SEVERITY OF HEMORRHAGE AND THE SURVIVAL BENEFIT ASSOCIATED WITH PLASMA: RESULTS FROM A RANDOMIZED PREHOSPITAL PLASMA TRIAL Introduction Recent randomized clinical trial evidence demonstrated a survival benefit with the use of prehospital plasma in patients at risk of hemorrhagic shock. We sought to characterize the survival benefit associated with prehospital plasma relative to the blood transfusion volume over the initial 24 hours. We hypothesized that the beneficial effects of prehospital plasma would be most robust in those with higher severity of hemorrhage. Methods We performed a prespecified secondary analysis using data derived from a prospective randomized prehospital plasma trial. Blood component transfusion volumes were recorded over the initial 24 hours. Massive transfusion (MT) was defined a priori as receiving ≥ 10 units of red cells in 24hrs. We characterized the 30-day survival benefit of prehospital plasma and the need for MT and overall 24-hour red cell transfusion volume utilizing Kaplan-Meier survival analysis and Cox proportional hazard regression. Results There were 501 patients included in this analysis with 230 randomized to prehospital plasma with 104 patients requiring MT. Mortality in patients who received MT were higher compared to those that did not (MT vs. NO-MT, 42% vs 26%, p=0.001). Kaplan-Meier survival curves demonstrated early separation in the NO-MT subgroup (log rank p=0.008) with no survival benefit found in the MT group (log rank p=0.949). Cox regression analysis verified these findings. When 24-hour red cell transfusion was divided into quartiles, there was a significant independent association with 30-day survival in patients who received 4-7 units (HR 0.33, 95% CI 0.14-0.80, p=0.013). Conclusion The survival benefits of prehospital plasma was demonstrated only in patients with red cell requirements below the transfusion level of MT. Patients who received 4-7 units of red cells demonstrated the most robust independent survival benefit attributable to prehospital plasma transfusion. Prehospital plasma may be most beneficial in those patients with moderate transfusion requirements and mortality risk. Secondary Analysis Level of Evidence- I Presented as a quick shot presentation at the 78th annual meeting of the American Association For the Surgery of Trauma & Clinical Congress of Acute Care Surgery, Sept 18-21, 2019, Dallas, TX Conflicts of Interest: The authors have no conflicts of interest to declare and have received no financial or material support related to this manuscript Corresponding Author: Jason L. Sperry MD, MPH, University of Pittsburgh Medical Center, 200 Lothrop St., Pittsburgh, Pennsylvania 15213, office 412-802 8270; fax 412-647-1448. sperryjl@upmc.edu Funding: This work was supported by the US Department of Defense (USAMRAA, W81XWH-12-2-0028) and (USAMRAA, W81XWH-12-2-0023) © 2019 Lippincott Williams & Wilkins, Inc.

Authors Reply RE: Intermittent REBOA Translational Science Papers No abstract available

Letter to the Editor: Titrate to equilibrate and not exsanguinate! No abstract available

Ultrasonographic IVC Diameter Response to Trauma Resuscitation after One Hour Predicts 24 Hour Fluid Requirement Introduction Identification of occult hypovolemia in trauma patients is difficult. We hypothesized that in acute trauma patients, the response of ultrasound-measured minimum inferior vena cava diameter (IVCDMIN), IVC Collapsibility Index (IVCCI), minimum internal jugular diameter (IJVDMIN) or IJV Collapsibility Index (IJVCI) after up to 1 hour of fluid resuscitation would predict 24-hour resuscitation intravenous fluid requirements (24FR). Methods An NTI funded, AAST-MITC prospective, cohort trial was conducted at 4 Level I Trauma Centers. Major trauma patients were screened for an IVCD ≤ 12 mm or IVCCI ≤ 50% on initial FAST. A second IVCD was obtained 40-60 minutes later, after standard-of-care fluid resuscitation. Patients whose second measured IVCD was < 10mm were deemed Non-Repleted (NON-REPLETED), those ≥10mm were Repleted (REPLETED). Prehospital and initial resuscitation fluids and 24FR were recorded. Demographics, ISS, arterial blood gasses, LOS, interventions and complications were recorded. Means were compared by ANOVA and categorical variables were compared via Chi-square. ROC curves analysis were used to compare the measures as 24FR predictors. Results 4798 patients were screened, 196 were identified with admission IVCD of 12 mm or IVCCI of 50% or less, 144 were enrolled. There were 86 REPLETED and 58 NON-REPLETED. Demographics, initial hemodynamics or laboratory measures were not significantly different. NON-REPLETED had smaller IVCD (6.0mm ± 3.7 vs.14.2mm ± 4.3, p< 0.001) and higher IVCCI (41.7% ± 30.0 vs. 13.2% ± 12.7, p< 0.001) but no significant difference in IJVD or IJVCCI. REPLETED had greater 24FR than NON-REPLETED (2503ml ± 1751 vs. 1243ml ± 1130, p= 0.003). ROC analysis indicates IVCDMIN predicted 24FR (AUC= 0.74, C.I.: 0.64-0.84, p<0.001) as did IVCCI (AUC= 0.75, C.I.: 0.65-0.85, p<0.001) but not IJVDMIN (AUC= 0.48, C.I.: 0.24-0.60, p=0.747) or IJVCI (AUC= 0.54, C.I.: 0.42-0.67, p=0.591). Conclusion Ultrasound assessed IVCDMIN and IVCCI response initial resuscitation predicts 24-hour fluid resuscitation requirements. Levels of Evidence II+ Study Type Diagnostic tests or criteria Correspondence: Jay Doucet, MD, Division of Trauma, Surgical Critical Care, Burns, and Acute Care Surgery, Department of Surgery, University of California San Diego, 200 W. Arbor Drive. MC 8896, San Diego, CA 92103, Phone 619 543 7200, Fax 619 543 7202. jdoucet@ucsd.edu The authors declare they have no conflicts of interest regarding this work. This work was a podium presentation at the 77th Annual Meeting of the American Association for the Surgery of Trauma and Clinical Congress of Acute Care Surgery & 4th World Trauma Congress, September 24-16, 2017. San Diego, CA. This study was funded by National Trauma Institute Subaward # NTI-NCH-10-016 and sponsored by the Department of the Army, Prime award W81XWH-15-1-0709, Proposal/Study Number JW140026. The US Army Medical Research Acquisition Activity (820 Chandler Street, Fort Detrick, MD 21702–5014) is the awarding and administering acquisition office. The ClinicalTrials.gov identifier is NCT01989273. © 2019 Lippincott Williams & Wilkins, Inc.

Detecting Direct Oral Anticoagulants in Trauma Patients using Liquid Chromatography-Mass Spectrometry: a Novel Approach to Medication Reconciliation Background Accurate medication reconciliation in trauma patients is essential but difficult. Currently there is no established clinical method of detecting direct oral anticoagulants (DOACs) in trauma patients. We hypothesized that a liquid chromatography-mass spectrometry (LCMS) based assay can be used to accurately detect DOACs in trauma patients upon hospital arrival. Methods Plasma samples were collected from 356 patients who provided informed consent including- 10 healthy controls, 19 known positive or negative controls and 327 trauma patients over 65 years of age who were evaluated at our large, urban Level 1 Trauma Center. The assay methodology was developed in healthy and known controls to detect apixaban, rivaroxaban and dabigatran using LCMS and then applied to 327 samples from trauma patients. Standard medication reconciliation processes in the electronic medical record documenting DOAC usage was compared with LCMS results to determine overall accuracy, sensitivity, specificity and positive and negative predictive values (PPV, NPV) of the assay. Results Of 356 patients, 39 were on DOACs (10.96%): 21 were on Apixaban, 14 on rivaroxaban and 4 on dabigatran. The overall accuracy of the assay for detecting any DOAC was 98.60%, with a sensitivity of 94.87% and specificity of 99.06%, (PPV 92.50% and NPV 99.37%). The assay detected apixaban with a sensitivity of 90.48% and specificity of 99.11% (PPV 86.36% and NPV 99.40%). There were three false positive results and two false negative LCMS results for apixaban. Dabigatran and rivaroxaban were detected with 100% sensitivity and specificity. Conclusions This LCMS-based assay was highly accurate in detecting DOACs in trauma patients. Further studies need to confirm the clinical efficacy of this LCMS assay and its value for medication reconciliation in trauma patients. Study type diagnostic test Basic Science paper therefore does not require a level of evidence. Corresponding Authors: Sudha Jayaraman, MD MSc FACS, Associate Professor of Surgery, Division of Acute Care Surgery, Co-Director, Program for Global Surgery, Department of Surgery, VCU School of Medicine, VCU Health System, P: (804)827-2409 F: (804) 827-0285, Email: sudha.jayaraman@vcuhealth.org; And Dayanjan S Wijesinghe, Assistant Professor, Department of Pharmacotherapy and Outcomes Sciences, VCU School of Pharmacy, P: (804) 628 3316 F: (804) 828 0343, Email: wijesingheds@vcu.edu Conflicts of interest and sources of funding: MM is funded through DOD W81XWH-16-2-0040, W81XWH-17-1-0602, W81XWH-18-1-0759, and W81XWH-18-1-0579. SJ has support from: NIH R21: 1R21TW010439-01A1 (PI); Rotary Foundation Global Grant #GG1749568 (PI); NIH P20: 1P20CA210284-01A1 (Co-PI); DOD grant W81XWH-16-2-0040 (Co-I); DSW and SJ has support from VCU Quest for Innovation Commercialization Grant (PIs); and Commonwealth Research Commercialization Fund (CRCF) (PI and Co-I respectively). Both are co-founders of Mass Diagnostix, Inc but have not received any direct funding and therefore do not report any conflict of interest. Disclosures: The authors have nothing to disclose. © 2019 Lippincott Williams & Wilkins, Inc.

Determining the Clinical Significance of the Chest Wall Injury Society Taxonomy for Multiple Rib Fractures Background The Chest Wall Injury Society (CWIS) proposals for standardized nomenclature for Multiple Rib Fracture (MRF) classifications were derived by international expert Delphi consensus. This study aimed to validate the CWIS taxonomy using a single instituion clinical database. Methods Computed Tomography (CT) scans, of 539 consecutive patients with MRFs admitted to a regional Major Trauma Centre over a 33 months period, were reviewed (blinded for clinical outcomes). Every rib fracture in every patient was assessed according to each of the CWIS criteria (the degree of displacement, characterization of the fracture line, location of each fracture and the relationship to neighboring fractures). The clinical significance of the proposed CWIS definitions were determined from independently coded, routinely collected Hospital Episodes Statistics data. Results The radiologic aspects of 3944 individual rib fractures were assessed. Indicators of injury severity (severe displacement greater series length, and flail segment) were positively associated with other fractures (p<0.001), haemo-pneumothorax (p<0.001), pulmonary complications (p=0.002), adverse outcomes (p=0.006), mechanical ventilation (p<0.001) and prolonged hospital and ITU length of stay (p=0.006, p=0.007 respectively). Four of the CWIS proposed definitions were correlated with pulmonary complications and adverse outcomes: the categories of displacement, the definition of individual fracture characterisation, the presence of a flail segment. Two definitions for which there was CWIS consensus were not correlated with clinical outcomes: the definition of a series to describe associated fractures on neighboring ribs, the inclusion of a paravertebral sector for fracture localisation. Conclusions The CWIS rib fracture taxonomy demonstrates clinical relevance. There were associations between the severity of category groups within three of the proposed definitions, based on the clinical outcomes observed. Clinical outcome assessment proved inconclusive for four agreed definitions. Comprehensive, multi-institutional data collection would be required to provide validation for all the CWIS proposed defintions. Levels of Evidence Level IV Correspondence: Mr JG Edwards PhD FRCS (C/Th), Consultant Thoracic Surgeon, Department of Cardiothoracic Surgery, Northern General Hospital, Herries Road, Sheffield, S5 7AU, United Kingdom, Telephone: +44 (0) 1142 269279, Fax: +44 (0) 1142 610350, Email: john.edwards@sth.nhs.uk Conflict of interest statement detailing all sources of support, including pharmaceutical and industry support. If no conflicts are declared, this must also be stated. No conflicts of interest are declared. List of meetings at which the paper was presented 3rd Annual Meeting of the Chest Wall Injury Society, March 30, 2019, Santa Fe, NM 83rd Annual Meeting of the Society for Cardio-Thoracic Surgery in Great Britain and Ireland, March 12, 2019, London, United Kingdom Disclosures of funding received for this work No funding was received for this work. © 2019 Lippincott Williams & Wilkins, Inc.

Regional Analgesia for Patients with Traumatic Rib Fractures – A Narrative Review Rib fractures are a common complication of trauma and a marker of internal injuries and can carry a high mortality rate. Advanced age, multiple rib fractures, flail chest, and concomitant injuries are poor prognostic risk factors. Fractured ribs and chest drains are painful which can lead to splinting and impaired respiratory mechanics, thereby exacerbating underlying lung injuries and leading to pneumonia, the need for ventilatory support, and death. Younger patients and those with ≤3 rib fractures and non-severe internal injuries/comorbidities generally do not require hospitalization, and should receive multimodal analgesia according to the World Health Organization pain ladder. For the elderly and those with ≥3 rib fractures, significant comorbidities, and/or associated injuries, multimodal analgesia, which includes opioids, is rarely sufficient. Regional analgesia is a safe, effective, reliable modality that can facilitate chest physiotherapy, ambulation and possibly weaning from mechanical ventilation with the advantage of avoiding the central nervous depressive effects of opioids. Regional analgesia relies mainly on low-concentration local anesthetics (with or without low-dose opioids), and can be performed as a single dose injection, or, more commonly, by placing a catheter for continuous/prolonged infusion. Regional analgesia options include epidural, paravertebral block (and its variants), intercostal block, and serratus anterior block. Newer (and theoretically safer) techniques have emerged in recent years and can be easily mastered by trauma and emergency physicians, respirologists, and intensivists using ultrasound guidance. The purpose of this review is to summarize and review the literature for commonly used analgesic strategies in patients with rib fractures, with an emphasis on regional blocks. Level of Evidence 1-3 Study Type Review Article Corresponding Author: Glenio B. Mizubuti (MD, MSc), Department of Anesthesiology & Perioperative Medicine, Queen’s University, Victory 2, Kingston General Hospital, 76 Stuart Street, Kingston, ON. Canada. K7L 2V7, Tel: (613) 548-7827 Fax: (613) 548-1375, Email: gleniomizubuti@hotmail.com Conflicts of Interest: None Funding Disclosures: No external funding was acquired for completion of the current work. © 2019 Lippincott Williams & Wilkins, Inc.

Consequences of pre-injury utilization of direct oral anticoagulants (DOACs) in patients with traumatic brain injury (TBI): a systematic review and meta-analysis No abstract available

Western Trauma Association Critical Decisions in Trauma: Cervical Spine Clearance in Trauma Patients No abstract available

Multiple Impacted Colonic Foreign Bodies Presenting Months After Ingestion No abstract available