expect that our words alone should not change your practice, but you should go home and the pertinent papers that resonated with you, you should look those up, do a deep dive and figure out what should be moving in your institution towards kind of changing practice. So that is the purpose of us kind of talking through these slides is just giving you our very high level thoughts on each one of these pertinent papers from the last year so you can decide how it changes your practice. So we're gonna go through the trauma section. I have a few disclosures, none of them are relevant to the comments that I'm about to make. I'm also gonna kind of go from head to toe from the trauma world so that it's a little bit more makes sense in terms of how we're doing this. I'm gonna talk quickly, again, make notes of which papers you wanna look up later, the QR code will be at the end. All right, blunt cerebrovascular screening. This paper looked at the cost effectiveness of screening and how that should be done. It was a very complex analysis using a Markov model where they took a huge cohort of patients, they looked at who got screened, who didn't get screened, what was ultimately found, who had strokes, who died, a whole nine yards and ultimately looked at what type of screening model was most cost effective. This was their findings. They looked at a couple different models that are out there, the Memphis and Denver criteria, but ultimately they found the top black line there was that if you screened everyone, that was the most cost effective measure of preventing subsequent downstream issues. Take that as you wish, think about how that might get incorporated into your practice, but potentially screening everyone might be the way in which we are going. Next paper, the TRACK-TBI study. This looked at six month outcomes after traumatic brain injury. They took patients with mild, moderate and severe brain injuries, compared them to patients who presented with isolated orthopedic injuries and looked at their outcomes at six months. Really interesting findings. Two thirds of patients actually had no cognitive impairment or decline at six months. However, that left another third of patients who actually had issues and those issues were along a huge spectrum from the memory issues, executive functioning issues, and ultimately the authors concluded that really when we talk about a personalized approach to recovery, we need to kind of take all of these things into consideration when we look at long-term outcomes after TBI. Next paper, this really wasn't a scientific study, but I think this is a topic we all should know something about because it's a world in which we practice and it's an important thing. This is the determination of brain death. Determination brain death was created by the Uniform Determination of Death Act back in 1980. This was created by the US Uniform Law Commission. And at that time, the belief was that if you were brain dead that would lead to cardiac death. Well, fast forward now 40 some odd years, critical care has gotten really, really good and brain death does not always lead to cardiac death. And so now there's a mismatch between the law and what actually happens. So on the table right now are considerations of what we should do as a profession moving forward for brain death. Do we change our societal guidelines to match the original determination law? Or do we change the definition of brain death, which is what the UK did in 2008 and make it more about consciousness and the ability to breathe? Or do we just maintain the status quo? This is out there, we need to be thinking about this. There will be more to come I'm sure in the literature. Next paper, looking at pre-hospital intubation and outcomes in terms of survival. Now, this was a single center study in a very specific population. So these may not be relevant to all of our locales, but interestingly, 100 field intubation attempts, many of which were unsuccessful. What occurred later, some needed crikes, some were successfully intubated in the trauma bay. But ultimately there was a very large kind of distribution of outcomes in this cohort that needed pre-hospital intubation. So the authors made some very interesting conclusions. First, they found that those who actually were successfully intubated pre-hospital had no survival benefit. And so they caution us to say, pre-hospital intubation one is inconsistently successful. Again, that's going to range depending on where you work. But it may also delay definitive care. So another argument about stay and play versus scoop and run, this time pre-hospital intubation. Think about it. Next paper, management of hemothorax and failures in that management profile. This was an East multi-center trial that included a thousand patients with a traumatic hemothorax. Some were observed, some were drained, some required surgery. They then looked at all of those groups and what the outcomes were in terms of management failures. Really interesting findings. They looked at a lot of different things and they ultimately found the contributors to management failures included things that I think we all can predict. Things like age, chest AIS score, comorbidities, et cetera, et cetera. So we all should think about, can we predict who's going to have a management failure in our own hands? I think is an important thing. The other interesting thing about this paper is that 17 trauma centers contributed data. And when they looked at the outcomes of each individual trauma center, they found vast differences between trauma centers. And so it's very interesting. We should all be doing this type of analysis. I mean, this is kind of NISQIP, TQIP style, right? We should all be doing these things. In this study, they found some pretty big differences and the centers on either end of that spectrum were doing a hard look at their own outcomes and how they can improve some of their own management failures. Next paper. This is looking at blunt hepatic injury. This is a West algorithm. So it's not a scientific study, but it is a result of many great thought leaders putting together a very busy algorithm. This is in the publication. You don't have to take pictures of it. It is a very busy slide also, and I'm not going to take you through the whole slide, but it is a very helpful thing to think through the basics, going to the OR, packing, et cetera, moving all the way down your algorithm to liver resection and even liver transplant. So it's something you sit there and you just kind of go through this in your mind. It's very helpful when you're dealing with a complex patient to have this algorithm. So it's out there in the literature and it's helpful. They further stratified patients by grade, low grade versus high grade, hepatic injuries, and some of the incidences and things that were there in terms of biloma and abscess formation. And of course, these are real things that we deal with every day. Next paper, looking at hepatic angioembolization outcomes. So for those who we take to the OR for hepatic trauma, what are the outcomes when we have to add on top of that angioembolization? There were times where anyone who operated on their liver were going to IR for an angioembolization. Should we be doing that? Well, this was 13 trauma centers contributed data. They had 442 patients, 90 required angioembolization post-op compared to 352 who did not. And you can kind of see the outcomes there, but really what they found was that if you required angioembolization on top of your operative intervention, your risk of complications went much higher. Complications of bilomas, bile leaks, return to the operating room, and even things like ARDS and VTE events were higher if you required angioembolization. What does this mean? I don't know. I think we need to think critically about who we go to angioembolization with. If someone's really bleeding, then it's a necessary evil, but it may not just be that knee-jerk answer that, well, if I left the liver packed, we should be going to IR. That may not be the best pathway. I don't know. Think about it. Think about your practices. All right, how about pseudoaneurysm screening for penetrating solid organ injury? How often do you guys do subsequent imaging for pseudoaneurysm formation? Well, this was an interesting study, looked at 136 patients, 42% got screened, so we don't know what happened with the others, but of those who got screened, 23% needed an intervention, and 18 of those were interventions for pseudoaneurysms. So ultimately, this group concluded that if you have a AAST grade three or higher solid organ injury after penetrating trauma, you should be doing delayed imaging to rule out pseudoaneurysm formation. Change in practice. All right, next paper, TXA in the prehospital realm. We know we have CRASH-2. This is patched trauma. This was performed in Australia, New Zealand, and Germany. This was a randomized controlled trial to prehospital TXA versus not, and they had some really interesting findings. Ultimately, they did not see major outcome differences with those who got TXA. Now, curiously, this was a six-month outcome data, whereas CRASH-2 was 28 days, and there were a lot of controversies with this data, mostly because of protocol violations. There were people in the TXA group who weren't supposed to get it or who did not get it, and there were folks in the control arm who did get it. So a little bit of a controversial study, but it was interesting that they didn't see six-month outcomes, but they did still see 28-day mortality benefit in their cohort. So just more data on TXA, more stuff for us to think about in terms of the efficacy, but for now, I think it's unchanged in terms of what we're doing. All right, we heard in some of our other talks the use of factor XA levels in emergency surgery. Here, we're gonna talk about it in trauma. This study in particular looked at whether or not a low anti-XA level predicted VTE events. Now, of course, if you're checking VTE, or sorry, XA levels, that means you probably had an algorithm to dose titrate, but this study particularly looked at what happens if your first check was low, regardless of what you did afterwards, even if you dose titrated, what happens if your first check was low? And these authors found that if that first check was low, that was associated with an increase in VTE events alone, 4.2 versus 1.3. So in theory, we need to do more than dose titrate, and perhaps I might suggest that we need to do something else maybe weight-based in terms of our empiric dosing before we get to dose titration by anti-XA level or some measure. Take it what you wish, but this is what these papers suggest. So let's move forward then. What about dose titration? Is dose titration effective when we're talking about preventing VTE events in trauma patients? This was a flow diagram of their PRISMA analysis this was a meta-analysis of 15 different papers, and ultimately these authors found that outcomes in terms of VTE events favored the use of an anti-TIN-A guided algorithm as opposed to fixed dosing for preventing VTEs, DVTs, PEs, et cetera, and even mortality. Now the data was still weak, but it was suggesting that that's where we're heading. Again, probably an indication we need to do more work in this direction, but I think there's enough papers and enough data telling us that we need to be thinking about this more critically in our own patient populations. All right, moving forward into some of the coagulation. This is a sub-analysis of the proper trial data. Yet again, another analysis. However, this is a really interesting one, and these authors must have run through a million algorithms to come up with this finding, but this finding ultimately was if you took the MA to R time ratio, and if that was less than 11, that these patients had a much higher risk of a poor outcome. So again, they ran through a million different things, but MA to R time, less than 11, was associated with increased inflammatory cytokines, increased pro-inflammatory markers, increased chance of death, increased less ventilator-free days, less ICU-free days, et cetera. So if you can incorporate something like this into your algorithms and you wanna identify at-risk patients, especially if you can do this electronically within your EMR when you run a tag, this is one thing that may cue us into a high-risk population and maybe make us be a little bit more attentive to these patients. All right, transitioning to whole blood. Whole blood resuscitation, does it improve survival in terms of trauma? This was a randomized controlled trial of ultimately 1,000 patients who got randomized to whole blood versus component therapy. Really interesting findings and very striking findings. Otherwise, in a randomized group with pretty equal groups, if you got whole blood, your probability of death was much, much lower. And this was true at both four hours and at 28 days. So whole blood is really, I think, here to stay and going to provide our patients with a much better resuscitation than component therapy. How about whole blood in traumatic brain injury? And not just in terms of overall survival. That was the purpose of this study. Ultimately, these authors found, and interestingly, their whole blood group actually had higher ISS, had higher arrival lactate and lower field blood pressures. And despite that, the whole blood group had overall decreased mortality and TBI specific mortality. So even in brain injury, whole blood seems to be holding true in terms of a better resuscitation. All right, well, what type of whole blood and is whole blood truly safe? This was looking at low titer group O whole blood in recipients from all of the different blood groups. Is it safe and do we see any differences in outcomes? Well, these authors looked at all of the outcome variables on the left side in terms of complications. And did those rates of complications differ based on the blood group of the recipient? And as you can see, whether the recipient was group A, B, AB, group O, all of those things did not fall out as being different. And it seems as though low titer group A whole blood is safe to administer. All right, UK reboot trial, how can we not talk about it? It was done, it was published, so we need to talk about it. This was a randomized controlled trial of REBOA versus not in the United Kingdom. And the findings are pretty striking and shocking to the world. Patients who got REBOA had higher mortality, they did worse. So this is out there, this is published. However, I will tell you that this paper and the publication and the study itself were fraught with controversies and complications. Only 41% of patients in the REBOA arm actually had the REBOA balloon blown up. The provider experience was really, really low. The time to REBOA inflation was 32 minutes. I mean, that would kind of never fly in my trauma bed. And there were some folks with really long, prolonged times of balloon up. So lots of opportunities to try to do this study better in the future. And I hope that we see a better study in the future. If anything, this paper is up here because it teaches us how to think more critically when we review some of these papers and don't just take things at face value. All right, outcomes in older adults following trauma. In today's world, our biggest metric is in hospital mortality. And that might not actually be appropriate for our older trauma patients. And so these authors looked at many different outcomes that you can see down the left-hand side and said, maybe we need to be thinking about how we assess quality of care because it might not just be hospital survival. It might be the risk of readmissions. It might be the risk of another injury at some point. It might be the fact that they never make it back home. And so in a really nice way, these authors gave us some things to think about as we move forward in our outcomes for trauma patients in the longterm. All right, this paper looked at trauma video review and compared it to what we document in our trauma flow sheets. Really, really interesting. They literally looked at trauma video review and looked at timestamps of specific occurrences like when the aorta got cross clamped or when an incision was made, et cetera, et cetera. And very interestingly, they found that the times we document in our flow sheet do not correlate with what we're seeing in the video. And so these authors ultimately concluded that all of us should be incorporating some type of video review into our practices so that we can do better performance improvement. All right, predicting futility in our severely injured patients. This was really an interesting study that looked at ways in which to predict who was gonna have a bad outcome and actually creates criteria to stop. And so they created what they called their stop criteria. Really interesting list. Again, you're not gonna be able to memorize everything now, but look this paper up later. But they found some really interesting associations that we probably do in our gut, but they did it on paper with science. And things like a low blood pressure and a prolonged LY30, and we all know prolonged LY30s aren't great, but you can see some of the metrics that are associated with that. If you have ROSC, but you still have a very high lactate, really associated with poor outcome. So lots of interesting things that we should think about when we think about stopping resuscitation for futility. And the last paper I'm gonna present to you is just kind of, you know, something I think we all should be thinking about, and that's diversity, equity, inclusion in our practices. And this was a perspective paper published in JTACs last year. And the authors very thoughtfully provided a lot of context for us in our field to think about, and they provided many opportunities and solutions, such as tailoring some of our interventions to our local community, thinking about minority tax, creating pipelines, et cetera. And again, I thought it was a really nice paper that can help us kind of think about how to do this in an efficient way in our practices. So I know I talked really, really fast. Here's the QR code. Please take the papers that you think are gonna be most meaningful to you and your practice. And I hope you found these 60 papers in 60 minutes helpful. Thank you very much. Thank you.

trauma care

clinical practices

brain injuries

TXA efficacy

diversity in medicine