All right, so we're going to go over what's new in emergency general surgery. So the flyer, the handouts will be coming shortly, and we're going to go through a lot of literature in a short period of time, but I'm also going to slow down and go over a few key points, key articles. Which way does this go? This way? Okay, I have no financial disclosures. So we're going to cluster these by different topics. So the first one is EGS systems and care processes. So as we are very familiar, there is a high burden of disease in EGS surgery, and lots of literature looking at both retrospective, prospectively collected databases looking at what and trying to define the burden of disease. One of the ones I wanted to point out to you is coming out of the Danish study, and basically looking at a longitudinal cohort of emergency laparotomies and looking at categorizing between major laparotomies, meaning major bowel resections, major operative intervention versus minor laparotomy, which is maybe a single band adhesiolysis. And you'll note that one in five patients died within one year after emergency laparotomy for all comers of laparotomies. And if you exclude only to the major laparotomies, one in three patients had a one-year mortality, which is pretty significant, huge burden of disease. Many, many articles looking at workforce models of care, variations in delivery of care among surgeons based on surgeon specialties, one by myself as well, looking at acute care surgery models of care, and in some ways, really pushing the concept of having an acute care surgery model. But it's really hard to define what exactly is the perfect model, and lots of groups trying to define this. Case volume and resource allocation, again, confirming a lot of the thoughts and really analyzing the literature in terms of high-volume sites having better outcomes for emergency general surgeries, but high volume based on different types of cases. And you can review through these. Timing of the OR and the weekend effect. So we all have this concept that during the weekends and nights, there may be worse outcomes for our patients. And there's a meta-analysis that actually looks at all of this. And what they found was internationally, there is a lot of variability between patient outcomes based on timing and based on the so-called weekend effect. In the UK, they actually did not find a difference in mortality. But in many of the other studies, especially in the US, there was an increased mortality. And you can see that some of these in this meta-analysis also crossed zero. Transfers. Lots of groups interested in looking at what is the burden of disease in transfers? Are the transfer patients sicker? What are the resources? And how are these patients' outcomes related? And then follow-up to transfers is if the patient survives to discharge from the hospital, what is their readmission rate? There is actually the second paper, the last paper here, the Linardi one, talks about the recurrence of emergency general surgery, meaning patients who presented with an emergency general surgery process who discharged subsequently have a higher rate of readmission to the hospital. Disparities in care. Lots of groups looking at various types of disparities from socioeconomic status, which is the big one, to insurance status and payer status. Many risk calculators coming out. Most of us are familiar with the American College of Surgeons NISQIP calculator, but we are also comparing these to the National Exploratory Laparotomy Audit, which is the UK study for the NILA, PFAS studies, and looking at time in the operating room as a potential prognosticator for worse outcomes as well. ICU-specific prognosticators. Wouldn't it be great if we had a crystal ball that could tell us exactly which patients are going to do worse and take up the most resources? Well, lots of people are trying to figure this out and developing different protocols and specifically targeting the older patient population, our geriatric population, because they do have the highest rates of mortality and morbidity. In addition to all these retrospective reviews, the collaborative care bundles are being developed across the various collaboratives that have generated this data, and in the forefront, of course, are the UK group from the National Exploratory Laparotomy Audit, the NILA group, the Denmark group, and looking at quality improvement bundles. Followed to the NILA was the Emergency Laparotomy Collaborative Quality Improvement, or ELPQIP, initiative, and this is basically an ERAS, if you will, for the emergency general surgery, as well as the standardization of processes such as sepsis protocols and standardizing post-operative care, critical care management, and you can look through these articles. Two of them will tell you that there is an improvement in patient outcome, and then one will say that, you know, maybe we need a little bit more data because we still have to tease out all the different components and the resources and the time management needed to actually enact such a bundle in your local institution. Elderly and frailty. Tons of articles looking at elderly. What can we do about them? How do we make them better? What was really interesting is this one here by Kaduru, where they looked at a clinical effectiveness program for what they called an elderly-friendly approaches to the surgical environment initiative, or the EAST program, and it is getting geriatricians on board into your multidisciplinary care, getting a pathway for physical therapy, discharge, and what they found was that they do have a decrease in post-operative complications after implementing this EAST program, so I would encourage you all to look at this. Hot off the press from this week. Palliative care. As we have this aging population of really old, frail patients in our units undergoing emergency laparotomy, you know, the concept of getting palliative care on board early, even if they are still full-code, still going for an operation, but getting that service and those resources for our patients up front is important and can impact outcome. These are a few articles that look at it, also addressing the issue of it's really okay to not operate if someone's really sick, and how can we help patients transition their goals of care from a fully aggressive but maybe not dignified way to spend their last days to getting them to address the values that are important to the patient. Lots of focus on EGS laparotomy. This is the lowest hanging fruit in terms of morbidity and mortality, and starting first off with abdominal compartment syndrome and how we are managing abdominal hypertension and abdominal compartment syndrome in the modern era. Management of the open abdomen, to close or not to close at first look laparotomy and what are the predictors of whether or not someone should be or should not be closed or is or is not able to be closed at the index operation. Dr. Cal and Etal looked at the outcomes of patients who remain with an open abdomen versus patients who actually had their abdominal wall closed at the index operation and did a propensity match analysis. Again, there are many factors that contribute to this, but what they found was that the patients that were able to undergo primary closure at the index operation had decreased cost, decreased length of stay, and decreased outcome or complications for their patient population. More articles on the open abdomen, and subsequent to the open abdomen is what do you do with the abdominal wound? What do you do with the abdominal wall? These are some articles looking at facial reconstruction as well as different strategies for wound closure. There is the PROPEL trial that is going to be in process looking at primary closure of the skin as opposed to leaving the wound open with WICs or with packing. So, using negative wound pressure therapy or wound vacs over the incision to decrease surgical site infections. Vial obstruction, a long time process and with new angles at looking at when should we operate? Do you let the sun set on this operation and how do you diagnose or how do you triage who needs an operation and who doesn't? So, Dr. Liu et al. looked at the use of low osmolar water soluble aka gastrographin contrast pathway in a small vial obstruction in their group. This is a pre-imposed trial and basically they looked at all patients who present with a small vial obstruction, give them gastrographin and follow this for 8 hours and 24 hours and then observing the long-term effects. Decision to operate was still surgeon dependent but what they found is that water soluble contrast is safe and may reduce the length of stay in the sense that you can identify early those who would benefit from an operative intervention rather than waiting longer. Laparoscopy and EGS may be a skill that our younger surgeons will acquire and may be something that we can do more of in terms of adhesive valve disease or diagnosis and treatment. Few articles looking at timing of mesenteric ischemia, different approaches, getting vascular surgeons on board before you get into the operating room may improve the patient's outcome and earlier intervention can also reduce the patient's overall morbidity. Looking at different anastomotic techniques and the safety of primary anastomosis with a diverting ostomy for diverticulitis. Valve prep, some people may need a whole case of Charmin's but looking at the surgeon's attitudes towards valve prep because we've had this huge swing right first week everybody got a valve prep then nobody got a valve prep then everybody got a valve prep because it's supposed to reduce their surgical site infection and yet in the elective cohort they're looking to see if maybe this really is not as big of an effect as we think and given that in our emergency population we don't typically have the opportunity to give these patients a valve prep maybe it's not such a bad thing that they're not getting a prep. Diverticular disease, there will be the prevent trial looking at surgical site infections in diverticular disease and different pathways a few reviews here on outcomes and management, number of articles looking at cholecystectomy, cholecystostomy tubes and timing of who needs an operation post cholecystostomy tube because some of your patients will quite frankly once you get them past their acute cholecystitis issue or a calculus cholecystitis issue they leave the ICU they go on to recovering life and they may not necessarily need an operation so these articles will go over the pros and cons of that and who should benefit. Acute and necrotizing pancreatitis is a major source of morbidity and mortality in our critical care population so we have a number of articles looking at the AAST guidelines for acute pancreatitis validation of algorithmic pathways for treatment and this is a follow-up to the PANDOR study so if you all remember the PANDOR study was looking at the step-up approach for minimally invasive necrosectomy versus open necrosectomy for acute pancreatitis and specifically acute necrotizing pancreatitis so 88 patients were randomized in the original study this is a long to no follow-up of those patients looking at their outcomes and overall in line with the original findings the patients who underwent a minimally invasive technique did do better and had long-term less exocrine insufficiency better quality of life indicators. More articles on severe and acute necrotizing pancreatitis, peptic ulcer disease, here are a few articles looking at outcomes and the impact and burden of disease for patients who present with perforated peptic ulcers, adopting ERAS early recovery after surgery pathway and these emergent populations may be beneficial and then a few articles on appendicitis and for a very rare disease there's a process that there's a greyer's appendicitis which is the appendix and involved in ephemeral hernia there are 10 case reports of this extremely rare disease published in 2018 alone so that was a quick review breeze through of the new articles for 2019 in emergency general surgery thank you all for your attention and I also want to put in a plug we do have the stop the bleed booth it is at the back of the exhibit hall so near critical care connections all the way at the back if you're not an instructor please come do the course with us become an instructor register as an instructor with us and if you have fellows or other colleagues who are not stopped to bleed train please bring them along thank you you Good afternoon. I'm Deborah Kuhls. I'm going to briefly talk about what's new in trauma care. This is the QR code. If you didn't see it before, if you just access it, you'll get all of our bibliographies. I'll have it again at the end of my talk. So, I'm also going to deal with just several topics within trauma surgery. The first is coagulopathy, which is near and dear to all of our hearts and impacts outcomes in patients. So, our military colleagues published this article in 2019, and they used a primate model, and they tried to simulate pre-hospital bleeding with a standardized amount of blood loss, and they looked at whole blood versus crystalloid just for the transport time until someone would typically get to the hospital. And they found that this helped to prevent not only the coagulopathy, but the acid-base status of patients, of these simulated primates, if you will. In terms of vital signs and so forth, they were about the same in the two groups, but clearly coagulopathy was different. Also, there's been some work on, continued work on freeze-dried plasma, and this is an Israeli study that it was a retrospective review of casualties who received either the freeze-dried plasma versus crystalloid in the field. And what they found is that the INR was significantly different. It was significantly lower in the group that got the frozen FFP, even though the platelet count was lower. And they went on to look at survival, but it was, I think it was not a perfect study with regards to overall survival. So, there continues to be a lot of work on coagulopathy. So, I included this article on pediatric mass of transfusion. It is a review article. It's a systematic review of best evidence practices. And really, what they found is there's no common definition of who needs mass of transfusion in children, nor exactly how to administer that. So, this is a gap, and this would be a great research project for someone. This is also, this next one is a study of four-factor prothrombin complex concentrate, and plus FFP versus FFP alone. This is a TQIP study done by our colleagues from multiple institutions. The lead author was from Tucson. And they did propensity matching, and they found improved survival with a combination of four-factor PCC plus FFP and decreased blood transfusion. I'm going to switch to one of our favorite controversial topics, Roboa. And this is, again, a review of the published literature on Roboa in civilian trauma. And really, what they concluded is that there really needs to be a better definition of the application and who would benefit from it. So, again, they used the TQIP, and they used a match cohort study technique. And so, I think the interest continues in this technique, but its exact role, I think, remains to be defined. There's a new lower profile device, and this is a study of 60 patients out of shock trauma who were either in arrest or hypotensive on arrival. The overall survival rate was 43% and 19% of those who arrived in arrest did survive. And so, again, we see kind of an evolution of this equipment. Pediatric trauma. And we all know that there's been quite a bit of work in the adult population on minor blunt head trauma and the need for repeat CAT scans and need for level of admission and so forth. And so, again, I think this study points out probably a great opportunity in children. But this was a secondary analysis of a prospective study that used a decision support algorithm to define care. And what they found is that there was only a modest decrease in CAT scans and length of stay. And I think this is another area that needs significant work. So, there's an opportunity for all of us. I also just wanted to note, and it's included in my references, there are new pediatric TBI guidelines that were published in 2019. Contrast enhanced ultrasound is a technique that's been around for a while. And with pediatric patients, we're always trying. We don't want to miss injuries, and yet we really want to limit the exposure to x-rays and CAT scans. And so, this was a study that looked at low energy blunt trauma children. And what they found was that this is really a good technique in low energy blunt trauma. And they thought it was a good way to really decrease the use of CAT scan and plain x-rays. But for high impact blunt trauma, they did not feel it was reliable enough. I'm going to switch to geriatric trauma. Again, this is work that's been the Arizona group was very prolific this last year. And this is looking at what is the inflammatory response after blunt trauma based upon whether a patient is frail or not. And they use the definition of the trauma specific frailty index. Those that were frail had higher levels of inflammatory mediators, including IL-6 and tumor necrosis factor, and lower levels of growth hormone. When they looked at hospital outcomes, frail and non-frail, they were very significant in terms of increased complications, increased length of stay, increased ICU, although this seems pretty nominal. But mortality is also significantly different in this group. So, this was an attempt to try to explain why we see this difference and could it be the host response. I'm going to, I have several references that you'll see on rib fractures and the role of rib fixation is clearly evolving. And there's better literature this last year. And I think it continues every year. I'm going to talk next about firearm injury prevention. And all of us know that there's really been a dearth of quality research that's been funded by reliable sources for a very long time. This is work out of a group at the University of Michigan who have, I believe, the largest NIH grant that relates to firearm injury prevention. And they are focusing on youth. And this, again, was a literature review to look at what are the long-term consequences of youth exposure. And they wanted to look at this in terms of is there a need for additional research in this area. The consortium was called the FACTS Consortium. And they found that just exposure to firearm injury has very high rates of mental health and recidivism supported by the literature. And, again, the dearth of research. So this is an effort from the same group to develop a research agenda, an evidence-based research agenda among children and adolescents. And so they were able to really define the areas where they feel the greatest payoff and benefit would be to additional research. And they include attitude knowledge of firearms, firearm carriage, exposure to witnessing firearm violence, and a whole variety of topics that relate to intentional firearm injury. One of my roles has been with the American College of Surgeons. I chair their injury prevention committee. And as many of you know, we've really been trying to use a consensus evidence-based approach to defining a strategy to address firearm injuries and death in the U.S. So one of the tactics that we used was to really engage firearm owners to help come up with solutions. And so this is a publication, again, this last year, that was a consensus-based recommendations. And the recommendations ranged from education, training, registration, background checks, research agenda. And the FACTS group continues to work on implementing their recommendations. This isn't the only group that's engaged firearm owners, but it is one of only a few groups. And it's a strategy, I think, that makes a lot of sense. If we're looking at bicycle injuries, we would certainly want the opinions of people who ride bicycles. I also wanted to highlight a medical summit. Those of you who have colleagues in other specialties, every specialty is trying to see what their responsibility is to prevent firearm injuries. Because in the last available CDC data, firearm deaths actually exceed motor vehicle crash deaths for the first time ever. And so we got together about 42 organizations, healthcare and other related organizations, to see what we could do together through collaboration. And so we came up with a consensus statement that had basically nine action steps, identifying it as a public health crisis, and that we need a combined public health and medical approach. Research is needed, including research dollars. And as you know, $25 million was appropriated for the first time in a very long time this last year. Engaging firearm owners, healthcare providers, we have a significant role in terms of counseling our patients. Screening for the risk of depression, suicide, intimate partner violence. And those of us who do trauma surgery for a living, we see the victims of this intentional trauma as well. Hospitals and healthcare systems must genuinely engage. And there are several around the country, including Kaiser and Well Health out east. And our professional organizations should continue to work together. So this is, I think, an area of significant action going forward. Excuse my phone. This is the photo of everyone who is at the medical summit. And we look at this as only the first step going forward. And again, here's the QR code. And that is the end of my presentation. And next up to the podium is someone that you all know and admire, Dr. Naylor. Thank you, Deb. All righty. Thank you very much for your attention and your presence. We're going to be doing a couple different things. There's a considerable amount of overlap for both of these pieces. And we really have to take our hats off to Terrence and to Sal for doing something pretty revolutionary with this QR code. I do not have a copy of it, however. There were some copies. I did make some paper copies, being the Luddite that I am. We kept those in the back. And it has been our practice, if you are a member of the surgical section and you're a member of the section membership is not exclusive. You can choose up to be a member of three sections. But as we will in the past, and we will do this in the future, we will continue to send out the bibliography. There will be a blast email that will come out. And it depends on when we go through and vet it all and make it all into a nice compact list. All right. So we're looking at the year from 2019 to 2020. I limited myself to only those articles that were published between 2019 and 20. All right. Special kudos to my compatriots in crime in this project. All right. And there's a couple pieces here. There were limited copies of that bibliography. If you cannot download the QR image, then you can always contact me or contact the panel members and we'll be able to get that to you. All right. Okay. So as in the past, we will break this down into seven sections. And without further ado, we'll start. We'll go through statistics sections first. And so when I break these down, I look at type-specific data sets, worldwide data sets, country-specific, USA statewide generally, smaller databases, and any literature-derived guidelines. All right. Now, with any of these expressions, this is not a you must do this, but these are suggestions. So you're all adult learners, and that's why we provide the bibliography. So you can go read it yourself, draw your own conclusions, and get back to us if there are any questions. All right. So for type-specific data sets, we have National Trauma Database to derive. We've already looked at a couple of these, but there has been a large number of them. Geriatric groundfalls are dangerous. The cautionary note with this particular review, and mine, instead of giving actually the reference, you have to go back to the biblio, and I put them in so it saves a lot of space on the slides because they're pretty dense. They're pretty compact. Even if the patient appears to be normal, be very careful. All right. So old folks, they're closer to their point of exit, this planet, and we don't want to hasten them along by being a little bit too cavalier. All right. All right. Now, what if they, is there a difference between large center, small center? If they go to a higher-graded American College of Surgeons Committee on Trauma verified center, their outcome is approximately better. All right. However, if it's a lower level, they're more likely to be discharged to an LTAC. Leave it up to the reader to figure out that. Now, for selective management, in the past, those of you who started out in the surgical area early, we operated on everything and anything. All right. And now we have the benefit of having our interventional radiology specialists that are really helping us. And so there were two large reviews this time they looked at. These are also National Trauma Database reviews. And they looked at the non-operative management of penetrating renal wounds. All right. Does not dictate an immediate trip to the operating room, nor does a penetrating wound through the liver if there is angiographic evidence of no extravasation. All right. Now, we all recognize this guy. Okay. All right. Whether you believe the promises or not will, and I'm going to be, I'm an equal opportunity. I harpoon everybody, as you all know. So it really doesn't much matter. But what this guy came up with is, this is Medicare for all. Now, what exactly has this wrought? How has this helped us here? Well, the ACA is relatively mature, though some would argue that it's not complete yet. But yes, it has improved coverage. So it's promoted that promise. This is for trauma victims. Unfortunately, there's been no change in overall mortality. Those places with the lower, lowest amounts of covered patients had the best rise of increase in coverage. However, it doesn't look like Medicare for all is going to be the panacea that we all think it may be. All right. Pancreatic injuries. We reviewed some of those. Michelle reviewed some of those for us. Cerebral vascular injury in victims with mandibular trauma. What do you do with a person who has a severely damaged face? Are they at risk for intracranial or extracranial vascular injury? This review will help you there. Alcohol and MVCs. Okay. Does God truly protect the drunk, the fool, and the children? Okay. Well, what it says is, if you're intoxicated or sober, there's really, in this particular review, there is no difference in mortality. All right. Now, we have other data sets out there. T-QIP data. Okay. Length of stay variations are not patient-driven. All of you who work in a very busy center realize there is this sort of obstipation, if you will, on the floor. And then there has obstipation to get them discharged to the LTAC or back to home. Or sometimes they don't have a bus fare or whatever. It always drags out. So, it's really not our fault. Okay. All right. Those who are at a level one trauma center, if they have penetrating torso trauma, they fare much better than those admitted to lower centers. That makes perfect sense. This particular group looked at the risk of renal injury after traumatic injury. But curious enough, they looked at a whole series of comorbidities, and they found that, unfortunately, or fortunately, depending on if you live in North Carolina or not, smoking did not seem to increase your risk of renal failure. Okay. Lower extremity injuries. We want to get them to the operating room, get them there quickly, and get them repaired. All right. Stab wounds, intoxication. These people with no insurance, you better make sure they have an ankle bracelet on because they're going to elope. They will leave your institution. All right. Those are your risks. All right. There is more support for ratio-driven resuscitation. We have to thank our colleagues in the military for looking at this. And there is definite more support for a one-to-one FFP to packed cell ratio. All right. That being said, overall, and this is not military data here. The second one is the fact that overall, looking at a national study, there are fewer transfusions overall. So, perhaps, is it are we giving less or are we really giving more? And then, finally, there are some derivative studies. TRICARE, it's a military database, claims increased ICU length of stay would increase your mortality. So, the longer you stay, the less likely you have to go home. Good. There was a Western Trauma Association, how all of our patients die. This is, I will recommend this to you. All right. We all have our preconceived biases. This will actually allow us and reinforces some of the things that we've been told in the past. All right. So, we'll start moving a little bit quicker. We look at the news media. The news media shapes our thoughts, shapes our actions every day. We all know there's an opioid crisis. However, it is not just the United States. We seem to have more. There are some prescribing differences there. All right. We now have some country-specific data, South African surviving sepsis. So, the better you are at bundleese, that is to say, the better you are at regurgitating the high points that the bundle people look at or your coders or your billers want to see, does that equate to better improvement? Unfortunately not. All right. This is not an indictment of the surviving sepsis campaign. However, it is something to be provided or to be applied with caution. All right. Damage control for orthopedic surgery. Don't spend all sorts of time plating an obscure fracture if the patient is exsanguinating. This makes common sense. Canyon injuries. What is canyon injuries? So, this is the interpretation of all politics is local, but also the way we speak, our choice of words is also local application. So, in Austria, they talk about canyoning, which means directly repelling off cliffs, mountaineering, and mountain climbing. So, we have to understand what the difference between there. That's a nice review of their injuries. That being said, very close to Austria, same continent, if you will, they look at it in a different way. They call it via ferrata, which means this is a protected hiking path. They look at their routes. There are all sorts of suggestions, I did not include them on there, of dropping drone AICDs or defibrillators to help people who have an arrest after they climb too high. All right. Good idea, but you can imagine there'll be a little funding for that. Okay. In northeastern Scotland, they had a big review on necrotizing fasciitis. If you're in the Canadian province of Ontario, they had a nice review on adhesive small bowel obstruction. Okay. Unfortunately, in the UK, and this was referred to, Michelle actually pointed this reference out, that quality improvement projects don't seem to make the grade for emergency general surgery patients. Okay. We'll say it again. So, quality improvement projects don't make the grade for emergency general surgery patients. Does that make sense? Of course, it makes perfect sense. You cannot predict when they come in in a random fashion. Okay. Perfect. United States, California hospitals increasing volume, decreasing mortality for only selected general surgical patients. This doesn't translate, if you've done 3,000 hernias in one year, it doesn't translate on your ability to do a pancreatic or do an ectomy. Okay. Pennsylvania, obesity is always a growing problem. It is a big burden in trauma care also. Okay. Our military databases. We have a military to thank for actually a recrudescence of a lot of different items. For those of you who perhaps grew up in the 60s, perhaps, I'm probably dating myself. When you went through your scout training, whether it be Girl Scouts or Boy Scouts, when they're actually two separate organizations, you were advised never to place a tourniquet. Now we're seeing increasing uses of tourniquets, and they're actually saving some lives. All right. Additional for transfusion injury, there is low titer O blood, whole blood versus a cold or a low factor or low titer factor. And there was a nice review about that. That's in austere environments. So they can actually save this as freeze-dried blood and use it later. Okay. And there's some nice reviews on forward surgical teams. Okay. Okay. Now for guidelines. We talked a little bit about earlier about appendicitis. Michelle actually, this reference was buried on the bottom of her list. And the East group actually did a, wrote a guideline, very nice guideline for the use of appendicitis or the treatment. Double AST for general surgery patients. This is acute care general surgery patients. Liver and cardiac transplant care guidelines, vasopressors and shock. All right. Now the difference here, if we looked at all three of these, is we had one group, one discussion that was talked on acute or focused on acute care general surgery, the other for trauma, and now for the ICU. But it would be nice if we could strain the soup that thin and split it all out and say, today I'm only going to be an intensivist. Tomorrow I'm going to be a traumatologist. The next day I'm going to be an emergency general surgery specialist. We can't do this. There's a lot of overlap. This is why I commend this reference to you. Hemodynamic monitoring, duodenal pancreatic injuries, German nutrition guidelines, and preoperative care of the demented patient. Maybe you're going to suggest after this lecture that I should probably take a look at this myself. Okay. Now for primary injury prevention. Okay. Firearms. Big topic. Big topic. There's a lot of angst. There's a lot of emotion involved with both of these pieces. But unfortunately or fortunately, depending on what you look at, we always talk about we need more registration. This particular reference mentioned that illegal firearm transfers across states are generally from illegal guns. So the ones that aren't registered. I would really enjoy to live in a community where all the criminals follow the rules. Okay. All right. Mass shootings. Are they the same as cluster events? We can thank the city of brotherly love for this. It depends on where you are, what neighborhood you're in, whether it hits the news media or not. Okay. And so what they've done is they've actually dumbed down the concept and said it's not really a mass shooting. It's just a cluster. It's just a family disturbance or some family violence. Trauma data registry may not match police records with actual findings, which leads us to believe or leads us to take with a jaundiced eye all the databases I've just suggested to look at. You have to be very careful and look at the data. What is it actually telling me and question your impressions. That being said, all right, we know that this is the end of the world. Okay. All right. This is the guy that is the great Satan. He is the Antichrist himself has under that nice fluffy orange hair. He has 666 on his forehead. Perhaps, perhaps. Okay. But perhaps not. All right. So why bring this up this this directly goes back to the mass shootings, the same as cluster events, two separate publications. So when they talked about neighborhood events, perhaps this was more of the advent of the yellow press. If you remember, during the Spanish-American conflict, there was a big battle between Hearst and other newspaper publishers, and they became more and more sensational headlines. Sensational headlines ruled the day. All right. All right. Nine years of Southern California shotgun injuries came out of a Demetriotis group. Suicide attempts and post gunshot wounds sequelae, not just for the victim, but for the family members. And Deb did actually mention this a little bit earlier. When present, alcohol in motor vehicle crashes, it will increase both your morbidity and mortality. Prevalence systems, they looked at alcoholism in VA medical centers. Alcohol on board at the time of trauma, however, increased your risk of pneumonia, but not of overt sepsis. Alcohol on board decreases the incidence of DBT. So there is some protective events here, protective coverage. Okay. One of my least favorite scales in the entire world, the SEWA scale. All right. And when you think about it and cone down on those aspects on there, you'll see, we'll give, they'll suggest treatment for people with sweating. So when I forgot my antiperspirant this time, I just spread some Ativan under my axilla. Okay. All right. What they did, this was from, this was in the Mayo Clinic and they actually looked at it and coned down on those particular data points and they realized they were actually able to curb their use of benzodiazepines. All right. For resisting alcohol withdrawal, perhaps phenobarb might be a nice rescue drug. And then pre, if somebody's using ahead of time, they're going to have problems later. All right. Obesity. It has a negative impact on all outcomes. So I know you're here. We have great food, a lot of adult beverages, but please moderation today. Okay. There are negative effects on ventilation. It's a little bit more difficult, especially since we're using positive pressure ventilation to elevate large masses of tissue. There are increased, other increased outcomes such as renal failure and they're more, they have a higher propensity for dialysis. All right. Increased rates of sepsis. And then you could think perhaps with, even with my admonition to be careful in what you eat, can we thin them down in the ICU? Can we use hypocaloric feeling, feeding? And if you remember, that was all the rage probably six or seven years ago. Unfortunately, it doesn't seem to work. Okay. All right. How many of you live in a large city that you get to walk over top of manmade obstructions everywhere? All right. Or you get to see some particularly individuals who are on the lower end of the evolutionary scale trying to prove that this is not going to work. All right. And so we have unregulated scooter use. And this was a nice review and it talked about the higher incidence of maxillofacial trauma and extremity injuries with people who use these little devices. All right. Pre-hospital care. When you see this heading drop down, that means there's not a whole lot in pre-hospital care. All right. So we've already mentioned the patients that are demented. How do we care for them? Hyperlacteemia may predict transfusion risks or rates. Okay. There is increasing evidence for scoop and run, those minutes count. And if you remember years ago, we had this debate. Do we intubate them on the scene? Do we stabilize them on the scene? Do we resuscitate them on the scene? Well, the pendulum has swung back. Okay. So now get them to the hospital. Initial choice of level of care will be abrogated by later transfers. That is to say, if they go to a lower level of care, that does not necessarily necessitate poor or demand that they will have a bad outcome. The people who die generally are transferred later. Okay. Initial care. All right. All right. Pre-op benzos and our Z-drugs, zolotopam, these are the non-benzodiazepines, are usually evil. They are drugs of the devil that will increase our adverse events. Okay. Be careful with your local anesthetics. This was a plastic surgery review, and they used a lot of local, and they talked about the toxicities of local. So it's not the panacea that we think it is. Interoperative fentanyl, in direct opposition to this, because these are all less is better, this one suggests judicious use of interoperative fentanyl in the naive patient may actually have benefits postoperatively, reducing overall opioid loads, as well as decreased postoperative respiratory events. That being said, not all patients need opioids. Okay. Regional techniques, there's a lot of excitement about in this area. That will actually tie back into the difference between a well-applied regional technique versus rib stabilization. Ketamine, exciting drug. It's an oldie but goodie. It's been out there. It's coming. It has an increasing resurgence. Pre-hospital hypothermia. In this event, this was for the accidental hypothermia. This was the environmentally injured patient. And then finally, planned hypothermia. Who do we cool? Why do we cool? And why should we do it? And what should we expect? All right. Emergency rheumathoracotomy, there's both a comparison with Thailand and a European perspective. All right. The outcomes are the same. All right. And they're relatively dismal. Any electrolyte replacement, hypokalemia has been associated with a lot of bad effects. Replacement fluid and fluid balance, again, this is still a taste great, less filling. In certain instances, emergency general surgery suggests that less fluid is better. However, buried in here, in the later ones, there's a section you're going to see it repeated later on in terms of pancreatic disease, elective pancreatic disease. So it seems that if you can maintain their resuscitation, they will do better even with larger amounts of fluid. Weakened effects and transfer, I'm not going to belabor this. This was discussed already. Osmolar therapy, we're specifically looking at mannitol, hypertonic saline in the head injured patient. And there's some pros and cons and benefits. All right. Hemorrhage, coagulation, resuscitation, a lot of them, we mentioned these ones with whole blood, with low titer. Okay. We either use whole blood warm or whole blood cold. Those of you who may have been in the military or have a relative in the military, they always have a transfusion buddy. That's where the whole blood warm comes from. Tags and coagulation, a lot of information, including a review of tags for the orthopedic surgeon. Fancy that. Okay. All right. Use of platelets, who we need to respond to or not, and prothrombin concentrates. All right. Roboa, Deb has mentioned this. Sepsis, these are just different reviews. Now, I'm suggesting these to you, not going to tell you any specific golden nugget to take home, but I would like, I would commend you to pick these articles up and look at them and read through them yourselves. Okay. All right. Specific injuries, head injuries, lots been written, spinal cord injuries, colon injuries. There is a caution against proximal diversion for everybody. This is not a one size fits all. So, the protective stoma may not in fact be protective. Necrotizing fasciitis. This was my Scotland, my Northeastern Scotland article and then later's. Obstetrical complications. What do we do with a postoperative obstetrical hemorrhage? Okay. That can be quite challenging. Pancreatic surgery and resuscitation of lungs, I mentioned these. So, we saw that reference repeated. Okay. All right. Novel therapies. Hemoperfusion. So, I'm perfusing patients in an effort to reduce their cytokines against a usually an albumin charged or albumin loaded perfusion column. Sepsis and anticoagulation therapy. These are just reviews. Reviews again of pressors, inotropes or inodilators. And there's a difference. All right. And some of these articles are very, very nice. They actually expand this and you can get a better handle on it. Peripheral infusion of vasopressors, unfortunately or fortunately, depending on your standpoint, might be okay. Because in the past, it was completely a quality metric. You should never infuse it in a peripheral vein. This came from the emergency room medicine literature and it appears to be safe. Levosomedian. Again, it's an oldie but goodie. It's coming back into vogue. Midodrine. Some of our favorite medications. And why do we like midodrine? Because it smooths out my vital signs. So, it reduces the number of alarms. All right. Does it really help? Unfortunately, it gets them out of the hospital, but then they expire. Okay. But if they don't expire on your watch, I'll leave that question to you. Okay. All right. It's a little bit dark. How much monitoring is needed? All right. And there's been reviews previously in here on monitoring and how much do you actually need? And I'm going to submit to you that no monitor out there will replace a well-trained, awake physician at the bedside. Okay. Ventilators, large review. Okay. So, now we're to secondary injury prevention. We're going to go a little bit quicker. Fluid management, always the same. Less or more. Tastes great, less filling. And I was not going to bother you this year with those silly cartoons that I put up. Tracheostomy is a lot of review. Whether they're open, closed, they're done at the bedside, they're done in the operating theater. Okay. Trach and PEG. Does one come with the other? Is this like soup and sandwich, peanut butter and jelly? Do you always need a PEG with that trach? There's some suggestion now that perhaps you may not. All right. Stroke in the ICU, a very, very nice review. Open abdomen, Deb's talked about some of these. And now we're going to talk about some of my favorites, the persistent myths. The things like, you know, it's on your finger and you can't get rid of it until you wipe it on something. All right. Okay. Trendelenburg position, is it useful? Well, back in the day, we would call it the position of imminent death. And indeed it was. And this review highlights that and talks about alterations of blood flow, alterations of things that you really need if you're not intubated, perhaps like diaphragmatic motion, and you're adding a lot of weight and you're increasing the work of breathing. All right. Cricoid pressure, again, doesn't help. All right. Finally, weekend effects, pro and con. All right. Okay. Swallowing evaluations. After we extubate our patient, we have to wait the mandatory 24 hours. This depends on the aggressiveness of your speech and language pathologists. All right. Or there is no publication, which I may suggest for somebody to do, is there a weekend effect for speech and language pathology? All right. Sodium bicarbonate, one of my favorite pinatas. All right. No benefit in acute kidney injury and acidosis. So, this has been out there so long that we should finally nail this coffin shut. Okay. All right. Post-hospital care. Benefits of early mobilization. It's better to get up and walk around than it is to be lying in bed. Post-ICU weakness is a very, very, very, very real phenomenon. It is related to mobilization. Delirium. And unfortunately, this was another bright spot. We thought melatonin was going to fix things, but unfortunately, it is not as protective as we once thought. Okay. All right. The big key here is avoid polypharmacy. All right. More is not better. And finally, to the last section. We're almost out of time. I made this the first time in many, many years we've actually finished on time. All right. So, our future directions. Vitamin C, a lot of review. There's been a lot of interest in vitamin C, especially the last session we looked at in even using vitamin C to treat atrial fibrillation. Who would have thunk it? All right. Unfortunately, it's all over the chart. Education is a nice section on education. And then we have to recognize our microaggressions. And for those of you who have been offended, I do apologize. I don't apologize anyway. Forget it. Okay. All right. But that's the whole issue. So, I'll probably be offended that you're offended. Okay. And that being said, we have to be very careful about where we publish or where we look. And there's a whole list of predatory publications. Some of these places you can pay, you can get your work published, but then it's up to you to be able to find the editorial board. It's up to you to be able to find the address of where they're published. Okay. And it's a cautionary note. Okay. Thank you very much. Just a quick straw poll in the audience because I know some people are having problems with the QR code. Did people at the beginning of the session get access? Were they able to access the QR code? Yeah. Okay. So, there must be something to do with the server. We will work on that. But for those of you who weren't able to access the bibliography list, we're going to post it on the SOGI section portal, the Connect portal. And if you don't have access to that, then come find one of us and we will get you sorted out. Thank you very much to our speakers. Thank you for your attention. And if you have questions, we'll be hanging around for a few minutes to respond. Thank you.

emergency general surgery

trauma care

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timing of the OR

weekend effect

transfers

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