BACKGROUND Hemorrhage remains the leading cause of preventable death after trauma. The XSTAT expandable minisponge hemostatic device was developed for the control of severe, life-threatening bleeding from junctional wounds not amenable to tourniquet application. This is an initial report of the clinical use of this novel method of hemorrhage control for civilian penetrating injury. METHODS A review of trauma admissions at a high-volume Level I trauma center was performed from July 2016 to November 2017. All patients sustaining penetrating trauma with active hemorrhage were evaluated for XSTAT use. Ten device deployments occurred during this time. Each deployment was reviewed in detail, capturing patient and injury data, efficacy of hemorrhage control, and evaluation of any potential device or treatment related complications. RESULTS Six thousand three hundred sixty-three trauma admissions were reviewed with 22.1% sustaining a penetrating mechanism of injury. XSTAT was deployed in 10 (0.7%) penetrating trauma admissions with a mean age of 38.3 (range, 16–59) years, systolic blood pressure (SBP) of 126.7 (range, 74–194) mm Hg, Glasgow Coma Scale (GCS) score of 14.5 (range, 13–15), and New Injury Severity Score (NISS) of 9.5 (range, 1–27). Eight patients had an identifiable arterial injury; the remainder had vein or soft tissue bleeding. Overall, half were junctional injuries. XSTAT was able to stop bleeding in nine of ten patients on the first deployment, with the remaining patient requiring one repeat injection. Dwell times ranged from 1 hour to 40 hours (median, 15 hours). There were no technical device failures or embolic complications. Retained sponges were identified in two patients on initial postremoval x-rays following wound exploration for definitive hemorrhage control and sponge removal. No patient died during the study period. CONCLUSION XSTAT use appears safe. It is rapid, reliable, and provides a high degree of hemorrhage control on first deployment. Sponge removal should always be followed by radiographic clearance. For patients with hemorrhage from cavitary wounds not amenable to tourniquet placement, this device was effective. Further study is warranted as XSTAT use becomes more widespread. LEVEL OF EVIDENCE Therapeutic study, level V.

BACKGROUND: Resuscitative endovascular balloon occlusion of the aorta (REBOA) has been increasingly used as part of damage control resuscitation for patients with non-compressible truncal hemorrhage. We hypothesized that there might be a select group of patients that could have benefited from prehospital placement of the REBOA. STUDY DESIGN: This was a retrospective cohort study including patients who presented to a Level I trauma center with cardiac arrest between January 2014 and March 2018. The findings of a full autopsy were reviewed for the details of internal injuries. A patient was determined to be a REBOA candidate if the patient sustained abdominal organ injuries or pelvic fractures and no associated severe head injuries. The candidate group was compared with the non-candidate group based on prehospital vital signs and other patient characteristics. A multiple logistic regression analysis was performed to identify certain prehospital factors associated with candidacy for prehospital REBOA. RESULTS:A total of 198 patients met our inclusion criteria. Of those, 27 (13.6%) patients were deemed REBOA candidates. Median Injury Severity Score was 22 (interquartile range 17 to 29). Patients in the candidate group were more likely to have a Glasgow Coma Scale score 9 (48% vs 15%; p ¼ 0.012), oxygen saturation >90% (56% vs 35%; p ¼ 0.03), and systolic blood pressure <90 mmHg (48% vs 26%; p ¼ 0.04) in the field. Logistic regression showed that these 3 clinical parameters of prehospital vital signs were significantly associated with REBOA candidacy. CONCLUSIONS: Our data suggest that >10% of trauma patients who presented with cardiac arrest could have benefited from prehospital REBOA. Additional prospective studies are warranted to validate the use of field vital signs in selecting candidates. (J Am Coll Surg 2019;229:383e388.

BACKGROUND Near hangings are an infrequent cause of trauma, and the optimal workup for these patients is unclear. The study objectives were to define the epidemiology, injury patterns, and use of investigations, including computed tomographic angiography (CTA) neck, after near hangings. METHODS All patients presenting to LAC+USC Medical Center (2008–2015) after near hanging (International Classification of Diseases, Ninth Revision, code of E913.8, E953.0, E963, or E983.0) were screened for inclusion. Transferred patients were excluded. Patient demographics, clinical data, injury data, investigations performed, and outcomes were collected. RESULTS Over the study period, 71 patients were identified. Median age was 32 years (interquartile range [IQR], 24-44), and 85% (n=64) were male. Median Glasgow Coma Scale was 12 [IQR 5-15], and median Injury Severity Score was 1 [IQR 1-2]. Mortality rate was 14% (n = 10). The most common finding on physical examination was a ligature mark (n = 38, 54%). Cervical injuries after near hangings occurred infrequently (five injuries in four patients [6%]: 3 [4%] arterial injuries and 2 [3%] laryngotracheal injuries). Only one patient (1%) required surgical and/or endovascular intervention. Two (3%) arrived in cardiac arrest, underwent resuscitative thoracotomy, and were pronounced dead. All others (n = 69, 97%) underwent CTA of the neck. No patient in this series manifested signs or symptoms of cervical injury during hospitalization after a normal CTA neck on presentation. CONCLUSION Near hangings infrequently result in cervical injury, and intervention is rarely needed. When injuries are sustained, they occur to critical structures such as the larynx, trachea, and cervical vasculature. Therefore, effective injury screening is important. We recommend CTA of the neck as the optimal initial imaging investigation after near hangings. LEVEL OF EVIDENCE Epidemiologic, level IV; therapeutic/care management, level IV.