I'd like to welcome you to the 51st Critical Care Congress. I'm Debra Kuhls. I'm a trauma and critical care surgeon at the Kirkuk Korean School of Medicine at UNLV in Las Vegas, and I'm the current SCCM Surgery Section Chair. I'm going to present trauma and burns as part of the surgery year in review. The first study I'm going to review looks at the impact of COVID-19 infection on outcomes after injury in a Pennsylvania statewide trauma system. They categorized patients COVID positive, COVID negative, or not tested. Those that were COVID positive were less likely to be white, had a higher incidence of firearm injuries, and after performing multivariate analysis, they found that those patients that were COVID positive had increased hospital death, increased complications, and increased pulmonary complications. The bar graph to the right reports on mortality according to injury severity, age, and chest injury, and across all these dimensions, there was a higher mortality in those patients that were COVID positive. The next study I'd like to review with you is changes in traumatic mechanisms of injury in Southern California related to COVID-19. This was a retrospective study of 11 level 1 and level 2 trauma centers, and they grouped their patients into one of three groups, a control group, which was pre-COVID, second group was pre-stay-at-home orders, and third group was post-stay-at-home orders. What they consistently found when comparing post-stay-at-home order groups was that there was a higher incidence of penetrating injury, shortfalls, sports injuries, they presented with lower systolic blood pressure. Also, there was a higher percentage of Latino as well as Medicare and Medicaid patients. I should mention that there were several other studies that had very similar results, all pointing towards increased violence-related mechanisms of injury. In order to address violence and its root causes, the American College of Surgeons formed an ISAFE group. This consisted of diverse, multidisciplinary health care workers of multiple specialties, as well as community organizations that represent other stakeholders. They met several times, developed consensus-based recommendations, and they recommend four strategies to trauma centers. Number one, that trauma-informed care be adopted at all trauma centers. Number two, that social care be integrated into trauma care. Number three, that trauma centers invest in at-risk communities. And four, that advocacy be used to meet these objectives. Firearm deaths now exceed motor vehicle crash deaths in the U.S. The American College of Surgeons decided to survey its membership to learn their views on firearm ownership, as well as to inform ACS initiatives to decrease firearm injuries and deaths. They had a response rate of approximately 20%. They found that 42% of respondents keep a firearm in the home. 75% felt it was very or extremely important for the American College of Surgeons to support policies to decrease firearm injuries and deaths. There was broad variability on opinions about private citizen firearm ownership. However, there was very broad support for 16 of 25 policy and advocacy issues to decrease firearm injuries and deaths. The next few studies I'm going to review have to do with blood resuscitation. This study is a secondary analysis of the PAMPER trial involving pre-hospital use of resuscitative products. And they had four groups, crystalloid, pacred blood cells, plasma, and plasma plus pacred blood cells. And looking at 30-day mortality, they found that the lowest mortality was in patients that were resuscitated with pacred blood cells plus plasma. This study looks at never-afrozen plasma and compares it with FFP using the TQIP database. And they looked at several outcome measures, mortality, length of stay, and various complications, which are presented in the table to the right. And while there were no differences in these outcome measures, there was a decreased time to transfusion in the never-frozen plasma group. This may represent the potential to expand available blood product options for resuscitation. There continues to be increasing interest in whole blood. And I cite three studies. I'm going to start with number two. And it compares component therapy versus low titer group O whole blood in adult patients. And overall, they did not find significant difference in outcomes, including mortality. However, there was statistically lower incidence of multi-organ dysfunction in the whole blood group. The volume of blood transfused was lower in the whole blood group compared to component therapy. Number three on your slide is a small study in pediatric patients where they found, again, no difference in outcomes. Number one on the slide is a review article. And while they do not find any significant differences, they indicate there are too few articles and urge future studies. This next study is a proof of concept operationalizing the deployment of low titer O positive whole blood within a regional trauma system that's well established. That involves helicopter units, ground EMS units, a level one, level four trauma center. The figure to the right depicts donation and a blood rotation system so that if blood is not used at one site, it is rotated to a higher blood use site. All of this results in 1% to 2% wastage, which is considered very low. And it really is the first demonstration of a multidisciplinary, multi-institutional system wide system using low titer O positive whole blood. This next study looks at the gap between the evidence and practice of pre-hospital and in-hospital blood product usage for trauma resuscitation. It uses both the TQIP database and the NEMSIS database. And over the study period of 2015 to 2020, in-hospital usage of whole blood increased from only 16.7% to 24.5%. When we look at the NEMSIS database, less than 1% of those patients who are hypotensive with systolic blood pressure of less than 90 and heart rate of greater than 120 received whole blood. In 2021, the Joint Trauma System Defense Committee on Trauma and Armed Services Blood Program published a consensus statement on whole blood. And I just give you a couple of highlights here. They indicate that fresh whole blood improves outcomes in military settings compared to component therapy. Cold stored whole blood improves outcomes in trauma patients and is FDA approved, whereas fresh whole blood is not FDA approved. So therefore, they recommend that whole blood should be used to treat hemorrhagic shock. And that low titer O whole blood is a resuscitation product of choice. Component therapy should be used when whole blood is not available. There are many other important details, but I wanted to make you aware of this consensus statement. The next few studies are going to address TXA. The first one is a phase three multicenter double blind placebo controlled randomized superiority trial that was conducted for US trauma centers. And they found that the 30-day mortality was lower when TXA was administered within one hour of injury. And that in the cases of severe shock with systolic blood pressure less than 70, there was also a lower 30-day mortality. There were no higher thrombotic complications in the TXA group. The next study is a multi-institutional retrospective study involving 17 level one and two trauma centers comparing TXA and non-TXA cohorts. They found that mortality was higher and more blood products were given in the no TXA group. There was no difference in thrombotic events of MICVA or pulmonary embolus. Interestingly, the DVT rate was higher in the no TXA group. This next study looks at fibrinolytic activation patients with progressive intracranial hemorrhage after traumatic brain injury. It's a single level one trauma center study. The aim was to look at the progression of intracranial hemorrhage and TAG as well as other labs. They drew Q6-hour labs. The only association they found was between rising D-dimer levels and progressive intracranial hemorrhage. This is somewhat consistent with the CRASH-2 results. And there's a suggestion that TXA may end up being a treatment that is helpful to these patients. Next, we're going to switch briefly to Roboa. And I reported a retrospective TQIP study using Roboa in pelvis fractures. It was compared with preperitoneal packing. The results indicated that there was decreased mortality time to the OR in transfusion requirements using Roboa versus preperitoneal packing. The Denver group has protocolized the use of Roboa in pelvis fractures, which is depicted in the figure on this slide. Next is a study on the FAST exam. And the title is Trust the FAST. Confirmation of the FAST examination is highly specific for intra-abdominal hemorrhage in over 1,200 patients with pelvic fractures. This is a 10-year single-center retrospective review of these patients. And as background, FAST examination has not been considered to be reliable for intra-abdominal fluid detection in the event of a pelvis fracture. This study went on to look at positive and negative FAST and calculated a sensitivity of 85.4%, specificity of 98.7%, positive predictive value of 83.5%, and a negative predictive value of 98.9%. This study looks at the clinical impact of a dedicated trauma hybrid, OR. It's a retrospective cohort analysis at a level one trauma center. The two groups are hybrid OR versus historic controls. The hybrid group had more use of Roboa, 9% versus 1%. Time to OR was shorter in the hybrid group, 49 versus 60 minutes. Angio was used in 21% of the cases. There were decreased ventes, transfusions, and infections in the hybrid OR group. We're going to switch gears to mass casualty events. So this was a cross-sectional survey of 17 academic level one trauma centers using a computerized model that was designed to realistically model consumption of limited resources, including blood products. Blood products could not be replenished during the event. Under what was considered to be one of the least demanding computerized mass casualty events, 20% of the patients would require blood, 6% of the mass of transfusion. One of the findings was that more than 50% of those trauma centers could not meet the blood requirements of 100 patients during the mass casualty event. The median size event that resulted in failure was 80 patients. If we considered platelets, as the above numbers did not include platelets in the calculation, but if we did consider platelets, more than half would fail at 60 patients. This slide is a continuation of the same study with Table 2 indicating the median number of units of blood products of various types. On the right is a graph depicting the number of admitted patients on the x-axis, and on the y-axis is the percentage of successful model runs. We can see that trauma centers fail to meet the blood product needs at well below 100 patients, and when you go upwards of 200, they fail to meet the needs of a large number of patients. I'd like to switch gears to burns. This study looks at the resuscitation practices in North America, and it is called the ABRUPT trial. It's a prospective non-interventional observational study of burn resuscitation practices among 21 burn centers in the U.S. and Canada. During the first 48 hours following a burn of 20% or greater, it compares an albumin group versus crystalloid, and the outcomes were worse in the albumin group. There were increased need for limb fasciotomies, renal replacement therapy, longer ventilator days, longer length of stay, and decreased survival. These results have informed a prospective study that is underway. I'd like to thank you for your attention, and I hope you enjoy the rest of the Society of Critical Care Medicine Critical Care Congress.

COVID-19 impact on injury outcomes

penetrating and violence-related injuries during the pandemic

trauma-informed care

firearm injury prevention policies

blood resuscitation and trauma resuscitation practices