Diagnostic test, level III.

A 21-year-old male trauma patient presented after a motor vehicle crash, witnessed massive aspiration and sustained traumatic brain injury. On postinjury day 3, the patient progressed to adult respiratory distress syndrome (ARDS) refractory to all conventional therapies, prompting the use of extracorporeal membrane oxygenation (ECMO). After 5 days of ECMO support and 3 thrombosed oxygenators, systemic anticoagulation was initiated. After 20 days of ECMO, 15 of which required systemic anticoagulation, the patient was decannulated and transferred to a rehabilitation facility. The patient is currently home without any neurological deficits. Although controversial, ECMO may serve a role as a rescue therapy in ARDS when conventional therapies fail in the brain-injured patient.

During the past decades, the only effective treatment option for severe, symptomatic, aortic valve stenosis was surgical aortic valve replacement. More than 10 years ago, Alain Cribier performed the first transcatheter aortic valve implantation (TAVI). Since 2007, CE-mark certified aortic valves are available for TAVI. This new technology rapidly achieved a very high clinical acceptance as a treatment option, in patients considered to be at high risk for surgical aortic valve replacement. Today, more than 80.000 patients in more than 40 countries have undergone TAVI. Despite a very-high-risk patient profile, data from multi-and single-center registries have confirmed the safety and efficacy of the procedure. The randomized, controlled PARTNER trial has confirmed both a superiority of TAVI over medical treatment in patients deemed ineligible for conventional surgical aortic valve replacement and a noninferiority of TAVI in comparison to surgical aortic valve replacement in high-risk patients. Although residual, mostly trivial or mild, paravalvular aortic regurgitation is frequent, promising preliminary data exist for the long-term outcome following TAVI. Cerebrovascular and vascular complications as well as atrioventricular block leading to permanent pacemaker implantation remain the most relevant periprocedural complications after TAVI. Next generation heart valves addressing some of these issues are currently under evaluation. In the future, valve-in-valve procedures for the treatment of a degenerated bioprosthesis will become an increasingly important application of transcatheter heart valves. Our growing knowledge, the introduction of next generation devices along with a confirmed long-term durability of transcatheter heart valve prostheses will pave the way for the expansion of TAVI.

Nurse practitioners and physician assistants, collectively known as advanced practitioners (APs), enhance the provision of care for the acutely injured patient. Despite their prevalence, institutions employ, train, and utilize these providers with significant variability. The Eastern Association for the Surgery of Trauma, the Society of Trauma Nurses, and the American Association of Surgical Physician Assistants acknowledge the value of APs and support their utilization in the management of injured and critically ill patients. This position paper offers insight into the history of, scope of practice for, and opportunities for optimal utilization of APs in trauma, critical care, and acute care surgery services.