Good afternoon. Thank you for that warm welcome and to the Society for this opportunity. OK, nothing to disclose. My objectives today are to review articles related to trauma, and particularly to review a broad range of topics that will both impact care and improve delivery of patient care. I looked through articles using a PubMed search, followed by a journal review, and finally by recommendations through valued colleagues and experts in the field. I then carefully curated a final list to cover 10 comprehensive topics that I thought were impactful for this year. To start with, it's phenothromboembolism. The first article is a single center retrospective, sorry, prospective cohort study that assesses time-dependent changes in antithrombin activity in high-risk trauma patients, and the association between AT activity and responsiveness to anoxaparin prophylaxis. The authors found that acquired antithrombin efficiency was not only common in patients that were severely injured, but also induced a response to prophylaxis and was independently associated with VTE events. This year, the CHESS also updated and published the second update to the Antithrombotic Therapy for VTE Disease Guideline. An expert panel produced 29 guidance statements, 13 of which were recommended as strong, and eight were substantially modified from the previous update. I'd like to review just three impactful changes. The first is for patients with VTE-induced antithrombotic changes. The first is for patients with VTE, DOACs are recommended over vitamin K antagonists for the initial treatment phase defined as zero to three months. For patients with unprovoked VTE, DOACs are also recommended over vitamin K antagonists for the extended phase of treatment, which is defined as beyond three months. Lastly, this guidance offers the opportunity to observe patients with acute isolated distal DVT or sub-segmental pulmonary embolism if specific criteria are met. Next is resuscitation. Birla et al. published a prospective observational cohort study at a single center, looked at all patients who received emergency release blood. They then separated those patients into two groups, one who received whole blood and one who received component therapy. Results showed that there was an improved survival at 30 days for patients who received whole blood only and that within 24 hours, patients who received whole blood required less total number of transfusions. Importantly, the effect on survival and impact was persistent across three important subgroups, pre and in-hospital, those with a high or low ISS and those with or without a TBI. These findings were impressive, although I think there's some work to be done to find out what the best guidelines are for practice. Next up is geriatric trauma. The first article by Stepensky et al. focuses on geriatric trauma patients who required operation. They found that NISQIP, Surgical Risk Calculator, which accounts for both functional outcomes and comorbidities was superior in defining the post-operative length of stay, mortality and complication rate as compared to the trauma injury severity score. The second article by Park et al. focuses on geriatric patients who do not require surgery. After implementation of a multidisciplinary pathway, they found that their incidence of delirium was decreased from 28% to 18%. This was best seen in patients with mild or moderate injuries. And interestingly, those patients who are not primarily English speaking did not have the same benefit. Their conclusion is that although this tailored pathway is important for geriatric patients, it really demands a multidisciplinary team and more research about certain populations of geriatric patients. Next up is pneumothorax management. The first article investigates the association of pre-hospital needle decompression with early mortality in patients requiring emergent chest decompression. Through a cohort analysis of 800 trauma patients, pre-hospital needle decompression was associated with a 25% decrease in odds of 24-hour mortality when compared to tube thoracostomy placed within 15 minutes of arrival to the trauma bay. This was statistically significant. One limitation to this study is the use of a hospital-based registry to examine pre-hospital data. Regardless, the authors conclude that pre-hospital needle decompression is likely life-saving but underutilized maneuver. The next article by Figaro et al. investigates and examines the impact of observing hemodynamically stable patients with a pneumothorax measured to be less than or equal to 35 millimeters on CAT scan. They found that observation avoided unnecessary chest tubes in patients without any change in observation failure or hospital outcomes, including pulmonary complications, length of stay, or mortality. Also, they found that provider compliance with this new guideline significantly improved over two years as patients did better with this new guideline. Moving on to rib fractures. The first article refers to patients who do not require surgical intervention. Burton et al. created and implemented a multimodal pain program that was started on admission and found that during the inpatient phase of stay, patients consumed less total opioids over time and required less amounts prescribed at discharge. The next article by Dagon et al. was published in JAMA Surgery this year. It looked at the surgical stabilization of rib fractures. Patients aged 16 to 85 years old were included and those that had displaced rib fractures, a flail segment, or chest, sorry, or rib fractures with a chest wall deformity, and those that either had prolonged mechanical ventilation for other injuries or were just not operative candidates were excluded. 207 patients were randomized one-to-one, operative versus non-operative management. The results show that those who required mechanical ventilation at the time of randomization and underwent surgery had a trend toward ventilator-free days and improved length of stay. This, however, was not seen in patients who were not ventilated on randomization. Next up is traumatic brain injury. The first article is titled Chronic Traumatic Encephalopathy in the Brains of Military Personnel and was published in the New England Journal of Medicine. Neuropathologic examinations for the presence of CTE were performed in 225 brains from a bank that was dedicated to the study of deceased service members. Information was obtained regarding exposure, both in civilian and military life, including blast exposure, contact sports, and other causes of TBI. CTE was found in only 4.4% of brains and marked by minimal and sometimes only one single neuropathologic finding. Risk ratios for CTE were numerically higher in those who had contact sport exposure or civilian causes of TBI compared to those who had blast exposure or military causes of TBI. This is really very interesting, although due to the small case numbers, we cannot make casual conclusions, but I think we'll see more about this in the future. The next article is a secondary analysis of the RESQ-ICP randomized clinical trial. The authors assess outcomes at 24 months for patients with traumatic intracranial hypertension who received decompressive craniectomy versus medical treatment. They again found at 24 months, patients who underwent surgery, although had an increased survival, still had an increased rates of vegetative state, severe and moderate disability. They did suggest that the time, the trajectory of improvement over time with surgery was improved, and so perhaps following these patients for longer periods of time post-op would show some more improvement. Moving on to trauma nursing. This year in the Journal of Trauma Nursing, an article was published related to compassion fatigue. This 12-week pilot study was used to determine the feasibility of structured debriefings among healthcare professionals experiencing patient death. Compassion fatigue was measured using a professional quality of life survey, and ultimately 56 healthcare professionals participated in over 20 briefings. Although there was no significance in the amount of burnout scenes, secondary traumatic stress, or compassion fatigue, they learned that it was feasible to do these debriefings, although we need to learn more about how we can better impact the wellness of our team. Second to last topic is cervical trauma. Most guidelines recommend that patients who present following penetrating cervical trauma with hard signs of vascular injury should go directly to the operating room, while those with soft signs can stop at the CAT scanner to direct care. The authors of this article sought to analyze the association between the initial exam, the operative findings, and the management. They found that 56% of patients who presented with hard signs of vascular injury underwent immediate operative exploration, while 44% actually underwent CAT scan first. After CAT scan, only 18% required open surgical intervention, seven, endovascular intervention, and up to 19% did not require operation at all. In other words, they suggest that hard signs should no longer be an absolute indication for operation, but perhaps CAT scan may guide less invasive intervention or avoid intervention in a population. And then last, but certainly not least, is acute kidney injury. Schneider et al. published this article looking at retrospective analysis from the National Trauma Data Bank of over a million patients. They found that the incidence, in terms of background, the incidence of contrast-induced nephropathy is up to 5% in trauma patients, but only up to 2.5% in non-trauma patients. So they used this data bank to examine the incidence of AKI-requiring dialysis by examining these patients and determining the relative increased risk of IV contrast. They found that, in fact, IV contrast administration, through contrast-enhanced CAT scan or angiography, was independently associated with an increased risk of requiring HD after traumatic injury. And angiography inferred an even greater risk compared to CAT scan, perhaps through the volume of contrast. Other patient populations that were identified to be at increased risk were those with a reduced GCS, a higher shock index, higher injury severity score, or preexisting diabetes and hypertension. A couple of limitations to this study are important. Besides the retrospective design and inability to determine stages and severity of AKI, patients who had a preexisting need for HD were excluded. However, those who had a decreased renal function on admission but didn't quite yet require HD were not excluded, and those patients, as we know, are at increased risk of contrast-induced nephropathy, and so that does seem to be an opportunity for the next study. I hope this review was informative and will influence your practice going forward. Thank you again.

trauma care

antithrombotic therapy

geriatric trauma

traumatic brain injury

acute kidney injury