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j.jamcollsurg.2017.07.098

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CRITICAL CARE AND TRAUMA
Acute Alcohol Intoxication Predicts
Fibrinolysis Shutdown in Injured Patients
Gregory Stettler, MD, Ernest E Moore, MD, FACS,
Hunter B Moore, MD, Geoffrey R Nunns, MD,
Benjamin Huebner, MD, Peter Einersen, MD,
Christopher C Silliman, MD, PhD, Anirban Banerjee, PhD,
Angela Sauaia, MD, PhD
University of Colorado, Aurora, CO; Denver Health Medical
Center, Denver, CO
Assessment of Blood Flow Patterns Distal
to Aortic Occlusion (AO) Using Computed
Tomography in Patients with Resuscitative
Endovascular Balloon Occlusion of the Aorta
(REBOA)
Philip Wasicek, MD, Kathirkamanathan Shanmuganathan, MD,
William A Teeter, MD, William B Gamble, MD, Peter F Hu, PhD,
Deborah M Stein, MD, FACS, Thomas M Scalea, MD, FACS,
Megan L Brenner, MD, FACS
University of Maryland Shock Trauma Center, Baltimore, MD
INTRODUCTION: Distinct phenotypes of fibrinolysis have been
identified after injury, but the risk factors have not been fully elucidated. Chronic alcohol abuse has been associated with postinjury
multiple organ failure (MOF) and venous thromboembolism
(VTE). We hypothesized that acute alcohol intoxication in severely
injured patients will decrease sensitivity to tissue plasminogen activator (tPA) and manifest as fibrinolysis shutdown by
thrombelastography.
INTRODUCTION: REBOA is used to decrease hemorrhage below
the level of aortic occlusion (AO). The aim was to investigate blood
flow patterns during complete AO in patients who underwent CT
scan after REBOA.
METHODS: Between February 2013 and January 2017, patients who
received REBOA and underwent CT scan with intravenous contrast
during full AO were included. Patients were excluded if they had a
CT scan performed with the balloon partially or fully deflated.
METHODS: Correlations between viscoelastic measurements
and blood alcohol level (BAL) were determined in consecutive
trauma activation patients (n ¼ 436) enrolled from 2014 to
2016. This was adjusted for clinical and laboratory risk factors
by multiple regression. Receiver operator curve analysis
evaluating BAL as a predictor of fibrinolysis phenotype was
also done.
RESULTS: Nine patients (8 male) were included, all blunt trauma.
Mean injury severity score was (SD) 48 8 and mean age was
45 19 years. Four had supraceliac AO, 5 had infrarenal AO.
Arterial contrast enhancement was noted below the level of AO
in all patients, and distal to REBOA sheath placement in 5. Collateralization from arteries above and below AO was identified in all
patients. Contrast extravasation distal to AO was identified in 4 patients, and hematomas in 8. Distal vascular enhancement patterns
varied by level of AO and contrast administration site.
RESULTS: In trauma patients, a high BAL (>150 mg/dL) is associated with lower systolic blood pressure (SBP), higher base deficit,
and lower LY30 on rapid TEG (r-TEG) and tPA challenge TEG
(p < 0.05 for all). Inverse correlations between BAL and LY30
(rho ¼ 0.31479, p < 0.0001) existed. BAL > 150 mg/dL is associated with a 3-fold increase in the odds of shutdown compared
with other fibrinolysis phenotypes adjusted for age, blunt mechanism, Glasgow Coma Scale, and SBP. BAL > 150 mg/dL is a predictor of fibrinolysis shutdown area under the receiver operator
characteristic curve (AUROC) 0.76 (95% CI 0.68e0.85), while
BAL 150 mg/dL is a predictor of hyperfibrinolysis, AUROC
0.71 (95% CI 0.63e0.79) (Figure).
HYPER
PHY
CONCLUSIONS: AO appears to dramatically decrease, but does
not completely impede, blood flow during REBOA due to multiple
pathways of collateralization. Active extravasation and hematomas
can be still be detected in the setting of full AO with properly
timed contrast and image acquisition. Blood flow persists below
the level of both the AO and indwelling sheath. Dynamic flow
studies are needed to determine the contribution of AO and sheath
placement to distal tissue ischemia; however, these data suggest the
ischemia may not be as severe as initially anticipated.
SD
% PATIENTS
60
Automatic Acoustic Gunshot Sensor
Technology’s Impact on Trauma Care
Magdalene A Brooke, MD, Stefania Kaplanes,
Gregory P Victorino, MD, FACS
University of California, San Francisco - East Bay; Highland
Hospital, Oakland, CA
50
40
30
20
10
0
0
1-150
>150
INTRODUCTION: As cities nationwide combat gun violence, use
of acoustic gunshot sensor technology is increasingly common.
With less than 20% of shots fired reported to police, there is clear
potential for crime-fighting purposes. However, there have been no
studies to date investigating whether these technologies affect
outcomes for victims of gunshot wounds (GSW). We hypothesized
that the ShotSpotter system would be associated with decreased
prehospital time intervals.
CONCLUSIONS: In the injured patient, acute alcohol intoxication
is associated with reduced sensitivity to tPA. With postinjury fibrinolysis shutdown associated with increased risk of MOF and VTE,
a high BAL may identify a target for therapeutic intervention to
attenuate shutdown.
S50
http://dx.doi.org/10.1016/j.jamcollsurg.2017.07.096
ISSN 1072-7515/17
Vol. 225, No. 4S1, October 2017
METHODS: All GSW patients, from 2014 to 2016, were collected
from our institutional registry and cross-referenced with local
police department data regarding times and locations of ShotSpotter (SST, Inc) alerts. Each GSW incident was categorized as related
or unrelated to a ShotSpotter alert based on its temporal and
geographic proximity. Admission data, trauma outcomes, and
prehospital time intervals were then compared.
RESULTS: We analyzed 731 patients. Of these, 192 were
ShotSpotter-related (26%) and 539 were not (76%). ShotSpotter-related patients were more likely to be female. They also had
higher Injury Severity Scores (ISS), more ventilator days, longer
total lengths of stay, and were more likely to require an operation.
Mortality, however, did not differ between the groups. Both total
prehospital time and emergency medical services (EMS) time
on-scene were lower in the ShotSpotter group.
CONCLUSIONS: To our knowledge, this is the first study to
investigate acoustic gunshot sensors’ relationship to clinical trauma
care. ShotSpotter patients experienced decreased prehospital and
EMS on-scene times. Additionally, despite higher ISS and use of
more hospital resources, mortality was similar to that in non-ShotSpotter counterparts. Therefore, this technology may benefit both
law enforcement and trauma centers.
Baseline American College of
Surgeons-Trauma Quality Improvement
Program (ACS-TQIP) Functional Status
Screen Correlates with Attributable Mortality
after Geriatric Trauma
Nicole L Werner, MD, Jill R Cherry-Bukowiec, MD,
Jinkyung Ha, PhD, Lillian Min, MD, Pauline K Park, MD
University of Michigan, Ann Arbor, MI
INTRODUCTION: We previously demonstrated that assessment of
pre-injury baseline functional status by the 5-element ACS-TQIP
functional screen (ACS-TQIP-FS) correlates with mortality
after hospitalization for trauma. We evaluated the populationattributable mortality fraction (PAF) due to trauma based on degree of baseline impairment identified by pre-injury screen.
METHODS: Centers for Medicare and Medicaid Services (CMS)
Inpatient Claims data were linked with nationally representative
Health and Retirement Study (HRS) data to identify older (age
65 years) patients who had functional status evaluation before
and after hospitalization for injury. Patients were stratified by
ACS-TQIP-FS and the PAF after the trauma hospitalization determined by baseline functional status.
RESULTS: Between 1998 and 2010, 2,882 patients were identified who had baseline functional status evaluation before hospitalization for injury; 708 (24.6%) died before follow-up interview
during the study period. Patients with mild (1 element loss) or
more severe (2 element loss), had higher mortality rates, 33.5%
and 45%, respectively, when compared with patients who had no
impairment on the baseline ACS-TQIP functional screen,
15.9%. Mortality rates observed in 10,597 control patients without
Scientific Forum Abstracts
S51
trauma hospitalization were used to determine the PAF due to
trauma. The attributable mortality was highest in patients without
baseline functional loss, less in those with mild baseline loss, and
essentially nil in patients with more severe baseline disability.
Table.
Pre-injury functional
status
No impairment
Mild impairment
Severe impairment
Total
Total n
mortality %
p Value
RR
1,773
15.91
638
33.54
471
45.01
2,882
24.57
0.143
2.541
0.246
1.590
0.205
0.996
0.167
1.858
PAF*, %
18.1
12.7
0.1
12.5
*PAF ¼ p(RR e 1)/(1 + p(RR 1))
Where p is proportion of the population injured and RR is relative risk of
death.
CONCLUSIONS: In older patients, attributable mortality due to
trauma hospitalization varies with baseline level of function, with
the highest fraction observed in previously healthy patients. The
ACS-TQIP-FS can help stratify patient risk to inform further interventions aimed at improving long-term trauma outcomes in older
patients.
Burn-Induced Endothelial Dysfunction Is
Ameliorated by Administration of Plasma
Mariana V Cruz, MD, Bonnie C Carney, Jason Chen, MD,
Lauren T Moffatt, PhD, Jeffrey W Shupp, MD
MedStar Health Research, MedStar Georgetown University
Hospital, MedStar Washington Hospital Center, Washington,
DC
INTRODUCTION: A complex inflammatory response mediates the
systemic effects of burn shock. Disruption of endothelial glycocalyx
(EGL) causes shedding of structural glycoproteins, primarily syndecan-1 (SDC-1), leading to endothelial dysfunction. These effects
may be mitigated by resuscitative interventions, including plasma
(FFP) administration.
METHODS: Sprague-Dawley rats were used to create 25% (medium)
and 40% (large) total body surface area burns, plus uninjured controls.
Resuscitation used lactated Ringer’s (LR) alone, or equivalent volume
of LR and FFP. Blood was serially collected. Evan’s blue dye (EBD)
was administered pre-euthanasia. Lungs were harvested for
quantification of EBD with spectrophotometry as a functional assay
of vascular permeability. Quantification of plasma SDC-1 employed
ELISA. qRT-PCR was run for TNF-a gene expression changes.
Statistical analysis applied 2-way ANOVA and Pearson correlation.
RESULTS: EBD extraction from lung was significantly greater
with higher injury severity (p ¼ 0.009) vs controls; this diminished
significantly in large burn animals by addition of FFP vs LR-only
(p ¼ 0.032). Plasma SCD-1 increased in all injured animals, and
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