Background: Numerous advancements in hemorrhage control and volume replacement that comprise damage control resuscitation (DCR) have been implemented in the last decade to reduce deaths from bleeding. We sought to determine the impact of DCR interventions on mortality over 12 years in a massive transfusion protocol (MTP) population. We hypothesized that mortality would be decreased in later years, which would have used more DCR interventions. Study Design: This was a retrospective review of all MTP patients treated at a large regional Level I trauma center from 2008 to 2019. Interventions by year of implementation examined included MTP 1:1 ratio ( 2009), liquid plasma (2010), tranexamic acid (2012), prehospital tourniquets (2013), REBOA/TEG (2017), satellite blood station (2018), and whole blood transfusion (2019). Relative risk and odds of mortality for DCR interventions were examined. Results: There were 824 MTP patients included. The cohort was primarily male (80.6%) injured by penetrating mechanism (68.1%) with median (interquartile range) age 31 years (23-44) and New Injury Severity Score 25 (16-34). Overall mortality was unchanged [(38.3%-56.6%); P ¼ 0.26]. Tourniquets (P ¼ 0.02) and whole blood (WB) (P ¼ 0.03) were associated with lower unadjusted mortality; only tourniquets remained significant after adjustment (OR: 0.39; 95% CI: 0.17-0.89; P ¼ 0.03). Conclusions: Despite lower mortality with use of tourniquets and WB, mortality rates due to hemorrhage have not improved at our high MTP volume institution, suggesting implementation of new in-hospital strategies is insufficient to reduce mortality. Future efforts should be directed toward moving hemorrhage control and effective resuscitation interventions to the injury scene.

A patient presented to the ED with 2 days of chest pain radiating to the back. Symptoms were associated with dyspnea and diaphoresis. The patient had a significant history of self-inflicted stab wounds and retained foreign bodies. He was status-post multiple endoscopic removals and laparotomies. The patient was recently admitted to the hospital secondary to an abdominal foreign body removed by general surgery. The day of presentation the patient denied any new injuries. He had no history of cardiac disease or venous thromboembolic events. Review of systems was negative other than noted. His vital signs showed an initial BP 120/55, pulse rate 118, temperature 36.9 C, respiration rate of 20, and peripheral capillary oxygen saturation 97% on room air. His general appearance was significant for an ill-appearing, diaphoretic man. Cardiovascular examination was notable for sinus tachycardia with intact distal pulses and no detectable abnormal heart sounds. Respiratory examination revealed clear lungs and normal work of breathing. Abdominal examination revealed multiple well-healed scars without tenderness or peritoneal signs. The rest of his physical examination was unremarkable.On arrival to the ED, two large-bore IV lines were established. ST changes were noted on the monitor, prompting an ECG that revealed diffuse ST segment elevations. Troponin was elevated to 2.01. A bedside cardiac ultrasound was performed (Video 1).

Background We present a video case with a novel, minimally invasive approach to the thymus, which does not require a sternotomy, thoracic incision, or entry into the pleural space. Methods A 14‐year‐old girl was referred to our clinic with dysphagia and left sided thymic mass. A detailed video shows the operative techniques used to perform a thymectomy with robotic assistance via a transaxillary approach. Results The procedure was tolerated well and without complication. The patient was discharged the day after surgery and was symptom free at her 2‐week follow‐up appointment. Conclusion We present a novel approach to thymic surgery that does not require a neck incision, sternotomy, or entry into the pleural space. There could be several benefits from this minimally invasive approach; however, concerns related to exposure and adequacy of resection need further research prior to recommending this technique for myasthenia or malignancy.

Background: Current algorithms for resuscitation in blunt trauma patients rely on chest x-ray, FAST, and pelvic x-ray to quickly elicit a source of major bleeding in the trauma bay.  There are currently no good recommendations for the patient in whom all three of these imaging studies are negative.  Methods:  We identified blunt trauma victims who presented with a systolic blood pressure below 100mmHg.  Chest x-ray, FAST, and pelvic x-ray obtained in the trauma bay were reviewed, and patients who had all three studies negative underwent thorough chart review and characterization of injuries.   Results:  Of the total hypotensive blunt trauma victims (n=649), we found 47 who had a “non-diagnostic triad” (NDT).  Of the NDT group, 31.9% (n=15) were found to have a major injury contributing to hypotension, while 61% (n=29) were not diagnosed with a severe injury that could have contributed to hypotension.  Of the NDT group with severe injury, 40% (n=6) were found to have retroperitoneal bleeding, 40% (n=6) were found to have intraperitoneal bleeding despite negative fast, 13% (n=2) were thought to have spinal shock, and one patient had a blunt cardiac injury.    Conclusions:  Most of the NDT group patients in this study were not diagnosed with a serious injury.  However, a significant minority (31%) were found to have a major injury contributing to hypotension.  Of these patients, retroperitoneal and/or intra-abdominal bleeding were found in 80%, with neurogenic and cardiogenic shock less common.  We feel these sicker NDT patients may benefit from REBOA, although more study is warranted before formal algorithms and recommendations are made.

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