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IntroductionGunshot wounds to the brain (GSWB) confer high lethality and uncertain recovery. It is unclear which patients benefit from aggressive resuscitation, and furthermore whether patients with GSWB undergoing cardiopulmonary resuscitation (CPR) have potential for survival or organ donation. Therefore, we sought to determine the rates of survival and organ donation, as well as identify factors associated with both outcomes in patients with GSWB undergoing CPR.MethodsWe performed a retrospective, multicenter study at 25 US trauma centers including dates between June 1, 2011 and December 31, 2017. Patients were included if they suffered isolated GSWB and required CPR at a referring hospital, in the field, or in the trauma resuscitation room. Patients were excluded for significant torso or extremity injuries, or if pregnant. Binomial regression models were used to determine predictors of survival/organ donation.Results825 patients met study criteria; the majority were male (87.6%) with a mean age of 36.5 years. Most (67%) underwent CPR in the field and 2.1% (n=17) survived to discharge. Of the non-survivors, 17.5% (n=141) were considered eligible donors, with a donation rate of 58.9% (n=83) in this group. Regression models found several predictors of survival. Hormone replacement was predictive of both survival and organ donation.ConclusionWe found that GSWB requiring CPR during trauma resuscitation was associated with a 2.1% survival rate and overall organ donation rate of 10.3%. Several factors appear to be favorably associated with survival, although predictions are uncertain due to the low number of survivors in this patient population. Hormone replacement was predictive of both survival and organ donation. These results are a starting point for determining appropriate treatment algorithms for this devastating clinical condition.Level of evidenceLevel II.

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Introduction:The Medical Emergency Team (MET) was developed in response to a need for emergent advanced assessment skills outside of the ICU. The MET nurse provides immediate bedside expertise to manage patients experiencing sudden clinical changes. Timely intervention and crisis prevention are key principles. Methods: Budgetary constraints led us to build our MET from an elite team of experienced nurses within the Medical Intensive Care Unit. All MET nurses have Advanced Cardiac Life Support (ACLS) certification and are trained in the Fundamentals of Critical Care Support (FCCS). Around the clock coverage is provided seven days a week. Results: These changes drove a 55% increase in the volume of MET calls. Preliminary data with the implementation of a dedicated MET nurse has indicated a 26.9% decrease in codes outside of the ICU and an 18% decrease in transfers back to the ICU post-MET calls. In addition, our hospital had a considerably longer door to balloon time (D2B) for inpatient cases of acute ST-elevation myocardial infarction (STEMI) than those presenting to the Emergency Department (ED). The Centers for Medicare and Medicaid Services set a goal D2B time of 90 minutes or less for patients presenting through the ED. An increase in early inpatient STEMI detection and rapid transfer to the cardiac catheterization lab has reduced symptom to balloon time by 31%, from 88 minutes to 61 minutes. Secondary benefits of the dedicated MET nurse have been improved communication and collegiality among care providers, and more robust staff education. Conclusions: These changes drove a 55% increase in the volume of MET calls. Preliminary data with the implementation of a dedicated MET nurse has indicated a 26.9% decrease in codes outside of the ICU and an 18% decrease in transfers back to the ICU post-MET calls.

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