Patients undergoing emergency surgery typically require resuscitation, either because they are hemorrhaging or because they are experiencing significant internal fluid shifts. Intravascular hypovolemia is common at the time of anesthesia induction and can lead to hemodynamic collapse if not promptly treated. Central pressure monitoring is associated with technical complications and does not improve outcomes in this population. Newer modalities are in use, but they lack validation. Fluid resuscitation is different in bleeding and septic patients. In the former group, it is advisable to maintain a deliberately low blood pressure to facilitate clot formation and stabilization. If massive transfusion is anticipated, blood products should be administered from the outset to prevent the coagulopathy of trauma. Early use of plasma in a ratio approaching 1:1 with red blood cells (RBCs) has been associated with improved outcomes. In septic patients, early fluid loading is recommended. The concept of "goal-directed resuscitation" is based on continuing resuscitation until venous oxygen saturation is normalized. In either bleeding or septic patients, however, the most important goal remains surgical control of the source of pathology, and nothing should be allowed to delay transfer to the operating room. We review the current literature and recommendations for the resuscitation of patients coming for emergency surgery procedures.

A novel FIP improved OR efficiency. Given the small amount of money involved, it seems unlikely that financial incentives were solely responsible. Effectively communicating the importance of TATs and on-time FCSs and publishing individual results more likely increased staff awareness. Teamwork created by linking assignment of points to a team result likely contributed to success.

Early recognition of hemorrhage during the initial resuscitation of injured patients is associated with improved survival in both civilian and military casualties. We tested a transfusion and lifesaving intervention (LSI) prediction algorithm in comparison with clinical judgment of expert trauma care providers. We collected 15 min of pulse oximeter photopletysmograph waveforms and extracted features to predict LSIs. We compared this with clinical judgment of LSIs by individual categories of prehospital providers, nurses, and physicians and a combined judgment of all three providers using the Area Under Receiver Operating Curve (AUROC). We obtained clinical judgment of need for LSI from 405 expert clinicians in135 trauma patients. The pulse oximeter algorithm predicted transfusion within 6 h (AUROC, 0.92; P < 0.003) more accurately than either physicians or prehospital providers and as accurately as nurses (AUROC, 0.76; P = 0.07). For prediction of surgical procedures, the algorithm was as accurate as the three categories of clinicians. For prediction of fluid bolus, the diagnostic algorithm (AUROC, 0.9) was significantly more accurate than prehospital providers (AUROC, 0.62; P = 0.02) and nurses (AUROC, 0.57; P = 0.04) and as accurate as physicians (AUROC, 0.71; P = 0.06). Prediction of intubation by the algorithm (AUROC, 0.92) was as accurate as each of the three categories of clinicians. The algorithm was more accurate (P < 0.03) for blood and fluid prediction than the combined clinical judgment of all three providers but no different from the clinicians in the prediction of surgery (P = 0.7) or intubation (P = 0.8). Automated analysis of 15 min of pulse oximeter waveforms predicts the need for LSIs during initial trauma resuscitation as accurately as judgment of expert trauma clinicians. For prediction of emergency transfusion and fluid bolus, pulse oximetry features were more accurate than these experts. Such automated decision support could assist resuscitation decisions, trauma team, and operating room and blood bank preparations.

There is no gold standard for the diagnosis of mTBI. BAM screening is a useful diagnostic adjunct in patients with mTBI and may facilitate decision making. An abnormal BAM reading adds significance to LOC as a predictor of a new abnormality on head CT. In our study, opting not to CT scan patients with a normal BAM signal would have missed no new CT findings and no patients who required medical intervention for TBI, at a cost savings of $202,950.

There is a growing recognition that trauma anesthesiology represents a distinct area of subspecialty knowledge. Anesthesiology specialty organizations advocate for trauma-specific knowledge and training for trauma anesthesia providers. Requiring the in-house presence of anesthesia providers in level I and level II trauma centers may impose significant costs on medical centers that do not currently provide those services.

IntroductionPhysicians and other prescribing clinicians use opioids as the primary method of pain management after traumatic injury, despite growing recognition of the major risks associated with usage for chronic pain. Placebos given after repeated administration of active treatments can acquire medication-like effects based on learning mechanisms. This study hypothesises that dose-extending placebos can be an effective treatment in relieving clinical acute pain in trauma patients who take opioids.Methods and analysisThe relieving acute pain is a proof-of-concept randomised, placebo-controlled, double-blinded, single-site study enrolling 159 participants aged from 18 to 65 years with one or more traumatic injuries treated with opioids. Participants will be randomly assigned to three different arms. Arm 1 will receive the full dose of opioids with non-steroidal anti-inflammatory drugs (NSAIDs). Arm 2 will receive the 50% overall reduction in opioid dosage, dose-extending placebos and NSAIDs. Arm 3 (control) will receive NSAIDs and placebos. The trial length will be 3 days of hospitalisation (phase I) and 2-week, 1-month, 3-month and 6-month follow-ups (exploratory phase II). Primary and secondary outcomes include feasibility and acceptability of the study. Pain intensity, functional pain, emotional distress, rates of rescue therapy requests and patient-initiated medication denials will be collected.Ethics and disseminationAll activities associated with this protocol are conducted in full compliance with the Institutional Review Board policies and federal regulations. Publishing this study protocol will enable researchers and funding bodies to stay up to date in their fields by providing exposure to research activity that may not otherwise be widely publicised.Date and protocol version identifier3/6/2019 (HP-00078742).Trial registration number NCT03426137.

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