),
Trauma-Associated Severe Hemorrhage (TASH), Prince of Wales Hospital (PWH), and
shock index (SI)] were calculated for each patient according to the published methods.
Performance of each scoring system to predict the need of MT was compared using area
under the receiver operator curve (AUROC). MT was defined as (1) ≥1 RBC unit within 2
h and (2) ≥5 RBC units or death from hemorrhage within 4h.
Results: Among the 562 patients who met the inclusion criteria, 176 (31.3%) patients
were classified as MT patients. According to multivariate logistic regression, initial
systolic blood pressure, heart rate, Glasgow coma score, and free abdominal fluid were
associated with MT. When receiver operator curve of ABC, TASH, PWH, and SI were
plotted, all four scoring systems were good predictors of MT with AUROC of 0828,
0.844, 0.866 and 0.811, respectively. When previously reported cut-off values were
applied, ABC, TASH, PWH scores showed high specificity (93.8%, 96.8%, and 93.4%
respectively), but low sensitivities (50.6%, 31.8%, and 49.1% respectively).
Conclusion: ABC, TASH, PWH, and SI showed comparable capabilities in predicting
MT in Korean trauma patients. However, previously proposed cut-off values of ABC,
TASH, and PWH were skewed towards higher specificity leading to low sensitivity and
high false negative rate.
 Session XXIV: WTC IV Session: Shock/Resuscitation
Paper 3: 5:00pm - 6:00pm
ASSOCIATION OF THE TIME INTERVAL FROM HOSPITAL ARRIVAL TO
CT SCANNING WITH MORTALITY AMONG ADULT TRAUMA PATIENTS
WITH PREHOSPITAL SHOCK ON SCENE; A NATIONWIDE
HOSPITAL-BASED REGISTRY IN JAPAN
Takeyuki Kiguchi MD,Ph.D., Hiroshi Ogura* MD,Ph.D., Yusuke Katayama MD,Ph.D.,
Tomoya Hirose MD,Ph.D., Junya Sado Tasuku Matsuyama MD,Ph.D., Kosuke Kiyohara
Taku Iwami MD,Ph.D., Satoshi Fujimi MD,Ph.D., Tetsuhisa Kitamura MD,Ph.D., Osaka
General Medical Center

Introduction: In recent years, the implementation of computed tomography (CT)

scanning has become faster and provided physicians various information on patients.
Therefore, in treatments of trauma patients, CT scanning is absolutely necessary.
However, the appropriate timing of CT scanning is still unknown among trauma patients
with shock vital. The purpose of this study was to assess the relationship between the time
from hospital arrival to CT scanning and mortality among adult trauma patients with
prehospital shock on scene.
Methods: We used data from the Japan Trauma Data Bank, in which 256 institutions of
all over Japan have been involved since 2008 through 2015. Adult trauma patients with
prehospital shock vital on scene were included in our study. Patients who were transferred
to another hospital, and traumatic cardiac arrest on hospital arrival were excluded, and
they were divided into the following three groups according to the time interval from
hospital arrival to CT scanning; immediate scanning group of 0-29 mins, intermediate
scanning group of 30-59 mins, late scanning group of more than 60 mins. We analyzed
separately the head injury patients (Abbreviated Injury Scale of head ≥3) and trunk injury
patients (Abbreviated Injury Scale of chest or abdomen ≥3). Primary outcome was
mortality on discharge. Multivariable logistic regression adjusting for age, sex, day of
week, Injury Severity Score, Glasgow Coma Scale on hospital arrival, shock on arrival,
focused assessment with sonography for trauma (FAST), and the time interval from
finding to hospital arrival was performed to test the association between CT scan timing
and mortality by the type of injury (head or trunk).
Results: A total of 23,988 patients were included. Of them, the immediate group were
10066 (42%), the intermediate group were 9753 (40.6%), and the late group were 4169
(17.4%). Among head injury patients, mortality gradually increased from 25.3% to 30.4%
as CT scan timing delayed (p for trend =0.02). The adjusted odds ratio of the late group
for mortality after adjusting for potential confounders was 1.28 (95% confidence interval,
1.04-1.57) compared with the immediate group. Among trunk injury patients, mortality
gradually increased from 13.1% to 21.0% as CT scan timing delayed (p for trend <0.001).
The adjusted odds ratio of the late group for mortality was 1.37 (95% confidence interval,
1.12-1.67).
Conclusion: Among adult trauma patients with shock on scene, delayed CT scan timing
was associated with increased mortality on discharge.
 Session XXIV: WTC IV Session: Shock/Resuscitation
Paper 4: 5:00pm - 6:00pm
LOOKING AT THE OTHER SIDE OF THE COIN: USING VISCOELASTIC
METHODS (ROTEM TO HOLD BLOOD TRANSFUSIONS IN TRAUMA
PATIENTS
Jose G. Parreira MD,Ph.D., Carolina Gomez MD, Joao B. Rezende - Neto MD,Ph.D.,
Sandro Rizoli MD,Ph.D., St. Michael's Hospital
Introduction: Hemorrhage and coagulopathy are a major cause of death and morbidity in
trauma. Exams using viscoelastic characteristics of the clot have been introduced more
recently to guide blood product transfusions in these patients. The objective of this study
was to assess the importance of ROTEM parameters as a tool to hold transfusions in
trauma patients.
Methods: Retrospective analysis of the trauma registry data in a period of 12 months,
starting in November, 2014, including all adult patients that had a ROTEM test upon
hospital arrival. We used the ROTEM cut-offs parameters (Extem CT, Extem A10, Extem
MCF, Extem CFT, Extem ML, Extem Angle, FibtemA10 and Fibtem MCF), as defined
by the manufacturer, to assign patients into one of two groups: “normal” or
“abnormal”. The variable “normal ROTEM” (NL ROTEM) was created to identify
patients in whom all ROTEM parameters were normal. The two groups were compared
regarding the use of blood products in 2x2 tables. Negative predictive values (NPV) for
blood products transfusion were calculated. The utilization of blood products was
assessed regarding the type and the volume of transfusion. These analyses were repeated
in subgroups of patients with ISS>15, as well as, with systolic blood pressure (SBP)
lower than 90mmHg on admission. Chi square and Fisher's exact tests were used for
statistical analysis, considering p<0.05 as significant
Results: 793 patients fulfilled the inclusion criteria. Blunt trauma accounted for 80.2% of
the admissions (73.5% were male). Median age was 42 y.o. (range 15-96). Forty six
patients (5.8%) were admitted with SBP lower than 100 mmHg, and 161 (20.3%)
sustained a AIS head higher than 2. Median ISS was 9 (2-19) and 269 patients sustained
an ISS>15 (33.9%). At least one unit of blood products was transfused in the first 24
hours in 92 (11.6%) cases and NL ROTEM was observed 604 (76.2%) patients. The NL
ROTEM NPV in predicting the transfusion of: any blood product (BBP), plasma (FFP),
platelets (PLT) and massive transfusion (MT) were, respectively, 94.7%, 98.3%, 98.8%
and 99.7%. Regarding patients with ISS>15, the NL ROTEM NPV in predicting the
transfusion of: BBP, FFP, PLT and MT were, respectively, 83.8%, 92.5%, 96.3% and
98.8%. In the subgroup of patients admitted with SBP<90 mmHg, NL ROTEM predicted
14/15 (93.3%) cases in which MT did not happen.
Conclusion: There is evidence that NL ROTEM is able do identify patients who will not
need BBP transfusions in the first 24 hs. after trauma, even in subgroups of patients
sustaining severe injuries and hemodynamic instability.
 Session XXIV: WTC IV Session: Shock/Resuscitation
Paper 5: 5:00pm - 6:00pm
TRIBULATIONS OF CONDUCTING RANDOMIZED CONTROLLED TRIALS
IN COLOMBIA: THE EXPERIENCE FROM THE CELTA TRIAL
(HYPERTONIC SALINE FOR EARLY ABDOMINAL FASCIAL CLOSURE
AFTER EMERGENT LAPAROTOMY IN TRAUMA PATIENTS
ALBERTO F. GARCIA MD, JULIAN CHICA MD, ALVARO I. SANCHEZ MD,Ph.D.,
RAMIRO MANZANO MD, MARIA P. NARANJO MD, JORGE H. MEJIA MD,
GUSTAVO A. OSPINA MD,Ph.D., CARLOS A. ORDOÑEZ MD, JUAN C. PUYANA
MD, FUNDACION VALLE DEL LILI
Introduction: A randomized controlled trial (RCT) evaluating the effect of hypertonic
solutions (HS) for abdominal fascial closure (AFC) after damage control laparotomy
(DCL) in trauma patients was proposed and started to recruit patients since November of
2015. We described our experience on conducting a RCT in Colombia and provided
preliminary data.
Methods: Since November 2015, trauma patients who require DCL were randomized to
50mL/hour of HS during the next 70 hours following laparotomy plus standard fluid
resuscitation, or standard fluid resuscitation alone. Sample size was calculated on 400
patients in a multicenter fashion. However, the National Institute of Food and Drug
Monitoring (INVIMA) implemented on May 2016 a new regulation and required an
insurance that increased dramatically the costs of conduction of the trial, discouraging
other settings, and limiting our ability to conduct the trial in our hospital. Labels were not
open for this preliminary data analysis.
Results: From our hospital and during November 2015-December 2017, we were able to
recruit 35 patients. Mean age was 33.6 years (standard deviation [SD], 13.2); 31 were
males (88.6%). Mechanism of injury was penetrating in 29 patients (82.8%). Mean
injury severity score was 26 (SD, 11.1). Mean fluid balance at day 4 were 803cc (SD,
1248) and -137cc (SD, 1732) for each group (p=0.109). Between groups, AFC was
achieved in 14 patients (77.7%) and in 15 patients (93.7%), respectively (p=0.340).
Conclusion: Regulatory barriers and budget limitations exist for the conduction of trauma
trials in Colombia. This preliminary data analysis demonstrated nonsignificant trends
towards differences in fluid balance at day four and AFC rates, when we compare the
study groups. To date, there has been no need to open labels for safety reasons. Question
remains whether results will favor the intervention group after other centers helps us to
finishing the trial and we are able to open the study labels.
WTC 23: Trauma Education Sponsored by Chinese Medical Doctor Association
Trauma Committee (CMDATC)
Location: La Jolla, Second Level (Seaport Tower)
Moderator: Ashok Puranik, MD and Lian-Yang Zhang, MD, India and China
Keynote: Guixi Zhang, BS, MBBS, MHSM, MTS, Trauma Education in China, China
THE FEASIBILITY OF TELEPHONE-ADMINISTERED INTERVIEWS TO EVALUATE
LONG-TERM OUTCOMES OF TRAUMA PATIENTS IN SUB-SAHARAN AFRICA
Presenter: Adam Laytin, MD, MPH, USA

A PROSPECTIVE ANALYSIS OF SHORT AND MID-TERM KNOWLEDGE RETENTION

AFTER AN ULTRA-SHORT ULTRASOUND COURSE FOR MEDICAL STUDENTS
Presenter: Carlos Augusto Menegozzo, MD, Brazil

PREPARED TO CARE: AN EXPLORATION OF CONTINUING EDUCATION TRENDS OF

NURSES CARING FOR INJURED CHILDREN
Presenter: Linda Roney, RN, USA

ESTABLISHMENT OF TRAUMA SYSTEM FRAMEWORK IN SHENZHEN, CHINA

Presenter: Guixi Zhang, BS, MBBS, MHSM, MTS, China

WORLD TRAUMA EDUCATION: HEMORRHAGE CONTROL TRAINING FOR

HEALTHCARE PROVIDERS IN INDIA
Presenter: Lindsay Smith, BA, USA
 Session XXIV: WTC IV Session: Trauma Education
Paper 1: 5:00pm - 6:00pm
THE FEASIBILITY OF TELEPHONE-ADMINISTERED INTERVIEWS TO
EVALUATE LONG-TERM OUTCOMES OF TRAUMA PATIENTS IN
SUB-SAHARAN AFRICA
Adam Laytin MD,MPH, Nebyou Seyoum MD, Aklilu Azazh MD, Ayalew Zewdie MD,
Rochelle Dicker MD, Catherine Juillard MD,MPH, University of California, San
Francisco
Introduction: Accurate measurements of the long-term functional outcomes of trauma
patients in low-income countries are crucial to evaluate the quality of trauma care and
inform advocacy efforts. In sub-Saharan Africa, most long-term functional outcomes data
are collected from clinic follow-up visits, which can introduce significant sampling bias
since both the healthiest and most significantly disabled patients may be less likely to
return to clinic. Mobile phone service is rapidly expanding in sub-Saharan Africa, and
70% of the population now has mobile phone coverage. In light of this growing
technology, we sought to determine whether structured, telephone-administered
interviews are a feasible means of collecting long-term functional outcomes data about
trauma patients in sub-Saharan Africa.
Methods: We piloted a telephone-administered interview tool based on the Extended
Glasgow Outcomes Scale (GOSE). Using departmental logbooks and trauma registries in
two academic medical centers in an East African metropolis, 400 consecutive patients
presenting with injuries were identified retrospectively. Patient telephone numbers and
demographic and injury data were collected from clinical charts. When a telephone
number was available, patients or their caretakers were contacted and interviewed about
their functional status six months after their injuries.
Results: Of 400 patients, we were able to contact 189 patients or their caretakers, and 186
of those contacted were willing to complete the interview with allowing us to calculate a
GOSE score (97%). Language barriers and patient refusal to participate were not
significant barriers. At six months, 142 patients had made a good recovery (77%), 5 had
made a moderate recovery (3%), 31 were severely disabled (17%), and 7 had died (4%).
Of those who we were unable to contact, 70% did not have a phone number recorded and
30% had numbers that were not answered or were out of service.
Conclusion: This pilot study demonstrates that structured, GOSE-based, telephone-
administered interviews are a feasible means of collecting long-term functional outcomes
data about trauma patients in sub-Saharan Africa when a reliable telephone number has
been recorded. Because patient follow-up is limited in this setting, this research
methodology provides a valuable new means of collecting patient data following hospital
discharge. These data are essential for understanding the true burden of injury in this
context, where almost a quarter of trauma victims had significant persistent disability at
six months. Future prospective studies using telephone-administered interviews should
emphasize accurate telephone number collection prior to hospital discharge.
 Session XXIV: WTC IV Session: Trauma Education
Paper 2: 5:00pm - 6:00pm
A PROSPECTIVE ANALYSIS OF SHORT AND MID-TERM KNOWLEDGE
RETENTION AFTER AN ULTRA-SHORT ULTRASOUND COURSE FOR
MEDICAL STUDENTS.
Carlos Augusto M. Menegozzo MD, Priscila G. Cazolari MD, Fernando C. Novo MD,
Ramiro Colleoni MD,Ph.D., Edivaldo M. Utiyama MD,Ph.D., University of Sao Paulo
Introduction: Point‑of‑care ultrasound is becoming an invaluable tool in emergency
surgery and is already considered as he new stethoscope by some authors.
Ultrasound techniques may be taught early for medical students. FAST represents a
simple exam that might be used to teach important aspects of ultrasound imaging.
We sought to investigate knowledge retention on short‑ and mid‑term after an
ultra‑short FAST course for medical students. As a secondary outcome, we persued
to find what the students consider as barriers to participate in ultrasound courses.
Methods: This prospective study involved medical students enrolled to the FAST
course of the Sao Paulo State Trauma Leagues Symposium, and included those who
responded to a pre‑course (PRT) questionnaire. The same 8‑question form was
presented 1 week (1POT) and 3 months (3POT) after the course. The course
duration was 50 minutes and involved theoretical explanations and hands‑on
training. Correct responses obtained from the questionnaires were compared to
assess knowledge gain with the course after 1 week, and the retention after 3
months. Statystical analysis was performed using Chi‑square and Fisher's Exact
tests, and a p < 0.005 was considered significant.
Results: Fifty‑two students participated in the course. Thirty‑seven answered the
pre‑course questionnaire (PRT) and were included in the analysis. Response rates to
1POT and 3POT were 47% and 32%, respectively. No student had previously
participated in an ultrasound course. Comparison between PRT and 1POT showed
that there was significant knowledge retention for 6 of the 8 questions (Table 1).
Comparison in Table 2 showed that the acquired knowledge was retained, despite
small reduction in correct answers. Regarding the barriers for undergoing an
ultrasound course, students reported costs (65%), concerns about being released
from routine activities (38%), course location (38%), and time spent in the course
(24%) as the main factors.
Conclusion: this data show that even an ultra‑short FAST course can effectively
impact theoretical knowledge retention in medical students. Efforts should be made
to disseminate this knowledge early during medical education. This should be made
by customized courses with low costs, short duration, in accessible places and with
previous consent from the university directors.

.
 Session XXIV: WTC IV Session: Trauma Education
Paper 3: 5:00pm - 6:00pm
PREPARED TO CARE: AN EXPLORATION OF CONTINUING EDUCATION
TRENDS OF NURSES CARING FOR INJURED CHILDREN
Linda N. Roney RN, EdD EGAN School Of Nursing And Health Studies

Introduction: The significance of nursing competence in the care of pediatric trauma

patients has been well documented (AAP, 2016). Continuing education for trauma nurses
is an important component of maintaining competence yet there is significant variability in
the resources used to support this goal. The purpose of this current study was to explore
the types of educational programs and requirements that members of the Society of
Trauma Nurses (STN) must complete to work in verified/ designated trauma centers.
Trauma nursing education requirements by state and selected countries (Canada and
Norway) are also presented.
Methods: A descriptive non-experimental research design was utilized to describe the
educational programs that members of the Society of Trauma Nurses (STN) must
complete to work in verified/designated trauma centers. An invitation to participate in this
study was sent to all (2990) members of STN during May 2017. Participants completed a
15-question survey instrument that included questions about demographics, pediatric
trauma educational programs required/offered by their employer, and feedback about
pediatric trauma nursing education.
Results: A total of 265 responses were included in this current study. Most participants
worked at community hospitals (n= 78; 30%) followed by those working at children’s
hospitals within larger medical centers (n=45; 17%) and free-standing children’s hospitals
(n=45; 17%). Most worked in an adult trauma centers with county/ state verification/
designation as an adult trauma center (n=68; 26%) or an ACS verified adult trauma center
(n=62; 23%). Two international member responses were received. Most participants were
trauma program managers/coordinators (n=131) and a wide-variety of other nursing roles
were represented. Most participants reported (n=186; 70%) that their verifying/
designating agency required trauma nursing education to support their trauma center.
Trauma Nurse Core Curriculum (TNCC) was the most popular educational course
required by members’ employers (n=208; 79%) followed by Pediatric Advanced Life
Support (n=194; 73%) and Emergency Nursing Pediatric Course (ENPC) (n=101; 38%).
Course in Advanced Trauma Nursing (n=2) and International Trauma Life Support (ITLS)
Pediatric (n=1) and ITLS Provider (n=1) were least common. Participants provided
feedback about challenges accessing pediatric-specific trauma nursing education;
operational and budgetary limitations of requiring pediatric trauma continuing education
that is not required by trauma verifying/designating organizations; limited pediatric
trauma content in established trauma courses offered by professional nursing
organizations; and suggestions to include additional content about non-accidental trauma
in pediatric trauma nursing education offerings.
Conclusion: While there is strong support for continuing education in pediatric trauma
nursing for all nurses who care for injured children, there is a lack of consensus with
regards to standards in programming, content and the amount of time that should be spent
in learning activities. Many hospitals continue to expend resources in developing
programs for their own institution often due to the limitations related to not being able to
endorse a program because it is not mandated by a verifying/designating agency. In
addition to high-quality programming developed by professional nursing organizations,
some regional and state trauma systems have developed continuing education programs
for nurses that include evidenced-based pediatric content that could also serve as a model.
 Session XXIV: WTC IV Session: Trauma Education
Paper 4: 5:00pm - 6:00pm
ESTABLISHMENT OF TRAUMA SYSTEM FRAMEWORK IN SHENZHEN,
CHINA
GUIXI ZHANG BS, MBBS MHSM MTS, Joe K. FAN BS, MS, Gilberto K. LEUNG
BS,Ph.D., MS, Hong ZHANG BS,MD, Xiaohua PAN MD,Ph.D., Chung Mao LO
BS,MD, Lianyang ZHANG BS,MD, Ronald V. MAIER MD, FACS FRCS Ed (Hon)
Medical School Of Chinese PLA
Introduction: The trauma triage in Shenzhen is currently sending trauma patients to the
nearest hospital, and has caused some major trauma patients to be sent to hospitals where
they do not have appropriate resources and capacity for treatment. The study performed in
2016 showed patients who are considered to have suffered a major trauma, from scene to
hospital, as 8.5% were taken to a teaching hospital, 13.6% to a regional hospital, 42.6% to
a community hospital and 35.3% to a private hospital.
Methods: A geographical analysis of traumatic accidents happened in Shenzhen in 2014
and the results showed that trauma patients were highly clustered. A multi-party group
was formed to discuss the feasibility and rationality of designated hospitals for trauma
patients based on traumatic accidents location, hospital location, hospital level, previous
trauma patient volume and trauma care resources. The recommendation of the regional
trauma centers among these hospitals will depend on hard and soft criteria.
Results: A consensus has been formed that trauma patients need to be sent to designated
hospitals. 22 hospitals were designed to be trauma care hospitals that cover the entire
population throughout the Shenzhen area. Five trauma networks were suggested to be
established and five hospitals were designed to be regional trauma centers that are
expected to meet all the hard and soft criteria by December 31, 2018.
Conclusion: The rationale behind the Shenzhen Trauma System Framework is to ensure
that the right patient goes to the right hospital at the right time, to receive the right care
under the right organization, in order to achieve the right result. This framework will
provide experiences for other parties in China to refer to, and it may provide a model for
other parties in China to follow as well, in the near future.
Key words: Geographical Analysis; Designation; Trauma Center
 Session XXIV: WTC IV Session: Trauma Education
Paper 5: 5:00pm - 6:00pm
WORLD TRAUMA EDUCATION: HEMORRHAGE CONTROL TRAINING
FOR HEALTHCARE PROVIDERS IN INDIA
Lindsay A. Smith BA, Sarah Caughey BA, Susan Liu BSN, RN, Cassandra Villegas MD,
MPH, Robert Winchell MD, Mohan Kilaru MD, Mayur Narayan MD, MPH, MBA,
MHPE Weill Medical College of Cornell University
Introduction: Hemorrhage remains a major cause of death around the world. Eighty
percent of trauma patients in India do not receive medical care within the first hour. The
etiology of these poor outcomes is multifactorial. To date, there has only been one
documented first-responder civilian training course for basic trauma care in India. The
first Stop the Bleed (StB) course was recently offered to a group of medical providers in
India.
Methods: A cross-sectional survey of 101 participants who attended a StB training in
Puttaparthi and Bangalore, India was performed. Ninety-six participants were healthcare
providers and five were laypersons, ages 19 to 75 y.o. Pre- and post-training
questionnaires were collected from each participant (5-point Likert scale). Data from the
five laypersons was excluded, along with that of eight healthcare providers whose
questionnaires were incomplete. In total, 88 healthcare providers’ pre- and post-training
questionnaires were included in the analysis. Training time was distributed evenly
between didactic and skills sessions. Three bleeding control skills were presented: wound
compression, wound packing, and tourniquet application.
Results: Among participants, 88.6% had previously taken a CPR or first-aid training
course. Only 23.9% reported receiving bleeding control training. The 88 healthcare
providers consisted of nine resident physicians (10.2%), 24 attending physicians (27.3%),
and 55 nurses (62.5%). Participants who reported feeling “extremely confident”
responding to an emergency medical situation rose from 68.2% prior to StB training to
94.3% post-training. Regarding hemorrhage control abilities, 37.5% felt extremely
confident before the training, compared to 95.5% after the training. For wound packing
and tourniquet application, 44.3% and 53.4%, respectively, felt extremely confident pre-
training, followed by 97.7% for both skills post-training. Importantly, 90.9% of StB
trainees felt comfortable teaching newly acquired hemorrhage control skills, as all of the
physicians and nurses who completed this course were certified as StB instructors. The
training was well received, with 96.6% stating they would recommend the course to
others. When evaluating instructional equipment, 95.5% and 94.3% of participants stated
that confidence in their wound packing and tourniquet skills would improve with a more
realistic mannequin. Additionally, seven trainees requested supplementary videos or real-
life scenarios/case discussions where these skills could be used. Lastly, three participants
suggested translation of this program into local languages.
Conclusion: To our knowledge, this is the first StB training in India. Disparities in access
to care, long transport times, and insufficient numbers of prehospital personnel contribute
to the nation’s significant trauma burden. Dissemination of these critical lifesaving skills
into this region and the resulting civilian interventions will increase the number of trauma
patients who survive long enough to reach a trauma center. Much more work is needed to
match the training required for the large population. Additionally, considerations should
be given to translating the course into local languages to increase program reach.
WTC 24: Prehospital Sponsored by JSACS/KSACS
Location: Old Town, Second Level (Seaport Tower)
Moderators: Susan Brundage, MD, MPH and John Cook-Jung Lee, MD, England and South
Korea
Keynote: John Cook-Jung Lee, MD, Invasive Prehospital Care
ASSESSMENT OF POLYTRAUMATIZED PATIENTS ACCORDING TO THE BERLIN
DEFINITION: DOES THE ADDITION OF PHYSIOLOGICAL DATA REALLY IMPROVE
INTEROBSERVER RELIABILITY?
Presenter: Carina Pothmann, MD, Switzerland

PHYSICIAN BASED ON-SCENE AIRWAY MANAGEMENT IN SEVERELY INJURED

PATIENTS AND IN-HOSPITAL CONSEQUENCES - IS THE MISPLACED INTUBATION AN
UNDERESTIMATED DANGER IN TRAUMA MANAGEMENT?
Presenter: Orkun Özkurtul, MD, Germany

DEVELOPMENT OF TRAUMA LEVEL PREDICTION MODELS UTILIZING EMS VITAL

SIGNS TO REDUCE OVER- AND UNDERTRIAGE RATES FOR PENETRATING WOUNDS
AND ELDERLY FALLS
Presenter: Robert Riggs, PhD, USA

THE STATE OF PRE-HOSPITAL CARE AND AMBULANCE UTILIZATION IN RURAL

GUJARAT, INDIA
Presenter: Maunil Bhatt, MD, BS, USA

EMERGENT TRAUMA LAPAROTOMY WITH OR WITHOUT THORACOTOMY IN THE

EMERGENCY DEPARTMENT: RISKS AND BENEFITS.
Presenter: Kaori Ito, MD, Japan
 Session XXIV: WTC IV Session: Prehospital
Paper 1: 5:00pm - 6:00pm
Assessment Of Polytraumatized Patients According To The Berlin Definition: Does
The Addition Of Physiological Data Really Improve Interobserver Reliability?
Carina E. Pothmann MD, Kai O. Jensen MD, Ladislav Mica MD, Georg Osterhoff MD,
Hans P. Simmen MD, Kai Sprengel MD, University Hospital Zurich
Introduction: Several new definitions for categorizing the severely injured as the Berlin
Definition have been defined. Here, severely injured patients are selected by additive
physiological parameters and by the general Abbreviated Injury Scale (AIS)-based
assessment. However, all definitions should conform to a AIS severity coding applied by
an expert. We examined the dependence of individual coding on defining injury severity in
general and in identifying polytrauma according to several definitions.
Methods: We investigated the interobserver reliability (IR) between several trauma-scoring
systems (AIS, Injury Severity Score [ISS], New ISS [NISS], and The Trauma and Injury
Severity Score [TRISS]) for identifying polytrauma using several cutoff levels (ISS ³16,
³18, ³20, and the Berlin Definition). Three hundred and nineteen patients were included for
analyzing IR of trauma scores, with 187 for polytrauma definitions. IR for scoring was
assessed by intraclass correlation coefficient Cronbach’s alpha (ICC) and Cohen’s kappa
for the polytrauma definitions.
Results: IR showed good agreement (³0.80) with ISS, NISS, maximum AIS of each body
region (MAIS; with the exception of MAISexternal), and TRISS. IR for identifying
polytrauma according to the relevant definitions showed moderate agreement (<0.60) in
the ISS cutoff categories (ISS ³16, ³18, and ³20), while the Berlin Definition demonstrated
a correlation of >0.81.

Conclusion: Compared with the ISS-based definitions of polytrauma, the Berlin

Definition proved less dependent on the individual rater. This underlines the need to
redefine the selection of severely injured patients. Using the Berlin Definition for
identifying polytrauma could improve the comparability of patient data across studies, in
trauma center benchmarking, and in quality assurance.
 Session XXIV: WTC IV Session: Prehospital
Paper 2: 5:00pm - 6:00pm
PHYSICIAN BASED ON-SCENE AIRWAY MANAGEMENT IN SEVERELY
INJURED PATIENTS AND IN-HOSPITAL CONSEQUENCES - IS THE
MISPLACED INTUBATION AN UNDERESTIMATED DANGER IN TRAUMA
MANAGEMENT?
Orkun Özkurtul MD, Johannes K. Fakler MD, Tonja Weber MD, Christoph Josten
MD,Ph.D., Unversity Hospital Leipzig
Introduction: Establishing and maintaining an adequate airway by endotracheal
intubation (ETI) is an essential component of advanced trauma life support (ATLS ®) to
ensure best possible oxygenation and ventilation. Orotracheal intubation remains the gold
standard for securing a definitive airway in trauma care. When performed in the
out-of-hospital environment special attention has to be paid to cervical spine protection,
the risk of aspiration and possible sideeffects of analgesia and sedation. The aim of our
study was to determine the influence of airway management associated problems on
neurological outcome after out-of-hospital intervention by EMS physicians in patients
suffering from severe and multiple injuries and the consequences for the trauma leader.
Methods: In this retrospective study (01/2011-12/2013), all patients admitted to the
trauma room of a level I trauma center were analyzed consecutively. The subgroup of
patients with advanced airway management in the out-of-hospital setting by EMS
physician as inclusion criteria were investigated in detail. The incidence of unrecognized
esophageal misplaced tube, endobronchial intubation and massive aspiration of stomach
content were recorded as airway associated problems. The neurological outcome at
hospital discharge was evaluated using the Glasgow Outcome Scale (GOS).
Results: During the study period 1,176 patients were admitted. Out of these, 151 patients
received advanced airway management in the out-of-hospital setting. Airway associated
problems were identified in 12 cases (8%). Esophageal intubation was recorded in 5
patients (3%) and other problems were identified in 5%. Airway associated problems was
significant associated with vegetative state or severe disability (GOS 2/3) in 36,3%.
Conclusion: Out-of-hospital airway management problems may contribute to the
neurological outcome of severe and multiple injured patients. Intensive and routine
trauma and airway management trainings seem to be a prerequisite for successful trauma
management. The trauma leader should consider airway associated pitfalls. Trauma room
checklists may be a useful tool for avoiding life-threatening mistakes.
 Session XXIV: WTC IV Session: Prehospital
Paper 3: 5:00pm - 6:00pm
DEVELOPMENT OF TRAUMA LEVEL PREDICTION MODELS UTILIZING
EMS VITAL SIGNS TO REDUCE OVER- AND UNDERTRIAGE RATES FOR
PENETRATING WOUNDS AND ELDERLY FALLS
Robert J. Riggs Ph.D., Sara Riggs Ph.D., Megan Byham MS, Morgan Witherspoon BS,
Nathan Baugh BS, Ashley Metcalf RN, MSN, Debra Kitchens RN, MBA, John Cull MD,
Benjamin Manning MD, Greenville Health System
Introduction: The process to determine the triage activation level can be difficult and
inaccurate, resulting in excessive overtriage (OT) and undertriage (UT) rates. This study
focuses on the development of trauma activation prediction models using field data to
accurately predict trauma activation level and achieve triage rates that are consistently
within The American College of Surgeons (ACS) recommended ranges.
Methods: We utilized the 2014 National Trauma Data Bank (NTDB) to create a binary
regression equation for each injury type under study (geriatric patients with blunt injury
from falling while standing (GF), and patients with penetrating wounds (i.e., gunshot and
stab wounds)). The 2014 trauma data was randomized and divided into halves, where the
first half of the data for each injury type was used to generate the prediction model, and
the second half of the 2014 data, 2013, and 2015 NTDB data was used for model
verification. The binary regression equations were generated from vital signs collected by
EMS. Patients with any incomplete vital sign values or values outside required ranges
were removed from the data set. A Cribari Grid with an ISS≥15 was used to determine
appropriateness of activation level. Chi-square analysis was utilized to determine
significant differences between OT, UT, and accuracy predictions.
Results: Using our
triage models, we were
able to obtain an UT
rate of less than 4%
and an OT rate of less
than 40% for GF, an
UT rate less than 4%
and OT of less than
50% for patients
suffering from gunshot
wounds (GSW), and an
UT rate less than 4%
and OT rate less than
25% for patients
suffering stab wounds.
For GF, the UT rate for GF patients in 2013 was significantly different (p=0.002) from
the 2014 Validation and 2015 data, and the OT rate for 2015 was significantly different
from the 2013 and 2014 Validation data (p<0.001). For GSW, there were no significant
differences for UT rates (p=0.201), but the OT rate for the 2014 Model was significantly
different from the 2013 and 2015 data (p=0.037). For stab wounds, there were no
significant differences for UT (p=0.712) or OT (p=0.381) rates.
Conclusion: Our developed trauma level prediction models enable health providers to
predict trauma activation levels that result in over- and undertriage rates that fall in line
with the recommended ranges by ACS.
 Session XXIV: WTC IV Session: Prehospital
Paper 4: 5:00pm - 6:00pm
THE STATE OF PRE-HOSPITAL CARE AND AMBULANCE UTILIZATION IN
RURAL GUJARAT, INDIA
Maunil Bhatt BS,MD, Mayur Shinde BS, [Link], Kandarp Talati BS,MPH, Ajay Phatak
BS,MPH, Karthik Vishwanathan BS, MS, Somashekhar Nimbalkar BS,MD, Heena
Santry MD, Boston University Medical Center

Introduction:Low and Middle income countries (LMICs) like India are going through
rapid urbanization and have high injury associated mortality rates. Lack of infrastructure
and resources has led to poor prioritization of pre-hospital care and ‘Golden Hour’. In
Gujarat, despite the recent implementation of a state sponsored ambulance
service, its direct impact on outcomes in trauma patients has never been studied. We
aimed to investigate the utilization of this ambulance service amongst trauma patients and
its impact on mortality in rural western India.
Methods: Retrospective analysis of prospectively collected trauma registry data at an only
tertiary care hospital serving a rural catchment area of 11,300 sq km in state of Gujarat,
India was conducted between September 1, 2017 and January 15, 2018. Basic patient
demographics, injury related details, pre-hospital data points and mortality were compared
between patients arriving in an ambulance vs other modes of transport. Multivariable
logistic regression models were used to determine the impact of mode of transport on
patient mortality.
Results: Of 1,117 patients, majority (74%) were males, and mean age was 33.6 years (±
17.9). Only 364 (33%) patients utilized the ambulance service. Most patients (68%) were
brought in either by their relatives or the bystanders in a private vehicle. Patients arriving
by ambulance vs private vehicles were similar in age, gender, and time of injury.
However, patients arriving in ambulance had lower overall revised trauma score (RTS)
suggesting more severe injuries (7.47 vs 7.76, p < 0.001). The median ambulance
response time was 17.5 minutes. Patients using ambulances had longer transport times
(55 mins vs 45 mins, p = 0.023). Patients arriving >60 minutes had significantly higher
mortality compared to shorter transport times (OR 9.17, 95% CI 2.12 - 39.71, p = 0.003).
Despite the existing capabilities, the quality of basic pre-hospital care was poor especially
for the critically injured patients. Zero endotracheal intubations were performed en route
when necessary (GCS < 8), and 0 cervical spines were protected when indicated.
Consequently, the adjusted mortality rate (by age, cause of injury and RTS) amongst
patients transported in the ambulances was no better than in patients arriving by other
modes of transport (aOR 1.92, 95% CI 0.50 - 7.38, p = 0.338). 319 (28%) patients initially
went to the other hospitals which had inadequate capabilities to treat the sustained injuries
and were eventually transferred to our hospital. For these inappropriately triaged patients,
the median duration from the time of injury to definitive care was longer (160 vs 45
minutes, p < 0.001). Additionally, these patients had higher adjusted mortality rates (by
age and cause of injury) [aOR 3.15, 95% CI 1.33 - 7.47, p = 0.009].
Conclusion: The use of ambulance by trauma patients in rural Gujarat remains poor.
Ambulance transport is not associated with lower mortality, but on the contrary appears to
take longer than private vehicles. Inappropriate triage in the field is common and is
associated with increased mortality. Significant improvement in pre-hospital
training and triage protocols may improve patient outcomes associated with ambulance
transport of trauma patients in rural Gujarat.
 Session XXIV: WTC IV Session: Prehospital
Paper 5: 5:00pm - 6:00pm
EMERGENT TRAUMA LAPAROTOMY WITH OR WITHOUT THORACOTOMY IN
THE EMERGENCY DEPARTMENT: RISKS AND BENEFITS.
Kaori Ito MD, Kahoko Nakazawa MD,MPH, Tsuyoshi Nagao MD, Hiroto Chiba MD, Takashi
Fujita* MD,Ph.D., Teikyo University School of Medicine

Introduction: Different from the level I trauma centers in the United States or other western
countries, trauma centers in Japan don’t mandate to have one operating room (OR) and one OR
team to be available for 24 hours/7 days for emergent trauma surgery. Therefore, our emergency
department (ED) in the advanced trauma center have trauma resuscitation rooms with OR set-up
which allow surgeons to perform trauma laparotomy/thoracotomy without transferring patients to
the OR. This study was conducted to assess the risks and benefits of this practice pattern.
Methods: Patients who underwent emergent trauma surgery by our acute care surgery group
(4/2013 – 12/2017) were reviewed. Patients’ demographics, injury severity score (ISS), location
of surgery, type of surgery, time from admission to surgery, vital signs (at the scene, on
admission, and prior to surgery), preoperative interventions, transfusions, postoperative outcomes,
and in-hospital mortality were recorded. For patients who underwent surgery in the ED, risk
factors associated with the in-hospital mortality were analyzed.
Results: There were 121 patients who met inclusion criteria. There were 64 patients (53%,
64/121) who underwent surgery in the ED and 57 patients (47%, 54/121) in the OR. The mean
ISS was higher in the ED group than OR group (31.0±16.1 vs 13.9±10.1, p=0.04). Patients who
underwent surgery within 90 minutes from admission were more frequent in the ED group than
the OR group (72%, 46/64 vs 35%, 20/57, p<0.01). The in-hospital mortality rate was 36%
(23/64) in the ED group; whereas, there were no mortality in the OR group (p<0.01). Outcomes of
59 patients in the ED who had signs of life on admission were shown on Table 1. Blunt trauma
and shock (systolic blood pressure [SBP] < 90 mmHg) were more common in patients who died
than who survived. Time from admission to surgery were not different between who died and who
survived. Patients who died received more transfusions of red blood cells (RBCs) and platelets
than patients who survived. Among patients who died, there were 12 patients (67%, 12/18) who
were not shock on admission and 7 patients (50%, 7/18) who developed shock after induction of
anesthesia. All patients (100%. 5/5) who underwent laparotomy followed by thoracotomy died in
the ED. All patients (100%, 5/5) who needed the placement of resuscitative endovascular balloon
occlusion of aorta (REBOA) died. Twelve patients (67%, 12/18) died in the ED following
surgery. Among patients who survived, 30 patients (73%, 30/41) were not shock prior to surgery
(Table 1).
Conclusion: Emergent trauma surgeries in the ED were associated with shorter time from
admission to surgery, higher ISS, larger amount of transfusions, and higher mortality compared to
surgeries in the OR. There were some concerns regarding pre- and intra-operative anesthetic
management in surgeries in the ED. Patients who died in the ED following surgery might not be
survivable regardless of the timing of surgery nor the place of surgery. Patients who were not
shock prior to surgery could have been brought to the OR. Further study is warranted to assess the
safety of this practice pattern.
 77th Annual Meeting of the
American Association for
the Surgery of Trauma and OTA/
Clinical Congress of Acute
Care Surgery DGOA
4th World Trauma
Schedule
Congress

September 26-29, 2018 • San Diego, CA

*All activities will take place in Mission Beach (3rd Floor) unless otherwise
indicated

7:00-8:30 am Breakfast
Friday Location: Harbor Ballroom (2nd Floor)

9/28 8:00-8:15 am Introduction & Welcome

8:15-10:30 am • Pelvic Fracture with Shock

Emergencies in Phillip Wolinsky, MD/OTA and Ingo Marzi, MD/DGOU
• Compartment Syndrome
Trauma Todd Swenning, MD/OTA and Raul Coimbra, MD, PhD
• Open Fractures
Alexandra Schwartz, MD/OTA and Radko Komadina, MD/DGOU
• Unreduced Dislocations
Douglas Lundy, MD

10:30-10:45 am Break

10:45 am-12:00 pm • Timing

Damage Control Charles Moon, MD/OTA and Zsolt Balogh, MD/DGOU
• Injuries to Treat Immediately
Orthopaedic Philip Wolinsky, MD/OTA and Christoph Josten, MD/DGOU
Surgery • Staged Procedures
Jeffrey Smith, MD/OTA and Hans-Christoph Pape, MD/DGOU

12:00-1:00 pm Lunch (on own)

 1:00-2:20 pm • Infection
Prevention/ Alexandra Schwartz, MD/OTA and Hans-Christoph Pape, MD/DGOU
• Post-operative/rehabilitation issues
Management
Jeffrey Smith, MD/OTA and Bertil Bouillon, MD/DGOU
Complications
2:00-4:00 pm • Femoral shaft fractures
Injury Updates Philip Wolinsky, MD/OTA and Hans-Christoph Pape, MD/DGOU
• Tibial shaft fractures
Todd Swenning, MD/OTA and Radko Komadina, MD/DGOU
• Articular elbow fractures
Alexandra Schwartz, MD/OTA and Christoph Josten, MD/DGOU
• Articular knee injuries
Jeffrey Smith, MD/OTA and Bertil Bouillon, MD/DGOU
• Articular ankle injuries
Todd Swenning, MD/OTA and Zsolt Balogh, MD/Radko Komadina, MD/DGOU
4:00-5:00 pm
• Bone graft options
Management of Charles Moon, MD/OTA and Ingo Marzi, MD/DGOU
Bone Defects • Distraction osteogenesis
Douglas Lundy, MD/OTA and Christoph Josten, MD/DGOU

5:00 pm Conclude
 77th Annual Meeting of the
American Association for Society
the Surgery of Trauma and
Clinical Congress of Acute of Trauma
Care Surgery
Nurses
4th World Trauma Schedule
Congress

September 26-29, 2018 • San Diego, CA

*All activities will take place in Mission Beach (3rd Floor) unless otherwise indicated
Wednesday
7:00-8:30 am Breakfast
9/26 Location: Seaport Foyer (2nd Floor)

8:00-10:40 am STN International Council Meeting and other STN

Committee Meetings
Location: Cortez Hill A (3rd Floor)
1:00-5:00 pm
Back to Basics: The Nuts Speakers:
and Bolts of Building Your Susan Auerbach, MSH, RHIA
Trauma Center Cindy Blank-Reid, MSN, RN
Sean Elwell, MSN, RN
Heidi Hotz, BSN, RN
Sarah Mattock, MSN, RN
Linda Reinhart, MSN, RN

• Basic Trauma Registry Needs

• Leadership Skills
• Starting a Performance Improvement Program
• Nursing and Physician Education Standards
 6:15-7:15 am Speaker: Knut Magne Kolstadbraaten, RN
Thursday International Nursing • Europe
Panel-Trauma Care in My • South America
9/27 Corner of the World •
•
Asia
Africa
• Oceania
• North America

7:30-8:30 am Speaker: Helen Jowett, RN

A World Wide Issue-
Family Violence

8:35-9:30 am Speaker: Rochelle Dicker, MD

Injury-A Neglected Global
Health Priority

10:00-11:00 am Speaker: Linda Littlejohns, MSN, RN, CNRN, FAAN

Neuro Trauma Care – the
Amazing Race to Save
Lives

12:30-1:30 pm Speaker: Knut Magne Kolstadbraaten, RN

International Nursing • Europe
Panel – Caring for the • South America
World’s Aging Population • Asia
• Africa
• Oceania
• North America

2:15-2:45 pm Speakers:
International Nurses Jessica Badillo, MSN, RN
Experience with American Lisa Falcon, MSN, RN, TCRN, Ne-BC
College of Surgeons Gregory Peck, MD
Committee on Trauma
Verification Process: A
Pilot Project

3:00-4:00 pm Speaker: Jerome Stenehjem, MD

Life After Trauma:
Rehabilitation and
Afterwards
4:00-5:00 pm
STN Reception (Nurses
ONLY)
 AAST
INFORMATION
 BOARD OF MANAGERS 2017–2018

President...............................................................................Michael F. Rotondo, M.D.

Rochester, New York

President-Elect............................................................................Martin A. Croce, M.D.

Memphis, Tennessee

Vice-President.............................................................................James W. Davis, M.D.

Fresno, California

Secretary-Treasurer..................................................................Eileen M. Bulger, M.D.

Seattle, Washington

Recorder and Program Chairman..................................................Patrick Reilly, M.D.

Philadelphia, Pennsylvania

Past President 2014–2015.......................................................Thomas M. Scalea, M.D.

Baltimore, Maryland

Past President 2015–2016............................................Grace S. Rozycki, M.D.,M.B.A

Edgewater, Maryland

Past President 2016–2017....................................................Raul Coimbra, M.D.,Ph.D.

San Diego, California

Manager-at-Large (2018)...................................................David H. Livingston, M.D.

Newark, New Jersey

Manager-at-Large (2019)...............................................Raminder Nirula, M.D., Ph.D.

Salt Lake City, Utah

Manager-at-Large (2020)...............................................................Sharon Henry, M.D.

Baltimore, Maryland

Critical Care Manager-at-Large (2018)..........................Karen J. Brasel, M.D., M.P.H

Portland, Oregon

Acute Care Surgery Manager-at-Large (2020).................Clay Cothren Burlew, M.D.

Denver, Colorado
 REPRESENTATIVES
OF
THE AMERICAN ASSOCIATION
FOR THE
SURGERY OF TRAUMA

2017–2018
REPRESENTATIVE TO THE AMERICAN BOARD OF SURGERY
Amy Goldberg, M.D. (2012–2024)
Philadelphia, Pennsylvania

REPRESENTATIVE TO THE
BOARD OF GOVERNORS
OF THE AMERICAN COLLEGE OF SURGEONS
Therese M. Duane, M.D., M.B.A. (2012–2018)
Fort Worth, Texas

Kimberly A. Davis, M.D., M.B.A. (2013–2019)

New Haven, Connecticut

THE ABS TRAUMA, BURNS & CRITICAL CARE COMPONENT BOARD

Joseph P. Minei, M.D., M.B.A (2016–2022)
Dallas, Texas

Kimberly A. Davis, M.D., M.B.A. (2018–2024)

New Haven, Connecticut

REPRESENTATIVE TO THE AMERICAN ASSOCIATION OF BLOOD BANKS

Colonel John B. Holcomb, M.D. (2007–2018)
Houston, Texas

REPRESENTATIVE TO THE ADVISORY COUNCIL FOR GENERAL

SURGERY THE AMERICAN COLLEGE OF SURGEONS
Michael Chang, M.D. (2013–2019)
Winston-Salem, North Carolina

REPRESENTATIVE TO THE WORLD HEALTH ORGANIZATION

Raul Coimbra, M.D., Ph.D. (2012–2018)
San Diego, California

ARCHIVIST
Basil A. Pruitt, Jr., M.D. (1996– )
San Antonio, Texas
 AAST COMMITTEES 2017–2018
OPERATING COMMITTEES

ACUTE CARE SURGERY COMMITTEE

Clay Cothren Burlew, MD, Chair (2020) D'Andrea Joseph, MD (2020)
Stephanie Savage, MD, Vice-Chair (2020) Daniel Yeh, MD (2020)
Paula Ferrada, MD (2018) Eric Toschlog, MD, (2020)
Oliver Gunter, MD (2018) March de Moya, MD (2020)
Addison May, MD (2018) Nathan Mowery, MD (2020)
Nicole Stassen, MD (2018) Thomas Scalea, MD, Ex-Officio (2018)
Gary Vercruysse, MD (2018) Kimberly Davis, MD, MBA, Ex-Officio (2018)
Brian Eastridge, MD (2019) Grace S. Rozycki, MD, MBA, Ex-Officio
Joseph Galante, MD (2019) (2019)
Peter Rhee, MD, MPH (2019) Eileen Bulger, MD, Ex-Officio (2019)
Preston Miller, MD (2019) David Lindsey, MD, Ex-Officio (2020)
Joseph Rappold, MD (2019) Raul Coimbra, MD, PhD, Ex-Officio (2020)
Richard Miller, MD (2019) John Fildes, MD, ACS Program Directors
A. Britton Christmas, MD, (2020) Chair (2018)
Christopher Dente, MD, (2020)
Alicia Mohr, MD, (2020)
PROGRAM DIRECTORS SUBCOMMITTEE
of the Acute Care Surgery Committee

John Fildes, MD, Chair Addison May, MD

James Davis, MD Linda Maerz, MD
Indermeet Bhullar, MD Nathan Mowery, MD
Clay Cothren Burlew, MD Jason Sperry, MD, MPH
Bryan Cotton, MD Eric Toschlog, MD
Jose Diaz, MD Mbaga Walusimbi, MD, MSc
Christopher Dente, MD Jonathan Gates, MD
Andrew Doben, MD David King, MD
Mark Falimirski, MD Narong Kulvatunyou, MD
Alicia Mohr, MD Ronald Sing, MD, DO

CRITICAL CARE COMMITTEE

Karen Brasel, MD, MPH, Chair (2019) David Gourlay, MD (2020)

Alexander Axelrad, MD (2018) David Zonies, MD, MPH (2020)
Richard Bagdonas, MD (2018) Heather Dolman, MD (2020)
Susan Evans, MD (2018) John Agapian, MD (2020)
Wendy Greene (2018) Matthew Lissauer, MD (2020)
Michaela West, MD, PhD (2018) Melvin Stone Jr, MD (2020)
Sonlee West, MD (2018) Panna Codner, MD (2020)
Joseph Cuschieri, MD (2019) Pauline Park, MD (2020)
Dennis Kim, MD (2019) Rachael Callcut, MD (2020)
Christopher Michetti, MD (2019) Ronald Simon, MD (2020)
Niels Martin, MD (2019) Travis Polk, MD (2020)
Krishnan Raghavendran, MD (2019) Charles Adams, Jr., MD, SCCPDS
Addison May, MD (2020) Representative (2018)
Christine Cocanour, MD (2020)
 EDUCATIONAL DEVELOPMENT/MOC COMMITTEE

Stephen Barnes, MD, Chair (2020) Nicole Stassen, MD (2019)

Mark Bowyer, MD, Vice-Chair (2020) Martin Schreiber, MD (2019)
Carlos Brown, MD (2018) Linda Maerz, MD (2019)
Tomas Jacome, MD (2018) Susan Rowell, MD (2019)
Randeep Jawa, MD (2018) Bellal Joseph, MD (2020)
Matthew Martin, MD (2018) Elizabeth Benjamin, MD, PhD (2020)
Susan Steinemann, MD (2018) Glen Tinkoff, MD (2020)
Jose Diaz, MD (2019) Jamie Coleman, MD (2020)
Devashish Anjaria, MD (2019) Paul Schenarts, MD (2020)
Mark Seamon, MD (2019) Thomas Weiser, MD (2020)
Andre Campbell, MD (2019)

GERIATRIC TRAUMA/ACS COMMITTEE

Deborah Stein, MD, MPH, Chair (2020) Bellal Joseph, MD (2020)

Jody DiGiacomo, MD, Vice-Chair (2020) Carrie Sims, MD (2020)
Soumitra Eachempati, MD (2018) David Livingston, MD (2020)
Anne Mosenthal, MD (2018) Jennifer Hubbard, MD (2020)
John Owings, MD (2018) Matthew Carrick, MD (2020)
Kenji Inaba, MD (2019) Rosemary Kozar, MD,PhD (2020)
A. Tyler Putnam, MD (2019) Sasha Adams, MD (2020)
Abhijit Pathak, MD (2019) Scott Armen, MD (2020)
David Lindsey, MD (2019) Toan Huynh, MD (2020)
Stanley Kurek, MD (2019) Zara Cooper, MD, MSc (2020)
Jay Yelon, MD, DO (2019) Todd Costantini, MD, Ex-Officio, MIT
Patrick Bosarge, MD (2019) Representative (2020)
Orlando Kirton, MD, MBA (2019) Robert Barrco, MD, MPH Ex-Officio
Alexander Axelrad, MD (2020) (2018)
Aurelio Rodriguez, MD (2020)

INTERNATIONAL RELATIONS COMMITTEE

Michel Aboutanos, MD, Chair (2020) Susan Brundage, MD,MPH (2019)

Rochelle Dicker, MD, Vice Chair (2020) Nirav Patel, MD (2019)
Gerardo A. Gomez, MD (2018) Jana MacLeod, MD (2019)
Weidun Alan Guo, MD, PhD (2018) Akio Kimura, MD (2019)
Christopher Salvino, MD (2018) Ari Leppaniemi, MD, PhD (2020)
Ronald Simon, MD (2018) Eric Voiglio, MD, PhD (2020)
Mamta Swaroop, MD (2018) Gustavo Fraga, MD, PhD (2020)
A. Peter Ekeh, MD (2019) Marc de Moya, MD (2020)
Li Hsee, MD (2019) Mauro Zago, MD (2020)
Timothy Fabian, MD (2019) Ruben Peralta, MD (2020)
Pal Naess, MD, PhD (2019)

INTERNATIONAL SOCIETY REPRESENTATIVES

of the International Relations Committee (two representatives from each)

European Society for Trauma and International Association for Trauma

Emergency Surgery (ESTES) (IAT)
Trauma Association of Canada (TAC) Trauma Society of South Africa
Pan American Trauma Society (PTS) Surgery and Intensive Care (SIC)
World Society of Emergency Surgery
 MILITARY LIAISON COMMITTEE

Joseph Galante, MD, Chair (2020) Joseph DuBose, MD (2019)

Jennifer Gurney, MD, Vice Chair (2019) William Bromberg, MD (2019)
Eric Bradburn, DO (2018) Alec Beekley, MD (2020)
Kevin Dwyer, MD (2018) Daniel Grabo, MD (2020)
Stacy Shackelford, MD (2019) David Zonies, MD, MPH (2020)
Juan Asensio, MD (2019) Kirby Gross, MD (2020)
Nichole Ingalls, MD (2019) Peter Rhee, MD (2020)
Sid Brevard, MD (2019) R. Stephen Smith, MD (2020)
Warren Dorlac, MD (2019) Matthew Matin, MD (2021)
Matthew Wall, Jr., MD (2019) M. Margaret Knudson, MD, ACS
Liaison

MULTI-INSTITUTIONAL TRIALS COMMITTEE

Todd Costantini, MD, Chair (2020) Bryan Morse, MD (2020)

Jose Pascual Lopez, MD, Vice-Chair (2020) Grant Bochicchio, MD, MPH (2020)
Dennis Ashley, MD (2018) Hasan Alam, MD (2020)
Juan Duchesne, MD (2018) Joseph DuBose, MD (2020)
John Holcomb, MD (2018) Kenji Inaba, MD (2020)
Nicholas Namias, MD, MBA (2018) Lance Stuke, MD, MPH (2020)
Martin Zielinski, MD (2018) Matthew Lissauer, MD (2020)
Gregory Victorino, MD (2019) Michael Cripps, MD (2020)
Oscar Guillamondegui, MD, MPH (2019) Scott Brakenridge, MD (2020)
Ajai Malhotra, MD (2019) Jason Sperry, MD, MPH Ex-Officio (2020)
Nathan Mowery, MD (2019) Raul Coimbra, MD, PhD Ex-Officio (2020)
Brandon Bruns, MD (2020) Mitchell Cohen, MD, WTA MIT Chair, Ex-
Officio

PATIENT ASSESSMENT COMMITTEE

Marie Crandall, MD, MPH, Chair (2020) Leonard Weireter, MD (2019)

Gail Tominaga, MD, Vice-Chair (2020) James Davis, MD (2019)
Joaquim Havens, MD (2018) Daniel Holena, MD (2020)
Lawrence Lottenberg, MD (2018) David Efron, MD (2020)
Babak Sarani, MD (2018) Garth Utter, MD (2020)
Stephanie Savage, MD (2018) Haytham Kaafarani, MD (2020)
Kevin Schuster, MD, MPH (2018) James Booker, MD (2020)
Alan Tyroch, MD (2018) Krista Kaups, MD, MSc, MS (2020)
Ali Salim, MD (2019) Michelle McNutt, MD (2020)
Chris Cribari, MD (2019) Robert Martin, MD (2020)
Ronald Simon, MD (2019) Toby Enniss, MD (2020)
Kristan Staudenmayer, MD, MSc (2019)

PEDIATRIC TRAUMA SURGERY COMMITTEE

Richard Falcone, Jr., MD, Chair (2019) Chris Newton, MD (2019)
David Notrica, MD, Vice-Chair John Bilello, MD (2019)
(2019) James Betts, MD (2019)
Lydia Lam, MD (2018) L.R. Tres Scherer III, MD (2019)
Errington Thompson, MD (2019) John Hall, MD (2019)
Nilda Garcia, MD (2019) Stephen Megison, MD (2019)
M. Margaret Knudson, MD (2019) Andrew Kerwin, MD (2020)
Denis Bensard, MD (2019) Erik Barquist, MD (2020)
Steven Moulton, MD (2019) Kathryn Bass, MD (2020)
Robert Letton, MD (2019) Randall Burd, MD, PhD (2020)
Jeremy Cannon, MD (2019) Scott Thomas, MD (2020)
Jonathan Groner, MD (2019)
R. Todd Maxson, MD (2019)
 PREVENTION COMMITTEE

Zara Cooper, MD, MSc Chair (2018) Michael Rosenblatt, MD (2019)

Keith Clancy, MD, MBA Vice-Chair (2018) Sheldon Teperman, MD (2019)
Christine Cocanour, MD (2018) Spiros Frangos, MD (2019)
Robert Driscoll, MD (2018) Amy Goldberg, MD (2020)
Alexander Eastman, MD, MPH (2018) Carnell Cooper, MD (2020)
Kimberly Joseph, MD (2018) D'Andrea Joseph, MD (2020)
Erik Streib, MD (2018) Deborah Kuhls, MD (2020)
Scott Thomas, MD (2018) Heena Santry, MD (2020)
Michael Coburn, MD (2019) Kathryn Tchorz, MD (2020)
Mayur Narayan, MD, MPH, MBA (2019) Omar Danner, MD (2020)
Rochelle Dicker, MD (2019) Ronald Stewart, MD (2020)

COMMUNICATIONS COMMITTEE
Jason Smith, MD, Chair (2019) Ben Zarzaur, Jr., MD (2019)
Adrian Maung, MD, Vice Chair (2020) Jon Simmons, MD (2019)
Chad Ball, MD (2018) Jose Pascual Lopez, MD (2019)
Vishal Bansal, MD (2018) Jordan Weinberg, MD (2019)
William Bromberg, MD (2018) Michael Truitt, MD (2019)
Janette Capella, MD (2018) David Skarupa, MD (2020)
Murray Cohen, MD (2018) Elliot Haut, MD, PhD (2020)
Amy Goldberg, MD (2018) Jamie Coleman, MD (2020)
Patrick Kim, MD (2018) Jasmeet Paul, MD (2020)
Eric Toschlog, MD (2018) John Como, MD (2020)
James Tyburski, MD (2018) Matthew Benns, MD (2020)
Amy Wyrzkowski, MD (2018) Paula Ferrada, MD (2020)
Jay Yelon, MD, DO (2018) Robert Winfield, MD (2020)
Rachael Callcut, MD 2019)

RESEARCH AND EDUCATION RESTRICTED FUND COMMITTEE

Michael J. Sise, MD, Chair (2019) Joseph Minei, MD, MBA (2020)
Adil Haider, MD, MPH (2020) Oscar Guillamondegui, MD, MPH (2020)
Demetrios Demetriades, MD (2020) Suresh K. Agarwal, Jr., MD (2020)

DISASTER COMMITTEE

Jay Doucet, MD, MSc Chair (2020) Jeannette Capella, MD (2020)

David Shatz, MD, Vice Chair (2020) Jeffrey Upperman, MD (2020)
Marko Bukur, MD (2018) John Harvin, MD (2020)
Eric Bradburn, MD, DO (2018) Mark Gestring, MD (2020)
Eric J. Kuncir, MD, MSc (2019) EAST Representatives
Joseph Amos, MD (2019) Kyle Remick, MD (2020)
Adam Fox, MD, DO (2019) Daniel Grabo, MD (2020)
A. Tyler Putnam, MD (2020)
David Blake, MD, MPH (2020)
Eileen Bulger, MD (2020)
Gerd Pust, MD (2020)

STANDING COMMITTEES

MEMBERSHIP COMMITTEE

Martin Croce, MD, Chair (2018) Karen Brasel, MD, MPH (2019)
David Livingston, MD (2018) Raminder Nirula, MD, PhD (2019)
James Davis, MD (2018) Sharon Henry, MD (2020)
Eileen Bulger, MD (2019) Clay Cothren Burlew, MD (2020)
 PROGRAM COMMITTEE

Patrick Reilly, MD, Chair (2020) Clay Cothren Burlew, MD (2020)

Ben Zarzaur, Jr., MD (2018) Robert Winchell, MD (2020)
Michael F. Rotondo, MD (2018) Rosemary Kozar, MD, PhD (2020)
Eileen Bulger, MD (2019) Ernest Moore, MD, Ex-Officio
Karen J. Brasel, MD, MPH (2019) Jason Smith, MD, Ex-Officio
Lena M. Napolitano, MD, MPH(2019) Timothy Fabian, MD, Ex-Officio
Martin Croce, MD (2019)

NOMINATING COMMITTEE

Thomas M. Scalea, MD, Chair (2018) Michael F. Rotondo, MD (2021)

Grace S. Rozycki, MD, MBA (2019) Martin Croce, MD (2021)
Raul Coimbra, MD, PhD (2020)

SCHOLARSHIP AND AWARDS COMMITTEE

Martin Croce, MD, Chair (2018) Raminder Nirula, MD, PhD (2019)
David H. Livingston, MD (2018) Karen J. Brasel, MD, MPH (2019)
Ajai Malhotra, MD (2018) Clay Cothren Burlew, MD (2020)
James Davis, MD (2018) Sharon Henry, MD (2020)
Eileen Bulger, MD (2019)

AD HOC COMMITTEES

REIMBURSEMENT/CODING AD HOC COMMITTEE

R. Lawrence Reed, MD, Chair (2019) Laura Johnson, MD (2019)

Preston Miller, MD, Vice Chair (2019) Raminder Nirula, MD, PhD (2019)
Samir Fakhry, MD (2018) Nicholas Namias, MD, MBA (2019)
Shahid Shafi, MD (2018) Marie L. Crandall, MD, MPH (2019)
Thomas Esposito, MD, MPH (2018) Obeid Ilahi, MD (2019)
Garth Utter, MD (2019) Raeanna Adams, MD (2019)
Jeffrey Claridge, MD, MSc (2019)
John Armstrong, MD (2019)
Jose Diaz, MD (2019)
Michael Sutherland, MD (2019)
Ronald Gross, MD (2019)

WTC 2018 AD HOC COMMITTEE

Raul Coimbra, MD, PhD Chair (2018) Luke Leenen, MD, PhD (2018)
Ajai Malhotra, MD (2018) Marc de Moya, MD (2018)
Ari Leppaniemi, MD, PhD (2018) Mayur Narayan, MD, MPH, MBA (2018)
Eileen Bulger, MD (2018) Michael Rotondo, MD (2018)
Eric Voiglio, MD, PhD (2018) Michel Aboutanos, MD (2018)
Gustavo Fraga, MD, PhD (2018) Ronald Maier, MD (2018)
Ian Civil, MD (2018) Yasuhiro Otomo, MD (2018)
 JOURNAL OVERSIGHT AD HOC COMMITTEE

J. Wayne Merdith, MD, Chair (2018) Michael Rotondo, MD (2020)

Raul Coimbra, MD, PhD (2018) David Spain, MD (2018)
Rosemary Kozar, MD, PhD (2018)
David Livingston, MD (2018)

PALLIATIVE TRAUMA AD HOC COMMITTEE

Anne Mosenthal, MD, Co-Chair (2020) Mark Malangoni, MD (2020)

Zara Cooper, MD, MSc, Co-Chair (2020) Richard Miller, MD (2020)
Karen Brasel, MD, MPH (2020) Herbert Phelan, III, MD (2020)
Christine Cocanour, MD (2020) Christine Toevs, MD (2020)
Raquel Forsythe, MD (2020) Gail Tominaga, MD (2020)
Vanessa Ho, MD, MPH (2020) David Zonies, MD (2020)
Orlando Kirton, MD, MBA (2020) Ronald Maier, MD, Consultant, (2020)
David Livingston, MD (2020)
Linda Maerz, MD (2020)

AAST STAFF

Sharon Gautschy, Executive Director Karla Stuecker, Senior Meeting Planner ACS
Jermica M. Smith, Program Manager Bridget Lindbloom, Manager, Acute Care
Rachel Sass, Education Manager Surgery Committee
Brea Sanders, Program Coordinator Miguel Gutierrez, Intern
Erin Lillis, Intern

JOURNAL OF TRAUMA AND ACUTE CARE SURGERY STAFF

Ernest E. Moore, MD, Editor Rachel Hendrick, Assistant Managing

Judy Connors Managing Editor Editor
Amiee DeSouza, Editorial Assistant

TRAUMA SURGERY AND ACUTE CARE OPEN JOURNAL STAFF

Timothy C. Fabian, MD, Editor Chloe Lackey, Editorial Assistant

 FUTURE AAST MEETINGS

78th Annual Meeting of the American Association for the

Surgery of Trauma and Clinical Congress of Acute Care Surgery

September 18–21, 2019

Sheraton Dallas
Dallas, TX

79th Annual Meeting of the American Association for the

Surgery of Trauma and Clinical Congress of Acute Care Surgery

September 16–19, 2020

Hilton Waikoloa Village
Waikoloa, HI

80th Annual Meeting of the American Association for the

Surgery of Trauma and Clinical Congress of Acute Care Surgery

September 29–October 2, 2021

Hilton Atlanta
Atlanta, GA

81st Annual Meeting of the American Association for the Surgery

of Trauma and Clinical Congress of Acute Care Surgery

September 21-24, 2022

Hyatt Centric Chicago Magnificent Mile
Chicago, IL

82nd Annual Meeting of the American Association for the

Surgery of Trauma and Clinical Congress of Acute Care Surgery

September 20-23, 2023

Hilton Anaheim
Anaheim, CA
 PAST PRESIDENTS AND MEETING SITES

2017 Baltimore, Maryland Raul Coimbra, M.D., Ph.D

2016 Waikoloa, Hawaii Grace S. Rozycki, M.D., M.B.A
2015 Las Vegas, Nevada Thomas M. Scalea, M.D.
2014 Philadelphia, Pennsylvania William G. Cioffi, M.D
2013 San Francisco, California Robert C. Mackersie, M.D.
2012 Kauai, Hawaii J. Wayne Meredith, M.D.
2011 Chicago, Illinois L.D. Britt, M.D., M.P.H.
2010 Boston, Massachusetts Andrew B. Peitzman, M.D.
2009 Pittsburgh, Pennsylvania Gregory J. Jurkovich, M.D.
2008 Maui, Hawaii Timothy C. Fabian, M.D.
2007 Las Vegas, Nevada David V. Feliciano, M.D.
2006 New Orleans, Louisiana C. William Schwab, M.D.
2005 Atlanta, Georgia Steven R. Shackford, M.D.
2004 Maui, Hawaii H. Gill Cryer, M.D., Ph.D.
2003 Minneapolis, Minnesota David B. Hoyt, M.D.
2002 Orlando, Florida Ronald V. Maier, M.D.
2001 No Meeting Due to 9/11 Ronald V. Maier, M.D.
2000 San Antonio, Texas Frank R. Lewis, Jr., M.D.
1999 Boston, Massachusetts J. David Richardson, M.D.
1998 Baltimore, Maryland Anna M. Ledgerwood, M.D.
1997 Waikoloa, Hawaii Anthony A. Meyer, M.D., Ph.D.
1996 Houston, Texas Kenneth L. Mattox, M.D.
1995 Nova Scotia, Canada Cleon W. Goodwin, M.D.
1994 San Diego, California Ernest E. Moore, M.D.
1993 New Orleans, Louisiana C. James Carrico, M.D.
1992 Louisville, Kentucky Lewis M. Flint, M.D.
1991 Philadelphia, Pennsylvania F. William Blaisdell, M.D.
1990 Tucson, Arizona P. William Curreri, M.D.
1989 Chicago, Illinois H. David Root, M.D., Ph.D.
1988 Orange County, California Donald S. Gann, M.D.
1987 Montreal, Canada Donald D. Trunkey, M.D.
1986 Honolulu, Hawaii Francis C. Nance, M.D.
1985 Boston, Massachusetts David S. Mulder, M.D.
1984 New Orleans, Louisiana George F. Sheldon, M.D.
1983 Chicago, Illinois Basil A. Pruitt, Jr., M.D.
1982 Colorado Springs, Colorado Robert J. Freeark, M.D.
1981 Hot Springs, Virginia Charles R. Baxter, M.D.
1980 Phoenix, Arizona Leonard F. Peltier, M.D.
1979 Chicago, Illinois Roger Sherman, M.D.
1978 Lake Tahoe, Nevada William R. Drucker, M.D.
1977 Detroit, Michigan Alexander J. Walt, M.D.
1976 Colorado Springs, Colorado Joseph D. Farrington, M.D.
1975 Scottsdale, Arizona John H. Davis, M.D.
1974 Hot Springs, Virginia John A. Moncrief, M.D.
1973 Chicago, Illinois Crawford Campbell, M.D.
1972 San Francisco, California Moore Moore, Jr., M.D.
1971 New York City, New York Curtis P. Artz, M.D.
1970 Chicago, Illinois Sawnie R. Gaston, M.D.
1969 Portland, Oregon John E. Raff, M.D.
1968 Montreal, Canada Fraser N. Gurd, M.D.
1967 Chicago, Illinois Edwin F. Cave, M.D.
1966 Santa Barbara, California Raymond Householder, M.D.
1965 Philadelphia, Pennsylvania William T. Fitts, Jr., M.D.
1964 Chicago, Illinois Rudolph J. Noer, M.D.
1963 San Francisco, California Oscar P. Hampton, Jr., M.D.
1962 Hot Springs, Virginia Preston A. Wade, M.D.
1961 Chicago, Illinois Harrison L. McLaughlin, M.D.
1960 Coronado, California James K. Stack, M.D.
1959 Bretton Woods, New Hampshire Truman G. Blocker, M.D.
1958 Chicago, Illinois W.L. Estes, Jr., M.D.
1957 Hot Springs, Virginia Charles G. Johnston, M.D.
1956 Santa Barbara, California Warren H. Cole, M.D.
1955 Chicago, Illinois Robert H. Kennedy, M.D.
1954 Atlantic City, New Jersey Eslie Asbury, M.D.
1953 Chicago, Illinois Martin C. Lindem, M.D.
1952 New York City, New York Arthur R. Metz, M.D.
1951 Montreal, Canada R. Arnold Griswold, M.D.
1950 Salt Lake City, Utah Gordon M. Morrison, M.D.
1949 Atlantic City, New Jersey Paul B. Magnuson, M.D.
1948 Chicago, Illinois Casper F. Hegner, M.D.
1947 Atlantic City, New Jersey Ralph G. Carothers, M.D.
1946 San Antonio, Texas Grover C. Penberthy, M.D.
1945 No Meeting Due to War Charles S. Venable, M.D.
1944 Chicago, Illinois Charles S. Venable, M.D.
1943 No Meeting Due to War Henry C. Marble, M.D.
1942 Boston, Massachusetts Henry C. Marble, M.D.
1941 Montreal, Canada Fraser B. Gurd, M.D.
1940 Atlantic City, New Jersey Edgar L. Gilcreest, M.D.
1939 Hot Springs, Virginia Kellogg Speed, M.D.
 AAST
ABSTRACT OF
PAPERS
 AMA PRA Category
77th Annual Meeting of the 1 CreditsTM will be
American Association for awarded based upon
the Surgery of Trauma and actual hours attended.
Total number of hours
Clinical Congress of Acute
will be calculated from
Care Surgery information individual
4th World Trauma physicians provide in the
Congress online CME evaluation
forms.

September 26-29, 2018 • San Diego, CA

WELCOME
Wednesday, September 26, 2018
7:30 AM-8:00 AM
Location: Seaport D-H, Second Level (Seaport Tower)
PRESIDING: Michael Rotondo, MD

Session I: Plenary - Papers #1-8

Wednesday September 26, 2018
8:00 AM-10:40 AM
Location: Seaport D-H, Second Level (Seaport Tower)
Moderator: Michael Rotondo, MD
Recorder: Patrick Reilly, MD
 Session I: Papers 1-8 Plenary
Paper 1: 8:00-8:20 am
ACS-COT VERIFICATION LEVEL AFFECTS TRAUMA CENTER
MANAGEMENT OF PELVIC RING INJURIES AND PATIENT MORTALITY
Bryant Oliphant MBA,MD, Christopher Tignanelli MD, Lena M. Napolitano* MD, James
A. Goulet MD, Mark R. Hemmila* MD, University of Michigan
Invited Discussant: Todd Costantini, MD
Introduction: Pelvic ring fractures represent a complex injury that requires specific
resources and clinical expertise for optimal trauma patient management. We examined the
impact of treatment variability for this type of injury at Level 1 and 2 trauma centers on
patient outcomes.
Methods: Trauma quality collaborative data (2011-2017) were analyzed. This includes
data from 29 ACS_COT verified Level 1 and Level 2 trauma centers. Inclusion criteria
were adult patients (≥16 years), ISS ≥ 5, blunt injury, and evidence of a partially stable or
unstable pelvic ring fracture which was classified via the Abbreviated Injury Scale
version 2005 (AIS2005). Patients directly admitted, transferred out for definitive care,
penetrating trauma or with no signs of life were excluded. Propensity score matching was
used to create 1:1 matched cohorts of patients treated at Level 1 or 2 trauma centers.
Trauma center verification level was the exposure variable used to compare management
strategies, resource utilization, and in-hospital mortality in univariate analysis.
Results: We selected 1220 well matched patients, from 1,768 total patients, using
propensity score methods (610 Level 1 and 610 Level 2 cohort). There were no significant
baseline characteristic differences noted between the groups. Patients with pelvic ring
fractures treated at Level 2 centers had significantly increased mortality (Table). These
patients were also less likely to receive interventional angiography, undergo complicated
definitive orthopaedic operative treatment, and to be admitted to the ICU. Level 2 centers
were more likely to admit their patients to stepdown type units. The failure to rescue rate
was lower in patients in an ICU than in those in a non-ICU setting.
Conclusions: Admission with a partially-stable or unstable pelvic ring injury to a Level 2
trauma center is associated with increased mortality. Level 2 trauma centers had
significantly less utilization of advanced treatment modalities. This variation in clinical
practice highlights processes to emphasize in the appropriate treatment of these critically
ill patients.
NOTES
 Session I: Papers 1-8 Plenary
Paper 2: 8:20-8:40 am
KETAMINE INFUSION FOR PAIN CONTROL IN ADULT PATIENTS WITH
MULTIPLE RIB FRACTURES: RESULTS OF A RANDOMIZED
CONTROLLED TRIAL
Thomas Carver* MD, Nathan Kugler MD, Janelle Juul PharmD, William Peppard
PharmD, Lewis Somberg MD, Karin Madsen MD, Aniko Szabo Ph.D., Ziyan Yin MS,
Jasmeet Paul* MD, Medical College of Wisconsin
Invited Discussant: David Spain, MD

Introduction: Rib fractures occur in up to 40% of trauma patients with pulmonary

complications increasing the associated mortality. Opiate-based pain regimens remain the
cornerstone of rib fracture management; however, concerns around opioids have fostered
interest in alternative analgesics. Ketamine is an attractive analgesic but evidence to
support the use of ketamine within the trauma population is lacking.

Methods: A prospective, randomized, double-blind placebo-controlled trial of

non-elderly adult patients with at least three rib fractures admitted to a Level 1 trauma
center was conducted. Patients over 64 years of age, GCS less than 13, or chronic opiate
users were excluded. Patients were treated using a standardized multi-modal pain
management protocol. Those randomized to the experimental arm received ketamine at a
rate of 2.5 mcg/kg/min within 12-hours of arrival. The placebo cohort received an
equivalent rate of normal saline and all infusions were continued for 48-hours. The
primary outcome of the study was reduction in numeric pain score (NPS) in the first 24
hours after infusion initiation. Secondary outcomes include oral morphine equivalent
(OME) utilization, intensive care unit and overall length of stay, epidural placement rate,
pulmonary complications, and adverse events related to ketamine.

Results: Ninety-one patients were enrolled with 45 (49%) randomized to the

experimental arm. Experimental and placebo groups were similar in makeup. Overall,
74.7% of patients were male, had a median age of 49 years, and an injury severity score
(ISS) of 14. Motor vehicle collision was the most common (45.7%) mechanism of injury.
Ketamine infusion was not associated with a significant reduction in 24-hour NPS or
OME totals. Subgroup analysis of 45 severely injured patients (ISS >15) demonstrated
ketamine infusion was associated with a significant reduction in OME utilization during
the first 24-hours (35.7 vs. 68, p=0.03), 24-48 hours (64.2 vs 96, p=0.03), and overall
(152.1 vs 198, p=0.048). There was no difference in adverse events between groups. No
other secondary outcome differences were observed.

Conclusion: This is the first prospective randomized double-blind, placebo-controlled

trial of ketamine in patients with rib fractures. While ketamine infusions failed to decrease
NPS or OME within the overall cohort, a decrease in opioid use among severely injured
patients was observed. While further studies are necessary to expand on these results,
ketamine infusions appear to be a useful adjunct among severely injured trauma patients.
NOTES
 Session I: Papers 1-8 Plenary
Paper 3: 8:40-9:00 am
CLEARING THE CERVICAL SPINE FOR PATIENTS WITH DISTRACTING
INJURIES: AN AAST MULTI-INSTITUTIONAL TRIAL
Sean Liebscher Hannah C. Reiser MD, Michael Anstadt MD, Patrick Bosarge* MD,
Jacob Quick MD, Stephen Barnes* MD, LaDonna Allen RN, Nicholas Morin MD, Mario
Gomez MD, Abid Khan MD, Thomas Schroeppel* MD, Heitor Consani MD, Shannon
Carroll MD, Richard P. Gonzalez* MD, Loyola University Medical Center
Invited Discussant: Kenji Inaba, MD

Introduction: Previous single institution studies have shown that clinical examination of
the cervical spine (c-spine) is sensitive for clearance of the c-spine in blunt trauma
patients with distracting injuries. Despite an unclear definition and a paucity of data
defining distracting injury in the context of c-spine clearance, ATLS guidelines and most
trauma centers adhere to the notion that distracting injuries adversely affect the sensitivity
of c-spine clinical examination for identification of clinically significant injury. A
prospective AAST sponsored multi-institutional trial was performed to assess the
sensitivity of clinical examination screening of the c-spine in awake and alert blunt
trauma patients with distracting injuries.

Methods: Seven Level 1 trauma centers participated in the study. During the 42-month
period from July 2014 to December 2017, blunt trauma patients older than 18 years were
prospectively evaluated with a standard cervical spine examination protocol. Awake and
alert patients with a Glasgow Coma Score (GCS) >14 underwent clinical examination of
the c-spine. Clinical examination was performed regardless of the presence of distracting
injuries. Patients without complaints of neck pain, tenderness or pain on range of motion
were considered to have a negative c-spine clinical examination. All patients with and
without distracting injuries were assessed. All patients with positive or negative c-spine
clinical examination underwent computerized tomographic (CT) scan of the entire
c-spine. Clinical examination findings were documented prior to CT scan. Distracting
injuries were classified into three anatomic regions: head injuries, torso injuries and long
bone fractures.

Results: During the 42-month study period, 2929 patients were entered. 70% of the
patients (2,058 patients) were diagnosed with at least one distracting injury. Two
hundred and twenty-three (7.6%) patients in the study population were diagnosed with a
c-spine injury. One hundred and thirty-six patients with distracting injuries were
diagnosed with c-spine injury, 14 (10.3%) of which were missed by clinical
examination. Eighty-seven patients without distracting injury were diagnosed with
c-spine injury of which 11 (12.6%) were missed by clinical examination (p = 0.58). Only
one injury missed by clinical examination underwent surgical intervention.

Conclusion: In the awake and alert blunt trauma patient with distracting injuries, clinical
examination is a sensitive screening method for significant cervical spine injury.
Distracting injuries do not appear to affect the sensitivity of c-spine clinical examination.
As with patients who do not have distracting injuries, radiological assessment is
unnecessary for safe clearance of the asymptomatic cervical spine in awake and alert
blunt trauma patients with distracting injuries. These findings suggest potential reduction
of both healthcare cost and patient radiation exposure.
NOTES
 Session I: Papers 1-8 Plenary
Paper 4: 9:00-9:20 am
THE EFFECTIVENESS OF THE 1994-2004 FEDERAL ASSAULT WEAPONS
BAN IN CONTROLLING MASS SHOOTING DEATHS: ANALYSIS OF
OPEN-SOURCE DATA
Charles DiMaggio MPH,Ph.D., Cherisse Berry* MD, Marko Bukur* MD, Michael
Klein* MD, Manish Tandon* MD, Spiros Frangos* MD,MPH, New York University
Langone Medical Center
Invited Discussant: Ernest Moore, MD

Introduction: The Federal Assault Weapons Ban (AWB) of 1994 made the manufacture
and use by civilians of a defined set of automatic and semi-automatic weapons and large
capacity magazines illegal. The ban expired in 2004 and was not renewed. A federal
assault weapons ban has been proposed as a way to prevent and control mass shootings in
the United States; thus, the period from 1994 to 2004 serves as a natural experiment to
assess the effectiveness of this policy intervention.
Methods: Mass shooting data from 1982 to 2017 were obtained from a documented,
referenced, open-source set of data based on news reports. These data have been cited and
used in a number of prior studies. The yearly rates of mass shooting fatalities per 10,000
gun homicide deaths in the United States were calculated. To help control for secular
trends in population, we chose to normalize by gun homicides, gun ownership and
violence. The period from 1994 to 2004 was compared to the non-ban periods using a
linear regression model with an indicator variable for the ban period and a year variable to
control for trend. The analysis was repeated for the subgroup of data restricted to
incidents in which an assault-type weapon was explicitly noted.
Results: Between 1982 and 2017, 97 shooting incidents involving 4 or more victims
resulted in 816 deaths among 2,091 total victim injuries, for an overall case-fatality ratio
of 39.0% (95% CI 36.9, 41.1). On average, each year an additional gun-related death in
the United States was due to a mass shooting (coefficient for year = 1.01, p = 0.0001),
with increment in year alone capturing over a third of the overall variance in the data
(Adjusted R-squared = 0.3745). This strong underlying linear trend reversed during the
years in which the AWB was in effect. After the ban expired, there was a dramatic
increase in the rate of mass shooting fatalities. (Figures 1 and 2) In a linear regression
model controlling for yearly trend, the federal ban period was associated with a
statistically significant 12 fewer mass shooting related deaths per 10,000 gun homicides
(p = 0.02). The model indicated that year and the federal ban alone accounted for nearly
half of all the variation in the data (Adjusted R-squared = 0.4549). A similar pattern was
evident in data restricted to those incidents characterized as involving assault weapons.
Conclusion: The federal assault weapons ban of 1994 to 2014 was effective in preventing
and controlling mass-shooting related homicides.
NOTES
 Session I: Papers 1-8 Plenary
Paper 5: 9:20-9:40 am
NATIONWIDE ANALYSIS OF RESUSCITATIVE ENDOVASCULAR
BALLOON OCCLUSION OF THE AORTA (REBOA IN CIVILIAN TRAUMA.
Bellal Joseph* MD, Muhammad Zeeshan MD, Mohammad Hamidi MD, Narong
Kulvatunyou* MD, Joseph Sakran* MD, Terence O'Keeffe* MD, Peter Rhee* MD,
University of Arizona - Tucson
Invited Discussant: Megan Brenner, MD, MSc

Introduction: The need for improved methods of hemorrhage control and resuscitation
along with the translation of endovascular specialty skills has resulted in reappraisal of
resuscitative endovascular balloon occlusion of the aorta (REBOA). The aim of our study
was to evaluate the outcomes in trauma patients after REBOA placement. We
hypothesized that REBOA is associated with improved survival.
Methods: We performed a 2-year (2015-2016) review of TQIP and identified trauma
patients who underwent REBOA placement and matched them with a similar cohort of
patients (No-REBOA). Both groups were matched in a 1:2 ratio using propensity score
matching for demographics, vitals (prehospital and ED SBP, HR, GCS), mechanism of
injury, ISS, h-AIS, c-AIS, Pelvic fractures (intact, incompletely disrupted and completely
disrupted pelvic ring), lower extremity vascular injuries and fractures, number and grades
of intra-abdominal solid organ injured (liver, splenic, kidney injuries). Outcomes were
rates of complications and mortality.
Results: Of the 593818 trauma patients, 420 patients (REBOA: 140; No-REBOA: 280)
were matched. Mean age was 44±20 years, ISS was 29 [18-39], 74% were males and 92%
patients had blunt mechanism of injury. Overall rate of complications and mortality were
7.4% and 24.5% respectively. There was no difference in 4-hours or 24-hours blood
transfusion, and hospital or ICU length of stay as shown in Table 1. Mortality rate was
higher in the REBOA Group as compared to the No-REBOA group (36% vs 19%,
p=0.01). Patients who underwent REBOA placement were also more likely to develop
AKI (10.7% vs 3.2%, p=0.02) and more likely to undergo lower extremity amputation
(4.5% vs 0.7%, p=0.04). On sub-analysis using logistic regression based on SBP,
REBOA was associated with worse mortality in patients with SBP 80-110 group (OR:
4.67[1.35-15.42], p=0.03) or in the SBP<80 group (OR: 2.51[1.16-14.41], p=0.03).
Conclusion: In a matched cohort of severely injured patients REBOA placement as
compared to standard therapy was associated with higher rates of complications and
mortality. Further clinical trials are required to define the trauma patients that may benefit
from REBOA.
NOTES
 Session I: Papers 1-8 Plenary
Paper 6: 9:40-10:00 am
MORTALITY OUTLIER HOSPITALS AND IMPROVING THE QUALITY OF
CARE IN EMERGENCY GENERAL SURGERY
Robert D. Becher MD, MS, Michael P. DeWane MD,MPH, Nitin Sukumar MS, Marilyn
J. Stolar Ph.D., Thomas M. Gill MD, Adrian A. Maung* MD, Kevin M. Schuster*
MD,MPH, Kimberly A. Davis* MBA,MD, Yale School of Medicine
Invited Discussant: Shahid Shafi, MD, MPH, MBA

Introduction: Expected performance rates for various outcome metrics are a hallmark of
hospital quality indicators used by AHRQ, CMS, and NQF. The identification of outlier
hospitals with above- and below-expected mortality for emergency general surgery (EGS)
operations is therefore of great value for EGS quality improvement initiatives. The aim of
this study was to determine hospital variation in morality after EGS operations, and
compare hospital-level characteristics between outlier hospitals.
Methods: Using data from the California State Inpatient Database (2010-2011), we
identified patients who underwent one of eight common EGS operations. Expected
mortality was obtained from a Bayesian model, adjusting for both patient- and
hospital-level variables. A hospital-level standardized mortality ratio (SMR) was
constructed (ratio of observed to expected in-hospital deaths). Only hospitals performing
≥3 of each operation were included. High-SMR (>1.0) and low-SMR (<1.0) “outliers”
were compared; outliers had 80% confidence interval that did not cross SMR=1.0.
Results: There were 140,333
patients included from 220
hospitals. SMR (Figure 1) varied
from a high of 2.56 (mortality
156% higher than expected) to a
low of 0.22 (mortality 78% lower
than expected). A total of 12
hospitals were high-SMR outliers,
and 28 were low-SMR outliers.
Patient-level characteristics (age,
gender, comorbidities) were
similar in both outlier groups.
Standardized mortality was over 3 times worse in the high-SMR outliers compared to the
low-SMR outliers (1.68 vs 0.51; p<0.001). Hospital-level characteristics were equivalent
in each outlier group, including percentage of verified trauma centers, high-tech hospitals,
teaching hospitals, average hospital volume, and small hospitals (<100 beds).
Conclusion: There exists significant hospital variation in standardized mortality after
EGS operations. High-SMR outliers have significant excess mortality, while low-SMR
outliers have superior EGS survival. Common hospital-level characteristics do not
explain the wide gap between under- and over-performing outlier institutions. These
findings suggest that SMR can help guide assessment of hospital EGS performance;
further research is essential to identify and define the hospital processes of care which
translate into optimal EGS outcomes.
NOTES
 Session I: Papers 1-8 Plenary
Paper 7: 10:00-10:20 am
VARIATION IN MISSED READMISSIONS AFTER APPENDICITIS:
NATIONAL ANALYSIS INCLUDING READMISSION TO A DIFFERENT
HOSPITAL
Rishi Rattan MD, Joshua Parreco MD, Georgia Vasileiou MD, Daniel D. Yeh* MD,
Sarah A. Eidelson MD, Joann Gold BS, Tanya L. Zakrison* MD,MPH, Nicholas
Namias* MBA,MD, University of Miami
Invited Discussant: Christopher Dente, MD

Introduction: Accurate tracking of outcomes after treatment for acute appendicitis (AA)
is essential. There are no national studies examining readmission after AA that include
readmissions to different hospitals. The objective of this study was to determine the
national rate of and risk factors for readmission after AA.
Methods: The Nationwide Readmissions Database (2010-2014) was queried for
non-elective adult AA discharges. Outcomes included 30-day (d) and 1-year (yr)
AA-related readmission requiring percutaneous drainage (PD) or appendectomy to index
and different hospitals. Multivariate logistic regression identified risk factors.
Results: For the 1,194,014 included patients, initial management included: appendectomy
(91.9%, n=1,097,835), non-operative management (NOM) (6.8%, n=81,652), and PD
(1.2%, n=14,526). 30-d and 1-yr readmission for AA was 0.4% (n=4,936) and 0.7%
(n=8,456) and of those, 12.6% (n=623) and 13.3% (n=1,122) were to a different hospital,
respectively. Patients readmitted within 30-d and 1-yr underwent appendectomy in 34.4%
(n=1,699) and 51.2% (n=4,325), and PD in 16.1% (n=795) and 11.7% (n=990) of cases,
respectively. Patients readmitted to a different hospital had higher rates of appendectomy
at 30-d (47.8% vs 34.4%, p<0.0001) and 1-yr (57.4% vs 51.2%, p=0.0001). 30-d and 1-yr
AA-related readmission rates in the subgroup treated initially with NOM was 3.9%
(n=3,173) and 6.9% (n=5,642) and of those, 14.1% (n=447) and 14.4% (n=811) were to a
different hospital, respectively. Patients readmitted within 30-d and 1-yr after NOM
underwent appendectomy in 38.5% (n=1,223) and 56.0% (n=3,157) and PD in 11.5%
(n=336) and 8.2% (n=465) of cases, respectively. At 30-d and 1-yr, 20.6% (n=252) and
16.2% (n=513) of patients initially treated with NOM and readmitted with AA underwent
an appendectomy at a different hospital, respectively. Risk factors for and protective
factors against 1-yr AA-related readmission included: NOM (OR 64.73 [60.74-68.99],
p<0.0001), leaving against medical advice (AMA) (OR 2.02 [1.70-2.39, p<0.0001),
Medicaid (OR 1.26 [1.19-1.34], p<0.0001), diabetes (OR 1.24 [1.13-1.37], p<0.0001),
and discharge to skilled nursing (OR 0.59 [0.51-0.69], p<0.0001). Risk factors for and
protective factors against 1-yr AA-related readmission to a different hospital included:
NOM (1.21 [1.00-1.46, p=0.052), leaving AMA (OR 4.51 [3.23-6.29], p<0.0001), drug
abuse (OR 2.00 [1.34-2.99], p<0.0001), diabetes (OR 1.75 [1.06-2.89], p=0.03),
for-profit hospital index admission (OR 1.56 [1.24-1.95], p<0.0001), age ≥65 years (OR
1.44 [1.10-1.88], p<0.0001), and metropolitan teaching hospital index admission (OR
0.64 [0.55-0.74], p<0.0001).
Conclusion: One in eight patients readmitted with AA and one in seven failures of NOM
are missed by existing quality measures due to different hospital readmission. Current
benchmarking is inaccurate and results in reporting more favorable for for-profit hospitals
and less favorable for metropolitan teaching hospitals. Recurrence rates after NOM in the
United States are lower than those reported in European clinical trials. Patients
experiencing fragmentation of care have higher rates of operative intervention. Risk
factors for readmission to a different hospital are distinct, suggesting analyses including
only same hospital readmissions miss a unique subpopulation.
NOTES
 Session I: Papers 1-8 Plenary
Paper 8: 10:20-10:40 am
MANAGEMENT OF ADHESIVE SMALL BOWEL OBSTRUCTION: A
DISTINCT PARADIGM SHIFT IN THE UNITED STATES
Kazuhide Matsushima MD, Andrew Sabour BS, Caroline Park MD,MPH, Aaron
Strumwasser MD, Kenji Inaba* MD, Demetrios Demetriades* MD,Ph.D., LAC+USC
Medical Center
Invited Discussant: Martin Zielinski, MD

Introduction: Recent studies showed that early operative intervention in patients who
fail non-operative management of adhesive small bowel obstruction (SBO) is associated
with improved outcomes. The purpose of this study was to determine the trend in practice
pattern and outcomes of patients with adhesive SBO in the United States.

Methods: Data from the Nationwide Inpatient Sample data (2003-2013) were extracted
for analysis, and included patients (age ≥18 years) who were admitted with primary
diagnosis codes consistent with adhesive SBO. We analyzed the data to examine changes
in mortality and hospital length of stay (HLOS) in addition to any trends in rate and
timing of operative intervention.

Results: During the study period, 1,930,289 patients were admitted with the diagnosis of
adhesive SBO. While the rate of operative intervention declined (46.1 to 42.1%,
p=0.0025), the timing between admission and operative intervention was significantly
shortened (3.09 to 2.49 days, p<0.0001). In-hospital mortality rate decreased significantly
(5.29 to 3.77%, p<0.0001). In the multiple logistic regression analysis, the relative risk of
mortality decreased by 5.7% per year (OR: 0.943, 95% CI: 0.936-0.949, p<0.0001).
HLOS decreased from 10.4 days to 9.06 days (P<0.0001).

Conclusion: Over the last decade, fewer patients with adhesive SBO were managed
operatively, whereas those requiring an operation underwent one earlier in their
hospitalization. Although further studies are warranted, our results suggest that recent
changes in practice pattern may have contributed to improved outcomes.
NOTES
 Session II: WTC Panel I
Hemorrhage Control for Complex Pelvic Fractures
Wednesday September 26, 2018, 10:40 AM-1:40 AM
Location: Seaport D-H, Second Level (Seaport Tower)
Moderators: Ingo Marzi, MD &
Clay Cothren Burlew, MD
Panelist:
Ingo Marzi, MD, Role of Fixation
Clay Cothren Burlew, MD, Role of Pelvic Packing Ryosuke
Usui, MD, Role of Endovascular Techniques
 Wednesday, September 26, 2018
11:50 AM-12:50 PM
Session III: AAST Presidental Address
Location: Seaport D-H, Second Level (Seaport Tower)

Execute On the Vision: Pyramids and Mirages in Shifting Sands

Michael F. Rotondo, MD
Chief Executive Officer
School of Medicine and Dentistry
University of Rochester Medical Center

Presiding: Martin Croce, MD

AAST President-Elect, 2017-2018
 Session V: Trauma Systems - Papers #9-16
Wednesday, September 26, 2018, 2:15 PM-4:55 PM
Location: Seaport D-H, Second Level (Seaport Tower)
Moderator: Martin Croce, MD
Recorder: Robert Winchell, MD
 Session IV: Papers 9-16 Trauma Systems
Paper 9: 2:15-2:35 pm
SHOULD THEY STAY OR SHOULD THEY GO? WHO BENEFITS FROM INTERFACILITY
TRANSFER TO A HIGHER LEVEL TRAUMA CENTER FOLLOWING INITIAL
PRESENTATION FROM A LOWER LEVEL TRAUMA CENTER
Christopher J. Tignanelli MD, Tessa Adzemovic BS, Thomas Murray Ph.D., Julie Ottosen MD, Patei Iyegha
MD, Lena M. Napolitano* MD, Mark R. Hemmila* MD, Krishnan Raghavendran* MD, Pauline K. Park*
MD, Jonathan Gipson MD, University of Minnesota Dept of Surgery
Invited Discussant: Jason Sperry, MD, MPH
Introduction: The interfacility transfer of injured patients from verified or designated level 3 or 4 trauma
centers to a level 1 or 2 center has been associated with improved outcomes. However, a drawback to transfer
is significant rates of secondary over-triage and unnecessary resource utilization. Little data are available
describing which patients derive benefit from transfer. In this study, we investigate specific injury patterns
and physiologic/demographic parameters associated with improved survival following interfacility transfer to
level 1 or 2 trauma centers after initial presentation at a lower level facility.
Methods: Data from the National Trauma Data Bank covering 2007 to 2014 was utilized. Inclusion criteria
were adults (≥16 years). Patients with Injury Severity Score (ISS) < 10, those who arrived with no signs of
life, or with missing data were excluded. Patients were divided into two categories: those who were initially
evaluated at and subsequently admitted to a level 3-4 trauma center verses those who were transferred from a
prior hospital’s Emergency Department (ED) to the ED of a level 1-2 trauma center for evaluation and
treatment. Multilevel mixed effects logistic regression models were fit to the data to estimate the effect of
transfer to a level 1-2 trauma center on all-cause in-hospital mortality for 16 injury patterns. Injury patterns
included: any traumatic brain injury (TBI), severe (Glasgow Coma Scale (GCS) < 9) TBI, TBI with
intracranial bleed, TBI with no bleed and GCS > 13, any C-spine injury, C-spine injury with spinal cord
injury, all solid organ injuries, grade 3 or higher solid organ injury, bowel or pancreas injury, femur fracture,
all pelvis fractures, complex pelvic fracture, any rib fracture, greater than 3 rib fractures, greater than 6 rib
fractures, hemo/pneumothorax. Additional physiologic and demographic parameters were also evaluated.
Each model adjusted for demographic parameters, mechanism (blunt/penetrating), injury severity parameters
(ISS, TMPM-ICD-9 predicted mortality, ED vitals, GCS, assisted respirations, blood alcohol content),
medical comorbidities, and hospital level random effects.
Results: 253,013 patients were included in this study. 14,405 (5.7%), were admitted to level 3-4 trauma
centers and 238,608 (94.3%) were transferred into to a level 1-2 trauma center. The mean ISS was 17.8 (SD:
6.8) for patients admitted to a level 3-4 trauma center verses 20.0 (SD: 8.1) for patients transferred into a
level 1-2 trauma center. Compared to the patients who were admitted to a level 3-4 trauma center, patients
who were transferred to level 1-2 trauma centers had reduced mortality (OR 0.74, 95% CI 0.63 – 0.88, p <
0.001). Of the 16 injury patterns, physiologic, and demographic parameters evaluated, 3 injury patterns and 4
parameters were associated with reduced mortality, i.e. estimated OR < 1 (Table). Of the patients transferred
to a level 1-2 trauma center, 56,432 (23.7%) did not have any of these 7 minimum elements. The cumulative
mortality at level 1-2 centers for transferred patients without any elements was 0.5% compared with 11.2%
for patients with one or more element present. Patients admitted to level 3-4 trauma centers without any
elements present did not have increased mortality (0.3%).
Conclusion: Interfacility transfer of patients presenting to lower level trauma centers was associated with a
survival benefit for specific cohorts of patients. Patients with TBI with intracranial bleed, GCS < 13, grade 3
or higher solid organ injury, multiple rib fractures, age ≥ 65, respiratory distress, or shock benefited from
transfer. These data suggest that implementation of minimum evidence-based criteria for interfacility trauma
transfer to higher level care would promote appropriate trauma triage, reduce overall resource utilization, and
save lives.
NOTES
 Session IV: Papers 9-16 Trauma Systems
Paper 10: 2:35-2:55 pm
DEVELOPMENT OF A GIS-BASED APPROACH FOR THE QUANTITATIVE ANALYSIS
OF TRAUMA CENTER ACCESS
Paige Xu BS, Lauren E. Mount MD, Reed Huegerich MCRP, AICP, Robert J. Winchell* MD, Weill
Cornell Medicine
Invited Discussant: Frederick Rogers, MD
Introduction: Decisions around trauma center (TC) designation have become contentious in many
parts of the country. The problem is compounded by the fact that there is no consensus as to the ideal
number and geographic distribution of TC in a region, and no reliable, objective metrics to assess the
effect of changes in structure on system capacity, access, and impact on existing TC. We aim to
develop a set of quantitative metrics for population access within a regional network, using publicly
available data and geographic information systems (GIS)-based methodology. We hypothesize that
geospatial analysis can provide a reproducible approach to transparently and quantitatively assess
potential changes in trauma system structure.
Methods: Based on data availability and relative isolation, the area near Rochester, NY, was chosen for
initial model development. Network analyst tools in ArcGIS Desktop 10.4 were used for geospatial
calculations. Population coverage was estimated using US census tracts, with tract population located at
the geographic centroid. Drive time polygons were created in 10-minute increments around target TC,
and the population covered was estimated by summing the census tract centroids within the drive time
area. Transport time was estimated by calculating drive time from each census tract centroid to the
nearest TC. The existing TC model includes the single designated TC in the region. Model 1, with 1
additional TC, and model 2, with 2 additional TC, were created by selecting additional candidate
centers from existing acute care facilities in the region in order to maximize population covered within
60 minutes of travel, and population covered in 10-minute travel increments to a TC. The population
covered, distribution of estimated transport times, and estimated population covered by a specific TC
were also calculated for each model.
Results: The single TC model (Fig 1) covered an estimated population of 1,093,186. The predicted
median transportation time was 26.2 minutes. In model 1, with a second TC placed to optimize
coverage, the population served with both centers increased by 7.7%, while the population served by
the existing TC decreased by 8.5%. Median transportation time to the nearest TC was 21.1 minutes.
Model 2 (Fig 2), with 3 TC, increased population covered by 10.7%, while that covered by the existing
TC decreased by 18.1%. Median transportation time to the nearest TC decreased to 18.5 minutes.
Conclusion: Geo-spatial analysis can provide objective measures of population access to trauma care,
including the estimated population within 60 minutes of a TC, the distribution of transport times to a
TC, and the population covered by a specific TC. The analysis can be performed using different
numbers and locations of TC, allowing direct comparison of changes in coverage and impact on
existing centers. This type of data is essential to guide difficult decisions regarding trauma center
designation in order to optimize access to care and allocation of resources.
Fig. 1: Single TC Model Fig. 2: Three TC Model
NOTES
 Session IV: Papers 9-16 Trauma Systems
Paper 11: 2:55-3:15 pm
AVOIDING CRIBARI GRIDLOCK 2: THE STANDARDIZED TRIAGE
ASSESSMENT TOOL (STAT OUTPERFORMS THE CRIBARI MATRIX
METHOD (CMM. A REPLICATION STUDY IN 35 ADULT AND PEDIATRIC
TRAUMA CENTERS.
Jacob W. Roden-Foreman BA, Nakia R. Rapier RN, Michael L. Foreman* MD, Chris
Cribari* MD, Megan Parsons BS, Raymond A. Coniglio MSN, Abigail R. Blackmore
RN, Cassie A. Lyell RN, Stephanie D. Flohr RN, Marie Campbell RN, The Trauma
Measurement Workgroup Baylor University Medical Center At Dallas
Invited Discussant: James Davis, MD

Introduction: CMM is widely used to identify over/undertriage (OT/UT) but requires

case review to correct for the inadequacies of ISS. We previously developed the Need
For Trauma Intervention (NFTI), which uses registry variables likely to be considered in
case reviews to indicate major trauma based on resource consumption. Patients meeting
any NFTI criteria are labeled NFTI+
indicating major trauma. Patients meeting
no NFTI criteria are NFTI-. STAT was
developed as a NFTI-adjusted version of
the CMM that emulates the case review
process as shown in the flowchart. This
multicenter study attempted to replicate a
single-center study presented at AAST in 2017 where STAT safely reclassified 52% of
CMM OT/UT. We predicted lower injury burdens for OT and higher burdens for UT.
Methods: 35 adult and pediatric US trauma centers submitted data for 88,083 patients.
Generalized estimating equations with robust standard errors modeled the effects of
OT/UT vs. appropriate triage by triage metric on the odds of mortality and complication,
as well as percent difference in total length of stay (LOS) and in number of procedures
performed within three days. Total LOS and number of procedures within three days
were used as surrogates for overall and early resource consumption, respectively. All
models controlled for age, injury mechanism, and site-level effects.
Results: The median CMM OT rate was 53% vs. 32% with STAT. The median CMM
UT rate was 22% vs. 3% with STAT. CMM and STAT OTs had significantly reduced
odds of mortality and complication, shorter LOSs, and fewer early procedures, but the
reductions were significantly larger with
STAT. STAT UTs had significantly higher
odds of mortality and complication, longer
LOS, and more early procedures vs. CMM
UTs. CMM UT was not associated with
complication risk and was negatively
associated with mortality and number of
early procedures.
Conclusion: While case review is the
ultimate determinant, STAT safely
reclassified 76% of CMM OT/UT. Though
the degree of improvement varied by
center, STAT was substantially more
accurate than CMM. This multicenter
replication confirms that STAT can flag a smaller portion of patients for more detailed
review and reduce the amount of subjectivity introduced by manual triage determinations.
This may allow trauma centers to better refine activation criteria and reduce workload.
NOTES
 Session IV: Papers 9-16 Trauma Systems
Paper 12: 3:15-3:35 pm
Effect of Damage Control Laparotomy on Major Abdominal Complications and
Lengths of Stay: a Propensity Score Matching and Bayesian Analysis
John A. Harvin* MD, John P. Sharpe MD, Martin A. Croce* MD, Michael D. Goodman
MD, Timothy A. Pritts* MD,Ph.D., Elizabeth D. Dauer MD, Benjamin J. Moran MD,
Rachel D. Rodriguez MD, Ben L. Zarzaur* MD,MPH, Laura A. Kreiner MD, Jeffrey A.
Claridge* MD, John B. Holcomb* MD, University of Texas Medical School-Houston
Invited Discussant: Peter Rhee, MD, MPH

When creating your abstract, the only section headers to be used are listed below, and
they need to be in this format (please remove this line before creating your abstract):

Introduction:
In patients for whom surgical equipoise exists for damage control laparotomy (DCL) and
definitive laparotomy (DEF), the effect of DCL and its associated resource utilization are
unknown. We hypothesized that DEF would be associated with fewer abdominal
complications and less resource utilization.
Methods:
In 2016, 6 US Level 1 trauma centers performed a year-long, prospective, quality
improvement project with the primary aim to safely decrease the use of DCL. From this
prospective cohort of patients of undergoing emergent trauma laparotomy, a group who
underwent DCL but were retrospectively judged by majority faculty vote to have been
candidates for definitive laparotomy (potential DEF or pDEF). These pDEF patients were
matched in a 1:1 ratio using propensity scoring to the DEF patients. The primary outcome
was the incidence of major abdominal complications (MAC), defined as fascial
dehiscence, organ/space surgical site infection, reopening of fascia, enteric suture line
failure, and secondary outcomes were lengths of stay (hospital-/ICU-/ventilator-free
days). Deaths within 5 days were excluded. Outcomes were assessed using Bayesian
multilevel generalized linear modeling and negative binomial regression.
Results:
872 total patients were enrolled, 639 (73%) DEF and 209 (24%) DCL. Of the 209 DCLs,
44 were judged to be patients who could have safely been closed at the primary
laparotomy and survived 5 days. 39 of these pDEF patients were matched to 39 DEF
patients. There were no difference in: demographics; mechanism of injury; Injury
Severity Score: prehospital/emergency department/operating room vital signs, labs, and
resuscitation; procedures performed during laparotomy. There was no difference in MAC
between the two groups (31% DEF vs 21% pDEF, relative risk 0.99, 95% credible
interval 0.60 – 1.54, posterior probability 56%). DEF was associated with a 72%, 77%,
and 72% probability of more hospital-, ICU-, and ventilator-free days, respectively
(Table).

Conclusion:
In patients for whom surgeons have equipoise for damage control laparotomy versus
definitive surgery, definitive abdominal closure was associated with no difference in
major abdominal complications, but was associated with more hospital-, ICU-, and
ventilator-free days.
NOTES
 Session IV: Papers 9-16 Trauma Systems
Paper 13: 3:35-3:55 pm
TRAUMA SYSTEM RESOURCE PRESERVATION: A SIMPLE SCENE
TRIAGE TOOL CAN REDUCE HELICOPTER EMERGENCY MEDICAL
SERVICES (HEMS OVER-UTILIZATION IN A STATE TRAUMA SYSTEM
Pascal Udekwu* MBA,MD, Sharon Schiro Ph.D., Eric Toschlog* MD, Meagan Farrell
Ph.D., Sarah McIntyre RN, BSN, James Winslow III, MD, North Carolina Trauma
Registry
Invited Discussant: Mark Gestring, MD

Introduction:The intent of HEMS is to improve outcomes in time sensitive injuries.

Although some studies have purported that HEMS improves survival, they are hampered
by limitations in methodology, and doubts remain regarding HEMS value. Given the cost
and risk associated with HEMS, the purpose of our study was to identify scene variables
that mitigate inappropriate utilization.
Methods:A state trauma registry was utilized to identify patients admitted 2013-2015.
Logistic regression was utilized to evaluate the influence of scene variables on mortality
in ground (GEMS) and HEMS cohorts. Variables were analyzed across the
GEMS/HEMS cohorts to assess impact on mortality. Time sensitive injuries (TSI) to the
trauma center were defined as Emergency Department (ED) death, dispositon to
Operating Room, Invasive Procedure or Intensive Care Unit.
Results: The statewide registry accrued 94,558 patients in the period 2013-2015 of whom
71,623 were transported by GEMS and 9,180 by HEMS. 60.7% of GEMS responses were
from the scene as were 50.8% of HEMS responses. Percentage of HEMS scene responses
increased from 7.28% to 9.29% from 1987-1993 data previously published, total scene
flights increased from 192/year to 1,554/year. Age, gender, injury type, systolic blood
pressure, pulse rate and Glasgow Coma Scale Score – Motor (GCS-M) were all
significantly associated with mortality as continuous variables. To create a triage model
differentiating normal from abnormal information; age, systolic blood pressure,
respiratory rate, pulse and injury types were converted to categorical variables where age
16.0 - 69.9, blunt injury type, systolic blood pressure greater than 90, pulse 60 – 120,
respiratory rate 10 – 30 and GCS-M 6 were considered normal. Logistic regression
demonstrated a strong association between these variables and mortality and
incorporating all variables allowed for creation of a low risk category. HEMS and GEMS
patients were separated into two groups based on these characteristics and compared.
Mortality rate (MR) was low and not significantly different in HEMS and GEMS low risk
patients (1.5% vs 1.3%). MR was highest in the HEMS patients not selected as low risk
(12.6%). 1815 or 38.9% of all HEMS patients fell into our low risk model. 1134 (62.5%)
of low risk patients were perceived not to have TSI and 15.1% were discharged home.
The dominant HEMS vendor reported an average revenue of $12,875.00 per patient in
2016. Estimated revenue for all low risk patients in this study was $23.4 million, for low
risk patients without TSI, $14.6 million and for patients discharged home from the
emergency department, $3.5 million. For comparison, ground ambulance costs were
calculated at $224 - $2204 per ride for Medicare beneficiaries in 2016, using the high
estimate cost for transporting all low risk patients by ground would cost $4.0 million,
with a savings of $19.4 million.
Conclusion: Adult patients with normal vital signs and GCS-M 6 can be safely
transported by GEMS with no increase in mortality from HEMS. Implementing a simple
“no fly” decision tool could significantly reduce inappropriate HEMS utilization and
reduce trauma system costs.
NOTES
 Session IV: Papers 9-16 Trauma Systems
Paper 14: 3:55-4:15 pm
LONG-TERM OUTCOMES AFTER SINGLE-LOOK TRAUMA LAPAROTOMY: A
LARGE POPULATION-BASED STUDY
Jason Bowie MD, Jayraan Badiee MPH, Richard Y. Calvo Ph.D., Michael J. Sise* MD,
Lyndsey E. Wessels MD, William J. Butler MD, Casey E. Dunne MPH, C. Beth Sise MSN,
Vishal Bansal* MD, Scripps Mercy Hospital Trauma Service
Invited Discussant: Adil Haider, MD, MPH
Introduction: Although damage control laparotomy for trauma has been studied in detail, the
outcomes for patients who require only one operation, single-look trauma laparotomy (SLTL)
have not been well studied. We evaluated the association between SLTL and long-term
outcomes in a large, population-based dataset.
Methods: The California Office of Statewide Planning and Development patient discharge
(OSHPD) database was evaluated for calendar years 2007-2014. Patients with SLTL during
their index admission were identified using ICD-9-CM procedure codes. Diagnosis and
procedure codes were evaluated for specific abdominal organ injuries, surgical interventions,
and perioperative complications. Subsequent acute care admissions were evaluated for post-
operative complications and additional related surgical interventions. Variations among clinical
characteristics, injuries, surgical interventions, and outcomes were evaluated by mechanism of
injury.
Results: There were 2,113 trauma patients with SLTL at their index admission; 712 (33.7%)
had at least one readmission to an acute care facility with a median time to first readmission of
110 days. Penetrating mechanism was more common than blunt (61% vs. 39%). Blunt-injured
patients had a significantly higher ISS compared to those patients with a penetrating injury
(median 18 vs. 9, p < 0.0001), and significantly higher rate of mortality during their index
admission (27% vs. 4%, p < 0.0001). Over 30% of SLTL patients requiring readmission had a
surgery-related complication, with the most common primary reason for readmission being
bowel obstruction (17.7%), followed by infection (9%) and incisional hernia (7%). There was
no significant difference between the mechanism of injury and the development of surgery-
related complications requiring readmission.
Conclusion: Patients requiring trauma laparotomy continue to have high rates of post-injury
morbidity and mortality with over 10% of SLTL patients developing a surgery-related
complication requiring readmission. This rate did not vary by mechanism. All SLTL patients
who survive to discharge are at significant risk for subsequent complications and should be
educated on the signs and symptoms of these common complications. Further investigation
should focus on the factors associated with the development of these complications.
NOTES
 Session IV: Papers 9-16 Trauma Systems
Paper 15: 4:15-4:35 pm
PRE-HOSPITAL TOURNIQUET USE IN PENETRATING EXTREMITY
TRAUMA: DECREASED BLOOD
TRANSFUSIONS AND LIMB COMPLICATIONS
Alison A. Smith MD,Ph.D., Joana Ochoa MD, Sunnie Wong BA, Sydney Beatty BS, Jeff
Elder MD, Chrissy Guidry DO, Patrick McGrew MD, Juan Duchesne* MD, Rebecca
Schroll MD, Tulane School of Medicine
Invited Discussant: Joseph DuBose, MD
Introduction: Despite increasing popularity of pre-hospital tourniquet use in civilians, few
studies have evaluated the efficacy and safety of tourniquet use. Furthermore, previous
studies in civilian populations have focused on blunt trauma patients. The objective of this
study was to determine if pre-hospital tourniquet use in patients with major penetrating
trauma is associated with differences in outcomes compared to a matched control group.
Methods: An eight-year retrospective analysis of adult patients with penetrating major
extremity trauma amenable to tourniquet use
(major vascular trauma, traumatic amputation and near-amputation) was performed at a
level I trauma center. Patients with pre-hospital tourniquet placement (TQ) were identified
and compared to a matched group of patients without tourniquets (N-TQ) and similar limb
injury severity. Univariate analysis was used to compare outcomes in the groups.
Results: A total of 204 patients were included with 127 (62.3%) in the TQ group. No
differences in patient demographics or injury severity existed between the two groups.
Average time from tourniquet application to arrival in the ED was 22.5 +1.3 minutes.
Patients in the TQ group had higher average SBP on arrival in the ED (120.4+1.7 vs. 112.3
+2.1, p=0.0033). TQ group required less total PRBCs (2.0+0.1 vs. 9.3+0.6, p<0.0001) and
FFP (1.4+0.08 vs. 6.2+0.4, p<0.0001). Tourniquets were not associated with nerve palsy
(p=0.33) or secondary infection (p=0.43). Fasciotomy was significantly higher in the N-TQ
group (12.6% vs. 31.4%, p=0.0008) as was limb amputation (0.8% vs. 9.1%, p=0.005).
Table 1. Outcomes for pre-hospital (TQ) vs. no pre-tourniquet (N-TQ) in patients with
penetrating extremity trauma

Conclusion: This study demonstrated that pre-hospital tourniquets could be safely used to
control bleeding in major extremity penetrating trauma with no increased risk of major
complications. Pre-hospital tourniquet use was also associated with increased SBP on
arrival to the ED, decreased blood product utilization and decreased incidence of limb
related complications, which may lead to improved
long-term outcomes and increased survival in trauma patients.
NOTES
 Session IV: Papers 9-16 Trauma Systems
Paper 16: 4:35-4:55 pm
What is the Best Surgical Management for Duodenal Trauma? A Panamerican Trauma
Society (PTS Multi-CenterTrial
Paula Ferrada* MD, Juan Duchesne* MD, Gustavo Fraga* MD, Elizabeth Benjamin* MD,
Andre Campbell* MD, Aberto Garcia MD, Carlos Morales MD, Bruno Pereira MD, Marcelo
Ribeiro MD, Martha Quiodettis* MD, Gregory Peck DO, Juan C. Salamea MD, Vitor Kruger
MD, Rao Ivatury* MD, Thomas Scalea* MD, Virginia Commonwealth University
Invited Discussant: Gregory Jurkovich, MD
Introduction: The operative management of duodenal trauma remains controversial. We
hypothesized that a simplified operative approach could be safe and effective.
Methods: We conducted an international multicenter study, involving 11 PTS centers, and
retrospectively reviewed duodenal injury management from January 2007 to December of 2016.
Using the Research Electronic Data Capture (REDCap) tool, data on demographics, mechanism,
blood loss, operative time, and associated injuries were collected. Outcomes included post-
operative intra-abdominal sepsis, leak, need for unplanned surgery, length of stay, renal failure,
and mortality.
Results: We collected data in 372 patients with duodenal injuries. Penetrating trauma was the
most common mechanism (blunt 21%, penetrating 79%). 253 patients (68%) had associated
injuries, included colon (128), pancreas (107), stomach (90), kidney (44), IVC (34), Liver (24),
spleen (23), bile ducts (20), diaphragm (14), and aorta (3). Patients were badly injured with a
mean ISS of 22, mean abdominal AIS of 4, and AAST grade 3 duodenal injuries. However,
primary repair alone was the most common operative strategy (80%). Overall mortality was
24%. On a univariate analysis, mortality was associated with male gender, lower admission
systolic blood pressure, preop transfusion, higher blood loss, longer operative time, renal failure
needing dialysis, higher ISS, and associated pancreatic injury. On logistic regression, higher
ISS, associated pancreatic injury, renal failure requiring dialysis and need for pre-op transfusion
remained significant predictors of mortality. There was no statistical difference regarding ISS,
operative time, pre-op transfusion requirement and mortality between various surgical
techniques. Sepsis, leaks, and need for unplanned surgeries were statistically lower in patients
that had 1 primary repair.( Table 1)
Conclusions: Need for pre-op transfusion, associated pancreatic injuries and renal failure
predict mortality after duodenal injury. Primary repair alone is common and safe, even for
complex injuries ß ( Table abbreviations: PADT=repair with antegrade duodenal tube, or with a
duodenostomy tube, with or without jenunostomy, PEwGJ =pyloric exclusion with
gastrojejunostomy, PE without GE = Pyloric exclusion without gastrojejunostomy)
NOTES
 Session VI: WTC Panel II
Traumatic Coagulopathy: Is It All the Same?
Wednesday, September 26, 2018, 5:00 PM-6:00 PM
Location: Seaport D-H, Second Level (Searport Tower)
Moderators: Yasuhiro Otomo, MD, PhD &
Mitchell Cohen, MD
Panelists:
Radko Komadina, MD, European Bleeding Guidelines
DIC or Trauma-Induced Coagulopathy
Bryan Cotton, MD, Western Perspective
Yasuhiro Otomo, MD, PhD, Eastern Perspective
 Session VII: AAST/WTC Posters / Exhibit Hall Opening
Wednesday, September 26, 2018, 6:00 PM-7:30 PM
Location: Harbor D-I, Second Level, (Harbor Tower)
Session I Poster #1-10
Trauma Systems
Brian Eastridge, MD and Joseph Rappold MD
Session II Poster #11-20
Neurotrauma
Jose Pascual, MD and William Chiu, MD
Session III Poster #21-30
REBOA
Erik Barquist, MD and Joseph DuBose, MD
Session IV Poster #31-40
Pediatric Trauma
Richard Falcone, MD and David Nortrica, MD
Session V Poster #41-50
Imaging
Stephen Barnes, MD and Jay Doucet, MD, MSc
Session VI Poster #51-60
Critical Care
Pauline Park, MD and Christopher Michetti, MD
Session VII Poster #61-70
Military
Joseph Galante, MD and Jennifer Gurney, MD
Session VIII Poster #71-80
Coagulation
Grant Bochicchio, MD and Jay Johannigman, MD
Session IX Poster #81-90
Geriatric
Anne Mosenthal, MD and Jay Yelon, DO
Session X Poster #91-100
Firearm/Prevention
Kimberly Joseph, MD and Keith Clancy, MD, MBA
Session XI Poster #101-110
EGS
Marie Crandall, MD, MPH and Ajai Malhotra, MD
Session XII Poster #111-120
Abdominal Injury
Juan Duchesne, MD and Robert Mackersie, MD
Session XIII Poster #121-130
Outcomes
Daniel Holena, MD and Michel Aboutanos, MD
Session XIV Poster #131-140
Torso Trauma
David Livingston, MD and David Blake, MD, MPH
WTC Session I Poster #141-150
International Trauma Care
Peep Talving, MD and Walter Biffl, MD
WTC Session II Poster #151-160
Challenging Cases from Around the World
Marcelo Ribeiro, MD and Mayur Narayan, MD, MPH, MBA
 Session IX: Plenary Session - Papers #17-20
Thursday, September 27, 2018, 7:30 AM-8:50 AM
Location: Seaport D-H, Second Level (Seaport Tower)
Moderator: R. Lawrence Reed, MD
Recorder: Preston MIller, MD
 Session VIII: Papers 17-20
Paper 17: 7:30-7:50 am
THE ECONOMIC FOOTPRINT OF ACUTE CARE SURGERY IN THE UNITED
STATES: IMPLICATIONS FOR SYSTEMS DEVELOPMENT
Lisa M. Knowlton MD,MPH, Joseph Minei* MBA,MD, Andrew Bernard* MD,
Kimberly A. Davis* MBA,MD, Jay Doucet* MD, Adil Haider* MD,MPH, Tres Scherer*
MBA,MD, Kristan L. Staudenmayer* MD, MS AAST Healthcare Economics Committee
Invited Discussant: David Hoyt, MD

Introduction: Acute Care Surgery (ACS) comprises Trauma, Surgical Critical Care, and
Emergency General Surgery (EGS), encompassing both operative and non-operative
conditions. Acute care surgeons also serve as primary admitting as well as consulting
physicians for ACS conditions. While the burden of EGS and trauma have been
separately considered, the global footprint of ACS has not been fully characterized.
Furthermore, the makeup of ACS practice has anecdotally been described as varying
between institutions. We sought to characterize the scope of influence of ACS-related
conditions, even when these are not the primary reasons for admission. We hypothesized
that ACS patients comprise a substantial portion of the U.S. inpatient population. We
further hypothesized that the ratio of trauma and EGS differs substantially across
organizations, reflecting the variability among ACS practices.

Methods: We queried the National Inpatient Sample (NIS), a nationally representative

database for inpatient hospitalizations. These most recent data include inpatient
admissions from January to September 2015. In order to capture all adult ACS patients,
we included adult admissions with any ICD-9-CM diagnosis of trauma or an ICD-9-CM
diagnosis for one of the 16 AAST-defined EGS conditions. Weighted patient data are
presented to provide national estimates.

Results: Of the 29.7 million adult patients

admitted to U.S. hospitals, approximately
4.7 million (14%) patients had an ACS
diagnosis over the 9-month study period.
ACS patients accounted for $70.3 billion
dollars, or 20% of total U.S. inpatient costs
($357 billion). EGS comprised the greatest
proportion of the ACS population (3.4
million, or 72%). When comparing ACS to
non-ACS inpatient populations, ACS patients had higher rates of healthcare utilization
with longer lengths of stay (6.0 vs. 4.5 days, p<0.001), and higher mean costs ($15,057
vs. $11,464, p<0.001. Of all inpatients undergoing an operative procedure, 27% were
patients with an ACS diagnosis. We next determined the mix of ACS patients at
hospitals. Overall, 3,153 (70%) of U.S. hospitals cared for both trauma and EGS patients.
The median percent of ACS to all patients in these centers was 16% (IQR: 13%-18%).
The percent of all ACS patients who were trauma patients was similarly variable, with a
median of 28% (IQR: 21%-33%).

Conclusion: Acute care surgery patients comprise 14% of the inpatient population, but
20% of total inpatient costs in the U.S. Furthermore, almost 1/3 of all inpatient operations
were for an ACS diagnosis. These findings suggest that ACS conditions have the ability
to significantly impact local and national healthcare and costs. Furthermore, as EGS
comprises 70%-80% of ACS activities, the greatest impact may lie in improvements in
care for the EGS population.
NOTES
 Session VIII: Papers 17-20
Paper 18: 7:50-8:10 am
HOW MUCH GREEN DOES IT TAKE TO BE ORANGE? DETERMINING COST
ASSOCIATED WITH TRAUMA CENTER READINESS
Dennis W. Ashley* MD, Robert F. Mullins MD, Christopher J. Dente* MD, Laura E.
Garlow MHA, BSN, TCRN, RN, Regina S. Medeiros DNP, RN, Elizabeth V. Atkins MSN,
RN, Gina Solomon RN, CCRN, TCRN, Dena Abston Colville H. Ferdinand MD, Medical
Center of Central Georgia/Mercer University School of Medicine
Invited Discussant: John Fildes, MD
Introduction: Readiness Costs are real expenses incurred by trauma centers to maintain
essential infrastructure to provide emergent services on a 24/7 basis. Although the
components for readiness are well described in the American College of Surgeon’s
Resources for Optimal Care of the Injured Patient (Orange Book), the cost associated with
each component or regulation is not well defined nor accounted for by standard hospital
accounting systems. The purpose of this study was to quantify the cost of trauma center
readiness based on these criteria.
Methods: The state trauma commission in conjunction with trauma medical directors,
program managers, and financial officers of each trauma center standardized definitions for
each component of trauma center readiness cost and developed a survey tool for reporting
them. Components of readiness were grouped into four main categories: Administrative
Support, Clinical Medical Staff Support, In-House Operating Room Services, and
Education/Outreach with appropriate subcategories. To verify consistent cost reporting, an
independent financial auditor reviewed all data. Trauma centers noted to be outliers were
further reviewed to validate significant variances. The survey was completed by all
designated Level I and Level II trauma centers (n=16) statewide based on calendar year
2016 data.
Results: Average annual readiness cost is $10,078,506 for a Level I trauma center and
$4,925,103 for a Level II center. The clinical medical staff was the costliest component
representing 55% of costs for Level I trauma centers and 65% for Level II’s. Although
education/outreach is mandated, Level I and II trauma centers only spend on average
approximately $100,000 annually on this category (1-2%) demonstrating a relative lack of
resources in this area.

Conclusion: This study defines the cost associated with each component or regulation of
readiness as defined in the American College of Surgeons Resources for Optimal Care of
the Injured Patient manual. Average readiness cost for a Level I trauma center is
$10,078,506 and $4,925,103 for a Level II. The significant cost of trauma center readiness
highlights the need for additional trauma center funding to meet the requirements set forth
by the American College of Surgeons.
NOTES
 Session VIII: Papers 17-20
Paper 19: 8:10-8:30 am
MEDICAID EXPANSION ASSOCIATED WITH INCREASED ACCESS TO
POST-DISCHARGE CARE FOR TRAUMA PATIENTS
John W. Scott MD,MPH, Pooja U. Neiman MD, MPA, Tarsicio Uribe-Leitz MD,MPH, Cheryl K.
Zogg MSPH, MHS, Ali Salim* MD, Adil H. Haider* MD,MPH, Center For Surgery And Public
Health, Department Of Surgery, Brigham And Womens Hospital
Invited Discussant: Andrew Bernard, MD
Introduction: UUninsured trauma patients have worse outcomes and worse access to critically
important post-discharge care. As a part of the Affordable Care Act (ACA), 33 states expanded
Medicaid eligibility criteria in 2014, in an effort to increase access to insurance coverage. The
national impact of Medicaid expansion on trauma patients is not well understood.

Methods: We used the 2011-2016 National Trauma Data Bank (NTDB) to evaluate for changes in
insurance coverage among 18-64 year-old trauma patients admitted to level 1 and level 2 trauma
centers. Our pre-/post- Medicaid expansion models used 2011-2013 as the pre-policy period,
2015-2016 as the post-policy period, and 2014 as a washout year. To evaluate for policy-associated
changes in inpatient mortality and discharge disposition, we used a risk-adjusted before-and-after
linear model, which accounted for year-to-year variation in patient demographics, injury
characteristics, and facility traits.

Results: We identified 1,961,102 patients meeting inclusion criteria over the six-year study period.
Prior to 2014 there were no significant year-to-year changes in rates of private insurance, Medicaid,
and no insurance coverage (p>0.05). The table shows pre- and post-policy insurance coverage rates.
Notably, rates of private insurance were unchanged. The uninsured rate, however, fell by over a
quarter. This change was driven by the >50% relative increase in Medicaid coverage post-expansion.
No changes in inpatient mortality were observed (p=0.314). However, a significant increase in the
rate of discharge to a facility, an increase in discharge with home services, and a decrease in the rate
of discharge to home was noted (p<0.001 for all).

Conclusion: Although only two-thirds of states have elected to expand Medicaid eligibility through
the ACA, this policy has led to a large reduction in the uninsured rate among US trauma patients.
The observed increases in insurance coverage were not associated with changes in mortality, but were
associated with greater access to post-discharge care—critically important to patient recovery and
wellbeing after trauma.
NOTES
 Session VIII: Papers 17-20
Paper 20: 8:30-8:50 am
ASSOCIATION BETWEEN LENGTH OF STAY AND ACCESS TO
POST-ACUTE CARE: CHALLENGES WITH DISPOSITION AND THE
IMPACT ON INPATIENT COSTS
Lisa M. Knowlton MD,MPH, Mary T. Hawn MD,MPH, Lakshika Tennakoon MD,
Charlotte Rajasingh David A. Spain* MD, Kristan L. Staudenmayer* MD, MS Stanford
University Medical Center
Invited Discussant: Jay Doucet, MD, MSc

Introduction: Hospital costs are partly a function of length of stay (LOS), which can be
impacted by the local availability of post-acute care resources, particularly for injured
patients who require rehabilitation. We hypothesized that LOS for trauma patients
destined for rehabilitation would be highly variable based on insurance type and hospitals
from which they are discharged.

Methods: We used the 2014-2015 National Inpatient Sample, a nationally representative

database for inpatient hospitalizations. We included all admissions with a primary
diagnosis of trauma (ICD-9CM codes), ages of 18 to 64, insured, and whose discharge
disposition was rehabilitation. We then excluded hospitals that did not treat trauma
patients with all three insurance types or those who did not discharge patients to
rehabilitation to ensure accurate between-group comparisons. The primary outcome was
inpatient LOS; secondary outcome was cost of admission. Centers were divided into
quartiles by mean LOS. Univariate and multivariate analyses were performed. Weighted
patient data provide national estimates.

Results: Of the 727,900 trauma patients

meeting inclusion criteria, 156,305
(22%) treated in 152 hospitals were
discharged to rehabilitation and included
in the analysis. Mean LOS for trauma
patients discharged to rehabilitation was
5.3 days (SD 0.1), with significant
variability based upon insurance type
(Medicaid vs. Private vs. Medicare: 13.3 vs. 10.4 vs. 7.4 days, p<0.001). The mean LOS
between quartiles was found to be 4.6 vs. 5.9 vs. 7.4 vs. 12.0 days (p<0.001). When
comparing LOS by insurance type within each hospital group, there were significant
differences. The top 25% of hospitals had a marginal variation in LOS based on insurance
types (Medicaid vs. Private vs. Medicare: 4.7 vs. 4.4 vs. 4.6 days, p<0.001). In contrast,
the bottom quartile had mean LOS that varied by as much as one week (16.1 vs. 11.6 vs.
8.9 days, p<0.001). Multivariate regression controlling for patient characteristics and
injury factors revealed that Medicaid patients overall spent an additional 2.8 inpatient
days compared to other insurance types (95% CI: 2.21-3.31, p<0.001). However, there
was no difference in Medicaid patient LOS in the top 25%, when controlling for known
confounders. The average daily cost of inpatient care was $3,500 (SD $132). Applying
this average, Medicaid patients at hospitals without easy access to rehabilitation
experience additional inpatient costs of $16,800.

Conclusion: Prolonged LOS is likely a function of access to post-acute facilities, which is

largely out of the hands of trauma centers. These findings highlight that efficiencies in
care are magnified by availability of post-acute beds, suggesting that increased
availability of post-acute care might help to reduce length of stay.
NOTES
 Session X: AAST Panel
How Should We Position Acute Care Surgery in the Landscape
of Healthcare Economics
Thursday, September 27, 2018, 8:50 AM-10:00 AM
Location: Seaport D-H, Second Level (Seaport Tower)
Moderator: Joseph Minei, MD, MBA &
Kristan Staudenmayer, MD, MSc
Panelists:
Joseph Minei, MD, MBA
Kristan Staudenmayer, MD, MSc
Jay Doucet, MD, MSc
Andrew Bernard, MD
 Session XI: Scholarship Presentations
By 2017-2018 AAST Research Scholarship Recipients
Thursday September 27, 2018, 10:00 AM - 10:30 AM
Location: Seaport D-H, Second Level (Seaport Tower)
Presiding: Michael Rotondo, MD, AAST President

10:00 AM-10:08 AM Vanessa Nomellini, MD, PhD

Univerisry of Cincinnati Medical Center
Cincinnati, Ohio
AAST Research & Education Fund (2017-2018)
Project Title: “The Role of Sphingosine in the
Susceptibility of Pneumonia in the Elderly”

10:10 AM-10:18 AM Jonathan Wisler, MD, MS

The Ohio State University Medical Center
Columbus, Ohio
AAST Research & Education Fund (2017-2018)
Project Title: “Target Aberrant Epigenetic Events in
the Treatment of Sepsis”

10:20 AM-10:28 AM Samuel Pierce Mandell, MD, MPH

University of Washington, Harborview Medical
Center
Seattle, Washington
AAST Research & Education Fund (2017-2018)
Project Title: “Optical Coherence Tomography to
Predict Burn Wound Healing”
 Thursday, September 27, 2018
10:45 AM-11:15 AM
Session XII: Master Surgeon Lecture I
Location: Seaport D-H, Second Level (Seaport Tower)

A Long Run for A Short Slide:

A Story of Trauma Care in New Zealand
Ian Civil, MD
Director
Trauma Services
Auckland City Hospital
Professor of Surgery
University of Auckland
Auckland, New Zealand
 Session XIII: WTC Panel III
Pro/Con Debate
Thursday, September, 27, 2018
11:15 AM-12:15 PM
Location:
Moderators: Ari Leppaniemi, MD, PhD &
Zsolt Balogh, MD, PhD
Panelist:
Laparoscopy in Trauma
Selman Uranus, MD, Pro
David Feliciano, MD, Con
Grade IV Spenic Injury with Blush
Andrew Pietzman, MD, Splenectomy
Federico Coccolini, MD, Angio Embolization
 Lunch - Grab & Go in Exhibit Hall
Location: Harbor D-I, Second Level (Harbor Tower)

Session XIV: WTC Power Sessions

12:30-1:30 pm
WTC PS1 How Good Can Highly Performing Trauma Systems Get?
Location: Coronado A, Fourth Level (Harbor Tower)

WTC PS2 Understanding EAST Practice Management Guidelines and Practical Tips to
Adapting at your Hospital
Location: Coronado DE, Fourth Level (Harbor Tower)

WTC PS3 DCIR and REBOA

Coronado B, Fourth Level (Harbor Tower)

WTC PS4 ACS Education Program in Asia (JSACS/KSACS)

Location: Golden Hill, Third Level (Seaport Tower)

WTC PS5 Hot Topics in Trauma

Location: Harbor B, Second Level (Harbor Tower)

WTC PS6 How to Organize Trauma Care in the ICU

Location: Harbor A, Second Level (Harbor Tower)

WTC PS7 Did You Think You Had Seen It All? Unusual Cases and Discussions with Panel
(You May Be On It)
Location: Harbor C, Second Level (Harbor Tower)

WTC PS8 Short Clinical Updates by the Experts: What is New and Important
Location: Seaport A-C, Second Level (Seaport Tower)

WTC PS 9 The Impact of Big Data and Artificial Intelligence on Trauma Care
Location: Hillcrest, Third Level (Seaport Tower)
 Session XVA: Parallel Session - Papers #21-29
Thursday, September 27, 2018, 1:30 PM-4:30 PM
Location: Seaport D-H, Second Level (Seaport Tower)
Moderator: Deborah Kuhls, MD
Recorder: Christine Cocanour, MD
 Session XVA: Papers 21-29: Parallel Session
Paper 21: 1:30-1:50 pm
PEDIATRIC FIREARM INCIDENTS: IT’S TIME TO DECREASE ON-SCENE
MORTALITY
Jessica Friedman MD, Kareem Ibraheem MD, Marcus Hoof BS, Alison Smith
MD,Ph.D., Riley Santiago BS, Rebecca Schroll MD, Chrissy Guidry DO, Juan
Duchesne* MD, Patrick McGrew MD, Tulane University
Invited Discussant: L.R. Tres Scherer, MD

Introduction: Previous epidemiological studies on pediatric firearm mortality have

focused on overall mortality rather than on-scene mortality. In spite of advances in trauma
care the number of potentially preventable deaths remains high. This study utilized the
National Emergency Medical Services Information Systems (NEMSIS) database to
characterize patterns of on-scene mortality in order to identify patients who may benefit
from changes to pre-hospital care practices.
Methods: The NEMSIS database was searched for all pediatric firearm incidents from
1/1/10 - 12/31/15. Information regarding age; gender; intention of incident; wound
location, categorized as compressible for extremities and non-compressible for chest,
abdomen and back; location of incident, and on-scene mortality was collected and an
analysis of variance done. A linear regression model was used to calculate independent
predictors of mortality.
Results: A total of 16808 patients were identified, with an on-scene mortality of 6.1%. A
large percentage of mortalities suffered cardiac arrest on-scene; 72.6% of these were
prior to EMS arrival, which carried a significantly higher mortality rate than cardiac
arrest after EMS arrival. No difference was seen in anatomic location of injury in those
who arrested before and after EMS arrival. Compressible injuries were most common
at and carried the lowest mortality. Non-compressible injuries together accounted for
25.8% of injuries and 23.5% of mortalities. The mortality of self-inflicted gunshot
wounds was higher than assault or accidental injury.
Conclusion: To our knowledge, this is the largest study of on-scene mortality in pediatric
firearm injury to date. Cardiac arrest prior to EMS arrival was a considerable source of
on-scene mortality; significantly more of these patients died than those who arrested after
EMS arrival. The mortality of compressible injuries is very low, implying that use of
compression and tourniquets have been effective in stopping life-threatening extremity
bleeding. Based on our analysis, non-compressible injury mortality could be decreased
with education of bystanders and more aggressive on-scene intervention. Consideration
of modification of the current Traumatic Cardiac Arrest Treatment Algorithm with more
aggressive on-scene interventions could be of benefit. Through the evaluation of on-scene
mortality specifically, this study offers insight into potential areas of focus to improve
pre-hospital care of pediatric gunshot victims.
NOTES
 Session XVA: Papers 21-29: Parallel Session
Paper 22: 1:50-2:10 pm
EFFECT OF MASS SHOOTINGS ON GUN SALES – A 20 YEAR PERSPECTIVE
Rachael A. Callcut* MD, MSPH, Anamaria J. Robles MD, Lucy Z. Kornblith MD,
Rebecca E. Plevin MD, Matthew W. Mell MD, M.S. University of California, San
Francisco
Invited Discussant: Ronald Stewart, MD

Introduction:Granular data on gun sales has been historically difficult to obtain. In 2016,
California (CA) made monthly data from 1996-2015 publically available. Control charts
are a well-accepted method to analyze how a process changes over time in response to
non-routine events. We utilized this technique to study the impact of US mass shootings
on CA gun sales.
Methods:Monthly gun sales were provided by the CA Department of Justice and
monthly fatalities from the CDC Wonder Death Certificate Registry. Mass shooting
events were obtained from after-action reports, news media, and court proceedings. Time
ordered data were analyzed with control charts (with upper/lower control limits [UCL,
LCL]) using QiMacros.
Results:9,917,811 individual gun sales occurred in CA with a median monthly rate of
41,324 (range 20,057 – 132,903). A median 263 people lost their lives monthly from
firearms (124 homicide, 128 suicide), totaling 53,975 fatalities from 1999-2015. 12/20
current deadliest mass shootings occurred during this study period with 42% from
2012-15. Also, 36 school shootings occurred during the study (mean 5 deaths, range
0-33; 6 injuries, range 0-23) with 33% in 2012-15 at rate of 4 events/year vs. 1.4
events/year in the 17 prior years (p<0.05). Sales were generally consistent from
1996-2011 (except post Columbine [Col]). Starting in 2012 (Figure), sales exceeded
the predicted UCL every single month. Before 2012, there was no statistically significant
effect of mass shootings on sales (except briefly following Col); however, since Sandy
Hook (SH; 2012), a statistically significant proportional spike in sales occurred in the
months immediately following every single deadliest mass-shooting event. Every year
since SH, CA has strengthened gun laws in response to mass shootings yet sales have
risen immediately preceding enforcement of these laws each January.
Conclusion:Gun sales are more frequent since 2012, with additional spikes following
both mass shootings and legislative changes enacted in response to these shootings.
NOTES
 Session XVA: Papers 21-29: Parallel Session
Paper 23: 2:10-2:30 pm
INCREASINGLY PERMISSIVE FIREARM CARRY LEGISLATION IS ASSOCIATED WITH
INCREASED FIREARM-RELATED SUICIDE RATES
Matthew C. Hernandez MD, Mark E. Hamill* MD, Kent Bailey Ph.D., Martin D. Zielinski* MD, Henry J.
Schiller* MD, Mayo Clinic - Rochester
Invited Discussant: Zara Cooper, MD, MSc
Introduction: Public opinion about where legal gun owners may carry firearms is rapidly changing. State
legislation for firearm concealed carry applications and permits (no issue, may issue, shall issue and
unrestricted) have been associated with mixed results and inconclusive findings. We aimed to determine
whether incremental liberalization of the concealed carry state legislation was associated with firearm related
suicides.
Methods: The US Department of Justice Uniform Crime Reporting program (UCR) and Centers for Disease
Control (CDC) and Prevention Web-based Injury Statistics Qurery and Reporting System databases were
combined into a dataset for 51 states (including D. C.) between 1986 and 2015. Data was collected on rates
of all suicide, firearm-related suicide, unemployment, and poverty by state and year throughout this time
period. State level data on concealed carry legislation was recorded for every study year, broken down into
four broad categories – no carry, may issue, shall issue and no restrictions. Data were analyzed using general
multiple linear regression models with Y being the log of the event rate, and main effects for each unique
state and year. Legislative status was analyzed both as a scale (no issue, may issue, shall issue and
unrestricted), and as a binary variable non-restrictive (shall issue or no restrictions) versus restrictive (may
issue or no carry). To allow for non-independence among the serial observations within a state, an
autocorrelation structure was implemented in PROC GENMOD using generalized estimating equations
(GEE) estimates for standard errors. The standard errors thus obtained were approximately twice as large as
those assuming independence.
Results: During the study period, there was liberalization of concealed-carry legislation and is demonstrated
by the distributions in Table 1 which also summarizes the temporal changes in the means of the two suicide
rates. The mean (±SD) all suicide rate was 13.9 (±3.6) per 100,000 and firearm-related suicide rate was 7.6
(±3.1) per 100,000. The study period poverty rates in 1986 and 2015 were 13.9% (±4.4%) and 13.1%
(±5.1%) respectively. The unemployment rates were 6.9% (±2.2%) and 5.1% (±1.1%) during 1986 and 2015.
Table 2 shows regression results for both suicide event rates. The variables state and year accounted for 90%
of the variation in log (rates). After adjusting for state, year, poverty, and unemployment rate, there was a
marginally significant and a significant association of “non-restrictive” legislation on the rates of total and
firearm-related suicides resulting in 3.23% +/- 1.70% (p=0.057) and 4.67% +/- 2.21% (p=0.035) increase,
respectively. The effect of permission level (no issue, may issue, shall issue and unrestricted) on these two
rates also demonstrated marginally significant increasing trends per level increase, 2.54% +/- 1.33%
(p=0.057) and 3.21% +/- 1.64% (p=0.050), respectively.
Conclusions: At the macro-level, we demonstrate a relationship between expanding concealed carry firearm
applications/permits with suicides committed using a firearm. The study findings were indicative of an
increasing relationship with the degree of state firearm concealed-carry legislation liberalization (no carry,
may issue, shall issue, and unrestricted). In order to mitigate potential loss of life, suicide prevention efforts
might benefit from identifying potential gun owners with known at-risk features.
NOTES
 Session XVA: Papers 21-29: Parallel Session
Paper 24: 2:30-2:50 pm
COMPARISON OF MALE AND FEMALE VICTIMS OF INTIMATE PARTNER HOMICIDE IN
OPPOSITE SEX RELATIONSHIPS - AN ANALYSIS OF THE NATIONAL VIOLENT DEATH
REPORTING SYSTEM
Catherine G. Velopulos MD, MHS, Heather Carmichael MD, Tanya L. Zakrison* MD,MPH, Marie Crandall*
MD,MPH, University Of Colorado
Invited Discussant: D'Andrea Joseph, MD

Introduction: Intimate partner violence (IPV) is a growing public health issue, affecting at least 1 in 4 women and
1 in 9 men. Because of their greater numbers, most of the literature focuses on female victims; however, men are at
significant risk. A recent multi-center trial on universal screening for IPV in trauma patients showed similar rates of
positive screen between men and women. Few studies have explored the bidirectional violence in opposite sex
relationships, with this dynamic likely underappreciated. Our goal was to estimate prevalence of and risk factors for
the most severe manifestation of IPV, intimate partner homicide (IPH).
Methods: This is a retrospective review of the National Violent Death Reporting System (NVDRS) from
2003-2015, a CDC database comprised of surveillance data from 40 states, the District of Columbia, and Puerto
Rico. Deaths were coded as IPV if the primary relationship between the suspect and victim fell into the following
categories: spouse, ex-spouse, girlfriend/boyfriend, and ex-girlfriend/ex-boyfriend, collapsed here into “current
partner” or “ex-partner.” Cases were selected where the victim and suspect were of the opposite sex.
Results: While women were far more likely than men to be the victims in these pairings (79.3%), men constituted a
significant proportion at 20.7%. Although current partners were more likely to perpetrate in either situation, male
victims were significantly less likely to be murdered by an ex-partner. Black men were the only group to constitute a
larger proportion of male victims, with 45.4% of male victims compared to 28.4% of female victims (p<0.001).
Women were more likely than men to use a stabbing instrument, although firearms were still the most common
means for each group. Alcohol was present in a higher proportion of male victims, and a preceding argument was
more common. Male victims were also more likely to have been killed in self-defense as determined by detective
reports, to have been a perpetrator of violence in the past month, and to survive long enough to be taken to a hospital.
Male perpetrators frequently had a history of abusing the victim prior to the homicide (22.1%), and they attempted
suicide at the time of the homicide in nearly half of the cases (46.5%), being successful in over one third (35%).
There was no difference in mental illness diagnosis between men and women, with a low reported rate at around
7%.

Conclusion: Although affected at different rates, homicide due to IPV is a significant public health crisis for both
men and women, with women and Black men at particular risk. Firearms are the most commonly used weapon for
homicide in both genders, and mental illness is not a common risk factor. A staggering proportion of these
homicides involve suicide of the perpetrator, suggesting that each potential incident has two victims to target for
prevention and intervention. Interventional programs to prevent such bidirectional mortality are urgently needed.
NOTES
 Session XVA: Papers 21-29: Parallel Session
Paper 25: 2:50-3:10 pm
ESSENTIAL VIOLENCE INTERVENTION RESOURCES: AN UPDATE USING
THE NATIONAL NETWORK OF HOSPITAL-BASED VIOLENCE
INTERVENTION PROGRAM'S MULTI-INSTITUTIONAL DATABASE
Catherine J. Juillard* MD,MPH, Adaobi Nwabuo MPH, Kim Gajewski BS, Theodore
Corbin MD, Jessika Brock BS, Rachel Myers BS, Joel Fein MD,MPH, Anne Marks
MPH, Marlene Melzer-Lange MD, Thea James MD, Ariana Perry Ph.D., Rochelle A.
Dicker* MD, University of California, Los Angeles
Invited Discussant: Amy Goldberg, MD

Introduction: Violence is a public health issue. Hospital-based violence intervention

programs (HVIPs) have been shown to reduce violent re-injury in single institutional
studies through mentorship and mitigating risks associated with violent injury. The ACS
Committee on Trauma has interest in research into best practices to build HVIPs. The
purpose of this study is to identify the most commonly accessed risk reduction resources
in HVIPs by examining our multi-center database. We examine success rates in
addressing needs.
Methods: The National Network of Hospital-Based Violence Intervention
Programs database contains demographic, injury and resource utilization information
about clients enrolled in five HVIPs from 2014 to 2017. Resource utilization patterns for
HVIP services (education, employment, housing, legal services, mental health, and
“other” )were determined based on groups of interest (client age, gender, race and
ethnicity). Analysis was done using frequency tables to determine proportions of services
identified across the various groups of interest. Chi-squared and Fisher’s exact tests were
used to probe for dependence among the groups of interest.
Results: Of the 1647 clients enrolled, the majority were male (80%) and African
American (AA)(86%); the median age of enrolled clients was 23 years. Overall, the most
common needs identified were mental health (21%) and housing (20%). AA had a higher
rate of identifying mental health and employment as a need compared to other
ethnicities(p=0.00). White clients identified housing more frequently(p=0.00). Success in
meeting employment needs was greatest in the AA population(p=0.00) whereas meeting
the housing need was most successful in the white population(p=0.00). Needs were
frequently identified and met in the Latino population but not at a significantly higher
rate than other groups. Need by age catagory is listed below.
Conclusion: Early HVIP outcomes include successful enrollment of the target population
and capacity to identify and address risk factors associated with violent injury. Our
first-ever multi-center HVIP database identifies client needs (risk reduction targets) and
ability to address needs. Our results represent a national lens on detailed differences
amongst our programs' client risk factors and current abilty to address them. This insight
is a critical step in identifying risk reduction activity that could ultimately reduce
re-injury. As we add clients and programs to this database, future work will focus on the
long term outcome of recidivism. These results can help flegling HVIPs prioritize
services offered to demographic groups reflected in their often resource contrained
communities.
NOTES
 Session XVA: Papers 21-29: Parallel Session
Paper 26: 3:10-3:30 pm
THE GATE PROGRAM: A MULTIDISCIPLINARY INTERVENTION TO
REDUCE JUVENILE GUN VIOLENCE RECIDIVISM AND POTENTIAL
MODEL FOR NATIONWIDE EXPANSION
Hahn Soe-Lin MD, MS, Joyce Kaufman MD, Anjali Sarver University Of Miami Miller
School Of Medicine
Invited Discussant: Rochelle Dicker, MD

Introduction: Youth firearm violence has been a growing and increasingly recognized
problem in the United States. Several programs across the country aimed at reducing
recurrent gun violence in this vulnerable population have published recidivism rates of
40-50%. For the past 18 years, the GATE Program in Miami-Dade County has provided
a unique multidisciplinary intervention encompassing 100 hours of violence education,
behavioral modification, and social mentoring. The present study defines its outcomes as
a national model for youth firearm recidivism prevention.
Methods: Retrospective analysis of the Florida Juvenile Justice Department records from
2008-2016 defined a group of youths convicted of firearm related crimes and
subsequently enrolled in the GATE program. Cohorts were grouped by youth who
demonstrated successful completion of the GATE program versus those who only
partially completed the program. At 6 and 12 months after release, records were cross
referenced with the Florida Department of Justice criminal record system to prospectively
capture rates of new all-comer and firearm specific criminal charges.
Results: 215 youth were included in the prospectively followed cohort at 6 months and
163 youth followed at 12 months after release. The 6-month recidivism rate for any
criminal charge was 20.1% for program completers versus 32.9% for those who did not
complete the program (p=0.047). When excluding unarmed criminal offenses, the
recidivism rate dropped to 10.1% versus 22.4% respectively (p=0.008). At 12 months,
all-comers recidivism was 33.6% for the GATE program completion cohort vs 50% for
the incomplete cohort (p=0.045). When excluding unarmed offences, the recidivism rates
were 18.6% vs 33.9% respectively (p=0.035).
Conclusion: The GATE program has one of the lowest recidivism rates in the country
both for firearm and non-firearm related criminal offenses. Its demonstrated efficacy
should serve as the basis for expansion to other local and state jurisdictions with the aim
of decreasing juvenile gun violence across the country.
NOTES
 Session XVA: Papers 21-29: Parallel Session
Paper 27: 3:30-3:50 pm

USE OF SHOTSPOTTER TM DETECTION TECHNOLOGY DECREASES

TRANSPORT TIME FOR PATIENTS SUSTAINING GUNSHOT WOUNDS
Deviney Rattigan MD, Joshua P. Hazelton* DO, Michael Dalton MD, John Gaughan
Ph.D., John S. Thompson Kyle Remick* MD, John Porter* MD, Anna Goldenberg DO,
Cooper University Hospital
Invited Discussant: Alexander Eastman, MD

Introduction: Shorter transport times in patients sustaining penetrating trauma have been
shown to be independently associated with improved survival. Literature has also
demonstrated that these patients, when transported by police vehicle vs. EMS, have
decreased transport times to a trauma center. The purpose of this study was to delineate if
a gunshot detection technology called ShotSpotter TM , which triangulates the location of
gunshots and alerts nearby police officers to respond, expedited patient transport to
definitive care by increasing the likelihood of police response and patient transport.

Methods: All fatal shooting incidents, with the victim being at least 18 years old, which
occurred within the city of Camden, New Jersey from 2006-2016 were retrospectively
reviewed. Demographic, geographic, transportation, and field intervention data were
collected from medical and police records. We compared fatal shootings where the
ShotSpotter TM technology was activated versus fatal shootings where
ShotSpotter TM was not activated. Incidents which involved children, occurred outside
the city limits, or where complete data was not available were excluded from the study.

Results: There were 105 fatal shooting incidents which met all of the inclusion criteria,
with 24 (23%) resulting in the activation of the ShotSpotter TM system. Victims involved
in shootings where the ShotSpotterTM system was activated were more likely to arrive at
the trauma center for evaluation and potential resuscitation, rather than being pronounced
dead in the field (55% vs 37%;p=0.037). Furthermore, these victims were more likely to
be transported by police rather than by EMS (29% vs 6%;p=0.005) and less likely to have
field interventions performed (25% vs 60 %;p=0.003). There was no difference in the
trauma bay resuscitation efforts or number of procedures performed (intubation, ED
thoracotomy, central venous access, chest tube, resuscitative medications) between the
two groups (all p>0.05). When corrected for distance from the location of incident to the
trauma center, we found that transport time in ShotSpotterTM activation incidents was
significantly shorter (12min vs 16min;p=0.021).

Conclusion: The use of ShotSpotterTM technology significantly decreased transport time

of victims sustaining gunshot wounds, likely due to the increased police transport of
these patients rather than waiting for EMS. This resulted in fewer pre-hospital procedures
and fewer victims being pronounced dead at the scene. While our data only includes
incidents which were fatal, future work will involve studying the use
of ShotSpotter TM technology and its potential to improve survival.
NOTES
 Session XVA: Papers 21-29: Parallel Session
Paper 28: 3:50-4:10 pm
OBSERVING PNEUMOTHORACES: THE 35 MM RULE IS SAFE FOR BOTH
BLUNT AND PENETRATING CHEST TRAUMA
Savo Bou Zein Eddine MD, Kelly A. Boyle MD, Christopher M. Dodgion MBA,MD,
MSPH, Christopher S. Davis MD,MPH, Travis P. Webb* MD, MHPE, Jeremy S. Juern*
MD, David J. Milia MD, Thomas W. Carver* MD, Marshall A. Beckman MD, Panna A.
Codner* MD, Todd A. Neideen* MD, Colleen Trevino Ph.D.,RN, FNP, Marc A. De
Moya* MD, Medical College of Wisconsin
Invited Discussant: Andrew Kirkpatrick, MD

Introduction: As more pneumothoraxes (PTX) are being identified on chest computed

tomography (CT), the appropriate management of observation versus tube thoracostomy
(TT) remains debatable. We hypothesize that PTX measuring ≤35 mm on chest CT can be
safely observed in both penetrating and blunt trauma mechanisms.
Methods: A retrospective review was conducted of all patients diagnosed with PTX by
chest CT between January 2011 and December 2016. Patients were excluded if they had
an associated hemothorax, had immediate tube thoracostomy (TT), or if a TT was done
before the initial chest CT. PTXs were quantified by measuring the radial distance
between the parietal and visceral pleura/mediastinum in a line perpendicular to the chest
wall on axial imaging. Based on previous work, a cut-off of 35 mm on the initial CT was
used to dichotomize the groups. Failure of observation was defined as the need for a
delayed TT during the first week. A univariate analysis was performed to identify
predictors of failure in both groups and multivariate analysis was constructed to assess the
independent impact of PTX measurement on the failure of observation while controlling
for demographics and chest injuries.
Results: Of the 1767 chest trauma patients screened, 832 (47%) had PTX and of those
meeting inclusion criteria, 353 (92%) were successfully observed until discharge. Of those
successfully observed, 335 (95%) patients had a measurement ≤ 35 mm. The negative
predictive value for 35 mm as a cutoff was 94.9% to predict successful observation. In the
univariant analyses, age (p= 0.011), rib fractures (p= 0.012), and size of the pneumothorax
(≤35 mm or >35 mm) (p< 0.0001) were associated with failed observation. In multivariate
analysis, PTX measuring ≤35 mm was an independent predictor of successful observation
[OR 0.153, (95% CI: 0.061, 0.384)] for both blunt and penetrating trauma.
Conclusion: A 35 mm cut-off is safe as a general guide with only 5% of stable patients
failing initial observation regardless of mechanism.
NOTES
 Session XVA: Papers 21-29: Parallel Session
Paper 29: 4:10-4:30 pm
TO SLEEP, PERCHANCE TO DREAM: ACUTE AND CHRONIC SLEEP
DEPRIVATION IN ACUTE CARE SURGEONS
Jamie J. Coleman* MD, Ben L. Zarzaur* MD,MPH, Lava Timsina MPH,Ph.D., Grace S.
Rozycki* MBA,MD, David V. Feliciano* MD, Indiana Univesity School of Medicine
Invited Discussant: Nicole Stassen, MD

Introduction: Acute and chronic sleep deprivation are significantly associated with
depressive symptoms and felt to be contributors to the development of burnout. In-house
call (IHC) inherently includes frequent periods of disrupted sleep and is common
amongst acute care surgeons. The relationship between IHC and sleep
deprivation amongst acute care surgeons has not been previously studied. The goal of this
study was to determine prevalence and patterns of sleep deprivation in acute care
surgeons.
Methods: A prospective study of acute care surgeons with IHC responsibilities from two
ACS verified Level I trauma centers was performed. Participants wore a Whoop! fitness
and sleep tracking device continuously over a 3-month period. Data collected included
age, gender, schedule of IHC, hours and pattern of each sleep stage (light, slow wave, and
REM), and total hours of sleep. Sleep patterns were also analyzed for each night
excluding IHC and categorized as normal, acute sleep deprivation (ASD), or chronic
sleep deprivation (CSD). Test of proportions for categorical and t-tests for continuous
variables were done to identify any difference between pre and post-call days at 0.05
level of significance.
Results: A total of 1421 nights, including 230 nights of IHC, were recorded amongst 17
acute care surgeons (35.3% female; ages 37-65, mean of 45.5 years). Excluding nights of
IHC, the average amount of sleep was 6.54 hours with 70% of nights with abnormal
amounts of REM sleep, 56.4% with abnormal amounts of slow wave sleep, and 64.8%
with sleep patterns categorized as ASD or CSD. The average amount of sleep was
significantly higher
than baseline on post-call
day 1 (6.96 hours,
p=0.0016), but decreased
significantly on post-call
day 2 (6.33 hours,
p=0.0006) and returned to
baseline on post-call day 3
(6.65 hours,
p=0.274). Normal sleep
patterns were significantly
more prevalent on post-call
day 3 as compared to
post-call day 2 (p=0.045).
Conclusions: Sleep patterns consistent with ASD and CSD are common amongst acute
care surgeons and worsen on post-call day 2. Baseline sleep patterns were not recovered
until post-call day 3. Future study in a multicenter setting is needed to identify factors
which impact physiologic recovery after IHC and further elucidate the relationship
between sleep deprivation and burnout.
NOTES
 Session XVB: Basic Science - Papers #30-38
Thursday, September 27, 2018, 1:30 PM-4:30 PM
Location: Seaport A-C, Second Level (Seaport Tower)
Moderator: Suresh Agarwal, MD
Recorder: Marc deMoya, MD
 Session XVB: Papers 30-38: Basic Science
Paper 30: 1:30-1:50 pm
DOES A LUNG INFECTION AFTER BRAIN INJURY WORSEN EARLY BRAIN
INFLAMMATION AND SUBSEQUENT NEUROLOGICAL RECOVERY?
Christina L. Jacovides MD, Syed M. Ahmed MD, Yujin Suto MD,Ph.D., Andrew J. Paris
MD, Ryan Leone Maura T. Weber BA, Victoria E. Johnson Ph.D., MBChB, Melpo
Christofidou-Solomidou Ph.D., Lewis J. Kaplan* MD, Douglas H. Smith MD, Daniel N.
Holena MD, MSCE, C W. Schwab* MD, Jose L. Pascual* MD,Ph.D., University of
Pennsylvania
Invited Discussant: Deborah Stein, MD, MPH

Introduction: Respiratory complications after traumatic brain injury (TBI) worsen

mortality and neurologic outcomes. How pulmonary infection influences active cerebral
leukocyte (LEU)-mediated inflammation and resultant neurologic recovery is unknown.
We hypothesized that an infection-relevant inflammatory lung insult after TBI increases
penumbral LEU trafficking and worsens neurological recovery.
Methods: CD1 male mice underwent either sham craniotomy or severe TBI (controlled
cortical impact – CCI: velocity=6m/sec, depth=1.0mm) ± intratracheal
lipopolysaccharide (LPS – low: 0.3mg/kg in 0.02ml saline, high: 2mg/kg in 0.1ml saline).
Randomization defined 4 groups (Sham, CCI, CCI+LPS low, CCI+LPS high, n=6/each).
Neurological recovery (Garcia Neurological Test (GNT), max score=18) was assessed
twice daily. Forty-eight hours after CCI, pial microscopy assessed in vivo cerebral
circulating LEUs and bronchoalveolar lavage fluid was sampled for total LEU count. We
used Kruskal-Wallis test with Bonferroni correction to determine intergroup differences
(p<0.05).
Results: Animals exposed to high dose LPS following CCI demonstrated the greatest in
vivo cerebral leukocyte adherence (Fig A) (p=0.016) and were significantly more
neurologically impaired than sham animals at all post-injury time periods (Fig B)
(p<0.05). While cerebral LEU rolling was similar across groups, alveolar LEU
sequestration was greatest in LPS-exposed brain-injured animals (p<0.05).
Conclusion: An endotoxin-induced inflammatory lung insult after TBI focuses cerebral
LEU trafficking to injured brain and is associated with impaired neurological
recovery. LEU sequestration offers a mechanism to explain clinically relevant outcomes
after TBI.
NOTES
 Session XVB: Papers 30-38: Basic Science
Paper 31: 1:50-2:10 pm
ELECTROPORATION-MEDIATED LUNG GENE TRANSFER OF HUMAN
FELINE SARCOMA RELATED (FER TYROSINE-KINASE MOBILIZES
TOLL-LIKE RECEPTOR-4 GRANULO-MONOCYTES AND IMPROVES
SURVIVAL IN MURINE MODEL OF PSEUDOMONAS AERUGINOSA
PNEUMONIA
David Machado-Aranda MD, Vladislav Dolgachev Ph.D., Matthew J. Delano*
MD,Ph.D., MV Suresh Ph.D., Boya Zhang BS, Samatha Swamy Sanjay Balijepalli Lynn
Frydrych MD, Mark R. Hemmila* MD, Krishnan Raghavendran* MD, University of
Michigan
Invited Discussant: James Hoth, MD

Introduction: Infection from Pseudomonas aeruginosa is a leading cause of death

among trauma patients. The increasing incidence of Colistin and Carbapenem-resistant
strains has been compelled the WHO to declare Pseudomonas a threat to global health. As
an innovative strategy, restoring and stimulating our immune system by using short-term
gene therapy, could be of potential therapeutic value. A recent genome-wide association
study showed that Feline Sarcoma Related (FER) a non-receptor protein tyrosine kinase
of the Fes/fps family as protective in patients (including trauma) with sepsis. In proof of
concept, we have shown that non-viral electroporation-mediated (EP) delivery of
FER gene, can improve survival in murine models of primary and secondary Klebsiella
pneumonia (PNA). We asked if this same benefit could be achieved against highly
virulent Pseudomonas.
Methods: C57/BL6 female mice received 108 CFU of Pseudomonas clinical isolate
via hypo pharyngeal drop injection into lungs. At 1 h, a 100 μg dose of naked plasmid
encoding the human FER gene - was given by similar technique. After waiting several
breaths; 8 square wave pulses were delivered at 200 V/cm strength; 10 ms duration and 1
s apart using a BTX ECM 830 generator with electrodes under each forelimb. Survival
curves were recorded. In parallel, animals were euthanized at 24 h. The trachea was
cannulated and a Bronchial-alveolar lavage (BAL) was obtained. Flow cytometry, ELISA
and Taqman were used to characterize BAL cells and cytokines in supernatant. Naive and
infected sham-EP were used as controls. A p value of < 0.05, in Log-rank testing (for
KM curves) and one-way ANOVA (for all other data) was considered significant (N=10).
Results: Clinical isolate of Pseudomonas aeruginosa was highly virulent, showing
significant lung damage at 48 hours. Nevertheless, EP-mediated delivery of FER gene
improved 5-day survival (40% vs 10%, p < 0.05). At 24-h post-infection, FER treatment
increased total cells in BAL by 2.5 fold (p = 0.013). Flow cytometry and cytospin slides
showed a majority of cells belonging to Granulo-monocytic lineage, with Toll-like
receptor-4 (TLR-4), a major pattern recognition molecule receptor against
Gram-negatives, as a predominant surface marker. Additionally electroporation of FER
showed higher levels of cytokines TNFα , IL-1β , IL-6 and KC in BAL, supporting a
heightened response against Pseudomonas infection.
Conclusion: Though showing modest results in contrast to previously reported success
against Klebsiella infection, EP mediated gene delivery of human FER gene was able to
improve survival in a primary murine model of Pseudomonas pneumonia. This beneficial
effect appears to be mediated by robust recruitment and enhanced mobilization of
TLR-4-sensitized innate inflammatory cells into alveolar spaces and therefore adapted to
fight off Gram-negative infections with possible acceleration of clearance of bacteria
from the lung. This provides a promising avenue of research against multidrug resistant
nosocomial organisms in trauma.
NOTES
 Session XVB: Papers 30-38: Basic Science
Paper 32: 2:10-2:30 pm
RED BLOOD CELL STORAGE AND ADHESION TO VASCULAR ENDOTHELIUM UNDER NORMAL
OR STRESS CONDITIONS: AN IN VITRO MICROFLUIDIC STUDY
Lawrence Diebel* MD, David M. Liberati MS Wayne State University
Invited Discussant: Rosemary Kozar, MD, PhD

Introduction: Observational studies have identified an association between duration of red blood cell (RBC) storage
and adverse outcomes in trauma. Hemorrhagic shock (HS) leads to impaired tissue perfusion which is associated
with endothelial cell (EC) injury and glycocalyx (GC) shedding. Adhesion of stored RBC to the vacular endothelium
has been shown to lead to impaired perfusion in the microcirculation and contribute to organ failure and poor
outcome following HS. The role of either or both of the EC and RBC glycocalyx in this process is unknown and
was studied in a in vitro model.

Methods: Human umbilical vein endothelial cells (HUVEC) wer plated in a microfluidic device system (MDS)
under perfusion for 72 hrs. to allow EC confluence and GC maturation. RBC obtained from human volunteers (fresh)
or RBC obtained from the blood bank (< 14 day storage or < 21 day storage) at 1.5% suspension were added to the
perfusate at increasing flow rates. In some experiments the HS microenvironment was simulated by
hypoxia-reoxygenation (HR) + epinephrine (epi) during the perfusion experiments. EC and RBC glycocalyx were
measured using fluorescein labeled wheat germ agglutinin and image analysis with a fluorescent microscope. RBC
adhesion to the EC in the MDS under constant flow was determined by microscopy with progressively increasing
shear rate to index RBC adherence strength.
Results:

EC glycocalyx thickness was 41.2 ± 6.8 nm for the control and was reduced to 13.9 ± 5.1 nm in the HUVEC + HR
+ epi group (p<0.05). A significant fraction of the RBC adherent to the EC surface at low shear stress remained
attached as the shear stress was sequentially increased to 5.0 dyne/cm2, indicating firm adherence, especially in the
“old” RBC + HUVEC + HR +epi group.

Conclusion: RBC storage duration and EC exposed to "shock conditions" decrease the glycocalyx layer of each
entity.. These data may help explain some of the remaining discrepancies in the clinical studies regarding the effect
of RBC storage duration in the trauma population. Our data suggest that GC degradation is a component of the RBC
storage lesion. Transfusion of RBC, based on the status of the RBC and EC glycocalyx may guide future strategies
in trauma. Additionally the MDS platform may offer a high throughput modality to study emerging therapies for the
endotheliopathy of trauma.
NOTES
 Session XVB: Papers 30-38: Basic Science
Paper 33: 2:30-2:50 pm
TRANEXAMIC ACID SUPPRESSES THE RELEASE OF MITOCHONDRIAL
DAMPS AND REDUCES LUNG INFLAMMATION IN A MURINE BURN
MODEL
Damien W. Carter MD, Igor Prudovsky Ph.D., Doreen Kacer BS, Tee Soul BS, Monica
Palmieri RN, Robert Kramer MD, Joseph Rappold* MD, Maine Medical Center
Invited Discussant: Carl Hauser, MD

Introduction: Severe burn injuries are known to initiate a profound systemic

inflammatory response (SIRS) that may lead to burn shock and other SIRS related
complications. Damage associated molecular patterns (DAMPs) are important early
signaling molecules that initiate SIRS after burn injury. Mitochondrial DAMPs
(mtDAMPs) – such as mitochondrial DNA (mtDNA) - are thought to be the most critical
of these early signaling molecules. Previous work in a rodent model has shown that
application of a topical immune modulator (P38 MAPK inhibitor) applied directly to the
burn wound decreases cytokine expression, reduces pulmonary inflammation and edema.
Our group has demonstrated that tranexamic acid (TXA) – in addition to its use as an
anti-fibrinolytic – has anti-inflammatory in vitro effects. We hypothesized that
administration of TXA after burn injury would attenuate mtDAMP release and reduce
lung inflammation.
Methods: C57/BL6 male mice were subjected to a 40% TBSA scald burn by immersion
in an 80°C water bath. Sham animals underwent the same procedure in room temperature
water. All animals were resuscitated according to the Parkland formula (3cc x %TBSA x
Weight [Kg]) by intraperitoneal injection (IP). One treatment group received the topical
application of 1mM solution of p38 MAPK inhibitor after burn injury. The other
treatment group received an IP administration of TXA (10 mg TXA per 25 g weight
mouse) after burn injury. Animals were sacrificed at 4 or 8 hours. Plasma was collected
by cardiac puncture. MtDNA levels in plasma were determined by qPCR. Lungs were
harvested, formalin fixed and paraffin embedded. Sections of lungs were deparaffinized
and stained for Mac1 antigen to detect macrophages. Numbers of macrophages per a
standard square unit of lung section were calculated.
Results: Topical p38 MAPK inhibitor significantly attenuated mtDNA release while
TXA trended toward a significant reduction in mtDNA release (p≤ 0.13). Both TXA and
the topical p38 MAPK inhibitor significantly reduced lung inflammation as represented
by decreased macrophage infiltration.

Conclusion:
Both p38 MAPK inhibitor and TXA demonstrated the ability to attenuate burn induced
DAMP release and lung inflammation. Beyond its role as an anti-fibrinolytic, TXA may
have significant anti-inflammatory effects pertinent to burn resuscitation. Further study is
required; however, TXA may be a useful adjunct in burn resuscitation and other
non-hemorrhagic shock states.
NOTES
 Session XVB: Papers 30-38: Basic Science
Paper 34: 2:50-3:10 pm
ENDOTHELIAL CELL DYSFUNCTION DURING ANOXIA-REOXYGENATION
IS ASSOCIATED WITH A DECREASE IN ATP LEVELS, REARRANGEMENT
IN LIPID BILAYER PHOSPHATIDYLSERINE ASYMMETRY, AND AN
INCREASE IN ENDOTHELIAL CELL PERMEABILITY
Javid Sadjadi* MD, Aaron M. Strumwasser MD, Gregory Victorino* MD, University of
California San Francisco - East Bay
Invited Discussant: Timothy Pritts, MD

Introduction: Normanlly, phosphatidylserine (PS) is confined to the inner layer of the

cell membrane (CM) and the maintenance of this PS asymmetry is an energy-dependent
process. During times of stress PS is exteriorized on the CM. Because cellular stress is
often accompanied by decreased energy levels and maintaining PS asymmetry is an
energy-dependent process, cellular stress associated with decreased energy levels may
be associated with PS exteriorization that ultimately leads to endothelial cell (EC)
dysfunction and increased permeability. Anoxia-Reoxygenation (A-R) is associated with
decreased adenosine triphosphate (ATP) levels, increased PS exteriorization on cells, and
increased EC permeability.
Methods: : The effect on ATP levels of A-R was measured with cultured human
umbilical vein endothelial cells (HUVECs). After exposure to anoxia or A-R, ATP levels
were measured using a standard colorimetric assay from: 1) Controls , 2) Cells that
underwent 45 minutes of anoxia, and 3) Cells that underwent anoxia followed by
reoxygenation. To measure the effect of A-R on PS exteriorization, bovine pulmonary
artery endothelial cells (BPAECs) and HUVECs underwent the A-R treatment as above.
Cells were then incubated with annexin which binds to exposed CM PS, but not internal
or unexposed PS. annexin fluorescence was read at 680nm. Next we were interested in
the effect of A-R on total cell PS quantity, not just exteriorized PS. A-R was induced as
described in BPAEC and HUVEC monolayers which were then treated with detergent to
open the CM, thereby allowing annexin intracellular access and the ability to measure
total PS. Finally, to measure EC permeability, monolayers of BPAECs and HUVECs
were formed and confirmed by measuring resistance to confirm tight junction integrity.
A-R was induced as described. The apical side of the cells was treated with either PBS
(controls) or PBS with biotinylated-bovine serum albumen (BSA), while the basolateral
surface contained normal medium. To measure the amount of leaked BSA, solution from
the basolateral compartment underwent color reaction.
Results: ATP levels in HUVECs decreased 27% from baseline after 45 minutes of
anoxia and decreased further from baseline by 63% after 45 minutes of anoxia followed
by 240 minutes of reoxygenation (p<0.02). Exteriorized PS doulbed as compared to
controls in both BPAECs (p<0.01), and HUVECs (p<0.01). We also found that during
A-R, the total amount of cellular PS increased almost 2-fold in BPAECs (p<0.01), and
nearly 3-fold in HUVECs (p<0.01). This finding that total PS changed 2-fold after A-R
suggests that not only is there a change in distribution of PS from the inner to the outer
CM, but there may also be an increase in the amount of PS inside the cell, either on the
inner CM or within cytosol. Finally, compared to controls, A-R increased monolayer
permeability 12-fold in BPAECs (p<0.01), and by 37% in HUVECs (p<0.01).
Conclusion: Taken together, these data support the idea that EC dysfunction during A-R
is associated with: 1) a decrease in ATP levels, 2) PS exposure to the outer CM, 3) an
increase in total cellular PS levels, and 4) an increase in monolayer permeability . These
data strengthen the notion that PS arrangement in CMs play a critical role in the
endothelial dysfunction during cellular stress and may hold the key to potential novel
therapies for hemorrhagic shock and ischemia reperfusion injury.
NOTES
 Session XVB: Papers 30-38: Basic Science
Paper 35: 3:10-3:30 pm
SELECTIVE AORTIC ARCH PERFUSION WITH FRESH WHOLE BLOOD OR
HBOC-201 EFFECTIVELY REVERSES HEMORRHAGE-INDUCED
TRAUMATIC CARDIAC ARREST IN A LETHAL MODEL OF
NON-COMPRESSIBLE TORSO HEMORRHAGE
Heather E. Hoops MD, James E. Manning MD, Todd L. Graham BS, Belinda H.
McCully Ph.D., Shane L. McCurdy BS, James D. Ross Ph.D., Oregon Health & Science
University
Invited Discussant: Samuel Tisherman, MD

Introduction: Hemorrhage-induced traumatic cardiac arrest (HiTCA) has a dismal

survival rate. Previous studies demonstrated selective aortic arch perfusion (SAAP) with
fresh whole blood (FWB) improved the rate of return of spontaneous circulation (ROSC)
after HiTCA, compared to REBOA and CPR. Hemoglobin-based oxygen carriers, such
as HBOC-201, may alleviate the logistical constraints of using FWB in a prehospital
setting. It is unknown whether SAAP with HBOC-201 is equivalent in efficacy to FWB,
whether conversion from SAAP to Extracorporeal Life Support (ECLS) is feasible, and
whether physiologic derangement after HiTCA treated with SAAP therapy is reversible.
Methods: Twenty-six swine (79 ± 4kg) were anesthetized and underwent HiTCA which
was induced via a grade V liver injury and controlled hemorrhage. Following 3 minutes
of arrest, swine were randomly allocated to resuscitation using SAAP with either FWB (n
= 12) or HBOC-201 (n = 14). After SAAP was initiated, animals were monitored for a
20-minute pre-hospital period prior to a 40-minute damage control surgery and
resuscitation phase, followed by 260 minutes of critical care. Primary outcomes included
rate of ROSC, survival, conversion to ECLS, and correction of physiology.
Results: Baseline physiologic measurements were similar between groups. ROSC was
achieved in 100% (12/12) of the FWB animals and 86% (12/14) of the HBOC-201
animals (p = 0.483). Survival (t = 320 min) was 92% (11/12) in the FWB group and 67%
(8/12) in the HBOC-201 group (p = 0.120), with 2 exclusions in the HBOC-201 group
due to equipment failure. Conversion to ECLS was successful in 100% of both groups.
Following hemorrhage, SAAP with HBOC-201 restored carotid flow (CF) to baseline
levels at t=20min (p=0.302) and the end of the experiment (p=0.302), which was not seen
with FWB (p=0.020, p=0.004). Lactate peaked at 80 minutes after arrest in both groups,
and significantly improved by end of experiment in the HBOC-201 group (p = 0.001) but
not the FWB group (p = 0.104).

Conclusion: SAAP is effective in eliciting ROSC after HiTCA in a swine model, using
either fresh whole blood or HBOC-201. It is feasible to transition from SAAP to ECLS
after definitive hemorrhage control, resulting in overall survival greater that 66% in both
groups. The physiologic derangements were severe but reversible, with a carotid flow
and lactate levels returning to baseline levels by endo of experiment in the HBOC-201
group, but not the FWB group.
NOTES
 Session XVB: Papers 30-38: Basic Science
Paper 36: 3:30-3:50 pm
DOES BLOOD TRANSFUSION PRESERVE THE GUT MICROBIOME (GM AFTER
TRAUMA? A PROSPECTIVE, CLINICAL STUDY IN SEVERELY INJURED PATIENTS
Susannah E. Nicholson MD, MSCI, Taylor R. Johnson BS, David M. Burmeister Ph.D., Yi Zou
Ph.D., Zhao Lai Ph.D., Shannon Scroggins MS, Mark DeRosa Rachelle B. Jonas RN, Daniel R.
Merrill BS, Caroline Zhu Larry M. Newton MS, Ronald M. Stewart* MD, Martin G. Schwacha
Ph.D., Donald H. Jenkins* MD, Brian J. Eastridge* MD, University of Texas Health Science Center
at San Antonio
Invited Discussant: Mitchell Cohen, MD
Introduction: Traumatic injury can lead to a compromised intestinal epithelial barrier, inflammation
and immune derangements. The impact of trauma on gut microbial composition is unknown.
Alterations in the GM of the critically injured may contribute to infectious or inflammatory
complications and influence clinical outcomes. Our objective was to determine if the gut microbiome
is altered in severely injured patients and to characterize the microbial composition of the gut over
time following trauma.
Methods: We conducted a prospective, observational study in adult patients (n=72) sustaining severe
injury admitted to a Level I Trauma Center. Healthy volunteers (n=13) were also enrolled. Fecal
specimens were collected on admission to the Emergency Department (ED) and at 1, 3, and 7 days
(±2 days) following injury. Microbial DNA was isolated from all fecal samples for 16s rRNA
sequencing. GM analysis and taxonomic classification were performed using the QIIME Greengenes
16S rRNA gene database (OTUs; 97% similarity). Alpha and β-diversity were estimated using the
observed species metrics.
Results: Characteristics of our study population are shown in Table 1. The GM profile was altered
within 30 minutes following injury compared to healthy volunteers (Fig. 1). Patients with an
unchanged GM on admission arrived to the ED faster and were transfused more RBCs than those
with an altered GM (Table 1). The GM composition among the majority of subjects returned to a
profile similar to the healthy volunteers by Day 5. Despite the observed trends in the β-diversity, the
total number of species was similar between admission and healthy samples but decreased over time
thereafter, signifying loss of α-diversity during hospitalization. Injured patients on admission had a
decreased abundance of traditionally beneficial microbial families compared to healthy controls
(p<0.05). In contrast, an increased abundance in opportunistic families in the injured patients was
noted on admission compared to healthy controls (p< 0.05).
Conclusion: The human GM changes as early as 30 minutes following injury with additional
dysbiosis occurring during the hospital stay. The GM in patients receiving large quantities of RBCs
was preserved on admission suggesting a potential protective effect on microbial profile by reducing
gut ischemia. Ultimately, the GM of trauma patients may provide valuable diagnostic and therapeutic
strategies for the improvement of outcomes post-injury.
NOTES
 Session XVB: Papers 30-38: Basic Science
Paper 37: 3:50-4:10 pm
PRECIOUS CARGO: NEURO-ENTERIC MODULATION OF THE
MESENTERIC LYMPH EXOSOME PAYLOAD AFTER HEMORRHAGIC
SHOCK
Elliot C. Williams MD, Raul Coimbra* MD, Theresa W. Chan MD, Andrew Baird Ph.D.,
Brian Eliceiri Ph.D., Todd W. Costantini* MD, University of California, San Diego
Invited Discussant: Jason Smith, MD

Introduction: Trauma/hemorrhagic shock (T/HS) causes a release of pro-inflammatory

mediators into the mesenteric lymph (ML) that triggers a systemic inflammatory response
and can result in organ failure. Recently we showed that exosomes in post-shock ML are
biologically active mediators of this inflammation, but the specific inflammatory
mediators in post-shock ML exosomes have yet to be characterized. To this end, we
hypothesized that T/HS leads to production of a distinct ML pro-inflammatory exosome
phenotype that could be identified by mass spectrometry analysis of exosome proteins.
We further hypothesized that their regulation by the neuro-enteric axis via the vagus
nerve would modify this pro-inflammatory profile.
Methods: Male rats underwent cannulation of the femoral artery, jugular vein, and ML
duct. T/HS was induced by laparotomy and 60 minutes of HS (mean arterial pressure 35
mm Hg) followed by resuscitation with shed blood and two times shed blood volume of
normal saline. ML was collected for 1 hour before HS (pre-shock) and for two hours
after resuscitation (post-shock). A subset of animals underwent cervical vagus nerve
electrical stimulation (VNS) immediately after the HS phase. Ultra-high-pressure liquid
chromatography with tandem mass spectroscopy (LC-MS/MS) followed by protein
identification and label free quantification was performed on exosomes from the
pre-shock and post-shock phases in the T/HS and T/HS+VNS groups.
Results: Seven hundred and forty-three unique proteins were identified in ML exosomes
from T/HS rats. Thirty-three proteins were found to be statistically significantly
increased in exosomes in the post-shock phase relative to pre-shock (see Figure).
Procollagen type XVIII (Col18a1, 56-fold), Hephaestin (Heph, 42-fold), Laminin C1
(Lamc1, 39-fold), and Thrombospondin 1 (Thbs1, 26-fold) showed the greatest increase
in ML exosomes after T/HS.
Gene Ontology analysis of the
increased proteins revealed
significant functional enrichments
in the “Response to Stress”
biological process in the T/HS
group. Stimulation of the vagus
nerve following injury attenuated
the T/HS-induced inflammatory
phenotype of ML exosomes, with
protein expression similar to
pre-shock and no significant
enrichments in Gene Ontology
analysis.
Conclusion: The protein payload of ML exosomes changes after T/HS with an increase
in proteins involved in the response to stress. Stimulating the neuro-enteric axis alters the
biological activity of ML exosomes by attenuating this change.
NOTES
 Session XVB: Papers 30-38: Basic Science
Paper 38: 4:10-4:30 pm
ACUTE RESUSCITATION WITH POLYETHYLENE GLYCOL-20K: A
THROMBOELASTOGRAPHIC ANALYSIS
Niluka A. Wickramaratne BS,MD, Kristine Kenning MD, Heather Reichstetter LVT, Charles Blocher
MS, Ru Li Ph.D., Michel Aboutanos* MD,MPH, Martin Mangino Ph.D., Virginia Commonwealth
University
Invited Discussant: Jeremy Cannon, MD
Introduction: Polyethylene glycol-20,000Da (PEG-20k) is a synthetic polymer with impermeant and
colloidal properties that is highly effective for resuscitation in animal models of shock. Its proposed
mechanism involves prevention of metabolic swelling by energy independent osmotic water transfer,
moving water out of the cell and into the capillary space. In rodents, PEG-20k increases tolerance to the
shocked state after severe hemorrhage by 6-8 fold compared to controls. However,
thromboelastography (TEG) showed an abnormal hypocoagulable effect on human blood that was
treated ex-vivo with a 10% volume dose of PEG-20k. The objective of this study was to determine the
in-vivo effects of PEG-20k on coagulation and peak plasma levels in a preclinical porcine model of
hemorrhagic shock. We hypothesize that any coagulation effect of PEG-20k will be dependent on the
peak blood levels after resuscitation.
Methods: Anesthetized juvenile Yorkshire pigs underwent femoral vessel cannulation and laparotomy
to simulate soft tissue trauma. They were then hemorrhaged (MAP held 30-40 mmHg) until either the
lactate reached 7 mmol/L, 115 minutes of hemorrhage time had passed, or 50-55% of their estimated
blood volume (EBV) was removed. The pigs then underwent low volume resuscitation (LVR) with
either a 10% PEG-20k solution (100mg/ml) containing a FITC-labelled PEG-20k marker or Lactated
Ringers (LR) as a control (n=5 in each group), both delivered at a volume equal to 10% of the EBV.
Whole blood TEG analysis was performed after the surgery (baseline, BL), after hemorrhage (HS), and
15, 120, and 240 minutes (LVR+15, 120, 240) after resuscitation, if the animals survived that long.
Plasma samples were serially collected after resuscitation and plasma PEG-20k concentration was
determined by fluorescence indicator dilution. Other outcomes included survival time. Of note, all
studies were arbitrarily terminated at 240 minutes due to the acute nature of the experiment.
Results: Pigs given low volume resuscitation with PEG-20k were able to survive 3 times longer than
LR volume controls (p<0.001). This was a marked underestimation because of termination at 240
minutes in the PEG group. Coagulation and platelet function analysis using TEG was limited to the 15
minute post-resuscitation time point in the control group due to lack of survival. Trauma and
hemorrhage induced a slightly hypercoagulable state on individual TEG parameters, R Time, K Time,
Angle, and Maximum Amplitude (MA). However, these normalized after LVR with PEG-20k, but not
LR (Figure). For example, the Coagulation Index (CI), which is a compilation of R, K, Angle, and MA,
rose to an average of 3.3 (normal -3 to 3) after hemorrhage in both groups, but normalized to 0.1 fifteen
minutes after PEG-20k administration. The CI continued to rise to 4.8 fifteen minutes after LVR with
LR alone. The plasma concentration of PEG-20k peaked at an average of 3.58 mg/ml and had a half-
life of 138 minutes. The peak plasma concentration was 3-fold lower than predicted by simple dilution
(10 mg/ml), which is likely responsible for the lack of abnormal TEGs after in-vivo PEG-20k
administration.

Conclusion: These data demonstrate that acute resuscitation with PEG-20k not only improves
tolerance to hypovolemia but also normalizes the initial hypercoagulative state of trauma and shock.
Although PEG-20k may interfere with coagulation and platelet function, when given at an effective
dose for resuscitation, it does not induce a hypocoagulable TEG profile due to much lower in-vivo
plasma concentrations than predicted.
NOTES
 Session XVIII: Coagulation - Papers # 39-44
Friday, September 28, 2018, 7:30 AM-9:30 AM
Location: Seaport D-H, Second Level (Seaport Tower)
Moderator: Martin Schreiber, MD
Recorder: Sharon Henry, MD
 Session XVIII: Papers 39-44: Coagulation
Paper 39: 7:30-7:50 am
MICROVESICLES GENERATED FOLLOWING TRAUMATIC BRAIN INJURY INDUCE PLATELET
DYSFUNCTIONVIA ADP RECEPTOR
Grace E. Martin MD, Amanda Pugh MD, Rose Veile BS, Lou Ann Friend RVT, Amy T. Makley MD, Charles C.
Caldwell Ph.D., Timothy A. Pritts* MD,Ph.D., Michael D. Goodman MD, University of Cincinnati
Invited Discussant: John Holcomb, MD
Introduction: Traumatic brain injury (TBI) can result in an acute coagulopathy including platelet dysfunction that
can contribute to ongoing intracranial hemorrhage. Previous clinical studies have shown ADP-induced platelet
aggregation to be reduced after TBI. In addition, circulating microvesicles are increased following TBI and have been
shown to play a role in post-TBI coagulopathy. We hypothesized that post-TBI microvesicles would affect platelet
aggregation in a murine head injury model.

Methods: Moderate concussive TBI was performed using an established weight-drop method in anesthetized mice.
Sham mice underwent anesthesia without TBI. Whole blood, plasma, microvesicles, and microvesicle-poor plasma
were isolated from blood collected 10 minutes following TBI or sham. Post-TBI plasma, microvesicles, and
microvesicle-poor plasma were mixed separately with whole blood from uninjured mice. Platelet aggregation was
measured with Multiplate impedance platelet aggregometry in response to arachidonic acid and adenosine
diphosphate (ADP). Platelet contribution to maximum clot formation was calculated using the rotational
thromboelastometry extrinsically-activated and fibrin-based extrinsically activated tests. Normal saline was used as a
dilution control. The ADP P2Y 12 receptor inhibitor, R-138727 (100uM, prasugrel active metabolite), was
incubated with plasma and microvesicles from post-TBI mice, and platelet inhibition was again measured. To
confirm P2Y12 presence in post-TBI microvesicles, Western blots were performed and analyzed using densitometry.
Results: Whole blood taken from 10 minute post-TBI mice demonstrated diminished ADP-induced platelet
aggregation compared to sham mice (13.6 ± 2.3 vs. 29.5 ± 5.2 units, p<0.01). When mixed with normal donor blood,
post-TBI plasma induced diminished ADP-induced platelet aggregation compared to sham plasma (16.1 ± 2.3 vs.
24.4 ± 3.5 units, p<0.05). The addition of post-TBI microvesicles to uninjured whole blood similarly reduced ADP-
induced platelet aggregation compared to sham microvesicles (13.8 ± 3.2 vs. 22.0 ± 2.0 units, p<0.05). By contrast,
the addition of microvesicle-poor post-TBI plasma to normal blood did not change ADP-induced platelet aggregation
and was not different compared to sham microvesicle-poor plasma (31.8 ± 3.8 vs. 32.8 ± 2.5 units, p>0.9). No
differences were observed in the ability of arachidonic acid to induce platelet aggregation. Thromboelastometry
demonstrated no difference in the platelet contribution to maximum clot formation after addition of sham and post-
TBI microvesicles. The observed dysfunction in post-TBI ADP platelet aggregation was prevented by the
pretreatment of post-TBI plasma with 100uM R-138727 (46.8 ± 1.5 units, p<0.0001 compared to post-TBI plasma).
Treatment of post-TBI microvesicles with R-138727 resulted in similar findings of improved ADP-induced platelet
aggregation compared to non-treated post-TBI microvesicles (42.8 ± 1.8 units vs. 13.8 ± 3.2 units, p<0.0001).
Inhibition of ADP-induced platelet aggregation was also was mitigated by freezing the post-TBI microvesicles prior
to whole blood treatment (44.0 ± 1.7 units frozen vs. 13.8 ± 3.2 units fresh, p<0.0001). Western blots of post-TBI
microvesicles demonstrated the presence of the ADP P2Y12 receptor.

Conclusion: ADP-induced platelet aggregation is inhibited acutely following TBI in a murine model. This platelet
inhibition is reproduced in normal blood by the introduction of post-TBI plasma and microvesicles. Furthermore,
platelet inhibition is abrogated by post-TBI plasma and microvesicle treatment with an inhibitor of the P2Y12 ADP
receptor. Clinically observed post-TBI platelet dysfunction may therefore be explained by the presence of the ADP
P2Y12 receptor within post-TBI microvesicles and may represent a future therapeutic target for TBI patients.
NOTES
 Session XVIII: Papers 39-44: Coagulation
Paper 40: 7:50-8:10 am
GUIDELINE-BASED CORRECTION OF PLATELET INHIBITION IN TBI PATIENTS
IS ASSOCIATED WITH IMPROVED MORTALITY
Andrew B. Sorah MD, Kyle Cunningham MD, Colleen Karvetski Ph.D., Michael Ekaney Ph.D.,
Rita Brintzenhoff MD, Susan Evans* MD, Carolinas Medical Center
Invited Discussant: Michael Cripps, MD
Introduction: Platelet dysfunction has been demonstrated following traumatic brain injury (TBI)
regardless of the use of platelet inhibitors. The purpose of this study is to determine the efficacy
of a platelet mapping thromboelastography (PM-TEG) based guideline in predicting traumatic
brain injury (TBI) patients who would benefit from platelet transfusion. We hypothesized that
adenosine diphosphate (ADP) and Arachadonic Acid (AA) inhibition in patients with TBI is
associated with increased mortality and can be corrected with platelet transfusion.
Methods: This is a retrospective review of patients admitted to a Level I trauma center from
January 2016 through September 2017 with moderate to severe TBI (msTBI), defined by an
initial GCS ≤13 with intracranial hemorrhage. According to our guideline, patients with msTBI
receive PM-TEG. Those patients who demonstrate platelet dysfunction (either ADP or AA
inhibition ≥60%) receive 1 apheresis pack of platelets followed by repeat PM-TEG, until
inhibition <60% or maximum 3 packs of platelets transfused. Cohorts were defined as patients
without (NPI) and with (PI) platelet inhibition, and subdivided into those whose inhibition
corrected after transfusion (PI-C) versus those whose inhibition did not correct (PI-NC).
Outcome variables (mortality, length of stay (LOS), and venous thromboembolism (VTE) were
compared for all groups. Patient age, APACHE IV Score and ISS were utilized for risk
adjustment.
Results: A total of 240 patients received PM-TEG during the timeframe of the study; NPI n= 85,
PI-NC n= 39, PI-C n= 36. Patients who did not receive f/u PM-TEG result after transfusion were
excluded from analysis n=26. Patients who were inhibited at baseline, but did not receive
platelets (n= 54) were included as a subgroup in the analysis. Platelet inhibition was associated
with increased mortality (PI = 43.2% vs. NPI = 29.4%), with a 1.8x increased likelihood of
mortality after controlling for ISS and age (p=0.05). There was no difference in LOS among
survivors between the inhibited and non-inhibited groups (NPI = 14(8,29) vs. PI=18(12,27);
p=0.48). Among patients with platelet inhibition at baseline, mortality was greater if platelet
transfusion did not result in correction of inhibition (PI-NC = 56.4% vs. PI-C = 22.2%) with an
OR of death = 4.8 after adjusting for age and ISS (p=0.006; 95% CI [1.6,14.4]). In addition, the
subset of patients who were inhibited at baseline but did not receive platelets had a mortality rate
twice that of patients who were transfused and corrected (44.4% vs 22.2%), with an OR of 3.6
[1.3,11.5] after correcting for ISS and age (p=0.02). LOS among survivors and rate of VTE were
not different between these groups.

Conclusion: Platelet inhibition in patients with moderate to severe TBI is associated with
higher mortality and guideline directed correction of platelet inhibition is associated with
improved survival. Additional study of the mechanisms involved in this association is
warranted. A multicenter trial utilizing this guideline would aid in external validation.
NOTES
 Session XVIII: Papers 39-44: Coagulation
Paper 41: 8:10-8:30 am
Platelet Derived Extracellular Vesicles are Equivalent to Platelets with Respect to
Hemostasis and Vascular Permeability
Shibani Pati MD,Ph.D., Byron Miyazawa BS, Daniel R. Potter Ph.D., Ernesto E. Lopez
MD, Amit K. Srivastava Ph.D., Charles E. Wade* Ph.D., Martin A. Schreiber* MD, John
B. Holcomb* MD, University of California, San Francisco
Invited Discussant: Susan Evans, MD

Introduction: Platelet extracellular vesicles (Plt-EVs) have the potential to alleviate the
logistical difficulties associated with platelet transfusion. Plt-EVs are membrane vesicles
(50-1000nm) which are shed from platelets. Plt-EVs can be stored frozen and have
demonstrated hemostatic properties. Circulating platelets, in addition to hemostasis,
function to stabilize the vasculature and inhibit endothelial cell (EC) permeability. We
hypothesized that Plt-EVs would have therapeutic effects on permeability similar to fresh
platelets and plasma (FFP). To investigate this hypothesis we used in vitro and in vivo
models of vascular endothelial compromise and bleeding.
Methods: In vitro: EVs from FFP and platelets were isolated by ultracentrifugation. EVs
were characterized for platelet markers (CD41b and CD62P) by flow cytometry. Human
lung microvascular endothelial cells (HMVEC-L) were utilized for assessment
of endothelial barrier function by changes in trans-EC electrical resistance (TEER). ECs
were treated with Plts (25 X10 3 /ml), Plt-EVs and FFP-EVs (70 μg/ml) and FFP (2%).
EC tight junction breakdown induced by thrombin was assessed by staining for
VE-Cadherin. In vivo: Vascular Permeability: A Miles assay was used to study the
effects of the test groups on permeability induced by VEGF-A in immunodeficient
NOD-SCID mice (n=5 mice/group). Mice were injected with test sample: 200 μl saline,
Plts (3 X108 ), Plt-EVs (30 μg), FFP (200 μl) and FFP-EVs (30 μg). VEGF-A was
injected in the dorsal skin to induce vascular leak of Evan’s blue dye (EBD) which was
quantitatively assessed. Bleeding Model: Tail snip assays in NOD-SCID mice were
conducted with the same test groups (n=5 mice/group). Blood loss was measured.
Statistical significance between groups was determined in all studies via one way
ANOVA post hoc tukey tests.
Results: In vitro: Flow cytometry
confirmed that 90% of the Plt-EVs and
FFP-EVs were of platelet origin. Plts
and Plt-EVs both decreased EC
monolayer permeability and restored EC
tight junctions after thrombin challenge
similar to FFP. Area under the curve
measurements of TEER reveal that Plts
and FFP are potent inhibitors of
permeability and their EVs also decrease permeability (Resistance readings of the EC
monolayer: Control: 0.69 ± 0.0067, Plts: 0.82 ± 0.029, FFP: 0.85 ± 0.0051, Plts-EVs: 0.74
± 0.0038, FFP: 0.73 ± 0.026). All groups statistically increase TEER compared to
control. In vivo: In a Miles assay of vascular leak, we observed that Plts, FFP and
Plt-EVs have similar inhibitory effects on vascular permeability (Figure. 1). In the tail
snip bleeding assay, we found that Plt-EVs decreased blood loss and demonstrated
superior hemostatic properties compared to Plts and FFP (Figure 2).
Conclusion: Plt-EVs can be important for achieving hemostasis and attenuating vascular
permeability in trauma. These findings indicate that Plt- EVs may be used in lieu of Plts
and provide a novel product that is logistically superior for transfusion in diverse settings.
NOTES
 Session XVIII: Papers 39-44: Coagulation
Paper 42: 8:30-8:50 am
Tranexamic acid as a risk factor for post-traumatic venous
thromboembolism: results from a propensity matched cohort study
Sara P. Myers MD, MA, MS, Matthew E. Kutcher* MD, Matthew R. Rosengart*
MD,MPH, Jason L. Sperry* MD,MPH, Joshua B. Brown* MD, MSc, Matthew D. Neal*
MD, University of Pittsburgh
Invited Discussant: Adrian Maung, MD

Background: Trauma remains a leading cause of mortality worldwide. Hemorrhage

control addresses the primary cause of early preventable deaths: bleeding. Tranexamic
acid (TXA) is used as a hemostatic adjunct, but may promote serious complications such
as venous thromboembolic (VTE) disease. Previous studies investigating the effect of
TXA on VTE vary in their findings and the population of interest. We aim to investigate
the association between TXA and VTE through a propensity matched retrospective cohort
analysis, hypothesizing that TXA is an independent risk factor for VTE.
Methods: We conducted a retrospective study of all trauma patients presenting to a
single level I trauma center during the period January 2012 to December 2016 to
determine the association between TXA and risk of VTE. Our primary outcome was
composite pulmonary embolus or deep vein thrombosis. Secondary outcomes included
mortality, transfusion requirement, ICU length of stay, and hospital length of stay. We
analyzed the data using a propensity matched mixed effects multivariate logistic
regression to determine the adjusted odds ratio (aOR) and 95% confidence intervals (95%
CI) of the association between TXA and our outcomes of interest, adjusting for
differences in prespecified confounders. A competing risks regression model was used to
determine subdistribution hazard ratio (SHR) of VTE after accounting for mortality as a
competing risk. A p-value <0.05 was considered significant.
Results: A total of 189 matched pairs were included from a population of 21,931
patients. Subject pairs were well matched across propensity score variables (standardized
differences <0.1). Median ISS was 19 (IQR 12, 27) in the TXA group, and 14 (IQR 8,22)
in the non-TXA group (p=0.41). TXA was associated with more than 3-fold increase in
the odds of VTE (aOR 3.3; 95%CI 1.3-9.1, p=0.02). TXA was not associated
with survival (aOR 0.86; 95%CI 0.23-3.25, p=0.827). Risk of VTE remained elevated in
patients treated with TXA despite accounting for mortality as a competing risk (SHR
2.42; 95% CI 1.11-5.29, p=0.027). Patients who received TXA experienced longer ICU
(9.4 vs. 6.5 days, p<0.001) and hospital length of stays (18.2 vs. 10.9 days, p<0.001).
Conclusion: TXA may be an independent risk factor for VTE development without
conferring survival benefit. Future investigation is needed to identify which injured
patients have a survival advantage from TXA, especially given the risks of this
intervention, to allow a more individualized treatment approach that maximizes benefits
and mitigates potential harms.
NOTES
 Session XVIII: Papers 39-44: Coagulation
Paper 43: 8:50-9:10 am
4-FACTOR PROTHROMBIN COMPLEX CONCENTRATE IMPROVES
SURVIVAL IN TRAUMA: A NATIONWIDE PROPENSITY MATCHED
ANALYSIS
Muhammad Zeeshan MD, Mohammad Hamidi MD, Lynn Gries Muhammad Khan MD,
Ara J. Feinstein* MD, Joseph Sakran* MD,MPH, Terence O'Keeffe* MD, Narong
Kulvatunyou* MD, Bellal Joseph* MD, University of Arizona - Tucson
Invited Discussant: Matthew Martin, MD

Introduction: Post-traumatic hemorrhage or Exsanguination is the most common

preventable cause of death in trauma patients. Numerous small single-center studies have
shown that 4-PCC+FFP is superior to FFP alone in the resuscitation of trauma patients.
The aim of our study was to evaluate outcomes of severely injured trauma patients who
received 4-PCC+FFP compared to FPP alone.
Methods: We performed a 2-year (2015-2016) retrospective analysis of the ACS-TQIP.
All adult (age≥18y) trauma patients who received 4-PCC+FFP or FFP alone were
included. We excluded patients who were on preinjury anticoagulants. Patients were
stratified into two groups: 4-PCC+FFP vs. FFP alone and were matched in a 1:1 ratio
using propensity score matching for demographics, ED vitals, injury parameters, and
hemorrhage control intervention. Outcome measures were pRBC, plasma & platelets
units transfused, thromboembolic complications, and mortality.
Results: We analyzed 593,818 trauma patients, of which 118,940 patients met inclusion
criteria. A total of 468 patients (4-PCC+FFP: 234, FFP alone: 234) were matched. The
mean age was 50±21y; 70% were males, median ISS was 27 [20–36], and 87% had blunt
injuries. 4-PCC+FFP was associated with a decreased requirement for pRBC units (6
units vs. 10 units; p=0.02) and FFP transfusion (3 units vs. 6 units; p=0.01) compared to
FFP alone (Fig 1). There was no difference in the rates of thromboembolic complications;
namely DVT (p=0.11) & PE (p=0.33), between the two groups ( Table 1.). Patients who
received 4-PCC+FFP had lower mortality (17.4% vs 27.7% p=0.01) Fig 2.
Conclusion: Our study demonstrates that the use of 4-factor PCC as an adjunct to FFP is
associated with improved survival and reduction in transfusion requirements compared to
FFP alone in the resuscitation of severely injured trauma patients. Further studies are
required to evaluate the potential role of the addition of PCC to massive transfusion
protocols.
NOTES
 Session XVIII: Papers 39-44: Coagulation
Paper 44: 9:10-9:30 am
DESMOPRESSIN IS A TRANSFUSION SPARING OPTION TO REVERESE PLATELET
DYSFUNCTION IN PATIENTS WITH SEVERE TRAUMATIC BRAIN INJURY
Elisa Furay MD, Mitchell J. Daley PharmD, Praveen N. Satarasinghe BS, Pedro Teixeira MD, Thomas
B. Coopwood* MD, Marc D. Trust MD, Jayson D. Aydelotte MD, Carlos V. Brown* MD, Dell Seton
Medical Center At The University Of Texas
Invited Discussant: Susan Rowell, MD
Introduction: Platelet dysfunction is an independent predictor of increased mortality in patients with
severe traumatic brain injury (TBI). Platelet transfusions have been shown to be an effective treatment
strategy to reverse platelet inhibition and reduce mortality, but may be associated with shortages, cost
and transfusion related complications. Therefore, desmopressin (DDAVP) is an attractive alternative
to enhance platelet aggregation. We hypothesized that DDAVP would correct platelet dysfunction
similarly to platelet transfusions in patients with severe TBI.

Methods: This retrospective study evaluated all blunt trauma patients admitted to an urban, level one
trauma center from July 2015 to October 2016 with severe TBI (Head AIS >/= 3) who presented with
platelet dysfunction (defined as adenosine diphosphate (ADP) inhibition greater than 60% on
thromboelastogram [TEG]) and subsequently received treatment. Per our institutional practice patients
with severe TBI and platelet dysfunction are transfused a unit of apheresis platelets to reverse
inhibition. If platelet inhibition persists the patient receives a second platelet transfusion. During a
platelet shortage, we interchanged DDAVP for the initial treatment. Patients were classified as
receiving DDAVP or platelet transfusion (PT) based on the initial treatment. Patients were excluded if
hemostatic agents were given prior to first TEG or DDAVP was co-administered with the platelet
transfusions.

Results: A total of 57 patients were included (DDAVP [n=23]; PT [n=34]). When comparing the
DDAVP group to the PT group there was no difference in age (41 vs. 40, p=0.86), male gender (82%
vs. 74%, p=0.44), but PT patients were more often Caucasian (94% vs. 65%, p=0.005). There was no
difference in admission systolic blood pressure (138 vs. 142, p=0.68) or pulse (97 vs. 105, p=0.30).
Patients who received DDAVP were more severely injured (ISS: 29 vs. 23, p=0.045) but there was no
difference in Head AIS (4 vs. 4, p=0.16). Prior to treatment both groups had similar admission platelet
counts (276 vs. 256, p=0.70) as well as arachidonic acid (AA) and ADP inhibition as measured by
TEG, AA (45% vs. 40%, p=0.58) and ADP (86% vs. 89%, p=0.34). After treatment both the DDAVP
and PT groups had similar correction of platelet inhibiton along the AA (p=0.80) and ADP (p=0.28)
pathways (Figure 1).

Conclusion: In patients with severe TBI and platelet dysfunction, DDAVP is an alternative to platelet
transfusions to correct platelet dysfunction.

Figure 1: Change in platelet inhibition along the AA (p=0.80) and ADP (p=0.28) pathways for
DDAVP vs. platelet transfusion.
NOTES
 Session XIX: Coagulation - Papers #45-47
Friday, September 28, 2018, 9:45 AM-10:45 AM
Location: Seaport D-H, Second Level (Seaport Tower)
Moderator: Raminder Nirula, MD, PhD
Recorder: Oscar Guillamondegui, MD
 Session XIX: Papers 45-47: Coagulation
Paper 45: 9:45-10:05 am
A Novel Platelet Function Assay for Trauma
Mitchell J. George MD, Charles E. Wade Ph.D., Charles S. Cox* Jr., MD, Brijesh S. Gill MD,
McGovern Medical School
Invited Discussant: Jordan A. Weinberg, MD
Background: Platelet function tests like thromboelastography platelet mapping and impedance
aggregometry have demonstrated significant reductions in platelet function in all trauma patients.
However, these two tests correlate poorly with one another and require reagents like arachidonic acid
or adenosine diphosphate for activation. In this study we introduce a platelet function test that
measures platelet contraction forces directly, the platelet contraction assay (PCA), without pathway
specific reagents. Platelet contraction is the final phase of platelet activation and requires energetic
substrates to drive actin-myosin crosslinking. We hypothesize that this platelet function test will
correlate with established coagulation tests like thromboelastography (TEG), demonstrate significant
differences between healthy subjects and trauma patients, and identify critically ill trauma patients.

Methods: Initial blood samples from eighty Level 1 Trauma patients with median ISS of 13 (4, 17)
were assayed in the PCA and compared to their initial TEG data using regression analysis. Blood
from ten healthy subjects was assayed seperately to establish a reference range. Results from trauma
patients surviving beyond 24 hours after admission were compared to healthy controls and trauma
deaths within 24 hours after admission using analysis of variance (ANOVA) with Tukey post-hoc
analysis. The primary PCA metric was maximum platelet contraction force (MF). The PCA measures
platelet contraction forces in whole blood that clots between two plastic discs in a heated chamber.

Results: The PCA MF correlates with TEG MA with R2=0.756 according to a power curve
regression of all eighty trauma patients. Trauma patients that survived for 24 hours after arrival
(N=74) demonstrated significantly elevated maximum platelet contraction forces compared to healthy
controls (6,705±2370 versus 4,825±480 µNewtons, p=0.0014) and trauma patients that died within 24
hours (6,705±2370 versus 2,904±2122 µNewtons, p=0.001). Those that died within 24 hours
demonstrated non-significant decreases compared to healthy controls (2,904±2122 versus 4,825±480
µNewtons, p=0.11). Of the six that died, four were from brain injury and two from blunt trauma.

Conclusions: The PCA is a platelet specific assay that correlates well with TEG MA and predicts
early mortality in severely injured trauma patients. Unlike thromboelastography platelet mapping and
impedance aggregometry, the PCA demonstrates increased platelet function in trauma patients unless
they die within 24 hours. An explanation for this difference is that platelet contraction is reflective of
platelet metabolics and thus a potential biomarker for survival after trauma.

Maximum Platelet Force in

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NOTES
 Session XIX: Papers 45-47: Coagulation
Paper 46: 10:05-10:25 am
TRANEXAMIC ACID CAUSES A ROBUST AND PROLONGED
FIBRINOLYTIC SHUTDOWN
Julia R. Coleman MD,MPH, Ernest E. Moore* MD, Angela Sauaia MD,Ph.D., Jason M.
Samuels MD, Geoffrey R. Nunns MD, Gregory R. Stettler MD, Joshua Ryon BA, Arsen
Ghasabyan MPH, James Chandler Anirban Banerjee Ph.D., Christopher C. Silliman
MD,Ph.D., Kenneth L. Jones Ph.D., University of Colorado Denver
Invited Discussant: Nicholas Namias, MD, MBA

Introduction: Tranexamic acid (TXA), an antifibrinolytic, has been used in military and
civilian trauma, but its preemptive utility has been called into question over mixed
evidence of survival benefit and increased thromboembolism. This study examines the
changes in fibrinolysis over time after TXA administration in trauma patients. We
hypothesize that TXA causes conversion to fibrinolytic shutdown which could have
thromboembolic consequences.
Methods: The Trauma Activation Protocol study is a prospective study of all trauma
activation patients admitted to a Level 1 Trauma Center. Whole blood samples were
collected at scene or upon presentation and at 2, 4, 6, 12, 24 and 48 hours. Citrated rapid
thrombelastography (TEG) was performed. LY30 (% lysis 30 minutes after maximum
amplitude) was examined and lysis phenotypes were defined as fibrinolytic shutdown
(LY30<0.9%), physiologic lysis (0.9%≥LY30<3.0%) and hyperfibrinolysis
(LY30≥3.0%). LY30 was compared at each time point between patients who received
TXA versus those who did not using a Mann-Whitney test, as well as through propensity
matched analysis to control for covariates. The incidence of venous thrombo-embolic
events (VTE) was examined by chi-square analysis.
Results: Overall, 274 patients were included. The median age was 31.4 years and 79%
were male. 59% presented after blunt trauma and the median new injury severity score
(NISS) was 33. 41 patients (15%) received TXA. Patients who received TXA had a higher
level of tissue injury (NISS of 43 vs 29, p=0.01) and more severe shock (base deficit of
-14.0 mEq/L vs -8.0 mEq/L, p<0.0001). TXA patients had more severe clot breakdown on
admission compared to non-TXA patients (median LY30 8.2% vs 1.2%, p<0.0001). By
two hours, the median LY30 of TXA patients decreased to 0.3% (vs 0.7% in non-TXA
patients) and by hour 4, the median LY30 of TXA patients reflected complete fibrinolytic
shutdown with an LY30 of 0.0% (vs non-TXA patients' LY30 of 0.6%,
p=0.02). Remarkably, the complete inhibition of lysis among TXA patients persisted at 24
hours, with median LY30 of 0.0% in TXA patients compared to 0.6% in non-TXA
patients (p=0.005). Even when controlling for baseline differences, degree of shock and
tissue injury, LY30 was still significantly lower in the TXA group (p=0.05). Patients who
received TXA had a trend towards increased rate of VTE (10% compared to 5% in
non-TXA patients), although this did not reach statistical significance (p=0.27).
Conclusion: TXA causes a more robust and prolonged conversion to fibrinolytic
shutdown in trauma patients compared to patients who do not receive TXA, a conversion
which persists to at least 24 hours. Although TXA reverses the hyperfibrinolytic profile, it
results in overcorrection with a transition to fibrinolysis shutdown within four hours of
administration. This may put patients at a higher risk for VTE, which is strongly
associated with fibrinolytic shutdown.
NOTES
 Session XIX: Papers 45-47: Coagulation
Paper 47: 10:25-10:45 am
EARLY FIBRINOLYSIS SHUTDOWN IS ASSOCIATED WITH INCREASED
NEUROSURGICAL INTERVENTIONS AFTER TRAUMATIC BRAIN INJURY:
IS SHUTDOWN AN EARLY MARKER OF HYPOCOAGULABILITY RATHER
THAN HYPOFIBRINOLYSIS?
Johana C. Gomez-Builes MD, Ori D. Rotstein MD, FRCP, Andrew Baker MD, Sergio A.
Acuna MD,Ph.D., Andrea Petropolis MD, FRCP, Mostafa Alwash MD, Arshpreet Gulati
MD, Ghassan Alkefeiri MD, Alan Rechamberg Ziroldo Estevao Pardi Sandro Rizoli*
MD,Ph.D., FACS, FRCP St Michael's Hospital
Invited Discussant: Martin Schreiber, MD

Introduction: Following a traumatic brain injury (TBI), patients’ outcome depends on

the severity of the primary brain damage and the secondary brain insults, including
intracranial hemorrhage progression (IHP). Coagulopathies, such as excessive
fibrinolysis, have been associated with IHP and the need for neurosurgical intervention
(NSX), but the association of hypofibrinolysis or fibrinolysis shutdown with IHP and
NSX has not been studied.
Methods: A retrospective cohort of patients with moderate to severe TBI (AIS head≥ 2),
admission ROTEM™, and serial imaging (CT head at admission and within 48 hours).
Clinical, laboratory and CT findings were reviewed, including the type of intracranial
hemorrhage (ICH), and number of ICH. IHP was defined as any new hemorrhage or
worsening of admission-ICH. Patients were classified according to fibrinolysis
phenotypes (physiologic, hyperfibrinolysis and shutdown). ROTEM™ ML<3.5% was
used to define shutdown (as recently published by our group). Univariable and
multivariable logistic regression evaluated the association between shutdown and
progression, NSX, and mortality.
Results: 173 patients were included. 41.6% had IHP and 18% had a NSX. Predominant
fibrinolysis phenotype was physiologic (71%), followed by shutdown (25.4%) and
hyperfibrinolysis (3.4%). Shutdown patients had higher ISS, lower base excess and
required more transfusions than the physiologic group. Progression was independently
associated with fibrinogen level (OR 1.3, 95%CI:1.02-1.65, p= 0.03), INR (OR 0.5, 95%
CI: 0.3-0.9, p= 0.04), and Glasgow Coma Scale motor response (GCSM, OR:1.38; 95%
CI: 1.1-1.72, p= 0.003), but not with shutdown (OR 1.12; 95%CI: 0.4-2.5; p= 0.78),
platelets, age, or acidosis. Shutdown (OR 3.1; 95%CI:1.8-8.2, p=0.02) and the number of
ICH (OR 1.5, 95%CI: 1-2.4, p= 0.04) were independently associated with NSX. Platelets,
fibrinogen level, INR, age, acidosis, GCSM, IHP were not associated with NSX. Age
(OR1.4; 95%CI: 1.1-1.7, p=0.0008), GCSM (OR: 2.2; 95%CI: 1.5-3.2, p <0.0001), NSX
(OR 5.6; 95%CI: 1.2-24.7, p=0.02), were independently associated with mortality. IHP
(p=0.06), acidosis (p=0.06), and shutdown (p=0.9) were not associated with mortality.
Conclusions: This is the first study to explore the association between early fibrinolysis
shutdown and progression of intracranial hemorrhage, and the need for neurosurgery. We
found an independent association of shutdown with the need for NSX, which could be
explained by a significant hemostatic activation (increased clot formation with fibrinogen
consumption, and higher transfusions needs) rather than hypofibrinolysis. Fibrinolysis
shutdown as an early marker of hypocoagulability could facilitate the recognition of
patients at risk of neurosurgical interventions and thus, assist in the reduction of the
secondary brain damage.
NOTES
 44TH WILLIAM T. FITTS, JR., M.D., LECTURE

William T. Fitts, Jr., M.D.

October 6, 1915 - June 17, 1984
William T. Fitts, Jr. was born on October 6, 1915, in Jackson, Tennessee. He received his
A.B. degree from Union University in Jackson in 1937 and his M.D. degree from the
University of Pennsylvania in 1940. He was an intern resident, Harrison Fellow in
Surgical Research, Rockefeller Foundation Fellow in Surgery and Instructor in Surgery at
the University of Pennsylvania from 1940-1942 and from 1945-1947. From 1942-1945,
he was a Surgical Ward Officer in the Affiliated Unit of the University of Pennsylvania,
the 20th General Hospital, in the China-Burma-India Theatre of World War II. He became
an Assistant Professor of Surgery in 1949, Associate Professor of Surgery in 1952, and
was John Rhea Barton Professor of Surgery and Chairman, Department of Surgery,
University of Pennsylvania, from 1972-1975. He spent his entire career at the University
of Pennsylvania. Because of his long service to the organization, the Fitts Lecture was
established by the American Association for the Surgery of Trauma in 1974 and first
presented by Curtis P. Artz, M.D. at the 35th AAST Meeting in Scottsdale, Arizona.
***************
American Association for the Surgery of Trauma:
Secretary, Vice-President, President-Elect, 1957-1964
President, 1964-1965
Editor, Journal of Trauma, 1968-1974

American College of Surgeons:

Vice-Chairman, Committee on Trauma, 1965-1966
Chairman, Pennsylvania Committee on Trauma, 1955-1967
National Safety Council Surgeon’s Award for Distinguished Service to Safety, 1971

American Trauma Society:

President, 1972-1973
 Friday, September 28, 2018
10:55-11:55 AM
Session XX: Fitts Lecture
Location: Seaport D-H, Second Level (Seaport Tower)

Damage Control and Firearm Deaths: “A Tale of Two Cities!”

C. William Schwab, MD, FACS, FRCS (H) Glas.
Emeritus Professor of Surgery, Perelman School of Medicine

Founding Chief, Division of Traumatology

Surgical Critical Care & Emergency Surgery

Senior Consultant
Penn Medicine
University of Pennsylvania
Philadelphia, PA, U.S.A.
 PREVIOUS FITTS ORATORS

1. 1975 Curtis P. Artz, M.D. 21. 1995 Jonathan E. Rhoads, M.D.

Charleston, SC Philadelphia, PA

2. 1976 Francis D. Moore, M.D. 22. 1996 Susan P. Baker, M.P.H.

Boston, MA Baltimore, MD

3. 1977 G. Tom Shires, M.D. 23. 1997 George F. Sheldon, M.D.

New York, NY Chapel Hill, NC

4. 1978 Lloyd D. MacLean, M.D. 24. 1998 Leonard Evans, Ph.D.

Montreal, Quebec, Canada Warren, MI

5. 1979 Mr. Peter S. London 25. 1999 Barbara Barlow, M.D.

Birmingham, England New York, NY

6. 1980 Carl T. Brighton, M.D. 26. 2000 Johannes A. Sturm, M.D.

Philadelphia, PA Hannover, Germany

7. 1981 John W. Kinney, M.D. 27. 2001 Janet Reno

New York, NY Washington, DC
(Cancelled)
8. 1982 Thomas W. Langfitt, M.D.
Philadelphia, PA 28. 2002 C. James Carrico, M.D.
Dallas, TX
9. 1983 Col. Robert Scott, L/RAMC
London, England 29. 2003 Ellen J. MacKenzie, Ph.D.
Baltimore, MD
10. 1984 F. William Blaisdell, M.D.
Sacramento, CA 30. 2004 Colonel John Holcomb, M.D.
Ft Sam Houston, TX
11. 1985 Donald P. Becker, M.D.
Los Angeles, CA 31. 2005 Sylvia D. Campbell, M.D.
Tampa, FL
12. 1986 Sheng Chih-Yong, M.D.
Woods Hole, MA 32. 2006 Sten E.V. Lennquist, M.D., Ph.D.
Linkoping, Sweden
13. 1987 Paul Dudley Hart
Woods Hole, MA 33. 2007 Thomas M. Scalea, M.D.
Baltimore, MD
14. 1988 Roderick A. Little, M.D.
Manchester, United Kingdom 34. 2008 Charles E. Lucas, M.D.
Detroit, MI
15. 1989 Prof. Martin Allgower, M.D.
Switzerland 35. 2009 Frederick P. Rivara, M.D., M.P.H.
Seattle, WA
16. 1990 Philip R. Lee, M.D.
San Francisco, CA 36. 2010 Charles N. Mock, M.D., Ph.D.,
M.P.H.
17. 1991 Donald D. Trunkey, M.D. Seattle, WA
Portland, OR
37. 2011 H. Leon Patcher, M.D.
18. 1992 Basil A. Pruitt, Jr., M.D. New York, NY
Fort Sam Houston, TX
38. 2012 David B. Hoyt, M.D.
19. 1993 John H. Davis, M.D. Chicago, IL
Burlington, VT
39. 2013 Frank R. Lewis, Jr., M.D.
20. 1994 John R. Border, M.D. Philadelphia, PA
Buffalo, NY
40. 2014 Ronald G. Tompkins, M.D.
Boston, MA

41. 2015 L.D. Britt, M.D., M.P.H.

Norfolk, VA

42. 2016 M. Margaret Kundson, M.D.

San Francisco, CA

43. 2017 Ronald Maier, M.D.

Seattle, Washington
 Friday, September 28, 2018
1:30 PM-2:00 PM
Session XII: Master Surgeon Lecture II
Location: Seaport D-H, Second Level (Seaport Tower)

Advise, Advance, Support, Teach -

The True Meaning of AAST To Me
Christine Gaarder, MD, PhD
Head of Department
Department of Traumatology
Oslo Univeristy Hospital Ulleval (OUHU)
 Session XXIIIA: Plenary Session - #48-56
Friday Septermber 28, 2018, 2:00 PM-5:00 PM
Location: Seaport D-H, Second Level (Seaport Tower)
Moderator: Christoph Josten, MD
Recorder: Andre Campbell, MD
 Session XXII: Papers 48-56
Paper 48: 2:00-2:20 pm
A NOMOGRAM PREDICTING THE NEED FOR BLEEDING INTERVENTIONS AFTER HIGH-GRADE
RENAL TRAUMA: RESULTS FROM THE AMERICAN ASSOCIATION FOR THE SURGERY OF
TRAUMA (AAST GENITOURINARY TRAUMA STUDY
Sorena Keihani MD, Douglas M. Rogers MD, Bryn E. Putbrese MD, Kaushik Mukherjee* MD, Sarah Majercik* MD,
Christopher M. Dodgion* MD,MPH, Scott A. Zakaluzny* MD, Brian P. Smith* MD, Jurek F. Kocik* MD, Matthew
M. Carrick* MD, Reza Askari* MD, Angela P. Presson Ph.D., James M. Hotaling MD, Raminder Nirula* MD,MPH,
Jeremy B. Myers MD, University of Utah
Invited Discussant: Neil Parry, MD

Introduction: The management of high-grade renal trauma (HGRT) and the indications for intervention remain
poorly defined. The American Association for the Surgery of Trauma (AAST) renal grading is a broad categorization
of injury severity and does not incorporate clinical and radiologic variables important in clinical decision-making
especially around bleeding interventions. We aimed to use data from our multi-institutional study, incorporating both
clinical and radiologic parameters, to develop a nomogram predicting risk of bleeding interventions after HGRT.

Methods: From 2014 to 2017, data on adult HGRT (AAST grades III-V) were collected from 14 participating Level-1
trauma centers. Patients with both clinical and radiology data were included. Data were gathered on demographics,
injury characteristics, management, and outcomes. Clinical parameters, easily obtained and previously shown to be
associated with bleeding interventions included: (1) trauma mechanism, (2) shock (systolic blood pressure <90
mmHg), (3) associated injury (i.e. any concomitant injury, including: solid organ, gastrointestinal, spinal cord, major
vascular, and pelvic fracture), (4) admission lactate levels, and (5) admission hemoglobin level. Initial CT-scans were
reviewed by two radiologists to extract renal injury specifics which included: (1) intravascular contrast extravasation
(ICE), (2) hematoma rim distance (HRD, i.e. largest measure from the edge of the kidney to the hematoma), and (3)
hematoma extension (none/subcapsular; peri-renal; para-renal [beyond the aorta on the left or IVC on the right or into
the pelvis]), and (4) laceration location (lateral, medial, complex). Bleeding interventions included: nephrectomy
(total or partial), renorrhaphy, renal packing, and renal-related angioembolization. We developed a prediction model
by applying backward model selection to a logistic regression model that included the above mentioned clinical and
radiologic variables. We developed a nomogram for the selected model and reported its accuracy as the area under the
receiver operating characteristic curve (AUC) and its 95% confidence interval (CI).

Results: A total of 326 patients from the overall cohort of 431 met the inclusion criteria. Mechanism of injury was
blunt in 81%, and 67% had one or more associated injuries. Mean age and injury severity score were 35.0±16.6 and
25.0±12.6. Injuries were reported as AAST grades III (60%), IV (33%), and V (7%). Overall, 47 (14%) underwent
bleeding interventions including 19 renal angioembolization 16 nephrectomies, and 12 other procedures. ICE was
found in 73 patients (23%). Hematoma extension was peri-renal in 160 (49%) and para-renal in 123 (38%); 43 (13%)
had no hematoma or only subcapsular hematoma. Mean HRD in the horizontal plane was 2.1 cm (SD: 2.0). The
nomogram for our bleeding intervention prediction model is presented in Figure-1. Of the clinical and radiologic
variables entered in backward model selection, lactate, hemoglobin, and laceration location did not significantly
improve the nomogram AUC, and were not included in the final model. Having a HRD of 12 cm was worth the most
points (100), followed by para-renal hematoma extension (34 points), penetrating trauma mechanism (32 points), ICE
(30 points), associated injuries (16 points), and shock (16 points). The AUC was 0.88 (95% CI: 0.83–0.92).
Conclusion: We developed a nomogram that integrates multiple clinical and radiologic factors immediately available
upon assessment of the trauma victim and can provide predicted probability for risk of bleeding interventions after
HGRT. While further studies are needed to validate our model, this nomogram may help in guiding appropriate
interventions such as decreasing unnecessary interventions especially at lower volume trauma centers with limited
experience with high-grade renal injuries.
NOTES
 Session XXII: Papers 48-56
Paper 49: 2:20-2:40 pm
PRESUMPTIVE ANTIBIOTICS FOR TUBE THORACOSTOMY FOR
TRAUMATIC HEMOPNEUMOTHORAX
Susan P. Schultz MD, Chengcheng Hu Ph.D., Alan D. Cook* MD, Jeanette G. Ward
MS-CR, Jeremy Juern MD, Geoffrey A. Funk MD, Ronald Gross* MD, David Turay
MD, Steven R. Allen MD, Paola G. Pieri MD, Christopher P. Michetti MD, Frederick B.
Rogers* MD, Shreya Jammula BS, Forrest O. Moore* MD, AAST ABX IN TUBE
THORACOSTOMY STUDY GROUP AAST Multi-Institutional Trials Committee
Invited Discussant: Timothy Fabian, MD

Introduction: Despite more than forty years of investigation, presumptive antibiotic use
for post-traumatic tube thoracostomy remains controversial. Researchers seek to balance
prevention of infectious complications with antibiotic stewardship. This study
investigated the benefit of presumptive antibiotic treatment for prevention of infectious
complications following post-traumatic tube thoracostomy. The primary outcomes were
pneumonia and empyema following chest tube insertion. Hospital and ICU lengths of
stay (HLOS and ICULOS respectively), ventilator days, death and C. difficile colitis
were secondary endpoints.
Methods: A prospective, observational, multi-center study included 1,887 subjects from
22 level I trauma centers. Nearest neighbor matching balanced covariate distributions in
the treatment (ABX) and control (NoABX) groups. Variables used for matching included
basic demographics, trauma center information, mechanism of injury, severity of injury,
and details of chest tube placement.
Results: There were 272 patients in each group. No significant differences among
matching covariates distinguished either group. No significant differences were found in
primary outcomes between the ABX and NoABX groups. Pneumonia was diagnosed in
15.4% and 9.9% of the ABX and NoABX group, respectively, p=0.07. Similarly, 2.2% of
the ABX group and 1.5% of the NoABX patients developed empyema, p=0.75. ICULOS
was one day longer in the ABX group, p=0.02.

Conclusion: This study found no evidence to support the use of presumptive antibiotics
for post-traumatic tube thoracostomy in the absence of other indications.
NOTES
 Session XXII: Papers 48-56
Paper 50: 2:40-3:00 pm
VASOPRESSOR USE IN SPINAL CORD INJURY INCREASES MORTALITY
AND COMPLICATIONS WITHOUT IMPROVING SHORT TERM
NEUROLOGIC FUNCTION
Caitlin A. Fitzgerald MD, Faiz U. Ahmad MD, Peter M. Rhee* MD, Bryan C. Morse*
MD, Mark L. Shapiro* MD, Jonathan Nguyen DO, Sebastian D. Perez MSPH, Christian
M. Mustroph MD, Griffin R. Baum MD, Rondi B. Gelbard MD, Emory University
Invited Discussant: David Zonies, MD, MPH

Introduction: An increase in spinal cord perfusion pressure is thought to improve

neurologic outcomes after spinal cord injury (SCI) but this has yet to be shown in trauma
patients. According to guidelines, vasopressors should be used to achieve a goal mean
arterial pressure (MAP) to optimize spinal cord blood flow. However, the outcomes and
complications associated with routine vasopressor use among SCI patients are not well
established. The purpose of this study was to determine the outcomes associated with
vasopressor use among SCI patients.

Methods: This was a retrospective review of all adult patients presenting to our Level 1
Trauma Center with acute traumatic SCI between September 2010 and September 2017.
Patients were identified from the Trauma Registry using the International Classification
of Diseases (ICD-9) codes for spinal cord injury. Patients were grouped according to
whether they received vasopressors for MAP goals or not. Outcome measures included
complications, hospital and Intensive Care Unit (ICU) length of stay (LOS), and change
in American Spinal Injury Association (ASIA) impairment scale from admission to
discharge.

Results: A total of 535 patients with SCI were

identified. Of these, 113 (21.1%) had normal
neurologic function on admission and were
excluded from further analysis. A total of 55.4%
(234/422) received vasopressors to achieve MAP
goals >85 mmHg for an average of 4.6 days.
Whether patients received MAP goals or not was
based on surgeon’s preference. There was no
difference between the vasopressor and no
vasopressor groups in terms of demographics. ASIA Grades at admission ranged from
168 (39.8%) ASIA A, 40 (9.5%) ASIA B, 84 (20%) ASIA C, and 116 (27.5%) ASIA D.
There was no difference in short term neurologic improvement in ASIA A-D patients with
the use of vasopressors. Overall mortality was higher among patients receiving
vasopressors (25/234, 10.7% vs 2/174, 1.1%, p=0.001). Even after controlling for ISS and
ASIA scores, vasopressors were independently associated with a significant increase in
mortality (OR= 8.87, p=.004). Hospital and ICU LOS were also significantly longer in
the vasopressor group (28 +35 vs. 19.1+29 days, p=0.007, and 18+21.2 vs. 7.8 + 8.9
days, p<0.001), as were cardiogenic complications such as myocardial infarction, acute
kidney injury, sepsis, pneumonia and urinary tract infections.

Conclusion: Although vasopressors may be of benefit in patients with SCI, our data
shows an association with increased morbidity and mortality without improving short
term neurologic recovery. Prospective studies are required to determine the potential
long-term benefits, risks and costs of vasopressor use for achieving MAP goals in patients
with SCI.
NOTES
 Session XXII: Papers 48-56
Paper 51: 3:00-3:20 pm
PREHOSPITAL END TIDAL CO2: A SUPERIOR MARKER FOR MORTALITY
RISK IN THE ACUTELY INJURED PATIENT
Robert G. Willis MD, MS, Kyle W. Cunningham* MD,MPH, Troia P. Algarin BS,
Ashley S. Gutierrez BS, Ashley B. Christmas* MD, Rita Brintzenhoff* MD, Ronald F.
Sing* DO, Carolinas Medical Center
Invited Discussant: Saman Arbabi, MD, MPH

Introduction: Emergency medical personnel must expeditiously triage acutely injured

patients to the appropriate medical facility. There continues to be a need for efficient and
objective variables to facilitate this process and provide information to the receiving
trauma center. Currently, multiple variables are used to prognosticate injury severity and
risk of mortality including vital signs, mental status, lactate and base excess. We
investigated the prehospital use of end tidal carbon dioxide (EtCO2) as a non-invasive
physiologic measure that can be obtained in the acutely injured patient.

Methods: We performed a retrospective analysis of 557 acutely injured patients over two
years (January 1, 2014- December 31, 2015) at a level I trauma center. All patients
arriving as trauma activations with EtCO2 measurements were included in analysis.
EtCO2 measurements were categorized as “low”, “normal”, and “high” based on
standard reference levels. Mortality was the primary outcome. Secondary receiver
operator curves (ROC) for base excess, venous lactate, blood pressure, and venous pH
were also compared. We hypothesized EtCO2 levels would be able to predict mortality.

Results: EtCO2 levels conferred a mortality rate of 38%, 17.3%, and 2.9% for “low”,
“normal” and “high” respectively (p<0.001). Furthermore, ROC analysis produced an
area-under-the-curve (AUC) predictive value for EtCO2 (0.748) which was superior to
lactate (0.660), SBP(0.578), pH(0.560), and base excess(0.497).

Conclusion: EtCO2 is a more sensitive and specific predictor of mortality in the acutely
injured patient compared to venous lactate, base deficit, blood pressure, or venous pH.
Additional studies are needed to determine if EtCO2 can be used as an effective
prehospital adjunct to prevent mortality in acutely injured patients.
NOTES
 Session XXII: Papers 48-56
Paper 52: 3:20-3:40 pm
PRE-INJURY PALLIATIVE PERFORMANCE SCALE (PPS PREDICTS
FUNCTIONAL OUTCOMES AT 6 MONTHS IN OLDER TRAUMA PATIENTS
Franchesca Hwang MD, Sri Ram Pentakota MD,MPH,Ph.D., Christopher McGreevy
MD, Patricia Walling RN, MS, Dorsa Seimaa MPH,RN, Nina E. Glass MD, David H.
Livingston* MD, Anne C. Mosenthal* MD, New Jersey Medical School
Invited Discussant: Karen Brasel, MD, MPH

Introduction: Older trauma patients have increased risk of adverse in-hospital outcomes
than their younger counterparts. Previously, we demonstrated that low Palliative
Performance Scale (PPS) independently predicted poor discharge outcomes. Yet, the
ability to predict long-term outcomes beyond discharge is unknown. We hypothesized
that pre-injury PPS would predict long-term outcomes in older trauma patients.
Methods: We conducted a prospective observational study of trauma patients aged > 55
admitted to a level I trauma center (7/2016-10/2017). Pre-injury PPS, which takes 1-2
minutes to complete, was assessed at admission; low PPS was defined as <70. Primary
outcomes were in-hospital mortality and Extended Glasgow Outcome Scale (GOSE) at
discharge and 6 months. Secondary outcomes were patient-reported outcome measures at
6 months: EuroQol (EQ)-5D and 36-Item Short Form Survey (SF-36). Poor functional
outcome was defined as GOSE < 4. Multivariable logistic regression was performed for
each primary outcome, adjusting for PPS, age, race, gender, and injury severity.
Results: We collected 376 patients’ in-hospital data. The mean age was 70; the mean ISS
was 14.8; and 30% had low PPS. Six percent (n=24) died in hospital (GOSE 1), and half
of survivors (n=190) had severe disability (GOSE 3/4) at discharge. No vegetative state
(GOSE 2) was observed. Low PPS was associated with in-hospital mortality (aOR 3.0,
95% CI 1.1-8.3) and poor functional outcomes at discharge among survivors (aOR 5.9,
95% CI 3.1-11.0). Severe TBI and ISS also predicted in-hospital mortality. Older age,
higher ISS, and lower extremity fractures predicted poor functional outcomes at
discharge. Six-month data were available for 113 (87%) of 130 patients who were
approached for follow-up. Functional outcomes improved in 62% at 6 months (Table).
However, 63% had moderate to extreme pain, and 43% felt moderately to extremely
anxious/depressed. Low-PPS patients were less likely to improve GOSE than high-PPS
patients (40% vs 70%). Low PPS independently predicted poor functional outcomes at 6
months (aOR 5.7, 95% CI 1.5-21.5) while age, ISS, and lower extremity fractures did
not. A higher proportion of low-PPS patients had problems with EQ-5D mobility (92% vs
51%, p=0.0002) and usual activities (77% vs 44%, p=0.003); they also scored lower on
the EQ-5D Visual Analogue Scale (59 vs 68, p=0.04) at 6 months. Similarly, the
low-PPS group scored lower than the high-PPS group in SF-36 physical functioning (27
vs 54, p=0.0004) and general health domains (37 vs 53, p=0.01).
Conclusion: Pre-injury PPS predicts in-hospital mortality and poor functional outcomes
at discharge and 6 months in older trauma patients. Patients with low PPS were less
likely to improve their functional outcomes after discharge; interestingly, majority of
survivors improved their function at 6 months, further emphasizing the importance of
long-term follow-up in understanding their true outcomes. Pre-injury PPS is a quick,
practical tool that can be utilized on admission for early prognostication of both short-
and long-term outcomes.
NOTES
 Session XXII: Papers 48-56
Paper 53: 3:40-4:00 pm
USING PERFORMANCE FRONTIERS TO DIFFERENTIATE ELECTIVE AND
CAPACITY-BASED SURGICAL SERVICES
Stephen E. Ranney MD, Loic J. Fabricant MD, Max W. Breidenstein BS, Kevin W.
Sexton MD, Ajai K. Malhotra* MD, Mitchell H. Tsai MD, University of Vermont
Invited Discussant: Kimberly Davis, MD, MBA

Introduction: In the past, our institution demonstrated how an Acute Care Surgery
service (ACS) can improve the clinical productivity of surgical departments (AAST
2016, 2017); however, the application of current productivity models is limited and
varied. At our institution, creating an ACS led to increased OR workload and a
concomitant decrease in clinical productivity. Current productivity models incorporating
over-utilized time may not apply to ACS systems because ACS is a capacity-based
service and requires a 24-hour block allocation which falsely decreases productivity.
Thus, a new technique to optimize multiple objectives is needed to determine the true
utility of implementing ACS. Performance frontiers provide a mathematical and
graphical system for evaluating a set of actions to determine optimal efficiency—a state
where allocation of resources is optimal and where it is impossible to reallocate any
resources without making any objective worse. We hypothesized that ACS and elective
general surgery (GS) would differentiate themselves along separate pathways on
superimposed performance fronts, and that the implementation of an ACS would help GS
reach optimal efficiency.
Methods: We extracted the time for in-block,
out-of-block, after-hours, and opportunity-unused
for GS and ACS for 12 months prior to and after
implementing ACS. Monthly data was plotted
along performance fronts and was viewed
graphically using GraphPad Prism®. For each
month, over-utilized time was plotted on the x-axis
and in-block and out-of-block times were plotted
on the y-axis.
Results: The performance frontiers demonstrated
obvious differences in OR utilization between
ACS and GS. Statistically, ACS had a significant increase in opportunity unused minutes.
The GS showed a significant decrease in after-hours, out of block, and opportunity
unused time. Although not statistically significant, an upward trend of in-block time was
observed.
Conclusion: The application of performance fronts
to productivity and OR utilization metrics hints at
the limitations of the current models. The graphs
demonstrate falsely elevated opportunity unused
for ACS while showing an increase in GS OR
efficiency. This suggests that hospital
administrators, OR managers, and physician
leaders need different frameworks to understand
capacity-based services and to identify limitations
of operational efficiency as well as to describe the
full value of an ACS model to a whole surgical
department, not an individual service. Performance fronts will allow for OR managers to
track efficiency of multiple services while making such changes.
NOTES
 Session XXII: Papers 48-56
Paper 54: 4:00-4:20 pm
MINIMALLY INVASIVE PREPERITONEAL BALLOON TAMPONADE AND
ABDOMINAL AORTIC JUNCTIONAL TOURNIQUET VERSUS OPEN
PACKING FOR PELVIC FRACTURE-ASSOCIATED HEMORRHAGE: NOT
ALL EXTRINSIC COMPRESSION IS EQUAL
Woo S. Do MD, Dominic M. Forte MD, Rowan R. Sheldon MD, Jessica B. Weiss MD,
Morgan R. Barron MD, Kyle K. Sokol MD, George E. Black MD, Matthew J. Eckert
MD, Matthew J. Martin* MD, Madigan Army Medical Center
Invited Discussant: Clay Cothren Burlew, MD

Introduction: Minimally invasive preperitoneal balloon tamponade (PPB) and abdominal

aortic junctional tourniquets (AAJT) have been proposed as alternatives to open
preperitoneal packing (OP) for the management of pelvic fracture associated hemorrhage.
We compared the effectiveness of PPB (SpaceMaker Pro TM ) and AAJT against the
standard of care (OP) in an animal model of open-book pelvic fracture.

Methods: 28 swine underwent creation of a combined open-book pelvic fracture and

major iliac vascular injuries. Animals were randomized to no intervention (n=7), OP
(n=8), PPB (n=7), or AAJT (n=6) at a mean arterial pressure <40 mmHg following
initiation of uncontrolled hemorrhage. Hemodynamics, laboratory values, survival time
(up to 60 min), preperitoneal pressure, and blood loss were compared between groups.

Results: Prior to injury, no significant difference was measured between groups for
variables including weight, hemodynamics, lactate, and hematocrit (all p=NS). The injury
was uniformly lethal without intervention, with survival time (mean) of 5 min, peak
preperitoneal pressure of 14 mmHg, blood loss of 1010 cc, and peak lactate of 2.6
mmol/L. Mean survival time was 44 min with OP, and was significantly longer at 60 min
with PPB and AAJT (p<0.01). Peak preperitoneal pressure was 21 mmHg with OP, 24
with PPB, and 23 with AAJT (p=NS). Blood loss was 850 cc with OP, 780 cc with PPB,
and 610 cc with AAJT (p=NS). Peak lactate was 3.0 mmol/L with OP, 3.8 mmol/L with
PPB, and 6.3 mmol/L with AAJT (p<0.01). Necropsy revealed bowel/bladder injury in
50% of AAJT subjects compared to 0% in all other arms (p<0.01). The following figure
depicts free pelvic hemorrhage on angiography (left); tamponade with PPB inflation
(middle); and bowel injury with AAJT (right).

Conclusion: PPB is a safe and more effective alternative to OP for the management of
lethal pelvic fracture associated hemorrhage, and has several significant advantages
including the ease of bedside placement. The AAJT offers a similar survival benefit to
PPB but has concerning rates of compressive abdominal organ injury.
NOTES
 Session XXII: Papers 48-56
Paper 55: 4:20-4:40 pm
OUTCOMES FOR POPLITEAL ARTERY INJURY REPAIR AFTER
DISCHARGE: A LARGE-SCALE POPULATION-BASED ANALYSIS
William J. Butler MD, Richard Y. Calvo Ph.D., Michael J. Sise* MD, Vishal Bansal*
MD, C. Beth Sise MSN, Jason M. Bowie MD, Lyndsey E. Wessels MD, Scripps Mercy
Hospital Trauma Service
Invited Discussant: David Feliciano, MD

Introduction: Data suggest that the short-term results after endovascular repair (EvR)
versus open repair (OpR) for popliteal artery injury are similar. However, studies on the
outcomes after discharge are limited. We evaluated popliteal artery injury repair in a
large population-based dataset. We hypothesized that post-discharge outcomes for OpR
are superior to EvR.

Methods: Patients with popliteal artery injury were identified in the California Office of
Statewide Health Planning and Development 2007-2014 patient discharge database.
Popliteal arterial and other lower-extremity skeletal, vascular, and nerve injuries were
identified using ICD-9-CM diagnosis codes. Procedure codes were evaluated to identify
OpR, EvR, fasciotomy, and lower-extremity amputation. Primary outcomes were
in-hospital mortality or amputation during index admission. The association between
repair method and each outcome was evaluated with logistic regression. Post-discharge
amputation and death were evaluated using survival analysis.

Results: We identified 769 patients with popliteal artery injury. Most were male (85%),
mean age was 38.1 (SD: 16.5) years, and median ISS was 13 (IQR: 9 – 21). OpR occurred
in 456 (59.3%) patients, EvR in 37 (4.3%), combined EvR and OpR in 18 (2.3%), and
non-operative management in 258 (33.6%). Although fasciotomy was performed more
frequently in OpR compared to EvR (40.8% vs 18.9%, p< 0.01), amputation during the
index admission was not significantly different (10.5% vs 2.7%, p = 0.13). Arterial
embolism or thrombosis during the index admission was more likely after EvR or
combined EvR and OpR compared with OpR (24.3%, 55.6% and 16.7% respectively, p
<0.001). Patients who required both EvR and OpR were 5.18 times (95%CI: 1.39-19.34)
more likely to undergo amputation after discharge and 4.44 times (95%CI: 1.27–15.57)
more likely to die after discharge compared to patients who only had OpR (median 98.5
days from discharge).

Conclusion: In a large cohort with popliteal artery injury, OpR was associated with
lower rates of arterial thrombus or embolism and both amputation and mortality after
discharge. Our results suggest that OpR is superior and that EvR needs to be carefully
evaluated to determine its appropriate use in managing popliteal artery injuries.
NOTES
PAPER 56 - WITHDRAWN
NOTES
 Session XXIIIB: Plenary Session - Papers #57-65
Friday, September, 28, 2018, 2:00 PM-5:00 PM
Location: Seaport A-C, Second Level (Seaport Tower)
Moderator: M. Margaret Knudson, MD
Recorder: Addison May, MD
 Session XXIII: Papers 58-65
Paper 57: 2:00-2:20 pm
APPLICATION OF EMR-DERIVED ANALYTICS IN CRITICAL CARE:
ROTHMAN INDEX PREDICTS MORTALITY AND READMISSIONS IN
SURGICAL ICU PATIENTS
Abdul Q. Alarhayem MD, Mark T. Muir* MD, Donald Jenkins* MD, Brian J. Eastridge*
MD, Maulik Purohit MD,MPH, Basil A. Pruitt* Jr., MD, Ramon F. Cestero* MD,
University of Texas Health Science Center at San Antonio
Invited Discussant: Sonlee West, MD

Introduction: The Rothman Index (RI) is an objective measurement of a patient’s overall

condition, automatically and continuously calculated from clinical data in the electronic
medical record (EMR). A maximum score of 100 reflects no additional mortality risk,
and a decreasing score signifies a deteriorating clinical status. Although studies in
medical patients suggest that RI scores may predict mortality and readmission rates, RI
has not been extensively evaluated in the surgical population. This study assessed the
validity of RI in predicting surgical ICU (SICU) readmission rates and mortality. We
hypothesized that lower pre-transfer RI scores are associated with higher mortality and
SICU readmission rates.
Methods: We conducted a single-center retrospective analysis over a two-year period at a
Level I trauma center which included surgical patients who were transferred from the
SICU to the surgical floor. Data included demographics, length of stay (LOS), mortality,
and RI at multiple pre-transfer time points (72, 48, and 24 hours before transfer) as well
as 24 and 48 hours post-transfer. Patients readmitted to the SICU within 48 hours of
transfer were compared with patients who did not require readmission within 48 hours
(control).
Results: A total of 1,445 SICU patients were transferred to the surgical floor; 79 patients
(5.5%) were readmitted within 48 hours of transfer. Demographics were similar in both
groups. Mean age was 52, and 67% were male. Compared to controls, patients readmitted
to the SICU within 48 hours experienced higher LOS (29 vs 11 days, p<.05) and higher
mortality (2.5% vs 0.6%, p<.05). Patients requiring readmission also had a lower RI at
72, 48, and 24 hours before transfer as well as at 24 and 48 hours after transfer (p<.05 for
all). Additionally, patients requiring readmission had less improvement in RI scores
during the immediate 24 hours after transfer (1 vs 17, p<.05). In trauma patients (n =
719), lower RI scores at 24 hours prior to transfer correlated with an increase in ISS and
mortality (p<0.05). Patients transferred with RI scores > 83 did not require SICU
readmission within 48 hours. The AUC value of RI for predicting mortality, calculated
from the receiver operator characteristic (ROC) curve, was 0.865 with standard errors of
0.05.
Conclusion: SICU patients requiring readmission within 48 hours of transfer to a surgical
floor have a significantly higher mortality and longer LOS compared to those who do not.
Patients requiring readmission also have significantly lower pre- and post-transfer RI
scores compared to those who do not. Lower RI values at 24 hours before transfer are
predictive of higher readmission rates and increased mortality risk, and patients with
pre-transfer RI scores >83 are unlikely to require early SICU readmission. As an
EMR-derived composite clinical measurement, RI scores may be used as a tool for
evaluating patients prior to SICU downgrade, and can assist in identifying patients at
higher risk for mortality and ICU readmission. Prospective studies are warranted to
further validate use of this technology.
NOTES
 Session XXIII: Papers 58-65
Paper 58: 2:20-2:40 pm
Predisposed to Failure? The Challenge of Rescue in the Medical Intensive Care Unit
Alexandra Briggs MD, Robert Handzel MD, Matt Kutcher MD, Andrew B. Peitzman*
MD, Raquel Forsythe* MD, University of Pittsburgh
Invited Discussant: Lena Napolitano, MD, MPH

Introduction: Patients in the Medical Intensive Care Unit (MICU) develop acute surgical
processes that require operative intervention. While the increased mortality in emergency
general surgery (EGS) patients is established, there are limited data addressing outcomes
in the MICU population. The aim of our study was to characterize the breadth of surgical
consults from the MICU and assess the mortality of patients requiring EGS.
Methods: All patients with an EGS consult originating from the MICU in a large urban
academic medical center between January 2010 and 2016 were identified from a
prospective, electronic medical record-based acute care surgery registry. Charts were
reviewed to determine the reason for consult and the surgical procedures performed.
Descriptive statistics were used to characterize patient demographics and outcomes for
both the entire cohort and patients who underwent abdominal operations.
Results: Over this six year period, 911 MICU patients were seen by our
service, 578 (63.4%) for an abdominal consult question, 333 (36.6%) for a
non-abdominal question. A total of 411 patients (45.1%) underwent an operative
procedure (186 abdominal, 225 non-abdominal). Patients undergoing abdominal
operations had a mean age of 59.6, 53.2% male. The postoperative unadjusted mortality
rate in patients undergoing abdominal operations was 37% (69/186), significantly higher
than the unadjusted mortality rate of 16.4% (1833/11192) for all patients admitted to the
MICU over the same time period. Damage control procedures were performed in 65
patients (34.9%), with 46.2% mortality in this group. The most common procedures were
bowel resections, which had a postoperative
mortality of 44.4% (32/72) and procedures
for severe clostridium difficile infection,
mortality rate of 34.8% (8/23). The highest
mortality procedures were those relating to
feeding tube complications and decompressive
laparotomies, though these were performed in
a small number of patients. Twenty-seven
patients met our definition of surgical rescue, requiring operative intervention
for complications of prior procedures. The majority of surgical rescue patients (19/27,
70.4%) had undergone procedures at an outside facility. Mortality in the surgical rescue
population was 48%. Twenty-six patients had abdominal pathology amenable to surgical
intervention but did not undergo surgery, with a mortality of 100%.
Conclusions: Twenty percent of EGS consults
from the MICU had an abdominal
process requiring an operative intervention.
This patient population has significant
comorbidities with a low tolerance for
intraabdominal processes, resulting in high
mortality. Surgical rescue is particularly
challenging for patients with
prior procedural complications. While the MICU population as a whole has a high
baseline mortality, patients requiring abdominal surgical intervention are at an even
higher risk.
NOTES
 Session XXIII: Papers 58-65
Paper 59: 2:40-3:00 pm
ULTRASONGRAPHIC IVC DIAMETER RESPONSE AFTER ONE HOUR
OF TRAUMA RESUSCITATION PREDICTS 24 HOUR FLUID REQUIREMENT
Jay Doucet* MD, Paula Ferrada* MD, Ram Nirula* MD,MPH, Sarah Murthi* MD,
Jinfeng Han BSN, Andrew Singleton MD, Katie Birkas [Link]., Daniel Haase MD, Sara
Edwards MD, Giovanna Casola MD, Raul Coimbra* MD,Ph.D., AAST
Multi-Institutional Trials Committee
Invited Discussant: Grace Rozycki, MD, MBA

Introduction: Identification of occult hypovolemia in trauma patients at admission can

be difficult without additional laboratory evaluation or advanced imaging. We
hypothesized that in acute trauma patients, the response of ultrasound-measured inferior
vena cava diameter (IVCd) or mean internal jugular diameter (IJd) in repeated eFAST
examinations (USA-IVC) during standard-of-care intravenous fluid resuscitation would
predict 24 hour resuscitation intravenous fluid requirements.
Methods: An interim analysis of the NTI / AAST-MITC group prospective,
multi-institutional IVC-FAST cohort trial was conducted at 4 Level I Trauma Centers.
Major trauma patients were screened in the supine position for an IVCd of 12 mm or less
on the initial FAST examination for enrollment. A second IVCd was obtained 40-60
minutes later, after the patient received standard-of-care fluid resuscitation. Patients
whose second measurement IVCd remained less than 10mm were deemed
Non-Responders (NON-RESP), those at or greater than 10mm were Responders (RESP).
Prehospital fluid, initial resuscitation fluid and 24 hour fluid requirements were recorded.
Demographics, ISS, arterial blood gasses, ICU admission, length-of-stay, interventions
and complications were recorded. Means were compared by ANOVA and categorical
variables were compared via Chi-square. Receiver-operator characteristic (ROC) curves
were used to compare the FAST-IVC test to Base Excess (BE), ISS and other fluid
volume predictors.
Results: There were 4798 patients screened by FAST-IVC, 378 were identified with
admission IVCd < 12mm, 127 were enrolled and had useable imagery. There were 80
RESP and 47 NON-RESP. Table 1 shows the univariate analysis. NON-RESP needed
significantly more fluid at 24 hours. ROC analysis indicates IVCd (AUC= 0.63, C.I.:
0.51-0.74, p=0.037) but not IJd (AUC= 0.42, C.I.: 0.24-0.60, p=N.S.) was comparable to
ISS (AUC=0.75, C.I.:0.60-0.90, p=0.002) in predicting 24 hour fluid requirement.

Conclusion: eFAST ultrasound IVC diameter, but not IJ diameter response to initial
trauma resuscitation is useful in predicting 24 hour fluid resuscitation requirements.
NOTES
 Session XXIII: Papers 58-65
Paper 60: 3:00-3:20 pm
VENTILATOR ASSOCIATED EVENT, NOT VENTILATOR ASSOCIATED
PNEUMONIA, IS A TRUE QUALITY INDICATOR
Ashley D. Meagher MD,MPH, Margaret Lind MS, Lara Senekjian MD, MS, Chinenye
Iwuchukwu MD,MPH, John B. Lynch MD,MPH, Joseph Cuschieri* MD, Bryce R.
Robinsom* MD, MS University of Washington
Invited Discussant: Martin Croce, MD
Introduction: Ventilator associated pneumonia (VAP) is an unreliable and inconsistent
quality indicator for trauma patients that require mechanical ventilation (MV) for greater
than 48 hours. In an effort to reduce variability and subjectivity of ventilator-associated
conditions, the Centers for Disease Control and National Health Safety Network defined
criteria for ventilator-associated events (VAE), which include the qualitative components
of VAP. The aim of this study is to identify the incidence of VAE in our trauma
population and the impact on outcome, compared to the traditional definition of VAP.
Methods: We retrospectively reviewed all trauma patients admitted to our trauma center
between 2011 and 2017 that required at least 4 days of MV, excluding those with AIS
head >4. This data was matched to our institutional physician adjudicated and culture
confirmed VAP and VAE database. The primary outcome was in-hospital mortality, with
discharge home and hospital length of stay as the secondary outcomes. We used Cox
proportional hazard models with time-varying exposure to estimate the associations
between VAE and VAP and in-hospital mortality, duration of MV, and discharge home.
Results: 1,753 trauma patients met criteria; 12% (n=221) of these developed a VAE, 7%
(n=117) developed a VAP, and 4% (n=73) had both. Baseline characteristics were not
different between those with VAE, VAP or both. After adjusted analyses, patients with
VAE had statistically significantly higher likelihood of death, longer MV, and were less
likely to discharge home (Table 1). Patients with VAP had no statistically significant
likelihood of death, but were more likely to require MV, and less likely to discharge home.
The probability of developing a VAP was 6%, developing a VAE was 15%, and
developing both VAE and VAP was 7%.
Conclusions: Critically injured trauma patients develop VAE at double the rate of VAP.
Compared to those with VAP alone, those who develop VAE are more likely to die and
utilize more MV. VAE is a quality measure with objective criteria that should be utilized
in trauma critical care units. Efforts should be made to identify risk factors for VAE as
these patients are at high risk for poor outcomes.
NOTES
 Session XXIII: Papers 58-65
Paper 61: 3:20-3:40 pm
TRAUMA ICU PREVALENCE PROJECT (TRIPP: THE PHENOTYPE OF A
TRAUMA ICU. AN AAST MULTI-INSTITUTIONAL STUDY
Christopher P. Michetti* MD, Samir Fakhry* MD, Karen Brasel* MD, Niels Martin*
MD, Erik Teicher MD, Anna Newcomb Ph.D., Inova Fairfax Hospital
Invited Discussant: Bryce Robinson, MD, MSc

Introduction: Specialized trauma ICU (TICU) care has considerable impact on patient
outcomes. Few studies describe where and how TICU care is delivered. We hypothesized
that assessment of TICU structure and function would uncover strengths, disparities and
opportunities to improve surgical critical care delivery in TICUs.

Methods: This was a 1-day, multicenter prevalence study (11/2/17). Participants supplied
information about their trauma centers, staff, clinical protocols, and study TICU (ICU
where majority of critical trauma patients were admitted).

Results: 27 Level I and 3 Level II trauma centers from across the U.S. participated;
21(70%) had <750 beds and treated 1000-3000 trauma activations/year. Median # of
hospital ICU beds was 102. Half were “closed” ICUs and 23 (76%) required an intensivist
consult. Ten (33%) ICUs were classified as trauma (>80% of patients were trauma), 15
(50%) surgical/trauma, and 5 (16%) medical-surgical. Intensivists were present 24 hours/
day in 25 (83%). Centers reported a median of 8 [IQR 6.25–10] full-time trauma surgeons
and 10 [7-12.75] intensivists. Trauma surgeons’ ICU duties comprised 25% of their
clinical time and 20% of their overall work time. 97% of ICUs conducted hand hygiene
surveillance, 80% used a daily patient care checklist, 86% included families in rounds,
43% had triggers for goals of care discussions, 13% had routine therapist-family
meetings, 36% had organized support activities after discharge, and 13% participated in
the American Trauma Society’s Trauma Survivors Network. Protocol use is listed in the
Table.

Conclusion: A survey of structure and function of Trauma ICUs at a sample of high level
trauma centers revealed significant variation including care delivery models and protocol
use suggesting that opportunities may exist to improve care through sharing of best
practices.
NOTES
 Session XXIII: Papers 58-65
Paper 62: 3:40-4:00 pm
Twenty-four hour versus Extended Antibiotic Administration After Surgery in
Complicated Appendicitis: A Randomized Controlled Trial
Sten Saar MD, Vladislav Mihnovitš BS, Thomas Lustenberger MD, Mariliis Rauk MD,
Vappu Zobel MD, Erast-Henri Noor MD, Edgar Lipping MD, Andrus Lomp BS,
Karl-Gunnar Isand MD, Urmas Lepner MD,Ph.D., Peep Talving* MD,Ph.D., University
Of Tartu
Invited Discussant: Robert Sawyer, MD

Introduction: A recent prospective investigation suggested that a three-days antibiotic

administration was non-inferior to a five-day therapy following appendectomy for
complicated appendicitis [1]. Another retrospective investigation noted that 24-hour
antibacterial therapy was non-inferior to extended administration [2]. We set out to
investigate noninferiority of 24-hour therapy to extended treatment after appendectomy in
complicated appendicitis in a pilot randomized controlled trial.
Methods: After IRB approval, all consecutive adult patients with complicated
appendicitis (gangrenous, perforated appendicitis, and periappendicular abscess)
subjected to appendectomy between 5/2016 and 12/2017 were randomly assigned to
antibacterial therapy limited to 24 hours vs. >24 hours (extended administration) after
appendectomy. Relevant exclusion criteria were applied. 30-day follow-up was available
for all patients. Primary outcomes included post-operative complications and
Comprehensive Complication Index (CCI). Secondary outcome was hospital length of
stay (HLOS).

Results: A total of 70 patients were enrolled with 34 and 36 cases in the 24-hour and the
extended-therapy group, respectively. Demographic profile was similar between the study
groups. Laparoscopic appendectomy was performed in 88.2% and 94.4% of patients in
the 24-hour and extended group, respectively ( p=0.42). Overall rate of complications
was 20.6% and 30.6% in the 24-hour and extended group, respectively (OR 1.70; 95% CI
0.57-5.06; p=0.34). Mean CCI did not differ between the study groups (p=0.53). HLOS
was significantly reduced in the 24-hour group (61.3 ± 35.7 vs. 81.4 ± 39.6 hours,
p=0.03).

Conclusion: In the current prospective randomized investigation, 24-hour

post-appendectomy antibiotic administration did not result in a worse primary outcome.
However, the 24-hour antibacterial administration resulted in a significant reduction in
HLOS with a major cost saving perspective.
References:
1. van Rossem CC et al. Antibiotic Duration After Laparoscopic Appendectomy for
Acute Complicated Appendicitis. JAMA Surg. 2015;18:1-7.
2. Kimbrell AR et al. Do postoperative antibiotics prevent abscess formation in
complicated appendicitis? Am Surg. 2014;80(9):878-83.
NOTES
 Session XXIII: Papers 58-65
Paper 63: 4:00-4:20 pm
P-SELECTIN IS CRITICAL FOR DE NOVO PULMONARY ARTERIAL
THROMBOSIS FOLLOWING BLUNT THORACIC TRAUMA
Linda M. Schutzman MD, Ian E. Brown MD,Ph.D., Robert R. Rigor Ph.D., Nasim
Khosravi MD, Karen Chung BS, Joseph M. Galante* MD, University of California, Davis
Invited Discussant: Alicia Mohr, MD

Introduction: Thromboembolic events within the pulmonary arterial vasculature are a

particularly troublesome complication of severe blunt thoracic trauma. Mechanisms
underlying these events are currently in question as pulmonary thromboembolic events in
this population tend to be diagnosed more rapidly, more frequently and without an
associated systemic thrombosis. This study investigates the role of P-selectin in thrombus
formation through the use of in vivo blocking antibodies. We hypothesize that activation
of the endothelium and increased P-selectin expression is necessary for de novo
pulmonary arterial thrombosis in the setting of blunt thoracic trauma.

Methods: A murine weight-drop model of right lateral blunt thoracic trauma was used.
Wild-type mice in the experimental group were given blocking antibodies against
P-selectin prior to the trauma. All mice were euthanized at 24 hours for evaluation with
hematoxylin-eosin staining or immunofluorescent staining for CD41, fibrin and P-selectin.

Results: Injured mice that did not receive the P-selectin antibody had a 7 fold greater
fibrin accumulation (fluorescence per um of arterial wall) in comparison to uninjured
sham mice. Injured mice that did receive the P-selectin antibody had less than a 2 fold
increase than sham controls. Right and left lobes were compared to identify potential
differences due to direct versus indirect lung injury. Equal increases in mean fibrin
expression were noted on the coup side of injury and the countercoup side. No difference
in mean fibrin deposition was found between sham controls that received the P-selectin
blocking antibody and those that received an isotype control antibody.

Conclusion:The use of blocking antibodies demonstrates a critical role for P-selectin in

early eccentric fibrin accumulation at the intraluminal surface of pulmonary arteries
following blunt thoracic trauma.
NOTES
 Session XXIII: Papers 58-65
Paper 64: 4:20-4:40 pm
HIGH PERFORMANCE EMERGENCY GENERAL SURGERY HOSPITALS:
GOOD AT ONE OPERATION, GOOD AT THEM ALL
Michael P. DeWane MD, Nitin Sukumar MS, Marilyn J. Stolar Ph.D., Thomas M. Gill
MD, Adrian A. Maung* MD, Kevin M. Schuster* MD,MPH, Kimberly A. Davis*
MBA,MD, Robert D. Becher MD, MS Yale School of Medicine
Invited Discussant: Avery Nathens, MD, PhD, MPH

Introduction: There is a longstanding interest in the field of management science to

study high performance organizations. Applied to medicine, research on hospital
performance indicates that some hospitals are high performing, while others are not. The
objective of this study was to identify a cluster of high performing emergency general
surgery (EGS) hospitals, and assess whether high performance at one EGS operation was
associated with high performance on all EGS operations.
Methods: Adult patients who underwent 1 of 8 EGS operations were identified in the
California State Inpatient Database (2010-2011), which we linked to the American
Hospital Association database. Beta regression was used to estimate a hospital’s
risk-adjusted mortality, accounting for patient- and hospital-level factors. Cluster analysis
grouped hospitals by pattern of mortality rates across the 8 EGS operations using
z-scores. Logistic regression compared hospital characteristics by cluster.
Results: A total of 220 acute care hospitals were included. Three distinct clusters of
hospitals (Figure 1) were
defined based on assessment
of mortality for each
operation type: high
performing hospitals (n=66),
average performing (n=99),
and low performing (n=55).
The mortality by individual
operation type (x-axis in
Figure 1) at the high
performing cluster was
consistently 2 standard
deviations better than the
low performing cluster
(p<0.001). Within-cluster
variation was minimal at
high performing hospitals
compared to wide variation at low performing hospitals. A hospital’s high performance
in one EGS operation type predicted high performance on all EGS operation types.
Conclusion: High performing EGS hospitals attain excellence across all types of EGS
operations, with minimal variability in mortality. Poor performing hospitals are
persistently below average, even for low-risk operations. These findings suggest that
top-performing EGS hospitals are highly reliable, with systems of care in place to achieve
outstanding results. Further investigation and collaboration is needed to identify factors
associated with high performance.
NOTES
 Session XXIII: Papers 58-65
Paper 65: 4:40-5:00 pm
THE EGS GRADING SCALE FOR SKIN AND SOFT TISSUE INFECTIONS IS
PREDICTIVE OF POOR OUTCOMES : AN AAST MULTI-CENTER
VALIDATION STUDY
Stephanie Savage* MD, MS, Garth H. Utter* MD, MSc, Salina M. Wydo MD, Babak
Sarani* MD, Therese M. Duane* MBA,MD, Patrick B. Murphy MD,MPH, Martin D.
Zielinski* MD, Josh Tierney MD, Thomas J. Schroeppel* MD, MS, Leslie Kobayashi*
MD, Kevin Schuster* MD,MPH, Lava Timsina MPH,Ph.D., Marie Crandall* MD,MPH,
Indiana University School Of Medicine
Invited Discussant: Eileen Bulger, MD

Introduction: Over the last five years, the American Association for the Surgery of
Trauma (AAST) has developed grading scales for Emergency General Surgery (EGS)
conditions. An initial validation study was published in 2015, using diverticulitis as a
conceptual framework. Though the grading scale was predictive of complications and
length of stay, there was no association with mortality. As the EGS grading scales
encompass a diverse group of conditions, the purpose of this study was to validate the
grading scale concept against a different disease process with a higher associated
mortality. We hypothesized that the grading scale would be predictive of complications,
length of stay and mortality in skin and soft tissue infections (STI), including necrotizing
infections (NSTI).
Methods: This multi-institutional trial encompassed 12 centers. Weighted sampling was
used to ensure roughly balanced representation of disease severity. 100 patients were
identified from each center and data collection included demographics, disease
characteristics and outcomes such as mortality, overall complications, hospital and ICU
length of stay. The EGS scale for STI was used to grade each patient and two surgeons
provided grades to evaluate inter- rater
reliability. Pearson’s chi-squares, simple and
multiple logistic regressions and ANOVA
were used as appropriate. Estimates with 95%
confidence intervals were reported and
inter-rater reliability was assessed.
Results: 1170 patients were included in this
study. Inter-rater reliability was moderate
(kappa coefficient 0.472-0.642, with 64-76%
agreement). Higher grades (IV and V)
corresponded to significantly higher LRINEC
scores when compared with lower EGS grades
(LRINEC scores : Grade 1 2.55 (SD 2.3), Grade II 2.89 (SD 2.1), Grade III 2.91 (SD
2.3), Grade IV 4.40 (SD 2.4), Grade V 4.72 (SD 2.7), p < 0.0001). Patients with grade
IV and V STI had significantly increased odds of all complications, as well as ICU and
overall length of stay. These associations remained significant in logistic regression
controlling for age, gender, comorbidities, mental status and hospital-level volume.
Grade V disease was significantly associated with mortality as well (Table 1).
Conclusion: This second validation effort demonstrates continued moderate inter-rater
reliability. Grade IV and V STI are significantly predictive of complications, hospital
length of stay and Grade V disease was predictive of mortality. Though predictive ability
does not improve linearly with STI grade, this is reflective of a relatively dichotomous
disease process, in which cellulitis and abscess are milder disease processes and invasive
infections are highly morbid. This second validation study confirms the EGS grading
scale as predictive, and reproducible, in disparate disease processes.
NOTES
 AAST Annual Business Meeting
(Members Only)
Friday, September 28, 2018 5:00 PM-6:30 PM
Location: Seaport A-C, Second Level (Seaport Tower)

AAST Reception and Banquet

Friday, September 28, 2018, 7:30 PM-11:00 PM
Location: Seaport Foyer &
Seaport D-H, Second Level (Seaport Tower)
 PETER C. CANIZARO, M.D.
June 30, 1935 - September 3, 1990

Peter C. Canizaro was born on June 20, 1935, in Vicksburg, Mississippi. He received his B.A. degree
from the University of Texas, Austin, in 1956 and his M.D. degree from the University of Texas
Southwestern Medical School, Dallas, in 1960. Following an internship at Parkland Memorial
Hospital/UTSMS, he spent two years as a Captain in the Surgical Research Unit, Brooke Army
Hospital, Fort Sam Houston. Following another year as a NIH Research Fellow, he completed his
surgical residency at Parkland/UTSMS from 1964-1968. He remained on staff at Parkland/UTSMS
from 1968-1974, and then subsequently served on the faculty at the University of Washington (1974-
1976) and Cornell University Medical Center (1976-1981) where he became Professor of Surgery.
Dr. Canizaro became Professor and Chairman of the Department of Surgery at the Texas Tech
University Health Sciences Center in 1982 and remained there until his untimely death in 1990. Dr.
Canizaro was an innovative surgical scientist who made multiple contributions to the field of trauma
and resuscitation. Examples of topics covered in his published manuscripts include the following:

1960 Distribution changes in extraceullular fluid during

acute hemorrhage (with G. Tom Shires, M.D.)
1963 Use of dextran
1963 Use of hypertonic glucose
1969 Diagnostic abdominal paracentesis in trauma
1970 Fluid resuscitation of hemorrhagic shock
1971 Use of Ringer’s lactate during shock
1974 Oxygen-hemoglobin dissociation curve
1975 Stroma-free hemoglobin
1985 Ultrasound detection of fluid collection
1986 Endopeptidase in human lung
In recognition of Dr. Peter Canizaro’s outstanding contributions to the science of trauma,
the AAST has presented the Canizaro Award since 1993 to the best paper by a new
member in their first two years of membership.

PETER C. CANIZARO AWARD

1993 Philip S. Barie, M.D., M.B.A.

1994 Frederick A. Luchette, M.D.
1995 Patrick J. Offner, M.D.
1996 Rodney M. Durham, M.D.
1997 Ronald J. Simon, M.D.
1998 Charles N. Mock, M.D.
1999 David A. Spain, M.D.
2000 John T. Owings, M.D.
2001 Hans-Christoph Pape, M.D.
2002 Karen J. Brasel, M.D., M.P.H.
2003 James Jeng, M.D.
2004 Eileen M. Bulger, M.D
2005 Carnell Cooper, M.D.
2006 Saman Arbabi, M.D.
2007 Kari Hansen, M.D.
2008 Randall S. Friese, M.D.
2009 Andrew C. Bernard, M.D.
2010 Oscar D. Guillamondegui, M.D., M.P.H
2011 Jay Manaker, M.D., FACEP
2012 Stephanie Savage, M.D.
2013 Jason Smith, M.D.
2014 Sarah Majercik, M.D.
2015 Matthew B. Bloom, M.D.
2016 Jon Simmons, M.D.
2017 Scott Brakenridge, M.D.
 Session XXV: Plenary Session - #66-68
Saturday, September 29, 2018, 8:00 AM-9:00 AM
Location: Seaport A-C, Second Level (Seaport Tower)
Moderator: Eric Toschlog, MD
Recorder: Thomas Esposito, MD, MPH
 Session XXV: Papers 66-68: Plenary Paper
66: 8:00-8:20 am
RESIILIENCE AND LONG-TERM OUTCOMES AFTER TRAUMA:
AN OPPORTUNITY FOR EARLY INTERVENTION?
Deepika Nehra MD, Juan P. Herrera-Escobar MD, Syeda S. Al Rafai MD, Joaquim
Havens* MD, Reza Askari* MD, Stephanie Nitzschke MD, George Velmahos* MD,
George Kasotakis MD, Karen J. Brasel* MD, Nomi Levy-Carrick MD, [Link], Ali
Salim* MD, Adil Haider* MD,MPH, Brigham and Womens Hospital
Invited Discussant: Ben Zarzaur, MD
Introduction: Resilience, or the ability to cope with difficulties, influences an
individual’s response to life events including unexpected injury. There are early life
experiences and biological variables that impact an individual’s response to adversity,
but research has demonstrated that resilience can be cultivated across the lifespan despite
adversity. We sought to assess the relationship between patient self-reported resilience
traits and functional and psychosocial outcomes six months after injury.
Methods: Adult trauma patients 18-65 years of age with moderate to severe injuries
(ISS ≥9) admitted to one of three Level I Trauma Centers between 2015-2017 were
contacted by phone at 6 months post-injury and asked to complete a validated Trauma
Quality of Life (T-QoL) survey and PTSD screen. The T-QoL survey assesses emotional
and physical well-being at the time of interview, in addition to recovery and resilience.
Patients were asked three questions to assess their resilience and the 5-point Likert scale
answers were used to classify the patients into “low” or “high” resilience categories
(Table 1). Long-term outcomes including functional limitations with activities of daily
living, return to work, chronic pain and the incidence of PTSD were compared between
groups. Adjusted logistic regression models were built to determine the association
between resilience and each of the long-term outcomes.

Results: A total of 222 patients completed the 6-month interview. 149/222 of the
patients (67%) were classified in the low resilience group. Mean age was 41±14 years
with 65% being male and 91% suffering a blunt traumatic injury. Average ISS was 15.5 ±
8.2 and 41% required ICU admission. Demographic and clinical characteristics were not
significantly different between the low and high resilience groups. After adjusting for
potential confounders we found that patients in the low resilience group had significantly
higher odds of functional limitations in activities of daily living. In addition, patients in
the lower resilience group were less likely to have returned to work/school, more likely to
report chronic pain and more likely to screen positive for PTSD (Table 2).

Conclusion: Patients with low resilience demonstrated worse functional and

psychosocial outcomes six months after injury. These data suggest that screening for
resilience and developing and deploying early interventions to improve resilience-
associated traits as soon as possible after injury may hold promise for improving
important long-term functional outcomes.
NOTES
 Session XXV: Papers 66-68: Plenary
Paper 67: 8:20-8:40 am
CORRELATION OF ON-CALL TRAUMA SURGEON FATIGUE
FLUCTUATIONS WITH BURNOUT RISK AND SURGICAL SKILL
PERFORMANCE
Brittany Lisjak PA-C, Irina Catanescu DO, Matthew L. Moorman MD, FACS, M. S.
O'Mara* MBA,MD, FACS, M. C. Spalding DO,Ph.D., Ohio Health Grant Medical Center
Invited Discussant: Heena Santry, MD

Introduction: Effects of fatigue are thought to be prevalent in the surgical profession, yet
descriptive metrics on fatigue are limited. We aimed to quantify trauma surgeon fatigue
while on 24-hour call, correlating to surgical task performance and burnout risk. We
hypothesize that fatigue levels differ significantly throughout call shifts and worse
average fatigue is associated with higher burnout risk and decreased surgical task
performance.
Methods: This was a 33 day, prospective, 9 trauma surgeon study at a Level I trauma
center. Call shifts were 24 hours. Fatigue was quantified for all subjects from actigraphy
monitors utilizing a validated alertness model. Surgeons with scores <70 sustained for
>/= 10% total shift time were labeled the “fatigued” group. A laparoscopic peg transfer
task was performed, recorded pre/post call and scored based on accuracy. At the end of
the trial period each surgeon completed a Maslach Burnout Inventory (MBI) to quantify
risk of burnout. Fatigue fluctuations were correlated with time of day, reported work
hours, sleep metrics, task performance, and MBI scores. Variables were compared
between the “fatigued” and “non-fatigued” groups.
Results: Post call fatigue levels were
significantly worse (80.8 vs 90.7,
p<0.001), more laparoscopic task errors
were made (p=0.05), and overall task
performance decreased (p=0.05) compared
to pre-call levels. The “fatigued” group had
shorter on-call sleep durations (160 vs 286
min; p = 0.007) and fatigued at a higher
velocity (p=0.02) when compared to
“non-fatigued” counterparts. Finally, a
strong correlation existed between increased
MBI burnout risk score and worsened surgeon fatigue (r = -0.69, p = 0.04). For every
one-point worse in fatigue score a surgeon had a 3.5x likelihood of increased risk of
burnout. There was no significant difference between groups in regards to hours worked
or sleep obtained three days prior to call.
Conclusion: Trauma surgeons experience a
significant increase in fatigue during a
24-hour call shift, average level of
surgeon fatigue is highly correlated with
self-assessment of burnout risk, and a trauma
surgeon’s ability to perform a surgical task is
significantly worse after a 24-hour call
shift. Future studies can expand
this investigational work to better
understand the impact of trauma surgeon
fatigue.
NOTES
 Session XXV: Papers 66-68: Plenary
Paper 68: 8:40-9:00 am
STOP FLAILING: THE IMPACT OF BICORTICALLY DISPLACED RIB
FRACTURES ON PULMONARY OUTCOMES IN PATIENTS WITH CHEST
TRAUMA - AN AAST MITC STUDY
Lara Senekjian MD, MSCI, Yekaterina Birkas BS, MBS, Milos Buhavac MBBS,
Saraswati Dayal MD, Sean Pierce MD, Jason Sperry* MD,MPH, Graciella Bauza MD,
Evert A. Eriksson* MD, Stuart Leon MD, Rachel Nygaard MD, Anthony Kopatsis MD,
Mario P. Marquez MD, Tammy Kopelman* MD, Forrest O. Moore* MD, Ram Nirula*
MD,MPH, University of Utah
Invited Discussant: Fredric Pieracci, MD, MPH

Introduction: Most studies examining outcomes related to thoracic trauma focus on the
presence or absence of flail chest, pulmonary contusion, hemothorax or pneumothorax
with little attention paid to bicortically displaced rib fractures. An association between
bicortical fractures and pulmonary outcomes such as pneumonia, ARDS and the need for
tracheostomy would influence care decisions. We therefore tested the hypothesis that
bicortical rib fractures were an important clinical marker for pulmonary outcomes in
non-flail chest trauma patients.
Methods: This AAST-MITC retrospective study analyzed bluntly injured adults with at
least 2 rib fractures collected from 9 US level I and II trauma centers from 2011 to 2016.
Each chest CT was independently reviewed and the location and severity of rib fractures
and pulmonary contusions were categorized. Univariate and multivariate logistic
regression analyses were performed to identify independent predictors of pneumonia,
ARDS and tracheostomy. Analyses were performed in non-flail patients as well as
controlling for flail chest to determine if bicortical fractures were independently
associated with pulmonary outcomes.
Results: Of the 1110 patients 103 (9.3%) developed pneumonia, 78 (7.0%) required
tracheostomy, and 30 (2.7%) developed ARDS. Bicortical fractures were present in 277
(25%) of all patients and in 206 (20.3%) of patients without flail chest. After adjusting
for patient demographics, injury and admission physiology, negative pulmonary
outcomes occurred more than twice as frequently in those with bicortical displacement
without flail chest - pneumonia (OR 2.01, 95% CI 1.1, 3.6), ARDS (OR 2.62, 95% CI
1.01, 6.82) and tracheostomy (OR 2.7, 95% CI 1.4, 5.2). Even when adjusting for the
presence of flail chest, bicortical displacement remained an independent predictor of
pneumonia, tracheostomy and ARDS.
Conclusion: Given that bicortical displacement can be difficult to identify on plain
radiography and its association with negative pulmonary outcomes, even in the absence
of flail chest, chest CT should be employed in the evaluation of rib fractures. Future
studies should investigate the utility of flail chest management algorithms such as
epidural and surgical stabilization on pulmonary outcomes in patients with bicortical
displacement.
NOTES
 Session XXVII: Quickshot Session I - #1-13
Saturday September 29, 2018, 9:00 AM-10:18 AM
Location: Seaport A-C, Second Level (Seaport Tower)
Moderator: Roxie Albrecht, MD
 Session XXVI: Quickshot I - 1- 13
Paper 1: 9:00-9:06 am
THE ACA AND EMERGENCY GENERAL SURGERY CHOLECYSTECTOMIES
Laura N. Godat* MD, Todd W. Costantini* MD, Jay Doucet* MD, University of
California, San Diego
Invited Discussant: Lance Stuke, MD, MPH

Introduction: Gallbladder disease is a common reason for visits to the emergency

department and frequently results in emergency general surgery (EGS). The Affordable
Care Act (ACA) was landmark legislation enacted in 2014 mandating health insurance
coverage for all. The ACA sought to improve access to care and decrease morbidity,
mortality and costs. We hypothesize that the ACA shifted EGS to teaching institutions,
and that the number of EGS cholecystectomies decreased as access to care improved.

Methods: This is a retrospective review using the National Inpatient Sample Database
from 2014 through quarter 3 of 2015. Patients age 18-64 who were admitted through the
emergency department with a diagnosis of gallbladder disease were identified by ICD-9
codes. Patient demographics, payer type (Medicaid, Private or Self-pay), Charlson
Comorbidity Index (CCI), hospital and regional characteristics and were obtained.
Outcomes were cholecystectomy, complications, mortality and wage index-adjusted
costs. The effect of the ACA was determined by comparing the pre-ACA (2012 & 2013)
years to the post-ACA years (2014 & 2015) and included univariate, bivariate and
adjusted Difference-in-Differences (DID) analyses.

Results: 189,023 patients with gallbladder disease were identified. In the post-ACA
period, the proportion of Self-pay admissions decreased from 19.3% to 13.6% (-5.7%,
p<0.001) and Medicaid admissions increased from 26.3% to 34.0% (+7.7%, p<0.001).
Private insurance admissions did not change significantly. Across all payer categories the
proportion of admissions to teaching hospitals increased, the number of EGS
cholecystectomies decreased, while complications increased (Figure). The portion of
patients with CCI≥2 increased significantly in all payer groups (Medicaid 20.0% to
21.1%, Private 13.8% to 15.5% and Self-pay 12.1% to 13.2% all p<0.05). Overall
mortality (pre-ACA 0.7% & post-ACA 0.8%, p=0.066) was unchanged within payer
groups. Median costs increased significantly for Medicaid and Private insurance while
Self-pay was unchanged. Based on adjusted DID analyses the number of EGS
cholecystectomies decreased more rapidly for Insured compared to Self-pay patients
(-2.7% vs. -1.21%, p=0.033) as did median cost (+$454.25 vs. +$113.60, p=0.017).

Conclusion: The ACA has changed EGS, shifting the majority of patients to teaching
institutions despite insurance type and decreasing the need for EGS cholecystectomy. The
trend towards higher complication rate with increased overall cost requires attention. A
national registry for EGS will better quantify these outcomes and could direct future
initiatives to improve EGS care.
NOTES
 Session XXVI: Quickshot I - 1- 13
Paper 2: 9:06-9:12 am
EMERGENCY GENERAL SURGERY IN GERIATRIC PATIENTS: HOW
SHOULD WE EVALUATE HOSPITAL EXPERIENCE?
Ambar Mehta MPH, Sanskriti Varma David T. Efron* MD, Bellal Joseph* MD, Nicole
Lunardi MSPH, Elliott R. Haut* MD,Ph.D., Zara Cooper* MD, Joseph V. Sakran
MD,MPH, MPA Johns Hopkins School of Medicine
Invited Discussant: Jody DiGiacomo, MD

Introduction: Emergency general surgery (EGS) remains a significant burden for

geriatric patients in the U.S. This study determined if either hospital proportion or annual
volume of geriatric patients is associated with outcomes after EGS procedures.
Methods: Using AAST criteria, we identified five EGS procedures in the 2012-2015
Nationwide Inpatient Sample in geriatric patients (65+ years old): small bowel resections,
large bowel resections, peritoneal adhesiolysis, control of GI ulcer and bleeding, and
laparotomy. We defined hospital volume as the absolute number of geriatric patients
undergoing EGS procedures, where hospital proportion referred to the ratio of geriatric
patients among all EGS procedures. To remove outliers, we excluded the top and bottom
5% of hospitals by proportion of geriatric patients. Hospitals were then divided into
quartiles both by proportion and by volume of geriatric patients. Logistic regressions
compared four outcomes between these quartiles: mortality, complications,
failure-to-rescue (FTR, death after a complication), and extended length of stay (eLOS,
procedure-specific top decile of patients). All regressions adjusted for both hospital
proportion and volume of geriatric patients, confounding factors, and clustering.
Results: We identified 25,084 EGS procedures in geriatric patients at 3528 hospitals
(mortality: 10.6%, complications: 30.5%, FTR: 27.7%, eLOS: 9.1%). The median
hospital proportion of geriatric patients among EGS procedures was 42.8% (IQR: 33.3%
to 52.2%), whereas the median hospital volume of these patients was 14/year (IQR:
8/year to 19/year). After adjustment, the lowest hospital proportion quartile relative to the
highest was associated with adverse outcomes: mortality (OR 1.21 [95%-CI 1.03-1.44]),
complications (OR 1.16 [1.05-1.29]), FTR (OR 1.32 [1.08-1.63]), and eLOS (OR 1.30
[1.12-1.50]). In contrast, the lowest volume quartile relative to the highest was not
associated with adverse outcomes (Table). Procedure-specific analyses revealed similar
findings. On sensitivity analyses, as the hospital proportion of geriatric patients increased
by 10%, the odds of all adverse outcomes decreased as follows: mortality by 7%,
complications by 4%, FTR by 9%, and extended LOS by 8%.

Conclusion: Higher hospital proportion of geriatric EGS patients, rather than hospital
volume, is associated with better postoperative outcomes. These findings have potential
implications for benchmarking endeavors.
NOTES
 Session XXVI: Quickshot I - 1- 13
Paper 3: 9:12-9:18 am
THE ACUTE ABDOMEN: FASTER AND SAFER WITH ACUTE CARE
SURGERY
David R. Jeffcoach MD, James W. Davis* MD, Alan Pang MD, Rachel Dirks Ph.D.,
UCSF Fresno
Invited Discussant: Brandon Bruns, MD

Introduction: There have been studies comparing outcomes between acute care surgery
(ACS) and traditional call models (TRAD) treating common surgical problems such as
acute appendicitis and acute cholecystitis. However, there is no data comparing these call
models for outcomes of patients with the complex acute abdomen. We hypothesized that
the ACS model would lead to more prompt care and fewer complications than the TRAD
model. The purpose of this study was to compare outcomes, patient flow and cost
between an ACS and TRAD model in the same community when treating the acute
abdomen.

Methods: The study was performed at two different medical centers in the same hospital
system; one a Level I Trauma center using an in house ACS call model, the other a
community hospital using a TRAD home call model. Medical records were searched for
ICD-9 codes, ICD-10 codes and CPT codes for the diagnoses of perforated viscous,
incarcerated with possible strangulated hernia, and diverticulitis with peritonitis requiring
emergent surgery from October 2011 through December 2017. Patients not requiring
emergent surgery were excluded. ACS and TRAD models were compared using
demographic data, time intervals to treatment, outcomes and cost.

Results: Over the study period, 1,465 patients had ICD-9, -10 or CPT codes meeting
screening criteria and 1,195 did not require emergent surgery leaving 269 patients in the
study cohort. There were 201 patients from the ACS center and 68 from the TRAD center
with similar rates of perforated viscus, hernia with possible strangulation and
diverticulitis requiring surgery. Time to surgeon at bedside was 46 min vs. 126 min
( p<0.001) and time from consult to operating room was 231 min vs. 309 min (p=0.011)
respectively. The American Society of Anesthesiologists (ASA) physical status
classification score was higher in the ACS group (p=0.011). While hospital length of stay
and cost were equivalent, the complication rate was significantly lower in the ACS group
(27% vs. 44%; p=0.01).

Conclusion: ACS was superior to TRAD when treating more complex abdominal
surgical emergencies with faster time to evaluation and reduced complications rates while
cost remained equivalent.
NOTES
 Session XXVI: Quickshot I - 1- 13
Paper 4: 9:18-9:24 am
OUTCOMES IN ADHESIVE SMALL BOWEL OBSTRUCTION FROM A
LARGE STATEWIDE DATABASE: WHAT TO EXPECT AFTER
NON-OPERATIVE MANAGEMENT
Lyndsey E. Wessels MD, Casey E. Dunne MPH, Richard Y. Calvo Ph.D., Jason M.
Bowie MD, William J. Butler MD, Vishal Bansal* MD, C. Beth Sise MSN, Michael J.
Sise* MD, Scripps Mercy Hospital Trauma Service
Invited Discussant: Jose Diaz, MD

Introduction: Although adhesive small bowel obstruction (ASBO) is frequently

managed non-operatively, little is known regarding outcomes on readmission following
this approach. We used a large-scale population-based database to examine patients
readmitted for ASBO who were initially managed non-operatively. We evaluated the risk
factors for operative intervention and mortality at readmission.
Methods: ASBO patients were identified from the California Office of Statewide Health
Planning and Development 2007-2014 discharge dataset. Patients who at primary
admission were either managed operatively or had an ICD-9 code for a chronic or
obstructive small bowel disease (e.g., Crohn’s, hernia) were excluded. Associations
between risk factors and both operative intervention and death following readmission
were evaluated using backward stepwise logistic regression.
Results: Of the 18,408 ASBO patients, we identified 3,656 (19.9%) who were
readmitted. Most were female (61.7%) and Caucasian (72.7%). Median age was 67 years
(range 18-102). The 1,474 (40.3%) requiring operation at readmission were younger (67
vs 69, p=0.001) and presented sooner (157 vs 320 days, p<0.001). After adjustment,
variables found protective against operative intervention were age ≥65 years (OR 0.84,
95%CI 0.73-0.96) and readmission after one year (OR 0.64, 95%CI 0.56-0.73). Risk of
operative intervention was associated with Hispanic ethnicity (OR 1.27, 95%CI
1.06-1.50) and LOS >2 days at index admission (OR 1.41, 95%CI 1.23-1.62). Patients at
greater risk for death were ≥65 years old (OR 5.12, 95%CI 2.62-10.01), were managed
operatively (OR 3.93, 95%CI 2.00-7.70), and had a readmission LOS >7 days (OR 2.47,
95%CI 1.37-4.46). Being discharged home after initial non-operative management was
protective against death in the adjusted multivariate model (OR 0.51, 95%CI 0.30-0.87).
Conclusion: In this large-scale study of patients readmitted for ASBO who were initially
managed non-operatively, those readmitted within a year were at greater risk for
operative intervention, and those who were ultimately managed operatively had a higher
risk of death. Prospective research is needed to further delineate outcomes associated
with initial non-operative management of ASBO.
NOTES
 Session XXVI: Quickshot I - 1- 13
Paper 5: 9:24-9:30 am
EGS PRESENTS GREATER FINANCIAL RISK THAN TRAUMA
Andrew C. Bernard* MD, Michael Baker BS, Andy Kelly MS, Daniel Davenport Ph.D.,
University of Kentucky
Invited Discussant: Oliver Gunter, MD
Introduction: Trauma and emergency general surgery (EGS) are two main pillars in acute
care surgery (ACS). EGS involves an older and more comorbid population and therefore be
associated with greater financial risk. We sought to determine the relative profitability of
trauma and EGS be analyzing cost and revenue.
Methods: Data were extracted from our healthcare data warehouse and the inpatient finance
database for emergency admissions ≥ 18 years to ACS Service at our referral level 1 trauma
center from 1/1/2015 to 12/31/2016. Outcomes, financial metrics, payor, case mix index
(CMI) and diagnosis-related group (DRG) were collected. Uninsured patients were
excluded. Complex care was defined as multiple services involved.
Results: There were 2216 EGS and 3249 trauma admissions. Trauma were more likely to
be admitted to the ICU (42% vs 32%, p<.001) but length of stay (LOS), ICU LOS and
mortality were the not different (Table). Complex care was more common in EGS. Trauma
were more likely to have managed care insurance (p<.001). EGS had lower CMI, total cost,
direct cost and indirect cost. But revenue for EGS was far lower than trauma, resulting in
lower contribution margin (revenue – direct cost) and net profit (net revenue – total cost).
Conclusions: Though outcomes are similar, EGS is associated with more care complexity
and narrower profit margin than trauma. Much higher revenue and net profit in trauma is
likely related to payor mix. Government insurance, more common in the older EGS
population, makes EGS less profitable. Cost reduction and revenue optimization strategies
more even more important in EGS in order to maintain a positive margin.
NOTES
 Session XXVI: Quickshot I - 1- 13
Paper 6: 9:30-9:36 am
Quantifying the Thousands of Lives Lost Due to Poor Emergency General Surgery
(EGS Outcomes: Why We Need A National EGS Quality Improvement Program
Zain G. Hashmi MBBS, Molly P. Jarman Ph.D., Joaquim M. Havens* MD, John W.
Scott MD,MPH, Eric Goralnick MD, MS, Zara Cooper* MD, Ali Salim* MD, Adil H.
Haider* MD,MPH, Brigham and Womens Hospital
Invited Discussant: Angela Ingraham, MD

Introduction: Nearly 4 million Americans present with an Emergency General Surgery

(EGS) condition annually, facing significant morbidity and mortality. Unlike elective
surgery and trauma, there is no dedicated national quality improvement program to
improve EGS outcomes. Our objective is to estimate the number of lives that could
potentially be saved through EGS quality improvement in the United States.
Methods: Adults with AAST-defined EGS diagnoses were identified in the Nationwide
Emergency Department Sample 2006-2014. Hierarchical logistic regression was
performed to benchmark treating hospitals into reliability adjusted mortality quintiles.
Weighted generalized linear modeling was used to calculate the relative-risk of mortality
at each hospital quintile, relative to best-performing quintile. We then calculated the
number of excess, potentially preventable deaths at each hospital quintile versus the
best-performing quintile using techniques that have previously been used to quantify
preventable
trauma
deaths.
Results:
Twenty six
million EGS
patients were
admitted and
6.5 million
(25%)
underwent an
operation.
In-hospital
mortality
varied from
0.3% to 4.1% across the treating hospitals. If all hospitals had outcomes similar to those
in the best-performing quintile, 158,177 lives could be saved. Overall, 47% of excess
deaths occurred at the worst-performing hospitals, while 27% of all excess deaths
occurred among the operative cohort.
Conclusion: Nearly 200,000 deaths could potentially be prevented in just over a decade
if EGS outcomes were improved across the nation. A national initiative to enable
structures and processes-of-care associated with optimal EGS outcomes is urgently
needed to achieve “Zero Preventable Deaths after Emergency General Surgery.”
NOTES
 Session XXVI: Quickshot I - 1- 13
Paper 7: 9:36-9:42 am
IMPACT OF A
SIMPLIFIED MANAGEMENT ALGORITHM ON OUTCOME FOLLOWING
EXSANGUINATING PELVIC FRACTURES: A 10-YEAR EXPERIENCE
Richard H. Lewis Jr., MD, MA, John P. Sharpe MD, Bennett Berning MD, Timothy C.
Fabian* MD, Martin A. Croce* MD, Louis J. Magnotti* MD, University of Tennessee
Health Science Center - Memphis
Invited Discussant: David Morris, MD
Introduction: Optimal management of exsanguinating pelvic fractures, specifically with
respect to stabilization (external pelvic fixation, pelvic orthotic device) and hemorrhage
control (angiography) remains controversial. Our previous experience suggested that
management decisions based on a defined algorithm were associated with a significant
reduction in transfusion requirements and mortality. Based on these outcomes, a clinical
pathway for the management of exsanguinating pelvic fractures was developed. The
purpose of this study was to evaluate the impact of this pathway on outcomes.
Methods: Consecutive patients over 10 years with blunt pelvic fractures (including vascular
disruption, open book component with symphysis diastasis, or sacroiliac disruption with
vertical shear) subsequent to the implementation of the clinical pathway were identified.
Data regarding patient characteristics, mechanism and severity of injury, severity of shock,
adherence to the pathway and outcomes including resuscitative transfusions and mortality
were recorded. Patients with hemodynamically unstable pelvic fractures are managed
initially with a pelvic orthotic device (POD). For those with continued hemodynamic
instability and no extra-pelvic source of hemorrhage, pelvic angiography was performed
followed by elective pelvic fixation. Patients managed according to
the pathway (PW) were compared to those patients whose management deviated from the
pathway (DEV).
Results: 3467 patients with pelvic fractures were admitted. 312 (9%) met entry criteria: 246
comprised the PW group and 66 the DEV group. Injury severity, as measured by ISS (35 vs
36, p=0.55) and admission GCS (10 vs 10, p=0.58), and severity of shock, as measured by
admission BE ( -7.4 vs -6.4, p=0.38) and admission SBP (107 vs 104, p=0.53), were similar
between the groups. There was also no significant difference in PRBC requirements during
initial resuscitation (6.1 vs 6.6 units, p=0.22). POD use was only 48% in the
DEV group (p<0.001). Only 24% of the PW group required angiography compared to 74%
of the DEV group (p<0.001). Both 48-hour transfusions (11 vs 16, p=0.01) and mortality
(35% vs 48%, p=0.04) were reduced in the PW group compared to the DEV group.
Pathway adherence was identified as an independent predictor of both decreased
transfusions (β =-5.8, p=0.002) via multiple linear regression and decreased mortality (OR
0.38; 95%CI 0.14-0.51) via multivariable logistic regression after adjusting for age, gender,
injury severity and severity of shock.
Conclusion: Adherence to a defined clinical pathway simplified the management of
exsanguinating pelvic fractures and contributed to a reduction in both transfusion
requirements and mortality. Use of this pathway has facilitated the rapid control of life-
threatening pelvic hemorrhage while providing the opportunity for definitive operative
fixation in a more controlled fashion. In fact, by consistently managing these complex
pelvic fractures according to a defined algorithm, an acceptably low morbidity and
mortality can be achieved and maintained.
NOTES
 Session XXVI: Quickshot I - 1- 13
Paper 8: 9:42-9:48 am
BLUNT SMALL BOWEL PERFORATION (SBP: A MULTICENTER UPDATE
15 YEARS LATER
Samir M. Fakhry* MD, Pamela L. Ferguson Ph.D., Ahmed Allawi MD, Christopher P.
Michetti* MD, Anna B. Newcomb Ph.D., Chang Liu Ph.D., East MultiCenter SBP Study
Group . Synergy Surgicalists
Invited Discussant: Stephen Gale, MD

Introduction: Previous work demonstrated delays in the diagnosis of blunt SBP with
increased mortality associated with inability of CT scans to reliably exclude the
diagnosis. We conducted a follow-up multicenter study to determine if these challenges
persist 15 years after the original study.
Methods:This multi-center study selected adult cases with ICD-9 CM code for blunt
SBP=863.20, no other major injury and at least one abdominal CT within the initial 6
hours. Cases were matched to controls who did not have SBP. Hospital and individual
patient data from each center were collected and analyzed. All centers had IRB approval.
Results: Data were available from 39 centers (33 had SBP cases) with 127,919 trauma
admissions and 94,743 trauma activations from 10/2013 to 9/2015. 25 centers were Level
1. There were 77 cases (mean age 39, 67.5% male, mean LOS 11.2) and 131 matched
controls (mean age 44, 64.9% male with LOS 3.6). SBP cases were 0.06% of admissions
and 0.08% of activations. Mean time to surgery was 8.43 hours (median 3.68, IQR
1.95-10.33). Initial CT scan
showed free air in 31 cases (40%)
and none in controls (table). Initial
CT scan was within normal limits in
3 case patients (4.2%) and 84
controls (64%). 5 case patients had
a second CT scan; two showed free
air (one had an initial normal CT
scan). One death occurred among
the case patients (mortality rate
1.3%) with a time to surgery of 13.8
hours. Multivariate logistic
regression analysis showed that
abdominal tenderness, abdominal
distention, peritonitis, bowel wall
thickening, free fluid and contrast
extravasation were significantly
associated with SBP.
Conclusion: Blunt SBI remains
relatively uncommon and continues
to present a diagnostic challenge 15
years after our initial multicenter
study. Trauma centers appear to
have shortened time to surgical
intervention with an associated
decrease in case mortality. Initial
CT scans continue to miss a small
but significant number of cases with potentially serious consequences making heightened
awareness of this injury and continued clinical vigilance paramount.
NOTES
 Session XXVI: Quickshot I - 1- 13
Paper 9: 9:48-9:54 am
THE NEED FOR TRAUMA INTERVENTION (NFTI DEFINES MAJOR
TRAUMA MORE ACCURATELY THAN INJURY SEVERITY SCORE (ISS
AND REVISED TRAUMA SCORE (RTS: DATA FROM A COLLABORATION
OF 35 ADULT AND PEDIATRIC TRAUMA CENTERS.
Jacob W. Roden-Foreman BA, Nakia R. Rapier RN, Michael L. Foreman* MD,
Raymond A. Coniglio RN, Constance E. McGraw MPH, Abigail R. Blackmore RN,
Vaidehi Agrawal Ph.D., John D. Cull* MD, Marie Campbell RN, Melinda A. Weaver
RN, Kevin W. Sexton MD, Jeremy Holzmacher MD, Joseph C. Hess Ph.D., Cheryl F.
Workman MSN, The Trauma Measurement Workgroup Baylor University Medical
Center At Dallas
Invited Discussant: William Hoff, MD

Introduction: A patient’s trauma burden is dependent on anatomic injury, physiologic

derangement, and depletion of reserve. Major anatomic injury is typically defined as ISS
>15 and major physiologic derangement defined as RTS <4, but there is no common
measure of reserve. The Need For Trauma Intervention (NFTI) was developed to identify
early consumption of critical resources—thought to reflect major depletion of
reserve—based on: (1) receiving PRBC within four hours of arrival; (2) discharge from
the ED to the operating room within 90 minutes; (3) discharge from the ED to
interventional radiology; (4) discharge from the ED to the ICU with ICU length of stay
(LOS) ≥3 days; (5) therapeutic mechanical ventilation within three days; or (6) mortality
within 60 hours. Patients meeting any of these criteria are classified NFTI+ and
considered to have severely depleted reserves given their need for emergent intervention
and/or early mortality. We hypothesized that NFTI would be a better predictor of
outcomes and resource requirements than ISS or RTS.
Methods: 35 adult and pediatric US trauma centers submitted data for 88,083 patients.
Generalized estimating equations with robust standard errors modeled the effects of ISS
>15, RTS <4, and NFTI+ on the odds of mortality, complication, and receiving a full
trauma team activation (TTA), as well as LOS and number of procedures performed in 3
days. All models controlled for these three definitions of major trauma, as well as age,
mechanism of
injury, and hospital.
Results: For all
outcomes except
receiving full TTA,
NFTI was a
significantly better
predictor than ISS
or RTS. The odds of
receiving full TTA
were highest with
RTS, however,
RTS’s large confidence intervals and smaller Wald χ 2 indicate its predictions may be
less reliable. Further, RTS was not predictive of LOS or number of procedures in 3 days.
Conclusion: In this multicenter study, NFTI out-performed the standard anatomic and
physiologic definitions of major trauma. By determining depletion of reserve via resource
consumption, NFTI appears to be less affected by the idiosyncrasies that confound ISS
and RTS (e.g., frailty, comorbidities). NFTI+, therefore, appears to be a better definition
of major trauma than ISS >15 and RTS <4. Use of NFTI may enable improved triage
monitoring and better case-mix adjustment.
NOTES
 Session XXVI: Quickshot I - 1- 13
Paper 10: 9:54-10:00 am
DIAGNOSIS OF DIAPHRAGM INJURIES USING MODERN 256 SLICE CT
SCANNERS: TOO EARLY TO ABANDON OPERATIVE EXPLORATION
Rindi Uhlich MD, Parker Hu MD, Jeffrey Kerby* MD,Ph.D., Patrick Bosarge MD,
University of Alabama Birmingham
Invited Discussant: David Skarupa, MD

Introduction: Missed injury of the diaphragm may result in hernia formation, enteric
strangulation, and death. Compounding the problem, diaphragmatic injuries are rare and
difficult to diagnose with standard imaging. Consequently, for patients with high
suspicion of injury, operative exploration remains the gold standard for diagnosis. As no
current data exists, we sought to perform a pragmatic evaluation of the diagnostic ability
of 256-slice multi-detector CT scanners for diagnosing diaphragmatic injuries after
trauma.

Methods: A retrospective review of trauma patients from 2011-2018 with acute

diaphragm injury was performed at an ACS verified Level 1 trauma center. Two separate
levels of CT scan technology, 64-slice and 256-slice, was used during this time period.
Patients without standard CT imaging prior to operative intervention were excluded.
Imaging reports were reviewed for the diagnosis of diaphragm injury. Injuries were
subsequently graded using operative description per AAST guidelines. Patient
demographics, injury patterns, operative details, and outcome results were further
recorded.

Results: Two-hundred fifty-nine patients were identified with 62.5% (162/259) receiving
preoperative CT scan. The majority underwent 64-slice CT (138/162, 85.2%). Comparing
patients receiving 64 or 256-slice CT scan, there was no difference in the side of injury
(left side 57.5% vs. 70.8%, p = 0.43) or median injury grade [3 (3, 3) vs. 3 (2, 3)]. 256
–slice CT successfully diagnosed diaphragm injury in 58.3% (14/24) while 64-slice CT
identified 47.0% (63/138) of injuries. The false negative rate was lower with 256-slice
than 64-slice CT (43.5% vs. 53.8%) overall, among left sided injuries (37.5% vs. 54.2%),
and both blunt (16.7% vs. 33.3%) or penetrating (47.1% vs. 62.1%) mechanisms of injury.

Conclusion: New 256-slice multi-detector CT offers improved diagnostic sensitivity in

comparison to 64-slice CT. However, given the continued high false negative rate of the
256-slice CT scanner, operative exploration is still required for high suspicion of injury.
NOTES
 Session XXVI: Quickshot I - 1- 13
Paper 11: 10:00-10:06 am
HOW SAFE AND EFFECTIVE ARE SMALL-BORE CHEST TUBES AT
MANAGING DELAYED HEMOTHORACES COMPARED TO LARGE-BORE
CHEST TUBES?
John Cordero MD, Alessandro Orlando MPH, Rebecca Vogel MD, Matthew M. Carrick*
MD, Allen Tanner II, MD, David Bar-Or MD, St. Anthony Hospital
Invited Discussant: Ali Salim, MD

Introduction: LB tubes are the standard treatment for emergent hemothoraces (HTXs),
but treatment of delayed HTXs remains variable. Previous studies have suggested that
small bore (SB, ≤14Fr.) pigtail tubes have the same efficacy for treating traumatic
HTXs as large bore (LB, >14Fr.) tubes, but data continues to be insufficient. The goal of
our study was to analyze the outcomes of SB tubes in patients with delayed HTX. We
hypothesized that SB tubes would be as safe and effective as LB tubes.

Methods: This was a retrospective observational study across 7.5yrs at 3 Level 1 trauma
centers. We included patients 1) diagnosed with a HTX, or multiple rib fractures with
bloody effusion from chest tube; 2) with an initial chest tube placed ≥36h from
hostpial arrival. We excluded tubes placed for hemopneumothoraces. SB tubes were
compared to LB tubes. The primary outcome was tube failure (requiring an
additional/replacement tube or video-assisted thoracoscopy [VATS]). Secondary
outcomes were tube falling out or clogging, pleural empyema, pneumonia, retained HTX
(persistent heterogeneous fluid collection detected by CT ≤14d from initial chest tube
placement and requiring intervention), time on chest tube, return to prior function
(obtained from discharge physical therapy note), and in-hospital mortality. Patients could
have had more than one tube in this study and possibly had bilateral tube placement.
Dependent and independent analyses were used to assess primary and secondary
outcomes. A repeated measures mixed model compared the mean time each tube was
placed by tube group (SB vs. LB); the facility was included as a random effect. All tests
were two-tailed with an alpha of 0.05. This study was IRB-approved at all sites.

Results: There were 161 SB patients (196 tubes) and 38 LB patients (46 tubes). There
were no significant differences between study groups in 13 demographic or injury
characteristics. 23 patients had bilateral chest tubes. The median (IQR) tube size for each
group was as follows: SB [12Fr. (12-14)] and LB [32Fr. (28-32)]. There was no
significant difference in SB and LB groups in the mean (SE) time each tube was in place
(91 [24.2] vs. 118 [50.7] hrs, p=0.63). The failure rate of SB tubes was significantly
smaller than LB tubes (7% vs. 20%, p<0.001). LB tubes placed in the operating room had
nearly 3-fold the failure rate of those placed at the bedside (33% vs. 12%). SB tubes
placed in interventional radiology (IR) had 2-fold the failure rate of those placed at the
bedside (9% vs. 5%). SB tubes clogged or fell out significantly more often than LB tubes
(4% vs. 0%, p<0.001, both); clogged SB tubes ranged 10–14Fr, while those that fell out
ranged 12–14Fr. There was no significant difference between SB and LB tubes in rates of
retained HTX (14% vs. 13%, p=0.86), pneumonia (9% vs. 0%, p=0.08), in-hospital
mortality (1% vs. 5%, p=0.09), or returning to prior function (36% vs. 26%, p=0.27).

Conclusion: SB tubes had a significantly smaller failure rate, similar complication rates,
and similar return to prior function rate, compared to LB tubes; however, SB tubes were
significantly more prone to clogging and falling out. The median size of SB tubes in this
study was smaller than those previously reported in the literature. Our multi-center data
lend support to the use of SB tubes for the management of delayed HTXs.
NOTES
 Session XXVI: Quickshot I - 1- 13
Paper 12: 10:06-10:12 am
COMPARISON OF 7 AND 11-12 FRENCH ACCESS FOR REBOA: RESULTS
FROM THE AAST AORTIC OCCLUSION FOR RESUSCIATION IN TRAUMA
AND ACUTE CARE SURGERY (AORTA REGISTRY
Joseph J. DuBose* MD, Jonathan Morrison MD, Megan Brenner* MD, Laura Moore*
MD, John Holcomb* MD, Kenji Inaba* MD, Jeremy Cannon* MD, Mark Seamon* MD,
David Skarupa* MD, Ernest Moore* MD, Chuck Fox* MD, Joseph Ibrahim MD,
Thomas M. Scalea* MD, Uniformed Services University Of The Health Sciences
Invited Discussant: Michael Sise, MD

Introduction:The introduction of low profile devices designed for Resuscitative

Endovascular Balloon Occlusion of the Aorta (REBOA) after trauma has the potential to
change practice, outcomes and complication profiles related to this procedure.

Methods:The AAST Aortic Occlusion for Resuscitation in Trauma and Acute Care
Surgery (AORTA) registry was utilized to identify REBOA patients from 16 centers
-comparing presentation, intervention and outcome variables for those REBOA via
traditional 11-12 F access platforms and trauma-specific devices requiring only 7 F
access.

Results:From Nov 2013-Dec 2017, 242 patients with completed data were identified,
constituting 124 7F and 118 11-12F uses. Demographics of presentation were not
different between the two groups, except that the 7F patients had a higher mean ISS (39.2
vs. 34.1, p = 0.028). 7F device use was associated with a lower cut-down requirement for
access (22.6% vs. 37.3%, p = 0.049) and increased ultrasound guidance utilization (29.0%
vs. 23.7%, p = 0.049). 7F device afforded earlier aortic occlusion in the course of
resuscitation (median 25.0 mins vs. 30 mins, p = 0.010), and had lower median PRBC
(10.0 vs. 15.5 units, p = 0.006) and FFP requirements (7.5 vs. 14.0 units, p = 0.005). 7F
patients were more likely to survive 24 hrs (58.1% vs. 42.4%, p = 0.015) and less likely
to suffer in-hospital mortality (57.3% vs. 75.4%, p = 0.003). Finally, 7F device use was
associated with a 4X lower rate of distal extremity embolism (20.0% vs. 5.6%, p =
0.014;OR 95% CI 4.25 [1.25-14.45]) compared to 11-12F counterparts.

Conclusion:The introduction of trauma specific 7F REBOA devices appears to have

influenced REBOA practices, with earlier utilization in severely injured hypotensive
patients via less invasive means that are associated with lower transfusion requirements
and improved survival. Additional study is required to determine optimal REBOA
utilization.
NOTES
 Session XXVI: Quickshot I - 1- 13
Paper 13: 10:12-10:18 am
THE IMPACT OF IN-HOSPITAL COMPLICATIONS ON THE LONG-TERM
FUNCTIONAL OUTCOMES OF TRAUMA PATIENTS: A MULTICENTER
STUDY.
Jae Moo Lee BA, Juan Herrera-Escobar MD, Michel Apoj BA, Syeda Al Rafai MD,
MHA, Kelsey Han BA, Deepika Nehra MD, Ali Salim* MD, Karen Brasel* MD,MPH,
George Kasotakis* MD,MPH, George Velmahos* MD,Ph.D., Adil Haider* MD,MPH,
Haytham Kaafarani* MD,MPH, Massachusetts General Hospital
Invited Discussant: David Efron, MD

Introduction: The long-term consequences of in-hospital complications in trauma

patients remain largely unknown. We sought to study the impact of complications on the
long-term functional outcome of trauma patients.
Methods: All patients with Injury Severity Score (ISS) ≥ 9 admitted to three Level I
Trauma Centers between 2015 and 2017 were contacted by phone at 6-12 months
post-injury and administered a validated Trauma Quality of Life survey assessing for
functional limitation (FL). FL was defined as the inability to independently perform one
or more activities of daily living (ADL; e.g. driving, walking on flat surfaces/upstairs,
dressing, cooking/preparing meals). The medical records were systematically reviewed
for additional demographic/socioeconomic variables, comorbidities, injury
mechanism/type/severity and the occurrence of pre-defined in-hospital complications.
The impact of complications on FL was assessed using univariate then multivariate
logistic regression models.
Results: Out of a total of 2511 patients, 1022 patients were included. The mean age was
58 years, 56% were male, 94% had blunt trauma, and the mean ISS was 15. A total of
168 patients (16.4%) had at least one in-hospital complication and reported significantly
more FL in most ADLs at 6-12 months, compared to those without complications
[Figure]. In multivariable analyses, adjusting for all other variables, the occurrence of an
in-hospital complication was associated with a greater likelihood of FL at 6-12 months
post-injury [OR = 1.82, 95% CI 1.22-2.69, P = 0.003].
Conclusion: Trauma patients with in-hospital complications have worse functional
long-term outcome. In addition to primary complication prevention, more rehabilitation
resources should be made available to the subgroup of trauma patients who survive
complications.
NOTES
Session XXVIII: Quickshot Session II - #14-26 Saturday
September 29, 2018, 10:30 AM-11:48 AM Location:
Seaport Foyer, Second Level (Seaport Tower)
Moderator: Elliott Haut, MD, PhD
 Session XXVII: Quickshot II - 14-26
Paper 14: 10:30-10:36 am
ARE YOU KIDDING? PEDIATRIC TRAUMA CENTER VERIFICATION
IMPROVES OUTCOMES AT AN ADULT CENTER
Sean R. Maloney MD, Eric J. Grossman MD, Ashley B. Christmas* MD, Kyle W.
Cunningham MD, Megan E. Waddell RN, BSN, CPEN, Ronald F. Sing* DO, Carolinas
Medical Center
Invited Discussant: Daniel Margulies, MD
Introduction: Trauma continues to be the greatest mortality cause in children. It is known
that trauma centers improve outcomes with 103 pediatric trauma centers in the US, of
which 54 are level 1. We undertook this study to assess potential outcome improvements
associated with the transition from ACS level 2 verification to level 1 status at our
pediatric trauma center.

Methods: Pediatric trauma patient outcomes were assessed from Fall 2014- Fall 2017.
Within this time frame 20 pediatric clinical guidelines were formed. In 2013, our facility
added its first Pediatric Trauma Medical Director.

Results: For all pediatric patients, the risk adjusted major complication odds ratio (OR)
was 2.94 in Spring 2015, decreased to 2.03 in Fall 2015 and decreased to 0.86 in Fall 2017.
Including death as a complication yielded a similar trend. Analysis of patients aged 0-13
years showed an OR decrease from Spring 2015 to Fall 2015 to Fall 2017 (2.50 to 1.83 to
1.24). Subgroup analysis of the traumatic brain injury cohort, demonstrated similar results
(2.02 vs. 1.43 vs. 0.88). There was also a decrease in median length of stay from 3.0 days
to 2.0 days from 2015 to 2017. Pneumonia rates in intubated patients decreased throughout
this time period (13.3% to 10.8% to 0.2%) as well as unplanned admission to the ICU
(5.2% to 0.8% to 0.4%). Of note, for patients requiring craniotomy, median time to the
operating room decreased from 4 hours to 2 hours.

Conclusion: During preparation for ACS level 1 pediatric trauma center verification in
2016, our institution noted significant improvements in the outcomes of pediatric trauma
patients. Our study is one of the first to look specifically at the improvements in care that
are associated with becoming a level 1 pediatric trauma center. Furthermore, these
improvements became even more pronounced following the verification process.
NOTES
 Session XXVII: Quickshot II - 14-26
Paper 15: 10:36-10:42 am
TRAUMA OVER-TRIAGE, CONCURRENT TRAUMA ACTIVATION AND OVERLAPPING
EGS SURGERY ARE NOT ASSOCIATED
WITH SHORT OR LONG TERM MORTALITY IN EGS PATIENTS
Matthew C. Hernandez MD, Eric J. Finnesgard BA, Johnathon M. Aho MD,Ph.D., Michelle Junker
MD, Ariel Knight MD, Brian D. Kim* MD, Mariela Rivera
MD, Daniel Stephens MD, Beth A. Ballinger MD, Donald H. Jenkins* MD, Martin D. Zielinski* MD,
Henry J. Schiller* MD, Mayo Clinic - Rochester
Invited Discussant: Sasha Adams, MD
Introduction: Acute care surgeons manage urgent and emergent tasks that often temporally overlap.
Concurrent operations are perceived to impact patient care. However, little is known about the impact
of concurrent activities such as trauma activations (TA) with emergency general surgical operations
(EGS). We sought to evaluate the frequency and impact of concurrent activity at an institution where a
single surgeon takes call for all aspects of acute care surgery at night. We hypothesized that trauma
over-triage rates, concurrent activities, and overlapping surgery would affect EGS patient mortality.
Methods: A single institutional review of historical data was performed. Trauma and EGS admissions
(for January 2016-July 2017) were reviewed. We included adults (>15 years-old for trauma, ≥18 years-
old for EGS). All EGS operations and TA during day-time hours (08:00-16:30) were excluded as
multiple surgeons would have been present to provide coverage. Patients were categorized as
concurrent when a TA (notification to ED discharge) coincided with an EGS operation (incision to
closure). EGS overlap was defined as two EGS cases in progress at the same time but the critical
portion of the case did not. Baseline demographics, ISS (Injury Severity Score), American Association
for the Surgery of Trauma (AAST) EGS grade, American Society of Anesthesiologist (ASA) score,
duration of hospitalization, 30-day readmission, 30-day and overall mortality were abstracted. Monthly
triage rates were calculated by Cribrari Matrix method, trauma over-triage was considered at >50%.
Unadjusted Kaplan-Meier analysis and adjusted Cox proportional hazards models quantified survival.
Results: In this study, EGS (n=1135), and TA (n=1324) patients were reviewed. The monthly triage
rate ranged from 37 to 70% (median 56%). The overall concurrent activity rate for EGS and TA was
62.5% (n=710). The EGS overlapping surgery rate was 26.5% (n=301). Outcomes in EGS patients
with concurrent TA were similar to those without TA with regard to duration of stay (median [IQR]) (2
[0-9] versus 4 [1-11] days, p=0.74), 30-day mortality rates (5.5% versus 5.6%, p=1), and 30-day
readmission (49.4% versus 44.9%, p=0.16). Similarly, outcomes in TA patients that coincided with a
concurrent EGS case did not differ significantly for duration of stay (4 [2-7] versus 4 [2-8] days,
p=0.54), 30-day readmission rates (10.4% versus 8.5%, p=0.88) or thirty-day mortality rates (3.5%
versus 3%, p=0.64). In operative EGS patients, factors that were independently associated with thirty-
day and one year mortality included AAST EGS grade, ASA, and age but not overlapping EGS
surgery, concurrent TA activation, or trauma over-triage rate >50% Table.
Conclusions: To foster transparency and examine adequate staffing we aimed to define the extent of
concurrent and overlapping acute care surgical tasks at night. The rate of concurrent EGS and TA was
62.5% when a single surgeon was covering night call. In this initial analysis, concurrent TA, trauma
over-triage (>50%), or overlapping EGS surgeries did not appear to impact thirty day or one-year EGS
patient mortality. Conversely, increased patient EGS disease severity, age, and ASA score were
associated with short and long term mortality. Prospective study is required to better appraise acute
care surgical practices, concurrent activities and their impact on patient specific outcomes.
NOTES
 Session XXVII: Quickshot II - 14-26
Paper 16: 10:42-10:48 am
BETA-ADRENERGIC BLOCKADE FOR TREATMENT OF TRAUMATIC BRAIN INJURY:
A RANDOMIZED CONTROLLED TRIAL
Thomas J. Schroeppel* MD, MS, John P. Sharpe MD, MS, Charles P. Shahan MD, MS, L. P.
Clement PharmD, Louis J. Magnotti* MD, Marilyn Lee PharmD, Micheal Muhlbauer MD, Jordan A.
Weinberg* MD, Elizabeth A. Tolley PhD, Martin A. Croce* MD, Timothy C. Fabian* MD,
Univeristy Of Colorado Health - Memorial Hospital
Invited Discussant: Bryan Cotton, MD
Introduction: Traumatic brain injury (TBI) is a leading cause of death and disability. While options
for preventing primary injury are limited, routine interventions preventing secondary injury due to
hypoxia and hypotension are within the armamentarium of current critical care. Other successful
interventions have been elusive. Catecholamine surges following TBI are proportional to the severity
of the underlying TBI. Multiple retrospective, observational studies have shown a benefit of
beta-blockade, with propranolol appearing to be the most effective agent. Sufficient data exists to
justify testing this intervention in a randomized controlled trial. In this pilot study, we tested the
hypothesis that propranolol given within 72 hours to patients with moderate to severe TBI would
improve mortality.
Methods: A single-center randomized controlled pilot trial was conducted at an urban level-one
trauma center from 1/1/16 to 12/31/17. Adult patients with a TBI as determined by GCS<12 on
admission and a documented injury on head CT were screened for eligibility. Patients with
significant injury in another body region (AIS>3), special populations, and home beta-blocker use
were excluded from randomization. Following appropriate informed consent, patients were
randomized within 72 hours of injury using block randomization in groups of 4. Patients randomized
to the propranolol group (PRO) were started on propranolol 20 mg TID and titrated up by 60 mg/day
until heart rate was less than 100. The control group was managed according to institutional
standards based on the Brain Trauma Foundation Guidelines. Medication duration was 14 days and
patients were followed until death or discharge. Demographics, physiologic variables, severity of
injury, LOS, urinary catecholamines, and mortality were compared between groups. Primary
outcome was mortality and secondary outcome was effect on urinary catecholamines. Statistical
analysis was performed using Student’s t test or Wilcoxon Rank Sum test based on distribution.
Chi-square or Fisher’s exact test was used for categorical variables where appropriate. A nested
factorial mixed model ANOVA with repeated measures was used to estimate differences between
treatment arms over time. The trial is registered on
[Link].
Results: Over the 24-month study period, 525 patients were
screened and 26 were randomized. One patient was excluded
after randomization due to home beta-blocker use. At
randomization, the groups were comparable with no
differences in demographics or clinical variables (table). The
PRO group had a longer hospital LOS (p=0.024), but no
difference was found in ICU LOS. Mortality was lower in the
PRO group (7.7% vs 36.4%), but this difference did not reach
significance. Several differences were found in heart rate,
temperature, mean arterial pressure, and ICP on a daily basis
both between and within groups. No overall differences were
detected for heart rate (p=0.143), temperature (p=0.339), or ICP
(0.141). Mean arterial pressure was significantly higher in the PRO group as compared to the control
(p=0.021). No overall treatment effect was noted for GCS (p=0.419), but day 14 GCS was
significantly higher in the PRO group (11.7 vs. 8.9l; p=0.044). No differences were found in the
levels of urinary catecholamines over the study period. Despite not being different at the traditional
significance level, all daily urinary catecholamines were higher in the PRO group from study day 2
to the end of the study.
Conclusion: This trial protocol is safe and feasible in the TBI population. While not powered to
detect differences between groups, the PRO group had a higher mean arterial pressure and GCS was
significantly better at the end of study despite no difference in mortality. A larger multi-center trial is
needed to validate these initial results and increase the power to detect clinically meaningful
differences between the treatment arms.
NOTES
 Session XXVII: Quickshot II - 14-26
Paper 17: 10:48-10:54 am
Physiologic impact of XSTAT 30 use in the management of non-compressible torso
hemorrhage
Alicia Bonanno MD, Todd Graham BS, Lauren Wilson BS, James D. Ross Ph.D.,
Oregon Health & Science University
Invited Discussant: Travis Polk, MD

Introduction: Non-Compressible Torso Hemorrhage (NCTH) remains one of the leading

causes of death in both civilian and military pre-hospital care. Novel techniques for
management of NCTH like REBOA, selective aortic arch perfusion (SAAP) and the
Abdominal Aortic Junctional Tourniquet-Torso Plate, have high potential for significant
co-morbidities including ischemia-reperfusion injury when applied in the prolonged field
care paradigm. One promising avenue for control of abdominal NCTH is through the
novel use of RevMedx XSTAT 30 (an FDA approved sponge-based dressing utilized for
extremity wounds). We hypothesized that XSTAT would effectively mitigate
uncontrolled NCTH during a prolonged pre-hospital period with correctable physiologic
dyshomeostasis following damage control surgery (DCS), resuscitation and critical care.
In addition we examined the incidence of intra-cavitary pellets remaining following DCS
prior to definitive closure by radiologic investigation.
Methods: Twenty-four male swine (53±2kg) were anesthetized, underwent line
placement for monitoring, laparotomy and splenectomy. Animals then underwent
laparoscopic transection of 70% of the left lobe of the liver and were allowed to
hemorrhage freely for a period of 10 minutes. They were then randomized into three
groups: Hextend (Hex), Free Pellets (FP), and Bagged Pellets (BP). The animals were
observed for a pre-hospital period of 180 minutes. At 180 minutes the surviving animals
underwent DCS, balanced blood product resuscitation and removal of pellets followed by
an ICU period of 5 hours with pre-defined paramaters for clinical intervention and care.
Postoperative fluoroscopy was performed to identify pellets or bags not recovered during
DCS.
Results: Baseline physiologic and injury characteristics were not different. Survival rates
were significantly higher in FP and BP (p<0.01) vs Hex. DCS duration was significantly
longer in FP in comparison to BP (p=0.001). There were two animals in the FP group with
pellets discovered on fluoroscopy following DCS in comparison to zero in the BP group.
There was no significant difference in blood product administration or pressor
requirements between groups. End ICU lactates trended to baseline in both FP and BP
groups.
Conclusion: In the setting of abdominal hemorrhage, XSTAT may be a viable
intervention to address NCTH in pre-hospital care as demonstrated by improved survival
in comparison to fluid resuscitation alone without secondary consequences of critical
metabolic dyshomeostasis. XSTAT can be easily identified and removed prior to
definitive abdominal closure.
NOTES
 Session XXVII: Quickshot II - 14-26
Paper 18: 10:54-11:00 am
PERCENT CHANGE FROM PRE-INJURY BLOOD PRESSURE IS AN
INDEPENDENT PREDICTOR OF MORTALITY IN ELDERLY TRAUMA
Savo Bou Zein Eddine MD, Kelly A. Boyle MD, Christopher M. Dodgion MBA,MD,
MSPH, Colleen Trevino Ph.D.,RN, FNP, Jeremy S. Juern* MD, Thomas W. Carver*
MD, Christopher S. Davis MD,MPH, David J. Milia MD, Panna A. Codner* MD, Jacob
R. Peschman MD, Travis P. Webb* MD, MHPE, Marc A. De Moya* MD, Medical
College of Wisconsin
Invited Discussant: Jennifer Hubbard, MD

Introduction: The correlation between baseline blood pressure and outcomes has been
poorly studied. We hypothesize that a decrease from baseline (preinjury) systolic blood
pressure(SBP) is an independent predictor of mortality among elderly trauma patients.
Methods: The 2010 to 2017 trauma registry at a Level 1 Trauma Center was linked to the
electronic health records to identify patients aged ≥65 years old with available baseline
SBP. Baseline SBP (bSBP) was defined as the average of the last 3 SBP measurements
recorded within 2 years of the trauma date in an ambulatory clinic or an outpatient setting.
Trauma SBP (tSBP) was defined as the first SBP reading in the Emergency department
after presentation for trauma. Delta SBP (dSBP) was defined as the percent change of
tSBP from bSBP. Univariate and logistic multivariate regression analysis were
constructed to assess the independent impact of the bSBP and the change from bSBP on
mortality controlled for demographics, comorbidities, injury mechanism/severity. Results:
A total of 2059 patients met our inclusion criteria with a mean age of 79.8 years (65.0
-102.0, ±8.4) and mean bSBP of 131.3 mmHg (75.3 – 209.0, ±17.5). Mortality was 5.0%
in this cohort. Of these patients, 533 (25.9%) had a decrease in tSBP from their bSBP (or
dSBP>0) on presentation to the emergency department. In the unadjusted analysis, sex
(p< 0.001), Glasgow Coma Scale (GCS) (p<0.001), Injury Severity Score (ISS)
(p<0.001), mechanism of injury (p<0.001), tSBP (p=0.002), and dSBP (p<0.001) were
significant predictors of mortality. In the multivariate analyses, 10% change from bSBP
[OR= 1.39, (95% CI: 1.02, 1.90)] and male sex [OR=3.45, (95% CI: 1.49, 8.01)] were
significant predictors of mortality. GCS 13-15 [OR=0.03, (95% CI: 0.01, 0.07)] was a
protective factor. Mortality exponentially increased after a 20% decrease of blood pressure
or more from bSBP.
Conclusion: A decrease from baseline preinjury SBP by 10% or more is an independent
predictor of mortality in the elderly trauma patient.
NOTES
 Session XXVII: Quickshot II - 14-26 Paper
19: 11:00-11:06 am
THE NLRP3 INFLAMMASOME PATHWAY LEADS TO THE LOSS OF
BLOOD-BRAIN BARRIER INTEGRITY IN TRAUMATIC BRAIN INJURY
Bobby D. Robinson MD, Chinchusha Anasooya Shaji BS, Claire L. Isbell MD, Stanley
Kurek* Jr., DO, Justin Regner MD, Binu Tharakan Ph.D., Baylor Scott And White
Medical Center - Temple
Invited Discussant: Mayur Patel, MD, MPH

Introduction: The integrity of the blood-brain barrier (BBB) is critical in limiting

vasogenic cerebral edema following traumatic brain injury (TBI). The proinflammatory
cytokine interleukin 1β (IL-1β) is a critical mediator of BBB breakdown following TBI.
The NLRP3 inflammasome pathway activated in TBI regulates IL-1β secretion. We
hypothesized that the activation of this pathway is critical to BBB breakdown and
hyperpermeability resulting in cerebral edema following TBI.
Method: In vitro studies consisted of immunofluorescence of tight junction-associated
proteins and monolayer permeability for evaluating barrier function. Rat brain
microvascular endothelial cells (BMECs) were treated with chitosan, an NLRP3
inflammasome activator. The tight junction protein zonula occludens-1 (ZO-1) and
adherens junction protein β-catenin were localized. Human BMECs were grown as a
monolayer on Transwell plates; permeability was induced with chitosan, and
transendothelial electrical resistance (TEER) was performed to evaluate barrier function.
In vivo studies utilized a mouse controlled cortical impact model of moderate TBI in
C57/BL6 mice. Sham mice had craniectomy only (n=5/group). Chitosan and inhibitors
(NLRP3 inhibitor MCC950 and caspase-1 inhibitor Ac-YVAD-cmk) were administered
10 minutes after injury (n=5/group). Intravital microscopy imaging of the pial venules
was performed for up to 70 minutes after injury. The difference in fluorescence intensity
between the intravascular space and interstitium (ΔI) was measured and represented BBB
hyperpermeability.
Results: Junctional localization of ZO-1 and β-catenin showed decreased integrity when
treated with chitosan in vitro. Chitosan administration led to a decrease in the TEER in
human BMECs ( p<0.05). TBI resulted in significant increase in BBB permeability when
compared to sham group (p<0.05). Chitosan administration led to BBB hyperpermeability
compared to control group ( p<0.05) in vivo. Treatment with the caspase-1 and NLRP3
inhibitors significantly decreased BBB hyperpermeability after TBI (p<0.05).
Conclusion: Activation of the NLRP3 inflammasome pathway leads to BBB
breakdown/microvascular hyperpermeability in vitro and in vivo, and specific pathway
inhibitors mitigates these effects.
NOTES
 Session XXVII: Quickshot II - 14-26
Paper 20: 11:06-11:12 am
OBESITY IS NOT ASSOCIATED WITH MICROVASCULAR INFLAMMATION
FOLLOWING INJURY
Robert D. Winfield* MD, James M. Howard MD, John G. Wood Ph.D., University Of
Kansas Medical Center
Invited Discussant: Carlos Brown, MD
Introduction: Obesity is associated with organ failure and thromboembolic events
following injury. Prior work has demonstrated that although obesity is associated with a
pro-inflammatory state in the uninjured, the obese show relative immune suppression
following major trauma. Furthermore, although obesity is clearly linked to
hypercoagulability, circulating markers with pro-inflammatory and procoagulant
properties are not elevated following trauma while simultaneously showing greater
expression in adipose tissue. This dichotomy suggests a possible adipose-mediated
perivascular effect that might explain an increased propensity for thrombosis in the obese.
We hypothesized that we would see evidence of enhanced microvascular inflammation in
obese subjects following injury.

Methods: Sprague-Dawley rats were divided into groups in which they were fed either a
standard diet or high-fat, high calorie diet for eight weeks. To create injury, the backs of
experimental subjects were exposed to steam for one minute while controls were not
exposed to steam. Leukocyte adherence (LA) in mesenteric venules of anesthetized
experimental and control subjects was measured using intravital microscopy. Adherent
leukocytes were defined as those that remained stationary to the venular wall for at least
30 seconds, and expressed as number per 100 μm venular length.
Results: Obese subjects weighed significantly more than lean at the time of injury (452
±16.3 vs. 366±12.7 grams, p<0.05). In subjects fed standard diet, LA increased four hours
after burn (16.2±2.2 vs 1.4±0.3 per 100 μm at 0 minutes, p<0.05, n=7), but not in controls
(2.3±0.3 vs 1.5±0.3 per 100 μm at 0 minutes, n=7). At four hours after burn, lean subjects
showed a significant increase in leukocyte adherence over obese subjects (12.9±2.6 vs 3.1
±0.3 per 100 μm, p<0.05), with the obese showing limited evidence of leukocyte
adherence and emigration at four hours following injury. Figure 1 shows representative
photographs of the microcirculation 4 hours after burn in lean and obese subjects.

Conclusion: While burn injury led to microvascular inflammation in lean subjects, there
was minimal inflammation in the mesenteric microvasculature of the obese. This is
consistent with previous work demonstrating that obesity in the setting of trauma leads to
a state of relative immune suppression. These data do not support the notion that adipose-
mediated perivascular inflammation is a causative factor for increased thromboembolic
phenomena in the obese following injury.
NOTES
 Session XXVII: Quickshot II - 14-26
Paper 21: 11:12-11:18 am
THE DIVERSITY OF SURGICAL CRITICAL CARE: A REPORT OF THE
TRAUMA ICU PREVALENCE PROJECT (TRIPP, AN AAST MULTI-
INSTITUTIONAL STUDY
Christopher P. Michetti* MD, Samir Fakhry* MD, Karen Brasel* MD, Niels Martin*
MD, Erik Teicher MD, Anna Newcomb Ph.D., Inova Fairfax Hospital
Invited Discussant: Panna Codner, MD
Introduction: Surgical Critical Care is crucial to the care of trauma and surgical patients.
This study was designed to provide a contemporary assessment of patient types, injuries,
and conditions in ICUs caring for trauma patients to inform the design of processes of
care to meet patient needs.

Methods: This was a 1-day, multicenter prevalence study where participants supplied
data on all patients in their TICU (ICU where majority of critical trauma patients were
admitted) on 11/2/17 and their 30-day outcomes.

Results: 27 Level I and 3 Level II trauma centers across the U.S. entered 501 pts
classified as: 244 (48%) trauma, 167 (33%) non-trauma surgical, 90 (18%) medical. The
most prevalent injuries, surgical conditions, ICU diagnoses, and operations are shown in
the Table. 360 patients (72%) underwent surgery, 5.7% had an open abdomen. 163 (33%)
had an infection: 51(10%) intra-abdominal, 43(8.5%) ventilator-associated pneumonia, 32
(6.3%) soft tissue, and 28 (5.5%) other pneumonia. 278 (55%) were on antibiotics, and 51
(10%) on antifungal agents. 338 (67%) had been intubated, with 46% currently on a
ventilator. 95 (19%) had a tracheostomy (performed after a median 8 days [IQR 5-12] of
intubation). Arterial and central lines were each present in >36% of patients; 62.6% had a
urinary catheter. 15% of patients were on vasoactive infusions and 64 (12.8%) were on
both vasoactive drugs and a ventilator. 14.5% were comatose and 36 (7.1%) had
intracranial pressure monitors. Altered mental status (46%) and enteral opioid use (47%)
were common. 20% of patients had a transfusion within the last 24 hours. 30-day follow-
up data were available for 440 patients (88%). 12 were still in the ICU, median ICU days
were 10 [4-19] and hospital days were 17 [9-31]. Mortality was 13% (n=57).

Conclusion: Acuity of trauma ICUs in the U.S. is very high, as is the breadth of
pathology and the interventions provided. Further assessment of the global predictors of
outcome is needed to inform the education, research, clinical practice, and staffing of
surgical critical care providers.
NOTES
 Session XXVII: Quickshot II - 14-26
Paper 22: 11:18-11:24 am
TEACHING HOW TO STOP THE BLEED: DOES IT WORK? A PROSPECTIVE
EVALUATION OF TOURNIQUET APPLICATION IN SECURITY AND LAW
ENFORCEMENT PERSONNEL
Fahd Ali MD, Patrizio Petrone MD,MPH, MSHSA, Ellen Berghorn RN, Judy Jax RN,
Lee Cartagena MD, Collin E. Brathwaite MD, D'Andrea Joseph* MD, NYU Winthrop
Hospital
Invited Discussant: Babak Sarani, MD

Introduction: In October 2015, the “Stop the Bleed (STB)” program, the brain child for
Dr. Lenworth Jacobs, was launched by the White House as a call to action for the use of
bleeding control techniques by persons at the scene of traumatic injury. With death
possible within 5 minutes of injury from a major vascular trauma, prompt control of
hemorrhage is key. Wartime data from 2000’s demonstrated that the correct tourniquet
use has a mortality benefit of 13-51% while incorrect application was associated with
lesser reduction in mortality. Studies have shown that proper education leads to
individuals becoming more apt to use tourniquets in the field. The purpose of this study
was to conduct a pre and post evaluation of the STB course in a group of private security
and law enforcement personnel.
Methods: A pre and post questionnaire using the Likert scale was shared with law
enforcement and security personnel on their knowledge and comfort level with the use of
tourniquets. Participants were also observed while placing tourniquets and the time for
placement recorded. The didactic portion and practical session of the STB was then
taught and participants were again observed placing tourniquets and a clean copy of the
questionnaire distributed. Fisher's Exact tests or Wilcoxon matched-pairs signed-ranks
tests were used, as appropriate, to compare pre-post measurements.
Results: A total of 54 subjects were enrolled over the course of three sessions. The
tourniquet was applied correctly by 14.5% (8/54) and 92.6% (50/54) of enrollees at the
pre- and post-instruction assessments, respectively (p<0.001). Mean times to apply the
tourniquet were 28.4±11.9 and 19.5±6.6 min, respectively (p<0.001). Subjects reported
their level of comfort with the tourniquet to be 5.7±3.2 and 8.9±2.0, respectively
(p<0.001) and their familiarity with anatomy and bleeding control to be 5.6±3.3 and
8.1±2.3, respectively (p<0.001). At the end of the course, the mean score in response to a
question about the extent to which the explanation had helped was 8.8±2.1 (95% CI: 8.2
to 9.4) and to a question about the extent to which teaching would make them feel more
secure and safe was 8.8±2.3 (95% CI: 8.2 to 9.4).
Conclusion: The teaching of STB improved the correct placement of tourniquets and
demonstrated dramatic improvements in application time. Moreover, participants
reported increased levels of comfort with addressing active bleeding and found the course
to be invaluable. These findings illustrate the importance of the STB program and
validate the need for ongoing education.
NOTES
 Session XXVII: Quickshot II - 14-26
Paper 23: 11:24-11:30 am
WHEN IS IT SAFE TO START VTE PROPHYLAXIS AFTER BLUNT SOLID
ORGAN INJURY? A PROSPECTIVE STUDY FROM A LEVEL I TRAUMA
CENTER
Morgan Schellenberg MD,MPH, Kenji Inaba* MD, Patrick Heindel BS, Elizabeth
Benjamin* MD,Ph.D., Aaron Strumwasser MD, Kazuhide Matsushima MD, Lydia Lam*
MD, Demetrios Demetriades* MD,Ph.D., LAC+USC Medical Center
Invited Discussant: Forrest Fernandez, MD

Introduction: The optimal timing of venous thromboembolism (VTE) prophylaxis

initiation after blunt solid organ injury is controversial. Trauma patients are known to be
at high risk for VTE, but competing concerns about bleeding exist in patients with blunt
solid organ injuries. Retrospective studies suggest initiation within 48 hours is safe. This
study was designed to prospectively study the timing of VTE prophylaxis initiation
among patients managed nonoperatively after blunt solid organ injury in order to
determine the optimal window for initiation of VTE prophylaxis.

Methods: All patients presenting to our Level I trauma center after blunt trauma over a 1
year period (12/01/16 to 11/30/17) were prospectively screened for inclusion in this
observational study. Patients were included if a solid organ injury (liver, spleen, and/or
kidney) was diagnosed on the initial CT scan and a plan was made for nonoperative
management. Patients were excluded if they were transferred to or from an outside
hospital, managed operatively from the outset, or on home anticoagulation.
Angioembolization was not an exclusion criterion. Demographics, injury and clinical
data, type and timing of initiation of VTE prophylaxis, and outcomes (need for blood
transfusion, need for delayed IR or OR intervention, hospital LOS, ICU LOS, mortality,
and complications including DVT and PE) were collected. The decision to initiate VTE
prophylaxis was at the discretion of the attending surgeon. Outcomes were compared
between patients who underwent VTE prophylaxis initiation ≤48 hours vs >48 hours after
hospital admission.

Results: After applying exclusion criteria, 198 patients were identified over the 1 year
study period who sustained a blunt solid organ injury managed nonoperatively. Mean age
was 40 years (range 16-92) and 65% of patients were male (n=129). Liver injuries were
most common (n=104, 52%), followed by spleen (n=78, 39%) and kidney (n=45, 23%).
Mean grade of injury was 3 (range 1-5) for liver, 2 (range 1-5) for spleen, and 3 (range
1-5) for kidney. Mean time of initiation of VTE prophylaxis was 69 hours after
admission. As compared to patients who were initiated on VTE prophylaxis >48 hours
after admission (n=88, 45%), patients who were initiated ≤48 hours (n=109, 55%) had
fewer DVTs (0 vs 9, p=0.006) and VTEs (2 vs 15, p=0.004) but similar numbers of PEs
(2 vs 6, p=0.254). No patients in either group required delayed IR or OR for bleeding
after initiation of VTE prophylaxis.

Conclusion: In this prospective observational study of patients with blunt solid organ
injuries managed nonoperatively, early (≤48h) initiation of VTE prophylaxis resulted in a
lower incidence of VTE without an associated increase in the risk of bleeding or need for
operative intervention or angioembolization. Early initiation of VTE prophylaxis is
therefore likely to be beneficial for patients with blunt solid organ injury. A prospective
multicenter trial should be performed to validate these findings.
NOTES
 Session XXVII: Quickshot II - 14-26
Paper 24: 11:30-11:36 am
THROMBOPROPHYLAXIS WITH NOVEL ORAL ANTICOAGULANTS IS
ASSOCIATED WITH LOWER VENOUS THROMBOEMBOLIC EVENTS IN
OPERATIVE SPINE TRAUMA
Muhammad Zeeshan MD, Mohammad Hamidi MD, Narong Kulvatunyou* MD, Faisal
Jehan MD, Lynn Gries MD, Andrew Tang* MD, Terence O'Keeffe* MD, El Rasheid
Zakaria MD,Ph.D., Bellal Joseph* MD, University of Arizona - Tucson
Invited Discussant: Mark Cipolle, MD, PhD

Introduction: Patients with spinal trauma are at high-risk for venous-thromboembolism

(VTE). The use of novel oral anticoagulants (NOACs) for thromboprophylaxis is
becoming more prevalent after elective orthopedic procedures. However, there is a
paucity of data regarding the use of NOACs in trauma patients. The aim of our study was
to assess the impact of NOACs vs low molecular weight heparin (LMWH) for
thromboprophylaxis in patients with operative spinal trauma.
Methods: A 2-year (2015-16) review of patients with isolated spine trauma (S-AIS≥3 and
other region-AIS<3) who underwent operative intervention and received LMWH or
NOACs for thromboprophylaxis. Patients were stratified into two groups based on the
type of thromboprophylaxis: NOACs and LMWH; and were matched in a 1:2 ratio using
propensity-score-matching for demographics, admission vitals, injury parameters, type of
operative intervention, hospital stay, and timing of initiation of thromboprophylaxis.
Outcomes were rates of DVT and/or PE, pRBCs transfusion, the rate of operative
interventions for spinal cord decompression and mortality after initiation of
thromboprophylaxis.
Results: A total of 6036 patients had isolated spine trauma and underwent operative
intervention, of which 810 patients (NOACs: 270; LMWH: 540) were matched. Mean
age was 50±20y, 64% were males, and median ISS was 14 [9-18]. Matched groups were
similar in demographics, injury parameters, ED-Vitals, hospital stay, rates of IVC filter
placement and timing of initiation of thromboprophylaxis. The overall rate of DVT was
5.6%, PE was 1.6, and mortality was 2.5%. Patients who received NOACs, were less
likely to develop DVT (1.8% vs 7.4%, p<0.01) and PE (0.3% vs 2.1%, p=0.04). There
was no difference in post-prophylaxis pRBCs transfusion requirements (p=0.76),
post-prophylaxis decompressive procedure on the spinal cord (p=0.49), and mortality
( p=0.48).
Conclusion: In patients with operative spine trauma, thromboprophylaxis with novel oral
anticoagulants is associated with lower rates of DVT and PE. NOACs can be considered
as an alternative to reduce the risk of VTE in this high-risk patient population. Further
prospective clinical trials should evaluate the role of NOACS in preventing VTE events.
NOTES
 Session XXVII: Quickshot II - 14-26
Paper 25: 11:36-11:42 am
AMERICAN FIREARM HOMICIDES: THE IMPACT OF YOUR NEIGHBORS
Erik J. Olson MD, Mark Hoofnagle MD, Elinore Kaufman MD, Patrick M. Reilly* MD,
Mark J. Seamon* MD, University of Pennsylvania
Invited Discussant: Omar K. Danner, MD

Introduction: Previous reports demonstrated that restrictive state firearm legislation

correlated with decreased overall, white, suicide, and pediatric firearm fatality rates (FFR)
but did not correlate with homicide or black FFR. We hypothesized that firearm
trafficking from less restrictive neighboring states influences firearm homicide rates,
making individual state firearm laws less effective.
Methods: For the years 2011-2015, state firearm legislation Brady Campaign to Prevent
Gun Violence scorecards were analyzed in relation to firearms traced to specific states by
the Bureau of Alcohol, Tobacco, Firearms and Explosives (ATF) and reported Center for
Disease Control and Prevention FFR (WISQARS). All states were then ranked by Brady
score (Normalized Brady Score [NBS]) and arranged by quintile. The effect of
less-restrictive neighboring states on the 10 most-restrictive firearm legislation states was
modeled by averaging the 10 most-restrictive states with their bordering states. All states
were then re-ranked based on the new Border Adjustment Score (BAS). FFR were
calculated for each quintile and Poisson regression models were created for each score
and outcome. Model fit was compared using Aikake information criterion (AIC).
Results: From 2011-2015, there were 169,396 total firearm fatalities including 57,885
firearm homicides (33,158 black, 23,158 white homicides). When top and bottom quintile
states for firearm legislation were compared, 65% vs 44% of firearms traced by ATF
originated in other states respectively (Figure, % Firearms Recovered). The BAS had a
more linear relationship with the overall FFR, all firearm homicide, and both black and
white firearm homicide as gun legislation BAS decreased (Figure, 2011-2015 Border
Adjusted). The BAS minimized the AIC with respect to the NBS for black homicide
(AIC 4443 vs. 4680) and white homicide (3243 vs. 4319), indicating improved model fit
after adjustment for neighboring state firearm legislation.
Conclusion: Our results suggest that firearm movement across state borders plays an
important role in firearm homicides. Accounting for firearm legislation in both individual
and neighboring states may improve our understanding of the relationship between
firearm legislation, homicide and race.
NOTES
 Session XXVII: Quickshot II - 14-26
Paper 26: 11:42-11:48 am
IMPACT OF LICENSED FEDERAL FIREARM SUPPLIERS ON FIREARM-RELATED
MORTALITY
Stephanie Chao* MD, Zachary Kastenberg MD, Sriraman Madhavan BS, Kristan Staudenmayer* MD,
MS Stanford University
Invited Discussant: Sherry Sixta, MD
Introduction: Legal firearm sales occur largely through suppliers that have Federal Firearm Licensees
(FFLs). These include a wide range of distributors, such as gun stores and pawnshops. Since FFL
density might reflect ease-of-access to firearm purchases, we hypothesized that the number of FFL
dealers would be associated with firearm-related deaths. We further hypothesized that licensee-type
subsets would be associated with differential risks for gun-related deaths.

Methods: We used data from the National Center for Health Statistics National Vital Statistics System
(2008-2014) and national data on Federal Firearms Licensees available through the Bureau of Alcohol,
Tobacco, Firearms and Explosives for 2014. FFL density was determined by normalizing FLL license
number by population. Correlation analysis and linear regression analysis were performed to determine
the relationship between different licensee types and firearm-related deaths. We controlled for
population, number of statewide registered firearms, and the density of other types of FFLs.
Results: We identified a total of 65,297 FFLs in 2014. There was a moderate correlation (R = 0.53, ρ =
0.48) between total FFL density and firearm-related death rates. Further analysis by type of firearm-
related death showed a strong correlation (R = 0.81, ρ = 0.76) between total FFL density and firearm-
related suicide rates. No correlation was found between total FFL density and firearm-related homicide
rate.
Among individual FFL types, FFL02 (firearm dealing pawnshop) density was the only FFL-type found
to be correlated with
firearm-related death rates. We found a strong correlation between FFL02 density and overall firearm-
related death rate (R = 0.69, ρ = 0.78) and firearm-related suicide rate (R = 0.72, ρ = 0.78) (Figure 1).
Linear regression analysis showed that even while controlling for number of registered firearms and
population, the number of
firearm-dealing pawnshops remained significantly associated with overall firearm-related deaths and
firearm-related suicides. Linear regression results show an incremental 4.23 gun-related deaths for each
additional firearm-dealing pawnbroker per state over the study period.

Figure 1: Firearm dealing pawnshop density vs. Firearm death rate and Firearm suicide rate
Conclusion: Access to legally-distributed firearms is associated with firearm-related death rates,
particularly firearm-related suicides. There was no association with firearm-related homicides.
Furthermore, firearm-dealing pawn shops were associated with suicide-related deaths. These findings
suggest that deeper exploration of legal firearm access and firearm-related injuries would benefit
discussion of preventative measures.
NOTES
POSTERS
 Poster # 1
Failure to Rescue and the Weekend Effect: A Study of a Statewide Trauma System
Catherine E. Sharoky MD, Morgan M. Sellers MD, Elinore J. Kaufman MD, MSHP,
Yanlan Huang MS, Wei Yang Ph.D., Rachel R. Kelz MD, MSCE, Patrick M. Reilly*
MD, Daniel N. Holena* MD, MSCE University of Pennsylvania
Introduction: Differential patient outcomes based on weekday or weekend patient
presentation (i.e. the “weekend effect”) have been reported for several disease states.
Failure to rescue (FTR, the probability of death after a complication) has been used to
evaluate trauma care. We sought to determine whether the weekend effect impacts
FTR across a mature statewide trauma system.
Methods: We examined all 30 Level I and II trauma centers using the Pennsylvania
Trauma Outcomes Study (PTOS) from 2007-2015. Patients age >16y with a minimum
Abbreviated Injury Score 2 were included; burn patients and transfers were
excluded. Our primary exposure was first major complication timing (weekday vs
weekend), FTR was the primary outcome. We used multivariable logistic regression to
examine the association between weekend complication occurrence and mortality.
Results: Of 178,602 patients, 15,304 had a major complication [median age 58 (IQR
37-77) years, 68% male, 89% blunt injury mechanism, median injury severity score (ISS)
19 (IQR 10-29)]. Patient characteristics by complication timing were clinically similar
(Table). Major complications were more likely on weekdays than weekends (9.3%
vs 7.1%, p<0.001). Pulmonary and cardiac complications were most common in both
groups (Table). Death occurred in 2,495 of 15,304 patients with complications, for an
overall FTR rate of 16.3%. Weekday vs weekend FTR was similar (16.1% vs 16.8%;
p=0.33). After controlling for patient age, ISS, complication type, and revised trauma
score (RTS), there was no association between weekend complication occurrence and
mortality (adjusted OR 1.03, 95% CI 0.92-1.16).

Conclusions: The ability for trauma centers to rescue patients from death after a
complication is not impacted by weekday or weekend complication timing. Requirements
for trauma centers to be operational with full staffing at all times likely counteracts the
weekend effect phenomenon seen in other time-sensitive conditions. Restructuring
staffing for management of other conditions to mimic the 24/7 trauma care model may
improve outcomes.
 Poster # 2
EVALUATION OF HELICOPTOR TRANSPORT OF TRUAMA PATIENTS IN A
RURAL STATE: HAVE WE GONE TOO FAR?
Lauren M. Dudas MD, Amy Tefft MD, Steven Talbert Ph.D., Daniel Davenport Ph.D.,
Marlene J. Broady Andrew C. Bernard* MD, University of Kentucky
Introduction: Helicopter emergency medical services (HEMS) overtriage increases the
cost of trauma care. Private HEMS expansion could increase overtriage. We sought to
determine whether increased utilization of HEMS in our rural state is associated with
overtriage.
Methods: A retrospective analysis of all trauma patients transported to an ACS verified
Level I trauma center via helicopter over a 26 year period (1990-2016) was performed
using data from the trauma registry. HEMS overtriage was defined as one or more of the
following: LOS <2 days, disposition from the ED other than ICU or OR, ISS <9.
Results: 21,177 HEMS patients were transported to our center. Annual helicopter
transports increased dramatically from 1990 (11) to 2016 (1076). Overall overtriage rate
was 57.3%. Overtriage doubled from 2007 to 2009, which corresponds to an increase in
air ambulances in the state within the same time period from 8 to 23. The counties with
the highest percent of patients transported who met overtriage criteria had the furthest
distance to the trauma center. Scene HEMS transports had greater overtriage rates than
interfacility transfers. Patients with LEG AIS scores <2 were more likely to be
transferred from the scene, 18.8% versus 11.9% (p<0.001) compared to interfacility
transfers which had higher rate of facial AIS scores <2, 6.9% versus 4.4% from scene (p
<0.001).
Conclusion: There was a near doubling of overtriaged HEMS patients in our rural state
from 2007-2009, at which time there was also a tripling of air ambulances. This suggests
an increase in HEMS is likely secondary to an increased number of available helicopters
and not an increase in injury severity. Our data also demonstrate that a higher percentage
of patients who met overtriage criteria were transferred from the scene. However,
patterns of injury were different when comparing scene versus interfacility transports.
 Poster # 3
DOES THE TIME OF THE DAY OF SURGERY INFLUENCE PERIOPERATIVE
COMPLICATIONS – A NATIONWIDE DATABASE ANALYSIS IN 31’692
PATIENTS
Sascha Halvachizadeh MD, Hans-Christoph Pape* MD, FACS, Valentin Neuhaus MD,
PD University Hospital Zurich
Introduction:Emergency and surgery for acute injuries is often required to avoid
excessive bleeding and prevent from infections in open fractures. However, it has
previously been discussed, that surgeon related factors (e.g. experience of the surgeon,
teaching vs. non-teaching hospital) might play a role in adverse outcomes for these
surgeries. The purpose of this study was to evaluate whether the time of day for emergent
surgery is associated with complications.

Methods: A prospective database (AQC, nationwide Swiss quality assurance project) was
used to evaluate all trauma surgeries within 11 years in more than 70 Swiss surgical units.
Inclusion criteria: All trauma coded diagnosis that were surgically treated in Swiss
hospitals. Exclusion criteria: missing data for time of surgery. The daytime of surgery was
stratified into morning (7AM - noon), afternoon (1PM – 6PM), evening (7PM – 11PM)
and night (Midnight – 6AM). The primary outcomes were intraoperative (e.g., nerve,
tendon, or vascular damage, iatrogenic fractures), postoperative (e.g., bleeding, infection,
impaired wound healing, incorrect axial, rotational or length reduction) and general
complications (pulmonary, cardiovascular, gastrointestinal, renal, or neurological) and
mortality. Co-factors included age, gender, ASA classification, type of surgery,
experience of the surgeon, length of surgery and length of stay). Variables were sought in
bivariable and multivariate anylysis.

Results: Of 31’692 patients, 44% were operated in the morning, 40% in the afternoon,
14% in the evening and 1.7% at night. The in-hospital mortality rate was significantly
higher after nightly (2.4%) as well as afternoon surgery (1.7%). The time of surgery had
no significant influence on intra- (0.5%) or postoperative complication rates (3.4%) in
multivariable analysis, but a significant influence on general complications (7.9%).
Afternoon- and night-surgery were significant predictors for general complications. Age,
gender, higher ASA classification, and emergency procedures were typical risk factors
for mortality and complications in this cohort.

Conclusion: Emergency procedures performed at night and in the afternoon appears to

be associated with an increased incidence of adverse outcomes. Further studies should
evaluate whether this is relevant for certain diagnoses and/or procedures.
 Poster # 4
THE PROGNOSTIC VALUE OF NATIONAL FIELD TRAUMA TRIAGE
GUIDELINES IN INJURED OLDER ADULTS AND DEVELOPMENT OF THE
GERIATRIC FIELD TRAUMA TRIAGE (GFTT) SCORE
Tabitha Garwe MPH,Ph.D., Kenneth Stewart MPH,Ph.D., Julie A. Stoner Ph.D., Craig
D. Newgard MD,MPH, John C. Sacra MD, Patrick Cody DO,MPH, Babawale O.
Oluborode MPH, MBBS, Jason S. Lees* MD, Roxie M. Albrecht* MD, University of
Oklahoma Health Science Center
Introduction: The Field Triage Decision Scheme developed by the American College of
Surgeons Committee on Trauma (ASCOT) with periodic revision forms the basis of field
triage guidelines for injured adult patients in many regions including Oklahoma. The
decision scheme has been shown to have low sensitivity for seriously injured older
patients. Proposed alternative criteria for injured older adults has been shown to improve
sensitivity at the expense of specificity (over-triage). We sought to develop two
prognostic tools with improved sensitivity and specificity to identify seriously injured
older adults including those at a high risk of in-hospital mortality in the prehospital or in a
resource-limited setting based on, current national field triage guidelines, previously
proposed alternative criteria, and other potential risk factors such as pre-existing
comorbidity.
Methods: This was a retrospective cohort study of injured adults >=55 years transported
directly from the scene of injury by EMS to a trauma facility for definitive care and
reported to the Oklahoma State Trauma Registry between 2005 and 2014. Patient
demographics, pre-existing comorbidity, variables used to define the current national
field trauma triage guidelines as well as variables proposed by other investigators for
alternative triage criteria were considered. The primary outcome of interest was serious
injury, defined as an Injury Severity Score (ISS) >=16. In-hospital mortality
was considered as a secondary outcome. Based on the two prognostic models, we
developed the Geriatric Field Trauma Triage (GFTT) score to summarize identified
significant risk markers/factors for the outcomes of interest. Logistic regression was used
for multivariable modeling, and bootstrapping with resampling was used to adjust the
prognostic models for overfitting and regression-to-the-mean bias.
Results: A total of 13275 patients met study eligibility. Of these, 28.5% (3782) had an
ISS >=16 (serious injury) and 9.8% (1300) died. The final models for predicting both
serious injury and in-hospital mortality included the following variables: demographic,
mechanism of injury, modified physiologic criteria, anatomic injury criteria and specific
comorbid conditions (cardiac disease and coagulopathy). At the optimal GFTT scores
where sensitivity and specificity are maximized, the prognostic model for serious injury
(AUC, 0.86; 95%CI 0.86-0.87) outperforms current triage guidelines, sensitivity (87.4%
vs 76%) with minimal loss in specificity (74% vs 78%); and the model for in-hospital
mortality (AUC, 0.82; 95%CI 0.80-0.83) shows reasonable accuracy (73.4% sensitivity
and 74% specificity). When stratified into low, moderate and high risk groups using
recursive partitioning analysis, patients in the highest risk category had 83% and 42%
predicted probability of serious injury and in-hospital mortality respectively.
Conclusion: Identification of high-risk injured older adults in the prehospital or
resource-limited setting could be improved by considering other variables such as age
group, pre-existing comorbidity, and modified physiologic criteria without loss in
specificity. Use of risk scores may be used to simplify the prehospital triage process,
enhance compliance with the triage guidelines, and reduce under-triage in the injured
older adult.
 Poster # 5
Leaving the frail behind: the role of frailty in trauma triage of the elderly
Barbara Haas MD,Ph.D., Priscila Pequeno MSc, Hannah Wunsch MD, MSc, Raquel
Duchen MPH, RD, Camilla Wong MD, MHSc, Lesley Gotlib Conn Ph.D., Damon Scales
MD,Ph.D., Avery B. Nathens* MD,Ph.D., University of Toronto, Department of Surgery
Introduction: Older adults with severe injuries are less likely to be triaged from the scene
of injury to trauma center care. Secondary triage at non-trauma centers allows those older
adults to be transferred to a trauma center for definitive care. Although physiologic and
anatomic critiera have traditionally been used to guide secondary triage, these factors
may not identify older adults at highest risk for adverse outcomes. Frailty is a geriatric
syndrome that represents a loss of physiologic reserve and is associated with increased
mortality and morbidity in trauma patients. In this study, we evaluated the impact of
frailty on transfer to trauma center care among older adults.

Methods: We performed a population-based, retrospective cohort study that evaluated

triage patterns for older adults in a large regional trauma system over 2006-2016. All
patients aged ≥ 65 with severe injury (ISS > 15 or death within 48 hours of injury) were
included. For patients initially triaged from the field to a non-trauma center, we evaluated
the relationship between frailty and subsequent transfer to a trauma center. Generalized
estimating equations were used to adjust for patient and injury factors associated with
transfer.

Results: We identified 21,499 patients aged ≥ 65 with severe injuries. One quarter of
patients were frail. 77% of patients were triaged from the field to a non-trauma center. Of
these patients, only 23% were transferred to a trauma center. Among those transferred,
18% were frail, compared to 30% who remained at a non-trauma center (Table 1).
Adjusting for patient and injury variables, frailty was independently associated with
decreased probability of transfer (OR 0.87, 95% CI 0.76-0.99) and with death (OR 1.32,
95% CI 1.21-1.44).
Conclusion: Despite being a strong predictor of adverse outcomes among older adults
with severe injuries, frailty was associated with a lower rate of transfer to trauma center
care. These data suggest that variables pertinent to the outcomes of older adults should be
incorporated into transfer guidelines.
Table 1: Characteristics of patients triaged to a non-trauma center

Abbreviations: NTC: non-trauma center; TC: trauma center; SD: standardized difference;
CHF: congestive heart failure; AMI: acute myocardial infarction; LTC: long-term care
 Poster #6
IMPLEMENTATION OF A TRAUMA RE-ORGANIZATION INITIATIVE TO
IMPROVE TRAUMA CARE AND TEAM DYNAMICS IN A LEVEL I TRAUMA
CENTER
Ming-Li Wang MD, Daniell Albright Ph.D., Isaac Tawil MD, Sonlee West* MD,
University of New Mexico
Introduction: Good teamwork and collaboration among multi-disciplinary and multi-
professional trauma team members has been known to improve timeliness of patient
disposition and management. While few would disagree that these qualities are important,
achieving and maintaining functional trauma response teams requires work. The Trauma
Re-Organization Initiative (Trauma Re-Org) was collaboratively developed between the
Departments of Emergency Medicine (EM) and Trauma Surgery at a Level 1 Trauma
Center to improve communication, teamwork, and the management of trauma patients in
the emergency department (ED).
Methods: Trauma Re-Org was launched in January 2017 after a 9 month planning
process. The planning team was comprised of faculty and residents from both departments
and ED nursing. The group reviewed and modified a protocol that designated the roles and
responsibilities for all personnel and designed the initiative didactic and simulation training
activities. Prior to the launch, planners also conducted a series of “listening tours” with key
stakeholder groups which included faculty, residents, and nursing leadership. The initiative
was supported by a formative process evaluation that included observation of planning and
training events, a survey of trauma response stakeholders, and post-implementation
observations of trauma response in the ED.
Results: The Stakeholder survey included responses from EM physicians, trauma
surgeons, and ED nurses (Pre N = 79; Post N = 91). Mann-Whitney U tests showed
positive and significant change in the post period for overall communication, organization,
and cooperation between personnel during trauma response, and improved perceptions of
the clinical skill competence of other responders. The analysis also showed specific
improvements for communication between EM attending physicians and nurses with
trauma surgery residents. In addition, trauma surgeons reported improved communication
with ED staff. Open-ended questions identified both achievements and areas for continuing
improvement, including: improved but imperfect communication, further need for role
clarification, and support for the designation of an identifiable trauma team leader.
Conclusions: A multi-faceted trauma improvement program that includes a number of
interventions, including organizing roles, organizing responsibilities within team
framework, in situ simulations, team building exercises, and the inclusion of stakeholder
perspectives can re-build a culture of cooperation, collaboration, and an overall increase in
the belief that one’s contribution is valued. The initiative is easily adaptable to other trauma
centers that have practitioners from various disciplines who want to optimize teamwork
and collaboration to improve trauma patient care.
 Poster # 7
COMPARISON OF SIMPLIFIED TRAUMA SCORES TO PREDICT
MORTALITY AT A SUB-SAHARAN TERTIARY REFERRAL CENTER
Rebecca Maine MD,MPH, Jared Gallaher MD,MPH, Nidia Rodriguez-Ormaza
MD,MPH, Malcolm Jefferson BS,MPH, Chifundo Kajombo BS, MB, Carlos Varela BS,
MB, Trista Reid MD,MPH, Anthony Charles* MD,MPH, University of North Carolina
Introduction: Injury severity scoring systems are often utilized to predict injury
outcomes but usually require diagnostic adjuncts and imaging that are often unavailable
in resource-limited settings. Several simplified scores have been developed for trauma
prediction, including the Malawi Trauma Score (MTS), which includes age, sex, AVPU
neurologic status (A-Alert, V-Voice, P-Pain and U-Unresponsive), presence of a palpable
radial pulse and body area injured; the Kampala Trauma Score (KTS), which uses APVU,
age, respiratory rate (RR), systolic blood pressure (SBP) and number of serious injuries;
and the Revised Trauma Score (RTS), which uses Glascow Coma Scale (GCS), SBP and
RR. While these scores have each shown predictive power in different low-resource
setting, their performance has not been compared in the same population.

Methods: A trauma surveillance registry from a tertiary referral hospital in sub-Saharan

Africa was analyzed using patients seen between 2010 through 2014. We used logistic
regression and generated ROC curves, using each of the three scoring systems for
patients. We then compared the performance of each score in predicting mortality.
Secondary analysis evaluated each scoring system's ability to predict hospital admission.

Results: A total of 62,425 patients were included in the trauma registry during that
time; 1,120 (1.8%) died while in the ED or hospital, and 10,954 (17.6%) were admitted to
the hospital. Sufficient information was available to calculate the MTS for 26,829
patients, the KTS for 22,127, and the RTS for 21,831. The MTS predicted mortality
(ROC AUC= 0.813) better than KTS and RTS (ROC AUC = 0.711 and 0.683
respectively) (Figure 1). The KTS and RTS curves did not differ statistically (p= 0.75),
however, the MTS curve, discriminated better than either KTS or RTS (p <0.001, both).
For admissions, KTS performed best, but prediction was low overall (AUC= 0.575)
(Figure 2).

Conclusion: Simplified scoring systems are needed for limited-resource settings to triage
patients appropriately and to allocate scarce resources. The MTS predicted mortality
better than KTS or RTS. The MTS also requires no equipment, not even a
sphygmomanometer, nor does it rely on subjective assessment of injury severity, as the
KTS does. Future work to compare these scores in varied populations, and in prehospital
triage, is imperative.
 Poster # 8
OUTCOMES WITH ADVANCED VERSUS BASIC LIFE SUPPORT IN BLUNT
TRAUMA
Michael S. Farrell MD, MBS, Benjamin Emery Richard Caplan Ph.D., John Getchell
RN, Kevin M. Bradley* MD, Christianacare Health Services
Introduction: The role of advanced life support (ALS) versus basic life support (BLS) in
blunt trauma is controversial. Previous studies have shown no mortality benefit for
penetrating trauma, particularly in urban environments, with ALS over BLS. The
distinction for blunt trauma in an urban/suburban environment has mostly remained
unaddressed.
Methods: A retrospective cohort study was conducted in patients transported to a Level
1 trauma center in an urban/suburban environment. Adult blunt trauma patients
transported by ALS and BLS from July 1, 2014 to December 31, 2014, were identified.
Institutional trauma records were used to assess Injury Severity Score (ISS) and select
Abbreviated Injury Score (AIS). Logistic regression was used to determine differences in
mortality, length of stay (LOS) and in-hospital complications based on mode of
transportation, time of transport, and number of interventions performed pre-hospital.
Results: 698 total patients were identified, 67.8% were transported by ALS. ALS
patients grossly had higher rates of mortality (p=0.01) and complications (p=0.009).
However, ALS patients did have a higher ISS (p < 0.001) and when adjusted for ISS and
AIS, there was no difference between patients transported by ALS and BLS with respect
to mortality (ISS: p = 0.47, AIS: head, thorax, abdomen p=0.6-0.8). There was no
difference between ALS and BLS for time of transport (p=0.61) or LOS (p=1.35). After
adjusting for ISS, the number of interventions performed in the field did not increase
transport time (p=0.46) but did correlate with increased mortality (p<0.001).

Conclusion: When accounting for injury severity, there is no mortality advantage for
patients being transported by ALS versus BLS transport. The number of interventions
performed did not alter transport time, but did influence mortality. This suggests that
ALS transport may not be necessary in blunt traumas and increased interventions may be
detrimental to patient outcomes.
 Poster # 9
BACK TO THE FUTURE: IMPACT OF A PAPER-BASED ADMISSION H&P ON
CLINICAL DOCUMENTATION IMPROVEMENT AT A LEVEL 1 TRAUMA
CENTER
Jordan A. WEINBERG* MD, Kristina M. Chapple Ph.D., Ronald A. Gagliano Jr., MD,
Jordan V. Jacobs MD, Sharjeel Israr MD, Scott R. Petersen* MD, St. Joseph's Hospital
And Medical Center
Introduction: Case Mix Index (CMI), calculated from patient MS-DRG-weights
determined from clinical documentation (CD), is a standard indicator of patient
complexity and determines reimbursement for inpatient care. CD language, however, is
not aligned with physician language, resulting in potential for CMI under-representative
of true patient complexity and severity of illness. We postulated that returning to a
paper-based admission form (H&P) that included a “picklist” of standard admission
diagnoses in CD language would improve CD at our trauma center. The purpose of this
study was to determine the impact of this practice change with regards to the change in
CMI.

Methods: Consecutive inpatient discharges from our trauma service from

October-December 2016 were deemed EHR cohort and May-November 2017 PAPER
cohort. Excluded cases included discharge dates during the period of transition to
paper-based charting between January and April 2017. Cases with DRG-weights greater
than 10, relatively unaffected by documentation, were excluded given their propensity to
skew CMI. MS-DRG weight, length of stay (LOS), Injury Severity Score (ISS), and
expected reimbursement were recorded for each patient. CMI calculated as the average of
MS-DRG-weights was determined for each cohort.

Results: Our cohort consisted of 218 (29%) EHR and 535 (71%) PAPER records coded
using MS-DRG version 34. There were not significant differences between groups in
hospital length of stay (LOS; P = 0.966) or Injury Severity Score (ISS; P = 0.350). CMI
and expected payment were significantly higher in the PAPER cohort (CMI: 2.3 ± 1.7 vs.
2.6 ± 1.9, P = 0.001; expected payment $24,599 ± 29,593 vs. $18,520 ± 19,553, P <
0.001). Regression modeling determined PAPER cohort was associated with average
increase in CMI of 0.30 (adjusted for ISS and LOS), resulting in an average increase of
11.1% in expected reimbursement per patient.

Conclusion: A paper-based H&P form at a level-1 trauma center was associated with an
increase in CMI and expected reimbursement. This simple approach provided physicians
with the ability to choose diagnoses that align with CD language, resulting in CD
improvement. H&P forms with "picklist" diagnoses should be considered by trauma
centers to more accurately document the relative complexity of their inpatient
populations.
 Poster # 10
WOULD PRE-HOSPITAL WHOLE BLOOD TRANSFUSION IMPROVE
MORTALITY IN SEVERELY INJURED PATIENTS?
Caroline Zhu Danielle Cobb MD, Rachelle Jonas RN, Meenakshi Rani Ph.D., Tracy
Cotner-Pouncy RN, Jenny Oliver RN, Andrew Cap* MD, Ramon Cestero* MD,
Susannah Nicholson MD, Brian Eastridge* MD, Donald Jenkins* MD, University of
Texas Health Science Center at San Antonio
Introduction: Hemorrhage is the most common cause of preventable death in trauma
patients, with approximately 40% of trauma deaths attributed to uncontrolled blood loss,
and up to half of these deaths taking place before the patient arrives at the hospital. These
mortalities might be prevented with pre-hospital transfusion. The goal of this analysis was
to characterize injured patients requiring massive transfusion to determine the potential
impact of a pre-hospital whole blood transfusio
Methods: Using our level I trauma center's registry, we retrospectively identified all adult
trauma patients from January 2015 to August 2017 requiring activation of the massive
transfusion protocol (MTP). Patient demographics, Emergency Medical Services (EMS)
times, vital signs [systolic blood pressure (SBP), diastolic blood pressure (DBP), heart
rate (HR), shock index [HR/SBP (SI)], pulse pressure divided by heart rate (PP/HR),
mean arterial pressure (MAP), and PP] and injury severity scores (ISS) were evaluated by
the independent samples t-test and chi-square test to assess for differences between
survivors and non-survivors.
Results: Our study population of 124 MTP patients had the characteristics shown in
Tables 1 and 2. The all-cause mortality was 73% (90/124) with 84% (76/90) of deaths due
to bleeding. Of the hemorrhage-related deaths, 57% (43/76) spent less than or equal to 30
minutes in the pre-hospital setting. The odds of death were higher for both elderly
patients (age ≥55 years) and for blunt trauma compared to penetrating, [1.22 (95% CI,
0.99 – 1.50 and 0.94 – 1.58 respectively)]. Positive predictive value (PPV) of death for
patients with PP<45 and SI>1 was 0.79 for all patients, but was 0.81 and 0.92 for blunt
injury and elderly patients, respectively.
Conclusion: Our data demonstrate a high mortality rate in trauma patients who require
MTP, with a mortality trend in older patients and patients with blunt trauma. We
recommend using EMS pulse pressure in combination with either shock index or systolic
blood pressure to serve as a trigger for initiation of pre-hospital whole blood transfusion.
This study supports the development and implementation of a pre-hospital whole blood
transfusion program. Realizing that most hemorrhage-related deaths had less than a 30-
minute pre-hospital time, transfusion initiated by EMS may decrease mortality in the
MTP patient.
 Poster # 11
HEAD INJURY ALERT: A NEW LEVEL OF TRAUMA ACTIVATION AT
COMMUNITY HOSPITALS?
Daniel Ricaurte MD, Daniel Slack MD, Aaron Gilson DO, Michael Nowicki MD, Monika
Nelson RN, Peter Zdankiewicz MD, Waterbury Hospital
Introduction: Trauma activation at a hospital requires mobilization of significant resources
and personnel. The trauma team, operating room, CT scan and X-ray technologists all have
to be available to assist at short notice. While Level 1 trauma centers are better equipped to
designate personnel and resources to trauma activations, community hospitals tend to be
more limited in their capacity to allocate resources to the trauma patient. In 2014, the
Committee on Trauma of the American College of Surgery issued the updated Orange
Book with its latest recommendations for optimal care of the injured patient. Amongst
trauma activation criteria was included elderly patients that sustain falls from any height on
anticoagulation. Based on our experience with this specific trauma population, we
hypothesized that a new tier of trauma activation composed of a limited trauma team could
preserve patient safety while reducing time and cost.
Methods: A “Head Injury Alert” was created to denote patients with a GCS > 14 who had
fallen from a height of <20 feet while on anticoagulation. The team, composed of an ED
attending, a surgical resident and one nurse, triage and evaluate the patient with the goal of
obtaining a CT scan of the head within 30minutes of presentation. At any time, the Head
Injury team could raise the level of trauma activation if deemed necessary. Data was
prospectively acquired utilizing the Electronic Medical Record at our institution for all head
trauma activations from its inception in June 2017 to January 2018. Data collected included
patient age, type of anticoagulation, Injury Severity Score (ISS), time from arrival to CT
scan, outcomes, missed injuries, disposition (admission vs discharge) and number of
activations requiring escalation of care.
Results: From June 1st 2017 to January 31st 2018, 150 head injury activations occurred.
52% of patients were female while 48% were male. The median age was 77 years old. The
most common anticoagulant observed was Coumadin, corresponding to 28% of all patients.
46% of patients were discharged to home from the emergency room, while 43% were
admitted and 7% required admission to the intensive care unit. The median time-to-CT was
26 minutes, with 45 out of 152 CT scans delayed more than 30minutes. The ISS ranged
from 0 to 25, with the worst ISS seen in patients taking ticagrelor. Eleven patients (7.3%)
presented with positive head CT, but only one underwent neurosurgical intervention. Of the
5 deaths, three patients (2%) succumbed to intracranial hemorrhage, one to pneumonia
present on admission and one to cardiac arrest which led to his fall.

Conclusion: Head Injury Alert can be safely applied as a new level of trauma activation
for patients that fall from <20 feet while on anticoagulation. This new level of activation
helps identify a specific patient population and injury mechanism that can be safely
triaged by a limited trauma team. With this, community hospitals can maximize their
resources and minimize cost, while maintaining patient safety.
 Poster # 12
FALL DOWNS SHOULD NOT FALL OUT -- BLUNT CEREBROVASCULAR
INJURY AND ITS SEQUELAE ARE COMMON IN GERIATRIC PATIENTS
FOLLOWING LOW ENERGY BLUNT TRAUMA
Erika Flashburg DO, Forrest B. Fernandez MD, Alison Muller Sara Wilhelm PA-C, Jared
Zavilla PA-C, Laura Castor PA-C, Alicia Sherwood PA-C, Shayne Layser PA-C,
Spencer C. Barbera BS, Reid A. Reinhart BS, Adrian W. Ong* MD, Reading hospital
Introduction: Blunt cerebrovascular injuries (BCVI) are associated with specific injuries
to the face, skull base and cervical spine. There are limited studies examining the impact
of screening protocols for BCVI in geriatric patients after low energy falls. We
hypothesized that BCVI screening in this cohort would rarely identify injuries and would
infrequently result in a change in management.
Methods: A retrospective study was conducted over a 36-month period (2014-2016) of
patients ≥ 18 years with Abbreviated Injury Scores for the head, neck or face region of
≥2. Patients were defined as meeting criteria for BCVI screening if any of these
anatomic criteria were present: diffuse axonal injury, C1-3 fracture, any cervical
subluxation or fractures involving foramina transversaria, Leforte 2 or 3, petrous
temporal bone or bilateral mandibular fractures. Outcomes were in-hospital mortality
and stroke in the 30-day period following presentation. Univariate analysis was used
where appropriate with a p value of 0.05 indicating statistical significance.
Results: 303 patients met criteria for BCVI screening with 141 (47%) being ≥65 years.
Patients were screened with computed tomographic angiography (94%) and magnetic
resonance angiography (6%). 120 (85%) sustained falls, of which 58 (48%) underwent
screening. Screened patients were younger (mean age 78 vs 82, p=0.02), less likely to
have serum creatinine of > 1.5 mg/dl (14% vs 29%, p=0.04) but had similar AIS- head
and neck scores (median, 3 vs 3, p=0.8). Mortality was similar for those with and without
screening (7% vs 16%, p=0.2). Of the 62 patients not screened, 38 (61%) were already on
antithrombotic agents and another 12 (20%) died from severe traumatic brain injuries or
had cardiac arrest shortly after arrival. Of the 58 screened patients, 17 (29%) had BCVI.
Four (24%) of the 17 BCVI patients had strokes compared with one (2%) of 41 without
BCVI (p=0.01). Seven of the 17 (41%) BCVI patients had antithrombotic agents started.
Mortality rates were similar for patients with and without BCVI (12% vs 5%, p=0.3).
Conclusion: In geriatric patients with falls who had screening for BCVI, the yield was
high and management changes common. BCVI was associated with stroke. Screening
seems warranted in this cohort when prognosis after trauma is not bleak.
 Poster # 13
INFUSED CEREBRAL NOREPINEPHRINE EXACERBATES NEUROLOGIC
DEFICITS FOLLOWING REPEAT TRAUMATIC BRAIN INJURY
Galinos Barmparas MD, Navpreet K. Dhillon MD, Noell Cho BS, Mor Alkaslasi BS,
Joshua Ghoulian BS, Nikhil T. Linaval Gretchen M. Thomsen Ph.D., Eric J. Ley* MD,
Cedars-Sinai Medical Center
Introduction: Catecholamine levels surge immediately after acute traumatic brain injury
(TBI), often to levels reflecting the severity of injury, causing inflammation and
apoptosis. The degree of catecholamine surge following mild repetitive TBI (rTBI) and
its relationship to the injury sequela is unknown. We hypothesized that mild repetitive
TBI (rTBI), causes increased basal norepinephrine (NE) levels over time and artificially
elevated NE is associated with further functional impairments in a rat rTBI model.

Methods: Fifty-six wild type rats were administered sham, or rTBI once per week for 5
weeks. NE levels were measured on the day prior to injury 1, 2 and 3. One week
following the last injury, animals received ventricular infusion of vehicle or NE (0.4
µg/hour) for 6 weeks. Rats were tested on the rotarod, the open field, Barnes Maze, and
Basso, Beattie, and Bresnahan (BBB) analysis to determine changes in neurologic
function.

Results: rTBI led to increased basal NE levels over the time course of injury, relative to
sham. No rotarod or open field differences were observed in TBI rats administered NE
compared to vehicle. However, after rTBI NE administration resulted in impairments in
short-term working memory. Cerebral NE infusion after rTBI led to lower BBB scores,
indicating mild paralysis and impaired locomotion (Figure 1). The infusion of NE to sham
rats did not alter BBB scores.

Conclusion: After mild recurrent TBI, elevated NE may lead to secondary brain injury
and additional functional deficits. Mitigation of an excess catecholamine response,
possibly with beta blockers, might therefore be essential for ameliorating the long-term
morbidity associated with rTBI.
 Poster # 14
ASSOCIATION OF EARLY MORTALITY AND ELEVATED SHOCK INDEX AT ADMISSION IN
PATIENTS WITH TBI AND CONCOMITANT HEMORRHAGHIC SHOCK: A POST-HOC ANALYSIS OF
THE PROHS STUDY
Matthew C. Hernandez MD, Martin A. Schreiber* MD, Deborah Stein* MD,MPH, Michael Goodman* MD, Jeffrey
D. Kerby*
MD,Ph.D., Kenji Inaba* MD, Eileen Bulger* MD, Erin E. Fox Ph.D., Johnathon M. Aho MD,Ph.D., John Holcomb*
MD, Charles E.
Wade Ph.D., Martin D. Zielinski* MD, Mayo Clinic - Rochester
Introduction: Rapid and effective treatment of hemorrhagic shock (HS) is important for critically injured patients
with traumatic brain injury (TBI) in order to reduce secondary brain injury. The shock index (SI) rapidly assesses
hypovolemic shock severity which can complicate TBI. The Prehospital Resuscitation on Helicopter Study (PROHS)
assessed the impact of blood product resuscitation during prehospital air transport for severely injured patients.
Utilizing the PROHS database, we evaluated whether elevated SI at admission impacted mortality in TBI-HS and TBI
+HS patients. We hypothesized that a normal SI on admission was associated with improved patient mortality.
Methods: A post-hoc analysis of the multi-center PROHS study was performed. PROHS inclusion criteria were: heart
rate > 120 bpm, systolic blood pressure ≤90 mmHg, penetrating truncal injury, tourniquet/pelvic binder application,
intubation or receipt of blood product during air prehospital [Link] with TBI (head abbreviated injury scale
≥3), prehospital HS (base excess ≤ -6 or a pulse pressure <45 mmHg) and/or receiving a massive transfusion (critical
administration threshold; CAT: at least three units of RBCs given in any one-hour interval during first 24 hours after
ED admission) were identified. SI was calculated for prehospital and admission time points with SI normalization
defined as a prehospital SI value >0.9 improving to 0.4-0.89 at admission. Comparison of patient mortality (3, 24
hours and 30 days) between TBI-HS and TBI+HS groups was performed. Logistic regression was used to evaluate
prehospital factors associated with 24 hour mortality using odds ratios (OR) with 95% confidence intervals (95% CI).
Results: A total of 396 patients were analyzed; 192 TBI+HS (48%) and 204 TBI-HS (52%). Table demonstrates
injury severity, fluid resuscitation, and coagulation parameters for each group. Notably at admission, TBI+HS patients
had a higher ISS, likelihood of receiving blood products, and coagulopathy than patients with TBI-HS. CAT rates
were dissimilar in TBI+HS and TBI-HS groups (43%vs 30% respectively, p=.03). The proportion of uncorrected SI (≥
0.9) at admission was higher in TBI + HS (60%) compared to TBI-HS (29%). Within the TBI-HS group, patients with
admission SI <0.9 demonstrated lower mortality compared to those with a SI ≥0.9 at three (0% vs 8.3%, p=.002) and
24 hours (6.7% vs 16%, p=.03). In the TBI+HS group, patients with admission SI <0.9 demonstrated lower mortality
compared to those with a SI ≥0.9 at three (5.6% vs 23.1%, p=.002) and at 24 hours (14.1% vs 36.4%, p=0.001). On
regression, factors independently associated with 24 hour mortality in both groups included penetrating injury (OR 6.7
95% 2.6-11.5), increasing age (OR 1.03 95% CI 1.01-1.05 per year), ISS (1.04 95% CI 1.01-1.1 per ISS unit), a lack
of normalized admission SI (OR 2.4 95% CI 1.1-5.6) and the presence of coagulopathy at admission (OR 4 95% CI
2-8.5).
Conclusions: Patients with TBI+HS demonstrated increased mortality compared to TBI-HS at 3 and 24 hours but not
at 30 days. TBI+HS patients also demonstrated concomitant coagulopathy by INR but not on thromboelastography
compared to TBI-HS. At admission, SI that improved with treatment was associated with a reduction in mortality
despite age, injury mechanism, or injury severity for both groups. Further analysis evaluating SI to improve pre-
hospital resuscitation in patients with TBI+HS is warranted.
 Poster # 15
A NOVEL LABORATORY RAT MODEL OF FOCUSED BLAST
WAVE-INDUCED MILD TRAUMATIC BRAIN INJURY
Hiroshi Matsuura MD, Mitsuo Ohnishi MD,Ph.D., Sanae Hosomi MD, Takeshi
Shimazu* MD,Ph.D., Osaka University Graduate School of Medicine
Introduction: Mild blast-induced TBI (mbTBI) is a quite common combat injury, and
the number of victims with mbTBI is increasing worldwide due to terrorism. Thus, the
mechanism of and treatment for blast injury must be understood. This study aimed to
establish a rat model of mbTBI to assess chronic disability including immunohistological
changes in the brain and discover clues for intervention.
Methods: We built and used a blast wave generator described by Jaffin et al. (1987). The
blast wave exited through a 20-mm I.D. nozzle aimed at the target. Rat brains showed no
detectable injury at a nozzle-to-brain distance determined by preliminary testing (n=5).
Peak shock wave pressure measured (93.7±10.2 psi) at 2.5 cm under the nozzle. The blast
wave was directed at the head of male SLC:Wistar rats weighing 247±3.9 g under general
anesthesia positioned prone 2.5 cm below the nozzle. Blast wave-induced brain injury
was evaluated by Iba1 immunoreactivity at 3 days and 1, 2, and 6 weeks after injury. A
forced swim test was performed 2 and 6 weeks after injury to assess depressive-like
behavior.
Results: The mbTBI rat model showed no macroscopic findings of brain hemorrhage or
contusion after blast injury, and behavioral changes appeared unchanged from the control
group. However, early post-injury food intake decreased significantly in the blast group
rats (day 1: 4.7 vs. 16.7 g/day; day 2: 11.3 vs. 18.7 g/day, n=3) and they lost weight
compared to control (-18 vs. +10 g on day 3; P=0.001, n=11 vs. 3). The blast group
showed increased immobility time in the forced swim test at 2 weeks (165 s vs. 125 s;
n=6) and at 6 weeks (199 s vs. 162 s; n=6). Iba1 immunostaining show microglial
accumulation in the hypothalamus at 2 weeks after injury and also in the thalamus and
brain stem at 6 weeks.
Conclusions: This novel mbTBI rat model showed chronic-phase immunohistological
abnormality and depressive-like behavior indicating that chronic traumatic
encephalopathy by mbTBI may cause mental state change. This model will allow more
precise identification of the mechanism of and best treatment method for mbTBI.

(Left) Shock wave from the generator.

(Right) Microglial accumulation in hypothalamus at 6 weeks.
 Poster # 16
MANAGING CRANIOMAXILLOFACIAL INJURY WITHOUT ROUTINE
INPATIENT CONSULTATION: OUTCOME REVIEW AND REDUCTION IN
PATIENT CHARGES
Georgina Alizo MD, Leeda Roshan Keely Muertos MPH, Jason D. Sciarretta* MD,
University Of South Carolina/Grand Strand Medical Center
Introduction: Traumatic craniomaxillofacial (CMF) injuries are commonly assessed by the
trauma team and refer consultation to otolaryngologist or oral maxillofacial specialist. We
hypothesized that trauma surgeons can safely selectively manage CMF injuries identified
on computed tomographic (CT) scans without specialized surgical services, thereby
decreasing the overall cost burden to patients.
Methods: We performed a retrospective analysis of all traumatic CMF fractures diagnosed
on facial CT scan at a Level 1 trauma center during a 3-year period (January 2013 to
December 2015). Those requiring CMF consultation were determined by the following
injuries: lower midface, upper midface, and the craniobasal-facial unit. Patient population
then categorized to those with CMF consultation versus no-CMF consultation. Patient age,
sex, Glascow Coma Scale (GCS) score, and Injury Severity Score (ISS) recorded. Specialty
consultation charges were also calculated for review. All penetrating injuries, skull
fractures or any patient completing inpatient craniofacial surgery were excluded from the
analysis.
Results: 303 patients with CMF fractures on CT met inclusion criteria (124 [41%] CMF
consultation versus 179 [59%] no-CMF consultation). Mean age was 47.8 ± 19.7 years
(range, 5 to 94 years), and 70% males. Mean GCS and ISS was 13± 3.4 (3-15) and 10 ± 9
(1-66) respectively. Patients with CMF consults were more likely to have higher ISS
(p<0.001) and need surgery on admission (p<0.001), while those with no-CMF consult had
shorter LOS (p<0.002). No in-hospital mortality or 30-day readmission rates were related
to no-CMF consult. Those with CMF consultation, only 18.5% had inpatient consult follow
up and 31 (22 patients [17.7%]) inpatient surgical procedures (18% ENT vs 52% OMFS)
by surgical specialist. Of the accepted transfers (7 of 11) for isolated CMF injuries, a mean
of 1.5 days length of stay was observed and no required surgical interventions recorded.
Total patient charges saved with no-CMF consultation was $26,539.96 during this review.
Conclusion: Trauma surgeons can selectively manage acute CMF injuries without
inpatient specialist consultation. Additional guidelines can be established to avoid tertiary
transfers to tertiary center for specialty consultation and decrease patient charges.
 Poster # 17
PREDICTORS OF CONCURRENT CERVICAL SPINE FRACTURES IN PATIENTS WITH
DIAGNOSED INTRACRANIAL HEMORRHAGE
Cecily E. DuPree DO, MBS, Jason D. Sciarretta* MD, Keely Muertos MPH, Christoph Kaufmann
MD, Grand Strand Medical Center
Introduction: Cervical spine fractures (CSF) have long been assumed present in high proportions of
patients with a primary diagnosis of intracranial hemorrhage (ICH) due to the magnitude of injury
required to cause ICH. However, the risk due to mechanism of injury (MOI) is unclear to suggest if
additional computed tomography (CT) imaging is required. We hypothesize that the incidence of
concurrent CSF injury with ICH is low based on MOI, and over utilization of CT scans has increased
radiation burden and hospital cost.
Methods: A 2-year retrospective review was conducted for all patients admitted at a Level 1
trauma center sustaining blunt injury. Demographic data, radiographic imaging, GCS, ISS, length of
stay (LOS), and ethanol levels were analyzed. To evaluate blunt impact trauma, patients were
categorized as low or high impact mechanisms, by either fall (low) or motor vehicle collision (MVC
- high); our facilities two most commonly treated MOI. Patients were further reviewed for
isolated or combined ICH/CSF injury. The diagnostic yield of CT scans for
clinically significant injury was then calculated.
Results: 3,222 patients were reviewed, and 861 identified with ICH or CSF. Patients were divided
into three injury groups: CSF only, ICH only, or combination injury (CI). MOI was
evaluated within injury groups and compared. Median age was 55 ± 23 years (range, 20-103)
and 65% male. Incidence of CI was 3.0% (26 of 861) in the fall and MVC study groups. Mean
GCS and ISS was 15 (3-15) and 5 (1-50), respectively. Fall patients with ICH were less likely to
have CSF compared to fall patients with a negative head CT (p>0.001). Increased age, higher ethanol
concentration (p = 0.030), higher ISS, and lower GCS were positive predictive factors in
CI fall patients (p<0.001). These factors were also similar for CI MVC group (ethanol p = 0.035; ISS,
GCS p < 0.001). MVC patients were 5.9 times more likely to have CI (p < 0.001). Patients with an
isolated CSF due to fall were 2.0 times more likely to have a C2 vertebra injury compared to
patients with an isolated CSF due to MVC (p = 0.049). Patients who sustained an isolated CSF due to
MVC were 4.0 times more likely to have a C7 vertebra injury compared to patients with CSF due to
fall (p < 0.001). There were no significant differences in location of cervical spine fracture between
CI groups.
Conclusion: Fall patients with ICH have low incidence of concomitant CSF, and fall as an MOI does
not have a significant positive predictive value for cervical spine injury. Existing guidelines for
cervical spine clearance should be followed to limit unnecessary additional
radiographic imaging thereby decreasing the radiation exposure and cost burden to the patient.
 Poster # 18
IS AGE PROTECTIVE OF LOSING CONSCIOUSNESS AFTER CONCUSSION:
WHAT CAN 35,000 MILD TRAUMATIC BRAIN INJURIES TELL US?
Alessandro Orlando MPH, Benjamin Rubin MD, David Bar-Or MD, Swedish Medical
Center
Introduction: Aging is significantly associated with decreasing volume of brain
parenchyma and increasing volume of cerebrospinal fluid (CSF). One role of CSF is to
protect the brain from forces caused by head trauma. Moreover, the mechanism by which
loss of consciousness (LOC) occurs after a head injury is not well defined but must
somehow be attributable to the forces experienced by the brain. Thus, it is possible that
age-related increases in CSF volume will protect against losing consciousness after a TBI.
The primary objective of this study was to examine to what extent age is associated with a
change in the risk of LOC after sustaining a concussion in the setting of mild TBI (mTBI,
Glasgow coma scale [GCS] 13-15). Our secondary objective was to generate hypotheses
to help direct future research on this topic.
Methods: This was a retrospective observational study utilizing six years of National
Trauma Data Bank data. We included patients with 1) diagnosis of concussion; 2)
positive or negative affirmation of post-injury LOC; 3) age ≥18 years; 4) had a “fall”
mechanism of injury; and 5) with an initial Glasgow coma scale 13-15. We excluded
patients with skull fractures or diagnoses of intracranial hemorrhage. Age groups were
analyzed continuously, and categorically by decade (starting at 18-29 and ending at ≥80).
The primary outcome was a reported LOC vs. a reported lack of LOC (ICD-9 850.1-850.5
vs. 850.0). Chi-square tests were used to assess differences in proportions between
outcome groups, and multivariable logistic regression examined independent predictors of
LOC. All statistical tests were two-tailed with an alpha of 0.05.
Results: There were 35,577 patients included in
our study. The overall rate of LOC was 78.7%
(n=27,990). The median (IQR) age in patients
with a LOC was 55 yrs (40-70), and in those
without LOC was 69 (52-81). There was a
significant decrease in the odds of LOC with
increasing age decile (Figure 1). The most
pronounced decrease in odds of LOC started after
age 50-59 yrs. (Figure 1). There was no significant
difference in the odds of LOC between patients
aged 18-29 vs. 30-39 yrs. Patients aged ≥80 yrs. had a 76% decrease in the odds of having
a LOC, compared to patients aged 18-29 (OR=0.24, 95%CI [0.21–0.26]). When age was
analyzed as a continuous predictor, each 10-year increase in age was associated with a
23% reduction in the odds of suffering a LOC (OR=0.77, 95%CI [0.76–0.78]).
Conclusion: These nationwide data suggest a strong inverse association between age and
odds of LOC, in a select population with concussion and mTBI. Furthermore, our data are
in agreement with multiple quantitative CT studies suggesting that age-related cerebral
atrophy begins to accelerate at age 50-55. It is possible that increased CSF volume
mitigates sheer-related diffuse axonal injury and the likelihood of LOC. It is also possible
that increased CSF volume helps to dissipate rotational and acceleration forces on the
brainstem, reducing their affects on the reticular activating system and thus reducing the
likelihood of LOC. These notable results offer a opportunity to generate important
hypotheses to examine in smaller clinical studies.
 Poster # 19
AN ANALYSIS OF OUTCOMES AFTER ADMINISTRATION OF KCENTRA
FOR URGENT REVERSAL OF ANTICOAGULATION IN PATIENTS WITH
INTRACRANIAL HEMORRHAGE
Michael S. Farrell MD, MBS, Matthew Painter MD, Richard J. Caplan Ph.D., Michael
Morton-Wiedner MD, Michael Perza PharmD, Mark Cipolle* MD,Ph.D., Christianacare
Health Services
Introduction: Intracranial hemorrhage (ICH) is presenting with increasing incidence in
anticoagulated patients. Kcentra is currently recommended for urgent reversal of vitamin
K antagonist (VKA) anticoagulation. While Kcentra is being used for urgent reversal of
Xa inhibitor (XaI) mediated anticoagulation, the data to support this is limited and
focused on relatively healthy patients with small ICHs. These studies do recognize an
accepted 30 day mortality risk of approx
imately 6% and an associated thromboembolic event rate of approximately 4%. We
evaluated the effectiveness and outcomes of utilizing Kcentra to urgently reverse
anticoagulation in patients with ICH.
Methods: A retrospective observation study of anticoagulated patients at a single
institution who received Kcentra between September 2013 and December 2016 for ICH
was completed. The primary endpoint was change in ICH size between initial and repeat
head CT in patients who did not have an intervening cranial procedure. Secondary
endpoints included: mortality, discharge disposition, and thromboembolism development.
Results: 110 ICH patients received Kcentra (31.8% traumatic). Three anticoagulation
groups were analyzed: warfarin (n=75), rivaroxaban
(n=21), and apixaban (n=14). No significant
differences were noted with respect to median ICH
size at initial (p=0.88) or repeat (p=0.48) head CT or
in median percent change (p=0.71) (Figure 1). There
was no difference among groups in the number of
patients in which ICH volume either increased or
decreased by 20% (p=0.75). Approximately half of all
patients died during their hospital course with a
median life expectancy of 3 days. Of those who
survived there was no difference in discharge
disposition between groups with 60-80% of those
who survived requiring further nursing care (p=0.99).
Overall, requiring a drainage procedure was not
associated with increased mortality (p=0.55). Rates of
thromboembolic complications, resulting in 2 deaths,
were noted in 13.3% of VKA patients, but 0% of XaI
patients.
Conclusion: In patients given Kcentra for warfarin
and rivaroxaban, ICH size does not change
significantly. The median ICH size increased in
apixaban but this was not significantly different due to wide variability and limited
sample size. Mortality rates were higher in all groups than previously reported though not
higher for any specific anticoagulant or in patients requiring a drainage procedure.
Thromboembolic complications were seen in the warfarin group and were directly related
to Kcentra administration.
 Poster # 20
ANTIBIOTICS FOR DRAINS AFTER TRAUMATIC SPINE INSTRUMENTATION ARE NOT
PROPHYLACTIC OR THERAPEUTIC
David J. Skarupa* MD, Firas G. Madbak* MD, David J. Ebler MD, Albert T. Hsu MD, Don W.
Johnson Pharm D, Gazanfar Rahmathulla MD, Andrew J. Kerwin* MD, Marie L. Crandall* MD,MPH,
University of Florida, Jacksonville

Introduction: Antibiotics after spine instrumentation are often extended while the surgical drain is in
place without strong evidence. Patients with traumatic spine injuries are considered a higher risk
population. The recommendations to continue antibiotics after instrumentation in this group of patients
is undefined. Judicious use of antibiotics is important for a myriad of reasons and is under
investigation. Some current studies in elective spine surgery patients have shown no benefit to
continuing antibiotics beyond 24 hours even if a surgical drain is in place. We sought to study if
continuing antibiotics past 24 hours after traumatic spine instrumentation when a surgical drain is
placed in a county safety net hospital impacted outcomes.

Methods: We performed a retrospective observational study of all patients who underwent spine
fixation with hardware and surgical drains for traumatic injury at our Level I Trauma Center between
1/1/14 and 12/31/17. Routine demographic and injury variables were obtained to determine the effect
of perioperative (≤ 24 hours of antibiotics) versus prolonged (>24 hours) antibiotics on surgical site
infections (SSI), mortality, hospital length of stay (HLOS), and intensive care unit length of stay (ICU
LOS). Bivariate and multivariable logistic and linear regression statistics were performed.

Results: Three hundred forty-six patients were included in the analysis. On multivariate analysis,
antibiotic duration longer than 24 hours did NOT predict surgical site infection (SSI) (OR 2.68, 95% CI
0.88-8.10, p=0.08), death (OR 0.59, 95% CI 0.10-3.44,
p=0.56), HLOS (p=0.13), or ICU LOS (p=0.37), when controlling for age, gender, mechanism of
injury, spinal cord injury, and insurance status.

Conclusion: Continuing antibiotics past 24 hours, even if a surgical drain is left in place, after
traumatic spine instrumentation is not necessary. Prolonged antibiotics are not inferior to standard
perioperative antibiotics. A prospective study that could control for potential confounders such as race
and comorbidities may be warranted.
Table 1. Bivariate Statistics
 Poster # 21
PROLONGED PARTIAL RESUSCITATIVE ENDOVASCULAR BALLOON
OCCLUSION OF THE AORTA (pREBOA) IS SAFE IN A SEVERE
HEMORRHAGIC SHOCK MODEL, IN THE ABSENCE OF TRAUMATIC
BRAIN INJURY
Aaron M. Williams MD, Umar F. Bhatti MD, Isabel S. Dennahy MD, Vahagn C.
Nikolian MD, Panpan Chang MD, Kiril Chtraklin DVM, Rachel O'Connell Nathan
Graham Jessica Lee Jing Zhou MD, Patrick E. Georgoff MD, Ben E. Biesterveld MD,
Yongqing Li MD,Ph.D., Jonathan L. Eliason MD, Hasan B. Alam* MD, University of
Michigan
Introduction: The use of partial REBOA (pREBOA) in combined hemorrhagic shock
(HS) and traumatic brain injury (TBI) has not been well studied. We hypothesized that
prolonged pREBOA deployment in the setting of concurrent TBI + HS would worsen the
clinical outcomes.
Methods: Fifteen female Yorkshire swine were subjected to a combination of 40% total
blood volume hemorrhage, computer-controlled cortical TBI, and pREBOA treatment (1
hr). Three groups were studied: HS + TBI (Group 1), HS + TBI + pREBOA (Group 2),
and HS + pREBOA (Group 3) (n=5/cohort). After 60 minutes of shock with a mean
arterial pressure (MAP) of 30-35 mmHg, Group 1 was left in shock for an additional 60
minutes, whereas Groups 2 and 3 were treated with Zone 1 pREBOA inflation (60
minutes). All animals were then resuscitated with normal saline (NS; 3 x volume of shed
blood). Physiologic parameters were monitored for six hours, during which further
resuscitation (CVP goal of 6) and vasopressor therapy (MAP goal of 55-60 mmHg) were
administered as needed. Brain edema (% increase compared to the uninjured side) and
lesion size (mm3 ) were quantified at the end of the observation period.
Results: pREBOA deployment resulted in a
higher maximal proximal MAP (Group 2, 64.4 ±
11.1 mmHg; Group 3, 66.6 ± 14.7 mmHg; Group
1, 33.4 ± 2.7 mmHg; p < 0.05), while
maintaining a distal MAP goal of 20-25 mmHg.
Mortality was highest in Group 2 (40% vs 0% in
the other groups, p = 0.1), but no significant
differences were noted in the brain edema and
lesion size (Group 2, 32.5 ± 6.6%, 3084 ± 619
mm 3 ; Group 1, 26.5 ± 8.6%, 3107 ± 999 mm 3 ;
p > 0.05). Severity of shock was greatest in
Group 2 ( Figure 1). Lactate level at the end of experiment was significantly higher in
Group 2 (Group 2, 15 ± 2 mmol/L; Group 3, 2 ± 1 mmol/L; Group 1, 3 ± 2 mmol/L; p <
0.01), while pH nadir was significantly lower for Group 2 (Group 2, 7.16 ± 0.04; Group
1, 7.26 ± 0.04; Group 3, 7.31 ± 0.03; p < 0.01). In addition, fluid and norepinephrine
requirements were significantly higher in Group 2 (Group 2, 3360 ± 706 mL, 0.14 ± 0.02
ug/kg/hr; Group 3, 660 ± 371 mL, 0.014 ± 0.001 ug/kg/hr; Group 1, 300 ± 0 mL, 0 ± 0
ug/kg/hr; p < 0.01).
Conclusion: Prolonged application of pREBOA for up to an hour is safe in severe HS
and does not worsen the extent of TBI. However, the addition of TBI to HS significantly
exacerbates the degree of circulatory shock when pREBOA is deployed. Aortic occlusion
should be undertaken with extreme caution in the setting of TBI.
 Poster # 22
IS INTRA-OPERATIVE REBOA DELAYED REBOA? AN ANALYSIS OF THE
AMERICAN ASSOCIATION FOR THE SURGERY OF TRAUMA AORTA
REGISTRY
Michael A. Vella MD, Ryan P. Dumas MD, Megan Brenner* MD, Thomas M. Scalea*
MD, Laura J. Moore* MD, Jeanette M. Podbielski RN, CCRP, Kenji Inaba* MD, Scott
T. Trexler MD, Sonya Charo-Griego RN, Marshall C. Spalding DO,Ph.D., Charles Fox*
MD, Ernest Moore* MD, David Turay MD,Ph.D., Mark J. Seamon* MD, Jeremy W.
Cannon* MD, SM AAST AORTA STUDY GROUP
Introduction: Resuscitative endovascular balloon occlusion of the aorta (REBOA) has
emerged as a less invasive alternative to open aortic occlusion (AO) in trauma. REBOA
is commonly performed in the emergency department (ED), while the role of
intra-operative REBOA is less well defined. We hypothesized that delayed insertion until
arrival in the operating room (OR) is associated with increased mortality.
Methods: The American Association for the Surgery of Trauma (AAST) AORTA
registry prospectively enrolls trauma patients undergoing open and endovascular AO
from 29 centers. Patient demographics, admission physiologic variables, and outcome
data from this registry were compared between OR and ED REBOA placement.
Mann-Whitney U and chi-square analyses were performed where appropriate.
Multivariable logistic regression was performed on the outcome of mortality.
Results: Of 321 patients who underwent REBOA, location and timing of insertion were
available for 305 (95%). 58 patients underwent OR REBOA (19%) vs. 247 in the ED
(81%). There were no differences between populations with respect to sex, lactate, and
injury severity score (ISS). Patients who underwent OR REBOA were younger (33 years
vs 41 years, p=0.01) and more likely to have a penetrating mechanism (36% vs 15%,
p<0.001). There were significant differences with respect to admission physiology
( Table 1). Unadjusted mortality was lower in the OR group (36.2% vs 68.8%, p<0.001),
but there were no differences in transfusion requirements or acute kidney injury. Time
from admission to AO was longer in the OR group (75 minutes vs 23 minutes, p<0.001).
After controlling for age, admission CPR, systolic blood pressure, heart rate, lactate, ISS,
and GCS, there was no association between REBOA insertion location or time to
successful AO and mortality.
Conclusions: Nearly one in five REBOAs is placed in the OR, generally in patients who
present with more stable initial physiology. In our analysis, delaying REBOA insertion in
the appropriate patient until OR arrival was not associated with adverse outcomes.
 Poster # 23
Resuscitative endovascular balloon occlusion of the aorta (REBOA) for severe torso
trauma in Japan: A descriptive study
Taku Akashi MD, Kyoungwon Jung MD, Tomohiko Orita MD, Tomohiro Funabiki MD,
Motoyasu Yamazaki MD, Mitsuhide Kitano MD, Shokei Matsumoto* MD, Saiseikai
Yokohamashi Tobu Hospital
Introduction: Resuscitative endovascular balloon occlusion of the aorta (REBOA)
spread early in clinical settings in Japan. REBOA has the potential to be applied as an
alternative to the aortic cross-clamp procedure (ACC). The practical indication, usage
conditions, and efficacy remain unknown, however. We examined the usage trend of
procedures related to aortic occlusion for resuscitation (REBOA and ACC) in Japan for
severe torso trauma, and investigated if these procedures were associated with time of
death distribution based on a large database from the Japan Trauma Data Bank (JTDB).
Method: The JTDB for 2004 to 2014 was reviewed. Eligible patients were restricted to
those with severe torso trauma, which was defined as an Abbreviated Injury Scale (AIS)
score of 4 or more for chest, abdomen, or pelvic fracture. Patients were classified into
groups according to aortic occlusion procedure: non-procedures, REBOA, and ACC. We
classified the clinical situation according to patient blood pressure and primary source of
hemorrhage (Figure 1). The primary outcomes were the rates of REBOA and ACC used
according to the clinical situation. We also evaluated whether the time of death
distributions for the first 8 h differed on the basis of aortic occlusion procedure.
Results: During the study period, a total of 21,533 patients met all of our inclusion
criteria. Of those, 611 patients (2.8%) underwent REBOA, and 322 patients (1.5%)
underwent ACC. ACC was more frequently used in cases of thoracic injury. Patients with
severe hypotension (1-59 mmHg) were more likely to receive REBOA. In contrast,
patients with cardiac arrest were more likely to receive ACC (Figure 1). Multiple
regression analysis revealed that REBOA (odds ratio [OR]: 5.07, 95% confidence
interval [CI]: 4.04-6.36) and ACC (OR: 21.4, 95%CI: 12.8-35.8) were greatly associated
with worse outcomes. With respect to the time of death distribution in the first 8 h, the
cumulative curve for death in REBOA cases was much more slowly elevated and
overtook those of non-aortic procedures around 4 h. It is of note that the cumulative curve
for death in REBOA cases was mostly flat for the first 100 min (Figure 2).
Conclusion: The intended purpose of REBOA in Japan is very similar to the current
proposed strategy. In addition, it appears that REBOA influences the time of death
distribution in the hyper-acute phase, and allows rapid death to be avoided for the first
100 min. Future research on REBOA is needed to investigate its indications and proper
use.
 Poster # 24
AORTIC ZONE 1 REBOA APPLICATION AS AN ADJUNCT TO STANDARD
HEMOSTATIC TREATMENT OF LIVER INJURY/HEMORRHAGE IN SWINE
Michael A. Dubick* Ph.D., Dale Prince BS, Amy Polykratis BS, Rodolfo De Guzman Jr.,
David S. Kauvar MD, Bijan S. Kheirabadi Ph.D., US Army Institute of
Surgical Research

Introduction: REBOA is recognized as adjunctive therapy for the temporary control of

bleeding from non-compressible torso wounds. For the military it has sparked interest in
endovascular approaches to hemorrhage control. The present study evaluated whether
REBOA placement in aortic zone I improves standard treatment (packing) of liver
hemorrhage in a swine model.
Methods: Anesthetized female swine (50.5 kg) were subjected to a controlled hemorrhage
(20 ml/kg), a femur fracture and then to a grade IV/V liver laceration injury (uncontrolled
hemorrhage). After a total of 40% blood loss, bleeding was controlled by standard gauze
packing of the liver alone (P) or by packing but after placing REBOA in aortic zone I (P
+R), n=10/gp. Aortic flow was occluded for 60 min. Five min before release of the
balloon, animals in both groups were resuscitated with autologous blood
(WB) at 15 ml/kg. A femur fracture only group (n=5) was included as a control. All
animals were monitored for 6 hr after liver injury or until death.
Results: Hemorrhage and liver injury reduced MAP ~ 38% in both groups. As expected,
REBOA placement raised MAP above baselines, while MAP continued to fall slowly in
the P group. Limited resuscitation with WB raised MAP transiently, but it continued to
fall toward post-hemorrhage levels during the remainder of the experiment in both groups.
Heart rate rose nearly 2-fold in both groups after hemorrhage and remained elevated
throughout the experiment. Cardiac output fell about 50% after hemorrhage and tended to
be higher in P than P+R after WB resuscitation. Lactate concentration rose nearly 6-fold
after hemorrhage and continued to rise in P+R where by the end of the experiment it was
over 2-fold higher than in the P group. A similar response was observed for base deficit.
Post-treatment blood loss was not different between the two groups. Overall survival was
7/10 in P and 4/10 in P+R with all deaths in P+R occurring after balloon deflation,
whereas deaths in the P group occurred within the first hr after injury due to
exsanguination. As a result, survival times did not differ significantly between groups.
None of these variables changes over time and there were no deaths in the femur fracture
only group.
Conclusion: These results suggest that in this model of predominately venous bleeding,
full occlusion of the aorta in zone I for 60 min did not improve standard hemostatic
treatment of liver injury. Although REBOA appears to delay death due to exsanguination,
the ischemia reperfusion injuries associated with its release caused significant
hemodynamic and metabolic derangement that were not reversed with limited WB
resuscitation in this model. Taken together these data suggest that additional research to
modulate the physiologic derangements observed after balloon deflation is warranted as
efforts continue to improve the safety of REBOA application, particularly in prolonged
care situations.
 Poster # 25
AORTIC OCCULSION TIME IS NOT ASSOCIATED WITH INCREASED
MORBIDITY OR MORTALITY IN REBOA OR RESUSCITATIVE THORACOTOMY:
AN ANALYSIS OF THE AAST AORTA MULTICENTER PROSPECTIVE REGISTRY
Kyle J. Kalkwarf MD, Ronald Chang MD, Megan L. Brenner* MD, Thomas M. Scalea* MD,
Kenji Inaba* MD, Scott T. Trexler* MD, Jeremy W. Cannon* MD, M C. Spalding* DO,
Charles J. Fox* MD, Ernest E. Moore* MD, David Turay* MD,Ph.D., David J. Skarupa* MD,
Joseph A. Ibrahim MD, Laura J. Moore* MD, Joseph J. DuBose* MD, University of Texas
Medical School-Houston

Introduction: Non-compressible torso hemorrhage is the most common cause of potentially

preventable death in trauma patients. Resusciative thoraocotomy (RT) has been employed for the
past half century as a method to obtain aortic occlusion (AO) in trauma patients and
Resuscitative Endovascular Balloon Occlusion of the Aorta (REBOA) use has become an
increasing common method of AO. We hypothesized that increasing AO time (by any method)
would be associated with increased ischemia reperfusion related complications and death.
Methods: The prospective multicenter AAST AORTA registry was utilized to identify patients
undergoing AO from Nov 2013 until Feb 2018. To evaluate late complications of AO, patients
receiving CPR during aortic occlusion or those who exsanguinated prior to 6 hours were
excluded from analysis. Chi-squared test was performed to compare incidence of inflammatory
complications in patients receiving RT or REBOA in Zone 1 (above celiac axis) or Zone 3
(below renal arteries). To examine time-associated morbidity, incidence of complications and
mortality were analyzed by 15-minute intervals of AO (0 to >90 min) using Chi-squared test and
multivariable Poisson regression.
Results: 992 patients from 18 AORTA centers were reviewed. 807 patients were excluded
because they received CPR during AO (621) or exsanguinated within 6 hours of admission
(186). The remaining 185 patients lived long enough to potentially develop ischemia reperfusion
related complications. Univariate analysis demonstrated there were no significant differences in
the rates of complications, (Table). 143 patients (77%) had duration of AO data available for
analysis (0 to >90 minutes). When inflammatory complications were examined based on
duration of AO, no association was observed based on univariate or multivariable analyses
(FIGURE).
Conclusion: RT and REBOA are techniques to rapidly obtain temporary hemorrhage control for
massive bleeding. After eliminating patients who received CPR or who died rapidly
from exsanguination, there were no differences in mortality or complications based on
technique, location, or duration of AO, suggesting that the initial physiological insult, and not
duration of AO, is the predominate cause of inflammatory mediated morbidity and mortality.
 Poster # 26
EFFECTS OF DIASTOLIC BLOOD PRESSURE ON MORBIDITY AND
MORTALITY IN BLUNT TRAUMA PATIENTS
Jeremy Dressler MD, Eric Benoit MD, Nishant Merchant MD, Jason Machan Ph.D.,
Stephanie Lueckel MD, Sean Monaghan MD, Tareq Kheirbek MD, Andrew Stephen
MD, Daithi Heffernan MD, Michael D. Connolly MD, Charles A. Adams* Jr., MD,
Brown University Rhode Island Hospital
Introduction: Trauma resuscitation protocols focus on maintaining systolic blood
pressure (SBP) to promote end-organ perfusion. However, whether a low diastolic blood
pressure (DBP) affects outcome or simply reflects progression of physiologic changes
from injury remains unclear. We hypothesize that diastolic blood pressure affects
morbidity and mortality in blunt trauma patients irrespective of systolic blood pressure.
Methods: We reviewed the trauma registry at our Level 1 trauma center for all adult
blunt trauma admissions to surgical critical care units between August 2015 to August
2016. Those with previously documented vascular disease and those who died within 24
hours were excluded from our sample. Hourly vital signs and lab values were extracted
for seven days after presentation. The primary outcome was mortality, and secondary
outcomes included rates of non-ST elevation myocardial infarction (NSTEMI) and acute
kidney injury (AKI). We used the collected data points to construct a model describing
the relationship among SBP, DBP, and outcomes based on Cox proportional hazard
regression with time varying covariates.
Results: Our sample population consisted of 458 patients with 52802 data points. The
median age was 63, 60% were male, and median ISS score was 14. Seven-day mortality
was 21 (4.6%). Rates of AKI and NSTEMI were 13.8% and 4.6%, respectively. We
identified no significant relationship between DBP and mortality. At 48 hours after
presentation, among those with a systolic pressure 80 mmHg the hazard ratios for AKI
and NSTEMI were 0.748 (95% CI:0.661-0.846) and 0.888 (95% CI: 0.761-1.037),
reflecting the decreasing risk of these two events per every mmHg increase of diastolic
pressure. Among those with a systolic pressure of 100 mmHg, the hazard ratios for AKI
and NSTEMI were 0.879 (95% CI: 0.805-0.959) and 0.908 (95% CI: 0.833-0.989) for
those with higher compared to lower diastolic blood pressures. From 72 to 168 hours
after admission we observed significant associations between DBP and both AKI and
NSTEMI regardless of SBP.
Conclusion: Higher DBP, even within normal SBP ranges, confers a decreased risk of
AKI & NSTEMI in blunt trauma patients. Diastolic hypotension may play a larger role in
the pathophysiology of end-organ injury than previously described. Treatment algorithms
that target patients with low DBP may decrease complications in blunt trauma patients.
 Poster # 27
HYBRID TRIAGE: PREDICTORS OF NEED FOR
SIMULTANEOUS OPERATIVE AND ANGIOGRAPHIC INTERVENTION
Michael Mazzei MD, MS, Elizabeth Dauer MD, Joseph M. Lopez Jr., MD, Zoë Maher
MD, Leonard L. Mason III, MD, Jessica Beard MD, Abhijit Pathak* MD, Thomas
Santora* MD, Amy J. Goldberg* MD, Lars O. Sjoholm MD, Temple University Hospital
Introduction: A subset of trauma patients requires both operative and angiographic
intervention for hemorrhage control. Conventionally, the surgeon must prioritize between
these treatments, but use of the hybrid operative suite – with both catheter-based and
open surgical capacities – can attenuate workflow logistics. However, most trauma
patients do not need angiography, and inappropriate patient selection may increase
resource strain or exclude appropriate patients from care. We hypothesize that there is a
subset of trauma patients whose initial presentations are predictive of need for both
operative and angiographic hemorrhage control, and that identifying these factors can
inform the decision to use the hybrid OR.

Methods: All trauma patients from 2013-2016 in the Trauma Quality Improvement
Program (TQIP) database who underwent operation for hemorrhage control with or
without angiography were evaluated. Injury patterns and presentations were compared
between those who underwent operative intervention alone, and those also requiring
angiography.

Results: Of the 28,908 patients who underwent hemorrhage control surgery, 4,277
(14.7%) also required angiography. While these cohorts presented with varying degrees
of hemorrhagic shock, vital signs were not predictive. Mechanisms associated with need
for angiography included blunt injury (OR 1.32), especially involving motor vehicles
(OR 1.63); injury patterns included pelvic injuries (OR 2.24), especially unstable pelvic
ring fractures (OR 4.00) or those with concomitant external genitourinary or perineal
injuries (OR 2.48), extremity vascular injuries (OR 2.62) and injuries in multiple
compartments (OR 3.24). Negative predictors include gunshot wounds (OR 0.63), and
isolated injuries to the thorax (OR = 0.41) Interventions were implemented in a mean of
1.89 hours for the operative group, but 5.65 hours in the angiography group, and need for
angiography was associated with transfusion of 1.5 to 2 times more blood products in 24
hours. (All p-values significant to p <0.0001).

Conclusion: Injury patterns can be identified in the trauma bay that correlate with a
heightened need for angiography in addition to operative control of hemorrhage. This will
allow the trauma surgeon to more accurately select patients who might benefit from
hybrid room use, potentially decreasing time to hemostasis. This information will allow
for optimal triage of the hybrid OR suite support while not overburdening a shared,
multidisciplinary resource.
 Poster # 28
CLINICAL IMPACT AND RESOURCE UTILIZATION OF A HYBRID
OPERATING ENVIRONMENT AMONG SEVERLY INJURED PATIENTS:
OVERSTATED OR UNDERUTILIZED?
David Carver MD, Julie Beveridge MD, Andrew W. Kirkpatrick MD, Scott D'Amours
MDCM, Rohan Lall MD, Paul B. McBeth MD, Paul Cantle MD, Chad Ball* MD,
University of Calgary
Introduction: The potential utility and clinical benefit of hybrid operating theaters are
increasingly postulated. Unfortunately, the economic cost and real-world efficiencies of
these environments remain unclear. The primary aim of this study was to evaluate the
utility, clinical impact and work flow of a new trauma hybrid operating theater.

Methods: All severely injured patients who were transferred to the hybrid suite for
emergent care between April 4, 2013 and April 4, 2017 were compared to matched
pre-hybrid patients from the 4 preceding years. Standard statistical methodology was
employed (p<0.05=significant).

Results: 170 patients with severe injuries (mean ISS=23; hemodynamic instability=69%;
hospital/ICU stay=21/10 days; mortality=14%) were transferred urgently (0-2hrs) to the
hybrid suite. Most were young (38 years) males (84%) with blunt injuries (51%).
Combined/hybrid trauma procedures occurred in 18% of cases (surgery (82%) and
angiography (7%) alone). Procedures within the hybrid suite included: laparotomy (57%),
thoracotomy/sternotomy (12%), extremity (14%), angioembolization of the
spleen/pelvis/liver/other (9%), neck (9%), craniotomy (4%) and aortic endostenting (6%).
The mean theater and procedure times were 178 and 124 minutes respectively. Compared
to historical matched controls, the hybrid suite resulted in shorter door to intervention and
total procedure times, and faster hemorrhage control in select patients (p<0.05). A clear
benefit for survival was evident in specific cohorts.

Conclusion: Availability of a hybrid environment for severely injured patients reduces

time to intervention, total procedural duration and salvages a select subset of patients who
would not otherwise survive. The cost associated with a hybrid suite remains prohibitive
for many centers.
 Poster # 29
ANALYSIS OF OUTCOMES POST OPERATIVE MANAGEMENT OF TRUNCAL
GSW AT LEVEL I
VERSUS LEVEL II TRAUMA CENTERS
Daniel Wu DO, Shreya Jammula BS, Brian W. Gross BS, Chet A. Morrison MD, Alan D.
Cook* MD, Susan P. Schulz MD, Jeanette Ward MS-CR, Frederick B. Rogers* MD,
Lancaster General Health/Penn Medicine
Introduction:While both Level I and II trauma centers have the resources necessary to
manage gunshot wounds
(GSW), limited research exists comparing outcomes for this injury mechanism between
designations. We hypothesized that there would be no differences in mortality or
complications following surgical intervention for truncal GSW victims between Level I vs.
II center types.

Methods: All adult (aged>18) firearm-related admissions to the Pennsylvania Trauma

Outcome Study database from 2003-2015 were queried. Dead on arrival, transfer, and
cases with a head Abbreviated Injury Scale (AIS) score ≥3 were excluded. The specific
population of interest included all patients with truncal injuries (thorax AIS and/or
abdomen AIS≥3). Multilevel mixed-effects logistic regression models assessed the
adjusted impact of trauma center level (Level I) on overall mortality and complications.

Results: Of the 385,689 adult patients presenting to Pennsylvania Level I-II trauma centers
from 2003-2015, 17,465 GSWs were identified, of which 4,761 met inclusion criteria
(Level I: 3,949; Level II: 812). Overall unadjusted mortality rate (Level I: 16.8%; Level II:
14.2%; p=0.063) was not different between center types. Unadjusted complication rate was
significantly higher at Level I centers (Level I: 35.6%; Level II: 29.4%; p=0.001). Adjusted
analysis did not reveal any significant differences between center types in mortality (AOR
0.978, p=0.918) and complication (AOR 1.305, p=0.112) rates post-surgical intervention
(Table 1). Within each institution, there was a difference in incidence of complications if
surgical intervention was mandated, with Level I centers associated with a 2.9 increased
odds of complications compared to 4.1 increased odds of complication at Level II centers.

Conclusion: Despite higher unadjusted complications at Level I centers, firearm-injured

patients may experience better outcomes when managed at Level I rather than Level II
trauma centers. Within center type, Level II institutions are associated with higher odds of
complications in the event of operative management for truncal GSW, which may be
attributed to low volume experience in treatment of these injuries.

Table 1. Adjusted odds ratios (AOR) for GSW outcomes post-operative management.
 Poster # 30
DO HOSPITAL CHARACTERISTICS INFLUENCE COMPLIANCE WITH 1:1:1
MASSIVE TRANFUSION PROTOCOL?
Matthew M. Fleming MD, Michael P. DeWane MD, Yawei Zhang MD,Ph.D., Kimberly
A. Davis* MBA,MD, FACS, FCCM, Kevin Y. Pei MD, Yale School of Medicine
Introduction: Studies suggest that the ratio of red blood cells to plasma to platelets
during massive transfusion impacts outcomes in trauma patients, though debate remains
which ratio is superior (6:6:1 or 6:3:1). It is unknown if current national practice reflects
these recommended standards. This study assesses overall compliance and the hospital
characteristics associated with nonadherence to the recommended massive transfusion
ratios.
Methods: The Trauma Quality Improvement Program database from 2013-2016 was
queried for patients undergoing massive transfusion (defined as 50% of blood volume
transfused within 4 hours of arrival or greater than 10 total units transfused within 24
hours of admission). Compliance was defined by transfusion ratios:
5.5-6.5:5.5-6.5:0.5-1.5 (blood:plasma:platelet packs) for 6:6:1 and 5.5-6.5:2.5-3.5:0.5-1.5
for 6:3:1. Univariate analysis was performed on patient and hospital characteristics and
multivariable logistic regression was performed to identify characteristics associated with
noncompliance in the use of the massive transfusion protocol (MTP). The role of
thromboelastography in resuscitation could not be assessed as these data are not
captured.
Results: There were 29,323 patients who underwent a massive transfusion protocol.
Overall, 1,205 (4.1%) patients received the recommended transfusion ratio and 28,118
patients (95.9%) did not in the 6:6:1 group compared to 1098 (3.7%) receiving the
recommended ratio and 28,225 (96.3%) receiving the non-recommended ratio in the 6:3:1
group. In the 6:6:1 group, transfusion volume >10 units (AOR 2.77, p<0.001), hospital
transfer (AOR 1.25, p = 0.018), ED disposition to the ICU (AOR 1.18, p = 0.044), West
region (AOR 1.30, p = 0.04), and hospitals with >15 ICU beds (16-25 beds AOR 1.41, p =
0.004, 26-35 beds AOR 1.44, p = 0.004, >35 beds AOR 1.19, p = 0.13) were associated
with increased odds of adhering to the recommended MTP ratio. Interventions other than
laparotomy (reference group, AOR 1.00), university teaching status (OR 0.76, p = 0.003),
and hospital bedsize >200 (201-400 bed OR 0.50, p < 0.001, 401-600 beds OR 0.79, p =
0.39, >600 beds OR 0.67, p = 0.18) were associated with decreased odds of standard
6:6:1 MTP administration. In the 6:3:1 group, increasing transfusion volume >10 units
(AOR 3.40, p<0.001), West region (AOR 1.30, p = 0.03), and increasing time in the ED
(40-100 minutes AOR 1.24, p = 0.007, >100 minutes AOR 1.26, p = 0.008) were
associated with increased odds of standard MTP. Interventions other than laparotomy
(reference group, OR 1.00), length of stay >24 hours (AOR 0.52, p<0.001), South region
(AOR 0.69, p<0.001), and >6 trauma surgeons at treatment hospital (AOR 0.84, p = 0.02)
were significantly associated with decreased odds of standard MTP.
Conclusions: Few massively hemorrhaging trauma patients receive recommended ratios
of transfusion products suggesting poor overall compliance. Notably, university teaching
status and smaller numbers of ICU beds (markers of hospital resources) are associated
with noncompliance with recommended transfusion ratios, although it is possible that
thromboelastography may have been used and resulted in lower ratios but equivalent
outcomes. Further studies are needed to improve compliance and evaluate mortality of
those receiving compliant versus noncompliant transfusion protocols.
 Poster # 31
ASSOCIATION BETWEEN CONTRAST EXTRAVASATION ON CT SCAN AND
PSEUDOANEURYSM IN PEDIATRIC BLUNT SPLENIC AND HEPATIC
INJURY: A MULTI-INSTITUTIONAL OBSERVATIONAL STUDY
Morihiro Katsura MD,MPH, Shingo Fukuma MD,Ph.D., Akira Kuriyama MD,MPH,
Tadaaki Takada MD, Yasuhiro Ueda MD, Yutaka Kondo MD,Ph.D., Takahiro Murakami
MD, Hidemitsu Mototake MD, Shunichi Fukuhara MD, DMSc Department Of Surgery,
Okinawa Prefectural Chubu Hospital
Introduction: Considerable practice variation remains in the management of pediatric
patients with solid organ injury, and only limited data regarding traumatic
pseudoaneurysm formation exist. The purpose of this study was to describe natural
history and practice pattern for blunt splenic or/and hepatic injury in pediatric patients
and to examine the association between an active contrast extravasation (CE) on initial
computed tomography (CT) scan and the incidence of pseudoaneurysm.
Methods: We conducted a multi-institutional observational study using retrospectively
enrolled children aged 16 years and under with blunt splenic or/and hepatic injury.
Patients who showed CE on initial CT scan were compared with those that did not. A
multivariate analysis using a logistic regression model was performed to determine the
association between CE on initial CT scan and subsequent pseudoaneusysm formation.
We generated the area under the receiver operating characteristic curve (AUC) to assess
predictive performance of CE for pseudoaneurysm formation.
Results: A total of 236 patients (150 liver injury and 90 spleen injury) were enrolled
from 10 institutions. Follow up CT scan were performed in 188 patients (80%).
Pseudoaneurysm formations were observed in 17 patients (7.2%), and 4 patients (2%)
were diagnosis by the delayed rupture of pseudoaneurysm. Abdominal angiography
with/without embolization was performed in 33
patients (14%). The incidence of pseudoaneurysm
was 29% in patients with CE and 5% in those
without CE. A multivariate analysis showed that
CE on initial CT was significantly associated with
the higher incidence of traumatic pseudoaneurysm
formation (Odds Ratio, 5.55; 95% Confidence
Interval (CI), 1.54-20.1) after adjusting for AAST
grade of injury, ISS and hemoperitoneum volume.
AUC of the model including CE was 0.82 (95%
CI, 0.72-0.92) and AUC of the model without CE
was 0.77 (95% CI, 0.66-0.88).
Conclusion: In this study, follow up CT scans were frequently performed and
angiographic intervention was considered the treatment modality of choice in a high
proportion of cases in Japan. These findings suggested that the aggressive screening and
treatment for pseudoaneurysm was carried out. Our results revealed that the sign of an
active CE on initial CT scan was an independent predictor for traumatic pseudoaneurysm
formation.
 Poster # 32
THE ASSOCIATION OF SIMULATION-BASED TRAINING FOR PEDIATRIC
TRAUMA RESUSCITAITON AND RISK-ADJUSTED MORTALITY AMONG
ACS TQIP PEDIATRIC CENTERS
Aaron R. Jensen MD, MEd, Cory M. McLaughlin MD, Haris Subacius MA, Katie
McAuliff Ph.D., Avery B. Nathens* MD,MPH,Ph.D., Carolyn Wong Ph.D., Daniella
Meeker Ph.D., Henri R. Ford* MD, MHA, Randall S. Burd* MD,Ph.D., Jeffrey S.
Upperman* MD, Children's Hospital Los Angeles
Introduction: The use of simulation-based team training for pediatric trauma
resuscitation has recently increased, but an impact on patient outcomes has not been
demonstrated. The purpose of this study was to determine the association between
simulation use and patient outcomes.

Methods: ACS TQIP-Pediatric centers were surveyed to determine frequency of

simulation use in 2014-15. Center-specific clinical data for 2016-17 were abstracted
from the ACS TQIP registry (N=57,916 patients) and linked to survey responses.
Comparisons were made across levels of simulation use: no simulation, low-volume
simulation, high-volume simulation, and survey non-responders. Multivariable
hierarchical logistic regression was used to evaluate the association of simulation use with
mortality.

Results: Survey response rate was 75% (94/125 centers) with 78% of the responding
centers (73/94) reporting simulation use. Risk-adjusted mortality was higher in centers
not using simulation compared to centers using high-volume simulation (OR 1.73, 95%
CI 1.09-2.73, p=0.02). Resuscitation process times (endotracheal intubation, head CT,
craniotomy, and surgery for hemorrhage control) were not different between centers of
differing levels of simulation use.

Conclusion: Risk-adjusted mortality is lower in TQIP-Pediatric centers using

simulation-based training, but this decreased mortality may not be mediated by a
reduction in time to critical procedures. Alternative mechanisms might relate to improved
communication and teamwork, which together may improve resuscitation quality or
decrease errors and lower the risk of adverse outcomes.
 Poster # 33
ADULT TRAUMA CENTERS CARE FOR MORE PEDIATRIC PATIENTS
THAN PEDIATRIC TRAUMA CENTERS: IS THERE A DIFFERENCE IN
OUTCOMES?
Faisal Jehan MD, Muhammad Zeeshan MD, Narong Kulvatunyou* MD, Mohammad
Hamidi MD, Lynn Gries MD, Andrew Tang* MD, El Rasheid Zakaria Terence O'Keeffe*
MD, Bellal Joseph* MD, University of Arizona - Tucson
Introduction: Trauma-centers (TC) designation requires substantial financial and human
resources. The aim of our study was to analyze the association of TC designation and
mortality in pediatric patients.

Methods: We performed 6-years (2005-2012) analysis of all pediatric (age1-16) trauma

patients in the NTDB. All severely injured (ISS>15) trauma patients were included. TC
designation [Adult (A): A-I, A-II, A-III, A-IV & pediatric (P): P-I, P-II] was recorded.
Our Outcome measure was mortality. We performed regression analysis to control for
demographics, injury and vital parameters, and operative intervention.

Results: We included 47,279 patients from 400 trauma centers. Mean age was 9±5y.
Median ISS was 17 [16-25]. Overall 45% were managed at pediatric-TC, with a mortality
rate of 5.6%. There was no difference in mortality between adult and pediatric-TC. On
regression analysis, the adjusted mortality was similar in patients managed at either center
(OR: 1.01 [0.93-1.12]). On Sub-analysis, patients managed at P-II were more likely to die
compared to P-I (OR:1.62[1.59-1.66]). Patients managed at P-II or A-II/III/IV centers
were independently associated with a higher mortality compared to P-I, while there was
no difference for A-I ( Figure 1)

Conclusion: Severely injured pediatric trauma patients managed at the ACS-Level-I

pediatric center have improved survival compared to those managed at level-II pediatric,
and level-II, III or IV adult centers. Appropriate triage to either pediatric level I or adult
level I trauma centers can improve survival in severely injured pediatric patients.
 Poster # 34
NATIONAL TRENDS OF THORACIC ENDOVASCULAR AORTIC REPAIR
(TEVAR) VERSUS OPEN REPAIR IN PEDIATRIC BLUNT THORACIC
AORTIC INJURY
Areg Grigorian MD, Cristobal Barrios* Jr., MD, Sebastian Schubl MD, Jeffry Nahmias
MD, Viktor Gabriel MD, Dean Spencer BS, Bima Hasjim BS, Carlos Donayre MD,
University of California, Irvine - Orange County
Introduction: Blunt thoracic aortic injury (BTAI) occurs in <1% of all trauma
admissions. Thoracic endovascular repair (TEVAR) has become the preferred treatment
modality in most adult patients with BTAI but its use in pediatrics is not currently
supported by device manufacturers. Little is known TEVAR application in pediatric
patients. Considering the increased trend of using TEVAR in adult trauma patients, we
hypothesized that this also extends to pediatric patients and confers a lower risk of
mortality compared to open repair.
Methods: The National Trauma Data Bank (2007-2015) was queried for patients age<16
with BTAI. The primary end-points of interest included the incidence of TEVAR and
open repair, as well as mortality in pediatric patients with BTAI undergoing intervention.
Covariates (injury severity score > 25 and hypotension on admission) were included in a
multivariable analysis to determine risk for mortality in pediatric patients with BTAI
undergoing open repair versus TEVAR.
Results: We identified 428 pediatric BTAI patients with 88 (20.6%) undergoing
intervention. Of these, 65 underwent TEVAR (15.2%) and 23 (5.4%) underwent open
repair. The rate of TEVAR increased from 2007 to 2015 (10.9% vs. 24.1%, p<0.001).
Compared to open repair, TEVAR had a shorter mean length of stay (LOS) (16.2 vs. 24.0
days, p<0.05) and similar rate of mortality (3.5% vs. 2.3%, p=0.49). TEVAR was not
associated with a lower risk for mortality compared to open repair (p=0.61). This
remained true in a subset analysis of patients with Glasgow Coma Scale > 8 (p=0.96).
Conclusion: The rate of TEVAR in pediatric BTAI more than doubled from 10.9% in
2007 to 24.1% in 2015. Compared to open repair, TEVAR was associated with a shorter
mean LOS but was not associated with a lower risk for mortality. This remained true in
patients without severe brain injury. Longitudinal studies to determine the long-term
efficacy and complication rates, including re-intervention, development of endoleak,
and/or need for further operations is needed as this technology is being rapidly adopted
for pediatric trauma patients.
 Poster # 35
COMPARISON OF GROUND LEVEL AND HIGHER LEVEL FALLS ON
SUBSEQUENT MIDLINE SHIFT IN PEDIATRIC TRAUMATIC BRAIN INJURY
Areg Grigorian MD, Michael Lekawa* MD, Matthew Dolich* MD, Sebastian Schubl
MD, Cristobal Barrios* Jr., MD, Victor Joe MD, Boris Borazjani MD, Jeffry Nahmias
MD, University of California, Irvine - Orange County
Introduction: The mechanism of injury in trauma triage criteria is associated with
pediatric traumatic brain injury (TBI). Up to 44% of cases occur after falls, with more
activations occurring after falls from an elevated height compared to ground level (62.2%
vs. 37.8%). We hypothesized that a fall from height is associated with higher risk for
subsequent midline shift in pediatric TBI, compared to a fall from ground level.
Methods: The pediatric Trauma Quality Improvement Program (2016) was queried for
patients age<16 with TBI. Patients with known midline shift (> 5 mm) within 24 hours
after time of injury were identified, as were patients that underwent imaging with no
midline shift. The mechanism was identified by ICD-10 event codes. A logistic
regression model was used for analysis.
Results: From 191 pediatric TBI patients with midline shift secondary to a fall, 44
(23.0%) were from ground level and 147 (77.0%) were from an elevated height. The
most common mechanism in those with a fall from height was a fall from bed (24.5%).
Compared to a ground level fall, patients with falls from height were younger (mean age,
3.3 vs. 5.5 years, p<0.05) with no difference in the highest Glasgow Coma Score within
24 hours (p=0.56). The risk of a midline shift was lower in those with a fall from a height
(OR 0.64, CI 0.46-0.91, p=0.01), compared to ground level. In a subgroup analysis of
patients age>4 years, there was no association between the level height of the fall and
subsequent midline shift (p=0.62). However, the risk for midline shift in patients age<4
years after a fall from height was even lower (OR 0.40, CI 0.24-0.67, p=0.001).
Conclusion: In infants and toddlers with TBI, trauma activations due to falls from ground
level (compared to from a height) are associated with nearly a three-fold higher risk of
subsequent midline shift. In children four years and older that arrive as a trauma
activation, there is no association between the level height of the fall and midline shift.
Between birth and four years, children undergo significant cranial changes, rapid increase
in brain size and suture ossification, possibly influencing their vulnerability to injuries
after a fall. Trauma activations due to a minor mechanism of injury should not be
discounted in predicting the severity of injuries, particularly in infants and toddlers with
TBI.
 Poster # 36
Pelvic angiography is effective for pediatric pelvic fracture; A Nation-wide propensity
score matching cohort study in Japan
Yusuke Katayama MD,Ph.D., Tetsuhisa Kitamura MD, [Link], Yuko Nakagawa
MD,Ph.D., Takeshi Shimazu* MD,Ph.D., Osaka University Graduate School of Medicine
Background: The guidelines of Eastern Association for the Surgery for Trauma
recommended that patients of pelvic fractures with hemodynamic instability and/or
evidence of arterial intravenous contrast extravasation by CT should be considered for
pelvic angiography. However, there was little evidence for children with pelvic fracture.
We assessed the relationship between pelvic angiography for children with pelvic fracture
and the prognosis using nation-wide hospital-based trauma registry in Japan.
Methods: Using Japanese Trauma Data Bank, we included pelvic fracture patients who
were under 19 years old and registered from 2004 to 2015 in this study. Multivariable
logistic regression analysis and conditional logistic regression analysis were used to assess
the association between pelvic angiography and the prognosis of pediatric pelvic fracture
patients after one-to-one propensity score matching for pelvic angiography versus non-
pelvic angiography. The primary outcome was dead at hospital discharge.
Results: Among 1351 eligible patients with pelvic fractures, 221 patients (16.4%) received
pelvic angiography and 1130 patients
(83.6%) did not receive pelvic angiography. In the univariate analysis, the proportion of
dead at discharge was higher in the pelvic angiography group than the non-pelvic
angiography group (13.6% [30/221] vs. 7.1% [80/1130]). However, in the multivariate
analysis, the pelvic angiography group showed a more favorable survival outcome than the
non-pelvic angiography group (adjusted OR 0.458, 95% CI; 0.251-0.836). In the
propensity-matched cohort, the pelvic angiography group also showed a more favorable
survival outcome than the non-pelvic angiography group (12.5% [27/216] vs. 19.9%
[43/216], adjusted OR 0.469, 95% CI; 0.248-0.889, confidential OR 0.500, 95% CI;
0.274-0.911).
Conclusion: Pelvic angiography is also effective among children with pelvic fractures.
 Poster # 37
THE TRAUMA “PIT STOP”: A MORE EFFICIENT MEANS OF EVALUATING
THE LESS SEVERELY INJURED PATIENT
Imad S. Dandan* MD, Gail T. Tominaga* MD, Kathryn B. Schaffer MPH, Fady S.
Nasrallah MD, Melanie Gawlik RN, Dunya Bayat BA, Jiayan Wang BS, Tala H. Dandan
BA, Walt L. Biffl* MD, Scripps Memorial Hospital La Jolla
Introduction: Avoidance of undertriage remains a primary goal of trauma systems and
centers. To manage the resultant overtriage, innovative programs to effectively use
hospital resources are essential. In our previously published study, we added Trauma
Resource (TR) category to our tiered Trauma Activation (TA) algorithm, which allowed
for prompt evaluation by the Emergency Department (ED) physician without activating
the trauma surgeon (TS) and team. The TR protocol was subsequently modified by
adding a Pit Stop (PS), wherein the patient would stop in the trauma resuscitation bay
rather than go to an ED bed. We hypothesized that we could further improve efficiency
without compromising patient care.
Methods: Patients in a level II trauma center not meeting criteria for TA but injured
enough to be brought to a trauma center were assigned as TR for expedited ED
evaluation. A PS was created in the ED resuscitation bay where TR patients were
immediately assessed by a trauma nurse and/or an ED nurse, and board-certified ED
physician. Diagnostic studies were ordered, and the TS consulted as needed.
Demographic and outcome data were analyzed over a period of nine months and
compared to the same data from pre-PS period. Comparisons were made using 95%
confidence interval for variance and standard deviation calculations and unpaired t tests
for two-tailed P values, with statistical difference, p<0.05.
Results: In the first 9 months after implementation, we treated 994 TAs and 474 TRs.
The mean door to doc time were similar in the PS and pre PS periods (6.6 vs 7.1 min,
p=0.535). Mean door to CT time were better in the PS than the pre PS period (39 vs 61.1
min, p<0.0001). Of the TR patients 346 (73%) were discharged from ED; 2 (0.4%) were
upgraded to TA, and 126 (27%) were admitted. The admitted patients were similar to
admitted TA patients (N=684) with regard to gender, mean Injury Severity Score, mean
LOS and in-hospital mortality, but were older (61.4 vs 47.2 years, p<0.0001) and more
often involved in a fall from same level injury (59.5% vs 20.1%, p<0.0001). TR patients
had increased door to doc evaluation times (8.5 vs 0.4 minutes, p<0.0001) and increased
door to CT times (34.5 vs 25.4 minutes, p<0.0001) as compared to admitted TA patients.
Conclusion: Instituting a PS resulted in a faster door to CT time and the same door to doc
time. This approach has been safe and efficient. Although there is technically a 9.2%
undertriage rate, the time to TS evaluation is minimized by the timeliness of CT scanning.
This approach could be readily generalized and could save many resources on a large
scale.
 Poster # 38
VALUE OF DIAGNOSTIC IMAGING VARIES BY PATIENT AGE AND
GENDER AND AFFECTS NEGATIVE APPENDECTOMY RATES
Joshua Tseng MD, Nicolas Melo* MD, Matthew Bloom* MD, Rex Chung* MD, Galinos
Barmparas* MD, Eric J. Ley* MD, Daniel R. Margulies* MD, Rodrigo F. Alban* MD,
Cedars-Sinai Medical Center
Introduction: Improved imaging modalities increase the accuracy of diagnosis for
appendicitis. However, negative appendectomies (NA) still exist and are associated with
unnecessary cost and morbidity. Past studies cite age and gender as predictors of NA, but
the value of advanced imaging modalities remains unclear. We sought to analyze the
effect of imaging on NA based on age and gender using a large national database.

Methods: The 2015 National Surgical Quality Improvement Project (ACS-NSQIP)

database was queried for all patients who underwent appendectomy for suspected
appendicitis. Data on patient demographics, imaging modality, imaging results, and
pathology results were obtained. NA were defined as patients with no evidence of
appendicitis on pathology. Patients were categorized by age and gender, with ≤45
defined as “younger” and >45 as “older”. Rates of NA (NAR) for each imaging
combination were calculated and compared with the Pearson’s chi-squared test.
Results: Of the 11,841 patients in the study, 5.4% proceeded to surgery without imaging,
while the rest had CT (78.7%), US (7.2%), MRI (0.3%), US+CT (7.5%), US+MRI
(0.5%), CT+MRI (0.4%), or all three (0.1%). Of all age/gender groups, younger males
were most likely to have no imaging (6.8%), while younger females were most likely to
have an US (13.0%), US+MRI (1.5%), or US+CT (12.9%), p<.001. Overall NAR was
4.5%. CT’s had the lowest overall NAR compared to US, MRI, or no imaging (2.5% vs
9.6% vs 11.1% vs 21.0%, p<.001). Younger males with no imaging had the lowest NAR
(14.9%) compared to older males, younger females, and older females (18.4%, 26.7%,
and 31.2%, p<.001). CT alone and US alone had similar NAR in older females (2.7% vs
2.5%, p=1), younger males (2.1% vs 2.0%, p=.95), and older males (2.2% vs 2.9%,
p=.54). For younger females, CT alone had the lowest NAR (3.3%) compared to US
only (15.4%), MRI only (11.5%), US+CT (9.8%), and US+MRI (9.4%), p<.001.
Conclusion: Imaging is frequently used in the diagnosis of appendicitis, and is associated
with lower NAR. While patients of all age and gender groups benefit from imaging
studies, CT alone and US alone are equivalent in older females, younger males and older
males. In contrast, younger females have the lowest NAR with CT alone. Of patients
who underwent surgery without imaging, younger males had the lowest NAR. These
variations in NAR should be considered when obtaining imaging for appendicitis.
 Poster # 39
EARLY VASOPRESSOR ADMINISTRATION IN PEDIATRIC BLUNT LIVER
AND SPLEEN INJURY
David M. Notrica* MD, Bethany L. Sussman Ph.D., Lois W. Sayrs Ph.D., Shawn D. St.
Peter MD, R. Todd Maxson* MD, Adam C. Alder MD, James W. Eubanks III, MD,
Robert W. Letton* MD, Daniel J. Ostlie Todd Ponsky MD, Charles Leys MD, Karla A.
Lawson MPH,Ph.D., Cynthia Greenwell RN, BSN, Amina Bhatia MD, Nilda M. Garcia*
MD, Phoenix Childrens Hospital
Introduction: Traditionally, use of vasopressors for children with blunt liver and spleen
injuries (BLSI) has been avoided. In a large multicenter prospective study of pediatric
BLSI, some centers reported use of vasopressors in patients with BLSI. No prior studies
have examined the outcomes associated with early vasopressor use in pediatric
populations with BLSI. In this research, we compared outcomes for pediatric BLSI
patients with and without vasopressor use in the first 48 hours of injury.

Methods: We completed a planned secondary analysis of vasopressor use from a

multicenter, prospective study of 1006 children with confirmed BLSI. We matched
vasopressor use within 48 hours to a propensity-scored control group of BLSI patients
who were not given vasopressors within 48 hours of injury. Propensity scores were
estimated from pre-treatment factors (demographics, hemodynamic instability upon
admission, injury type, GCS, injury severity). Logistic regression was utilized to assess
the risk of vasopressor use with mortality. Secondary outcomes were failure of BLSI
non-operative management (NOM) due to bleeding, delayed bleeding, and PICU
readmission. Fisher’s exact tests were used to assess subgroup differences.

Results: 69 patients received vasopressors within the first 48 hours of injury, 62% had
TBI and 54% were male. Median [interquartile range] age = 8.8 [3.9, 14.3] years; GCS =
5 [3, 15]; injury grade for spleen: 1 [0, 3]; and liver: 2 [1, 4]. The mortality rate for those
who received vasopressors was 33% versus 11% for those who did not (AOR=4.1;
p<.05). Failure of NOM for the patients who received vasopressors was 32% versus 7%
(AOR=4.8; p<.05). For the subgroup of patients with TBI who received vasopressors,
the mortality was 44% versus 20% [p=.09] for those who did not; and the failure of BLSI
NOM was 28% versus 0% [p<0.05] for those who did not. For the non-TBI subgroup, the
difference in mortality between the vasopressor group and the matched control did not
reach statistical significance (15% vs 0.0%; p=.20), nor did the NOM failure (39% vs
17%; p=.12).

Conclusion: Vasopressor use in pediatric patients with BLSI is uncommon. Compared to

a propensity matched control group, vasopressor use in pediatric BLSI is associated with
a 4.1 increased risk of mortality and a 4.8 increased risk of NOM failure.
POSTER 40 WITHDRAWN
 Poster # 41
DOWN AND OUT: A MULTICENTER ASSESSMENT OF ROUTINE SYNCOPE
WORKUP AFTER TRAUMATIC FALL
Abid Khan MD, Purvi Patel MD, Jacqueline Brosius MD, Eliza Moskowitz MD, Kristen
Ohe BS, Kevin Lee BS, Sean Liebsher BS, Michael Anstadt MD, Thomas Schroeppel*
MD, Richard Gonzalez* MD, University Of Colorado Health-Memorial Hospital
Introduction: As the population of the United States ages, the incidence of traumatic
falls is increasing. Falls are classified either as mechanical or as secondary to syncope.
Controversy exists as to the utility of a syncope workup in patients who suffer a traumatic
fall. Recent, single-institution studies suggest that routine syncope workup after a
traumatic fall may not be necessary. An ECG, an echocardiogram (echo), and an
evaluation of the carotid arteries by either ultrasound (US) or CT angiogram (CTA) are
frequently reported to be the components of a complete “trauma syncope workup”. The
purpose of this project is to provide a multicenter assessment of the utility of a routine
syncope workup after traumatic fall and of which factors may predict syncope as a cause
of fall.

Methods: A multi-institutional, retrospective review of all patients presenting with a

ground-level fall over a one year period was conducted at 2 ACS-verified centers.
Patients were classified as having syncope leading to a fall or a mechanical fall based on
review of the electronic medical record. Data collected included demographics, ISS,
length of stay (LOS), and information relating to syncope workup testing.

Results: A total of 545 patients met the inclusion criteria. 189 patients had syncope or
near syncope as a cause for fall and 356 sustained mechanical falls. Syncope positive
patients were more likely to have an ECG (75.6% vs. 52.0%, p<0.001), an echo (54.0 %
vs 20.2%, p<0.001), a CTA of the neck (15.9% vs 9.0, p=0.016), a carotid US (18.5% vs
2.5%, p<0.001), and to have received all 3 components of the complete trauma syncope
workup (26.5% vs 5.9%, p<0.001). Syncope positive patients were more likely to have
an arrhythmia on ECG (20.1% vs 11.0%, p=0.004), an ejection fraction (EF) <50% on
echo (7.9% vs 2.3%, p=0.002), and carotid stenosis (5.8% vs 1.7%, p=0.008). On
multivariable analysis, patients were more likely to be syncope positive if they had an
EF<50% on echo (OR-3.363, CI-(1.322-8.555), p=0.011) or a previous history of syncope
(OR-13.994, CI-(5.197-37.684), p<0.001), whereas patients were less likely to be
syncope positive with increasing age (OR-0.985, CI-(0.975-0.996), p=0.006).

Conclusion: Due to the high incidence of arrhythmia, an ECG should be part of the
routine workup of patients experiencing a fall after syncope. Echocardiogram has less
utility in the standard assessment of these patients, however it should be considered on an
individual basis. Carotid US or CTA is unnecessary in the routine workup of syncope
and should be employed only if additional indications exist. Patients who have syncope
as a cause for fall are more likely to have a low EF or a previous history of syncope than
patients experiencing a mechanical fall. Compliance was poor in this multi-institutional
review, as only a quarter of patients reporting syncope received a complete trauma
syncope workup.
 Poster # 42
WHOLE BODY COMPUTED TOMOGRAPHY VERSUS SELECTIVE
IMAGING FOR BLUNT TRAUMA IN AN ACADEMIC TRAUMA CENTER
Jessica R. Burgess MD, Samir Abu-Hamad BS, MS, Michael Martyak MD, Jay Collins*
MD, Eastern Virginia Medical Center
Introduction: Whole body computed tomography is frequently employed in trauma
centers to diagnose injury after blunt trauma. Recently, studies have suggested that
trauma surgeons and emergency medicine physicians can safely pursue selective imaging
based on clinical judgment and physical exam findings. Many level I trauma centers in
the United States are academic centers and resident physicians are an important part of
the trauma team. The objective of this study was to determine if chief residents are able to
accurately determine which computed tomography (CT) scans to obtain based on clinical
judgment and physical exam.
Methods: This was a prospective IRB approved study undertaken at an academic Level I
trauma center between. All patients between ages of 18-89 who were evaluated in the
emergency department as lower level alerts with blunt trauma and evaluated by the
trauma chief resident on arrival were included in the study. Patients who had already
undergone imaging at a referring hospital were excluded. After performing a FAST
exam and physical exam, the chief resident completed a questionnaire indicating whether
they thought the patient would have a thoracic, abdominal or pelvic injury that would
necessitate CT imaging. All patients received CT imaging of their head, cervical spine,
chest, abdomen and pelvis after initial evaluation in the trauma bay. Imaging results were
then compared to the questionnaires to determine resident accuracy in selective imaging
for blunt trauma. Additional data regarding incidental findings, blood alcohol level, time
of day, body mass index, Glasgow coma scale and presence of head or cervical injury was
also obtained.
Results: We studied 232 patients, of whom 59.5% were male with an average age of
43.5 +/- 18.5 years. The total number of clinically significant thoracic, abdominal and
pelvic injuries was 41, 17 and 10, respectively. If chief residents had proceeded with
selective imaging and not obtained a CT scan, 58.5% of chest injuries, 88.2% of
abdominal injuries and 80% of pelvic injuries would have been missed. Overall
sensitivity and specificity was 30.9% and 94.9%, respectively. Injuries most often missed
in the chest were rib, clavicle and scapula fractures. Lumbar fractures and pelvic
fractures were the most commonly missed in the abdomen and pelvis. With selective
scanning, 78 incidental findings (mostly pulmonary and adrenal nodules) would have
been missed.
Conclusion: Our data suggests that, at our level I trauma center, the practice of selective
scanning would have missed 69.1% of injuries. These injuries ranged in severity from
simple rib fractures to splenic lacerations and vertebral fractures. While chief residents
had excellent specifity, sensitivity was 30.9%. The poor ability to selectively image may
be in part due to a false sense of security, as the resident knew that the patient would have
a total body CT regardless of their predictions. There are frequently times when the chief
resident is not able to be present for the initial evaluation of lower level alerts if they are
involved in other patient care or are in the operating room. This further supports the use
of whole body CT scans. While some studies have shown that attending emergency
medicine and trauma surgeons can safely selectively scan blunt trauma patients, selective
scanning in an academic institution with residents may result in a significant number of
missed injuries and is not recommended at this time.
 Poster # 43
RUN DON'T WALK: IMPLEMENTATION OF A STAT INTERVENTIONAL
RADIOLOGY RESPONSE TO BLEEDING PATIENTS
Michelle K. McNutt* MD, Anil K. Pillai MD, Angie L. Garrett RN, Bryan A. Cotton* MD,
John A. Harvin* MD, Laura J. Moore* MD,
Charles E. Wade* Ph.D., Mouayyad Zaza Lillian S. Kao* MD, University of Texas Health
Science Center-Houston
Background: The American College of Surgeons Committee on Trauma (ACS-COT) now
requires an experienced radiologist to be available within 30 minutes to perform
interventional procedures for level 1 and 2 trauma centers. To address this, we created a
new interventional radiology (IR) STAT trauma activation pathway and prospectively
followed the impact on early blood product utilization and mortality.
Methods: Development and implementation of an IR STAT trauma activation pathway was
performed after identifying three activation criteria through retrospective review of our
trauma registry: intravenous (IV) contrast extravasation with transfusion requirement, zone
3 resuscitative endovascular balloon occlusion of the aorta (REBOA) placement, and need
for IR recognized in the operating room (OR). All activations from March 2017 through
January 2018 were prospectively identified and maintained in a database. Outcomes were
compared to a matched historical control group one year prior to IR STAT trauma with
same three clinical indications. Mann-Whitney U-test and chi-square analyses were
performed (p<0.05).
Resuts: Of the 5,715 adult trauma patients, 1,329 were level 1 trauma activations, and 30
IR STAT trauma activations occurred. Reasons for IR STAT included IV extravasation
with transfusion requirement [n=17, 57%], trauma attending discretion [n=6, 20%], zone 3
REBOA placement [n=4, 13%], and need for IR from OR [n=3, 10%]. Our survival rate
was 86% despite a median ISS of 36 and 50%predicted survival based on median trauma
injury severity score (TRISS). No deaths were secondary to hemorrhage and 68% of
survivors were discharged home. Compared to the historical control group, the IR STAT
group had a significantly shorter time to start of IR procedure (75 min vs 196 min,
p<0.001). Although the IR STAT group had a statistically lower predicted survival by
TRISS, there was no difference in actual survival rate (Table). While the overall
compliance with IR response time of 30 minutes was 53%, compliance improved over time
after PI opportunities were identified and the pathway adjusted. Patients that did not meet
the 30 minute IR response time had a median response time of 60 minutes.

Conclusion: Implementation of an IR STAT trauma pathway to treat critically injured,

bleeding patients at a high-volume level 1 trauma hospital is feasible and results in
excellent outcomes. This protocol was associated with a dramatic reduction in time to IR
intervention, and did so with a high therapeutic embolization rate (limited over-triage) and
zero bleeding-related deaths. Early IR remains an important adjunct to hemorrhage control
in the trauma patient.
 Poster # 44
Single Pass Whole-Body versus Organ-Selective Computed Tomography for Trauma:
Is it a matter of time to diagnosis versus radiation exposure?
Ana M. Del Valle MD, Hernan E. Munevar MD, Carlos A. Ordoñez* MD, FACS, Carlos
A. Garcia MD, Michael Parra* MD, FACS, Ferrada Paula* MD, Constanza Navarro MD,
Ricardo Ferrada MD, FACS, Juan P. Herrera MD, Alfonso Holguin MD, Alejandra De Las
Salas Laura C. Ibarra Juan C. Puyana* MD, FACS, Alberto F. Garcia MD, MSC Fundacion
Valle del Lili
Introduction: Single Pass Whole-body computed tomography (WBCT) has been used as a
high yield diagnostic tool in trauma. However, increased exposure to radiation and delay in
treatment, have been cited as challenges to its widespread use. We hypothesized that
WBCT has at least the same radiation exposure compared to organ-selective CT scan
(OSCT) and it does not necessarily inflict further delays in treatment.
Methods: We performed a retrospective review of all trauma patients in whom CT-scans
were performed on arrival at a Level I Trauma Center from January, 2016 to December,
2017. Patients were divided into two groups: patients with OSCT and patients in whom
WBCT’s were performed. Patient demographics, clinical, imaging (CT-scan), and injury-
related characteristics were compared between the two groups.
Results: A total of 123 patients were included: 53 in the OSCT group and 70 in the WBCT
group. In the OSCT group the median age was 28 (IQR 22-39), ISS 10 (IQR 9-17), RTS
7.9 (IQR 5.9-7.8), 64.1% of the patients had penetrating trauma and chest injuries were the
most common injured body cavity (79.3%). In the WBCT group the median age was 29
(IQR 23-50), ISS 16 (IQR 11-25), RTS 6,9 (IQR 5.9-7.8), the most common trauma
mechanism was blunt (65.7%) and head injuries were the most common (71.9%) injured
organ. The OSCT group had longer ER-to-CT scan time than the WBCT group (41 vs 28
minutes, p=0.01) (Table 1). The OSCT group required subsequent trips to the scanner suite
for follow-up studies to rule out other potential injuries which in turn did not occur in the
WBCT group (47.2% vs 0%, p< 0.001). CT Brain was the most frequent follow-up study
required in the OSCT group. The total radiation exposure dose was higher in the OSCT
group compared to the WBCT group [22 mSv (IQR 6-31) vs 15.1 mSv (IQR 9.9-24.8)
p<0.001].

Conclusion: Trauma patients undergoing WBCT’s had lower total radiation exposure
with no delay in treatment secondary to the information obtained from their initial scan.
OSCT has the potential of missing potentially life threatening injuries that require
subsequent follow-up scans, which in turn increases the patients overall radiation
exposure and potentially delaying definitive surgical treatment.
 Poster # 45
A NOVEL QUANTITATIVE METHOD TO PREDICT THE LIKELIHOOD OF HOLLOW
VISCUS INJURY IN ABDOMINAL TRAUMA WITH FREE FLUID ON COMPUTED
TOMOGRAPHY
Karen E. Burtt MD, Aaron Strumwasser MD, MSc, FACS, Kenji Inaba* MD, Kazuhide Matsushima
MD, Damon Clark MD, Elizabeth Benjamin MD,Ph.D., Lydia Lam MD, Demetrios Demetriades*
MD,Ph.D., LAC+USC Medical Center
Introduction: The presence of free fluid on Computed Tomography (CT) in a stable patient with
abdominal trauma presents a diagnostic and therapeutic challenge. A surgeon must balance the
likelihood of non-therapeutic laparotomy with the morbidity of delayed diagnosis and treatment of a
hollow viscus injury (HVI). Hounsfield units (HUs) in conjunction with other CT features suggestive
of HVI (bowel wall thickening, mesenteric vascular edema, fat stranding, free air, beading,
extraluminal contrast extravasation) may provide additional diagnostic and therapeutic value and lead
to more rapid diagnosis and treatment. We sought to validate the utility of HU of intraabdominal
fluid at predicting HVI, and to create a model integrating HUs to predict the presence of HVI in
stable patients with abdominal trauma.

Methods: We retrospectively reviewed the abdomino-pelvic CTs of 297 consecutive patients

(2011-2015) with free fluid findings (n = 152) that underwent exploratory laparotomy for suspected
HVI. Patients with concomitant solid organ injury and abdominal vascular injury on CT were
excluded from analysis. Variables abstracted from the registry included patient demographics,
presenting vitals, and findings suggestive of HVI on CT (Hounsfield Units, bowel wall thickening,
free air, fat stranding, mesenteric vascular edema, contrast extravasation). Stepwise logistic
regression analysis was used to identify statistically significant predictors on CT scan for HVI.

Results: Of 152 patients (mean age ± SD = 33 ± 15 years, mean ISS ± SD = 12 ± 9, 55% blunt
injury) with intraabdominal fluid on CT, 106 (70%) had HVI. Vitals were normal on presentation
(HR ± SD = 93 ± 20, BP ± SD = 127 ± 22/82 ± 18). A novel predictive index (Figure A) was
developed to rule out HVI in patients with intraabdominal free fluid on CT, defined by the equation:
PROBABILITY(ABSENCE of HVI) = 1/(1+e^-x),
where x= 0.64 - 0.021*(HU) - 1.34*(FREE AIR) - 1.60*(FAT STRANDING).
A receiver operating curve (ROC) analysis of the model achieved an AUC of 0.75 (CI 0.67-0.84,
p<0.01), with 0.66 (CI 0.55-0.75, p<0.01) attributable to HU (Figure B). A HU of 30 was identified
as the optimal threshold to maximize both sensitivity and specificity of the model (Youden’s J
index). Patients with HU<30 were substantially and significantly less likely to have HVI than their
HU>30 counterparts (OR 2.9, CI 1.4-5.9, p<0.01).

Conclusion: In trauma patients with intraabdominal free fluid on CT, a novel predictive index may
limit the number of unnecessary operations in patients with CT evidence of free fluid and miss fewer
HVIs.
 Poster # 46
DOES FAST EXAM DECREASE NON-THERAPEUTIC LAPAROTOMIES IN
ABDOMINAL GUNSHOT WOUNDS?
Nina S. Cohen MD, Rhiannon J. Bradshaw BS, Jay N. Collins* MD, Eastern Virginia
Medical Center
Introduction: Most abdominal gunshot wounds (GSW) that violate the peritoneal cavity
will cause injuries requiring therapeutic laparotomy. However, some abdominal, flank,
chest and back GSW do not violate the peritoneal cavity and will not require laparotomy.
Non-therapeutic laparotomy carries increased length of stay and many associated
morbidities. We hypothesized in hemodynamically normal patients with torso GSW,
FAST exam would be beneficial in minimizing non-therapeutic laparotomy rates.

Methods: Over the time period January 1, 2016 to Feb 28, 2018, a retrospective review
was conducted of patients with torso GSW and systolic blood pressure (SBP) greater than
90 mmHg. Demographics such as age, gender, initial systolic blood pressure, base deficit
and FAST results were identified. FAST results were correlated with computed
tomography (CT) or operative findings. The sensitivity, specificity, positive predictive
value (PPV) and negative predictive value (NPV) of FAST in abdominal GSW were
determined.

Results: Over 26 months we evaluated 683 patients at our level 1 Trauma Center with
GSWs. Torso GSW with SBP greater than 90 mmHg was seen in 231 patients. The mean
age was 29.1 years and 89% male. Fifty-one patients did not undergo FAST exam or
went directly to the operating room with high suspicion of abdominal injury and were
excluded. Of the remaining 180 patients, 31 had a positive FAST associated with
abdominal injuries for a PPV of 89%. Thirty-two patients had a negative FAST but
abdominal injuries found on CT or exploratory laparotomy for a NPV of 78% and
specificity of 97%. The sensitivity of FAST for torso GSW was 49%. A total of nine
non-therapeutic laparotomies were performed, four of whom had a negative FAST exam.

Conclusion: Not all patients with a torso GSW will require laparotomy. If the SBP is
greater than 90mmHg, it is safe to perform FAST. If the FAST is positive, it is prudent to
go directly to the OR as there is a 97% chance of finding an injury that needs definitive
care. If the FAST is negative, obtaining CT scan to identify possible injuries may avoid
non-therapeutic laparotomy in a significant number of hemodynamically normal
patients.
 Poster # 47
A SHOT IN THE DARK: USEFULNESS OF ULTRASOUND-GUIDED
DIAGNOSTIC PERITONEAL ASPIRATION IN THE ASSESSMENT OF NON
TRAUMA ACUTE SURGICAL PATIENTS
Mauro Zago* MD, FEBS EmSurg, Claudio Gianotti MD, Alessia Malagnino MD, Maria
Masutti MD, Giulia Carrara MD, Samantha Bozzo MD, Policlinico San Pietro

Introduction: Abdominal free fluid or localized collections are a common findings in

many acute abdominal conditions. They are usually diagnosed by ultrasonography (US)
or CT scans. Fluid characteristics can orient definitive diagnosis. The aim of this study is
to evaluate the impact of systematic use of US-guided diagnostic peritoneal aspiration
(US-DPA) in the decisional process of acute abdominal diseases.
Methods: US-DPA was prospectively and systematically performed in all patients (pts)
with spontaneous or postoperative acute abdominal conditions associated with free fluid
or localized collections found on US or CT, whenever final diagnosis or therapeutic
strategy remained undefined after imaging. Trauma cases were excluded. Fluid analysis
was performed only when the aspect of the retrieved fluid was not decisive for decision
making. US-DPA feasibility, safety and the number of clinical decisions influenced by
DPA were analyzed. The procedure was performed bedside, without local anesthesia,
with a 19/21 G needle, preferably with an in-plane technique. Statistical analysis was
made comparing observed vs. expected cases in which DPA had a positive impact on
patient management, and positive vs. negative DPA impact. The "N-1" Chi-squared test
was used. Significance level was set at alpha = 0.05.
Results: Fifty-nine pts (35 M, 24 F; mean age 61 y/o – range 18-92) underwent 64
US-guided DPA (Table 1). Fifty-two had free peritoneal fluid, 7 localized collections. In
5 (8.5%), DPA was performed twice at the same time in a different abdominal site, to
check the aspect of the first sample. In 1/64 (1.5%) no fluid was retrieved (DPA
feasibility = 98.5%). No complications were observed. Five samples were sent for
chemical analysis. Management was enhanced by US-DPA as depicted in Table 2. In
1/59 patient (1.7%) DPA results interpretation (2 samples, serous-hematic fluid) was
wrong, causing a one day delay of re-operation (anastomotic leak). In 17/59 (28.8%)
US-DPA authorized a successful conservative management, without resorting to any
other exam. In total, 39 pts (66.1%, p<0.001) had treatments (conservative,
procedural, surgical) favorably driven by US-DPA results, with a clear change on clinical
decisions in 23 (39%, p=NS). Positive impact of US-DPA resulted statistically significant
vs. negative impact (p<0.001). In 16/59 pts (30.5%) US-DPA was performed after CT.
Conclusion: Uncertainty about the qualitative characteristics of free fluid or collections is
not uncommon managing acute surgical pts. Our study shows that US-DPA is a safe
procedure. The risk of mismanagement due to US-DPA results was very low
(1,7%). US-DPA is a simple and safe bedside procedure. It enhances the clinical decision:
further imaging, surgical/procedural treatment, safer patient observation. US-DPA can be
diriment in the assessment of acute surgical patients.
 Poster # 48
BOWEL ISCHEMIA SCORE (BIS) CORRELATES WITH THE NEED FOR
OPERATION IN PATIENTS WITH ADHESIVE SMALL BOWEL
OBSTRUCTION
Kelly A. Boyle MD, Rachel S. Morris MD, Travis P. Webb* MD, MHPE, David J. Milia
MD, Savo Bou Zein Eddine MD, Christopher M. Dodgion MBA,MD, MSPH,
Christopher S. Davis MD,MPH, Lewis B. Somberg MD, Marc A. De Moya* MD,
Colleen M. Trevino Ph.D., MSN, FNP, Medical College of Wisconsin
Introduction: Nonoperative management of adhesive small bowel obstruction (SBO) is
successful in up to 80% of patients. Current recommendations advocate for computed
tomography (CT) scan in all patients with SBO to supplement surgical decision making. It
is unknown how CT findings influence need for surgery in patients without immediate
clinical operative indications. We hypothesized that a Bowel Ischemia Score (BIS)
predicts the need for operative intervention in the setting of SBO.
Methods: This was a retrospective analysis of a retrospectively and prospectively
collected adhesive SBO database over a 6-year period. A BIS was developed based on the
Eastern Association for the Surgery of Trauma (EAST) guidelines for CT findings
suggestive of bowel ischemia. One point was assigned for each of the six variables (see
table). Early operation was defined as within 6 hours of CT scan.
Results: Of the 296 patients in the database, 262 (88.5%) underwent axial imaging. The
operative rate was 30.9%with a median time from CT to operation of 21 hours (IQR
5.2-59.2 hours).

BIS ≥ 1 was present in 148 (56.5%) patients. Most (162 / 217, 74.6%) with a BIS of 0 or
1 were successfully managed nonoperatively, whereas the majority of those with a BIS of
3 required operative intervention (8 / 11, 72.7%). The odds ratio for early operative
intervention was 18.5 and 36 for those with a BIS of 2 and 3, respectively. With a BIS of
0, 1, 2, and 3, small bowel resection was performed in 3.5%, 8.7%, 17.6%, and 36.4%of
patients, respectively.
Conclusion: The cumulative signs of bowel ischemia on CT scan, rather than the
presence or absence of any one finding, correlate with the need for operative intervention.
Further work will be done to validate this scoring system and analyze the weight of each
variable, as well as establish comprehensive clinical factors that predict operation.
 Poster # 49
BLUNT CEREBROVASCULAR INJURY: HAVE WE GOTTEN CARRIED
AWAY WITH SCREENING CTA?
Laura A. Kreiner MD, John J. Como* MD,MPH, Benjamin L. Reed BS, Vanessa P. Ho
MD,MPH, Joseph F. Golob MD, Jeffrey A. Claridge* MD, MS MetroHealth Medical
Center
Introduction: Over the past several decades, blunt cerebrovascular injury (BCVI)
screening criteria have expanded in the hope of minimizing the incidence of stroke.
Recommended indications for computed tomographic angiography (CTA) of the neck
include cervical spine fractures, complex facial and skull base fractures, traumatic brain
injury, and major thoracic injuries. We hypothesized that there would be specific
characteristics of patients with cervical spine fractures such as age, mechanism of injury,
and fracture patterns, in whom CTA of the neck could be safely deferred.
Methods: Blunt trauma patients ≥ 15 years old admitted from January 2009-June 2015
who sustained occipital condyle and/or cervical spine fractures were included. Patient
demographics, mechanism of injury, cervical spine fracture patterns, and associated
injuries as they related to the rate of BCVI were recorded. Fracture patterns were
classified between upper (C1-3) and lower (C4-7) cervical spine, as well as at each
individual cervical spine level. Fractures were characterized as lateral mass, vertebral
body, lamina, pedicle, transverse process, or spinous process. A matched case-control
analysis was performed based on age and mechanism of injury. Low energy mechanism
of injury was defined as either a same level fall or assault. High energy mechanisms
included motor vehicle collision, motorcycle/ATV collision, fall from height, and
auto-pedestrian collision. Elderly patients were defined as those 65 years and older.
Results: A total of 1275 patients with occipital condyle or cervical spine fractures were
identified. Nine hundred and eight (71.2%) underwent BCVI screening, which established
the analyzed population. Mean age was 57.5±23.2 years, and 55.4% were male. BCVIs
were identified in 9.3% (n=84). BCVI was identified at all cervical levels. When
evaluating fracture types, lateral mass fractures were significantly associated with BCVI
in the upper (35.7%) and lower (41.7%) cervical spine. Within the total screened
population, low energy mechanism, when compared with higher energy mechanism, was
the only factor associated with lower rates of BCVI (5.9% vs 10.7%, p=0.024). No
additional injuries were associated with a lower rate of BCVI. Evaluation of fracture
pattern was performed via case-control by matching age and mechanism of injury.
Elderly patients were found to have a 5.7% BCVI rate. No fracture patterns were
associated with a lower rate of BCVI. Elderly patients with high energy mechanisms had
a BCVI rate of 10.7%, and no fracture patterns were associated with not having a BCVI.
Similarly, young patients with low energy mechanism had a BCVI rate of 6.9%,
compared with a 10.9% rate in those with high energy mechanism. Fracture patterns were
not identified to be associated with a lower rate of BCVI.
Conclusion: Within a screened population of patients with cervical spine fractures, age,
mechanism of injury, and fracture pattern were not associated with a lower rate of BCVI.
Thus, in this high-risk population, no patient should be excluded from BCVI screening
based on age, mechanism of injury, or specific fracture pattern. However, special
attention is warranted for lateral mass fractures as they have a significantly higher rate of
BCVI.
 Poster # 50
THE USE OF A NEW GENERATION MULTICHANNEL TEG® 6S ANALYZER
IN A MODERN SURGICAL INTENSIVE CARE UNIT: MORE IS LESS!
Galinos Barmparas MD, Christos Colovos MD,Ph.D., Navpreet K. Dhillon MD, Kavita
A. Patel George P. Liao MD, Russell Mason PharmD, Daniel R. Margulies* MD, Eric J.
Ley* MD, Cedars-Sinai Medical Center
Introduction: The use of thromboelastography (TEG) in critically ill, surgical and
trauma patients has expanded over the last decade. Several technical variations, however,
including the addition of anticoagulants and/or activators to the blood sample, may
complicate its use. In addition, the TEG instrument requires daily calibration and is
recommended to be used only by trained personnel. We recently initiated the use of a new
generation, multichannel TEG analyzer (6S) in our surgical intensive care unit (SICU)
that utilizes an innovative all-in-one cartridge and simplifies the process of obtaining a
full coagulation profile. It remains unclear, however, whether the combination of all
assays could provide a better understanding of the patient’s coagulation profile. The
purpose of this study was to evaluate the importance of the additional information derived
from these comprehensive coagulation analyses and explore the variation in stratifying
patients as coagulopathic based on the results from each assay.

Methods: Over a 6-month study period ending in 02/2018, data from all patients admitted
to the SICU who had a TEG analysis performed were prospectively collected. A citrated
multichannel cartridge developed for the TEG® 6S analyzer was utilized and the
following assays were performed simultaneously: (1) Kaolin (CK), (2) rapid TEG (CRT),
(3) Kaolin with heparinase (CKH) and (4) functional fibrinogen (CFF). TEG values from
all assays were stratified as indicative of coagulopathy based on elevated R-time, elevated
K-time, decreased MA, decreased angle, prolonged TEG-ACT and decreased FLEV
based on accepted ranges. Samples were accordingly classified as potentially requiring
transfusion of fresh frozen plasma (FFP), platelets (PLTs), or cryoprecipitate (Cryo).

Results: Overall, 417 TEG samples from 207 patients were analyzed. Almost half of the
samples (49.2%) were classified as indicative of coagulopathy based on at least one
component of the four assays. Overall, 24.6% of patients had a potential indication for
FFP transfusion per either a prolonged R-time from the CK assay (14.6%) and/or a
prolonged TEG-ACT from the CRT assay (11.9%). The proportion of samples with both
studies indicating FFP transfusion, however, was only 2.9%. Over a third of the patients
(33.8%) had a potential indication for PLT transfusion based on a decreased MA: 31.6%
with CRT and 23.5% with CFF. However, a decreased MA was consistently noted in both
assays 22.3% of the time. Lastly, 40.5% had a potential indication for Cryo based on
prolonged K-time, decreased angle and FLEV. More specifically, decreased K-time was
observed in 28.3% based on CK; decreased angle was noted in 20.7% with CK and 12.4%
with CRT; decreased FLEV was noted in 26.2%. However, only 6.0% of relevant studies
were all simultaneously indicative for the need for Cryo transfusion.​​
Conclusion: In addition to being easier to use and less labor intensive, the new generation
multichannel TEG® 6S analyzer provides a complete coagulation assessment of the
critically ill surgical patient. The additional information obtained simultaneously from the
four different assays may impact clinical decision making as they allow for increased
specificity and correlations between assays. Further studies will focus on whether this
may lead to improved and more targeted correction of coagulopathy, potentially saving
blood products, factors, and cost.
 Poster # 51
USING qSOFA AS SCREENING CRITERIA FOR SEPSIS AND SEPTIC SHOCK
DELAYS IDENTIFICATION AND TREATMENT IN PATIENTS PRESENTING
THROUGH THE EMERGENCY DEPARTMENT
Omar K. Danner* MD, Leslie R. Matthews MD, Jonathan Nguyen DO, K A.
Bashan-Gilzenrat MD, Kahdi Udobi* MD, Assad Taha MD,Ph.D., Dan Wu MD, Bhavin
Adhyaru MD, MS, Carmen Polito MD, MSc, Sherika Kimbrough RN, MSN, Brooks
Moore MD, Sandra Hendren BS, MS, Peter Rhee* MD,MPH, Ed W. Childs* MD,
Morehouse School Of Medicine
Introduction: Enhancing the efficiency of identification and treatment of severe sepsis
has been shown to improve the outcomes of septic patients. Timely diagnosis is essential
to early institution of empiric antibiotics and fluid resuscitation. Quick Sequential Organ
Failure Assessment (qSOFA) scoring has been suggested as a useful screening tool in
septic patients at higher risk death. We hypothesize that qSOFA is a poor screening tool
for sepsis and significantly decreases accuracy and delays timeliness of detection in
emergency department (ED) patients.

Methods: We evaluated the records of 116,227 ED patients from a large, urban teaching
hospital between January and December 2014. The qSOFA Criteria (SBP ≤ 100 mm Hg,
RR ≥ 22, and/or GCS ≤ 14) were compared to SIRS criteria for sepsis prediction. There
were 1991 patients with discharge diagnoses of sepsis, severe sepsis, and/or septic shock.
Results: Variations in three presenting variables, respiratory rate, systolic BP and mental
status were not determined to be primary early predictors of sepsis with a 7.94%
(158/1991) accuracy compared to 33% (657/1991) using SIRS criteria (p <0.0001) in
confirmed septic patients. Only 5.37% (508/9463) to the total ED population met ≥ 2
qSOFA criteria.

Conclusion: Using qSOFA decreases the accuracy and expediency of sepsis

identification and treatment in septic ED patients. This initial screening approach may
lead to delayed sepsis workup and hinder life-saving interventions in ED patients to a
greater extent than using SIRS vital signs criteria due its poor diagnostic sensitivity.
 Poster # 52
Bioelectrical Impedance Analysis Guided-Fluid Management Promotes Fascial
Closure of Open Abdomen: A Retrospective Cohort Study
Kai Wang MD,Ph.D., Jieshou Li* Sr., MD,Ph.D., Research Institute Of General Surgery,
Jinling Hospital, Medical School Of Nanjing University

Introduction: High volume fluid therapy in open abdomen (OA) trauma patients
contributes to excessive visceral edema, delayed fascial closure, and prolonged parenteral
nutrition. Thus, we investigated whether bioelectrical impedance analysis-directed
resuscitation reduced postoperative fluid overload, promoted earlier fascial closure, and
improved outcomes in OA trauma patients.

Methods: A retrospective cohort study was performed for all trauma patients requiring
OA admitted between 05/2013–04/2015 to a national gastrointestinal referral center.
Patients were divided into two groups: BIA-directed fluid resuscitation (BIA) and
traditional fluid resuscitation (TRD). Data for patients were collected and retrospectively
analyzed.

Results: Forty-eight patients were included (N=30, BIA; N=18, TRD). Fluid resuscitation
with BIA allowed cumulative fluid balance and fewer complications. BIA patients were
significantly more likely to achieve primary fascial closure (PFC) [HR 8.73 (95 % CI,
2.70-28.26); p < 0.001] and survive [HR 0.03 (95 % CI, 0.001-0.81); p = 0.036] than
TRD patients did. Resuscitation guided by BIA reduced time to PFC, enteral nutrition
(EN) initiation and volume of postoperative 7-day cumulative fluid balance, by an
average of 4.28 days (p < 0.001), 6.01 days (p < 0.001), and 6775.94 ml (p < 0.001),
respectively.

Conclusion: For trauma patients undergoing OA, BIA-directed fluid resuscitation is

associated with lower postoperative fluid overload and 30-day mortality, higher 30-day
PFC, earlier fascial closure and initiation of EN. Thus, BIA may be routinely used for
OA trauma patients.
 Poster # 53
TO FEED OR NOT TO FEED: ENTERAL FEEDING AND PREOPERATIVE
NPO STATUS AMONG ADULT TRAUMA ICU PATIENTS
Ronit Bassa DO, Jan Leonard MSPH, Denetta S. Slone* MD, Emmett L. McGuire MD,
Matthew M. Carrick* MD, Robert Madayag MD, Allen H. Tanner II, MD, David Bar-Or
MD, Swedish Medical Center
Introduction: For patients in the intensive care unit (ICU), the prevalence of malnutrition
has been estimated at 38-78% and has been independently associated with increased ICU
lengths of stay (LOS), ICU readmissions, infection, and mortality. Nutrition therapy is an
important component of in-hospital treatment but is often interrupted prior to surgical
procedures to prevent perioperative pulmonary aspiration and subsequent complications,
such as pneumonia and respiratory compromise. Guidelines on enteral feeding and
preoperative fasting in the trauma ICU patient vary by hospital. Our objective was to
compare the safety of enteral feeding protocols among trauma ICU patients undergoing
surgical procedures at four Level I Trauma Centers.
Methods: Adult (≥18 years) trauma patients admitted to the ICU were included in this
multicenter, retrospective cohort study if they had a cuffed endotracheal tube/
tracheostomy and received tube feedings prior to operative management of a traumatic
injury (June 2016 - May 2017). Patients were excluded if their surgical procedure was on
the abdomen, in the prone position, a manipulation of the airway, or a tracheostomy or
percutaneous endoscopic gastrostomy at the bedside. Hospitals A and B fed patients until
being called to the operating room, Hospital C kept patients nil per os (npo) for at least 4
hours prior to surgery, and Hospital D did not have a formal enteral feeding protocol, but
on average kept patients npo for 8 hours before surgery. Clinical characteristics and
outcomes (primary: aspiration; secondary: hospital and ICU LOS, in-hospital mortality)
were obtained from each hospital’s trauma registry and through chart review. An
intent-to-treat analysis was conducted using Chi-square and Kruskal Wallis tests to
examine differences between patients at each hospital.
Results: Fifty-seven patients were included in the study, of which 18 (32%), 14 (25%), 19
(33%), and 6 (11%) were from Hospitals A, B, C, and D, respectively. Patients had a
median age of 57 years, were primarily male (77%) and had a median injury severity
score (ISS) of 22. Surgical procedures were primarily orthopedic/spine (37%) followed
by neurosurgery (12%) and open reduction internal fixation of the face (11%). There
were no differences in age, sex, ISS, the number of days with a feeding tube or the
number of days on a ventilator between hospitals. Patients at Hospital C had significantly
more pneumonia (p=0.02),
but no differences were
observed in aspiration,
hospital and ICU LOS, or
mortality (Table).
Conclusion: Continuing
enteral feeding up until a
surgical procedure in
patients with a cuffed
endotracheal
tube/tracheostomy did not
lead to more complications
than in patients who were
npo prior to surgery and could benefit the patient in reaching their daily nutrition goals.
 Poster # 54
The usefulness of diameter and collapse index of inferior vena cava as a clinical
indicator of resuscitation for critically ill hypotensive patients.
Seongpyo Mun MD,Ph.D., Department Of Surgery, Chosun University, School Of
Medicine
Introduction:Fluid therapy is one of the most important management for critically ill
hypotensive patients. Diameter of inferior vena cava and collapse index (DCIIVC), how
much it is collapsed during respiratory cycle that is checked by ultrasound, is known to
reflect patient’s intravascular volume status and fluid responsiveness well. We wanted to
evaluate the clinical outcomes of using DCIIVC as a tool of point of care for resuscitation
in critically ill hypotensive patients by prospective observational
study. Methods:Hypotensive patients admitting to ICU between May 2017 and October
2017 were enrolled. The inclusion criteria were age between 17 and 70, systolic blood
pressure < 90 mmHg and abnormal DCIIVC. DCIIVC group used DCIIVC as a guide for
resuscitation until DCIIVC became normal. The total amount and infusion rate of
resuscitation was 20 ml/kg and 300 ml/hour. In Non DCIIVC group fluid therapy was
done by physician’s decision. Clinical outcomes were compared. Results: Among 612
patients, 30 patients were allocated to each group. The average age of DCIIVC vs Non
DCIIVC group was 64 vs 66 years old. Male and female ratio was 17:13 vs 19:11. Main
causes of admission were pneumonia, exacerbation of chronic obstructive lung disease,
cerebrovascular accident, post-major surgery, abdominal infection, major trauma,
unknown hypotension, heart failure, Dengue fever, major burn and complication of liver
cirrhosis. There were six major trauma patients; two epidural hematoma, one liver injury,
one spleen injury, one pelvic bone fracture and one multiple long bone fracture. Injury
severity score of each group was 17.2 vs 18.1. Mean systolic pressure at admission was
83 vs 81 mmHg. Mean diameter of IVC was 18.9 vs 18.3 mm. Mean collapse index of
IVC was 67 vs 64%. Total amount of fluid input (TAFI) in 24 hours was 3,560 vs 4,130
(p<0.05). TAFI in 48 hours was 6,910 vs 8,420 (p<0.01). Lactate at admission, 24 hours
and 48 hours after admission were 3.8 vs 4.1, 3.1 vs 3.2 and 2.1 vs 1.9 respectively.
Mean duration of mechanical ventilation, ICU stay, hospital stay was 4.5 vs 4.1, 6.3 vs
7.2, 17.2 vs 18.1 respectively. Overall mortality was 13.3 vs 16.7 % (Table 2). Except
TAFI, there was no statistical difference. Conclusion:DCIIVC can be checked easily
and used as a tool of point of care of resuscitation for critically ill hypotensive patients.
Using DCIIVC as a guide of resuscitation helps physician to infuse fluid restrictively
without adverse outcomes.
 Poster # 55
THE POSITIVE PHYSICAL EXAMINATION DOES NOT ALWAYS INDICATE
THE REQUIREMENT OF ENDOTRACHEAL TUBE INTUBATION IN PATIENTS
WITH FACIAL BURN
Ruo-Yi Huang MD, Yen-Chang Hsiao MD, Chang Gung Memorial Hospital
Introduction: The non-objective standards such as “physical examination”, “burn sites” as
well as “clinical evaluation” are usually used to determine the necessity of airway
protection for facial burn patients in the emergency department (ED). However, the
possibility of unnecessary intubation or delayed dyspnea after admission exists. The
objective criteria for airway protection of facial burn patients are required.
Methods: A large series of facial burn patients between January 2013 and May 2016 was
reviewed. These patients’ findings of physical examinations and laboratory data were
analyzed. All intubated patients received routine bronchoscopy for evaluation of the airway
injury. The comparisons were performed in patients with and without proved airway injury.
The reasons of intubation in patients without airway injury were also delineated.
Results: During the study period, there were 335 facial burn patients. A total of 121 patients
received intubation in ED, 73 of them were later proved to have suffered airway injury by
bronchoscopy. In other words, there were 40% (48/121) intubated patients without evidence
of airway injury. Although patients with airway injury had significantly higher TBSA (27%
vs. 9%), higher ISS (16 vs. 6), higher probability of positive physical examination and
higher probability of abnormal laboratory test than patients without airway injury.
Multivariate logistic regression revealed that only TBSA, injury severity score (ISS) and PH
of arterial blood gas have independently relevance to necessity of airway protection.
Elevation of one unit of TBSA and ISS independently results in elevation of intubation
requirement at 2.8% and 11.9% respectively.
Conclusion: In the management of the patients with facial burn, the conventional indication
which based on physical examination should be reconsidered. The TBSA and other
associated injuries (ISS) play important roles in the decision of the patients who required
endotracheal tube or not in ED.
 Poster # 56
ECHO IS A GOOD, NOT PERFECT, MEASURE OF CARDIAC OUTPUT IN
CRITICALLY ILL SURGICAL PATIENTS
Peter P. Olivieri MD, Rajan Patel BS, Stephanie L. Kolb MD, Syeda Fatima RDCS,
Samuel M. Galvagno* Jr., DO,Ph.D., Daniel J. Haase MD, Daniel Herr MD, David A.
Bruno MD, Thomas M. Scalea* MD, Sarah B. Murthi MD, RDCS University of
Maryland Medical Center
Introduction: Measurement of cardiac output (CO) is integral to the management of
critically ill patients. In comparison to a pulmonary artery catheter (PAC) critical care
transthoracic echo (TTE) has been shown to have excellent agreement in the
measurement of CO in non-surgical populations. Our hypothesis is that the feasibility and
accuracy of TTE CO relative to PAC is different in surgical and non-surgical patients.
Methods: Surgical Intensive Care Unit (ICU) patients (SP) with a PAC placed for
hemodynamic monitoring and nonsurgical patients (NSP) undergoing PAC right heart
catheterization in the echocardiography lab were prospectively enrolled. CO was
measured simultaneously by PAC thermodilution and TTE. For TTE, pulsed wave
Doppler of the left ventricular outflow tract (LVOT) velocity time integral (VTI) and
LVOT diameter (LVOTd) are used to assess CO. Pearson coefficients are used to assess
correlation. Bland-Altman analysis is used to determine agreement. Bias, limits of
agreement (LOAs), and percentage error (PE) are determined.
Results: Over 18 month period 81 patients were enrolled (50 SP, 31 NSP). In SP CO be
measured in 68% (34/50) vs 78% (26/38) p<0.002 in NSP. Inability to measure LVOTd
was the primary reason for failure to measure CO (15/16, 5/7, p=0.69). VTI could be
measured in all patients. The correlation between PAC and TTE measurement is strong in
both groups; SP ( r 0.76, p <0.001), NSP (r 0.86, p <0.001). In SP and NSP agreement
was moderate and similar between groups. Bland-Altman analysis demonstrated a bias of
-0.1 L/min, LOAs of -2.5 and 2.3 L/min, and PE of 40% for SP. For NSP Bland-Altman
analysis demonstrated a bias of 0.4 L/min, LOAs of -1.8 and 2.5 L/min, and PE of 40%.
Conclusion: TTE demonstrates strong correlation and only moderate agreement in both
surgical and non-surgical patients. The feasibility is lower in SP primarily because of
inability to measure the LVOTd. Currently, it is reasonable to use TTE as a measure of
CO in surgical ICU patients. Further research is needed to simplify, automate, and
remove the need to measure LVOTd to advance the critical care TTE in the Surgical
ICU.
 Poster # 57
MODULATION OF THE α-7 NICOTINIC ACETYLCHOLINE RECEPTOR
CONTRIBUTES TO VARIABILITY IN THE HUMAN
INFLAMMATORY RESPONSE TO INJURY
Theresa W. Chan MD, Elliot C. Williams MD, Brian P. Eliceiri Ph.D., Andrew Baird
Ph.D., Todd W. Costantini* MD, University of California, San Diego
Introduction: The α-7 nicotinic acetylcholine receptor (α7nAChR), encoded by the
CHRNA7 gene, mediates the anti-inflammatory response to injury. Only humans possess
the CHRFAM7A gene that acts to inhibit α7nAChR-mediated anti-inflammatory
signaling. We have previously shown that there is significant individual variability in
CHRFAM7A expression in human leukocytes. The ability of CHRFAM7A to alter the
macrophage inflammatory response is unknown. Here, we hypothesized that expression
of CHRFAM7A alters macrophage inflammatory gene expression.

Methods: THP-1 cells were differentiated with PMA and cultured to form mature
macrophages in vitro. Lentiviral transfection of the human CHRFAM7A gene was
performed prior to differentiation. CHRFAM7A expressing macrophages (n=6) were
compared to vector macrophages
(n=6) using RNA sequencing
analysis for changes in global gene
expression, clustering analysis, and
enriched pathway analysis to
identify changes in relevant
biological pathways.

Results: CHRFAM7A expression

in cultured macrophages altered the
expression of over 5,000 genes.
Heat map analysis demonstrated
changes in global gene expression
in CHRFAM7A transfected cells
compared to vector. Gene
expression pathways related to focal
adhesion and cell-cell adhesion were most significantly upregulated in CHRFAM7A
expressing cells. Clustering network analysis demonstrated that forced expression of
CHRFAM7A regulates biological pathways related to inflammation, extracellular matrix,
and leukocyte migration.

Conclusion: The uniquely-human gene CHRFAM7A alters macrophage gene expression

in pathways related to the injury response. Based on human variability in CHRFAM7A
expression, CHRFAM7A may contribute to individual variability in the inflammatory
response to injury.
 Poster # 58
MULTIMODAL ANALGESIA DECREASES OPIOID USE IN CRITICALLY ILL
TRAUMA PATIENTS
Kasey L. Hamrick PharmD, Carl A. Beyer MD, Jin A. Lee PharmD, Joseph M. Galante*
MD, Christine S. Cocanour* MD, Jeremiah J. Duby PharmD University of California,
Davis
Introduction: Opioids are the mainstay of treatment for pain in critically ill trauma
patients. However, the risks of opioid use, including over-sedation, respiratory depression,
and the development of chronic dependence, mandate a different approach. Multimodal
analgesia employs a combination of narcotic and non-narcotic agents with different
mechanisms that have synergistic effects in treating pain. This study examines the
effect of implementing a multimodal pain management order set on the opioid
requirements of critically ill trauma patients.

Methods: This was a pre-post cohort study of adult trauma ICU patients before and after
the implementation of a multimodal pain management order set. The pre-group and
post-group included consecutively admitted patients from September to December in
2015 and 2017, respectively. Patients were excluded if their hospital stay was less than
five days, head abbreviated injury scale score was greater than one, or pre-injury
medications included methadone or buprenorphine. The total oral morphine equivalent
(OME) dose was calculated for each 24-hour period on the 2 nd through 5th days of
admission and the last 24 hours prior to discharge using standardized ratios.

Results: There were 65 patients in the pre-group and 62 in the post-group. There were no
differences between groups in injury severity score (14.3±1.2 vs 13.3±1.3, p=0.58),
sequential organ failure assessment score (4.2±0.4 vs 4.8±0.4, p=0.29), or number of
surgeries within the initial five days of hospitalization (1±0.1 vs 1±0.2, p=0.74). As
shown in the table, patients on multimodal pain management had significantly lower
median OME doses on hospital days two through five. There was also a trend towards
significance in the 24-hour period prior to discharge. More patients in the post-group
received scheduled acetaminophen, gabapentin, lidocaine patches, and methocarbamol
compared to patients in the pre-group. There was a trend towards lower mean pain scores
in the post-group during hospital day five (4.5±0.3 vs 3.5±0.4, p=0.06) although there
was no difference in mean pain scores at hospital discharge between the groups
(3.4±0.3 vs 3.6±0.3, p=0.79).

Conclusion: The implementation of a multimodal pain management order set

significantly reduced the total daily OME dose in critically ill trauma patients without
compromising patient comfort. Multimodal analgesia is an important tool to reduce
opioid exposure in this patient population.
 Poster # 59
THE ANTI-INFLAMMATORY EFFECT OF LMWF5A AND N-ACETYL
KYNURENINE ON MACROPHAGES: INVOLVEMENT OF ARYL
HYDROCARBON RECEPTOR IN MECHANISM OF ACTION
Leonard Rael MS, Charles Mains* MD, Matthew Carrick* MD, Allen Tanner MD, Mark
Lieser MD, David Acuna DO, David Bar-Or MD, Swedish Medical Center
Introduction: After a traumatic insult, macrophages can become activated leading to
general inflammation at the site of injury. Activated macrophages are partially regulated
by the aryl hydrocarbon receptor (AhR) which when activated suppresses inflammation
by limiting the secretion of pro-inflammatory cytokines and promoting the over
expression of immuno-modulatory mediators. This study aims to determine whether the
low molecular weight fraction of 5% human serum albumin (LMWF5A) and N-acetyl
kynurenine (NAK), a breakdown product in LMWF5A, can regulate inflammation by
inhibiting macrophage activation through the AhR.
Methods: A human peripheral blood monocyte cell line (THP-1) was differentiated into
macrophages using phorbol 12-myristate 13-acetate (PMA). After a 3 day differentiation
period, macrophages were pre-treated with 2-fold dilutions of LMWF5A or synthetic
NAK (200µM) with or without an AhR antagonist (10µM CH223191) for 1 hour prior to
overnight stimulation with lipopolysaccharide (LPS). Supernatants were assayed by
ELISA for the pro-inflammatory cytokines IL-6 and CXCL-10.
Results: THP-1 cells were differentiated for 3 days into macrophages as evidenced by
adherence to tissue culture plates and other morphological changes such as increases in
size and development of vesicles associated with phagocytosis. More importantly,
treatment of LPS-stimulated, differentiated THP-1 cells with LMWF5A caused a 50-60%
decrease in IL-6 release throughout the dilution series. A dose-response inhibition of IL-6
release was observed for NAK with maximal inhibition (50%) seen at the highest NAK
concentration of 200µM. Finally, an AhR antagonist partially blocked the
anti-inflammatory effect of LMWF5A while completely blocking the effect of NAK. A
similar effect was observed for CXCL-10, but the AhR antagonist was not as effective
suggesting additional mechanisms for CXCL-10 release.
Conclusion: These findings suggest that LMWF5A and a breakdown component (NAK)
partially promote the suppression of activated macrophages via the AhR receptor. Known
AhR agonists include kynurenine and kynurenic acid. Therefore, LMWF5A, which
contains NAK, is potentially a useful therapeutic in medical conditions where
inflammation is prevalent such as trauma, sepsis, and wound healing.
 Poster # 60
CERVICAL SPINE FRACTURES AND SWALLOWING DYSFUNCTION IN
TRAUMA PATIENTS TREATED WITH SEMI-RIGID COLLARS: OUR
INSTITUTIONAL EXPERIENCE
Maryann I. Mbaka MD, Megan Parrott MD, Alyssa Good CCC-SLP, Leah Galluzzi
CCC-SLP, Mark Jones* MD, Jeremy Reeves MD, Raymond Bynoe MD, Unversity Of
South Carolina
Introduction: The decision to feed patients with cervical spine injuries necessitating
cervical spine immobilization is something that each provider must decide. In this study,
we set out to investigate the rates of dysphagia and aspiration in the presence of cervical
spine semi-rigid collars. We hypothesize that the presence of cervical collars will increase
the incidence of dysphagia and aspiration in patients with cervical spine injuries.

Methods: Trauma patients at a level 1 trauma center from January 1, 2013 – December
31, 2015 were analyzed retrospectively via the trauma registry. We included patients with
isolated cervical spine injuries treated with semi-rigid cervical collar and evaluated by
speech-language pathologist (SLP) for dysphagia and aspiration. This resulted in 319
patients. We excluded patient with head injuries, those less than 18years old, penetrating
trauma, and gravid patients.

Results: Of the 319 patients with cervical spine fracture who met the inclusion criteria,
268(84%) were evaluated by SLP prior to collar removal. 158(62%) of patients meeting
the inclusion criteria and were evaluated by SLP prior to collar removal were found to
have dysphagia on evaluation. 37% of patients meeting the inclusion criteria and were
evaluated by SLP prior to collar removal were found to have aspiration during
evaluation. Dysphagia is associated with longer hospital stay (p < 0.001) and longer ICU
stay (p <0.005). Other variables associated with increased dysphagia and aspiration rates
include increased age and injury severity score (ISS).

Conclusion: Patients with cervical spine fractures treated with semi-rigid cervical collars
show high rate of dysphagia (62%) and aspiration (37%). This outlines the need for
formal swallowing assessments in this population by SLP. In addition, as these resources
can often be limited those patients with higher ISS and advanced age should be high
priority for screening. If dysphagia and aspiration risk can be identified and mitigated
sooner it is possible ICU and overall hospital length of stay could be affected.
 Poster # 61
USING ARTERIAL PRESSURE INDEX TO PREDICT ARTERIAL INJURIES IN
PENETRATING TRAUMA TO THE UPPER EXTREMITIES
Lily Tung MD, Mark J. Seamon* MD, Elizabeth Dauer MD, Jesse Passman BS, Caitlin
Fitzgerald MD, Brone Lobichusky BA, Michael Mazzei MD, Wendy Rodriguez BS,
Randi N. Smith MD,MPH, Emory University
Introduction: In trauma patients, arterial pressure indexes (API) are used to predict the
need for computed tomography angiogram (CTA) to evaluate for lower extremity
vascular injuries. Due to collateral circulation in the upper extremities (UE), the
diagnostic algorithm for UE is less clear. We hypothesized that unlike its use in the lower
extremities, API cannot be used to predict arterial injury in the UE.
Methods: A multi-institutional retrospective review of adults with penetrating UE trauma
(defined as injury from the deltopectoral groove to wrists) and documented APIs from
2006 to 2016 was performed at three, urban, level I trauma centers. Patient demographics,
injury severity score (ISS), APIs, CTA results, and operative findings were recorded.
CTA was used as the gold standard and was considered positive for injury if thrombus,
occlusion, dissection, extravasation, pseudoaneurysm or arteriovenous fistula (AVF) was
identified. Sensitivity, specificity, positive and negative predictive values (PPV and NPV)
of API <0.9 in detecting UE arterial injuries were calculated.
Results: 222 patients met inclusion criteria. 88.5% were male and median age was 27.5
years (IQR 22–37). Gunshot wounds comprised 76.6%, stab wounds 17.9%, and other
mechanisms, such as dog bites, 5.5%. The median ISS was 9 (IQR 2–10) and median API
was 1 (IQR 0.93-1). 35 (16.1%) patients had signs of vascular injury, 53 (24.3%) had
associated fractures, and 26 (11.9%) had concomitant nerve or tendon injuries. Injuries
seen on CTA included thrombus or occlusion (9.7%), transection (4.2%), dissection
(2.8%), extravasation (1.4%), pseudoaneurysm (1.4%), or AVF (1.4%). Vascular injuries
on operative exploration included ulnar (34.4%), brachial (25%), and radial artery
(12.5%). Sensitivity and specificity of API<0.9 for identifying arterial injury was poor
(69% and 69%, respectively).
Conclusion: API should be used with caution to determine arterial injury in UE after
penetrating trauma.
 Poster # 62
IN THEIR OWN WORDS: PERSPECTIVES FROM THE SENIOR VISITING
SURGEON PROGRAM
Joseph M. Galante* MD, Raymond Fang* MD, David Zonies* MD,MPH, Todd E.
Rasmussen* MD, AAST Military Liaison Committee
Introduction: In an effort to facilitate military and civilian collaboration, the American
Association for Surgery of Trauma (AAST) and American College of Surgeons (ACS)
developed the Senior Visiting Surgeons (SVS) Program. Civilian experts in trauma
surgery worked alongside military surgeons at Landstuhl Regional Medical Center
(LRMC) in Landstul, Germany. We attempted to elucidate and codify the benefits of the
program through an oral history from the program’s participants.
Methods: A qualitative study was conducted with civilian SVS and their military
counterparts. Civilian surgeons were identified through the AAST/ACS database.
Military surgeons were identified through interviews with civilian surgeons. A single
semi-structured interview was conducted with SVS. All interviews were recorded. A
thematic array was constructed and relevant themes were organized into categories.
Results: There were 46 SVS indentifed. Each visiting surgeon went to LRMC for an
average of two weeks between 2006 and 2014. Eleven (24%) civilian surgeons agreed to
be, and were, interviewed. Five military surgeons were also interviewed. Four common
themes were identified through the civilian interviews. The first and most common was
humility. Humility was best exemplified through the quote: “I thought I knew trauma but
I was humbled but the efforts of the military given the catastrophic injuries”. The second
theme was admiration. “The young military surgeons and their teams were motivated and
delivered high quality care”. The third theme was identifying techniques which were
taken and implemented into civilian practice. “I ended up adopting the blood transfusion
strategies I saw in Landstuhl at my hospital”. Finally there was a strong desire to do more
for the military. “If they would have me, I would put on the uniform and serve”. The
military perspective was predominatly one of appreciation for the support and input from
the SVS. “It was great to have these well known surgeons there just helping out”. A
downside was the feeling that the SVS could occasionally disrupt the normal workflow.
Conclusion: The SVS program strengthened the historical relationship that has long
existed between military and civilian surgeons and emphasized the importance of
continued clinical collaboration. The program allowed the civilian surgeons to gain a
better understanding of the challenges military surgeons face, fostered a sense of
appreciation and resulted in valuable clinical exchanges. Sustaining the SVS program not
only benefits military and civilian surgeons, but can help lead the way for future
partnerships in direct support of the Misson Zero Act.
 Poster # 63
CHANGING OUTCOMES IN ABDOMINAL VASCULAR INJURIES OVER
TIME
Caitlin A. Fitzgerald MD, Yasmin F. Tootla MD, Christopher J. Dente* MD, Dipan C.
Patel MD, Emory University
Introduction: The incidence of major vascular injury in patients presenting with
abdominal trauma ranges from 5% to 25% and is frequently the ultimate cause of death in
this patient population. The management of abdominal vascular trauma is complex and is
currently determined by both the severity of the injury and the anatomic location of the
injured blood vessel. Furthermore, patients with an abdominal vascular injury oftentimes
present hypotensive with significant physiologic derangements secondary to acute blood
loss and numerous associated injuries. The purpose of this study was to evaluate the
current epidemiology and management patterns of traumatic abdominal vascular injuries
at an urban level I trauma center.

Methods: This was a retrospective chart review of all patients presenting to an urban
level I trauma center with an injury to a named intra-abdominal blood vessel from 2009 to
2017. This cohort of patients was then compared to a previous cohort of patients from our
institution who presented between 1989 and 1998. Data collected included demographics,
type and location of injury, and management strategies. Outcome measures included
mortality and post-operative complications.

Results: A total of 321 patients met inclusion criteria for this study. Of these, the vast
majority of patients were male (261/321, 81.3%) and the average age was 34.8 ± 15.1
years of age. Overall mortality was 29.9% (96/321) and 33 patients (34.4%) died prior to
definitive vascular repair. Similar to previously published data out of our institution,
40.5% (130/321) of patients presented with injuries to more than one named abdominal
blood vessel. Within the current cohort, the incidence of various types of trauma included
177 gunshot wounds (55.1%), 62 motor vehicle crashes (19.3%), and 32 stab wounds
(10.0%). The most common post-operative complications included pneumonia (74/321,
23.1%), organ space infections (60/321, 18.9%), and sepsis (56/321, 17.4%). The most
commonly injured vessels continue to include the inferior vena cava (77/508, 15.2%),
common iliac vein (49/508, 9.6%), aorta (43/508, 8.5%), and external iliac vein (30/508,
5.9%). When considering trends in mortality over time, patients in the current cohort who
presented with an arterial injury demonstrated an improvement in survival (69.4% vs.
46.0%) whereas patients with venous injuries have demonstrated similar survival over
time (65.6% vs. 64.0%). Interestingly, while there are similar rates of exsanguination
prior to repair in arterial injuries (10.2% vs. 13.3%), venous injuries appear to be
associated with an increase in death prior to repair in the current cohort (12.8% vs.
5.0%).

Conclusion: To our knowledge, this represents one of the largest reviews of

intra-abdominal vascular trauma in the current era. Although intra-abdominal vascular
injuries remain a significant source of morbidity within the trauma population, mortality
from these injuries appears to be improving over time, a trend which may be the result of
both improved pre-hospital care and resuscitation practices.
 Poster # 64
MAJOR VENOUS INJURY AND LARGE VOLUME CRYSTALLOID
RESUSCITATION: A LIMB THREATENING COMBINATION
Elizabeth D. Dauer MD, Seiji Yamaguchi MD, Kathryn Kelly BS, Daohai Yu Ph.D.,
Xiaoning Lu MS, John Sharpe MD, Nathan Manley MD,MPH, John Harvin* MD, Ethan
Taub DO, Anna Goldenberg-Sandau DO, Krishan Patel MD, Ellen Omi MD, Hassan
Mashbari MD, Jennifer Hartwell* MD, Jason Brocker MD, Temple University Hospital
Introduction:After major venous injury (MVI), there is still a risk of late compartment
syndrome (LCS). The contribution of intraoperative resuscitative efforts in patients with
hemorrhagic shock to the development of LCS are not well defined. We hypothesized
that initial hemodynamic instability, intraoperative large volume crystalloid resuscitation
(LVR) or massive transfusion (MT) does not increase the risk of LCS or amputation after
MVI.
Methods:We conducted a multi-institutional retrospective review of patients with injury
to the Inferior Vena Cava, External Iliac Vein, Common Iliac Vein and/or Femoral Vein
from 2005-2015 at seven centers. The outcome of interest was the development of LCS
and need for amputation
Results:478 patients met inclusion criteria. 214 (44.8%) patients underwent lower leg
fasciotomy at the index procedure of which 107 (50%) had LVR, 97 (45.3%) had MT, 99
(46.3%) had an abnormal heart rate, and 76 (35.5%) were hypotensive. LCS of the lower
leg occurred in 26 (9.8%) of the remaining 264 patients. LVR (OR=1.55, p=0.39), MT
(OR=1.03, p=1.00), abnormal HR (OR=1.39, p=0.49), and hypotension (OR=1.03,
p=1.00) did not significantly increase risk for LCS. Only non-African American race
(OR=2.95, p=0.01) was found to be a predictor of LCS. Overall, 31 patients with MVI
required amputation. LVR (p<0.001), combined arterial/venous injury (p=0.001), and
associated fracture (p=0.001) were individual risk factors for amputation, while
penetrating wound and abnormal HR were implicated as well (p=0.06 and 0.09,
respectively). MT was not shown to increase risk (p=0.44). A multiple logistic
regression model demonstrated that patients receiving LVR (OR (95% CI): 9.7
(2.9-33.0); p<0.001), with combined arterial/venous injury (3.6 (1.4-9.2); p=0.006), and
with an associated fracture (3.2 (1.4-7.1); p=0.004) were more likely to require
amputation.
Conclusion:Patients presenting in hemorrhagic shock, or who undergo LVR or MT do
not have a significantly increased risk of LCS after MVI. Patients who receive LVR,
have combined arterial/venous injuries and have associated fractures are more likely to
require amputation. Further prospective studies are warranted to clarify the role of
resuscitation in the development of LCS.
 Poster # 65
THE SIXTY MINUTE MYTH OF FIRST PHASE DAMAGE CONTROL
SURGERY
Alison Smith MD,Ph.D., Lynn Hakki BS, Riley Santiago BS, BA, Rebecca Schroll MD,
Chrissy Guidry DO, Patrick McGrew MD, Clifton McGinness MD, Danielle Tatum Ph.D.,
Juan Duchesne* MD, Tulane School of Medicine
Introduction: Damage Control Surgery (DCS) traditionally involves limiting operating
room (OR) time for patients with multiple life-threatening injuries and coagulopathy who
are reaching physiologic exhaustion. However, in the modern era of hemostatic
resuscitation, there is a paucity of evidence to support a survival benefit with shorter OR
times. The objective of this study was to determine the practice habits of trauma surgeons
in the modern era of DCS and to determine if operation length affects mortality in trauma
patients with abdominal injuries.

Methods: An 8-year retrospective review of consecutive adult patients with DCS for
penetrating abdominal trauma at a Level I trauma center was conducted. Patient
demographics, injury severity score (ISS), and penetrating abdominal trauma index
(PATI) scores were obtained. Average operating room times for initial DCS were
determined. Patient outcomes were analyzed with a t test for univariate analysis and a Cox
proportional hazard ratio modeling was used to predict factors for survival.

Results: A total of 193 patients were identified. The majority of patients were male with
penetrating trauma. Overall mortality was 14.0% (n=27/193). Average OR time was 168.7
min (range, 59-573 min). One patient had an initial DCS that was less than 60 min. Only
2.1% patients (n=4/193) had missed injuries with an average OR time of 117.5 min (range
86-157 min) for this group. In addition, 13.0% patients (n=25/193) had an early,
unexpected return to the OR. On multivariate analysis, OR time was not an independent
risk factor for mortality (OR 1.0, 95%CI 0.98-1.0, p=0.48).
Table 1. Patient demographics and outcomes for patients with first phase damage control
surgery

Conclusion: Modern damage control practices should focus on early surgical

hemorrhage control in combination with effective intra-op resuscitation efforts and not
on the amount of time required to accomplish resuscitative goals. These findings
suggest that in the era of modern DCS, the old tenet of 60 minutes may not be
applicable to the updated era of trauma surgery and hemostatic resuscitation.
 Poster # 66
STOP THE BLEED: A “GAP” ANALYSIS AND GEOGRAPHICAL
EVALUATION OF INCIDENT LOCATIONS
Shannon L. Carroll BS,MD, Daniel W. Dye MD, Aidan Gilbert BS,MPH, Griffin L.
Russell BS,MPH,Ph.D., Gerald McGwin Jr., BS,Ph.D., MS, Jeffrey D. Kerby*
BS,MD,Ph.D., Jan O. Jansen Ph.D., MBBS University of Alabama Birmingham

Introduction: Stop the Bleed (STB) is a national campaign to encourage bystanders to

become trained, equipped, and empowered to help in a bleeding emergency. STB training
discusses mass casualty events while also recognizing the benefit to those injured in more
usual circumstances. The aim of this study was 1) to conduct a gap analysis to determine
potential benefit from STB interventions on a day-to-day basis; and 2) to conduct a
geographical analysis of a major metropolitan area, to determine whether such incidents
might be clustered, facilitating the prioritization of training and locating of kits.
Methods: We performed a retrospective analysis of trauma registry and medical
examiners’ data from a single county, 2013-2017. Incidents potentially amenable to STB
were defined in terms of full (7-digit, pre- and post-dot) AIS codes. Medical examiners’
data were reviewed manually to identify prehospital fatalities who might have survived if
STB interventions had been applied. Incident location data and, where not available, place
of residence, were geocoded by ZIP code area, and analyzed using QGIS, an open-source
geographical information systems software package.
Results: We identified 159 patients who were admitted to our level I trauma center, who
might have benefitted from STB. 101 had suffered blunt trauma, and 58 penetrating
injuries. 137 survived to discharge, and 22 died in hospital. 12 patients with injuries
potentially amenable to STB died prior to accessing the trauma system. In total,
approximately 3 patients per month could benefit from STB intervention. Geographical
analysis was limited by small numbers of incidents per area, but did not reveal evidence
of clustering.
Conclusion: Aside from preparation for mass casualty events, STB training can
potentially benefit the community for isolated incidents associated with bleeding. The
number of patients who could benefit from STB, in this analysis, is relatively small.
Furthermore, the locations of these incidents did not show evidence of geographical
clustering, although the small number of incidents per area precluded a formal
geostatistical analysis. This analysis could be used by other communities to determine if
this information would inform STB activities.
 Poster # 67
NARROW PULSE PRESSURE IS INDEPENDENTLY ASSOCIATED WITH
MASSIVE TRANSFUSION AND EMERGENT SURGERY IN
HEMODYNAMICALLY STABLE TRAUMA PATIENTS
Brittany Bankhead-Kendall MD, MS, Pedro Teixeira MD, TB Coopwood* Jr., MD,
Jason Aydelotte* MD, Marc Trust MD, Sadia Ali Irene Tabas Carlos V. Brown* MD,
University Of Texas At Austin
®
Introduction: ATLS considers narrow pulse pressure (NPP) a sign of Class-II
hemorrhage and a precursor of hemodynamic instability. However, the true clinical
implication of NPP in hemodynamically stable trauma patients remains unknown. We
hypothesized that NPP is associated with massive transfusion and the need for emergent
surgery in hemodynamically stable trauma patients.

Methods: All hemodynamically stable (systolic blood pressure >/=90mmHg) trauma

patients admitted to our Level-1 trauma center (2010-2016) were reviewed. Patients with
NPP (<40mmHg) at presentation were compared to those with normal pulse pressure
(>/=40mmHg). Primary outcomes were need for massive transfusion (>/=10 units) and
emergent cavitary surgery.

Results: Over 7 years, 18,978 hemodynamically stable trauma patients were admitted and
13% (2,486) had NPP. NPP patients more often required massive transfusion (5% vs. 1%,
p<0.0001), emergent surgery (7% vs. 2%, p<0.0001), and the combination of both (3%
vs. 0.4%, p<0.0001). NPP patients had higher mortality (4% vs. 2%, p<0.0001) and
longer hospital stay (7 vs. 5 days, p<0.0001) and ICU stay (1.4 vs. 0.75 days, p<0.0001).
After logistic regression controlling for age, gender, mechanism, ISS, and GCS, NPP was
independently associated with massive transfusion, emergent surgery, and the
combination of both.

Conclusion: In hemodynamically stable trauma patients, a narrowed pulse pressure at

presentation is independently associated with a three-fold increase in the need for massive
transfusion and two-fold increase in emergent surgery need.
 Poster # 68
SHOULD ALBUMIN SOLUTION BE CONSIDERED AS AN ALTERNATIVE
FLUID FOR PREHOSPITAL RESUSCITATION IN AUSTERE MILITARY
ENVIRONMENTS?
Bijan S. Kheirabadi Ph.D., Nahir Miranda MBA, Irasema B. Terrazas MS, Amber N.
Voelker MBA, Rodolfo J. De Guzman Jr., BS, Ammon W. Brown DVM and PhD,
Michael A. Dubick* Ph.D., United States Army Institute for Surgical Research
Introduction:Damage control resuscitation (DCR) goals include control of hemorrhage
and hemostatic resuscitation (HR); i.e. early administration of blood or blood components
(1:1:1 ratio) to increase blood pressure to a permissible hypotensive level for treating
hemorrhagic shock. The in-hospital DCR protocol has been extended to prehospital care
for treating combat casualties. We studied the advantages of HR using blood or plasma
vs albumin in surviving rabbits subjected to severe hemorrhagic shock (HS).

Methods:Laparotomy (soft tissue trauma) was performed on IV-anesthetized

spontaneously breathing NZW rabbits (3.1-3.5 kg). Next, 40% of circulating blood
volume was removed from a venous line to produce HS (MAP=20-25 mmHg). 15 min
later, rabbits were randomly resuscitated with a small volume (12.5 ml/kg) of rabbit fresh
whole blood (FWB), rabbit thawed plasma (FFP), or 5% human albumin solution (ALB)
to a hypotensive target pressure (MAP) of 60 mmHg (n=9/grp) and monitored for 2hr
(i.e., prehospital period). Subsequently, animals received full resuscitation using
autologous blood and LR, surgically repaired, recovered and assessed over 1 week. An
untreated control group (no fluid, n=6) was also included. Blood samples were collected
at baseline, post-HS, post HR, day 0, 2, 4 and 8 post-operatively and analyzed for ABG,
CBC, chemistry and coagulation values. Tissue samples were collected and examined
histologically.

Results:Following hemorrhage lactate and base deficit levels were increased to 9.2 ±0.3
and 12.2±2.5 mM, respectively (i.e. class III/IV shock) with no difference among groups.
FWB resuscitation required less volume to raise MAP to 60 mmHg ( p<0.05 vs. albumin)
and similar to FFP, but unlike albumin MAP gradually declined during the 2hr
prehospital period. FWB administration also resulted in a higher % hematocrit but this
advantage did not treat shock faster than other fluids. Changes in coagulation
measurements (PT, aPTT, fibrinogen, and bleeding time) after surgery indicated a mild
hypocoagulation that was more evident in the ALB group. Untreated rabbits all died
within two hrs after hemorrhage. The resuscitated rabbits lived overnight but 2 of 9 in
each group had to be euthanized on day 1 due to poor recovery associated with abnormal
blood chemistry and histological evidence of multiple organ failure. All other rabbits
recovered well and had normal blood tests and histology at 1 week.

Conclusion:In this model of hemorrhagic shock with 2hr of prehospital hypotensive

resuscitation, no clinically significant advantage was found between early resuscitation
with rabbit blood or plasma versus a human albumin solution that is readily available,
stable at room temperature and compatible with all blood types. Albumin solution
deserves a consideration.
 Poster # 69
THE IMPACT OF PRE-HOSPITAL TOURNIQUET USE ON RESUSCITATION
IN EXTREMITY ARTERIAL TRAUMA
Allison G. McNickle MD, Paul J. Chestovich MD, Douglas R. Fraser MD, Deborah A.
Kuhls* MD, John J. Fildes* MD, University Of Nevada-Las Vegas School Of Medicine
Introduction: This study evaluated if pre-hospital tourniquet placement altered the initial
management and transfusion needs in peripheral arterial injuries.
Methods: Extremity arterial injuries were queried from our Level I Trauma Center
registry from 2013-17. Groups were defined by pre-hospital tourniquet use (TQ+) or not
(TQ-) and location of injury, upper (UE) versus lower extremity (LE). Variables included
tourniquet duration, initial heart rate (HR), systolic blood pressure (SBP), hematocrit and
severity scores. The primary outcome was transfusion within the first 24 hours, with
secondary outcomes of morbidity (rhabdomyolysis, acute kidney injury, compartment
syndrome), amputation (initial vs. delayed) and length of stay (LOS). Statistical tests
included t-test and Chi-square for continuous and categorical variables, respectively, with
p<0.05 significant.
Results: Injuries occurred in 192 patients with 152 (79%) males at a mean age 35.9±14.4
years. TQs were placed in 69 (36%) for 78±52 minutes. TQ use increased significantly
over time. TQ+ had higher initial HR, AIS extremity score (3.2 vs. 3.0, p=0.03), MESS
score (5.8 vs. 5.1, p=0.02) and more near amputations (30% vs. 17%, p=0.03). Despite
similar admission hematocrit, more of the TQ+ required transfusion. TQ+ had more initial
amputations; however delayed amputations, complications and LOS were not different.
UE injuries occurred in 100 with 43 (43%) having TQs in place for 72±44 minutes. TQ+
had higher admission HR (112 vs. 99, p<0.01) and more initial amputations (12% vs. 0,
p<0.01). Transfusions, LOS and morbidity were not different. Ninety-two had LE injuries
with 26 (28%) having TQ for 88±64 minutes. TQ+ had higher MESS scores (6.8 vs. 5.6,
p=0.01), more initial amputations (42% vs. 9%, p<0.01), higher frequency of transfusion
(77% vs. 53%, p=0.04) and longer LOS. Frequency of morbidity and mortality was not
different in TQ+.
Conclusion: Limbs receiving TQs had more severe injuries (higher injury scores, near
amputations and increased HR), required a higher frequency (but not volume) of blood
transfusion and initial amputation, without an increase in complications. The equivalent
complication and mortality rates, despite higher injury severity supports the field
application of TQs in severe extremity trauma.
 Poster # 70
DEFINING INDICATIONS FOR MASSIVE TRANSFUSION: NOT AS SIMPLE
AS LEARNING YOUR ABCS
Heidi Kipers Mullen DO, Tammy R. Kopelman* MD, Paola Pieri* MD, Karole Davis
MD, Alexzandra Hollingworth MD, Melissa Pressman Singer Ph.D., Sydney Vail MD,
Maricopa Medical Center
Introduction:Massive transfusion protocols (MTP) have been developed to expedite
treatment of substantial hemorrhage. However predicting who will require MTP can be
elusive. Recently, the Trauma Quality Improvement Program has added an Assessment
of Blood Consumption Score (ABCs) ≥ 2 to the triggers to initiate MTP. We hypothesize
that this addition will lead to overuse of MTP activation without significant improvement
in patient identification.

Methods:A retrospective review was performed of adult trauma patients with ISS >15
presenting to our trauma center over 2 years. ABC was computed and transfusion needs
were assessed for the first 24 hours. Massive transfusion (MT) was defined as needing ≥
10 units packed red blood cells (PRBC) in the first 24 hours.

Results:380 patients met inclusion criteria of which 35 (9%) required MT. Prior triggers
for MTP including transfusion in the emergency room, persistent hemodynamic
instability, or active bleeding requiring intervention identified 30 patients (86%) who
required MT. The addition of ABCs ≥ 2 identified one additional patient who required
MT and 41 patients who did not, including 16 patients that required no PRBCs during the
first 24 hours. Overall, the positive predictive value of ABCs ≥ 2 in identifying patients
needing MT was only 39%. In addition, it failed to identify 9 of the 35 patients (26%)
who ultimately requiring MT.

Conclusion:Use of ABCs ≥ 2 as a trigger for MTP will lead to a high over triage rate
without significant improvement in patient selection over previously defined indications.
 Poster # 71
TRANEXAMIC ACID SUPPRESSES THE RELEASE OF mtDNA AND
ACTIVATION OF THE CALCIUM SENSING ENZYME CaMKII IN HUMAN
PLATELETS
Joseph F. Rappold* MD, Damien Carter MD, Doreen Kacer BS, Kathleen Pyburn BS,
Chloe Kumpel BS, Monica Palmeri BS, MS, Robert Kramer MD, Igor Prudovsky Ph.D.,
Maine Medical Center
Introduction: Activated platelets are a major source of Damage Associated Molecular
Patterns (DAMPs) particularly mitochondrial DNA (mtDNA). Released systemically
during and after hemorrhagic shock, DAMPs are responsible for the development of the
endotheliopathy of trauma and the associated release of pro-inflammatory cytokines.
Tranexamic acid (TXA), a known anti-fibrinolytic used to ameliorate the effects of
hemorrhagic shock, has a host of additional functions such as the release of
anti-inflammatory cytokines. We hypothesized that TXA may prevent activation of
platelets by inhibiting the calcium sensing enzyme CaMKII and limiting the damage
caused by DAMPs release into the systemic circulation.
Methods: Platelet-rich plasma devoid of leukocytes and erythrocytes was prepared from
the blood of a healthy donor by low speed centrifugation. It was incubated for 2h at 37o C
in presence or absence of TXA at 20 or 100 mg/ml. Platelets were then precipitated by
high-speed centrifugation. MtDNA content in platelet-free plasma was determined by
qPCR. Electrophoresis and Western blotting were applied to detect the phosphorylation
of stress signaling kinases p38, MAPK and JNK, and the calcium sensing enzyme
CaMKII in platelets.
Results: TXA at 100 mg/ml strongly
suppressed the release of mtDNA from
platelets. Both concentrations of TXA
significantly decreased the phosphorylation of
CaMKII (Figures A and B) but did not
change the phosphorylation of p38 MAPK and
JNK (data not shown).
Conclusions: The observed TXA-induced
suppression of mtDNA release from platelets
and the decreased phosphorylation of CaMKII, the enzyme involved in platelet
activation, increases our knowledge of the method of action of TXA in hemorrhagic
shock. Additional studies are necessary to fully elucidate the signaling pathways upon
which TXA acts, thereby advancing understanding of the various potential uses of TXA
in the critically injured and ill patient.
 Poster # 72
EMPIRIC USE OF TRANEXAMIC ACID HAS NO BENEFIT IN URGENT
ORTHOPEDIC TRAUMA CASES.
Bryan W. Carr MD, Wendy Li BS, Jamel G. Hill BS, Cyrus Feizpour MD, Ben L.
Zarzaur* MD,MPH, Stephanie A. Savage* MD, MS Indiana University School Of
Medicine
Introduction: The orthopedic literature has demonstrated a significant decrease in
post-operative transfusion requirements when tranexamic acid (TXA) is given during
elective joint arthroplasty. In some institutions, this practice has spread with empiric
administration of TXA during semi-urgent orthopedic procedures in injured patients.
Injured patients are at elevated risk of venous thromboembolic events (VTE) and no
literature exists regarding the use of TXA in this manner, in this patient population. The
purpose of this study was to evaluate the empiric use of TXA in semi-urgent orthopedic
procedures. The hypothesis was that TXA would be associated with increased rates of
VTE and have no effect on transfusion requirements.
Methods: Patients who empirically received TXA during a semi-urgent orthopedic or
spine surgery following injury (TXA+) from 2014-2016 were matched using propensity
score matching to historical controls (CONTROL) from 2011-2013 who did not receive
TXA. Data were collected regarding injury characteristics, TXA administration,
operative details and incidence of VTE. Outcome variables included incidence of VTE
within 6 months of injury and packed red blood cell (PRBC) utilization. Multivariable
logistic regression was used to determine odds of VTE and transfusion. A p< 0.05 was
considered significant.
Results: 200 patients were included
in each group. There were no
differences between groups
regarding age, ISS, extremity AIS,
gender or mechanism of injury.
CONTROLS had a significantly
shorter ICU and hospital length of
stay compared to TXA+. There was
no difference in mortality between
groups (Table 1). There was no
increase in VTE in TXA+ patients
with logistic regression (OR 0.804
95% CI 0.310, 2.087). However,
TXA+ patients had a significantly
higher odds of being transfused during their hospital stay (OR 1.757 95% CI 1.057,
2.920) when controlling for fracture site, ISS, admission directly to the OR, need for
damage control, use of a tourniquet in surgery and total number of surgeries needed.
Overall transfusion was also significantly higher in the TXA+ group (CONTROL 0 units
(IQR 0, 3) vs TXA+ 2 units (IQR 0, 5), p<0.0001).
Conclusion: The empiric use of TXA in semi-urgent orthopedic and spinal surgeries did
not increase the odds of VTE, the incidence of which was low. Despite the elective
literature, TXA+ patients had a significantly higher odds of transfusion compared to
controls and received a significantly higher volume of PRBCs compared to control.
While VTE risk is static, lack of a benefit related to transfusion needs would indicate that
empiric TXA use is not indicated in injured patients.
 Poster # 73
ALL FIBRINOLYSIS IS NOT CREATED EQUAL – MORTALITY DIFFERENCES
ACROSS THE SPECTRUM
Luis R. Taveras MD, Tarik D. Madni MD, Jonathan B. Imran MD, Holly B. Cunningham MD,
So-Youn Park Michael Zhou Robert Myers Alexander L. Eastman* MD,MPH, Michael W.
Cripps* MD, MSCS University Of Texas Southwestern
Introduction: The discovery of increased mortality associated with hypofibrinolysis with
thromboelastography (TEG) has altered our perception of the spectrum of fibrinolysis. However,
this has not been identified with rotational thromboelastometry (ROTEM). Previous studies have
also identified subtypes of hyperfibrinolysis. However, no single study has examined the
mortality rates of the full fibrinolytic spectrum. Our aim is to describe the distribution of
fibrinolysis, as measured by ROTEM; and identify associated mortality rates.
Methods: Clinical and thromboelastometry data were analyzed on trauma patients evaluated at
an urban, Level 1 trauma center from May 2014 to May 2017. ROTEM analysis was performed
during initial evaluation and resuscitation. Hyperfibrinolysis (HF) was defined as maximum lysis
>15% in EXTEM and an enzymatic fibrinolysis index (EFI) greater 10%. Fulminant HF occurs
in less than 20 min, intermediate at 21-40 min, late at 41-60 min.
Descriptive statistics were compared using Chi-square analysis and the Kruskal-Wallis test for
categorical and continuous variables, respectively. Kaplan-Meier survival curves were compared
using the log-rank and Wilcoxon tests.
Results: ROTEM results from 1053 patients were included in our study, 40 patients were
excluded due to incomplete ROTEM assay data. Median age was 38 years (IQR 26-55), 76.5%
were male and 22.1% had penetrating injuries. Median ISS was 17 (IQR 9-27). 61 patients had
EXTEM ML >15%, and HF was confirmed by EFI in 58 patients.
Using a receiver operating characteristic curve with mortality as outcome the cutoff for
hypofibrinolysis was defined as maximum lysis on EXTEM < 3%. Distribution of fibrinolysis
was: hypofibrinolysis, 28.6%; physiologic, 65.7%; and hyperfibrinolysis, 5.7%. Mortality was
significantly different between the groups: 20.0%, 7.4% and 77.6%; respectively, at 28 days post-
hospitalization ( p < 0.0001). Among the hyperfibrinolysis subtypes, a significant difference in
survival was found in a Kaplan-Meier curve. Mortality for fulminant, intermediate and late HF
was 81.8%, 88.2% and 70%, respectively (p = 0.0223).
Conclusion: Different mortality rates are found across the spectrum of the fibrinolytic pathway.
Similar to the TEG results, we found that ROTEM can detect a unique entity of hypofibrinolysis
that has an increased mortality and can easily be differentiated from physiologic and
hyperfibrinolytic states. Furthermore, among hyperfibrinolysis subtypes, there are significant
mortality differences. These results have significant implications in the treatment of severely
injured patients and suggest potential different biologic mechanisms exist within the fibrinolytic
pathways.
 Poster # 74
EARLY CHEMOPROPHYLAXIS FOLLOWING TRAUMATIC BRAIN INJURY
DOES NOT INCREASE MORBIDITY
Lisbi Rivas MD, Michael Vella MD, Tammy Ju MD, Sara Perez BS, Ramamahesh C.
Seeni BS, Joseph S. Fernandez-Moure MD, MS, Andrew Sparks MS, Stephen Gondek
MD,MPH, Mark J. Seamon* MD, Babak Sarani* MD, George Washington University
Introduction:There is no standard of care regarding timing to initiation of
pharmacologic prophylaxis for venous thromboembolism (VTE) in traumatic brain injury
(TBI) patients. The aim of this study is to evaluate the safety of an early strategy for start
of VTE chemoprophylaxis in a select cohort of TBI patients. We hypothesize that early
administration is safe.

Methods:A retrospective study was performed at two Level 1 Trauma Centers. Inclusion
criteria included: age 18 years or older, blunt mechanism of injury, and head Abbreviated
Injury Score (AIS) > 1. Exclusion criteria included craniectomy prior to 24 hours,
progression of bleed on 6 hour follow-up CT scan, and patients that did not have a
follow-up head CT. Patients were divided in early (< 24 hours) and late (> 24 hours)
cohorts based on time to initiation of chemoprophylaxis. Progression of bleed was the
primary outcome. Secondary outcomes included need for craniectomy, incidence of VTE,
and mortality. Multivariate regression testing was performed to control for age, head AIS,
and ISS.

Results:289 patients were enrolled (table 1). Chemoprophylaxis used was 30 % vs 70%
heparin vs low molecular weight heparin, respectively. Progression of bleed after VTE
chemoprophylaxis administration was 4.5 % in the early group vs 7 % in the late group
(p= 0.5). Craniectomy rate after 24 hours was 2.8% vs 15.9% (Odds Ratio 0.2,
Confidence Interval 0.04-0.5, p < 0.01) in the early vs late group, respectively. There were
no VTE events in the early group vs 2.8% in the late group (p=0.08). There was no
difference in mortality.

Conclusion:Early initiation of VTE chemoprophylaxis is safe in TBI patients with a

stable head CT 6 hours following injury. Delay in start of chemoprophylaxis may be
associated with an increased VTE risk.
Table 1: Demographics
 Poster # 75
EVOLVING PRACTICE PATTERNS IN THE USE OF PHARMACOLOGIC
VENOUS THROMBOEMBOLISM PROPHYLAXIS AFTER BLUNT SOLID
ORGAN INJURY
Paige Newell BA, Deacon Lile MD, Michael Mazzei MD, Zoe Maher MD, Jessica Beard
MD,MPH, Joseph Lopez Jr., MD, Leonard Mason MD, Abhijit Pathak* MD, Thomas
Santora* MBA,MD, Lars Sjoholm* MD, Amy Goldberg* MD, Elizabeth Dauer MD,
Temple University Hospital
Introduction: The use of pharmacologic venous thromboembolism (VTE) prophylaxis in
patients undergoing non-operative management for blunt solid organ injury (BSOI) must
balance the risk of bleeding with that of VTE. Prior studies have examined the safety of
VTE prophylaxis at 48 and 72 hours, but limited evidence exists regarding earlier
administration. Despite its role in prevention of VTE, guidelines for the administration of
VTE prophylaxis in BSOI remain unclear. We sought to answer if standardized practice
management guidelines (PMG) existed, if these PMG recommendations differ from what
is practiced clinically and if there is a trend toward earlier VTE prophylaxis without an
increase in failure of non-operative management.
Methods: A nationwide sampling of PMG for VTE prophylaxis after BSOI were
compiled and the recommended timing of prophylaxis was compared with clinical data
reported through the Trauma Quality Improvement Program (TQIP) database from
2013-2016. Adult patients with blunt injury to the spleen, liver or kidney undergoing
initial non-operative management without concomitant TBI or pre-hospital
anticoagulation were included. Timing of VTE prophylaxis and need for intervention
related to the BSOI were the outcomes of interest. Data was analyzed using chi-squared,
ANOVA single factor analysis, and two sample t-tests.
Results: Institutional guidelines were solicited from 31 level I trauma centers nationwide.
26 institutions responded of which 12 (46%) had no formal PMG. The remainder had a
wide range of practices from immediate initiation to initiation after 48 hours with
evidence of stable hemoglobin. 22,549 patients met inclusion criteria in the TQIP
database. There was a statistically significant increase in the percentage of patients
receiving VTE prophylaxis before 24 hours from 23% in 2013 to 26% in 2016 (p=0.003).
There was a significant decrease in the mean time to VTE prophylaxis initiation from 66
hours in 2013 to 53 hours in 2016 (p < 0.001). Earlier administration (< 24 hours) did not
increase the rate of failure of non-operative management (p< 0.001).
Conclusion: Since 2013, there has been a significant trend toward earlier administration
of VTE prophylaxis in patients undergoing non-operative management for BSOI, though
institutional guidelines vary widely. With an increasing percentage of patients receiving
VTE prophylaxis at < 24 hours, there is a need for a multi-institutional trial directly
examining optimal timing for VTE prophylaxis in this population.
 Poster # 76
TRAUMA INDUCED PLATELET DYSFUNCTION IS NOT CORRECTED BY
TRANSFUSION
Lily Tung MD, Varun Danda BS, Antonio Davila Ph.D., Scott Diamond Ph.D., Carrie
Sims* MD,Ph.D., University of Pennsylvania
Introduction: Although trauma induced coagulopathy is a common problem following
severe injury, the contribution of platelet dysfunction (PD) remains unclear. We
hypothesize that while PD frequently occurs following trauma and persists despite
platelet transfusion, it does not impact outcome.
Methods:Trauma patients ≥18 years old were evaluated between March and December
2017. Only patients with injuries requiring ICU admission were included. Blood samples
were collected on arrival (T0), at 3h (T3), 6h (T6), 12h (T12), and 24h (T24) and assayed
by thromboelastography and platelet mapping (Haemonetics TEG6s). Patient
demographics, anti-platelet therapy, mechanism of injury (MOI), ISS platelet count,
blood products transfused, length of stay, and mortality were recorded. Mann-Whitney,
Chi-square, and Spearman’s tests were used where appropriate, ( P<0.05, significant).
Results:Forty-eight patients were enrolled with demographics as described in the table.
53.5% of patients had low MA at T0, which peaked at T3 (81.1%). During the first
24hours, when maximally stimulated with thrombin (HKH MA), only 18 pts
demonstrated platelet inhibition whereas 38 demonstrated ADP pathway inhibition (ADP
MA). ISS and ADP MA were negatively correlated at T3 (r s =-0.353, p=0.041). This was
more pronounced following blunt trauma (r s =-0.571, p=0.04). Those with low ADP MA
at T3 received significantly more platelet, blood, and FFP transfusions between T0 and
T3 than normal ADP MA patients (0.5 vs 0, p=0.021, 4 vs 0, p=0.002, 3 vs 0, p=0.004,
respectively). Platelet transfusion, however, did not significantly improve platelet
function in those with
low MA. PD did not
impact LOS or
mortality.
Conclusion:PD is
common in trauma
patients and appears to
impact both maximal
thrombin stimulation
and ADP pathway
activation. Although
more blood products are
required in trauma
patients with PD,
current platelet
resuscitation strategies
are either insufficient or
the platelets being
transfused are ineffective.
 Poster # 77
Epidemiology of Trauma-Induced Coagulopathy (TIC): Thrombelastography
Phenotypes
Geoffrey R. Nunns MD, Gregory R. Stettler MD, Ernest E. Moore* MD, Hunter B.
Moore MD, Anirban Banerjee MD, Christopher C. Silliman MD,Ph.D., Angela Sauaia*
MD,Ph.D., University of Colorado Denver
Introduction: Thrombelastography (TEG)-guided resuscitation has been shown to reduce
TIC-related deaths. TEG comprehensively assesses the coagulation process through
different indices: Activated clotting time (ACT): clot formation; 2) Maximum amplitude
(MA): clot strength; 3) LY30: fibrinolysis. Although fibrinolysis’ impact has been
extensively studied, the significance of combinations of TEG indices remains elusive.
We studied the impact of phenotypes defined by TEG indices combinations.
Methods: Trauma activation patients admitted to a Level 1 Trauma Center 2014-2017
were prospectively enrolled and a rapid TEG obtained within 1hr post-injury. Abnormal
(ABNL) TEG values were: ACT≥128 sec; MA<55mm; Lysis was categorized as
Hyperfibrinolysis (HYPER: LY30>=3%), Physiologic (PHY: LY30 0.9-2.9%);
Shutdown (SD: LY30<0.9%). Multinomial logistic regression (LR) identified predictors
of phenotypes and binomial LR the impact of phenotypes.
Results: 409 patients were included; median age 32 years; median New Injury Severity
Score (NISS) 22; 55% suffered blunt injuries. Overall, 7% required massive transfusion
(MT: >10 RBC units or death/6 hours), and 14% died. The most common TIC phenotype
was Normal (NL) ACT/NL MA/PHY, and the most lethal was ABNL ACT/ABNL
MA/SD. MT was associated with ABNL ACT/ABNL MA/HYPER. Among the tested
specific injuries, pelvic fractures were predictive of NL ACT/ABNL MA/PHY (Adjusted
OR= 12.4; 95%CI: 2.3-66.7) and of ABNL ACT/ABNL MA/HYPER (Adjusted OR=6.1;
95%CI: 1.9-19.4). No other specific injury tested was predictive of TIC phenotypes.
When indicators of injury severity/shock were added, NISS, age, ED-SBP were the only
significant predictors of TIC phenotypes (all p<0.009). The adjusted OR of MT for the
distinct TIC phenotypes are shown in the figure below. The phenotype independently
associated with death was ABNL ACT/ABNL MA/HYPER (Adj OR=5.7; 95%CI:
1.4-23.3).

Conclusion: The combinations of TEG indices are associated with specific risk factors
and outcomes. These phenotypes can be used to further assist in hemostatic resuscitation.
 Poster # 78
THE DYNAMICS OF ANTITHROMBIN III AND ITS ROLE IN
POST-TRAUMATIC VENOUS THROMBOEMBOLISM
Brandon J. Behrens MD, Elizabeth Dewey Mackenzie Cook* MD, David Martin John
Yonge Samantha Underwood MS, Diane Lape Andrew Goodman Keeley McConnell
Lelani Lealiiee Ariane Audett Jevgenia Zilberman-Rudenko Martin Schreiber* MD,
Oregon Health & Science University
Introduction: Trauma patients exhibit a complex balance of coagulopathy and
thrombosis that, if left untreated, leads to deep vein thrombosis (DVT) rates as high as
60%. The American College of Chest Physicians (ACCP), therefore, recommends
chemoprophylaxis with heparin or low-molecular weight heparin (LMWH). Despite
prophylaxis, rates of DVT remain unacceptably high. Our lab has shown that up to 67%
of trauma patients are found to be antithrombin III (ATIII) deficient. Previous studies
have suggested that trauma patients have depressed levels of ATIII and this deficiency
predisposes them to increased rates of DVT. We hypothesize that ATIII deficiency is
associated with increased rates of DVT and pulmonary embolism (PE).

Methods: This was a prospective, observational, single institution study performed at a

Level I trauma center. Data were collected on 293 trauma patients at the following time
points: baseline, 8 hours, 16 hours, 24 hours, 48 hours, and days 3, 4, 5, 6 following the
initial sample collection. Antithrombin III levels were measured via chromogenic
functional assay and reported as a percentage with a reference range of 80-120%.
Chemoprophylaxis strategy, DVT, and PE screening were conducted per institutional
protocol and were not influenced by this study. Subjects were followed to discharge to
assess for DVT/PE.

Results: In our cohort, 12.8% (38/287) of subjects were antithrombin III deficient at
baseline and a total of 44.1% (131/293) of subjects were deficient at any time point
across the first six days of admission. Antithrombin III deficiency was associated with
increased length of stay 10.2 d vs 6.2 d (p < 0.01), increased ICU length of stay 4.3 d vs
2.2 d (p < 0.01), increased number of ventilator days 2.2 d vs 0.4 d (p = 0.01), increased
ISS 19 vs 15 (p < 0.01), and increased mortality 9.2% vs 1.2% (p < 0.01). After
multivariate analysis, antithrombin III deficiency was not found to be associated with a
significantly increased rate of DVT 10.7% vs 5.6% (p = 0.1) or pulmonary embolism
1.5% vs 0% (p = 0.2). Average antithrombin III levels were only significantly different
between VTE and no-VTE groups at hour 8 and remained above 80% at all but one time
point for both groups.

Conclusion: ATIII deficiency is associated with increased severity of illness and worse
hospital outcomes. The current study failed to detect a difference in thromboembolic
complications in patients with ATIII deficiency but this could be related to inadequate
power.
 Poster # 79
EARLY INITIATION OF PHARMACOLOGICAL VENOUS
THROMBOEMBOLISM PROPHYLAXIS IN PATIENTS WITH HIGH-GRADE
BLUNT LIVER AND SPLENIC INJURIES IS NOT ASSOCIATED WITH AN
INCREASED RISK OF BLEEDING
Kerry K. Moore PharmD, Cassie A. Barton PharmD, BCPS, BCCCP, Yuxuan Wang
MD, Elizabeth Dewey MS, Albert Chi* MD, Martin Schreiber* MD, Susan Rowell*
MD, MCR Oregon Health & Science University
Introduction: Nonoperative management (NOM) is the standard of care for
hemodynamically stable patients with traumatic blunt solid organ injuries. Management
of these patients is challenging as the risk of venous thromboembolism (VTE) and
bleeding (failure of NOM) must be balanced. Current guidelines for the management of
these injuries do not define the time at which pharmacological VTE prophylaxis (VTEp)
can be initiated safely but suggest that VTEp should be considered within 48 hours if no
contraindications exist. We aimed to compare the safety of early versus delayed initiation
of VTEp in patients with high-grade (AAST grades ≥ 3) blunt liver and spleen injuries
undergoing initial NOM.
Methods: All patients 16 years and older admitted to a level 1 trauma center with
high-grade (AAST grades 3, 4, and 5) blunt liver and spleen injuries between January
2008 and October 2017 were included. Patients with an indication for therapeutic
anticoagulation, requiring massive transfusion upon presentation, or undergoing operative
intervention for their abdominal organ injuries within the first 24 hours were excluded.
Patients were divided into three groups based on the timing of the first-dose of VTEp:
early (≤ 48 hours), intermediate (49-71 hours), and late (≥ 72 hours) after presentation.
Bleeding was defined as the need for one or more units of blood product and/or surgical
or interventional radiology (IR) intervention for their solid organ injury after initial
resuscitation. The primary endpoint was the incidence of bleeding after initiation of
VTEp. The rate of VTE during the index admission was also evaluated.
Results: The study population included 232 patients. There were 75 grade 3 injuries (25
liver, 52 spleen), 145 grade 4 injuries (63 liver, 82 spleen), and 15 grade 5 injuries (7
liver, 8 spleen). Twenty-seven patients (11.6%) received early VTEp, 42 patients (18.1%)
intermediate, 51 patients (22.0%) late, and 112 patients (48.3%) never received VTEp.
Baseline demographic, physiologic, and laboratory variables were similar across groups,
with the exception of a lower ISS and higher GCS score in the early VTEp group. The
overall rate of IR intervention within the first 24 hours was 18.9% and was not different
across groups (p = 0.32). Early VTEp was not associated with an increased risk of
bleeding when compared to those receiving intermediate and late VTEp (7.4% early vs.
11.9% intermediate vs. 5.8% late, p = 0.84). The incidence of bleeding in patients who
never received VTEp was 8.9%. VTE developed in 10% of those who received VTEp (n
= 12) as compared to 1.8% (n = 2) of those who never received VTEp.
Conclusion: In this retrospective study of patients with high-grade blunt abdominal solid
organ injuries, early initiation of VTEp within 48 hours of admission did not lead to an
increase in delayed bleeding. Prospective studies should be conducted to further define
the optimal timing of VTEp in this patient population.
 Poster # 80
IDENTIFYING FIBRINOLYSIS SUBPHENOTYPES THAT GUIDE
ANTIFIBRINOLYTIC THERAPY
Joshua J. Sumislawski MD, Hunter B. Moore MD, PhD, Ernest E. Moore* MD, Angela
Sauaia MD, PhD, Lucy Z. Kornblith MD, Amanda S. Conroy Rachael A. Callcut* MD,
MSPH, Mitchell J. Cohen* MD, Denver Health Medical Center
Introduction: Dysregulated fibrinolysis after injury is associated with increased
mortality. The debate over antifibrinolytic therapy is complicated by the lack of a
physiologic parameter or laboratory test, including thromboelastography (TEG), to direct
treatment. Recent work has described fibrinolysis subphenotypes based on tissue
plasminogen activator (tPA) sensitivity; however, no conventional assay exists. Since tPA
is released from ischemic endothelium and international normalized ratio (INR) reflects
coagulation initiated by tissue damage, we hypothesized that INR combined with TEG
would identify patients in hyperfibrinolysis (HYP) or fibrinolysis shutdown (SD) with
highest mortality, guiding therapy.

Methods: Blood samples were collected prospectively from critically injured patients
upon arrival at an urban Level I trauma center. TEG and INR were used to classify
patients by fibrinolysis subphenotype. Outcomes were compared.

Results: During a six-year period, 657 patients (median ISS 10, mortality 11%) were
enrolled. Overall mortality was 15% for SD, 5% for physiologic fibrinolysis, and 19% for
HYP (p=0.001). In the normal-INR cohort, SD had highest mortality (11%, 3%
physiologic, 5% HYP; p=0.003; figure), fewer ventilator-free days (p=0.001), and longer
ICU and hospital stays (p=0.001) as well as increased ISS (p=0.001) and severe head
injury (37%, 15% physiologic, 16% HYP; p<0.001). In the elevated-INR cohort, HYP
trended toward highest mortality. After controlling for injury severity, SD and elevated
INR remained significant predictors of mortality.

Conclusion: Fibrinolysis subphenotypes can guide antifibrinolytic therapy. In patients

with normal INR, SD is associated with traumatic brain injury and increased mortality
compared with other fibrinolysis phenotypes. Empiric use of antifibrinolytic therapy
would likely not benefit these patients and should be avoided.
 Poster # 81
Complications in Low-Risk Elderly Trauma Patients: A Case-Control Study
Robert A. Tessler MD, Melissa M. Rangel BS, Micaela L. Rosser BS, Frederick P.
Rivara MD,MPH, Eileen M. Bulger* MD, FACS, Monica S. Vavilala MD, Saman
Arbabi* MD,MPH, Harborview Injury Prevention And Research Center
Introduction:The proportion of trauma patients 65 years and older is rising. Major
inpatient complications tracked in the Trauma Quality Improvement Program (TQIP) in
this population include unplanned return to the intensive care unit (ICU), unplanned
intubation, pneumonia, and unplanned return to the operating room (OR). Data on risk
factors for these common complications among elderly trauma patients thought to be
low-risk are limited. We sought to determine the association between comorbidities, home
medications, inpatient opioids, and inpatient benzodiazepines with risk of common
inpatient complications in low-risk elderly trauma patients.

Methods: Cases were trauma patients 65 years or older admitted to a Level I trauma
center from January 2015 to August 2016 with a TQIP predicted probability of
complication <20% and who experienced an unplanned return to the ICU, unplanned
intubation, pneumonia, or unplanned return to the OR. Two age-matched controls for
each case were randomly selected from within the same time period and same TQIP
predicted probability of complication. We generated estimated odds-ratios for any
complication using multivariable conditional logistic regression.

Results:We identified 94 (9.6%) unique cases from 983 trauma patients 65 years and
older with a TQIP predicted probability of complication <20%. Some cases had >1
complication: 51 unplanned returns to the ICU, 27 pneumonias, 18 unplanned intubations,
and 12 unplanned returns to the OR. There were 188 randomly selected age-matched
controls from the remaining 889 patients that did not experience a complication. Median
age for cases and controls was 78 (IQR=70, 85), 56.4% were male, and 74.5% were falls.
Half of patients had traumatic brain injury (TBI), and 31.6% had a chest injury with no
difference in proportions between cases and controls. Cases were more often intubated
(34.0% vs 22.3%, Chi-squared p=0.04) and had higher median Injury Severity Score
(ISS) (cases = 17 (IQR 10, 25), controls = 14 (IQR 10, 19)). After adjustment for age,
sex, intubation, undergoing an operation, TBI, ISS, and chest injury, the risk of
complication was higher for those on home beta blocker and home anticoagulants (aspirin,
Plavix , Coumadin, direct thrombin, and Xa inhibitors) compared to patients not on these
medications (beta blocker OR= 2.3, 95%CI 1.2,4.3 and anticoagulants OR=2.2, 95%CI
1.2, 4.1). Patients with a history of diabetes and dementia also had higher odds of
complication (OR=2.0, 95%CI 1.1, 3.7, and OR=2.0, 95%CI 1.0, 4.3, respectively). The
odds of complication were 10% higher for each additional 10
morphine-equivalents-per-hospital-day, although the confidence interval included 1
(OR=1.1, 95%CI 1.0, 1.2, p=0.2). There was no association between
lorazepam-equivalents-per-hospital-day and risk of complication in adjusted models.

Conclusion: Low-risk elderly trauma patients on home beta blockers and anticoagulants
may be at elevated risk for unplanned return to ICU, unplanned intubation, pneumonia,
or unplanned return to the operating room. History of diabetes and dementia are also
associated with greater risk. There may be an association between additional opioid
administration and risk for complications. Pre-existing co-morbidities appear to have the
strongest association with complications in low-risk elderly trauma patients.
 Poster # 82
THE FINANCIAL IMPACT OF GERIATRIC TRAUMA ON THE TRAUMA
SYSTEM: ANALYSIS OF MEDICARE DATA
Samir M. Fakhry* MD, R. Lawrence Reed* II, MD, Jennifer Ward MBA,RN, BSN
TRAUMA CENTER ASSOCIATION OF AMERICA

Introduction: Trauma is a significant and increasing contributor to the burden of disease

in the Medicare population. We analyzed Medicare data to determine geriatric trauma
volumes and expenditures and their impact on the trauma system

Methods: Using the 100% Medicare Standard Analytic File for inpatients and outpatients
for 2012-2015, we selected claims with trauma diagnoses and extracted patient
demographics, admission type, payments, utilization rates for 068x revenue codes, high
cost outliers and treating hospital descriptors.

Results: 253,948 patients and 259,995 claims were identified with an average inpatient
payment of $18,619 and an outpatient payment of $2,082. The total annual Medicare
expenditure for trauma was $982,022,622 in 2012, $1,030,003,625 in 2013,
$1,081,868,535 in 2014 and $1,151,419,712 (annualized) in 2015, representing a 17%
increase over 4 years. 3812 hospitals had at least 25 trauma inpatients: 174 level 1, 277
level 2, 397 level 3, 490 Level 4, 6 Level 5 and 2,468 non-trauma center. 77.9% of
patients were treated at a teaching hospital. According to the CMS CPT cost statistics file,
payment for outpatient claims for trauma activation (HCPCS G0390) were as follows:
2012: 2,653, 2013: 3,009, 2014: 3,131, 2015: 4,257. This suggests that either most
geriatric trauma activations become inpatients (their activation fee rolls into the inpatient
DRG) or centers are not charging activation fees.

Conclusion: Medicare expenditures for trauma increased 17% over the 4 years of this
study and represent approx. 0.65% of Medicare expenditures. 77.9% of geriatric trauma
inpatients were treated at teaching hospitals. A relatively small number of payments
were made for trauma activation. These data show that costs for geriatric trauma are
increasing and suggest that there may be opportunities for better triage of injured
geriatric patients in the trauma system.
 Poster # 83
AGE SHOCK INDEX: A VALID PREDICTOR OF MORTALITY IN
GERIATRIC TRAUMA PATIENTS
Ansab Haider MD, Jorge Con MD, Kartik Prabhakaran MD, Seungwhan Pee MD,
Matthew Bronstein MD, David Samson MS, Leandra Krowsoski MD, Patrice Anderson
MD, Gary Lombardo MD, Anthony Policastro MD, Rifat Latifi* MD, Westchester
Medical Center
Introduction: Shock index (SI=Heart rate/Systolic Blood Pressure) and age are both well
known predictors of mortality in trauma patients. However, it is often postulated that due
to the dampened physiologic responses in elderly trauma patients, traditional vital signs
including SI may have higher false negative rate for predicting mortality. The aim of our
study was to evaluate if age shock index (ASI= age x SI) may be a better predictor of
early mortality in geriatric trauma patients.
Methods: We abstracted two years of NTDB for all patients ≥65 years of age and Injury
Severity Score (ISS) >15 with complete data. Transferred patients and patients dead on
arrival were excluded. Patient demographics, injury parameters, and traditional vital signs
were recorded and SI, and ASI were calculated. Our outcome measure was early mortality
(≤24 hours). Area under receiver operating curve (AUROC) was calculated for each vital
signs and index and compared.
Results: A total of 18,736 patients were included. Mean age was 74±6 years, 58.7% were
male, median ISS [IQR] was 21 [17 - 26], and the overall early mortality rate was 4.1%.
HR, SBP, SI, and ASI were all significant predictors of early mortality ( p<0.001).
AUROC [95% CI] for SBP and HR was 0.43 [0.42-0.45] and 0.58 [0.56-0.60]
respectively. SI had an AUROC of 0.61 [0.59-0.63]. Highest AUROC was noted for ASI
0.62 [0.60-0.64]. Even in the subgroup of patients with normal traditional vital signs,
patients with ASI>50 had 30% higher odds of early mortality (OR [95% CI] : 1.3
[1.1-1.6]). SI was unable to predict mortality in this subgroup of patients.
Conclusion: Traditional vital signs significantly underperforms in predicting early
mortality in geriatric trauma patients. ASI has the highest predictive power followed by
SI. ASI may be a better tool for effective triage of seriously injured geriatric trauma
patients.
 Poster # 84
SATISFACTION OF OLDER ADULT TRAUMA PATIENTS AND THEIR
CAREGIVERS BEFORE IMPLEMENTATION OF THE PALLIATIVE CARE
TQIP GUIDELINES ACROSS THREE TRAUMA CENTERS: CAN WE DO
BETTER?
Rebecca Vogel MD, Constance McGraw MPH, Alessandro Orlando MPH, Pamela
Bourg Ph.D.,RN, Allen Tanner II, MD, Laura Peck DO, David Bar-Or MD, St. Anthony
Hospital
Introduction: Palliative care has been suggested to improve patient and family
communication, satisfaction with care, and decrease time to identification of poor
prognosis and hospital length of stay. Studies examining patient satisfaction and palliative
care in trauma patients are limited. The purpose of this study was to compare satisfaction
and in-hospital outcomes of older adult trauma patients and their primary caregivers with
our current palliative care services.
Methods: This prospective cohort study enrolled trauma patients aged ≥55 and their
primary caregiver, from 11/2016-10/2017, across three ACS-verified trauma centers
(three Level I). Patients were subject to usual care, including ad hoc palliative care
interventions. Consented patients and caregivers were administered satisfaction surveys
prior to decision to discharge; patients took the Family Satisfaction with Advanced
Cancer Care Scale (FAMCARE-P13, 65 possible points), while caregivers took the
FAMCARE survey (100 possible points); higher scores indicate higher satisfaction. Both
surveys were divided into four structures: Information Giving, Availability of Care,
Physical Care, and Psychosocial Care. Study outcomes were overall mean (SD)
satisfaction, satisfaction <85% versus ≥85%, and satisfaction by survey structure.
Univariate differences between satisfaction groups (<85% vs. ≥85%) and conceptual
structures were assessed using chi-squared tests and Student’s t-tests, respectively.
Results: There were 273 patients and 295 primary caregivers included in this study. The
overall mean (SD) satisfaction was 85.2% (11.0%) for patients and 86.6% (11.0%) for
caregivers. 53% of patients and caregivers had overall satisfaction scores ≥85%.
Compared to patients with satisfaction <85%, a greater proportion of patients with
satisfaction ≥85% were discharged home versus an outside facility (51% vs. 39%,
P=0.04), and a smaller proportion had a mental illness (5% vs. 13%, P=0.04). The
structure with the highest (mean, SD) patient satisfaction was Psychosocial Care (87.8%,
14.0%), and Availability of Care (88.6%, 13.5%) for caregivers. Information Giving was
the structure with the lowest (mean, SD) satisfaction for patients (84.2%, 13.5%) and
caregivers (84.2%, 13.5%). Caregivers were significantly more satisfied with Availability
of Care (88.6% vs. 86.2%, P=0.001) and Physical Care (86.7% vs. 85.5%, P=0.008) than
patients.
Conclusion: These data suggest that on average, patients and caregivers were more than
“satisfied” with overall care, and highly valued coordination of care and inclusion of
family in care decisions. Similar to other studies, there is room for improvement in
communication of information sharing among clinicians, patients and families, which
may also account for the lower patient satisfaction scores in Availability of Care. Moving
forward, these baseline data will help us best determine the impact of the new TQIP
guidelines on patient and caregiver satisfaction with trauma care.
 Poster # 85
OLD AGE WITH A SUSPICIOUS MECHANISM OF INJURY SHOULD BE A
TRAUMA TEAM ACTIVATION CRITERION
James M. Bardes MD, Elizabeth Benjamin* MD,Ph.D., Morgan Schellenberg MD, Kenji
Inaba* MD, Demetrios Demetriades* MD,Ph.D., LAC+USC Medical Center
Introduction: Trauma Team Activation (TTA) criteria have been described by the
Committee on Trauma (COT). Although age is not included in the standard criteria, many
believe that the vital signs in elderly patients are often unreliable, and many severely
injured patients may have normal vital signs initially, only to deteriorate rapidly a short
time later. This undertriage may affect outcomes. In addition, elderly patients are an at
risk population even after fairly moderate trauma. Based on outcome data, our institution
has included age≥70 in patients with certain mechanisms of injury, as a TTA
criterion. The purpose of this study was to determine if this TTA criterion appropriately
identifies patients in need of additional resources without significantly impacting
overtriage rates.
Methods: Retrospective study of all TTAs from Jan 2012-Dec 2016. Demographics,
injury and admission data, ISS, ER intubation, direct ICU or OR admission from ER, and
interventions were collected. Primary outcome was mortality, secondary outcomes, ICU
and hospital LOS. Patients were stratified into those meeting standard criteria (TTA-S),
and those that were activated based on age alone (TTA-A). TTA patients with ISS>15,
ED intubation, ICU admission, direct transfer to OR, immediate catheter based
intervention, hospital length of stay (HLOS) >48 hours, and mortalities were considered
appropriately triaged.
Results: During the study period there were 5436 total TTAs. Of the 739 TTAs in
patients age≥70, there were 198 (26.8%) who met the standard criteria for TTA, and 541
(73.2%) were had TTA based on only age >70. In the TTA-A group, despite activation
solely based on age, 49 (9%) died. More than a quarter of the TTA-A patients had ISS>15
(n=149; 27.5%), 65 (12%) underwent immediate OR or catheter-based intervention, 72
(13%) required ED intubation, and 306 (56.6%) required direct admission to the
ICU. Only 50% of TTA-A patients were discharged home. After exclusion of the
pre-designated criteria above, overtriage rate of the TTA-A subgroup was 33.5%, well
within the recommended range.
Conclusions: Elderly patients with severe trauma patients often do not meet the standard
TTA criteria, which might result in potentially dangerous undertriage. Addition of the
age ( >70 years) criterion for trauma team activation, reduces undertriage and at the same
time does not result in unacceptable overtriage.
 Poster # 86
Are We More Willing to Make Dad Comfortable after Trauma?
Stephanie N. Lueckel MD, ScM, Samuel Miller MD, Elizabeth Tindal MD, Tareq
Kheirbek MD, Sean F. Monaghan MD, Andrew H. Stephen MD, Eric Benoit MD,
Michael D. Connolly MD, Charles A. Adams* Jr., MD, William G. Cioffi* MD, Brown
University Rhode Island Hospital

Introduction: The American College of Surgeons (ACS) Trauma Quality Improvement

Program’s Palliative Care Best Practice Guidelines highlights the need to focus on patient
comfort at the end of life. Within our analysis, we hypothesize male sex plays a
significant role to continue medical interventions rather than transition to Comfort
Measures Only (CMO) status with further analysis looking at specific factors that might
be associated with transition to CMO.

Methods: This is a 2 year retrospective review of adult (age > 18years) patients from a
level 1 trauma center. Data extracted included age, sex, injury severity score (ISS),
mechanism of injury (MOI), and medical comorbidities. Patients were considered to be
CMO if support was withdrawn in hospital or if patients were discharged to hospice.
Logistic regression analysis was performed to identify significant predictors of CMO
status. Case-control matching was then performed matching for age, ISS, and MOI.
Repeat regression analysis was performed.

Results: 6803 patients were identified; 367 in the CMO group. CMO patients were older
(p<.001), had higher ISS (p<.001) and were more likely to be white (p<.001). CMO
patients were more likely to have hypertension (p<.001), diabetes (DM) (p<.001),
congestive heart failure (CHF) (p<.001), chronic obstructive pulmonary disease (COPD)
(p<.05), and functionally dependent health status (FDHS) (p<.001) CMO patients were
less likely to abuse alcohol, tobacco or other drugs (p<.001). Regression analysis
revealed independent predictors of CMO status: older age (p<.05), male sex (p<.001),
non-white race (p<.05), higher ISS (p<.001), DM (p<.05), CHF (p<.001), FDHS
(p<.001). Case-control matching yielded a cohort of 706 patients, 353 were CMO. CMO
patients were still more likely to be men (p<.05) and to be white (p<.05), but there were
no differences in age or ISS. Repeat regression analysis in this cohort revealed male sex
(p<.05) and non-white race (p<.05) as significant predictors of CMO status.

Conclusion: Previous studies found that non-white race was associated with a shift
towards life-sustaining care but sex has never been determined to have an impact on
CMO. Our findings highlight that sex may in fact play a role in CMO decisions.
Additional analysis should be done with regards to cultural and religious beliefs as well
as bias within physicians guiding decisions to transition patients to CMO.
 Poster # 87
HOSPITAL-LEVEL TENDENCY TO ADMIT ELDERLY TRAUMA PATIENTS
WITH ISOLATED RIB FRACTURES TO AN INTENSIVE CARE UNIT IS NOT
ASSOCIATED WITH IMPROVED OUTCOMES
Jessica Cox MD, Gregory Jurkovich* MD, Garth Utter* MD, MSc, University of
California, Davis
Introduction: Despite the known morbidity and mortality associated with isolated rib
fractures in the elderly, there are no widely accepted guidelines for intensive care unit
(ICU) admission. We sought to characterize any inter-hospital variability in emergency
department disposition of elderly patients with rib fractures. We hypothesized that greater
use of ICU admission would be associated with improved outcomes.
Methods: We used the 2015 National Trauma Data Bank to identify patients 65 years or
older with isolated rib fractures who were admitted to an ICU, step-down unit, or ward. We
excluded patients with a significant injury [Abbreviated Injury Scale (AIS) score >1] other
than the chest wall injury, those with GCS <9, and those who were intubated. We
categorized hospitals into quartiles based on the proportion of eligible patients admitted to
an ICU, excluding hospitals with <10 eligible patients in 2015. The primary outcome was a
composite of unplanned intubation, pneumonia, or death. We used logistic regression to
evaluate whether hospital-level quartile of ICU-use was associated with outcomes,
accounting for clustering of observations within hospitals and patient- and hospital-level
characteristics as potential confounders.
Results: Among 10,382 patients at 420 facilities, the mean age was 77±7 years, mean ISS
was 8±3, and mean thoracic AIS 2.6±0.8. 31% of patients had 1-2 fractured ribs, 28% had
3-5 fractures, and 14% had >5 fractures; 26% were characterized only as having
“multiple” fractures. The median proportion of patients admitted to the ICU per hospital
was 17% (IQR 7-31%, range 0-88%). Trauma center level, university affiliation, and
Southern or Western geographic region were associated with greater ICU use. Hospital-
level quartile of ICU use was not associated with a reduction in the composite adverse
outcome (Table), and greater ICU use was associated with increased risks of death and
unplanned intubation. Unplanned ICU transfer was no more likely among hospitals with
less ICU use. None of the available patient or hospital characteristics confounded these
associations.

Conclusions: Admission disposition of elderly patients with isolated rib fractures is highly
variable across centers. Hospitalization at a facility that admits a high proportion of such
patients to an ICU is not associated with improved outcomes, and may be associated with
greater risk of death. Hospitalization at a facility that admits a low proportion of patients to
the ICU is not associated with increased risk of unplanned transfer to the ICU. Further
research is needed to identify which patients benefit from ICU admission.
 Poster # 88
LIFE AFTER 90: OUTCOMES AND PREDICTORS OF MORTALITY IN 4,724
NONAGENARIAN PATIENTS UNDERGOING EMERGENCY GENERAL
SURGERY
Manasnun Kongwibulwut MD, Kevin Chiang MD, Jae M. Lee BA, Ask T. Nordestgaard
BSc, Ahmed I. Eid MD, MSc, Suzanne F. Van Wijck BSc, Napaporn Kongkaewpaisan
MD, Kelsey Han BA, David R. King MD, Peter J.
Fagenholz MD, Noelle N. Saillant MD, Martin G. Rosenthal MD, April E. Mendoza
MD,MPH, George C.
Velmahos* MD,Ph.D., Massachusetts General Hospital
Introduction: The decision to emergently operate on nonagenarian patients (NONAs) can
be complex due to the uncertainty about outcomes and goals of care at this advanced age.
We sought to: 1) determine the outcomes and predictors of mortality for NONAs
undergoing emergency general surgery (EGS) and 2) test the performance of the ACS-
NSQIP surgical risk calculator in this subgroup of patients.
Methods: Using the 2007-2015 ACS-NSQIP database, all patients 90 years of age or
older who underwent an emergent operation, as defined by ACS-NSQIP, with a CPT code
for “digestive system”, were included. Multivariable logistic regression analyses were
performed to identify independent predictors of 30-day mortality. NONAs mortality rates
for different combinations of risk factors were also studied. The actual mortality rates
were compared to those predicted by the ACS-NSQIP risk calculator.
Results: Out of a total of 4,456, 809 patients, 4,724 NONAs were included; 67.2% were
female and 81.5% were white. The overall 30-day patient mortality and morbidity rates
were 21% and 45%, respectively. In multivariable analyses, the key independent
predictors of 30-day mortality included recent history of weight loss, history of steroid
use, smoking, functional dependence, hypoalbuminemia and sepsis/septic shock. A
diagnosis of diabetes, heart failure, or COPD did not independently correlate with 30-day
mortality. NONAs with a history of weight loss with either steroid use or sepsis had a
100% and 93% mortalities, respectively. The ACS-NSQIP consistently underestimated
the mortality of all NONAs, especially those at the highest risk [Table 1].

Conclusions: Most NONAs undergoing EGS survive the hospital stay, but the ACS-
NSQIP calculator underestimated their risk. The combination of recent weight loss
with either steroid use or septic shock nearly ensures mortality and should be used in
the discussions with patients and families before a decision to operate is made.
 Poster # 89
COAGULOPATHY IS ASSOCIATED WITH INCREASED MORTALITY IN
GERIATRIC EMERGENCY GENERAL SURGERTY PATIENTS
Vanessa P. Ho* MD,MPH, Nicholas K. Schiltz Ph.D., Andrew P. Reimer Ph.D.,RN,
Elizabeth Madigan Ph.D.,RN, Siran M. Koroukian Ph.D., Elliott R. Haut* MD,
MetroHealth Medical Center
Introduction: Coagulopathy is a well-known risk factor for mortality in trauma surgery. It
is unknown whether coagulopathy carries a similarly increased risk of mortality for
emergency general surgery (EGS). Our aim was to apply a data-driven approach to study
mortality associated with coagulopathy, both alone, and in combination with other
comorbidities.
Methods: We performed a cross-sectional study of patients aged 65 and older from the
2011 Nationwide Inpatient Sample who underwent EGS, utilizing the AAST ICD-9
classification. Coagulopathy, including inherited and acquired coagulopathy, and other
comorbidities, were defined via the Elixhauser comorbidity index. We utilized Association
Rule Mining to determine common comorbidity combinations. We calculated adjusted
odds of in-hospital mortality for one, two, and three-way comorbidity combinations.
Results: We identified 992,892 encounters, with an overall mortality rate of 5.2%. The
most common procedures performed were gastrointestinal (30.3%) and soft tissue (29.8%).
Coagulopathy was associated with the highest adjusted mortality rate compared with all
other individual comorbidities (adjusted odds ratio [OR]: 3.52, 95% confidence interval
[CI]: 3.34 – 3.72, p<.001). Two- and three-way comorbidity combinations with the highest
adjusted mortality also included coagulopathy (Table).
Conclusion: For elderly patients undergoing EGS, coagulopathy is the strongest
comorbitity risk factor for death, both alone and in combination with other comorbidities.
Further studies to examine whether targeted treatment of coagulopathy can improve
outcomes should be undertaken.
 Poster # 90
TRAUMA RECIDIVISM IN THE ELDERLY: A NATIONAL AND LOCAL
CRISIS
Elliot C. Williams MD, Laura N. Godat* MD, Jay J. Doucet* MD, Todd W. Costantini*
MD, University of California, San Diego
Introduction: As the population ages, injury prevention efforts are needed to target
elderly patients requiring trauma center readmission after multiple falls. Prior studies on
elderly trauma recidivism were limited to single institutions. The goal of this study was to
measure rates of elder trauma recidivism nationally and identify potentially modifiable
risk factors.
Methods: The Nationwide Readmission Database (NRD) for 2015 and the trauma
registry at an urban, Level 1 trauma center (2000-2016) were queried for all patients aged
65 and older who were admitted with a primary diagnosis of trauma. Patients with more
than one admission in the database with a primary diagnosis of trauma were labeled
recidivists. The index admission for recidivists was compared with non-recidivist
admissions with respect to demographics, mechanism of injury (MOI), discharge
destination, and mortality.
Results: In the 2015 NRD, there are 373,413 elderly trauma patients, representing a 50%
national sample. 16,108 (4.3%) patients were identified as trauma recidivists. Compared
to non-recidivists, elderly trauma recidivists were more likely to be initially admitted for
a fall (78% vs 68%, p<0.001). Recurrent falls were common in recidivists, with 63%
having least one additional admission for a fall in the same year. Mortality within the
year was doubled for recidivists (5.0% vs 2.3%, p<0.001) and continued to increase with
each subsequent trauma
admission (see Figure). 70% of
recidivists presented to the same
hospital for all of their trauma
admissions. At our institution, a
total of 4219 unique patients aged
65 or older were admitted to
the trauma center, of which 210
(5.0%) were recidivists. The
local rate of recidivism has
increased every year since 2010.
Modifiable risk factors associated
with recidivism at the institution
level were alcohol abuse and
homelessness.
Conclusion: Trauma recidivism in the elderly is rapidly increasing and is associated with
increased mortality. Single institution data for our trauma center shows that alcohol
abuse and homelessness are modifiable risk factors. Nationwide data demonstrates that a
majority of recidivists will return to the same hospital for subsequent trauma admissions,
providing an opportunity for targeted intervention and injury prevention efforts.
 Poster # 91
THE UNDERAPPRECIATED FINANCIAL BURDEN OF NON-ADMITTED
FIREARM INJURIES.
Keith R. Miller* MD, Amir Motameni MD, Matthew V. Benns* MD, Kim Denzik RN,
MSN, Annabelle Pike MBA, Jon R. Chastain Wanda Bowen CAISS, Lindsay Arnold MD,
Matthew Bozeman MD, Nicholas Nash MD, Glen Franklin* MD, Brian G. Harbrecht*
MD, Jason W. Smith* MD,Ph.D., University Of Louisville

Introduction: Firearm injuries result in significant societal cost burden and individual
morbidity and mortality. Large databases compiled from trauma registries and inpatient
admissions often neglect to include patients sustaining injuries that are treated in the
emergency department but not admitted. These injuries represent a significant portion of
overall injuries and are associated with costs not generally recovered by hospitals.

Methods: All firearm injuries evaluated at a Level 1 trauma center from January to
December 2017 were prospectively collected and retrospectively anaylzed. All patients
treated in the ED and not admitted to an observation or inpatient bed were identified, and
demographic, hospital cost, and aggregate hospital reimbursement were collected. Hospital
cost was calculated based on department specific cost-to-charge ratios based on the most
recently filed Medicare Cost Report. Financial cost (dollars, $) were standardized to
December 2017 value, and univariate and multivariate analyses were performed. Values
are expressed with +/- standard error (SEM) and Standard Deviation (SD).

Results: Over the study interval, 268 firearm injuries were treated in the emergency
department and not admitted. Of the 268 patients, 33 died in the ED prior to admission. Of
the survivors, 11% were re-evaluated in the ED at some point following their initial
evaluation. The average hospital cost to treat a non-admitted firearm injury was $1,535 (SD
+/- $2041, SE +/- $99). Patients who died during treatment in the ED prior to admission
had a much higher cost of treatment than those discharged home ($2853 =/- X vs $938 +/-
X, p<0.001). Total hospital cost to treat non admitted firearm injuries was $524,005.
Aggregated reimbursement for the 268 non-admitted patients was
$389,080, which represented a $134,925 shortfall. Five year financial modeling of trauma
admissions, cost and payments was performed (table 1). Modeling predicted an estimated
hospital loss of $674,072 over the next 5 years to care for these injuries.

Conclusion: There is a paucity of data regarding actual hospital reimbursement for care
following firearm injury. Patients sustaining firearm injuries that do not require admission
are generally excluded from trauma registries and inpatient databases. This group
comprised over forty percent of the total number of firearm injuries evaluated at our
institution. In addition to significant patient morbidity and mortality, these injuries
represent an underappreciated and growing financial burden on urban trauma centers.
 Poster # 92
THE EPIDEMIC OF MASS CASUALTY INCIDENTS IN THE UNITED STATES:
A CALL FOR ACTION
Riley Santiago BS, BA, Alison Smith MD,Ph.D., Kareem Ibraheem MD, Jessica Friedman
MD, Marcus Hoof BS, Rebecca Schroll MD, Chrissy Guidry DO, Clifton McGinness MD,
Juan Duchesne* MD, Patrick McGrew MD, Tulane School of Medicine
Introduction: A mass casualty incident (MCI) is defined by the National Incident
Management System (NIMS) as an incident in which the number of patients requiring pre-
hospital emergency services overwhelms the local resources. MCIs related to active
shooter incidents in the United States have been reported with increasing frequency, which
has prompted a call for major changes to how EMS and hospital systems manage MCIs.
Most studies of MCIs analyze large-scale events, such as earthquakes, plane crashes, or
mass shootings. However no study has provided an analysis of the characteristics of all
national MCIs. The aim of this study was to provide a descriptive analysis of MCIs in
order to provide guidance for the allocation of resources to these devastating events.

Methods: A retrospective review of the prospectively maintained National EMS

Information System (NEMSIS) database was performed. All MCIs from Jan 1, 2010
through Dec 31, 2015 were identified and data was stratified by injury mechanism and
separated into blunt and penetrating trauma subgroups. Demographic information and on
scene mortality was obtained. Results were analyzed for statistical significance.

Results: A total of 61,789 patients were identified. 60,294 of MCIs were blunt trauma
from motor vehicle collisions (97.6%). Although only 2.4% of MCIs were due to
penetrating mechanism; the incidence of compressible injuries: extremity (36.1% vs.
30.2%, p=0.0001) and non-compressible injuries: abdominal (10.7% vs. 5.8%, p<0.001)
and chest (16.2% vs 12.4%, p=0.03) were higher when compared to blunt trauma MCIs.
Penetrating MCIs had higher mortality rate as well, with most of them occurring in the
pre-hospital arena (12.9% vs. 2.0%, p<0.001) when compared to blunt MCIs.

Conclusion: Blunt trauma continues to be the most common mechanism in MCIs, though
penetrating trauma results in a six-fold higher rate of pre-hospital mortality. Given an
increasing surge in MCIs related to penetrating trauma, results from this study raises the
awareness for improvement in
pre-hospital interventions that could potentially improve on scene mortality.
Table 1: Mass Casualty Incidents in the United States: A National Six Year Analysis
 Poster # 93
IS OPIOID PRESCRIBING DRIVING TRAUMA RECIDIVISM OR IS TRAUMA
DRIVING OPIOID USE?
Laura A. Harmon MD, Leah Sukri BS, Joseph A. Kufera MS, Andrew Nguyen MD,
MeiLin Grunnagle BS, Christine L. Ramirez MD, Cristina B. Feather MD, Isadora
Botwinick MD, Thomas M. Scalea* MD, Deborah M. Stein* MD,MPH, University Of
Maryland R Adams Cowley Shock Trauma Center
Introduction: Opioids are commonly used to treat pain after trauma. In the past 30 years,
opioid prescription rates have quadrupled and hospital admissions for opioid overdose are
rising. Previous studies have focused on alcohol use and trauma recidivism. However,
there are no studies looking at recidivism and opioid use. We hypothesized that there is an
association between opioid use and trauma recidivism.

Methods: We retrospectively reviewed patients admitted more than once for trauma from
2007-2017. Demographics, opioid toxicology screen (TS) on each admission, and injury
characteristics were collected. Statistical analysis was performed with Chi-square and
Poisson regression models.

Results: 1649 patients (age ≥18) had multiple trauma admissions. 61% were non-black,
82% male, and 34% were between the ages of 18–29, which was the most represented
age group. The mean duration between first and second admissions was 18 months. 25%
had an ISS >15 on their 2 nd admission. 11% sustained penetrating trauma on their 1st
admission which increased to 19% on the recidivist admission. 12% of recidivists had a
diagnosis of alcohol dependency and 15% a diagnosis of drug abuse. Of the 709 who had
opioid screening on both admissions, 31% (218) were TS-positive on the 1 st admission
compared to 34% (244) on their 2nd admission. 17% of patients who were TS-positive on
1st admission were positive on their 2nd, while 18% who were TS-negative on 1st
admission were subsequently positive on their 2nd admission (p<0.0001). Patients who
were TS+ on the subsequent admission were less severely injured than those who were
TS- (ISS >15, 26.3% vs 22.3%, p=0.04). The only significant risk factor for TS+ on the
2nd admission was TS+ on the 1st admission (RR 2.18, p<0.001). However, age >60
(RR=0.67, p=0.08) and ISS >25 trended toward a protective effect (RR 0.62, p=0.13).

Conclusion: A previous history of opioid use is the strongest predictor of recurrent use in
recidivists. However, nearly 20% of our patients were opioid negative on 1st admission
but subsequently opioid positive on their 2nd. The opioid epidemic is ravaging the US
and opioid prescribing practices are clearly contributing to this issue. Acute pain
associated with trauma is often treated with opioids and may be inadvertently
contributing to injury recidivism.
 Poster # 94
MULTIMODALITY THERAPY DECREASES OPIOID USE WHILE
MAINTAINING PAIN CONTROL AND PATIENT SATISFACTION IN
INPATIENT PAIN MANAGEMENT FOR TRAUMA PATIENTS
Jessica L. Gross MD, Anna N. Miller MD, Allyson K. Bryant MD, Margaret R. Rukstalis
MD, Robert S. Weller MD, Jose-Franck Diaz-Garelli Ph.D., Gerald J. Rebo PharmD,
Kristin A. Rebo PharmD, Christen M. Seguin MSN, Paul F. Smith Amy Chang Preston
R. Miller* III, MD, Wake Forest University School of Medicine
Introduction: Prescription opioids are often used to control pain after injury or
surgery. Unfortunately, opioid addiction and its sequelae have reached epidemic
proportions in the United States, and sales of prescription opioids have nearly quadrupled
between 1999 and 2014. Opioid prescribing has played a major role in today’s opioid
epidemic and 40% of opioid deaths in the United States are due to prescription opioids.
Acknowledging this worsening crisis, our trauma service created a pain management
protocol (PMP) for patients admitted to the trauma service. Our goal was to decrease
opioid use while maintaining pain control and patient satisfaction.
Methods: A multidisciplinary team (trauma, orthopedics, anesthesiology, psychiatry,
pharmacy, and information technology) designed the PMP to standardize opioid
prescribing on the inpatient trauma service. The PMP provided a step wise approach to
pain control: Acetaminophen or ibuprofen for mild pain, 5 mg oxycodone/ 325
mg acetaminophen every 6 hours as needed for moderate to severe pain (maximum of 8
tablets/24 hour period), and tramadol (50 mg to 100 mg) every 6 hours as needed for
breakthrough pain. The opioid containing oral medications were staggered to allow
administration of oral pain medications every 3 hours as needed. Long acting oral
opioids such as extended release oxycodone or extended release morphine were added as
needed. We also encouraged use of adjunct pain medications (gabapentin,
pregabalin) that would address neuropathic pain. We performed a retrospective review to
compare the amount of opioid medication (converted to morphine milligram equivalents
–MME) given during their inpatient stay before and after the implementation of the
PMP . The study period covered 2 years with initiation of the PMP at the halfway point.
The Wilcoxon Rank Sum Test was used to compare means and chi-squared test was used
to compare categorical variables.
Results: Between January 1, 2015 and December 31, 2016, 3696 patients were managed
on the inpatient trauma service; 1670 in the before arm(B) and 2026 in the after(A) arm.
The average total opioid dose per patient was higher in the B as compared to the A group
(B: 700.67 MME, A: 558.11 MME, p<0.0001). The mean opioid dose per patient per day
showed a similar pattern (B: 95.63 MME, A: 82.71 MME, p<0.0001). Increased use of
acetaminophen (p<0.0001) and neuropathic pain agents (p<0.0001) was associated with
the decreased opioid use. The Press Ganey scores for pain control (B: 49%, A: 53%
p<0.07) and overall patient satisfaction (B: 94%, A: 91% p<0.33) did not worsen after
implementation of the protocol.
Conclusion: A PMP for the trauma service created by a multidisciplinary team was
associated with decreased opioid use while maintaining patient satisfaction and the
patient’s perception of pain control. We hope that this protocol may serve as a bridge to
decreased overall opioid use in this difficult population.
 Poster # 95
DECREASED OPIOID USE FOLLOWING IMPLEMENTATION OF A PILL-
BASED, MULTI-MODAL PAIN REGIMEN IN TRAUMA PATIENTS
Shuyan Wei MD, Brad Domonoske PharmD, Teri Ogg PharmD, Rondel Albarado* MD,
Jaideep Mehta MD, Charles Green Ph.D., Lillian S. Kao MD, John A. Harvin* MD,
University of Texas Health Science Center-Houston
Introduction: In 2013, our level-1 trauma center implemented an oral multi-modal pain
(MMP) regimen based on best available evidence to decrease opioid consumption. The
MMP regimen scheduled non-opioid medications as first-line agents, supplemented by
oral/intravenous opioids as needed. This study describes the pattern of opioid
administration to trauma patients following implementation of MMP. We hypothesized
that the MMP regimen resulted in decreased opioid consumption in trauma patients.
Methods: We retrospectively reviewed administrative data from 2013 - 2017. Oral and
intravenous opioids were converted to oral morphine milligram equivalents (MME)
based upon Center for Disease Control guidelines. The number of opioid vials delivered
to patient controlled analgesia
(PCA) devices was also collected. However, the quantity of MMEs used per PCA vial
could not be determined as unfinished vials were discarded.
Results: Total patients-days during the study period were as follows: 30,681 (2013),
31,777 (2014), 30,144 (2015), 32,736 (2016), and 30,898 (2017). Acetaminophen use
appeared constant (ranging from 75,814,115 to 93,954,729 mg/year). The number of
PCA vials distributed to trauma patients dropped from 2,908 in 2013 (8 vials per day) to
317 in 2017 (< 1 vial per day). Over the six year period, non-steroidal anti-inflammatory
drugs (NSAIDs) and gabapentinoid prescribing increased dramatically. The MME/
patient-day fell from 148 in 2013 to 90 in 2017, a 39% decrease ( Graph).
Conclusion: Implementation of a pill-based, MMP regimen reduced opioid use by 39%
in hospitalized trauma patients. Further research is warranted to better understand the
economic and social impact of a multi-modal approach to pain management in trauma
populations.
 Poster # 96
THE ROLE OF HIV IN POST-INJURY COAGULATION
Anamaria J. Robles MD, Lucy Z. Kornblith MD, Amanda S. Conroy RN, Mitchell J.
Cohen* MD, Rachael A. Callcut* MD, MSPH University of California, San Francisco
INTRODUCTION: HIV infection is known to produce a chronic hypercoagulable and
pro-inflammatory state; viral replication leads to decreases in several anti-coagulant
factors and increases in pro-coagulant factors. Although antiretroviral therapy (ART)
decreases replication, low-level inflammation and immune activation persist. However,
the impact of HIV on post-injury coagulation milieu is unknown.
METHODS: Data were collected on 1349 injured patients from 2005-2016;
thromboelastography, coagulation factor activity, and standard coagulation measures
were measured. Multiple regression analysis was performed to determine the independent
association of HIV on post-injury coagulation.
RESULTS: Thirty-nine (3%) HIV patients were identified. 18 (46%) were on ART, with
24 (69%) having history of ART treatment; the median CD4 count was 399 (227-536
cells/mm 3 ). HIV-infected patients trended towards being older (43 vs 37 years, p=0.051)
and had significantly lower BMI (24 vs 26 kg/m2 p=0.007), WBC (7.8 vs 9.8 103 /μL,
p=0.011), hemoglobin (13 vs 14 g/dL, p<0.001), and platelet counts (239 vs 269 103 /μL,
p=0.005). HIV patients were hypercoagulable by citrated rapid TEG (CRT) (alpha angle
77 vs 74° , p=0.001; K time 0.95 vs 1.4 sec, p=0.005) and had lower antithrombin
activity (77 vs 90%,
p=0.04 9). On
multivariate analysis, HIV
was independently associated
with a hypercoagulable state
including significantly
increased CRT-alpha angle
(mean +4.90°, p=0.021)
and lower antithrombin
activity (mean -17.64%, p=0.046).
CONCLUSION: The impact of HIV on post-injury coagulation is unknown and our
findings suggest that following injury HIV infection independently contributes to
laboratory evidence of hypercoagulability. Further investigations of this study population
may help elucidate the complex crosstalk between coagulation and inflammation
following injury.
 Poster # 97
THE IMPACT OF MARIJUANA LEGALIZATION ON RISK OF TRAUMATIC
INJURY
Christine Chung DO, Kristin Salottolo MPH, Robert Madayag MD, Allen Tanner II, MD,
David Bar-Or MD, Swedish Medical Center
Introduction: The medical legalization of marijuana has been shown to result in an
increased risk of injuries. In Colorado, marijuana was effectively legalized for commercial
sale on January 1, 2014, resulting in rapid proliferation of its availability. The objective of
this study was to determine the association between commercial marijuana legalization and
drug test results following traumatic injury.

Methods: This retrospective cohort study included all patients admitted with a traumatic
injury to two Colorado trauma centers between 1/1/2012-12/31/2015, two years before and
two years after legalization of marijuana in Colorado. Generalized linear models (GLM)
and Pearson chi-square tests were used to examine changes (pre/post and across eight six-
month periods) in the prevalence of urine drug screen (UDS) testing, a positive UDS for
marijuana (+THC [tetrahydrocannabinol]), a positive UDS for other drugs (+Drugs;
amphetamines, cocaine, opiates, benzodiazepene, barbiturates, or PCP), and a positive
blood alcohol content (+BAC, ≥ 80 mg/dl). The analyses were performed for all trauma
admissions and the subset that required a full trauma team activation.

Results: There were 14,345 admissions over the study period, including 2,939 trauma
activations. The rate of UDS testing did not change over time (p=0.66), and was greater in
activated patients than all admissions (25% vs. 11%). The prevalence of +THC was
borderline significantly higher after legalization of marijuana (table 1). The increasing rate
of +THC was significantly greater
post-legalization (p=0.02) in activated patients, whereas the rate of increase was similar
across time periods in the overall population (p=0.78). There was a significant decrease in
+Drugs findings post-vs. pre-legalization; however, the rate of change demonstrated
decreasing rate of
+Drugs pre-legalization and an increased rate of +Drugs post-legalization (p<0.001). There
was a significant decrease in +BAC post-legalization; however, this rate of decrease was
similar pre- and post-legalization. The characteristics of +THC patients were similar pre-
vs. post-legalization, except an increase in males (72% vs. 80%, p=0.04) and a decrease in
MVCs (54% vs. 44%, p=0.02). There were no other differences in demographics, injury
characteristics, or outcomes.

Conclusion: With the growing number of trauma patients testing positive for marijuana in
Colorado, these data suggest that commercial legalization was associated with an increased
rate of marijuana use with traumatic injury, but only for those requiring full trauma
activation. A larger study is underway to add additional years and to compare Colorado
and non-Colorado hospitals.
 Poster # 98
MENTAL HEALTH SERVICE CONSULTATION FOR PTSD SYMPTOM
REDUCTION AFTER INJURY: MORE IS BETTER
Robert G. Sise MBA,MD,MPH, Douglas F. Zatzick MD, Joan Russo Ph.D., Richard Y.
Calvo Ph.D., Michael J. Sise* MD, Ronald V. Maier* MD, University of Washington
Introduction: Between 20-40% of trauma patients report high levels of posttraumatic
stress disorder (PTSD) symptoms. Although mental health services have shown promise in
reducing PTSD symptoms, little is known regarding the impact of these services when
provided during the index trauma hospitalization. We hypothesized that increases in both
the diversity of services and the number of visits patients receive across all services are
associated with a decrease in PTSD symptom severity.
Methods: We conducted a retrospective cohort study of 207 patients who participated in a
randomized mental health intervention trial between 04/2006-09/2009 at an urban Level I
trauma center. The primary exposures were the type of mental health consultation service
provided to patients and the number of times patients were visited by each service as
documented in the patient medical record. Service types evaluated included social work,
addiction intervention, rehabilitation psychology, and consult-liaison psychiatry. The
primary outcome was a reduction in PTSD symptoms at follow-up compared with baseline
as assessed by the PTSD Checklist-Civilian Version (PCL-C). Multiple linear regression
was used to assess the association between types of mental health consultation services
received and the number of visits the services provided versus PCL-C score change.
Results: Patients were young (mean: 38.5 years), 52% male, had a mean ISS of 13.6, and
an average hospital length of stay of 9 days. Consult service utilization was 89% for social
work, 22% for addiction intervention, 17% for rehabilitation psychology, and 8% for
consult-liaison psychiatry. After multivariable adjustment, neither service type nor
diversity of services received was associated with PCL-C reductions. However, a higher
number of visits provided across all services was significantly associated with reductions
in PCL-C (0.3 point reduction per visit). This association remained significant even after
adjusting for covariates including the number of prior traumas.
Conclusion: An increased number of consultation visits across all services was
significantly associated with PTSD symptom reduction. Trauma centers should consider
this when developing PTSD symptom management guidelines. : An increased number of
consultation visits across all services was significantly associated with PTSD symptom
reduction. Trauma centers should consider this when developing PTSD symptom
management guidelines.
 Poster # 99
OUTCOME AND ECONOMICS OF FIREARM INJURY BY BODY REGION AND
THE FINANCIAL TOLL ON AN URBAN TRAUMA CENTER.
Keith R. Miller* MD, Matthew V. Benns* MD, Annabelle Pike MBA, Kim Denzik RN, MSN,
Wanda Bowen CAISS, Jon R. Chastain Amir Motameni MD, Lindsay Arnold MD, Matthew
Bozeman MD, Nicholas Nash MD, Glen Franklin* MD, Brian Harbrecht* MD, Jason W. Smith*
MD,Ph.D., University Of Louisville

Introduction:Firearm injuries result in significant societal cost burden and individual morbidity and
mortality. Outcomes and cost following firearm injury are intuitively associated with the location of
injury but limited data are available. Although charges and cost are commonly reported, there is a
paucity of data regarding actual hospital reimbursement.

Methods:Firearm injuries at a Level 1 trauma center from Jan 2012-November 2017 were examined
retrospectively. Demographic data and injury patterns were abstracted from the registry and charts.
Hospital cost was calculated from department specific cost-to-charge ratios based on the most
recently filed Medicare Cost Report. Financial costs (dollars, $) were standardized to 2017 value,
and univariate and multivariate analysis was performed. Values are expressed with +/- standard error
(SEM) and Standard Deviation (SD).

Results:During the study interval, 19,102 patients were admitted following trauma of which 1,430
were firearm injuries (7.5%). 1075 injuries (75 %) involved single GSWs to an isolated body region.
Demographic, cost, and outcome data are noted in Table 1. Overall, average total hospital cost of
treating all firearm injuries was $17,545 (SEM +/- $949; SD +/- $20410). Patients who survived
initial injury had significantly higher costs than those succumbing to injuries ($28,230 +/- 5260 vs
$6836 +/- 5011, p=0.001). Rank sum ANOVA identified GSW location (Head P<0.001; Abdomen
P<0.01, and Chest P<0.01) as predictors of increased cost, however ISS (p=0.506) and LOS
(p=0.167) did not predict total cost in regression modeling. GSW location significantly predicted
depression scores [b =-0.0000195, t(0.0001) = -6.261, p < .001] and total cost [b = 1.578, t(0.179) =
8.829, p <0.001]. Additionally, GSW location explained a proportion of variance in both variables
[R2=0.426, F=(3,283) 87.168, p < .001]. Overall cost of care for firearm injuries was $25.1 million.
Aggregated payments to the hospital were $22,253,182. Over the study period, the hospital lost
$2,846,818 ($474,470/ annually) to care for firearm injuries.

Conclusion:
In the setting of isolated body region firearm injuries, there are significant differences with regard to
survival and cost dependent upon location of injury. Overall, aggregate hospital payments did not
cover the cost of care. Given increasing prevalence, the cost for caring for firearm injury will soon
become prohibitive for urban trauma centers.
 Poster # 100
POST-OPERATIVE OPIOID PRESCRIBING IN EMERGENCY GENERAL
SURGERY – THE SURGEON’S ROLE IN REDUCING OPIOID EXPOSURE
Celina Nahanni Ph.D., Avery B. Nathens* MD,MPH,Ph.D., Sunnybrook Health Science
Centre
Introduction: Here we report post-operative narcotic administration in-hospital and
on-discharge for opioid naïve patients who underwent laparoscopic emergency surgery at
an academic health sciences center. The purpose of this study was to develop guidelines
for narcotic administration that would reduce exposure without compromising pain
management.

Methods: NSQIP data for 2015-2017 was used to identify patients (N=138 patients) who
were managed surgically for either acute appendicitis or cholecystitis. Medication
administration, pain scores and prescription information was abstracted from patient
charts and opioid doses were converted to oral-morphine-equivalents (OME).

Results:The total quantity of opioids administered in hospital was 12.2 OME in the
24-hrs following surgery; approximately one-third of patients did not require any opioids.
Non-narcotic adjuvant medications were administered to 67.4% of patients; all of these
included management with acetaminophen while 5.1% were also treated with NSAIDs.
Upon discharge, patients were prescribed an average total of 81.3 OME. All discharge
prescriptions included opioids and over half of were for opioids alone, the remainder
included acetaminophen. The average daily maximum prescribed was three-times that
which was required in hospital. Further, the amount prescribed at discharge did not
correlate with either the average in-hospital pain score (Pearson=0.05, p=0.71) or
in-hospital opioid-consumption (Pearson= -0.02, p=0.42).

Conclusion: Non-narcotic pain medication was not consistently provided as a first line
treatment and there was an underutilization of NSAIDs. Prescriptions were frequently for
narcotics alone and the high variability in the amount prescribed was not associated with
actual patient need. Based on the results of this study, we recommend a default pain
management plan that includes non-narcotic pharmacotherapy, including NSAIDs, as a
first line therapy. Further, we recommend a standardized prescription that includes
separately prescribed non-narcotic adjuvants and discharge instructions that educate
patients to reserve opioids for break-through pain.
 Poster # 101
IMPACT OF PATIENT FRAILTY ON MORBIDITY AND MORTALITY AFTER COMMON
EMERGENCY GENERAL SURGERY OPERATIONS
Patrick B. Murphy MD,MPH, MSc, Stephanie A. Savage* MD, MS, Ben L. Zarzaur* MD,MPH,
Indiana Univesity School of Medicine
Introduction: Frailty has been increasingly recognized as a modifiable risk factor prior to elective
general surgery. There is limited evidence regarding the association of frailty with peri-operative
outcomes after specific emergency general surgery procedures. Our objective was to determine the
association between patient frailty and 30-day morbidity, mortality and discharge destination in adult
patients undergoing emergency general surgery.

Methods: A retrospective cohort study of 57 173 patients older than 40 years of age from 2010-2014
American College of Surgeons National Surgical Quality Improvement Program (NSQIP) who
underwent appendectomy, cholecystectomy, partial large bowel resection, total large bowel
resection, small bowel resection or lysis of adhesions on an emergent basis. The modified frailty
index (mFI) using a composite of 11 NSQIP variables was used to stratify patients into low (≤0.18),
intermediate (0.18-0.35) and high (≥0.36) frailty states. Multi-variable regression modeling included
age, sex, mFI, tobacco use, renal failure, steroid use, pre-operative sepsis and outside transfer status.

Results: A total of 57 173 patients underwent appendectomy (n = 26 067), cholecystectomy (n = 8

138), large bowel resection (n = 12 107), small bowel resection (n = 6 503) or lysis of adhesions (n
= 4 358) on an emergent basis. Of these patients, 25.0% experienced a complication, 3.2% died in
hospital and 5.1% died within 30 days. The majority of the population (52.3%) had low frailty and
3.6% were identified as highly frail. On univariate analysis frailty was related to complication rate
(low mFI, 17.5%, intermediate, 31.5% and high, 55.5% complication rate) and inversely related to
discharge destination (70.5%, 62.3% and 29.7% discharged home respectively). On multivariable
regression, regardless of procedure, intermediate and high mFI were independent predictors of any
complication, serious complication, death within 30-days and discharge to a destination other than
home, Figure 1.

Conclusion: Frailty is associated with worse outcomes after common emergency surgeries
independent of age, co-morbidities and pre-operative sepsis. Assessment of frailty prior to
emergency surgery can inform patients and surgeons on expected post-operative outcomes, including
discharge disposition, and may impact decision making to proceed with intervention.
 Poster # 102
READMISSION AFTER EMERGENCY GENERAL SURGERY
Katherine Kelley MD, Jay Collins* MD, LD Britt* MD, DaShaunda D. Hilliard MPH,
Rebecca Britt MD, Eastern Virginia Medical Center
Introduction: Readmission rates are an important metric both because they enable an
evaluation of care and because they affect Medicare funding. Patients undergoing
emergency general surgery procedures are an important and not fully studied subset of
surgical patients. This study evaluates factors contributing to readmission after
emergency general surgery.
Methods: The Virginia Health Information database was used to identify patients that
had undergone one of the seven most common emergency general surgery procedures in
the state of Virginia from January 2011-June 2016. Records were excluded if there was
insufficient data about insurance or readmission status, if patients were already readmitted
or had been transferred, were <16 years of age, were admitted for trauma, or were
military, research, jail, foreign or hospice patients. Demographic, admission, discharge
and readmission data were compiled. Comorbidity information was collected for patients
from Oct 2015-June 2016. Bivariate and multivariate analyses were performed assessing
for both 30 and 90 day readmission.
Results: There were 121,223 records that met initial inclusion criteria. After exclusions
there were 83,266 records. The number of readmissions in 30 days was 7995 (9.6%) and
in 90 days was 12,329 (14.8%). In multivariate analysis the factors found to be significant
(p<0.05) in contributing to 30 day readmission were government assistance vs private
insurance, longer length of stay, emergent admission (compared to urgent or elective),
discharge to rehab, skilled nursing facility, or intermediate medical care facility or with
home health, congestive heart failure, liver disease, metastatic cancer, rheumatoid
arthritis, coagulopathy, weight loss and anemia. For 90 day readmission the same factors
were all significant with the addition of the following significant factors: transfer to
psychiatric facility, renal failure, solid tumor without metastasis, weight loss and alcohol
abuse.
Conclusion: This study has identified several factors that contribute to readmission after
emergency general surgery. Inclusion of both 30 and 90 day readmission enables
assessment of late patient morbidity that is otherwise missed by only assessing for 30 day
readmission. By identifying these factors interventions can be directed towards those
patients at greatest risk for readmission.
 Poster # 103
WHICH HOSPITAL METRIC SHOULD WE TRUST FOR EMERGENT
SURGERIES: MORTALITY OR READMISSIONS?
Ambar Mehta MPH, Nicole Lunardi MSPH, David T. Efron* MD, Alistair Kent
MD,MPH, Raymond Fang* MD, Anuradha R. Kar MD, Elliott R. Haut* MD,Ph.D.,
Joseph V. Sakran MD,MPH, MPA Johns Hopkins School of Medicine
Introduction: The Centers of Medicare and Medicaid Services publicly reports hospital
mortality and readmission rates for elective services. However, little data exists regarding
the efficacy of these quality metrics for emergent surgeries. The purpose of this study
was to identify any correlation between hospital mortality and readmission rates from
emergent surgeries.

Methods: Using the 2005-2015 Maryland Health Services Cost Review Commission
(HSCRC) database, we identified patients undergoing one of 12 emergency general
surgeries (EGS), as established by AAST criteria. The HSCRC database captures all
readmissions, both to index and non-index hospitals. Hospitals performing fewer than
100 EGS procedures annually were excluded. After dividing hospitals into quartiles by
their risk-adjusted in-hospital mortality rates, we used a multivariable logistic regression
to compare 30-day readmission rates between the quartiles. We also calculated the
association between each hospital’s risk-adjusted in-hospital mortality and 30-day
readmission rates and then assessed whether hospital rankings differed when using
in-hospital mortality rates versus 30-day readmission rates. All analyses adjusted for
patient factors, EGS procedures, surgeon volume, and hospital clustering.

Results: We identified 169,135 EGS operations performed at 41 hospitals. The overall

in-hospital mortality rate was 2.1% and 30-day readmission rate was 10.0%. After
risk-adjustment, the lowest mortality quartile of hospitals did not also have a statistically
lower rate of 30-day readmissions relative to the highest mortality quartile (8.2% vs
11.4%, aOR 0.83 [95%-CI 0.55-1.26], P=0.38). Similarly, there was no association
(r-coefficient=0.01) between each hospital’s mortality rate and its readmission rate
(Figure 1). There also existed significant variation among hospitals when ranking was
performed by either in-hospital mortality rates or 30-day readmission rates (Figure 2).
Only 3 hospitals (7.3%) were ranked in the top ten by both mortality and readmission rate.

Conclusion: Risk-adjusted in-hospital mortality and 30-day readmission rates for

individual hospitals did not correlate for EGS procedures. These findings highlight the
need to develop a standardized set of quality metrics that universally recognize the same
high-performing hospitals and that distinct performance improvement initiatives will
be required to address each of these two critical clinical outcomes.
 Poster # 104
MOBILE REDCAP SYSTEM FOR DOCUMENTATION OF AAST ACUTE
CARE SURGERY FELLOWSHIP SUPERVISION
Oliver L. Gunter* MD,MPH, Oscar D. Guillamondegui* MD,MPH, Raeanna C. Adams*
MD, Addison K. May* MD, Bradley M. Dennis* MD, Vanderbilt University Medical
Center
Introduction: A graded increase in independence is a vital component of AAST Acute
Care Surgery (ACS) fellowship training and mandates the ability to appropriately
document trainee supervision and competence. There is currently no standard for
documenting supervision of ACS fellows. The objectives of this study were (1) to
demonstrate a mobile app system used for document a supervision of ACS fellows, (2) to
demonstrate a reproducible assessment tool for proctoring and supervision, and (3) to
report initial results of our proctoring system.
Methods: All AAST ACS fellows in our program are proctored, instructor-level faculty.
Supervision was defined as: type 1 direct face-to-face, type 2a immediately available
in-house, type 2b available after notification via phone with remote electronic medical
record access, and type 3 retrospective review. Our proctoring system provides type 1 or
2a supervision for all trauma resuscitations and trauma/EGS operative cases during an
initial period, defining our focused physician practice evaluation (fPPE) system. Using
research electronic data capture system (REDCap) a database was created to document
proctoring in 6/2016. Data collected were patient identification number and clinical
summary, ACS fellow, proctoring faculty, service (trauma vs emergency general surgery
[EGS]) and type of supervision. The database was updated in 2017 for the next cycle of
trainees to include qualitative fields using a Zwisch scale to assess level of autonomy,
and operative vs nonoperative data. fPPE data were collated and reviewed by a clinical
competency committee after completion of the proctoring period. As fellows are deemed
competent, they are graduated to an ongoing physician practice evaluation system (oPPE)
that allows type 2b and 3 supervision at faculty discretion. All data were collected by 11
supervising faculty using mobile devices on the REDCap mobile app and uploaded to the
database. Data were analyzed using REDCap reporting tools. An online search was
performed to identify REDCap partners and approved AAST ACS fellowships.
Results: In 2016 we recorded a total of 203 proctoring events during the fPPE period.
The majority of supervision was type 1 or 2a (98.5%). Trauma comprised 68% of
events; EGS made up 32%. After updating the database in 2017, we recorded a total of
176 proctoring events. Type 1 or 2a supervision comprised 97% of proctoring events.
Trauma events were 62% compared to EGS 38%. 51% of the proctoring events were
operations; the remaining 49% were trauma resuscitations. Guidance provided was
supervision only in 89% of cases vs 11% requiring some degree of faculty input. Fellows'
performance was graded as average in 62% of cases and above average in 38% with one
critical deficiency. Case complexity was: Easiest (6, 3.4%), Average (137, 78.3%),
Hardest (32, 18.3%).

Conclusion: A REDCap mobile data collection tool is well-suited for documentation of

ACS fellows' proctoring and was able to be utilized by all of our ACS faculty to record
supervision. A combination of clinical and objective data are useful to determine ACS
Fellows' autonomy as a basis for promotion from fPPE to oPPE. This tool helps target
remediation and education by identifying below average performance in individual
clinical cases. While most proctoring activities were supervision only, 11% required
faculty input indicating the benefit of faculty involvement in our proctoring system.
 Poster # 105
EFFECT OF TRANSFER STATUS ON OUTCOMES OF EMERGENCY
GENERAL SURGERY PATIENTS
Jennifer L. Philip MD, Xing Wang Ph.D., Sara Fernandes-Taylor Ph.D., Jessica
Schumacher Ph.D., Megan C. Saucke MS, Jeffery Havlena MS, Caprice C. Greenberg
MD,MPH, Heena P. Santry* MD, Angela M. Ingraham MD, MS University Of
Wisconsin - Madison
Introduction: Transferred emergency general surgery (EGS) patients are a vulnerable,
high acuity population. Outcomes among transferred (TRAN) vs directly admitted (DA)
patients have primarily been studied using single institution or hospital system data
limiting generalizability. We evaluated outcomes among these EGS patients using a large
national dataset.
Methods: We identified patients
aged ≥18 years with an American
Association for the Surgery of
Trauma-defined EGS diagnosis in
the 2008-2013 Nationwide
Inpatient Sample (NIS).
Multivariable regression analyses
determined if transfer status
independently predicted in-hospital
mortality (by logistic regression),
morbidity (number of
complications; by Poisson
regression), cost (by log-linear
regression), and length of stay
(LOS; by log-linear regression)
accounting for the NIS sampling
design.
Results: We identified 434,186
TRAN and 14,513,806 DA
patients. On univariate analysis,
TRAN patients were more likely to
have a higher Charlson
comorbidity index, Medicare
insurance, and a lower median household income compared to DA patients (p<0.0001).
Mortality was significantly higher in the TRAN vs DA groups (4.5% vs 1.7%; p<0.0001).
Morbidity (presence of any complication) was also higher among TRAN patients (41.8%
vs 29.0%; p<0.0001). Morbidity among TRAN patients was primarily due to urinary-
(15.4%), gastrointestinal- (14.7%), and pulmonary-related (14.0%) complications.
Median LOS was 4.3 days for TRAN vs 3.0 days for DA (p<0.0001) patients. Median
cost was higher for TRAN patients ($8,935 vs $7,167; p<0.0001). Regression analyses
determined that TRAN patients after adjustment had significantly higher mortality,
morbidity, and cost as well as longer length of stay. (Table)
Conclusions: Interhospital transfer of EGS patients is associated with increased
mortality, morbidity, cost, and LOS. As the EGS population grows and ages while the
EGS workforce declines, identifying risk factors of worse outcomes among transferred
EGS patients can inform the design of specific performance improvement initiatives.
 Poster # 106
ELEVATED BODY MASS INDEX AND ACUTE PULMONARY EMBOLISM
FOLLOWING EMERGENCY GENERAL SURGERY: AN ACS-NSQIP
DATABASE ANALYSIS
Maranda Pahlkotter MD, Jason D. Sciarretta* MD, Sharon Holmes MD, Keely Muertos
MPH, John M. Davis* MD, University Of South Carolina/Grand Strand Medical Center
Introduction: Obesity represents a known risk factor for venous thromboembolism (VTE)
following elective surgery and is well reported among surgical specialities. VTE
pharmacologic agents at standard dosing can result in high VTE rates in these subset of
patients. Following a review of the American College of Surgeons National Surgery
Quality Initiative Program (ACS-NSQIP) database nearly a decade ago, a heightened
awareness by surgeons demonstrated a reduction in VTE. The current efficacy of VTE
prophylaxis in emergency general surgery is unknown. We hypothesize that increasing
body mass index (BMI) observed in emergency general surgery (ES) is associated with
increased risk of acute pulmonary embolism (PE) and death.
Methods: ACS-NSQIP database was queried (January 2015-December 2015) for all
patients undergoing ES. The incidence of PE was reviewed for 5 BMI (kg/m2) groups
greater than 20kg/m2. Univariate comparisons was completed between normal weight
(NW) (18.5-24.9kg/m2), overweight (OW) (BMI 25-29.9 kg/m2), obesity (O) (30-39.9 kg/
m2), morbidly obese (MO) (BMI 40-50kg/m2), super obese (SO) (>50kg/m2).
Demographics, ES type, length of surgery, length of stay (LOS), ASA scoring, deep vein
thrombosis (DVT), and mortality reviewed. All elective surgery cases and BMI < 18.5kg/
m2 were excluded.
Results: 36,565 patients identified undergoing ES at >800 participating ACS-NSQIP
hospitals. Of those, 494 (1.3%) were diagnosed with a PE. Mean age was 65.9 ± 14.7
years, (range, 18-90+ years) 49.2% male, and a mean BMI of 29.5± 7.4 kg/m2 (range, 15.6-
57.6 kg/m2). Population was predominately group O (30.6%). The presence of a PE was
directly related to patient’s BMI (p=0.015). When compared to NW, MO (p=0.010) and SO
(p=0.023) groups were more likely to experience a PE following ES. Mean postoperative
day of PE diagnosis was 11.2 ± 7.6 days, an ASA of 3.2 ± 0.8, and a mean operative time
of 121.8 ± 72.6 min. Overall mean LOS was 17.6 ± 13.2 days. Patient groups O (p<0.001 )
and MO (p<0.001 ) had longer operative times compared to NW patients. Length of
operation was found statistically significant. Perioperative PE following emergent
appendectomy (p=0.005) and other abdominal surgery (p=0.004) were related to BMI in O
and SO groups. 54 PE (10.9%) deaths (BMI 28.1 ± 8.6 kg/m2) occurred, 14 (25.9%)
patients with concomitant DVT and PE. PE mortality was directly related to patient’s BMI
(p < 0.001), with SO group being 7 times more likely to expire from a PE after ES.
Conclusion: These findings suggest that an increasing BMI observed in ES amplifies the
PE risk in these subset of patients. Surgeon education and strict perioperative VTE
prophylaxis guideline adherence with ES can potentially decrease VTE events. Further
prospective studies are needed to reiterate the improtance of a weight-based prophylactic
dosing regimen for hospitalized obese emergency surgical patients. A multi-institutional,
randomized controlled trial is necessary to conclusively determine if a strandardized
weight-based prophylatic dosing regimen will improve the incidence of PE events.
 Poster # 107
RECURRING EMERGENCY GENERAL SURGERY: CHARACTERIZING A
VULNERABLE POPULATION
Joseph V. Sakran MD,MPH, MPA, Nicole Lunardi MSPH, Ambar Mehta MPH, Joseph
K. Canner MHS, Mohammad Hamidi MD, Faisal Jehan MD, Bellal A. Joseph* MD,
Avery B. Nathens* MD,MPH,Ph.D., David T. Efron* MD, Johns Hopkins School of
Medicine
Introduction: Limited data exists for long-term outcomes after emergency general
surgeries (EGS) in the United States. The purpose of this study was to characterize the
incidence of inpatient readmissions within 6-months and subsequent operations after an
initial EGS procedure.
Methods: Adult patients (≥18 years old) undergoing one of seven common EGS
procedures (appendectomies, cholecystectomies, small bowel resections, large bowel
resections, control of GI ulcers and bleeding, peritoneal adhesiolysis, and exploratory
laparotomies) were identified in the 2010-2015 National Readmissions Database. Patients
who died during their index hospitalization were excluded. The rates of all-cause
inpatient readmission and of undergoing a second EGS procedure within 6-months were
calculated. Risk-factors of undergoing a second EGS procedure were identified using a
multivariable logistic regression model. All analyses adjusted for patient factors, clinical
factors and hospital clustering.
Results: There were 1,343,166 patients who underwent one of seven EGS procedures.
Among patients with available postoperative data, 94,577 (14.9%) had an inpatient
readmission within 6-months, occurring at a median of 41 days (IQR: 16-95 days).
One-in-eight (16.3%) readmissions occurred at a different hospital than the index
hospitalization. Among the 94,577 patients who had an inpatient readmission, 9,936
(10.5%) underwent a second EGS procedure, the most common of which included control
of GI ulcer and hemorrhage (46.3%) and peritoneal adhesiolysis (18.7%) (Table). After
adjustment, the following were associated with undergoing a second EGS procedure:
number of comorbidities (adjusted odds ratio [aOR] 1.07 [95%-CI 1.06-1.09]), private
center relative to a governmental hospital (aOR 1.11 [1.02-1.23]), discharge to home
health care (aOR 1.30 [1.22-1.39]), and initial EGS procedures of control of GI ulcer and
bleeding (aOR 16.8 [15.5-18.2]), laparotomy (aOR 11.6 [10.4-13.0]), and peritoneal
adhesiolysis (aOR 6.8 [6.3-7.4]).

Conclusion: Nearly 15% of patients undergoing an EGS procedure have an inpatient

readmission within 6-months. One-in-ten readmitted patients underwent a second EGS
procedure. As half of all second EGS procedures occurred within six weeks of the index
procedure, carefully monitoring patients for at least two months postoperatively may help
surgeons preemptively identify patients at risk for subsequent procedures.
 Poster # 108
COMPARISON OF SCORING SYSTEMS (LRINEC, AAST IMAGING GRADE,
FGSI) TO DIAGNOSE NECROTIZING SOFT TISSUE INFECTIONS (NSTI) AND
THEIR ASSOCIATION WITH CLINICAL OUTCOMES
Tala F. Kana'an MBBS, Mohamed D. Ray-Zack MBBS, Matthew C. Hernandez MD,
Pooja N. Reddy MS, Martin D. Zielinski* MD, Mayo Clinic - Rochester
Introduction: Efforts to improve management of NSTI depend on early diagnosis and
characterization of its severity. This study aims to compare the diagnostic sensitivity of
pre-operative scoring systems, including the Laboratory Risk Indicator for Necrotizing
Fasciitis (LRINEC), the American Association for the Surgery of Trauma (AAST) imaging
grade, and Fournier's Gangrene Severity Index (FGSI) and their ability to associate with
key clinical outcomes.
Methods: A single institution review from 2004-2017 was performed. We included adult
patients (≥18 years) with AAST operative grade (IV, V) disease severity. Baseline
demographics, Charlson comorbidity index, and clinical outcomes (30-day mortality,
intensive care admission (ICU), Clavien-Dindo ≥3 complication severity) were analyzed.
Pairwise comparison of each scoring system was performed for selected outcomes and
quantified using area under curve (AUC) with 95% confidence intervals (CI).
Results: In this study, 114 patients were diagnosed with NSTI with a mean age (±SD) of
57 (±14) years, 68% male. With respect to diagnostic sensitivity, AAST imaging grade was
most accurate (67%) compared to FGSI (62%) and LRINEC (41%). In patients with NSTI,
FGSI demonstrated improved accuracy compared to the AAST imaging grade to discern
which patients required ICU admission (AUC 0.68 versus 0.52; p= 0.04) as well as 30-day
mortality (0.74 vs 0.55; p= 0.03). All systems had comparable accuracy for other key
outcomes studied and no significant differences using pairwise comparison, Table.
Conclusion: Pre-operative scoring systems provide valuable information to evaluate
disease severity and outcomes. The AAST imaging grade was the most sensitive for NSTI
diagnosis; however, FGSI was more accurate for ICU admission and 30-day mortality. All
scoring systems demonstrated limited ability to associate with other outcomes in patients
with NTSI.
 Poster # 109
ASSOCIATION BETWEEN EMERGENCY GENERAL SURGERY VOLUME
AND OUTCOMES IN MILITARY HOSPITALS
Muhammad A. Chaudhary MD, Carlos J. Rodriguez DO,MBA, Nicki Kwon MS, Eric
Goralnick MD, MS, Matthew J. Bradley MD, Peter Learn MD, Adil H. Haider*
MD,MPH, Brigham And Women's Hospital

Introduction: Low Emergency General Surgery (EGS) hospital volume is associated with
worse patient outcomes in the civilian setting. The military maintains treatment facilities
in remote locations to provide healthcare access to service personnel and their families.
Our objective was to determine if low volume military treatment facilities (MTF) are
associated with worse EGS outcomes, compared to high volume MTFs.

Methods: Analysis of the TRICARE database from 2006 to 2014. TRICARE provides
healthcare coverage to 9.5 million military personnel and families. Patients were
identified using the AAST defined ICD-9 CM codes for EGS and ages 18-64 years. MTFs
were divided into quartiles based on yearly volume. Outcomes of interest were 30-day
mortality, complications and readmissions. Logistic regression models adjusted for age,
sex, race, socio-economic status, geographic region, EGS condition category, surgical
intervention and comorbid conditions were used to determine the effect of volume on
outcomes.

Results: A total of 106,915 patients were treated for an EGS condition at 79 MTFs during
the study period. The overall mortality rate was 0.21%, complication rate was 8.55% and
readmissions rate was 4.45%. Highest volume quartile MTFs treated 61.1% of the
patients while lowest volume quartile MTFs treated only 1.1%. In risk adjusted analysis
lowest volume quartile MTFs were not associated with mortality (OR: 2.02, CI:
0.45-9.06) or readmissions (OR: 0.77, CI: 0.54-1.11), while they were associated with
lower odds of complications (OR: 0.76, CI: 0.59-0.98), compared to the highest volume
quartile.

Conclusion: EGS patients treated at low volume MTFs did not have worse patient
outcomes when compared to high volume MTFs. Remote location MTFs provide
adequate care to service personnel and their dependents for acute conditions and triage
complex cases appropriately.
 Poster # 110
LAPAROSCOPIC VERSUS OPEN ADHESIOLYSIS FOR ADHESIVE SMALL
BOWEL OBSTRUCTION: A 12-YEAR SINGLE CENTER RETROSPECTIVE
STUDY
Jacopo Guerrini MD, Guido Costa MD, Laura Samà MD, Simona Mei MD, Martina
Ceolin MD, Alan Biloslavo MD, Mauro Zago* MD, Daniela Zugna BS,Ph.D., Hayato
Kurihara MD, Trauma And Acute Care Surgery - Humanitas Clinical And Research
Center
Introduction: Laparoscopic adhesiolysis has become a widely accepted technique for
treating adhesive small bowel obstruction (ASBO). Aim of this study is to evaluate its
efficacy and safety.
Methods: Patients undergoing surgery for ASBO between 2005 and 2017 were included
in this study, in presence of a preoperative CT scan and a confirmed intraoperative
diagnosis of ASBO. The outcomes were postoperative length of stay (LOS), overall
complication rate, operative time. In univariate analysis, Kaplan-Meier estimator and
log-rank test were used to compare the outcomes of interest between patients treated
laparoscopically vs. open surgery. A multivariable Cox regression model was carried out.
CT scans of patients with ASBO caused by either surgically confirmed single band or
matted adhesion were analyzed. CT findings were compared to develop a predictive
model based on logistic regression to estimate the risk of ASBO caused by a single band
adhesion. The predictive ability of the model was quantified by ROC curve.
Results: 116 patients were included in the study (males 53.5%, median age 68 ys). 68
patients (54.3%) were approached laparoscopically, with a conversion rate of 44%, which
increased to 61.9% in case of matted adhesion ASBO, compared to 35.7% in single band
ASBO (p=0.05). Two skilled surgeons preferred laparoscopic approach in 85% of cases,
with an overall conversion rate of 30%, which decreased to 7% when considered only
single band ASBO. LOS and operative time were significantly lower in laparoscopic
group, without evident differences in terms of peritoneal tears, iatrogenic perforations and
postoperative complications. Patients treated traditionally had a triplicated risk of being
discharged later than those successfully treated laparoscopically (HR=3.43, 95% CI:
2.07-5.69). Intraoperative findings demonstrated single band ASBO in 65.5% of cases.
By multivariable analysis, risk of single band ASBO was positively associated with two
CT findings: presence of a complete obstruction (HR=4.14, 95% CI: 1.43-11.93) and “fat
notch” sign (HR=7.40, 95% CI: 1.64-33.28). Using 0.5 as cut-point probability of single
band for the predictive model, the sensibility was 85.5% and the specificity of 70.0%, the
positive and negative predictive values were 84.4% and 71.8% respectively, the area the
ROC curve was 0.86.
Concusion: Laparoscopic adhesiolysis is a safe and effective technique, associated with
shorter LOS and characterized by lower conversion rate when performed by skilled
surgeons for single band adhesion ASBO. Analysis of CT findings becomes extremely
helpful by predicting whether ASBO is caused by single band or matted adhesion.
 Poster # 111
THE IMPACT OF PRIOR LAPAROTOMY AND INTRA-ABDOMINAL
ADHESIONS ON BOWEL AND MESENTERIC INJURY FOLLOWING BLUNT
ABDOMINAL TRAUMA
Tyler J. Loftus MD, Megan L. Morrow MD, Lawrence Lottenberg* MD, Martin D.
Rosenthal MD, Chasen A. Croft* MD, R. Stephen Smith* MD, Frederick A. Moore*
MD, Scott C. Brakenridge* MD, MSCS, Philip A. Efron* MD, Alicia M. Mohr* MD,
University of Florida - Gainesville
Introduction:Identifying patients with bowel and mesenteric injuries following blunt
abdominal trauma is hindered by the suboptimal accuracy of initial physical exam and CT
scan findings. We hypothesized that patients with intra-abdominal adhesions from prior
laparotomy would be subjected to visceral sheering forces and increased risk for bowel
and mesenteric injury following blunt abdominal trauma.

Methods:We performed a multicenter retrospective cohort analysis of 267 consecutive

adult trauma patients who underwent operative exploration following moderate-critical
(abdominal injury score 2-5) blunt abdominal trauma, comparing patients with prior
laparotomy (n=31) to patients with no prior laparotomy (n=236). Multivariable
regression was performed to identify predictors of bowel or mesenteric injury.

Results:There were no significant differences between groups for injury severity scores
or preoperative CT scan findings. The prior laparotomy cohort had greater incidence of
full thickness bowel injury (26% vs. 9%, p=0.010) and mesenteric injury (61% vs. 31%,
p=0.001). Considering all patients with bowel or mesenteric injuries, the no prior
laparotomy group had a greater proportion of injuries occurring at the ligament of Treitz
or ileocecal region (52% vs. 25%, p=0.003). On multivariable regression, prior
laparotomy was an independent predictor of bowel or mesenteric injury (OR 5.1, 95% CI
1.6-16.8) along with history of prior intra-abdominal inflammation and CT evidence of
free fluid without solid organ injury (model AUC: 0.81, 95% CI 0.74-0.88).

Conclusion:Patients with a prior laparotomy are at increased risk for bowel and
mesenteric injury following blunt abdominal trauma. The distribution of bowel and
mesenteric injuries among patients with no prior laparotomy favors embryologic
transition points tethering free intraperitoneal structures to the retroperitoneum.
 Poster # 112
VARIABILITY IN MANAGEMENT OF BLUNT SPLENIC INJURY AT LEVEL 1
TRAUMA CENTERS
Elan Jeremitsky MD, Andrew R. Doben* MD, Ronald I. Gross* MD, Baystate Medical
Center
Introduction: Nonoperative management (NOM) for blunt splenic injury (BSI) is
common in the adult injured patient. Nationally, the incidence of splenectomy for BSI is
around 20% and there is no standardized protocol for the management of BSI. There is a
high discordance in the incidence of splenectomy (15-35%) regardless of grade at various
institutions. Our hypothesis is that certain institutions more likely perform splenectomies
than others without a concordant increase in the grade of BSI or overall injury severity
score (ISS).
Methods: National Trauma Data Bank was evaluated for the years 2012-2014 with
respect to BSI. Centers with more than 212 admissions for BSI were used for the study,
which represented the upper tertile of all facilities. Facilities were then assigned to be
either LOW or HIGH with respect to their overall splenectomy incidence by the median
cut point of 21.3%. Univariant analysis was performed to evaluate for differences
between these facilities.
Results: The incidence of splenectomy was 21.3% (3,941 with splenectomy out of
18,527 admissions with BSI). Splenectomy at LOW vs HIGH facilities is 15.4% vs
27.4%. ISS of LOW was significantly greater than HIGH, 23.8 + 13.7 vs 22.7 + 13.8
p<0.001. Mean age (39.7 + 18.1 vs 39.9 + 17.9 p=0.41) and the incidence of angiography
(7.6% vs 7.9% p=0.45) were similar between the facilities. Table 1 demonstrates the
incidence of splenectomy by grade.

Conclusion: There is a higher incidence of splenectomy, not driven by ISS or age, for
BSI occurring in some institutions. The use of angiography and Grade of BSI does not
explain the discrepancy of operative intervention between the two groups. There appears
to be an institutional preference for performance of splenectomy for BSI. A national
protocol for BSI is needed to determine the best practice or guideline of NOM for BSI.
 Poster # 113
COLON AND SEVERE LIVER INJURIES PREDICT ABDOMINAL
COMPLICATIONS AFTER DAMAGE CONTROL LAPAROTOMY FOR
GUNSHOT WOUNDS
John F. Tierney MD, John C. Kubasiak MD, Devan J. Schlund MD, Charles Fredericks
MD, Jennifer Poirier Ph.D., James Boron MD, Thomas Messer MD, Andrew Dennis DO,
Frederic Starr MD, Kimberly Joseph* MD, Faran Bokhari* MD, Matt Kaminsky MD,
Cook County Hospital
Introduction: Damage control laparotomy (DCL) has improved mortality in unstable
trauma patients undergoing laparotomy, but an open abdomen is associated with
considerable morbidity. Previous studies of open abdomen complications have been
dominated by patients with blunt injuries. It is unclear whether these studies apply to
patients who suffer penetrating trauma. We therefore examined if rates of open
abdomen-associated complications differ by mechanism of injury, and identified risk
factors for complications after DCL in patients who suffered gunshot wounds (GSW).
Methods: Patients who underwent DCL between May 2015 and December 2017 were
identified from a prospectively-compiled trauma database. Demographics, initial
physiologic parameters, injury patterns, and use of intraabdominal packing were noted.
Severe liver injuries were defined as grade IV or V injuries or injuries that required
arterial embolization. Variables of interest related to abdominal complications included:
superficial wound infection, dehiscence, intraabdominal abscess, anastomotic leak, and
enteric fistula. Our primary aim was to assess whether mechanism of injury is associated
with the development of any of these complications. Our secondary aim was to assess
rates of each type of abdominal complication as well as the need for re-exploration after
fascial closure or for percutaneous drain placement, and intensive care unit (ICU) and
hospital length of stay (LOS). Descriptive statistics, Fisher exact tests, Mann Whitney U
tests, and Kruskal-Wallis tests were performed when appropriate.
Results: A total of 112 patients underwent DCL. Of those, 93 patients (83%) were male,
with a median age of 29 ± 10 years. 91 patients (81%) sustained GSW. 59% of GSW
patients (54 of 91) developed abdominal complications, compared to 29% of patients (6
of 21) injured by another mechanism (p = 0.01). Among GSW patients, the rate of
abdominal complications was increased in patients with colon (OR: 2.92, p = 0.02) and
severe liver injuries (OR: 3.09, p = 0.03). Patients with colon injuries were more likely to
develop wound dehiscence (OR: 13.4, p < 0.01) and require re-exploration after fascial
closure (OR: 7.34, p = 0.01). Patients with severe liver injuries were more likely to
develop intraabdominal abscesses (OR: 3.01, p = 0.03) and require percutaneous drainage
(OR: 3.75, p = 0.01), and those who underwent liver embolization were more likely to
have a prolonged hospital LOS (median 35 days vs 21 days, p = 0.04).
Conclusions: GSW patients are more likely than other trauma patients to develop
abdominal complications after damage control laparotomy. Among GSW patients, colon
injuries and severe liver injuries are associated with an increased risk of abdominal
complications after damage control laparotomy, despite adherence to antibiotic
prophylaxis. Further investigation into optimal strategies to prevent these complications
in high-risk patients is required.
 Poster # 114
ANALYSIS OF OVER 2 DECADES OF COLON INJURIES IDENTIFIES
OPTIMAL METHOD OF DIVERSION: DOES AN END JUSTIFY THE MEANS?
John P. Sharpe MD, MS, Nathan R. Manley MD,MPH, Mark S. Iltis MD, Richard H.
Lewis MD, Timothy C. Fabian* MD, Martin A. Croce* MD, Louis J. Magnotti* MD,
University of Tennessee Health Science Center - Memphis
Introduction: Conflicting evidence exists regarding the definitive management of
destructive colon injuries. While some advocate resection plus anastomosis for the
majority of patients, others employ the routine use of a diverting ostomy in select cases.
In fact, although diversion with an end ostomy can theoretically decrease initial
complications, it mandates a more extensive reversal procedure. Conversely, anastomosis
with proximal loop ostomy diversion, while simplifying the reversal, increases the
number of suture lines and potential initial morbidity. Nevertheless, for those purporting
diversion, there is little data comparing end ostomy to anastomosis plus proximal
diversion. Thus, the purpose of this study was to evaluate the impact of diversion
technique on morbidity and mortality in patients with destructive colon injuries.
Methods: Consecutive patients with destructive colon injuries managed with diversion
over a 21-year period were stratified by age, gender, severity of shock and injury,
operative management, and timing of reversal. Deaths within 24 hours and patients with
rectal injuries were excluded. Outcomes, including ostomy-related complications
(obstruction, ischemia, readmission) and reversal-related complications (obstruction,
abscess, suture line failure, fascial dehiscence), were compared between patients managed
with a loop ostomy and those managed with an end ostomy.
Results: 115 patients were identified: 80 received an end ostomy and 35 received a loop
ostomy. 47 patients required a planned ventral hernia (PVH). Ostomy-related
complications occurred in 22 patients (19%) and 11 patients suffered reversal-related
complications. 71 patients (62%) underwent ostomy reversal. There was no difference in
ostomy-related (2.9% vs 3.8%, p=0.99) or reversal-related (0% vs 0%, p=0.99)
mortality. For patients without a PVH, there was no difference in ostomy-related
complications between patients managed with a loop ostomy and those with an end
ostomy (12% vs 18%, p=0.72). However, patients managed with a loop ostomy had a
shorter reversal operative time (112 vs 292 minutes, p<0.001) and reversal length of stay
(6 vs 12 days, p=0.008) with fewer reversal-related complications (0% vs 36%, p=0.02).
Use of a loop ostomy reduced hospital charges by $763,000. For patients with a PVH,
there was no difference in ostomy-related complications, reversal operative time or length
of stay, or reversal-related complications between patients managed with a loop ostomy
and those with an end ostomy.
Conclusion: For patients with PVH, loop ostomy provided no additional benefit over end
ostomy. However, for patients without PVH, loop ostomy reduced reversal-related
complications, operative time, LOS, and hospital charges without compromising initial
morbidity. Thus, for all patients, loop ostomy should be the preferred method of
diversion, if required, following destructive colon injury.
 Poster # 115
Serial Hemoglobin Monitoring in Adult Patients with Blunt Solid Organ Injury:
Less is More
Dustin Price DO, Marie Crandall* MD, David Skarupa* MD, Brian Yorkgitis DO, David
Ebler MD, Albert Hsu MD, Andrew Kerwin* MD, Firas Madbak* MD, University of
Florida, Jacksonville

Introduction: Patients who sustain blunt solid organ injury to the liver, spleen or kidney
and are treated nonoperatively frequently undergo serial monitoring of their hemoglobin
(Hgb) at set intervals as often as every four to six hours. We hypothesized that in
hemodynamically stable patients with blunt splenic, hepatic or renal injuries treated
without an operation, scheduled monitoring of serum hemoglobin values may be
unnecessary as hemodynamic instability, not merely hemoglobin drop, would prompt
intervention.

Methods:We performed a retrospective review of adult patients admitted to our urban

Level 1 trauma center following blunt trauma with any grade liver, spleen or kidney
injury from January 1, 2016 to December 31, 2016. Patients who were hemodynamically
unstable and went directly to the operating room were excluded. Patients who required
any urgent or unplanned operative or angiographic intervention were compared with
patients who did not require an intervention. Routine demographic and outcome variables
were obtained and bivariate and multivariate regression statistics were performed using
Stata v10.

Results: A total of 141 patients were admitted with blunt hepatic, splenic, renal or
combined injuries. Age distribution did not differ significantly between the two groups
(39.3 vs 41.4 years, p-value=0.51). Patients who underwent an intervention, in general
had a higher Injury Severity Score (ISS) (26.7 vs 22.1; p-value=0.12) and lower
admission Hgb (11.9 vs 12.8 g/dL; p-value=0.06). The number of Hgb draws (9.2 vs 10;
p-value=0.69) and the associated change in Hgb (3.7 vs 3.5; p-value=0.71) did not differ
significantly between the two groups. Number of RBC units transfused was higher in the
intervention group (3 vs 1; p-value=0.09). No patients in the non-operative group required
operative intervention based on decreasing Hgb. All of the 21 patients who required
laparotomy underwent surgery within 4 hours after admission.

Conclusion: Among patients with blunt solid organ injury, a need for emergent
intervention in the form of laparotomy or angioembolization typically occurs within the
first hours of injury. Routine scheduled hemoglobin monitoring did not alter management
and is unnecessary in the management of blunt solid organ injury.
 Poster # 116
SPLENIC ARTERY ANGIOEMBOLIZATION FOR HIGH-GRADE SPLENIC
INJURY: STOP WASTING TIME AND MONEY
Lara Senekjian MD, MS, Bryce Robinson* MD, Joseph Cuschieri* MD, Harborview
Medical Center
Introduction: Practice management guidelines advocate for non-operative management
(NOM) of hemodynamically normal patients sustaining blunt splenic injuries of all
grades. Splenic artery embolization (SAE) has been advocated to improve rate of splenic
salvage in the setting of NOM. The purpose of this study is to determine the
cost-effectiveness of SAE for high-grade splenic injuries, grade III-V.

Methods: Using TreeAge software, a cost-utility analysis was developed for a

40-year-old male base-case patient with blunt splenic injury. We compared non-operative
management to non-operative management with SAE. Non-operative patients were
modeled with the probability of failure requiring splenectomy, readmission, and post
procedure complications. Patients managed by SAE were modeled with probability of
failure leading to splenectomy, readmission, and post interventional radiology (IR)
complications. Probabilistic sensitivity analysis was completed by Monte Carlo
simulation with 10,000 random walks to account for variable and model uncertainties.
Each high-grade injury splenic injury (III-V) was evaluated separately. Probabilities of
procedural complications, readmissions requiring additional management, and
splenectomy rates were extracted from published data between 2000-2017. Costs were
collected from Centers for Medicare and Medicaid Services Healthcare Cost and
Utilization Project and expressed in 2014 dollars. Utility outcome was quality-adjusted
life years (QALY).

Results: For patients with grade III blunt splenic injury, NOM was $32,279 with gain of
0.96 QALY compared to SAE that costs $70,197 with gain of 0.89 QALYs, thus NOM is
the dominant strategy. For patients with grade IV injury, NOM costs $44,192 with 0.87
QALYs gained compared to SAE that costs $70,113 with 0.89 QALYs gained. This
results in an interval cost effectiveness ratio (ICER) of NOM to SAE of
$1,296,046/QALY. For patients with grade V injury, NOM costs $56,959 with 0.78
QALYs gained compared to SAE that costs $68,141 with 0.91 QALYs gained. The ICER
comparing NOM to SAE is $86,015/QALY. Using the standard willingness-to-pay
threshold of $50,000, NOM is the more cost-effective strategy for grade IV and V injury.
In grade III injury, NOM is the dominant treatment strategy.

Conclusion: For grade III injuries, NOM without SAE results in the most cost-effective
strategy yielding more quality-adjusted life years. NOM without SAE is the most
cost-effective strategy for all high-grade splenic injuries. Thus, non-operative
management of splenic injuries should routinely be performed without SAE.
 Poster # 117
EVALUATING THE 2009 REVISION OF THE 1989 AMERICAN ASSOCIATION
FOR THE SURGERY OF TRAUMA RENAL INJURY SCALE: CAN
WE IMPROVE?
Eric Ballon-Landa MD,MPH, Omer Raheem MD, Leslie Kobayashi* MD, Jill Buckley
MD, UC San Diego
Introduction:
To better characterize traumatic renal injury a revision to the 1989 American Association
for the Surgery of Trauma (AAST) Renal Injury Scale (RIS) has previously been
proposed. The key changes proposed were: grade IV includes collecting system and
segmental vein or artery injuries, and grade V omits the construct “shattered kidney” in
favor of main renal hilum vascular injury or complete ureteropelvic junction disruption.
We sought to validate the 2009 AAST-RIS, emphasizing grade reclassifications between
the 1989 and 2009 AAST scales and subsequent management.
Methods:
Using a prospective trauma database, patient demographics and renal injury
characteristics, computerized tomography imaging, radiology reports, and subsequent
management were recorded. Descriptive analyses were performed with original grade,
revised grade, and radiology reports; further analysis of major interventions was
performed for severe injuries. Two multivariate logistic regression models for
intervention were tested using 1989 and 2009 grades. We compared the models to
evaluate which grading scale better accounted for the study data.
Results:
Among 256 cases of renal injury from
2004-2016, 42 (21.9%) were reclassified
using the revised 2009 scale; 50 cases
(19.5%) were upgraded, 6 (2.3%) were
downgraded, and 200 (78.1%) were
unchanged. Among cases with grades III
or higher, 131 (81.4%) were managed
non-operatively, 9 (5.6%) with
angioembolization, 9 (5.6%) with
nephrectomy, and 12 (7.5%) with
renorrhaphy; management was
significantly associated with original and
revised grade ( Χ2 , p=0.02 and p<0.001, respectively). These associations were
preserved when correcting for covariates; further, the multivariate model using the 2009
grades significantly outperformed the 1989 model (Table 1).
Conclusion:
Employing the 2009 revision to the AAST-RIS led to more definitive classification of
renal injury and a stronger association with renal trauma management. Applying the
revised AAST criteria, which define renal trauma injuries with more clarity, may
facilitate and improve the multidisciplinary care of renal trauma by urologists, trauma
surgeons, and radiologists.
 Poster # 118
OPTIMAL TIMING OF DELAYED EXCRETORY PHASE CT SCAN FOR DIAGNOSIS OF
URINARY EXTRAVASATION AFTER HIGH-GRADE RENAL TRAUMA
Sorena Keihani MD, Gregory J. Stoddard MPH, Douglas M. Rogers MD, Bryn E. Putbrese MD,
Kaushik Mukherjee* MD, Sarah Majercik* MD, Christopher M. Dodgion* MD,MPH, Scott A.
Zakaluzny* MD, Brian P. Smith* MD, Reza Askari* MD, Matthew M. Carrick* MD, Jurek F.
Kocik* MD, Marta E. Heilbrun MD, Raminder Nirula* MD,MPH, Jeremy B. Myers MD,
University of Utah
Introduction: Delayed excretory phase CT scan is often needed to evaluate potential collecting
system injuries and accurately grade renal injuries after high-grade renal trauma (HGRT). Excretory
phase with adequate contrast accumulation into the collecting system allows to evaluate for urinary
extravasation. However, the optimal timing to obtain the excretory phase after renal trauma is not
established. We aimed to assess the association between excretory phase timing and diagnosis of
urinary extravasation and also suggest a cut-off point based on multi-institutional data on HGRT.

Methods: From 2014-2017, clinical and imaging data on HGRT (AAST grades III-V) were gathered
from 14 Level-1 trauma centers participating in the AAST Genito-Urinary Trauma Study. Patients
with missing initial CT scans or those who underwent immediate surgery without imaging were
excluded. Initial and follow-up CT scans were reviewed by two radiologists to extract injury details
including vascular contrast extravasation, as well as urinary extravasation. The time between early
(portal venous) and excretory phases was recorded. Hypotension was defined as systolic blood
pressure <90 mmHg. Kruskal-Wallis and Wilcoxon ranked-sum test with Hommel’s correction for
multiple comparisons were used to compare excretory phase time in different urinary extravasation
diagnosis groups (Yes/No/Inconclusive). Logistic regression was used to measure the association
between excretory phase timing (continuous) with diagnosis of urinary extravasation (binary
outcome). Predictive receiver operating characteristic (PROC) analysis, using positive and negative
predictive values (PPV and NPV) and the area under curves (AUC) were used to suggest a cut-off
point optimizing detection of urinary extravasation when present.

Results: A total of 326 patients met the inclusion criteria. Of these, 243 (74%) had excretory phase
CT scans for review either initially (210) or at their follow-up (33). At initial CT with excretory
phase, 46 patients (22%) were diagnosed with urinary extravasation and 25 patients (12%) had
inconclusive images. Median time between portal venous and excretory phases was 4 minutes (IQR: 4
–7 minutes). Time of initial excretory phase was significantly higher in those diagnosed with urinary
extravasation (median: 7 minutes, IQR: 4–10) vs. those not diagnosed with urinary extravasation
(median: 4 minutes, IQR: 4–6) and those with initial inconclusive images (median: 4 minutes, IQR:
4–5) [P <0.001 and 0.03, respectively]. In multivariable logistic regression, increased time to
excretory phase was positively associated with finding urinary extravasation at the initial CT scan,
after controlling for injury severity score, trauma mechanism, hypotension, and renal vascular
contrast extravasation (Odds Ratio per minute: 1.26, 95% CI: 1.14-1.40, P<0.001). The optimal cut-
off for detecting urinary extravasation in our study was 9 minutes (PPV: 56%, NPV: 84%; PROC
AUC: 70%).

Conclusion: The timing of excretory phase imaging is important in diagnosis of urinary extravasation
after HGRT. In our study, most excretory phases were timed about 4 minutes after the early contrast
phase. We suggest a 9-minute delay between the early and excretory phases to optimize diagnosis of
collecting system injuries.
 Poster # 119
CURRENT MANAGEMENT OF EXTRAPERITONEAL TRAUMATIC BLADDER
INJURIES: RESULTS
FROM THE AMERICAN ASSOCIATION FOR THE SURGERY OF TRAUMA (AAST)
GENITOURINARY TRAUMA STUDY
Rachel A. Moses MD,MPH, Sorena Keihani MD, Sarah Majercik* MD, Frank N. Burks MD, Sean
P. Elliott MD, Kaushik Mukherjee* MD, Bradley A. Erickson MD, Richard A. Santucci MD, Brian
P. Smith* MD, Christopher M. Dodgion* MD,MPH, Scott A. Zakaluzny* MD, Benjamin N. Breyer
MD, James M. Hotaling MD, Raminder Nirula* MD,MPH, Jeremy B. Myers MD,
University of Utah
Introduction: Bladder trauma is an uncommon urologic injury; research on extraperitoneal bladder
injuries (EBI) is mostly limited to retrospective, single-institutional studies. Our goal is to understand
current management trends and the role of surgical repair for EBI in a large contemporary multi-
institutional setting.

Methods: From 2014 to 2017, data on bladder injuries were collected from 12 participating Level-1
trauma centers. Demographics, injury characteristics, acute management, complications, and need for
delayed interventions were noted. Patients were excluded if they died during the first 48 hours after
arrival due to non-urologic injuries. Descriptive statistics were used to report management patterns of
EBI during this period.

Results: 82/160 (51%) bladder injuries were EBI. Patient and injury characteristics are summarized
in Table-1. Most injuries (79%) were blunt and 87% had concomitant injuries. 65 patients (79%) had
pelvic fracture, 31 (48%) of whom underwent open reduction and internal fixation (ORIF). EBI was
repaired in 34 (41%) patients at a median of 8 hours (IQR 2-23 hours) from admission. The three
leading reasons for EBI repair were: severity of the injury or bladder neck injury (38%), injury found
during laparotomy (38%), and concerns about pelvic hardware contamination (35%). Complications
in the non-operative group included UTI/sepsis (6), pelvic hardware infection and removal (3), and
persistent urine leak (3). Three patients with persistent leak eventually underwent bladder repair, 2 of
whom had intravesical bone fragments. Complications in the operative group included
vesicocutaneous fistula and pelvic osteomyelitis (2), UTI/sepsis (2), persistent urine leak (2), and
pelvic abscess (1). In patients undergoing ORIF, rates of complications or hardware infection were
not different between conservative and operative bladder management groups.

Conclusion: A large proportion of EBI are currently operatively managed and role of surgery should
be considered in evaluation of EBI. Both conservative and operative management of EBI is
associated with high rates of complications, however, there may be significant selection bias for
operative management of severe injuries, which hampers interpretation of similar complication rates.
 Poster # 120
BLAME IT ON THE TRAUMA: INURY IS AN INDEPENDENT RISK FACTOR
FOR PANCREATIC FISTULA FOLLOWING DISTAL PANCREATECTOMY
COMPARED TO ELECTIVE RESECTION
Noah S. Rozich MD, Katherine T. Morris MD, Tabitha X. Garwe MPH,Ph.D., Zoona
Sarwar MPH, Alessandra Landmann MD, Chesney Burgweger BS, Alexandra Jones BS,
Casey S. Butler MD, Paul K. McGaha II, MD, Benjamin Axtman MD, Barish H. Edil
MD, Jason S. Lees* MD, University Of Oklahoma
Introduction: Postoperative pancreatic fistula (POPF) remains a significant source of
morbidity following distal pancreatectomy (DP), both for elective resection and following
traumatic injury. There exists a lack of information regarding the impact of trauma on
POPF rates when compared to elective resection. We hypothesize that trauma would be a
significant risk factor for the development of POPF following DP.

Methods: All patients undergoing DP from 2000-2017 at a single-institution were

retrospectively reviewed. Patients undergoing resection for trauma were compared to
those undergoing elective resections for benign disease. This was done to attempt to
control for pancreatic parenchymal texture, as patients with benign diagnoses and trauma
are more likely to have similar gland texture compared to patients with malignant disease.
However, fistula rates between all elective cases (benign and malignant) were compared
to rates among trauma patients separately. Univariate and multivariable analyses were
performed using SAS (version 9.4). The updated version of International Study Group
for Pancreatic Fistula (ISGPF) definition of POPF was used to define a pancreatic fistula.
P-values of <0.05 were considered statistically significant.
Results: Of the 203 patients who underwent DP from 2000-2017, 43 (21.2%) were due to
trauma, 65 (32%) were due to benign diagnoses, and 95 (46.8%) were for malignant
diagnoses. Six patients did not survive for 72 hours and were excluded from the analysis.
When comparing trauma patients to patients undergoing resection for benign diagnoses,
there were significant differences between groups in mean age (29.8 vs 51.6 years,
p<0.0001), gender (71.1% male vs 41.5% male, p=0.0008), Body Mass Index
(low/normal: 55.6% vs 16.1%, overweight: 25% vs 28.6%, Obese: 19.4 vs 55.4,
p=0.0001), smoking status (73.7% current smokers vs 17.3%, p<0.0001), and the number
of patients with comorbid conditions (7.9% vs 55.4%, p<0.0001). While significantly
more trauma patients had stapled closure of their pancreas (62.2% vs 30.8%, p=0.0020)
compared to benign-elective cases, on univariate analysis, there was no significant effect
seen on the rate of developing a POPF (OR: 1.10, 95% CI: 0.47-2.56, p=0.8257). On
multivariable analysis, after controlling for age, gender, postoperative transfusion rate,
BMI, and tobacco use, the odds of developing a POPF in trauma patients were 11 times
those of benign-elective patients (OR: 10.67, 95% CI: 1.31-86.92, p=0.0270).

Conclusion: To our knowledge, this study represents the largest cohort of patients
comparing pancreatic leak rates in traumatic vs elective DP, and demonstrates that
traumatic injury is an independent risk factor for developing an ISGPF grade B or C
pancreatic fistula following DP. Adjusting surgical management, such as the practice of
leaving intraperitoneal drains after DP, should be considered to account for this
prominent risk factor.
 Poster # 121
DESIGNING A NOVEL METHOD FOR COLLECTING PATIENT-REPORTED OUTCOMES
IN THE TRAUMA POPULATION: UNDERSTANDING IMPLEMENTATION
CHALLENGES
Graeme M. Rosenberg MD, Emily J. Shearer MPP, MSc, David A. Spain* MD, Thomas G. Weiser*
MD,MPH, Stanford University
Introduction: Monitoring longitudinal patient-reported outcomes (PROs) and quality of life after
injury is the next frontier of comprehensive trauma care. Current methodologies for monitoring
outcomes are resource intensive with variable rates of engagement. We aimed to explore the feasibility
of using a secure, internet-based survey platform to improve collection of PROs after injury.

Methods: English-speaking patients ≥ 18 years-old admitted to a Level I University Trauma Center

with traumatic injuries were prospectively enrolled over three months. The following injury criteria
were used for eligibility: emergency operation; or ICUlength-of-stay greater than two midnights; or
hospital length-of-stay greater than 4 days. A GCS of 15 was required for consent. Surveys were
administered using an automated electronic survey platform taken on a tablet device provided at the
time of enrollment. The survey platform utilized customized questionnaires to collect demographic
details and user experience data. NIH-PROMIS tools relating to health-related quality of life, patient-
reported mental health, efficacy of symptom management, and social functioning were administered
via the survey platform which enables use of available computer adaptive tests. Follow-up surveys
were automated to be released by the survey platform via email at 3 months with a 2-week window for
completion; nonresponse generated an automatic reminder email. During enrollment, contextual field
notes were recorded by research staff including information related to interruptions in care, barrier to
enrollment and completion of the surveys, and challenges faced by the participants.

Results: During the 3-month pilot study, forty-seven patients were eligible for enrollment; 26 (55%)
enrolled and 19 (40%) patients completed surveys. Technical constraints and declined participation
were the primary barriers to enrollment (Figure 1). Twelve (26%) eligible patients could not participate
either because they did not use email or had insurmountable difficulties using the tablet device. Of the
26 patients who were enrolled, 7 requested email links so they could begin the survey after discharge –
none initiated the survey. Contextual field notes revealed three major obstacles to completing the
survey: competing hospital tasks, issues with technology, and declining participation. Participation in
this voluntary survey study was often lowest priority in the context of symptom management, team
rounding, and disposition planning. Casts, splints, slings, and symptoms such as fatigue and nausea
hindered use of the tablet. Some mild TBI and elderly patients struggled with the electronic interface
and touchscreen. Young male trauma patients were most likely to decline participation and frequently
believed they would not face issues while recovering. The final group of participants included 14
(74%) men and 5 (26%) women with an average age of 55 years (SD 19). The majority (89%) of
injuries were blunt force mechanisms. For those who did complete the survey, the average completion
time was 43 minutes – only 21% found this too long. Seventy-four percent of participants reported the
system easy to use, 26% had “slight” issues and 0% had “major” issues with the system. Ninety-five
percent of patients anticipated they would “very likely” or “definitely” respond to future surveys.

Conclusion: Patient engagement was the greatest barrier with lack of email access and technological
issues contributing to over half of the reasons for not enrolling. Advancing age, foreign-language, and
lower socioeconomic status is associated with reduced access to personal computers, handheld devices,
and internet services in the US. These population characteristics are over-represented in the trauma
population. Electronic capture of longitudinal PROs, while convenient, must consider socioeconomic
barriers to its use.
 Poster # 122
MEASURING PRE-INJURY FUNCTIONAL STATUS, WHICH INSTRUMENT?
Kevin M. Schuster* MD,MPH, Ian Schlieder DO, Yawei Zhang MD,MPH,Ph.D., Robert
Becher MD, MS, Adrian A. Maung* MD, Kimberly A. Davis* MBA,MD, Yale School
of Medicine
Introduction: Functional outcomes in the elderly after injury are as important as
commonly reported morbidity and mortality. Long term functional outcome depends on
pre-injury function in the aged. Measuring pre-injury functional status in the critically
injured may be difficult as it requires recollection of premorbid functional status, or by
report of a surrogate. Although multiple instruments are available for measuring
functional status, it is unknown which, if any, will perform well when used by a
surrogate. We assessed six commonly available instruments.
Methods: Elderly (>=65), minimally injured trauma patients or uncomplicated elective
colorectal surgery patients, with a normal mental status, and had a surrogate who either
provided care for or resided with the patient were enrolled within 48 hours of admission.
Patient and surrogate pairs completed identical instruments and were instructed to
complete the instruments considering the patient's pre-injury or pre-operative functioning.
Correlation was assessed with Pearson correlation coefficients. Linear regression assessed
factors potentially associated with degree of correlation.
Results: One hundred eighteen patient-surrogate pairs were enrolled with a mean age of
78.5 ± 8.4, 68 (60.0%) were female, 110 (93.2%) were trauma patients. Surrogates were
spouses (50.0%), children (42.4%), siblings (3.4%) or other (4.2%). Concordance was
excellent for the Glasgow Outcome Scale, Katz’s Index and the Barthel index (Table).
Physical functioning, activities of daily living (ADL) and instrumental activities of daily
living (I-ADL) had better surrogate correlation than measures of mental health and social
interaction. Katz’s index correlation was lower for siblings or children vs. a spouse
(p=0.017, 0.001 respectively).

Conclusion: Pre-injury physical functioning and ADL/I-ADL can be accurately assessed

through a surrogate with an excellent degree of agreement. Measures of psychosocial
functioning are good; however, the lower degree of concordance likely limits their use
for comparing pre- and post-injury change in the mental, emotional and social domains.
Katz's index performs less well when the surrogate is not the patient's spouse.
 Poster # 123
RISK FACTORS ASSOCIATED WITH POOR LONG-TERM SOCIAL
FUNCTIONING AFTER TRAUMA
Rachel Rivero BS, Juan Herrera Escobar* MD, Michel Apoj BS, Alexandra Geada BS,
MBS, Matthew Villanyi BS, Deepika Nehra MD, George Velmahos MD,Ph.D., Haytham
Kaafarani MD,MPH, Ali Salim MD, Adil Haider* MD,MPH, George Kasotakis*
MD,MPH, Boston University Medical Center
Introduction: Social Functioning (SocFun), the ability to participate in organized or
informal family, friend or peer groups and communal activities, is intertwined with
physical and emotional health. As trauma can have a lasting effect on both physical and
emotional well-being, it may also prevent injury victims from returning to their baseline
SocFun norms, although little is known about these complex interactions. With this project
we aim to determine risk factors associated with long-term Social Dysfunction (SocDys)
after trauma.

Methods: Adults with an Injury Severity Score >9 managed at three urban academic Level
I trauma centers were contacted at 6 and 12 months after injury. Phone interviews were
conducted to inquire about SocDys (whether patient’s physical and emotional health has
interfered with their social activities, such as visiting friends and interacting with family
members). Demographics, socioeconomic parameters, mechanism and severity of injury,
as well as hospital course information were also obtained. Data were compared between
patients who reported SocDys and those who did not. A stepwise backward logistic
regression model for SocDys, adjusting for the parameters that were different between the
two groups was fitted.

Results: Of the 632 screened patients, 48.1% reported SocDys. Differences in

demographics, socioeconomic parameters, injury characteristics and hospital course are
summarized in the table. High school (or lower) education, longer hospital stays, and
African American (AA) race independently increased risk for SocDys. AA patients were
more likely to be younger (p<0.001), Medicaid beneficiaries (p<0.001), penetrating injury
victims (p<0.001), have lower education (p<0.001), and be discharged home (p=0.02).

Conclusion: Lower educational attainment, lengthy hospital stays and AA race appear to
predispose to SocDys after trauma. This information should alert clinicians and caretakers
of this potential long-term adverse social outcome.
 Poster # 124
POST- INJURY COMPLICATIONS- AN ANALYSIS OF CAUSATIVE
FACTORS: WHERE DID WE ERR?
Elizabeth Warnack MD, Beatrix Choi H. Leon Pachter* MD, Charles DiMaggio Ph.D.,
Spiros Frangos* MD,MPH, Michael Klein MD, Marko Bukur* MD, New York
University Langone Medical Center
Introduction: Injury care involves the complex interaction of patient, physician, and
environment that impacts patient complications, level of harm, and failure to rescue
(FTR). FTR represents the likelihood of a hospital to “rescue” patients from death after
in-hospital complications. We hypothesize that error type and number of errors contribute
to increased level of harm and failure to rescue.
Methods: Patient information was abstracted from weekly Trauma Performance
Improvement (PI) (1/1/16 -7/19/17), where trauma surgeons determined level of harm and
identified factors associated with complications. Level of harm was determined by
definitions set forth by the Agency for Healthcare Research and Quality (AHRQ).
Logistic regression was used to determine the impact of individual factors on FTR and
level of harm, controlling for age, gender, Charlson score, ISS, error (in diagnosis,
technique, or judgment), delay (in diagnosis or intervention), and need for operation.
Results: 2,216 trauma patients presented during the study period. 224 (10.1%) had
complications reported at PI; of these, 31 patients (13.8%) had FTR. PI patients were
more likely to be older (median 51.8 vs 44.9 years, p = .002) and have higher ISS (median
22 vs 8, p < .01). Physician-attributable errors (OR 2.59, p < .01), most commonly errors
in technique, and nature of injury (OR 1.97, p < .05), were associated with higher levels
of harm, while delays in diagnosis or intervention were not. Each additional factor
involved increased level of harm (OR 2.08, p < .001) and nearly doubled likelihood of
FTR (OR 1.93, p < .05).
Conclusion: Physician-attributable errors in diagnosis, technique, or judgment are more
strongly correlated with harm than delays in diagnosis and intervention. Increasing
number of errors identified in patient care correlates with an increasing level of harm and
FTR.
 Poster # 125
Resuscitative Endovascular Balloon Occlusion of the Aorta may improve survival
among severely injured unstable patients experiencing post-intubation hypotension
Ramiro Manzano Nunez MD, Claudia P. Orlas MD, Michael W. Parra MD, Juan P.
Herrera-Escobar MD, Maria A. Londoño Camilo J. Salazar Juan E. Ruiz-Yucuma
Alexander Salcedo MD, Jose J. Serna MD, Juan J. Melendez MD, Camilo A. Peña MD,
Edison Angamarca MD, Fernando Rodriguez MD, Alberto F. Garcia MD, Carlos A.
Ordoñez* MD, Fundacion Valle del Lili
Introduction: We hypothesized that the deployment of REBOA among
hemodynamically unstable (HU) trauma patients experiencing post-intubation
hypotension (PIH) can result in improved survival. Methods: Retrospective analysis
performed at a Level I Trauma Center between December, 2014 and January, 2018 of all
adult torso trauma patients who 1) underwent surgery 2) developed PIH and were 3) HU
(SBP<=90) upon arrival to the operating room. We excluded patients who were intubated
prior to their arrival to the ER. Patients were subsequently divided into two groups:
REBOA and -REBOA. All patients were treated upon arrival according to established
damage control resuscitation (DCR) principles, and all REBOA’s were inserted in the
operating room after intubation by the treating trauma surgeon. All PIH patients were
managed equally by the supervising attending anesthesiologist by means of DCR and
vasopressors when required. The
predicted survival rate was calculated
usi ng the TRISS method and a
Kaplan-Meier survival analysis of both
the REBOA and the non-REBOA
groups. Results: A total of 391 surgical
torso trauma patients arrived at our
institution during the study period. Of
these, fifty-nine patients developed PIH
and were HU upon arrival to the OR.
The table presents an overview of
patients’ clinical characterist ics and
differences between groups. The
predicted survival rates in the REBOA
and non-REBOA groups were 80.7%
and 82% respectively. However, the
actual survival rate in the REBOA group exceeded
the calculated predicted survival by 11.6%.
Although overall initial survival was not
significantly different between the groups, REBOA
patients demonstrated an improved trend for greater
survival (P=0.07) (Fig). Conclusion: We were able
to show that the use of a REBOA in HU trauma
patients experiencing PIH may underpin these
patients initial ability to survive this second hit and
thus may improve on their overall survival. Our
findings provide a glimpse of the possible positive effect of REBOA of ameliorating the
negative effects of PIH on these patients’ already physiological fragile situation. We
advise that these results deserve further investigation.
 Poster # 126
EARLY OPERATIVE MANAGEMENT IS A COST-EFFECTIVE STRATEGY IN
PATIENTS WITH ADHESIVE SMALL BOWEL OBSTRUCTION: A
POPULATION-BASED, RETROSPECTIVE COST-EFFECTIVENESS ANALYSIS
Ramy Behman MD, Nicole Look Hong MD, MSc, Petros Pechlivanoglou Ph.D., Paul
Karanicolas MD,Ph.D., Avery Nathens* MD,MPH,Ph.D., University of Toronto,
Department of Surgery
Introduction: Adhesive small bowel obstruction (aSBO) is a recurrent, potentially
chronic surgical illness. While conservative management is often successful, operative
intervention for aSBO is associated with a lower risk of recurrence. The long-term costs
and benefits to patients of different management strategies for aSBO are not well
understood. We sought to compare the long-term cost-effectiveness of two competing
strategies for the management of aSBO: Trial of Conservative Management (TCM, the
current standard of care) and Early Operative Management (EOM).
Methods: We performed a retrospective cost-effectiveness analysis using health
administrative data. We identified patients admitted to hospital with their first episode of
aSBO between 2005-2013 and created propensity-matched cohorts based on patients’
likelihood to undergo EOM, defined as surgery the day-of or day-following admission.
Patients were followed forward over a 5-year time horizon to determine the number of
recurrences and adverse events as well as overall survival and accumulated inpatient-costs
to the healthcare system. Utility scores were attributed to aSBO-related events and we
estimated the incremental cost-effectiveness ratio (ICER) in terms of dollars per quality-
adjusted life-year (QALY). Cost estimates are reported from the perspective of the health
system in adjusted 2014 Canadian dollars.
Results: 25,150 patients were admitted for their first episode of aSBO and 3,174 (13%)
were managed by EOM. After matching, patients in each management strategy were
well-balanced with regards to age, sex, comorbidity burden, and socioeconomic
status. After 5 years of follow-up, the average accumulated costs associated with EOM
exceeded those of TCM ($17,752 vs $11,602, p<0.0001). However, patients managed by
TCM were 58% more likely to experience a recurrence of aSBO (20.9% vs 13.2%,
p<0.0001). These recurrences and the associated adverse events contributed to a
long-term survival benefit and overall net effectiveness in terms of QALYs associated
with EOM. The ICER associated with EOM decreased with each additional year of
follow-up, representing increasing cost-effectiveness over time. After 5 years of
follow-up the ICER of EOM compared to TCM was $26,608/QALY.
Conclusion: Optimal strategies of care for aSBO should consider long-term outcomes and
costs, including risks of recurrence and associated adverse events. Within 5 years
following the first episode of aSBO, EOM is a cost-effective approach to care compared
to TCM. Guidelines regarding the role of early surgical intervention for aSBO should be
revisited in view of this evidence.
 Poster # 127
A Propensity Matched Analysis Of Outcomes In Cases Of Elderly Patients Who Fell
From Ground Level At Home With Normal Vital Signs At The Scene: High Level
Vs. Low Level And Unranked Trauma Center Care
Nasim Ahmed* MD, Patricia Greenberg MS Jersey Shore University Medical Center

Introduction:According to the field triage criteria from the Center for Disease Control,
injured elders who experience a ground level fall should be taken to a high-level trauma
center if they have a history (hx) of anticoagulation use. Therefore, the purpose of the
study was to evaluate whether the higher level of care significantly affected the outcomes
of elderly patients who fell from ground level at home and had a normal physiological
examination at the scene.

Methods:Patients aged 65 and above, with normal physiological measures at the scene
(Glasgow Coma Score (GCS) = 15, systolic blood pressure (SBP) > 90 and < 160, heart
rate ≥ 60 and ≤100) from the 2011-2014 National Trauma Data Bank (NTDB) data sets
were included in the study. Patients’ characteristics, existing comorbidities, and outcomes
were compared between the American College of Surgeons’ (ACS) Level 1 or 2
designated trauma centers (Group 1) and the ACS Level 3, 4, and Unranked designated
trauma centers (Group 2). Following initial analyses, propensity score matching was
performed and the rate of in-hospital mortality, median hospital length of stay, and
discharge disposition was compared between the matched groups.

Results:Of the 40,800 patients who met the study inclusion criteria, 19,290 (47.3%) were
transported to a Level 1 or 2 trauma center and the remaining 21,510 (52.7%) were taken
to Level 3, 4, or Unranked trauma centers. There were significant baseline differences
(p<0.05) between the two groups regarding gender, race, the injury severity score (ISS),
and existing comorbidities [hx of smoking, chronic kidney disease (CKD) requiring
dialysis, hx of cerebrovascular accident (CVA), diabetes mellitus (DM), and hypertension
(HTN) requiring medication]. After propensity score matching on age, gender, race, SBP,
heart rate, respiratory rate, ISS, smoking status, CKD, CVA, DM, and HTN status, all
characteristics except ISS (Median [IQR]: 9 [4, 9] vs 9 [4, 9], p<0.001) were well
balanced and 18,813 patients remained in each group. There were no significant
differences regarding in-hospital mortality (2.5% vs. 2.3%, p=0.19) or time to hospital
discharge (Median [95% confidence interval]: 5 [5, 5] vs. 5 [5, 5], p=0.07) between
Groups 1 and 2 respectively. However, there was a significant increase in the proportion
of patients who required services after discharge in Group 2 (78.9% vs. 81.7%, p<0.001).

Conclusion:Cases of elderly patients whose physiological parameters are within normal

limits at the scene of a fall from ground level have been associated with a higher risk of
in-hospital mortality and significant morbidity requiring additional care after discharge
from the hospital. In this study, higher levels of care failed to show any significant
survival benefits or shorten the time to hospital discharge; however, a significantly higher
proportion of patients who went to lesser-care facilities required follow-up services after
discharge.
 Poster # 128
NECROTIZING SOFT TISSUE INFECTION (NSTI) IS ASSOCIATED WITH
PERSISTENT INFLAMMATION, HIGH RESOURCE UTILIZATION AND
POOR LONG-TERM FUNCTIONAL OUTCOMES.
Scott Brakenridge* MD, Alicia Mohr* MD, Gabriela Ghita Babette Brumback Ph.D.,
Chasen Croft MD, Martin Rosenthal MD, R. S. Smith* MD, Lyle L. Moldawer Ph.D.,
Philip Efron* MD, Frederick Moore* MD, University Of Florida
Introduction: Necrotizing soft tissue infection (NSTI) remains an acutely life
threatening and surgically morbid condition, with aggressive debridement remaining the
mainstay of care. The long-term systemic inflammatory phenotype and functional
outcomes of these patients remain poorly defined.

Methods: We analyzed all NSTI within a single-center, prospective longitudinal cohort of

critically ill surgical patients with sepsis. Clinical data included demographics, clinical
course, procedural interventions, and organ dysfunction parameters. Circulating
inflammatory biomarkers were measured serially between 0.5 and 28 days.
Health-related quality of life (HRQOL) and performance status assessments were
performed at 3 and 6 month follow-up visits. Surgical urosepsis (i.e., required minimally
invasive sepsis source control) patients within the cohort were utilized as a comparison
group.

Results: Over a 24-month period, 33 critically-ill NSTI and 25 urosepsis patients were
enrolled with similar baseline characteristics. NSTI source location included perineum
(42%), lower extremity (39%), torso (9%) and neck (9%). Early physiologic derangement
was severe in NSTI (and simlar to the urosepsis group) based on APACHE II (median 16,
IQR 13-22), and max SOFA (7, IQR 4-11) scores, with 30% (n=10) requiring
vasopressor support. Surgical source control required a median of 2 (IQR 1-3)
debridement and 750cm 2 (IQR 126-1200) of soft tissue excision. Both NSTI and
urosepsis (n=25) patients showed similar incidence of MOF, max SOFA score, and peak
inflammatory biomarker levels (IL-6, IL-8, IL-10, CRP), which remained persistently
elevated out to 28 days in both sepsis groups. However, NSTI patients had significantly
longer hospital LOS (median 15 vs 7 days, p=0.004). While there were no inpatient
NSTI deaths, 84% required either a post-discharge transitional facility
(LTAC/Rehab/SNF; n=14, 42%), or extended home health care resources (n=14, 42%).
In contrast to urosepsis patients (who returned to pre-admission baseline), NSTI patients
showed persistently lower HRQOL as compared to baseline values across multiple
domains at 3 months (EQ-5D utility index mean difference, -0.1270, p=005).
Additionally, overall performance status remained limited and significantly worse than
baseline at both three (WHO/Zubrod score 2.03±0.36, mean difference 0.786, p=0.006)
and 6 months (Zubrod score 1.90±0.39, mean difference; 0.607, p=0.002) after NSTI
onset.

Conclusion: Despite low inpatient mortality, NSTI remains a morbid condition with high
incidence of MOF and an immunophenotype of persistent inflammation. Additionally,
NSTI is associated with high resource utilization, persistent performance status deficits
and decreased HRQOL out to 6 months from onset. Novel advances in early
pharmacologic and long-term rehabilitation strategies are likely necessary to further
improve NSTI outcomes.
 Poster # 129
HEALTH CARE UTILIZATION PORTENDS ECONOMIC DISABILITY AFTER
INJURY IN CAMEROON
S. A. Christie MD, Drusia C. Dickson BA, Alain Chichom-Mefire MD, Theophile Nana
MD, Mbiarikai A. Mbianyor MS, Patrick M. Stern II, BA, Rochelle A. Dicker* MD,
Catherine Juillard* MD,MPH, University Of California San Francisco

Introduction:The United Nations has declared establishing Universal Health Coverage by

2030 to be a top health priority. Sub-Saharan Africa has among the highest rates of injury
in the world but limited data suggest that many injured persons do not utilize formal
medical services after injury due to cost constraints. In this study, we report the first
population data on patterns, barriers, and economic consequences of care utilization after
injury in Cameroon to establish targets for expanding access to care and improving trauma
outcomes.
Methods: We performed a mixed-methods community based survey on injury in an
urban-rural region of Cameroon. Three-stage cluster sampling was used to select target
households. Data was collected on all injuries occurring in the preceding 12 months
including care utilization, disability and economic outcomes. All survey data was adjusted
for cluster sampling.
Results: Of 8065 individuals surveyed, 503 injuries were identified. Over 1/3 (35%) of
injured persons did not utilize formal medical services. Disability affected 68% of injured
persons and resulted in over 11,000 lost days of work in the sample projecting to an
estimated 2 million days of work lost annually in the region. Family economic hardship
after injury was substantially worse among the injured cohort who utilized formal care.
Adjusted for age and severity, this group had higher treatment costs, more lost wages and
employment, and more frequently resorted to economic coping strategies such as
borrowing money or liquidating assets (all p<0.01). Formal medical care utilization in
Cameroon was found to be an independent predictor of severe economic hardship after
injury, defined as new inability to afford food or rent (aOR 1.69, p= 0.03).
Conclusion: Injury in Southwest Cameroon leads to substantive disability and impedes
regional economic growth. Formal medical services must be made economically viable to
expand utilization. Financial restructuring of emergency care in Cameroon has
considerable potential to mitigate poor outcomes for affected families and communities
after injury.
 Poster # 130
TRAUMA PATIENTS ADMITTED TO NON-SURGICAL SERVICES – A
MARKER FOR POOR OUTCOME
Frederick B. Rogers* MD, Shreya Jammula BS, Eric H. Bradburn DO, Alan D. Cook*
MD, Susan P. Schulz MD, Jeanette Ward MS-CR, Juliet Altenburg RN, MSN Lancaster
General Health/Penn Medicine
Introduction:Trauma systems and trauma centers were designed to optimize outcomes
post trauma. After initial trauma evaluation, trauma patients are occasionally admitted to
non-surgical services. We hypothesized that trauma patients admitted to a surgical service
(SS) would have lower mortality than those admitted to a non-surgical service (non-SS).
Methods: The Pennsylvania Trauma Outcome Study database was retrospectively queried
from 2003-2015 for adult (age ≥15) trauma patients admitted to accredited trauma centers
in Pennsylvania. Patients dead on arrival and burn mechanism of injury were excluded.
Patients were identified based on admitting service: surgical vs. non-surgical. Baseline
patient demographics and incidence of comorbidities between the two groups were
determined. Multilevel mixed-effects logistic regression model controlling for
demographic and injury severity covariates were utilized to determine the adjusted impact
of admitting service on mortality.
Results: 379,420 patients met inclusion criteria (SS: 354,748, non-SS: 24,672). Patients
admitted to SS were significantly younger, more severely injured and more likely to be
male. When adjusted for demographic and clinical characteristics (Table 1), admission to
SS was associated with lower odds of mortality (AOR 0.827, p<0.001). Of note, patients
who had delayed craniotomies had higher odds of dying on non-SS compared to SS
(AOR 3.421 vs. 1.677) (Table 2).
Conclusion: Admission to non-surgical service appears to be a marker for a deleterious
outcome in trauma patients. Patients with delayed craniotomies may be better managed on
a surgical service because of improved neuro critical care. Trauma accrediting
organizations should ensure that successful verification of trauma centers includes few
trauma patients admitted to non-surgical services.
 Poster # 131
RESUSCITATIVE THORACOTOMY IN ISOLATED PENETRATING TRAUMA
TO THORAX, DOES TRAUMA CENTER DESIGNATION MAKES A
DIFFERENCE?
Jorge Con MD, Asad Azim MD, Kartik Prabhakaran MD, Ansab Haider MD, Matthew E.
Bronstein MD, Rifat Latifi* MD, Westchester Medical Center

Introduction: Patients with isolated penetrating trauma to the thorax who arrive with
signs of life (SOL) and lose pulse in Emergency Department (ED) are most likely to
benefit from Resuscitative Thoracotomy (RT). The aim of our study was to determine the
differences in RT attempt rate and survival rate after RT between various levels of trauma
center (TC) designation in patients with penetrating trauma to the thorax.
Methods: We performed 5-year (2011-2015) analysis of National Trauma Databank. All
patients >18 years of age were included. Patients with isolated penetrating trauma to
thorax who arrived ED with SOL were identified. Patients who lost vitals in ED were
defined as those who died in ED or underwent RT. RT was defined as patients who
underwent Exploratory Thoracotomy (PCODE: 34.02) within 1-hour of ED arrival. RT
attempt rate was calculated as a percentage of patients who underwent RT out of all
patients who lost vitals in ED. RT attempt rate and survival rate were compared.
Results: A total of 54,780 patients with isolated penetrating trauma to the thorax were
identified. Mean ± SD age was 32±15, 82% were male and 62% were white. Mechanism
of injury (Gunshot: 72.3%, Stab: 27.7%). 90.4% (49,521) of the patients arrived at the
ED with signs of life of which 11.9% (5917) lost vitals in ED (Died in ED: 2265,
Underwent RT: 3562). Overall RT attempt rate was 60.2% which has increased from
45.2% in 2011 to 68.7% in 2015 (p=0.002). RT attempt rate was highest in Level-1 TC at
74.4% followed by Level-II at 61.1% and was lowest in Level-III TC at 48.2% (p<0.001).
Level-1 TC had better survival rate after RT as compared to level II and III TC (42.4% vs
31.1% vs 29.2%; p=0.013).
Conclusion: Our analysis demonstrates a significant increase in RT attempt rate over 5
years on patients with an isolated penetrating chest injury. Level-1 trauma centers had the
highest RT attempt rates and the highest survival rates. Further studies are required to
identify the factors influencing the decision to perform RT and to identify the factors
associated with better survival in this cohort of patients.
 Poster # 132
CAN CHEST ULTRASONOGRAPHY REPLACE THE CHEST X-RAYS DURING
THE INITIAL EVALUATION OF STABLE PATIENTS WITH PENETRATING
THORACIC TRAUMA?
Adolfo González MD, Ricardo Urzola MD, Juan F. Osorno MD, Isabel C. Angel MD,
Jose J. Serna MD, Alexander Salcedo MD, David O. Acero MD, Diego F. Valdez MD,
Paula Ferrada MD, Diego Caycedo MD, Orlando Arévalo MD, Juan C. Puyana* MD,
Ramiro Manzano-Nunez MD, Carlos A. Ordoñez* MD, Alberto F. Garcia MD, Hospital
Universitario Del Valle
Introduction: Recent literature suggests that chest ultrasonography (CUS) is an accurate
tool for the diagnostic assessment of traumatic hemothorax and pneumothorax and thus,
many consider CUS a reliable and accurate alternative to chest-Xray (CXR). However,
current guidelines still recommend the use of chest-Xray for the diagnosis of these
conditions. So far, there has been little discussion about the diagnostic yield of CUS in
patients with penetrating chest trauma (PCT) who present stable to the trauma bay. Our
objective was to evaluate the diagnostic accuracy of CUS for the emergency diagnosis of
pneumothorax and hemothorax in stable patients with PCT.
Methods: A consecutive series of stable patients with PCT was prospectively included.
Subjects submitted to emergent procedures and patients with trauma in the cardiac box
were excluded. The initial evaluation was performed following ATLS guidelines. The
findings of the CUS were registered and not used in the decision process.
Results: A total of 436 patients were included, 415(95.2%) were male. Trauma
mechanisms were stab wound in 286 patients (65.6%) and gunshot in 150 (34.4%). Chest
X-Rays showed hemothorax in 73 cases (16.7%), pneumothorax in 58 (13.3%) or both in
47 (10.8%) cases. One hundred seventy-six patients (40.4%) required a procedure.
Sensitivity for the detection of any intrapleural collection, hemothorax alone,
pneumothorax alone or the selection to a therapeutic procedure fluctuated between 0.56 to
0.86. The specificity ranged from 0.87 to 0.94. (Table)

Conclusion: CUS obtained during the initial evaluation of stable patients with penetrating
trauma is a good tool to confirm but not to rule out intrapleural collections or the need of a
therapeutic procedure. Although CUS seems unable to replace CXR, it seems to be a
valuable adjuvant diagnostic modality in the initial diagnostic approach of patients with
PCT who present hemodynamically stable to the trauma bay.
 Poster # 133
CONTINUOUS PARAVERTEBRAL ANALGESIA - IMPROVED OUTCOMES
DESPITE INCREASED RIB FRACTURES
Rindi Uhlich MD, Parker Hu MD, Jeffrey Kerby* MD,Ph.D., Patrick Bosarge* MD,
University of Alabama Birmingham
Introduction: Rib fractures may result in significant morbidity and mortality. Epidural
analgesia provides superior pain control, but its use may be limited due to associated
injuries, risk of complications, and lack of qualified personnel. Continuous local
anesthetic may be provided directly to the effected intercostal nerves via a paravertebral
catheter (PC). PC are widely available and easily placed at bedside. We sought to
evaluate outcomes of patients with multiple rib fractures following the addition of PC to
existing multimodal therapy.

Methods: Trauma patients with multiple rib fractures were reviewed retrospectively from
2015-2018 in a case-control study. All patients managed with PC were matched to
controls with multiple rib fractures in a 1:2 ratio using injury severity score (ISS), age,
and gender. Rib fractures were characterized by total number, laterality, and flail
segments. PC placement including timing, duration, and fracture coverage was recorded.
Rib fracture related morbidity was defined as the occurrence of unplanned intubation,
extubation failure, tracheostomy requirement, pneumonia, and death. Multivariate
regression models were used to assess the addition of PC with pulmonary morbidity.

Results: Forty-eight patients managed with PC were compared to 96 matched controls.

Patients with PC had a significantly greater 30-day (15.9±6.43 vs. 13.2±9.94, p=0.048)
and 90-day (74.7±12.53 vs. 63.3±28.12, p=0.001) hospital free days despite higher
average number of rib fractures (9.3±3.73 vs. 6.6±4.11, p=0.001) and flail segments
(2.0±2.94 vs. 0.8±1.76, p=0.02) compared to those without PC. The incidence of
pneumonia (4.2% vs. 16.7%, p=0.03) and hospital mortality (2.1% vs. 13.5%, p=0.03)
was significantly lower in patients managed with PC. Use of PC was significantly
associated with decreased likelihood of pulmonary morbidity when controlling for age,
ISS, and number of rib fractures (OR 0.27, p=0.008; 95 CI 0.10 – 0.71).

Conclusion: PC use is associated improved outcomes in patients with multiple rib

fractures managed with standard multimodal therapy.
 Poster # 134
Don’t rush to a wide-open chest when diagnosing a hemopericardium in
hemodynamically stable patients with penetrating injuries to the cardiac box
Adolfo González-Hadad MD, Juan F. Osorno-Moncayo MD, Isabel C. Ángel-Escobar
MD, Jose J. Serna MD, Alexander Salcedo MD, David O. Acero MD, Ramiro
Manzano-Nunez MD, Maria P. Naranjo MD, Julian Chica MD, Diego F. Valdez MD,
Ricardo Urzola MD, Carlos A. Ordoñez* MD, Juan C. Puyana* MD, Sandra Carvajal
MD, Alberto F. Garcia MD, Universidad Del Valle
Introduction: Currently, there is growing will toward a non-operative approach in cases
of patients with traumatic hemopericardium who present hemodynamically stable.
However, most trauma surgeons hesitate to perform these kinds of procedures and instead
rush to the operating room and perform unnecessary chest open surgeries. We sought to
describe the management and outcomes of a series of patient’s victims of penetrating
injuries to the cardiac box and definitive evidence of hemopericardium.

Methods: This is a retrospective case series performed with data obtained from a
prospectively collected database, from January 2015 to December 2017. We included
patients with penetrating wounds to the precordial area that arrived hemodynamically
stable to the trauma bay of our level-I trauma center and were diagnosed with
hemopericardium through a pericardial window.

Results: A total of 183 patients with penetrating injuries to the precordial area and
hemodynamically stable upon arrival to the trauma bay were seen at our institution during
the study period. Of these, 32 had hemopericardium evidenced by a pericardial window
(by thoracoscopy=9; by subxiphoid approach=23). Most patients were young [Age,
median: 25 (IQR, 19-30)]. Three and twenty-nine patients were victims of gunshot
wounds and stab wounds respectively. Median (IQR) of ISS was 17 (10-17), and 31
patients had serious intrathoracic injuries (AIS≥3). Fifteen patients had an associated lung
injury that required tube thoracostomy placement; these patients had a median (IQR) of
hemothorax of 600 (300-800). Nineteen patients underwent an open chest surgical
intervention of which 17 and 3 underwent thoracotomy and sternotomy respectively.
These patients presented a median (range) of Penetrating Cardiac Trauma Index (PCTI)
of 10 (10-25). 12 patients underwent pericardiotomy and drainage of hemopericardium
either by thoracoscopy (n=8) or by subxiphoid exploration (n=3). These patients had a
median (range) of PCTI of 10 (0-10). Overal, 40% of patients did not require any cardiac
repair. Of these, five patients were in the group of patients that underwent thoracotomy or
sternotomy.

Conclusion: We found that almost half of patients with evidence of traumatic

hemopericardium did not require therapeutic cardiac operative interventions after a
definitive diagnostic pericardial window which suggests that amongst these populations
mandatory thoracic incision for definitive surgical repair may not always be indicated.
We advise that these findings deserve further investigation.
 Poster # 135
‘PAIN’-TING A PICTURE: CHARACTERIZING CONTINUOUS
INTERCOSTAL NERVE BLOCKS FOR THE PAIN MANAGEMENT OF
ADULT TRAUMA PATIENTS WITH MULTIPLE RIB FRACTURES
Neal Lynch PA, Catherine Koola MPH, Alessandro Orlando MPH, Krislyn Foster DO,
Allen Tanner II, MD, Charles Mains* MD, Victor Portillo MD, David Bar-Or MD,
Penrose - St. Francis Health Center
Introduction: Achieving satisfactory pain management among patients with multiple rib
fractures (MRF) is critical to the prevention of pulmonary complications. Continuous
intercostal nerve blocks (CINB) utilizing non-narcotic--based analgesia are proposed for
patients with MRF, and we hypothesized that CINB would provide decreased pain
during treatment compared to epidural (EPI) or intravenous analgesia (IVA).
Methods: This was a retrospective multicenter study of adult (18+ years) patients
admitted for isolated MRF (3+ fractures) to four trauma centers (three Level I and one
Level III) from 06/1/2012 to 06/30/2016. Patients were excluded if they had an
abbreviated injury scale score >2 for body regions outside the chest, were treated solely
with oral analgesia, or had no pain scores either before or during treatment. The primary
outcome was change in average pain numeric rating scale (NRS; 0-10) from PRE (up to 6
hours prior to analgesic treatment initiation) to DURING (duration of treatment). We
compared the mean change in pain between patients treated with CINB, EPI, and IVA.
Secondary outcomes included hospital length of stay (LOS) and intensive care unit LOS
(ICULOS). Univariate differences in patient characteristics were evaluated with ANOVA
and chi-squared tests, and outcomes were evaluated with adjusted generalized linear
models.
Results: Of the 109 patients included, 53 (49%) received CINB, 22 (20%) received EPI,
and 34 (32%) received IVA. Overall, the majority of patients were male (70%), sustained
an injury through a fall (47%), had a unilateral rib fracture (83%), and had a mean (SD)
injury severity score (ISS) of 11.9 (3.6). CINB patients had similar demographic and
clinical characteristics to EPI patients but were significantly more likely to be older (≥65
years, p=0.02) and have more rib fractures (≥7, p<0.001) than IVA patients. Prior to
treatment, mean (SD) pain NRS scores were 4.5 (3.0), 4.6 (2.4), and 5.8 (3.0) for CINB,
EPI, and IVA patients, respectively (p=0.10). After adjustment for age and PRE pain,
mean (SE) pain changes were -0.5 (0.2) for CINB, -0.7 (0.4) for EPI, and -0.8 (0.3) for
IVA, suggesting no significant effect of treatment group on change in pain (p=0.86).
Patients treated with CINB had a significantly shorter mean (SD) ICULOS (0.6 (1.0)
days, p<0.001), but not hospital LOS, after adjustment, compared to EPI and IVA
patients.
Conclusion: CINB provided comparable pain relief to EPI and IVA. Average
pre-treatment pain was relatively low across all treatment groups, and change in pain was
also minimal. CINB treatment was associated with significantly reduced ICULOS, in
contrast to the results of a prior study comparing CINB to EPI pain management of rib
fractures. With the potential for decreased rates of narcotic addiction, CINB might offer
an efficient alternative for pain control in this population, even among patients with a
greater number of fractures. Future research should assess pain longitudinally to
characterize pain relief over time while on CINB treatment.
 Poster # 136
AMNIOTIC FLUID ALLOGRAFT ENHANCES HOST RESPONSE
TO VENTRAL HERNIA REPAIR USING ACELLULAR DERMAL MATRIX
Jeffrey L. Van Eps MD, Dmitry Zavlin MD, Christian Boada BS, Aaron Shi Dan
Bonville* MD, Joseph F. Buell MD, Warren A. Ellsworth MD, Joseph Fernandez-Moure
MD, Houston Methodist Hospital, Dept Of Surgery
Introduction: Ventral hernia repair (VHR) with acellular dermal matrix (ADM) is
plagued by high rates of recurrence. We have previously shown that augmenting repair
with allogeneic growth factors can enhance ADM incorporation and reduce recurrence.
Amniotic fluid allograft (AFA), a growth factor rich fluid, has been shown to improve
wound healing. We sought to assess the effect of AFA on VHR with ADM. We
hypothesized that AFA would modulate the host response to improve ADM
incorporation.

Methods: Lewis rats (n-36) underwent ventral hernia creation and repair with porcine
non-crosslinked ADM 30 Days (d) later. AFA was applied to mesh prior to skin closure
and tissue harvested at 3d, 14d, and 30d. To assess incorporation, H&E stained slides
were scored using a previously validated histomorphometric score based on
cellularization, presence of multinucleated giant cells, neovascularization, connective
tissue organization, mesh encapsulation, and degradation. Expression of genes positively
associated with wound healing (Col1, Col3, VEGF, and ACTA) was then quantified
using RTPCR. To assess the host inflammatory response, expression of pro-inflammatory
(iNOS, TNFα) and anti-inflammatory (Arg, IL-10, mrc) genes were similarly quantified.

Results: AFA-treated ADM showed greater histomorphometric scores at 14d (4.5 vs. 2.2,
p<0.001) but no difference at 3d or 30d. Col1, Col3, and VEGF expression was increased
at 3d. Col3 expression was increased at 14d. Col1 and ACTA expression was increased
at 30d. Expression of inflammatory genes showed a persistent increase in Arg at all time
points. IL-10 and iNOS expression, while initially low, were greater at 14 and 30d. TNF
and mrc expression decreased throughout the study.

Conclusion: Augmentation with AFA caused enhanced expression of wound healing

genes of early vascularization to later remodeling and regeneration, which correlated
histologically with improved histomorphometric scores at later time points. Collectively
this correlated with a host immune response characterized by increased anti-inflammatory
gene expression. The differential pattern of inflammatory gene expression underscores the
complexity of the immune response in wound healing and warrants further investigation.
These findings suggest AFA may have a role as an adjunct in improving ADM
incorporation in VHR.
 Poster # 137
EXPLORATORY LAPAROTOMIES: ARE THEY ALL THE SAME?
Ambar Mehta MPH, Nicole Lunardi MSPH, David T. Efron* MD, Bellal A. Joseph*
MD, Kent A. Stevens MD, Mariuxi Manukyan MD, Samir M. Fakhry* MD, Joseph V.
Sakran MD,MPH, MPA Johns Hopkins School of Medicine
Introduction: Emergent exploratory laparotomies exhibit the highest mortality rate
among all emergency general surgeries. This study aimed to characterize the most
common diagnoses for which emergent laparotomies were performed and leverage these
groups to improve risk-adjustment models for postoperative mortality.

Methods: We identified emergent exploratory laparotomies in the 2012-2015 Nationwide

Inpatient Sample using AAST criteria. After tabulating all ICD-9 diagnosis codes within
these hospitalizations associated with exploratory laparotomies, we divided them into
clinically-relevant groups. We then included each diagnosis group as an individual
covariate in a multivariable logistic regression for mortality. Using backwards
elimination, we performed iterative regressions after removing groups not statistically
associated with mortality (P<0.05). We repeated our analysis using forward selection, and
then selected groups that were significant for mortality in both methods. Finally, using
the area under the receiver’s operator curve (AUROC), we evaluated the addition of these
selected groups as individual covariates in a risk-adjustment model. All regressions
additionally adjusted for patient and clinical factors, hospital clustering, and the
Bonferroni correction.

Results: We identified 4127 patients with exploratory laparotomy as a primary procedure

(median age: 50 years, 46.0% female, 62.1% white), with an overall mortality rate of
13.4%. Among all patients, we tabulated a total of 27 distinct diagnosis codes, which
were clinically consolidated into 7 diagnostic categories (Table). These
diagnostic categories captured a majority of the laparotomy patients (70.4%) in our
database. Both backwards elimination and forward selection led to three common
diagnosis categories associated with mortality: shock, ischemia, and obstruction
(Table). Adjusting for these three diagnostic groups in a multivariable logistic regression
assessing mortality increased the AUROC from 72.6% to 88.3%.

Conclusion: While the procedural designation of exploratory laparotomy reflects a

variety of interventions, accounting for at least three associated diagnostic categories may
improve the accuracy of risk-adjustment models for mortality. Validating such analytic
standardization may optimize best research practices for emergency general surgery.
 Poster # 138
DURATION OF ANTIBIOTIC THERAPY DOES NOT INFLUENCE
INTRA-ABDOMINAL ABSCESS RATES FOLLOWING DAMAGE CONTROL
SURGERY
Rindi Uhlich MD, Parker Hu MD, Jeffrey Kerby* MD,Ph.D., Patrick Bosarge* MD,
University of Alabama Birmingham
Introduction: Damage control surgery is associated with increased risk of postoperative
infection, with rates of intra-abdominal abscess (IAA) formation between 10-30%. While
guidelines exist recommending limited duration of presumptive antimicrobial therapy
following injury, there is little data to guide duration of therapy following damage control
laparotomy (DCL). We sought to determine if prolonged antimicrobial therapy,
specifically with broad gram negative and anaerobic or antifungal agents, may lead to
decreased rates of IAA after DCL.

Methods: Patients managed with DCL following trauma were retrospectively reviewed
from 2011-2016 at an ACS verified Level 1 trauma center. Those with death within 48
hours were excluded. Demographic data, injury characteristics, antibiotic administration
and duration, and outcomes were recorded. IAA was defined by positive culture or
clinical identification of purulence. Antibiotics were categorized as providing broad gram
positive, broad gram negative and anaerobic, or antifungal coverage. Narrow spectrum
antibiotics were excluded. Patients were compared by duration of broad gram negative
and anaerobic therapy, with 5 or more days considered prolonged therapy. Univariate
analyses were performed and used to guide covariate selection for stepwise multivariate
logistic regression.

Results: Two-hundred and thirty nine patients met inclusion criteria following DCL. The
majority were male (82.0%, 196/239) and suffered penetrating injury (55.2%, 132/239).
IAA complicated 33.9% (81/239) of patients. Patients with IAA were more likely to
suffer gastric (19.8% vs. 7.6%, p = 0.006), colonic (48.1% vs. 32.9, p = 0.02), pancreatic
(19.8% vs. 7.6%, p = 0.006), and renal (9.9% vs. 2.5%, p = 0.01) injury. There was no
difference in duration of antimicrobial therapy on either univariate or multivariate
analyses between patients with or without postoperative IAA following DCL.

Conclusion: Prolonged duration of antimicrobial therapy with broad gram negative and
anaerobic or antifungal agents does not significantly decrease the likelihood of IAA
formation following DCL. Further prospective investigation is needed to determine the
utility of prolonged antimicrobial therapy in patients with significant risk of IAA.
 Poster # 139
PATIENT CENTERED OUTCOME MEASURES ARE NEEDED FOR
TRANSFUSION – MEASURING THE INCREASED RISK OF
INFLAMMATORY COMPLICATIONS IN SPLENIC TRAUMA PATIENTS
Bryce N. Taylor MS, Niki Rasnake BSN, Kelly McNutt BS,RN, Sneha Bhat MD, Brian J.
Daley* MBA,MD, University of Tennessee Medical Center, Knoxville
Introduction: Transfusion is best seen as a blood transplant. Blood products contain
exogenous proteins and other foreign particles that elicit an immune response with an
acute inflammatory reaction. An acutely injured individual has an inflammatory response.
Inducing more inflammation with a transfusion in the setting of this already increased
inflammatory state increases complications and mortality. From this second hit, an
aberrant inflammatory cascade can arise leading to inflammatory derived complications
such as SIRS/CARS and ARDS. Blood transfusion performance indicators from the Joint
Commission and AABB do not address patient outcomes beyond indications and
transfusion reactions.
Methods: We retrospectively analyzed patients admitted to a level 1 trauma center with a
splenic injury between 2006 and 2016 in the Trauma Quality Improvement Program
(TQIP). Our primary parameter was transfusion status, and our secondary parameter was
the development of an inflammatory complication. We defined an inflammatory
complication based on availability in TQIP and as being sepsis-like syndrome or acute
respiratory distress syndrome (ARDS). Statistical significance (p<0.005) was established
through the Pearson’s Chi-Square test controlled for splenic injury treatment modality,
either surgical or non-operative. We also analyzed all statistically significant results with
a follow up linear logit model controlling for the injury severity scores, abbreviated injury
score for the abdomen, age, gender, and comorbidities as confounders.
Results: 627 subjects were included, 237 in the population that was transfused and 390 in
that population that was not transfused. Transfused patients experienced a much higher
incidence proportions of inflammatory complications than those that were not transfused
(0.131 vs 0.008, p=0.000). The transfused population experienced higher incidence
proportions of both sepsis-like syndrome (0.046 vs 0.003, p=0.000) and ARDS (0.101 vs
0.005, p=0.000).
Conclusion: This data confirms an increased risk of inflammatory complications in
patients that are transfused. Even though the overall incidence proportions in both
populations are low, the transfused population still experienced an overwhelming increase
in inflammatory complications when compared to the population that was not transfused.
Transfusion must be used only when necessary and hemovigilance protocols must be
strictly followed. Remaining cognizant of the increased risk of these complications in
patients following transfusion will help to improve morbidity and mortality. We
recommend tracking inflammatory complications as a method of performance
improvement in transfusion.
 Poster # 140
IDENTIFYING PATIENTS WITH TIME-SENSITIVE INJURIES: WHEN IS
MORTALITY ASSOCIATED WITH INCREASING PREHOSPITAL TIME?
Joshua B. Brown MD, MSc, Xilin Chen MPH, Frank X. Guyette MD,MPH, Andrew B.
Peitzman* MD, Timothy R. Billiar* MD, Jason L. Sperry* MD,MPH, University of
Pittsburgh

Introduction: Severe injury is a time-sensitive disease. However, recognizing which

patients have time critical injuries in the field is challenging, but would prioritize those
for rapid transport to definitive care. Many recent studies have failed to identify an
association between increasing prehospital time (PHT) and mortality after trauma. This
may occur for two reasons; first is evaluation of unselected trauma patients unlikely to
have time-sensitive injuries, and second is inherent survival bias in registry data since
field deaths and those dying in closer nontrauma centers are not captured, the longer the
patient survives to make it to a trauma center, the more likely the patient is to survive
overall. Our objective was to determine if a subset of existing trauma triage criteria can
identify patients in which mortality is associated with increasing PHT after accounting for
potential survival bias.
Methods: Adult patients transported by EMS from the
scene with total PHT<3h in the NTDB 2007-2015 were
included. To overcome survival bias, mortality rates were
plotted against PHT and cubic spline analysis used to
identify an inflection where mortality increases to identify
a marginal population in which PHT is more likely
associated with mortality. Further analysis was conducted
on only these patients. Logistic regression determined the
association between mortality and total PHT, adjusting for demographics, transport mode,
vital signs, ISS, urgent surgery, and complications. Robust variance estimators were used
to account for center clustering. Interaction terms between existing trauma triage criteria
and PHT were tested, with model stratification across triage criteria with a significant
interaction to determine which criteria identify patients that have increased risk of
mortality associated with increasing PHT. Multiple imputation and false discovery rate
correction were used to address missing data and multiple comparisons respectively.
Results: Mortality risk increased in patients with total PHT≤30min (FIG), comprising a
study population of 517,863 patients. The median total PHT was 26min (IQR 22-28) with
a median ISS of 9 (IQR 4-14) and 7.4% mortality. Overall, PHT was not associated with
mortality (AOR 0.998; 95%CI 0.993-1.002, p=0.332). Interaction analysis was significant
for PH systolic blood pressure (SBP), Glasgow Coma Scale (GCS), and penetrating
injury (p<0.05). Patients with SBP<90mmHg, GCS≤ 8, or penetrating injury had
increased odds of mortality associated with increasing PHT (TABLE). When stratified by
transport mode, the association between mortality and increasing PHT remained for
ground but not helicopter transport.
Conclusion: In patients with short total
PHT, prehospital hypotension, GCS≤ 8,
and penetrating injury have higher
mortality with increasing PHT. These patients may have truly time-sensitive injuries and
benefit from rapid transport to definitive care. Further prospective research is necessary to
refine the identification of patients with time-sensitive injuries in the field, and overcome
the survival bias for patients with longer prehospital times.
 Poster # 141
Analyses of the of the self-reported confidence level of ASSET course among
participants and instructors
KENICHI HONDO MD, Koji Morishita MD,Ph.D., Kazuhide Matsushima MD,Ph.D.,
Ryuzo Abe MD,Ph.D., Takane Suzuki MD,Ph.D., Shunsuke Yoshikawa MD, Tomo Oka
MD, Shigeto Oda MD,Ph.D., Yasuhiro Otomo MD,Ph.D., Tokyo Medical and Dental
University
Introduction: ASSET (Advanced Surgical Skills for Exposure in Trauma) course is one
of the Trauma Education courses developed by the American College of Surgeons, and it
has been spread all over the world mainly in the United States since 2010. We conducted
the ASSET courses in Japan in 2017. In this study, we analyzed the self-reported
confidence level of each trauma surgical procedure using ASSET course questionnaire
survey collected from participants and instructors.
Methods: A total of 16 participants were enrolled and completed the course evaluation.
Participants were evaluated the self-reported confidence level using a 5-point Likert
scale. 4 instructors evaluated the level of the participant they have that the participant can
perform each procedure. We compared the score of the self-reported confidence level
between student and instructor.
Results: The 44 items were evaluated by both participants and instructors regarding the
cervical /chest / abdomen / upper limb / lower limb surgical procedure. The self-reported
confidence level of the instructors (33/44/65/20/36) (median) were higher in the cervical,
chest, and abdomen than that of the students (28/39/52/19/34).
Conclusion: The discrepancy of the evaluation might be influenced by several factors
such as psychological element or experience. Further analyses of these factors would be
an important in the future.
 Poster # 142
Comparison with aortic cross clamping and resuscitative endovascular balloon
occlusion of the aorta for sever torso trauma.
Hiroshi Yasumatsu Kazuki Mashiko MD, Nobuyuki Saito MD,MPH,Ph.D., Takanori
Yagi MD, Yoshiaki Hara MD,Ph.D., Hisashi Matsumoto MD,Ph.D., Shock And Trauma
Center, Nippon Medical School Chiba Hokusoh Hospital
Introduction:The use of resuscitative endovascular balloon occlusion of the aorta
(REBOA) has increased in recent years. Our facility has employed aortic cross-clamping
(AXC) for aortic occlusion (AO) during trauma resuscitation since 2000. However, the
use of REBOA remains controversial. This study aims to compare AXC with REBOA in
terms of survival discharge for patients with severe torso trauma.
Methods:This retrospective study was conducted at a single trauma center in Japan
between 2012 and 2015, and included patients with AO. Seventy-five eligible patients
with AO (excluding those with cardiac arrest on arrival) were divided into the following
two groups based on the initial treatment decision: AXC (N=58) and REBOA (N=17).
The association between the initial treatment decision and patient survival was examined
using multivariable logistic regression analysis.
Results:This study included 75 patients (94.7%) who sustained blunt injuries with a
median age of 61 [43–74] years. Prehospital treatment, including AXC, was performed to
78.7% of the patients. The initial treatment of 50 patients (86%) in the AXC group was
converted from ACX to REBOA. There was no difference in age and Injury Severity
Score (ISS) between the two groups. The AXC group had significantly lower chest injury
proportion (Maximum Abbreviated Injury Scale ≥3), Revised Trauma Score (RTS), and
prothrombin time (PT) activity (PT%) than the REBOA group (AXC vs. REBOA: chest
injury, 94.8% vs. 64.8%, P=0.001; RTS, 3.07 [2.19–5.14] vs. 5.14 [4.82–6.71], P<0.001;
PT%, 43.7 [34.4–61.1] vs. 68.9 [55.6–77.0], P=0.001). Additionally, the AXC group had
higher lactate values than the REBOA group (8.8 [5.9–11.7] vs. 4.2 [3.1–7.6], P <0.001).
Patients in the AXC group had a lower probability survival rate, which was calculated
using the Trauma and Injury Severity Score method, and a lower actual survival rate than
those in the REBOA group (9.7% vs. 31.3%, P=0.02; 24.1% vs. 52.9%, P=0.02,
respectively). Multivariate analysis, which was adjusted for risk of age, ISS, and RTS, did
not show a clear benefit of REBOA as a primary treatment choice on the survival
discharge of patients with AO (odds ratio, 2.01; 95% confidence interval, 0.46–9.78;
P=0.384). REBOA procedure-related complications was observed in 10.4% of the
patients (7/67; vascular injury, 2; limb ischemia, 7).
Conclusion:AXC is a reasonable treatment choice for severe trauma patients with
impending cardiac arrest. Although REBOA was selected for patients with high RTS, no
remarkable difference in the survival discharge was observed between the REBOA and
AXC groups. So far, REBOA cannot yet replace AXC as a treatment device for patients
with severe trauma.
 Poster # 143
POINT-OF-CARE ASSAY FOR THROMBIN GENERATION IN TRAUMA
PATIENT AND HEALTHY DONOR FRESH BLOOD
Alexander Olson BS, Shannon Prior BS, Nathan Dow BS, Kalev Freeman MD,Ph.D.,
Saulius Butenas Ph.D., Zachary Miller BS, Zachary Osborn BS, University of Vermont
Introduction: Hemostatic potential in trauma patients may be assayed by measurement
of viscoelastic clot strength, fibrinolysis, and quantitation of specific coagulation factors.
One of these factors, thrombin, has demonstrated clinical relevance in predicting
hypercoagulable events, and thrombin generation (TG) is accelerated in the presence of
histones and Factor (F)XIa. There are no standard assays for measurement of thrombin
generation in whole blood at the point-of-care. In this study, a new point-of-care device
for measurement of TG in fresh whole blood was utilized to evaluate the contribution of
histones and FXIa to procoagulant activity in trauma patients and heathy donors.
Simultaneous measurement of clot formation with rotational thromboelastometry
(ROTEM) methodology under identical or supplemental conditions was used to confirm
the nature of procoagulant activity in the trauma population.
Methods: Blood from healthy volunteers and trauma patients (male and female) was
collected into 3.2% sodium citrate. Anti-histone antibody (0.3 mg/mL) was added
immediately (“0 minutes”) or 15 minutes after blood draw, along with addition of corn
trypsin inhibitor (CTI; 0.1 mg/mL) at 0 or 15 minutes to block contact pathway
activation. CTI conditions with no anti-histone were also tested. Clot formation and TG
were analyzed using ROTEM and point-of-care TG methodologies, respectively, in the
presence and absence of an anti-FXIa antibody (0.1 mg/mL). Concentrations of FXIa
were calculated using calibration curves generated from titrating purified FXIa into
healthy donor blood.
Results: Whole blood samples from 14 trauma patients and 16 healthy volunteers were
analyzed. Median ROTEM clotting times for the trauma patients were 8 +/- 4 minutes
shorter than that of the healthy donors for a given condition. Median point-of-care TG lag
phases in the trauma patients were 5 +/- 1.7 minutes shorter. Lag phases were reduced
more than 4-fold if left to incubate for 15 minutes before addition of CTI, for both
populations. All conditions exhibited prolonged lag phases and clot times in the presence
of anti-FXIa antibody. For both assays, higher concentrations of FXIa were observed in
the trauma patients than healthy donors. Moreover, FXIa concentration was reduced 2 to
3-fold following addition of anti-histone antibody at 0 minutes compared to 15 minutes.
Conclusions: Trauma patients demonstrated increased procoagulant activity compared to
healthy donors, in both assays. The observed increases in activity are partially related to
generation of FXIa over time in citrated blood. Furthermore, histones appear to amplify
FXIa generation.
 Poster # 144
The size of pelvic hematoma can be predictive factors for angioembolization in
hemodynamically unstable pelvic trauma
Hak-Jae Lee MD,MPH, Nak-Jun Choi MD, Hyo-Geun No MD, Suk-kyung Hong
MD,Ph.D., Asan Medical Center

Introduction:Unstable pelvic fracture with bleeding can be fatal, with a mortality rate of
up to 40%. Therefore, early detection and treatment are important in unstable pelvic
trauma. We investigated the early predictive factors for possible embolization in patients
with hemodynamically unstable pelvic trauma.
Methods:From January 2011 to December 2013, 46 patients with shock arrived at a
single-hospital within 24 hours after injury. Of them, 44 patients underwent computed
tomography(CT) after initial resuscitation, except for 2 who were dead on arrival. Nine
patients with other organ injuries were excluded. Seventeen patients underwent
embolization. Demographic, clinical, and radiological data were reviewed retrospectively.
Results:Among 35 patients with hemodynamically unstable pelvic fracture, 22 (62.9%)
were men. Width (p=0.002) and length (p=0.006) of hematoma on CT scans were
significantly different between the embolization and non-embolization groups. The
predictors of embolization were width of pelvic hematoma (odds ratio[OR]:1.07,
p=0.028) and female sex (OR:10.83, p=0.031). The cut-off value was 3.35cm. More
embolization was performed (OR:12.00, p=0.003) and higher mortality was observed in
patients with hematoma width ≥ 3.35cm (OR:4.96, p=0.048).
Conclusion:Patients with hemodynamically unstable pelvic trauma have a high mortality
rate. CT is useful for the initial identification of the need for embolization among these
patients. The width of pelvic hematoma can predict possible embolization in patients with
unstable pelvic trauma.
 Poster # 145
Preparing Japanese surgeons for potential mass casualty situations will require
systematic programs.
Hayaki Uchino MD, Victor Kong MD,Ph.D., John Bruce MD, George Oosthuizen MD,
Wanda Bekker MD, Grant Laing MD,Ph.D., Damian Clarke MD,Ph.D., Kurashiki Central
Hospital
Introduction: The ongoing state of global geo-political instability means that it is prudent
to prepare civilian surgeons to manage major military-type trauma. many countries
including Japan has experienced a prolonged period of peace and consequently it is
unlikely that surgeons will have been exposed to a sufficient volume of trauma cases. This
study reviews the state of trauma training and preparedness in Japan and reviews the
trauma workload of a major Japanese emergency medical center and compared with a
major South African trauma center with the intention of quantifying and comparing the
time needed to gain adequate exposure to major trauma at the two centers.
Methods: The literature describing the surgical burden from a number of recent military
missions was reviewed and the core surgical skills to manage military-type injuries were
identified. We then went on to review all patients admitted to both Kurashiki Central
Hospital (KCH) and Pietermaritzburg Metropolitan Trauma Service (PMTS) following
trauma between the period September 2015 and August 2016. The burden of trauma at
each center was quantified and the number of core surgical competencies or procedures
performed at each center was then reviewed. These were then compared with the number
of the core procedures which were performed on the reported military missions.
Results: Three reports on military surgical missions were reviewed. These came from the
Dutch, French and British military surgical services. The most common procedures were
wound debriedment and orthopedic fixation, followed by trauma laparotomy, neck
exploration and thoracotomy. During the 12 month study period, 309 trauma patients were
admitted to KCH. There were 10 penetrating injuries and 299 blunt injuries. Of the
penetrating injuries, there were no gunshot wounds. The mechanisms of injury for blunt
trauma were as follows: Road traffic accidents (RTAs); 141 (47%), fall; 136 (46%) and
other injuries; 22 (7%). In the same period, 2887 trauma patients were admitted by the
PMTS. There were 1244 cases (43%) of penetrating trauma and 1644 cases (57%) of blunt
trauma in PMTS. The mechanisms of injury for penetrating trauma were as follows: Stab
wounds (SWs); 955 (77%), gunshot wounds (GSWs); 252 (20%) and other injuries; 37
(3%) and for blunt trauma were as follows: Assault; 739 (45%), RTAs; 669 (41%), fall;
166 (10%) and other injuries; 70 (4%). The exposure to all the key competencies required
to manage trauma is overwhelmingly greater in South Africa than Japan. The length of
time needed to obtain an equivalent trauma exposure to that achieved in South Africa,
working in Japan is prohibitively long.
Conclusion: Trauam training in Japan is hamstrung by a lack of clinical material as well
as by systematic factors. Training a trauma surgeon is difficult. Developing a trauma
system in the country may help address some of these deficits. South Africa in contrast has
a huge burden of trauma and sufficient infrastructure to ensure that surgeons working
there have adequate exposure to major trauma. Developing an academic exchange
program between Japan and South Africa may allow for the transfer of trauma experience
and skills between the two countries.
 Poster # 146
Analysis of the Use of Anti-thrombin III in the Severe Trauma Patients..
MARU KIM Ph.D., DAESANG LEE Ph.D., The Uijeongbu St. Mary Hospital, The
Catholic University Of Korea
Introduction: Antithrombin is a potent inhibitor of thrombin and have a properties of
anticoagulant with anti-inflammatory property. In trauma patients, anti-thrombin level is
inversely related with the injury severity score(ISS) and low anti-thrombin III level is
related with multi-organ failure(MOF). We hypothesized that antithrombin could
attenuate the detrimental effects on the inflammatory process and organ function. We
evaluated the influence of anti-thrombin III on the MOF and mortality in the severe
trauma patients (ISS>15)
Methods: This is a retrospective study using Trauma Database of our hospital between
January, 2016 and December, 2016. Major trauma patients (ISS>15) with low anti-
thrombin level(<70%) were enrolled in this study. We divide the patients into
antithrombin using group(AT-III(+)) vs non-using group(AT-III(-)) and compare the
mortality, MOF, bleeding event between two groups.
Results: Total 99 patients were included in this study and mean ISS score of the patients
was 25.1. Antithrombin level of survivor group(59.3%) was higher than non-survivor
group(44.7%)(p=0.002). All cause mortality of AT-III(+) (22%) was lower than AT-III(-)
(33%)(p=0.791). MOF of AT-III(+) was 8% and lower than that of
AT-III(-)(26%)(p=0.047)
Conclusion: Antithrombin level is inversely correlated with severity of trauma. There was
no difference of mortality between antithrombin using group and non-using group.
Antithrombin appear to attenuate the post traumatic response and multi organ failure.
 Poster # 147
TRAUMATIC DIAPHRAGMATIC HERNIA: HOW TO IMPROVE THE
DIAGNOSIS?
Vitor F. Kruger MD, Alcir E. Dorigatti MD, Bruno M. Pereira MD,Ph.D., Elcio S.
Hirano MD,Ph.D., Jose B. Bortoto MD, Gustavo P. Fraga MD,Ph.D., University of
Campinas, Brazil

Objective: Traumatic diaphragmatic hernia (TDH) is uncommon and difficult to diagnose

in trauma patients. The aim of this study is present demographics, how to improve the
diagnosis, surgical treatment and outcomes.
Method: This is a retrospective trauma registry based study in a single university trauma
center between 1990-2017.
Results: A total of 3.003 trauma patients were submitted to exploratory laparotomy. 425
(14.1%) had a diaphragm injury AAST grade ³ II. TDH was identified in 55 cases
(12.9%), with predominance of male (46 cases - 83.6%), and age ranging from 13 to 59
years old (median 34). Blunt TDH occurred in 40 cases (72.7%; automobile accident in
26 cases) and penetrating TDH in 15 cases (27.3%; stab wound in 9 cases). Diagnosis was
made mostly by chest x-ray (CXR) in the trauma bay (31 cases - 56.3%), following the
intraoperative finding (13 cases - 23%). Laparotomy was performed in 54 cases (98.1%)
and only one patient with stab wound was treated by laparoscopy. In two patients with
chronic TDH was necessary associated thoracotomy. In 13 patients (23.6%) with
hemodinamically instability the diagnosis was intraoperatively, 2 cases with diagnostic
peritoneal lavage. The surgical indication was based in CRX in the trauma bay in 30 cases
(54,4%). computed tomography in 7 cases (12.7%), laparoscopy in 3 cases (5,4%), in 3
cases 2 converted to laparotomy. 49 cases with left side, 5 right side and 01 bilateral. The
stomach was the organ most frequently found herniating into the chest (38 cases). The
rate of pulmonary complications was 18 cases (66%).The LOS average was 14 days. The
mean ISS was 24. Overall mortality was 20% (11 of 55).
Conclusion: TDH was identified in few trauma patients (1.8%) admitted at our hospital,
mainly after blunt trauma. Despite advances in imaging methods, CXR is still useful in
the diagnosis or suspicion of TDH and the ATLS® protocol should be followed. CT is
helpful for the diagnosis of TDH and identifies associated injuries. Laparoscopy was
useful diagnosis in three patients but only one was treated laparoscopilly. Laparotomy
remains the gold standard for the diagnosis and treatment.
 Poster # 148
OUTCOMES OF EMERGENCY DEPARTMENT LAPAROTOMY IN
NON-RESPONDER AFTER RESUSCITATION; EARLY EXPERIENCE IN A
SINGLE CENTER
Chan Ik Park MD, Jae Hun Kim MD, Pusan National University Hospital

Introduction: Outcomes of patients with bleeding depend on how rapid bleeding stop.
Emergency department laparotomy is considered one of ways to reduce intra-abdominal
bleeding. Here we evaluated the outcomes of emergency department laparotomy through
the early experience of a single trauma center.
Methods: We reviewed medical records and data of patients who were non-responder
after resuscitation and underwent emergency department laparotomy between January
2016 and December 2017.
Results: Twelve patients underwent emergency department laparotomy. Ten patients had
sustained blunt trauma, and two were victims of abdominal stab wounds. Injuries to the
small bowel, spleen, and liver were most common. One patient could not reach the
operating room. Three of 12 were survived. One of three who were survived had severe
neurologic sequelae.
Conclusion: Patients that underwent emergency department laparotomy showed high
mortality. However, emergency department laparotomy can be considered as an option to
reduce intra-abdominal bleeding for non-responder after resuscitation.
 Poster # 149
Predictive value of computed tomography in diagnosing bowel and/or mesenteric
injuries after blunt trauma: Correlation with surgery findings.
Kihoon Kim MD,Ph.D., Inje University Haeundae Paik Hospital

Introduction: Bowel and mesenteric injuries occur in about 5% of blunt abdominal

trauma patients. Delay in diagnosis may increase the morbidity and mortality. Computed
tomography(CT) is the current accepted standard imaging modality for abdominal organ
injury diagnosis and is now considered accurate in the diagnosis of bowel and mesenteric
injuries. There is still controversy as to how reliably CT alone could help identify those
blunt bowel and mesenteric injuries requiring surgery. Aims of this study are to review the
correlation between CT signs and intraoperative finding in case of bowel and mesenteric
injuries following blunt abdominal trauma and identify the diagnostic specificity of those
signs found at CT with practical considerations on the following clinical management.
Methods: This is single-center retrospective study of trauma patients from March 2010 to
December 2017. All patients admitted to our hospital after blunt trauma and CT scan at
admission were assessed. 211 patients required operative management following blunt
trauma. Data were analysed correlating operative surgical reports with the preoperative
CT findings.
Results: 77 patients presented bowel and/or mesenteric injuries. The median patient age
was 50 years(12-75 years), 75% of the patients were male(n=58). 78% of the patients
were CT grade 5. 3% of patients(n=2) showed CT grade 1. The median length of stay and
ICU were 26 days(1-254) and 4 days(0-91)
Conclusion: All images, charts and tables must be placed and uploaded in the body of
your abstract exactly as you want them (please remove this line when creating your
abstract).CT scan is the gold standard in the assessment of intra-abdominal blunt
abdominal trauma for not only parenchymal organs injuries but also detecting bowel and/
or mesentery; in the presence of specific signs it may provides an accurate assessment of
hollow viscus injuries, helping the trauma surgeons to choose the correct initial clinical
management.
 Poster # 150
CLINICAL SIGNIFICANCE OF CULTURE OF PAD USED FOR PACKING IN
DAMAGE CONTROL LAPAROTOMY
Younggoun Jo MD, Yunchul Park MD, Jungchul Kim MD, Chonnam National University
Hospital
Introduction: Damage control laparotomy (DCL) is a technique utilized to care of
massively injured trauma patient. We conducted bacterial analysis of the pad used for
packing in DCL and studied its association with morbidity and mortality.
Methods: This is a retrospective review of all patients undergoing immediate laparotomy
at our institute between 2011 and 2015. DCL was defined as temporary abdominal closure
at the initial surgery. 18 consecutive patients undergoing DCL were analyzed.
Microbiologic samples from pad used in DCL were collected.
Results: 15 microorganisms were cultured. Samples from 12 (66.7%) patients were
positive by microbiologic culture and six (33.3%) patients were negative. Morbidity rate
(91.7% vs. 66.7%) and mortality rate (41.7% vs. 16.7%) were higher in patients with
positive culture than patients with negative culture. Infection rates such as surgical site
infection (75.0% vs. 33.3%) and sepsis (41.7% vs. 16.7%) were higher in culture-positive
patients. Four patients underwent two or three take back surgeries and all samples from
these patients were positive for microorganism.
Conclusion: There was a high infectious complication rate in patients with positive
culture of pad. And two or more frequent take back surgery seems to increase risk of
infection in DCL.
 Poster # 151
A RARE CARDIAC TRAUMA BY MACHETE
BRUNO J. MEDEIROS MD, SURGERY INSTITUTE OF AMAZONAS STATE

Introduction: Chest trauma is one of the most common causes of death corresponding to
20 to 25 % of cases. It can be blunt or penetrating trauma. The majority of the patients,
85%, can be managed only with a tube thoracostomy and only 10 to 15 % will require a
trauma thoracotomy. Conventional indications for emergency thoracotomy are divided
into acute and not acute. One of the most common indications of thoracotomy in trauma is
the amount of blood immediately exiting the thoracic drain: immediate drainage of 1,500
ml of blood and deterioration of the hemodynamic status.
Methods: This was an observational study characterized by clinical inspection of a
patient with chest trauma by machete.
Results: A 37-year-old man entered on our emergency room at a central hospital of Rio
Branco – ACRE, Brazil, with a blunt, linear, 20-cm (Figure 1) sucking chest wound on
the right side, caused by a machete. Respiratory rate was 25 per minute, saturating 90%on
ambient air, blood pressure (BP) of 110x70 mmHg and heart rate of 115 per minute, he
was semiconscious. After the initial care, the patient becomes better and a great question
came to mind: operate or treat conservatively?
Conclusion: Noting that the machete is a very contaminated object, used in various
situations in agriculture, and that we are facing a large and deep lesion with a large part in
the Ziedler area and that the machete as shown must have a great impact energy. We
decided to go to the surgical center thinking that a large thoracic wound could not be well
cleaned without general anesthesia. In the operating room, the lesion was enlarged to the
lateral side and a Finochietto retractor was used. A large transversal laceration was
observed on the pericardial sac, associated with phrenic nerve lesion and right diaphragm
paralysis (Figure 2). At that moment the right anterolateral thoracotomy was
complemented with a transverse sternotomy with the control of the proximal and distal
right mammary artery. There was a right atrial lesion of about 3 cm with a large clot. The
lesion was controlled with a Satinski tweezers and a running suture with 4-0 prolene.
There was also an injury to the right ventricle with associated lesion of a distal branch of
the right coronary artery, controlled with U stitches. (Figure 3)
 Poster # 152
DELAYED RUPTURE OF SPLENIC PSEUDOANEURYSM AFTER BLUNT
ABDOMINAL TRAUMA
Younggoun Jo MD, Yunchul Park MD, Jungchul Kim MD, Chonnam National
University Hospital
Introduction: Incidence of splenic pseudoaneurysm after abdominal trauma could result
in critical consequences. Here, we present a case of delayed rupture of splenic
pseudoaneurysm after blunt abdominal trauma
Methods: A 68 year-old man referred to our hospital with an abdominal pain and
hemodynamic instability. 3 months ago, he bumped into cultivator handle while he was
moving the vehicle. At that time, he didn’t undergo any examination about accident. On
laboratory findings, hemoglobin was 9.1 g/dL and lactate was 2.0 mmol/L. Abdominal
computed tomography(CT) showed large amout of perisplenic hematoma with irregular
margin of spleen and hemoperitoneum at right paracolic gutter and pelvic cavity.
Results: An immediate angiography was performed. Superselective angiogram showed
pseudoaneurysms at splenic artery branches. Coil embolization was condected with
microcoils. 1 week later follow up CT showed no remarkable change of laceration of
spleen without bleeding and patient was discharged without any problems.
Conclusion: After high powered blunt abdominal injury when possible proper
evaluations should be performed to prevent the occurrence of late devastating events.
 Poster # 153
Colonic stricture after angioembolization of pseudoaneurysm at left colonic artery
Jungchul Kim MD, Yunchul Park MD, Wuseong Kang MD, Yoiunggoun Jo MD,
Chonnam National University Medical School
Introduction: Rupture of pesudoaneurysm at mesentery can resulted in fatal
consequences. Interventional radiology is one of the treatment method. Here, we present a
case of delayed stricture of left colon after angioembolization at branch of left colonic
artery.
Methods: A 68 year-old man referred to our hospital after cultivator rollover accident.
Abdominal computed tomography(CT) showed liver laceration and segmental thrombotic
occlusion in left common iliac [Link] angioplasty was done at left common
and external iliac artery. On the third day of hospitalization,patient showed sudden sign of
shock and follow up abdomen CT showed bleeding in left mesentery with large amount of
hemoperitoneum.
Results: An immediate angiography was [Link] angiogram showed
pseudoaneurysms at ascending branch of left colic artery..Coil embolization was
conducted with microcoils.1month later patient presented abdominal distension with pain
and follow up abdomen CT showed left colonic abstruction .Emergency operation was
performed and subtotal colectomy was done.
Conclusion: Angioembolization at coloninc artery can cause a rare complication, such as
colon obstruction. Careful observation and follow up after procedure is mandatory for
rapid diagnosis and treatment.
 Poster # 154
DAMAGE CONTROL SURGERY WITH PAD PACKING FOR ACTIVE
BLEEDING IN CRUSHING WOUND OF THE PERINEUM AND AMPUTATED
LEG STUMP
Wuseong Kang MD,Ph.D., Wonkwang University Hospital

Introduction: We reported a case of crushing wound of the perineum and amputated leg
stump which was treated by damage control surgery with pad packing.
Methods: A 67-year-old man had a crushing injury. His left leg was sucked in the wheel
of a tractor. His systolic blood pressure and hemoglobin level upon admission were 50
mm Hg and 7.5 g/dL, respectively. His perineum and leg had multiple crushing open
wounds and open fractures. The large defect of the leg wound was considered to require
amputation above the knee, which was performed immediately with the closure of the
perineal wound. However, a large volume of bloody discharge was observed in the
perineal and leg stump wounds postoperatively. Massive transfusion was performed, and a
second operation was performed. In the second operation, large bloody oozing of muscle
and several arterial bleeders was observed. Although the bleeders were ligated, the bloody
oozing continued. To control the bloody oozing, pad packing to the perineal and thigh
stump wounds, and approximation with suture to compress the wound were performed.
Diverting colostomy was performed to protect the wounds.
Results:After pad packing, the bloody discharge stopped and the pad was removed in the
third operation. Owing to the large defects with infection of perineal and thigh stump
wound, negative pressure wound therapy and repeated irrigation with debridement were
performed. At 6 months after the first operation, his wound was completely healed, and
colostomy repair was performed.
Conclusion: In this case, the hemodynamically unstable, crushing perineum wound and
leg stumps were treated safely by damage control surgery with pad packing.
 Poster # 155
LEFT VENTRICLE INJURY ASSOCIATED WITH CARDIAC TRAUMA BY
GUNSHOT WOUND: A CASE REPORT.
Francisco E. Silva Sr., MD, Rodrigo M. Féres Sr., MD, Ricardo J. Garcia Sr., MD, José
Alfredo C. Padilha Sr., MD, Renata P. Pereira Sr., MD, Adriana M. Rangel Sr., MD,
Raphael L. Coelho Sr., MD, Hospital Estadual Alberto Torres - Centro De Trauma
Introduction: The incidence of cardiac trauma is low in the universe of traumatic
injuries. Right ventricle (RV) is the most affected cardiac chamber in the penetrating
cardiac trauma.
Methods: R.L.R. 42, male, brought Trauma Center due to gunshot injury with an entry
orifice in the left paravertebral dorsal region, with no exit orifice. During the initial
clinical examination, the patient was eupneic in ambient air, vesicular murmur and
pulmonary expandability reduced in the left hemithorax, O2 saturation 98%, systemic
blood pressure of 210 x 110 mmHg, heart rate of 104 beats per minute. Glasgow Coma
Scale 14.
Results: A left anterior thoracotomy was performed, showing hemopericardium, with left
ventricular (LV) transfixing wound, with left posterolateral entry orifice and extensive
anterolateral exit orifice associated with bulky bleeding. The patient was referred to the
Intensive Care Center with satisfactory evolution.
Conclusion: Penetrating wounds of the left ventricle, even less common, may present a
favorable outcome if approached and treated effectively.
 Poster # 156
DAMAGE CONTROL IN ABDOMINAL TRAUMA: A CASE REPORT
Mariana N. Fernandes MD, Marcio R. Cruz Sr., MD, Hospital Geral Ernesto Simões Filho

Introduction: Hypothermia, coagulopathy and acidosis, a vicious cycle generally known

as “the lethal triad”, contribute significantly to the increase in trauma-related mortality.
Prolonged surgical time has been shown to worsen hemodynamic status, and if it is a
reversible cause, such as hypovolemic shock, damage control should be the choice
Methods: A 24-year-old male patient was victim of multiples gunshots wounds in
abdomen. At admission, he was unstable and in shock despite fluid resuscitation. At
physical examination he presented an abdominal gunshot wound (left iliac fosse).
Abdomen was flaccid and diffusely painful. On the laparotomy was evidenced lesion in
40% of the intestinal loop circumference at 80cm from the Treitz and lesion in 60% of the
circumference of the sigmoid colon. Opted for damage control surgery through the raffia
of small intestine lesion, sigmoid resection and burial of stumps, ureterostomy,
anastomosis of the branches of the left iliac vein, using hemostats and pelvic tamponade.
Referred to the ICU after 3 hours of surgery. A new reassembly was performed after 36
hours with removal of the compresses, catheterization of the ureter and terminal
colostomy. He was discharged from the ICU after 13 days
Conclusion: Damage control has proven to be an important ally to the restoration of the
physiological parameters of the polytraumatized patient. Due to the large number of
injuries in this patient, we could not perform damage control in one hour as it is
recommended. Even though it was not faithful to the ideal surgical time, the choice of
controlling potentially fatal lesions was fundamental for better healing and enhance the
patient’s hemodynamic status.
 Poster # 157
TENSION PNEUMOTHORAX SECONDARY TO
EXPANDING HEMORRHAGIC PNEUMATOCELE AFTER BLUNT CHEST
TRAUMA
John V. Agapian MD, FACS, FCCM, Maxim Gusev MD, Hector Ludi MD, FACS,
Arnold Tabuenca MD, FACS, Afshin Molkara MD, FACS University Of California,
Riverside/RUHS; LLU
Introduction: Tension pneumothorax can lead to hemodynamic shock by impairing
blood return to the heart and restricting cardiac output. Typically, this is may be due to a
large pneumothorax or hemothorax. A pneumatocele is a cavity in the lung parenchyma
usually filled with air that may result from pulmonary trauma. We present the first report
of a hemorrhagic pneumatocele secondary to trauma resulting in a tension pneumothorax.

Methods: 18 year old male presented to trauma center in shock, complaining that 'he
could not breathe'. He was subsequently intubated, and a right tube thoracosctomy placed
for diminished breath sounds. Chest computerized tomography identified a large air-fluid
cavity with extravasation of contrast, suggesting ongoing hemorrgae into the
pneumatocele. The chest tube continued with scant output. Patient's hemodynamic
condition continued to deteriorate, and repeat chest XR demonstrated significant right to
left mediastinal shift. Right thoracotomy was performed and massive hematoma removed
from the pneumatocele.

Results: The patient's hemodynamic condition improved after the large mass occupying
hemothorax was evacuated from the hemorrhagic pneumocoele contained in the right
chest cavity.

Conclusion: Hemorrhagic pneumatocele is rare, and has never been described as a cause
for tension pneumothorax. Do to the location of hematoma, a conventional thoracostomy
tube can not release the tension -a thoracotomy is needed. We describe the first report of
a tension hemorrhagic pneumatocele.
 Poster # 158
NON-OPERATIVE TREATMENT OF A TRAUMATIC GRADE V PANCREATC
LESION - CASE REPORT
Maria F. Oliva Detanico MD, Rogerio Fett Schneider MD, Guilhermo Taglietti MD,
Henrique Pauletti MD, Caroline Gargioni Barreto MD, Ledwyng D. Gonzalez Patino MD,
Mariana Pasin Bergamaschi MD, Joao A. Argenton Zortea MD, Kathrine Meier MD,
Gabriele Santos Persch MD, Shirley Lourenco Scorza MD, Hospital De Pronto Socorro
De Canoas
Introduction: Although pancreatic trauma is not a common injury, the mortality could be
as high as 50% in complex cases. The typical mechanism of injury is the compression of
the epigastric area against the vertebrae. The current treatment for grade V lesions is the
Whipple procedure.
Methods: Male patient, 18 years, transfered to our trauma center level I after 48h of a
blunt abdominal trauma. The first attendance and diagnosis were made at a rural Hospital
after 36h of trauma. He arrived at our facility hemodinamicaly stable but with a persistent
abdominal pain and nausea. A new abdominal CT scan was made and showed a laceration
at the pancreatic head and a large amount of free abdominal fluid.
Results: The surgical team decided to perform an exploratory laparotomy. During the
procedure, it was diagnosed a large hematoma of head and uncinate process of pancreas,
without other lesions (duodenum, bile duct and pancreatic body were intact). It was
decided to only drain the abdominal cavity. It was started TPN in the immediate
postoperative and the enteral feeding was re-started 10 days after the procedure with good
acceptance; no other surgical procedure was done.
Conclusion: The patient was discharged after 28 days of hospitalization with a good
evolution. He is still in follow-up without any complications.
 Poster # 159
ENDOVASCULAR REPAIR FOR AXILLAR ARTERY INJURY - CASE REPORT
Fabiana Kain De Moura MD, Barbara Andreazza MD, Gustavo Antonio Giolo MD,
Maria F. Oliva Detanico MD, Hospital De Pronto Socorro De Canoas
The use of endovascular technique for the correction of penetrating traumatic vascular
injuries is being encouraged, especially for those which the traditional approach could
have a higher morbidity due to the location. Lesions at the subclavian and axillar arteries
are one of these cases
The case we present is male patient, 28y, that arrived at our hospital with a gunshot
wound at the right shoulder without exit. At the first attendance, he was instable due to a
pneumo/hemothorax which was promptly drained. After the clinical stabilization, he still
didn’t have right braquial/ radial pulse, but the arm had good perfusion (no pain, good
warming and capillary filling). An angiography by CT scan was performed and showed
partial lesion of axillar artery but with good distal perfusion. As the patient remained
stable, he was transferred for another hospital and the endovascular repair was done with
a good result.
 Poster # 160
A case series study of blunt trauma causing aortic injury.
Shusuke Mori MD,Ph.D., Tomohiko Ai MD,Ph.D., Yasuhiro Otomo MD,Ph.D., Tokyo
Medical and Dental University
Introduction: Aortic injury caused by blunt trauma is common but it presents various
types of injury. Most cases are found dead or to have already fallen into a
cardiopulmonary arrest when the patient arrives at a hospital. Some cases demonstrate
progressive or delayed onset of aortic injuries, especially aortic dissections, which are
sometimes difficult to treat. This study is to investigate what types of aortic injuries
caused by blunt trauma are seen in one of the largest trauma centers in Japan.
Methods: Retrospective review of the patient records of blunt trauma cases with aortic
injury for 10 years since 2007 in one of high volume trauma centers in Japan was
performed. Each case alive on arrival was discussed in detail.
Results: Out of approximately eighty thousand ambulance cases and thirty thousand
admissions for 10 years in total, only 19 cases showed an aortic injury caused by blunt
trauma. A total of 11 cases presented a cardiopulmonary arrest on arrival, and 8 cases of
them seemed to have died mainly of severe aortic injury and the rest died of other organ
injuries. Eight cases were alive on arrival and 2 of them were initially asymptomatic.
Types of aortic injury were Stanford type A aortic dissections in 3 cases, type B in 3
cases, and aortic rupture in 2 cases. Two cases of type A dissection underwent an
emergency operation, whereas all 3 type B dissections went on a good course with
conservative treatment.
Conclusion: Aortic injury caused by blunt trauma is rare in Japan. Stanford type B aortic
dissections did not require aortic repair and showed good prognoses.
SCHOLARSHIP
FUND
 RESEARCH SCHOLARSHIP RECIPIENTS
AMERICAN ASSOCIATION
FOR THE SURGERY OF TRAUMA
1988 – 2018

WINTHROP

1988 – 1989 Stephen E. Morris, M.D.

AAST/SHERWOOD DAVIS & GECK

1988 – 1989 Sandra Beale, M.D.

1989 – 1990 Christine Cocanour, M.D.
1989 – 1990 Daniel J. Johnson, M.D.
1991 – 1992 Eric J. DeMaria, M.D.
1991 – 1992 Scott A. Dulchavsky, M.D., Ph.D.
1991 – 1992 Lena Napolitano, M.D.
1992 – 1993 Mark D. Cipolle, M.D., Ph.D.
1992 – 1993 William J. Mileski, M.D.
1993 – 1994 David A. Spain, M.D.
1993 – 1994 James R. Wallace, M.D., Ph.D.
1994 – 1995 Carnell Cooper, M.D.
1994 – 1995 David A. Spain, M.D.
1995 – 1996 Robert N. Cooney, M.D.
1995 – 1996 Charles N. Mock, M.D., M.P.H., Ph.D.
1996 – 1997 J. Perren Cobb, M.D.
1996 – 1997 Chong-Jeh Lo, M.D.
1997 – 1998 Kimberly A. Davis, M.D., M.B.A.
1997 – 1998 Joseph T. Murphy, M.D.
1998 – 1999 Kenneth H. Sartorelli, M.D.
1998 – 1999 Joseph T. Murphy, M.D.

AAST/WYETH-AYERST SCHOLARSHIP AWARD

1999 – 2000 Grant O’Keefe, M.D., M.P.H.

2000 – 2001 James C. Jeng, M.D.
2001 – 2002 Eileen M. Bulger, M.D.

AAST/JOHN B. DAVIS RESEARCH SCHOLARSHIP AWARD

1994 – 1995 Paul E. Bankey, M.D., Ph.D.

1995 – 1996 Chong-Jeh Lo, M.D.
1996 – 1997 Robert N. Cooney, M.D.
1997 – 1998 Charles N. Mock, M.D., M.P.H., Ph.D.
1998 – 1999 Jeffrey S. Young, M.D.
1999 – 2000 Glen A. Franklin, M.D.
2000 – 2001 Glen A. Franklin, M.D.
2001 – 2002 Alan D. Murdock, M.D.
2002 – 2003 Eileen M. Bulger, M.D.
2003 – 2004 Toan T. Huynh, M.D.
2004 – 2005 Louis J. Magnotti, M.D.
2005 – 2006 Gregory P. Victorino, M.D.
2006 – 2007 Carrie A. Sims, M.D.
2007 – 2008 Vishal Bansal, M.D.

AAST/RESEARCH & EDUCATION SCHOLARSHIP AWARD

2002 – 2003 Gregory P. Victorino, M.D.

2003 – 2004 Saman Arbabi, M.D., M.P.H.
2004 – 2005 Saman Arbabi, M.D., M.P.H.
2006 – 2007 Mark R. Hemmila, M.D.
2007 – 2008 Suresh Agarwal, Jr., M.D.

AAST/RESEARCH & EDUCATION FOUNDATION

SCHOLARSHIP AWARD

1999 – 2000 Kenneth H. Sartorelli, M.D.

2000 – 2001 Andrew J. Michaels, M.D., M.P.H.
2001 – 2002 Kimberly A. Davis, M.D.
2001 – 2002 James A. Murray, M.D.
2002 – 2003 Susan I. Brundage, M.D., M.P.H.
2002 – 2003 Colleen E. Jaffray, M.D
2003 – 2004 Raminder Nirula, M.D., M.P.H.
2003 – 2004 Kathryn M. Tchorz, M.S., M.D.
2004 – 2005 Jason J. Hoth, M.D.
2004 – 2005 Obeid Ilahi, M.D.
2005 – 2006 Carlos V.R. Brown, M.D.
2005 – 2006 Rochelle A. Dicker, M.D.
2005 – 2006 Ajai K. Malhotra, M.D.
2006 – 2007 Michel Aboutanos, M.D., M.P.H.
2007 – 2008 Barbara A. Gaines, M.D.
2008 – 2009 Timothy Browder, M.D.
2008 – 2009 Tam Pham, M.D.
2009 – 2010 Eric Ley, M.D.
2009 – 2010 Tam Pham, M.D.
2010 – 2011 Jared M. Huston, M.D.
2010 – 2011 Eric Ley, M.D.
2011 – 2012 David A. Machado-Aranda, M.D.
2011 – 2012 Susan Rowell, M.D.
2012 – 2013 Todd Costantini, M.D.
2012 – 2013 Steven Schwulst, M.D.
2013 – 2014 Susan Evans, MD
2013 – 2014 Robert David Winfield, MD
2014 – 2015 Jacob Glaser, M.D
2014 – 2015 Angela Ingraham, M.D.
2014 – 2015 Jon Simmons, M.D.
2015 – 2016 Matthew Delano, M.D.
2015 – 2016 Benjamin Levi, M.D.
2015 – 2016 Matthew D. Neal, M.D.
2016 – 2017 Robert Becher M.D.
2016 – 2017 Damien Carter, M.D.
2017 – 2018 Vanessa Nomellini, M.D., Ph.D.
2017 – 2018 Jonathan Wisler, M.D., MS
2017 – 2018 Samuel P. Mandell, M.D., M.P.H.
2018 – 2019 Vanessa Ho, M.D., M.P.H.
2018 – 2019 Marta McCrum, M.D., M.P.H.
2018 – 2019 Deepika Nehra, M.D.

AAST/NOVO NORDISK RESEARCH AWARD IN

HEMOSTASIS AND RESUSCITATION

2006 – 2007 Mitchell Jay Cohen, M.D.

2008 – 2009 Mitchell Jay Cohen, M.D.
2009 – 2011 Matthew Rosengart, M.D., M.P.H.

THE ACS, AAST AND NIGMS

JOINTLY SPONSORED MENTORED
CLINICAL SCIENTIST DEVELOPMENT AWARD (K08/K23)

2006 – 2011 Mark R. Hemmila, M.D.

2007 – 2012 Alicia Mohr, M.D.
2008 – 2013 Mitchell Jay Cohen, M.D.
2009 – 2013 Jason J. Hoth, M.D.
2010 – 2013 Jason Sperry, M.D.
2011 – 2013 Carrie Sims, M.D.

AAST/ETHICON RESEARCH GRANT IN LOCAL WOUND

HAEMOSTATICS AND HEMORRHAGE CONTROL

2007– 2008 Kenji Inaba, M.D.

2008 –2009 Jose Pascual, M.D.
2009 –2010 Jennifer Watters, M.D.
2010 – 2011 Jeffrey S. Ustin, M.D.

AAST/KCI RESEARCH GRANT IN WOUND CARE

2007 – 2008 Therese M. Duane, M.D.

2008 – 2009 Michael Corneille, M.D.
2009 – 2010 Ziad C. Sifri, M.D.
2010 – 2011 Lydia Lam, M.D.
2011 – 2012 Laurie Punch, M.D.

AAST/CIMIT RESEARCH FELLOWSHIP IN THE FIELD OF

TECHNOLOGY IN TRAUMA AND CRITICAL CARE

2009 – 2010 Jeffrey Ustin, M.D.

2010 – 2011 David King, M.D.
2011 – 2012 Suresh Agarwal, Jr., M.D.
2017 AMERICAN ASSOCIATION FOR THE SURGERY OF
TRAUMA
RESEARCH AND EDUCATION FUND DONORS:
(Donations received January 1, 2017– December 31, 2017)

Dr. Charles Adams, Jr. Dr. Michael Cripps

Dr. John Adamski II Dr. Martin Croce
Dr. Nikhilesh Agarwal Dr. James Cushman
Dr. Suresh Agarwal, Jr. Dr. Imad Dandan
Dr. John Armstrong Dr. Omar Danner
Dr. Richard Bagdonas Dr. Kimberly Davis
Dr. Chris Bandy Dr. Marc de Moya
Dr. Stephen Barnes Dr. Demetrios Demetriades
Dr. Erik Barquist Dr. Jody DiGiacomo
Dr. Andrew Bernard Dr. Warren Dorlac
Dr. James Betts Dr. Jay Doucet
Dr. Mary-Margaret Brandt Dr. Thomas Duncan
Dr. Susan Briggs Ms. Christine Eme
Dr. William Bromberg Dr. Blaine Enderson
Dr. Carlos Brown Dr. Thomas Esposito
Dr. Eileen Bulger Dr. Susan Evans
Dr. Clay Burlew Dr. Mary Fallat
Dr. Andre Campbell Dr. Richard Fantus
Dr. Jeannette Capella Dr. David Feliciano
Dr. Matthew Carrick Dr. Lewis Flint
Dr. William Cioffi Dr. Rajesh Gandhi
Dr. Christine Cocanour Dr. Donald Gann
Dr. Raul Coimbra Dr. Fernando Garcia
Dr. Arthur Cooper Ms. Sharon Gautschy
2017 AMERICAN ASSOCIATION FOR THE SURGERY OF
TRAUMA
RESEARCH AND EDUCATION FUND DONORS:
(Donations received January 1, 2017– December 31, 2017)

Dr. Thomas Genuit Dr. Anna Ledgerwood

Dr. Richard Gonzalez Dr. Frank Lewis
Dr. Kirby Gross Dr. Eric Ley
Dr. Ronald Gross Dr. David Livingston
Dr. Oliver Gunter Dr. Charles Lucas
Dr. Weidun Guo Dr. Hector Ludi
Dr. Mark Hamill Dr. Linda Maerz
Dr. Kimberly Hendershot Dr. Ronald Maier
Dr. Sharon Henry Dr. Mark Malangoni
Dr. Howard Hermans Dr. Ajai Malhotra
Dr. Jan Horn Dr. Matthew Martin
Dr. Jennifer Hubbard Dr. William Marx
Dr. Bellal Joseph Dr. Michael Metzler
Dr. D'Andrea Joseph Dr. Anthony Meyer
Dr. Christoph Kaufmann Dr. Andrew Mikulaschek
Dr. Krista Kaups Dr. Richard Miller
Dr. Paul Kearney Dr. Joseph Minei
Dr. Edward Kelly Dr. Ernest Moore
Dr. Orlando Kirton Dr. Matthew Moorman
Dr. Stanley Klein Dr. Sharon Moran
Dr. David Kluge Dr. David Mulder
Dr. M. Margaret Knudson Dr. Yoshinori Murao
Dr. Jaromir Koci Dr. Alan Murdock
Dr. Stanley Kurek, Jr. Dr. John Myers
2017 AMERICAN ASSOCIATION FOR THE SURGERY OF
TRAUMA
RESEARCH AND EDUCATION FUND DONORS:
(Donations received January 1, 2017– December 31, 2017)

Dr. Pal Naess Dr. John Sherck

Dr. Mayur Narayan Dr. Carrie Sims
Dr. Russell Nauta Dr. Michael Sise
Dr. Edmond Ng Dr. David Spain
Dr. Kathleen O'Hara Dr. Ronald Stewart
Dr. Patricia O'Neill Dr. Erik Streib
Dr. Pauline Park Dr. Ronald Tesoriero
Dr. Nancy Parks Dr. Scott Thomas
Dr. Andrew Peitzman Dr. Errington Thompson
Dr. Ruben Peralta Dr. Glen Tinkoff
Dr. Walter Pizzi Dr. Gail Tominaga
Dr. Charles Rice Dr. Bartholomew Tortella
Dr. Bryce Robinson Dr. Garth Utter
Dr. Susan Rowell Dr. Wendy Wahl
Dr. Grace Rozycki Dr. Brett Waibel
Dr. Ilan Rubinfeld Dr. Jennifer Watters
Dr. Jack Sava Dr. Jordan Weinberg
Dr. Thomas Scalea Dr. Michaela West
Dr. Henry Schiller Dr. Sonlee West
Dr. Carl Schulman Dr. James Wyatt, III
Dr. Kevin Schuster Dr. Mauro Zago
Dr. Jason Sciarretta
Dr. Steven Shackford
Dr. Forest Sheppard
2018 AMERICAN ASSOCIATION FOR THE SURGERY OF
TRAUMA
RESEARCH AND EDUCATION FUND DONORS:
(Donations received January 1, 2018– August 1, 2018)

Dr. Amy Goldberg Dr. Lillian Kao

Dr. Andrew Bernard Dr. Lonnie Frei
Dr. Andrew Peitzman Dr. M. Margaret Knudson
Dr. Arthur Cooper Dr. Mark Shapiro
Dr. C. William Schwab Dr. Martin Croce
Dr. Craig Brenner Dr. Mauro Zago
Dr. David Edelman Dr. Michael Moncure
Dr. Donald Klotz, Jr. Dr. Nikhilesh Agarwal
Dr. Edward Kelly Dr. Pal Naess
Dr. Ernest Gonzalez Dr. Pardon Kenney
Dr. Fernando Garcia Dr. Paul Schenarts
Dr. Jaromir Koci Dr. Ronald Stewart
Dr. Jody DiGiacomo Dr. Ronald Tesoriero
Dr. John Fildes Ms. Sharon Gautschy
Dr. John Pickhardt Dr. Stephen Kaminski
Dr. John Steele Dr. Steven Glorsky
Dr. Jonathan Groner Dr. Thomas Esposito
Dr. Karyn Butler Dr. Thomas Scalea
Dr. Kathleen O'Hara Dr. Wendy Wahl
Dr. Krista Kaups Dr. Yoshinori Murao
 2017-2018 AMERICAN ASSOCIATION FOR THE
SURGERY OF TRAUMA FUND 20forTwenty DONORS
(Donations received August 1, 2017 - July 6, 2018)

Dr. A. Britton Christmas Dr. Fernando Garcia Dr. Michael Cripps

Dr. A. Tyler Putnam Dr. Forest Sheppard Dr. Michael Dubick
Dr. Adam Fox Dr. Gail Tominaga Dr. Michael Hayashi
Dr. Ajai Malhotra Dr. George Maish, III Dr. Michael Sise
Dr. Alexander Eastman Dr. Gregory Timberlake Dr. Nikhilesh Agarwal
Dr. Andre Campbell Dr. Hector Ludi Dr. Oliver Gunter
Dr. Anil Srivastava Dr. Howard Hermans Dr. Richard Bagdonas
Dr. Arthur Cooper Dr. Imad Dandan Dr. Richard Miller
Dr. Barbara Gaines Dr. James Betts Dr. Robert Winfield
Dr. Bartholomew Tortella Dr. Jay Doucet Dr. Ronald Stewart
Dr. Brandon Bruns Dr. Jody DiGiacomo Dr. Ruben Peralta
Dr. Brett Waibel Dr. John Santaniello Ms. Sharon Gautschy
Dr. Charles Adams, Jr. Dr. Joseph Minei Dr. Sharon Moran
Dr. Christian Minshall Dr. Julie Wynne Dr. Stephanie Savage
Dr. Clay Burlew Dr. Karen Brasel Dr. Stephen Kaminski
Dr. David Edelman Dr. Kimberly Davis Dr. Steven Glorsky
Dr. David Notrica Dr. Laura Johnson Dr. Steven Shackford
Dr. David Skarupa Dr. Mark Cipolle Dr. Suresh Agarwal, Jr.
Dr. Deborah Kuhls Dr. Marko Bukur Dr. Thomas Broadie
Dr. Eleanor Winston Dr. Mary-Margaret Brandt Dr. Thomas Scalea
Dr. Elliott Haut Dr. Matthew Carrick Dr. Warren Dorlac
Dr. Erik Barquist Dr. Matthew Moorman Dr. William Marx
Dr. Ernest Block Dr. Mbaga Walusimbi
 2017 AAST #GIVINGTUESDAY DONORS
#GivingTuesday is a global day of giving fueled by the power of social media and collaboraƟon.

Dr. Charles Adams, Jr. Dr. Sharon Henry

Dr. Suresh Agarwal, Jr. Dr. Jeffrey Kerby
Dr. Scott Armen Dr. Eric Ley
Dr. Chris Bandy Dr. David Livingston
Dr. Andrew Bernard Dr. Lawrence Lottenberg
Dr. James Betts Dr. Hector Ludi
Dr. Carlos Brown Dr. Linda Maerz
Dr. Eileen Bulger Dr. Matthew Martin
Dr. Todd Costantini Dr. Christopher Michetti
Dr. Clay Cothren Burlew Dr. Alan Murdock
Dr. Martin Croce Dr. Jasmeet Paul
Dr. Omar Danner Dr. Andrew Peitzman
Dr. Kimberly Davis Dr. Gerd Pust
Dr. Bradley Dennis Dr. Michael Rotondo
Dr. Jody DiGiacomo Dr. Grace Rozycki
Dr. Heather Dolman Dr. Jeffrey Salomone
Dr. Jay Doucet Dr. Thomas Scalea
Dr. Joseph DuBose Dr. Kevin Schuster
Dr. Thomas Duncan Dr. Mark Seamon
Dr. Richard Falcone, Jr. Dr. Jason Smith
Dr. Mary Fallat Mrs. Jermica Smith
Dr. Richard Fantus Dr. David Spain
Dr. David Feliciano Dr. Ronald Stewart
Dr. Rajesh Gandhi Dr. Ronald Tesoriero
Ms. Sharon Gautschy Dr. Eric Toschlog
Dr. Kirby Gross Dr. Mbaga Walusimbi
Dr. Oliver Gunter Dr. Sonlee West
Dr. Elliot Haut
IN MEMORY
 IN MEMORY

Thomas L. Wachtel, M.D. Leonard Schweiberer, M.D.

Paradise Valley, Arizona Munich, Germany
(1938-2018) (1930-2017)
Member Since 1977 Member Since 1998

Frederick W. Ackroyd H. Bruce Williams

Boston, Massachusetts Montreal, Canada
(1930-2017) (1929-2017)
Member Since: 1930 Member Since: 1967

AAST was notified in 2017 THAT

the following members are deceased

Henry C. Cleveland, M.D. John F. Connolly, M.D.

Denver, Colorado Orlando, Florida
(1924-2016) (1936-2007)
Member Since: 1962 Member Since: 1936

Calvin B. Ernst, M.D. Elmer R. Maurer, M.D.

Juniper, Florida Winter Haven, Florida
(1934-2015) Member Since: 1952
Member Since: 1983

David Yashon, M.D.

Bexley, Ohio
(1935-2016)
Member Since: 1972
 THOMAS L. WACHTEL, M.D.
(1938–2018)

Dr. Wachtel was born on July 25, 1938, in Mansfield,

Ohio. He received degrees from Case Western Reserve
University, his medical degree from Saint Louis
University, and his masters in medical management
from Tulane University.
For more than 30 years, he was a senior trauma
surgeon and medical director of trauma centers in San
Diego (UCSD & Sharp), Denver, Phoenix, and
Scottsdale. He has held prestigious leadership
positions at medical organizations including the American Burn Association
and the American Surgical Association. Dr. Wachtel was a Clinical Associate
Professor of Surgery at the University of Arizona, and a retired Captain (USN)
who served two tours in Vietnam and spent a total of 37 years in the service.
He was also a writer who published two novels, Melt My Wings and Vietnam,
I Love You, 22 chapters in medical books, and more than 165 published papers
on trauma, burns, nutrition, and surgical education.
In 2008, Dr. Wachtel was in a car crash which left him a quadriplegic, but he
retained his wit and a dedication to the family members around him.

He is survived by his loving wife, Carolyn; three children, John Wachtel

DMD, David Wachtel and Julianne Wachtel-Bosch; three brothers (James,
John, and Edward); and ten grandchildren.
 LEONARD SCHWEIBERER, M.D.
(1930-2017)

Leonhard Schweiberer was married to Helgard

Schweiberer, born Abel. From the marriage, the karateka
and physician Birgit Schweiberer , the actor Thomas
Schweiberer and another daughter emerged, also a
physician.

As a member of the German alpine skiing national team ,

Schweiberer was among others 1956 Bavarian downhill
champion .

Schweiberer completed a degree in human medicine at the Ludwig-

Maximilians-University Munich (LMU), where he also obtained his
doctorate. In 1960 he moved to the Surgical Clinic of the University Hospital
of the Saarland in Homburg . There he habilitated, was appointed professor in
1976 and medical director of the department of trauma surgery , later acting
director of the medical department. In 1981 he was appointed to the chair of
the Surgical Clinic and Polyclinic of the Klinikum Innenstadt of the LMU
Munich and held this position until 1999. In 1981 he was Senate President of
the German Society of Traumatology. As a founding member of the working
group emergency medication he helped the pre-hospital emergency medicine
to a scientific basis. He was co-founder and initiator of the Institute for
Emergency Medicine and Medicine Management at LMU.

Von Schweiberer developed a trauma score (severity I to III) for the

exclusively descriptive classification of multiple injured emergency patients.
Schweiberer, who was a member of Rotary-Club München-Mitte, wrote twelve
books and monographs as well as more than 600 scientific papers. He was
editor or co-editor of textbooks, journals and book series.
FREDERICK W. ACKROYD
(1930-2017)

Frederick W. Ackroyd died on February 12, 2017, at

home, surrounded by family.
 H. BRUCE WILLIAMS
(1929-2017)

It is with deep sadness that we announce the

passing of Bruce Williams on March 24, 2017 at
the age of 87 after a brief illness. He was
predeceased, in 1997, by Dorothy, his loving wife
of 40 years. He will be greatly missed by his sons
Bruce (Beatrijs) and David (Bethany), his
grandsons Martin, Patrick, Ryan, Andrew and
Jason, and his loyal four- legged companion
Daisy.

He will also be fondly remembered by his sister Violet Fellows, sister-in- law
Edith Williams, and many relatives, friends, colleagues, students and patients.
He was predeceased by his siblings James, Betty, Sidney and Fraser, and in-
laws Robert, Margaret, Mary, Jack, Corum and Thomas from Harrisburg,
North Carolina.

Born in Barney's River Nova Scotia, he completed his BA at Acadia University

and graduated from Medical School at McGill University in 1955. Known for
his work repairing congenital deformities and facial injuries in children, he also
pioneered microvascular surgical techniques that improved the lives of
thousands.

Emeritus Professor of Surgery at McGill University, he was the Chairman of

McGill's Division of Plastic Surgery and Director of its Residency Program,
and founded the burn unit at the Montreal General Hospital. He led numerous
national and international medical organizations, and served as Surgeon-in-
Chief of The Montreal Children's Hospital for 14 years. The recipient of many
awards and distinctions, he was inducted into the Order of Canada in 2014.

An avid golfer, he was a member of the Royal Montreal Golf Club, Royal
Poinciana (Naples, FL) and the Abenakee Club (Biddeford Pool, ME) and
enjoyed playing rounds with his family and friends. Among other philanthropic
endeavors, he co-founded the very successful Montreal Children's Hospital
Foundation's Annual Golf Tournament in 1997 that supports research and
excellence in pediatric care by attracting and retaining the best and brightest
medical talent.
 HENRY C. CLEVELAND, M.D
(1924-2016)

It is with deep sadness that we announce the passing of

Bruce Williams on March 24, 2017 at the age of 87 after
a brief illness. He was predeceased, in 1997, by Dorothy,
his loving wife of 40 years. He will be greatly missed by
his sons Bruce (Beatrijs) and David (Bethany), his
grandsons Martin, Patrick, Ryan, Andrew and Jason, and
his loyal four- legged companion Daisy.

He will also be fondly remembered by his sister Violet Fellows, sister-in-law

Edith Williams, and many relatives, friends, colleagues, students and patients.
He was predeceased by his siblings James, Betty, Sidney and Fraser, and in-
laws Robert, Margaret, Mary, Jack, Corum and Thomas from Harrisburg,
North Carolina.

Born in Barney's River Nova Scotia, he completed his BA at Acadia University

and graduated from Medical School at McGill University in 1955. Known for
his work repairing congenital deformities and facial injuries in children, he also
pioneered microvascular surgical techniques that improved the lives of
thousands.

Emeritus Professor of Surgery at McGill University, he was the Chairman of

McGill's Division of Plastic Surgery and Director of its Residency Program,
and founded the burn unit at the Montreal General Hospital. He led numerous
national and international medical organizations, and served as Surgeon-in-
Chief of The Montreal Children's Hospital for 14 years. The recipient of many
awards and distinctions, he was inducted into the Order of Canada in 2014.
An avid golfer, he was a member of the Royal Montreal Golf Club, Royal
Poinciana (Naples, FL) and the Abenakee Club (Biddeford Pool, ME) and
enjoyed playing rounds with his family and friends. Among other philanthropic
endeavors, he co-founded the very successful Montreal Children's Hospital
Foundation's Annual Golf Tournament in 1997 that supports research and
excellence in pediatric care by attracting and retaining the best and brightest
medical talent.
 JOHN F. CONNOLLY, M.D.
(1936-2007)

Dr. John F. Connolly, respected orthopedic surgeon

and educator, died unexpectedly at his home in Orlan-
do, FL, on July 20, 2007, at the age of 71. He is re-
membered as a born educator and leader endowed with
conviction and compassion, a mentor, friend, and heal-
er. Born in Teaneck, NJ, on January 22, 1936, Connol-
ly was a 1953 graduate of Regis High School in New
York City. He graduated cum laude in 1957 from St.
Peter's College in Jersey City, NJ, and earned his medi-
cal degree with AOA honors at the New Jersey College
of Medicine (formerly Seton Hall) in 1961. He then completed surgical train-
ing in Seattle, New York and the University of Miami Jackson Memorial Hos-
pital.

After two years service as a captain in the United States Air Force, he took a
faculty position at Vanderbilt University (1968-1973), followed by a position
at the University of Nebraska Medical Center (UNMC) where he conducted
the bulk of his research career. Connolly’s role at UNMC was pivotal in the
development of a prominent residency program. In 1974, he joined the Depart-
ment of Orthopedic Surgery and Rehabilitation as its first full-time chairman
and built a nationally recognized orthopedic residency training program.

Although Dr. Connolly had broad academic interests, much of his research
focused on the healing process of difficult fractures. He did pioneering work
on bone marrow stem cells, including stimulating the bone marrow through
biologic and electrical techniques to promote healing of cartilage and bone.
Beyond his professional achievements, Connolly was also a devoted husband
and father of six daughters, and deeply committed to his religious beliefs. He is
survived by his loving wife of 43 years, Anne, and six daughters, Mari, Katie,
Ednamarie, Jeanine, Anne McGrath and Claire. He was blessed by fifteen
grandchildren at the time of his death.
 CALVIN B. ERNST, M.D.
(1934–2015)

Calvin B. Ernst, MD, died in Lexington, Kentucky on

July 7, 2015, barely a month after he had been diagnosed
with an extremely aggressive renal angiosarcoma. He
was born in 1934 in Detroit, Michigan, the only child of
Edward and Irene Ernst. He attended the University of
Michigan as an undergraduate, ran middle-distances on
the track team, and met and married his wife, Elizabeth
Abbott, in 1957. He attended the University of Michigan
Medical School, graduating in 1959 cum laude and a
member of AOA honorary. Following completion of his surgical residency at
the University of Michigan, he became a faculty member at his alma matter for
6 years, interrupted by 2 years as a captain in the U.S. Army from 1966 to
1968 during the Vietnam Conflict, serving in a MASH unit during the Tet
Offensive. In 1972, Ward Griffen recruited him to the University of Kentucky,
where he became the Chief of Vascular Surgery until 1979. He was
subsequently recruited by George Zuidema to the Johns Hopkins University,
where he was the Chief of Surgical Services at the Baltimore City Hospitals
until 1985. He then returned to Michigan and became the Chief of Vascular
Surgery at the Henry Ford Hospital for 12 years, leaving to head up the
Vascular Service for 3 years at the Allegheny University of the Health
Sciences-MCP Hahnemann School of Medicine. He retired in 2001, continuing
life as a serious cook, patient fisherman, and avid golfer.

Cal was a frequent contributor to the field of surgery, having authored more
than 295 papers and textbook chapters, edited eight surgical textbooks
including four editions of Current Therapy in Vascular Surgery, and presented
more than 280 scientific papers in the United States and abroad. He served on
the editorial boards of Surgery and the Archives of Surgery and was Editor of
the Journal of Vascular Surgery from 1991 to 1996. He had been the president
of a number of the more than two dozen learned societies that he was a
member of, including the Southern Association of Vascular Surgery in 1982,
the Frederick A. Coller Surgical Society in 1988, and the Society for Vascular
Surgery in 1990. He was a Director of the American Board of Surgery from
1991 to 1997. Cal was a surgeon’s surgeon and a legendary task master as an
educator who taught by example. His intensity and drive was matched by his
integrity and caring for his patients. Those who fell in his shadow were
fortunate for the experience.

He was most recently a resident of Jupiter, Florida and East Orleans,

Massachusetts. His wife Elizabeth passed away in 2011. He was the proud
grandfather of six and is survived by his four children, Lisa, Matthew, David,
and Susan, who were with him during his last days. He will be greatly missed
by many patients and friends, including those of us who were his surgical
colleagues.
ELMER R. MAURER, M.D.
Member Since: 1952
Winter Haven, Florida
 DAVID YASHON, M.D.
(1935-2016)

Dr. David Yashon was born on May 13, 1935, in Chicago,

Illinois, to Sam and Dorothy Yashon, immigrants from
Ukraine and Poland respectively. David graduated from the
University of Illinois with a [Link]., in 1958. He attended the
University of Illinois, receiving his Doctor of Medicine in
1960, remaining at the University of Illinois for his
internship and residency in Neurosurgery and
Neuropathology.

David started General Surgery at Presbyterian St. Luke's Hospital and then
continued to have many appointments during his medical career in the
Neurology Field of Medicine. David began his career as an Assistant in
Neuroanatomy, (University of Illinois, 1960), Clinical Instructor in
Neurosurgery (University of Chicago, 1965-1966), Associate Attending
Neurosurgeon (Cook County Hospital, Chicago, Illinois, 1965-1966), Assistant
Professor of Neurosurgery (Case Western Reserve University, Cleveland,
Ohio, 1966-1969), Associate Professor of Neurosurgery (The Ohio State
University, 1969-1974), and Professor of Neurosurgery (The Ohio State
University, 1974). David retired in 2011 as Professor of Neurosurgery,
Emeritus at The Ohio State University, Associate Neurosurgeon at Children's
Hospital, Columbus, Ohio and Neurosurgeon at Central Ohio Neurological
Surgeons, Westerville, Ohio. David was a member of the Hospital Staffs of
Riverside Methodist Hospital, Doctor's Hospital (courtesy), Mount Carmel
Hospitals (East and West), OSU East Hospital, and Grant/Riverside Hospital.
 77thAnnual Meeting of AAST and Clinical Congress of Acute Care Surgery
San Diego, CA September 26-29, 2018
TUE. 9/26/2018 FUNCTION ROOM
11:00 AM – 7:00 PM Registration Manchester Lobby (1st)
1:00 PM – 5:00 PM Presessions See Ticket for Locations
6:30 PM – 9:30 PM President’s Reception/Dinner Invite Only
WED. 9/27/2018 FUNCTION ROOM
6:15 AM – 7:15 AM International Breakfast (registration required) Coronado DE (4th)
6:15 AM – 7:15 AM Committee Meetings Various Locations
6:30 AM – 5:30 PM Registration Seaport Foyer (2nd)
7:00 AM – 8:30 AM Continental Breakfast Seaport Foyer (2nd)
7:30 AM – 8:00 AM Opening Session Seaport D-H (2nd)
8:00 AM – 10:40 AM Session I: Plenary Papers 1-8 Seaport D-H (2nd)
10:40 AM – 11:40 AM Session II: WTC Panel I Seaport D-H (2nd)
11:40 AM – 11:50 AM Break Seaport Foyer (2nd)
11:50 AM – 12:50 PM Session III: Presidential Address, Michael F. Rotondo, MD Seaport D-H (2nd)
1:00 PM – 2:15 PM Session IV: AAST Lunch Sessions (6) See Ticket for Locations
2:00 PM – 2:15 PM Break Seaport Foyer (2nd)
2:15 PM – 4:55 PM Session V: Papers 9-16 Seaport D-H (2nd)
5:00 PM – 6:00 PM Session VI: WTC Panel II Seaport D-H (2nd)
5:00 PM – 7:30 PM Exhibits Open Harbor D-I (2nd)
6:00 PM – 7:30 PM Session VII: AAST/WTC Posters Harbor D-I (2nd)
6:30 PM – 10:00 PM Journal of Trauma & Acute Care Surgery Editorial Board Meeting & Reception Harbor D-I (2nd)
THURS. 9/27/2018 FUNCTION ROOM
6:15 AM – 7:15 AM Medical Student/Resident/In-Training Fellow Breakfast (registration required) Coronado DE (4th)
6:15 AM – 7:15 AM Committee Meetings Various Locations
6:15 AM – 7:15 AM Session VIII: WTC I Sessions Various Locations
7:00 AM – 3:00 PM Exhibits Open Harbor D-I (2nd)
7:00 AM – 8:30 AM Continental Breakfast in Exhibit Hall Harbor D-I (2nd)
7:00 AM – 5:00 PM Donor Lounge Open Harbor Foyer (2nd)
7:30 AM – 8:50 AM Session IX: Papers 17-20 Plenary session Seaport D-H (2nd)
8:50 AM – 10:00 AM Session X: AAST Panel Seaport D-H (2nd)
10:00 AM – 10:30 AM Session XI: Scholarship Presentations Seaport D-H (2nd)
10:30 AM – 10:45 AM Break in Exhibit Hall Harbor D-I (2nd)
10:45 AM – 11:15 AM Session XII: Master Surgeon Lecture: Ian Civil, MD Seaport D-H (2nd)
11:15 AM – 12:15 PM Session XIII: WTC Panel III Seaport D-H (2nd)
12:15 PM – 1:30 PM Lunch in Exhibit Hall/Break Harbor D-I (2nd)
12:30 PM – 1:30 PM Session XIV: WTC Power Sessions (9) Various Locations
1:30 PM – 4:30 PM Session XVA: Papers 21-29: Parallel Session Seaport D-H (2nd)
1:30 PM – 4:30 PM Session XVB: Papers 30-38: Basic Science Seaport A-C (2nd)
4:45 PM – 5:45 PM Session XVI: WTC II Sessions Various Locations
6:30 PM – 9:30 PM San Diego Night (USS Midway) – Optional USS Midway
FRI. 9/16/2016 FUNCTION ROOM
6:15 AM – 7:25 AM Committee Meetings Various Locations
6:15 AM – 7:15 AM Session XVII: WTC III Sessions Various Locations
7:00 AM – 8:30 AM Continental Breakfast Harbor D-I (2nd)
7:00 AM – 3:00 PM Registration Open Seaport Foyer (2nd)
7:00 AM – 2:00 PM Exhibits Open Harbor D-I (2nd)
7:00 AM – 4:00 PM Donor Lounge Open Harbor Foyer (2nd)
7:30 AM – 9:30 AM Session XVIII: Papers 39-44 Seaport D-H (2nd)
9:30 AM – 9:45 AM Break in Exhibit Hall Harbor D-I (2nd)
9:45 AM – 10:45 AM Session XIX: Papers 45-47 Seaport D-H (2nd)
10:55 AM – 11:55 AM Session XX: Fitts Lecture: C. William Schwab, MD Seaport D-H (2nd)
12:00 PM – 1:15 PM Session XXI: AAST Lunch Sessions (6) See Ticket for Locations
1:15 PM – 1:30 PM Break in Exhibit Hall Harbor D-I (2nd)
1:30 PM – 2:00 PM Session XXII: Master Surgeon Lecture: Christine Gaarder, MD, PhD Seaport D-H (2nd)
2:00 PM – 5:00 PM Session XXIIIA: Papers 48-56 Seaport D-H (2nd)
2:00 PM – 5:00 PM Session XXIIIB: Papers 57-65 Seaport A-C (2nd)
5:00 PM – 6:30 PM AAST Business Meeting Seaport A-C (2nd)
5:00 PM – 6:00 PM Session XXIV: WTC IV Session Various Locations
7:30 PM – 11:00 PM Reception and Banquet Seaport Foyer & D-H
SAT. 9/17/2016 FUNCTION ROOM
7:00 AM – 10:00 AM Registration (If necessary) Seaport Foyer (2nd)
7:30 AM – 9:00 AM Continental Breakfast Seaport Foyer (2nd)
7:00 AM – 8:00 AM New Member Breakfast La Jolla (2nd)
8:00 AM – 9:00 AM Session XXV: Papers 66-68: Plenary Seaport A-C (2nd)
9:00 AM – 10:18 AM Session XXVI: Quick Shot Session I: Papers 1-26 Seaport A-C (2nd)
12:00 PM – 2:00 PM TSACO Editorial Board Meeting La Jolla (2nd)