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This is a joint statement from the American College of Surgeons Committee on Trauma, the American College of Emergency Physicians, the National Association of Emergency Medical Services Physicians and the National Association of Emergency Medical Technicians regarding the clinical use of resuscitative endovascular balloon occlusion of the aorta (REBOA) in civilian trauma systems in the USA. This statement addresses the system of care needed to manage trauma patients requiring the use of REBOA, in light of the current evidence available in this patient population. This statement was developed by an expert panel following a comprehensive review of the literature with representation from all sponsoring organizations and the US Military. This is an update to the previous statement published in 2018. It has been formally endorsed by the four sponsoring organizations.

Venous thromboembolism (VTE) is a potential sequela of injury, surgery, and critical illness. Patients in the Trauma Intensive Care Unit are at risk for this condition, prompting daily discussions during patient care rounds and routine use of mechanical and/or pharmacologic prophylaxis measures. While VTE rightfully garners much attention in clinical patient care and in the medical literature, optimal strategies for VTE prevention are still evolving. Furthermore, trauma and surgical patients often have real or perceived contraindications to prophylaxis that affect the timing of preventive measures and the consistency with which they can be applied. In this Clinical Consensus Document, the American Association for the Surgery of Trauma Critical Care Committee addresses several practical clinical questions pertaining to specific or unique aspects of VTE prophylaxis in critically ill and injured patients.

Rhabdomyolysis is a clinical condition characterized by destruction of skeletal muscle with release of intracellular contents into the bloodstream. Intracellular contents released include electrolytes, enzymes, and myoglobin, resulting in systemic complications. Muscle necrosis is the common factor for traumatic and non-traumatic rhabdomyolysis. The systemic impact of rhabdomyolysis ranges from asymptomatic elevations in bloodstream muscle enzymes to life-threatening acute kidney injury and electrolyte abnormalities. The purpose of this clinical consensus statement is to review the present-day diagnosis, management, and prognosis of patients who develop rhabdomyolysis.

Current severity of disease in the Covid-19 population As of 26 March 2020, the Centers for Disease Control and Prevention (CDC) reported 68 440 total confirmed plus presumptive cases of Covid-19 in the USA, with 994 deaths.1 These numbers are expected to change daily as more data are collected and more testing for the virus is performed. In previous studies, early tracheostomy has been associated with reductions in the duration of mechanical ventilation4 and short-term mortality and in specialized populations such as those with traumatic brain injury, reduced ICU and hospital days and risk of nosocomial pneumonia.5 In the trauma population, percutaneous bedside tracheostomy is common and safe. In Wuhan, China, 40 of 138 hospitalized patients were healthcare providers who were infected from presumed hospital spread.6 With the current pandemic, significant attention has been focused on the safety of healthcare workers, and many organizations have published guidance on infection prevention and control for these essential personnel.9–12 Considerations for indications and timing Surgeons should consider both short-term and long-term outcomes of tracheostomy along with the risks of exposure of the clinical team. In some circumstances, tracheostomy may accelerate ventilator weaning,4 which might improve throughput of patients with Covid-19 in the hospital system, making room for new patients if ICU resources and ventilators become scarce.

Correspondence to Dr Ronald M Stewart, Department of Surgery, University of Texas Health Science Center at San Antonio, 7703 Floyd Curl Drive, San Antonio, Texas 78229, USA ; stewartr@uthscsa.edu Introduction Resuscitative Endovascular Balloon Occlusion of the Aorta (REBOA) provides a new tool in selected patients for the management of non-compressible torso hemorrhage.1–3 Recent improvements in technology have facilitated more rapid placement through smaller femoral access sheaths, which may reduce access-related complications.4 However, high grade evidence to guide REBOA use is limited, and there is a substantial complication risk should this approach be used inappropriately.5 To address the current state of implementation of this new therapeutic strategy, the American College of Surgeons Committee on Trauma (ACS COT) has worked in collaboration with the American College of Emergency Physicians to issue this joint policy statement which addresses the current practice relevant to patient indications, potential complications, implementation, patient management, and training of providers. Acute care surgeons can learn and safely perform REBOA after a formal training course.9 REBOA is currently standard practice for select patients at a small number of trauma centers where surgeons are immediately available for the management of REBOA.2 6 The major rate-limiting step to REBOA is the ability to safely and efficiently cannulate the common femoral artery (CFA) in a hypovolemic patient.5 10–12 If percutaneous cannulation is not possible, surgical cut down is required. An acute care surgeon must be immediately available to definitively address the specific cause of hemorrhage to avert the dire complications of truncal and or spinal cord ischemia from prolonged aortic occlusion.10–12 Emergency medicine (EM) physicians with added certification in critical care (EMCC) trained in REBOA, may train and perform REBOA in conjunction with an acute care surgeon or vascular surgeon trained in REBOA, as long as the surgeon(s) is/are immediately available to definitively control the focused source of bleeding. Transfer of patients Due to the inability of prehospital providers to appropriately manage and troubleshoot the devices during transport, and the lack of evidence to support safe duration of aortic occlusion, transfer of patients with REBOA is not recommended. [...]REBOA should not be placed in Emergency Departments in institutions where the patient cannot receive definitive surgical care and hemostasis at that same institution.

In April 2017, the American Association for the Surgery of Trauma (AAST) asked the AAST Patient Assessment Committee to undertake a gap analysis for published clinical practice guidelines in emergency general surgery (EGS). Committee members performed literature searches to catalogue published guidelines for common EGS diseases and also to identify gaps in the literature where guidelines could be created. For five of the most common EGS conditions, acute appendicitis, acute cholecystitis, acute diverticulitis, acute pancreatitis, and small bowel obstruction, we found multiple well-referenced guidelines published by leading professional organizations. We have summarized guideline recommendations for each of these disease states stratified by the AAST EGS anatomic severity score based on these published consensus guidelines. These summaries could be used to help inform evidence-based clinical decision-making, but are intended to be flexible and updatable in real time as further research emerges. Comprehensive guidelines were available for all of the diseases queried and identified gaps most commonly represented areas lacking a solid evidence base. These are therefore areas where further research is needed.

BackgroundAntibiotic prophylaxis is routinely administered for most operative procedures, but their utility for certain bedside procedures remains controversial. We performed a systematic review and meta-analysis and developed evidence-based recommendations on whether trauma patients receiving tube thoracostomy (TT) for traumatic hemothorax or pneumothorax should receive antibiotic prophylaxis.MethodsPublished literature was searched through MEDLINE (via PubMed), Embase (via Elsevier), Cochrane Central Register of Controlled Trials (via Wiley), Web of Science and ClinicalTrials.gov databases by a professional librarian. The date ranges for our literature search were January 1900 to March 2020. A systematic review and meta-analysis of currently available evidence were performed using the Grading of Recommendations Assessment, Development and Evaluation methodology.ResultsFourteen relevant studies were identified and analyzed. All but one were prospective, with eight being prospective randomized control studies. Antibiotic prophylaxis protocols ranged from a single dose at insertion to 48 hours post-TT removal. The pooled data showed that patients who received antibiotic prophylaxis were significantly less likely to develop empyema (OR 0.47, 95% CI 0.25 to 0.86, p=0.01). The benefit was greater in patients with penetrating injuries (penetrating OR 0.25, 95% CI 0.10 to 0.59, p=0.002, vs blunt OR 0.25, 95% CI 0.06 to 1.12, p=0.07). Administration of antibiotic prophylaxis did not significantly affect pneumonia incidence or mortality.DiscussionIn adult trauma patients who require TT insertion, we conditionally recommend antibiotic prophylaxis be given at the time of insertion to reduce incidence of empyema.PROSPERO registration numberCRD42018088759.

Table 1 Contamination considerations Type of contamination Antibiotic recommendations Additional considerations Water contamination Short course, 3–5 days Salt water Doxycycline and ceftazidime Fluoroquinolone Freshwater Ciprofloxacin Levofloxacin Third or fourth-generation cephalosporin Vibrio Aeromonas Pseudomonas Soil contamination Short course, 3–5 days High-dose penicillin Clostridium sp Farm-related injuries Mammalian bites (human, dog, or cat) Short course, 3–5 days Amoxicillin-clavulanate Clindamycin plus trimethoprim-sulfamethoxazole for penicillin-allergic patients Table 2 Summary of antibiotic recommendations Injury Antibiotic recommendations Additional considerations Face and scalp Open or contaminated facial fractures Prophylactic antibiotics 24 h or less Cefazolin—coverage against GP bacteria Ceftriaxone—broader GN coverage and CNS penetration Ampicillin/sulbactam—broader GN and anaerobic coverage Clindamycin—for penicillin-allergic patients Frontal sinus fracture that involves the posterior table Contaminated fractures Open mandible fractures Closed or non-contaminated operative facial fractures Preoperative antibiotics Cefazolin—coverage against GP bacteria Ceftriaxone—broader GN coverage and CNS penetration Ampicillin/sulbactam—broader GN and anaerobic coverage Clindamycin—for penicillin-allergic patients No postoperative antibiotics Fractures of the upper one-third of the face Frontal sinus fractures that do not involve the posterior table Fractures of the middle one-third of the face (LeFort, zygomaticomaxillary complex, orbital, maxillary sinus, nasal bone) Fractures of the lower one-third of the face (non-dentate segments of mandible) Non-operative facial fractures No prophylactic antibiotics Orbital fractures Upper face fractures Mid-face fractures Mandibular fractures Facial and scalp lacerations Prophylactic antibiotics 24 h or less if complex or high-risk patient Amoxicillin-clavulanate Clindamycin—for penicillin-allergic patients Communication to oral cavity High infection risk: significant tissue destruction, large dead space, extensive contamination, underlying medical problems that place a patient at high risk (diabetes, immunosuppression, steroids, extremes of age, obesity, etc) Nasal packing No prophylactic antibiotics Central nervous system Pneumocephalus No prophylactic antibiotics Associated with open skull fracture and communication to the sinuses CSF leaks No prophylactic antibiotics Associated with basilar skull fractures Penetrating brain injury Short course of prophylactic antibiotics, <3 days Cefazolin Clindamycin - for penicillin-allergic patients Visible contamination—add metronidazole Penetrating spine injury Short course of prophylactic antibiotics, no more than 48 h First and second-generation cephalosporins Ampicillin-sulbactam Piperacillin-tazobactam Clindamycin with second-generation cephalosporin Gastrointestinal involvement, specifically transcolonic Extremity Closed extremity fractures No prophylactic antibiotics if non-operative management Preoperative antibiotics within 1 h of incision First-generation cephalosporin Clindamycin—for penicillin-allergic patients Open extremity fractures Prophylactic antibiotics 24 h or less Types I and II should be treated with GP coverage First-generation cephalosporin Clindamycin - for penicillin allergic patients Type III should be treated with GP and GN coverage First-generation cephalosporin and aminoglycoside Piperacillin/tazobactam Ceftriaxone Antibiotics should be initiated within 1 h of injury and continued for 24 h Washout and debridement should take place within 24 h of injury Soft tissue injury Soft tissue Lacerations/stab wounds Prophylactic antibiotics 24 h or less if complex or high-risk patient First-generation cephalosporin Clindamycin—for penicillin-allergic patients High-risk infection Specific wound-related concerns (presence of significant contamination, crush injury, or specific at-risk anatomic sites) Underlying patient factors that would increase the risk or worsen the outcome of infection GSW Prophylactic antibiotics 24 h or less if complex or high-risk patient First-generation cephalosporin Clindamycin—for penicillin-allergic patients Surgical debridement of devitalized tissue if needed Consideration of low-energy vs. high-energy mechanism Burn injury No prophylactic antibiotics Providers should take into account their institutional antibiogram when choosing antibiotics for prophylaxis and/or treatment. Iterative selection of studies was not performed as in a systematic review, and the methodology of the literature search was at the discretion of the authors. Freshwater wounds should be managed with ciprofloxacin, levofloxacin, or a third-generation or fourth-generation cephalosporin.1 Potential clostridial contamination, such as farm-related injuries, requires high-dose penicillin irrespective of the fracture type.2 A full review of the treatment of bite injuries is beyond the scope of this document, but wounds caused by human, cat, and dog bites (the most common bite wounds encountered) are often treated with antibiotics due to the high load of more variable pathogens found in the oral cavity and the wound mechanism, with punctures that make both natural movement of the bacteria and adequate irrigation difficult.3 A course of 3–5 days of amoxicillin-clavulanate is a suggested regimen, with clindamycin plus trimethoprim-sulfamethoxazole two times per day as an alternative for patients with a penicillin allergy.4 5 While there is increasing question in the literature about the benefit of treating bite injuries with empiric antibiotics, there seems to be general consensus that injuries in high-risk locations (specifically hands, and over cartilage) and in high-risk patients should be treated.4–6 Rabies treatment should also be considered and addressed with any mammalian bite wounds (table 1). [...]there is tremendous variability in practice patterns among treating surgeons, and many providers continue antibiotic prophylaxis longer than proposed, which leads to overuse of antibiotics in this patient population.7 8 The Surgical Infection Society (SIS) recently published a guideline for prophylactic antibiotic use in patients with traumatic facial fractures.9 The authors of the SIS guidelines defined prophylactic antibiotics as antibiotics administered for more than 24 hours.

The evaluation and workup of fever and the use of antibiotics to treat infections is part of daily practice in the surgical intensive care unit (ICU). Fever can be infectious or non-infectious; it is important to distinguish between the two entities wherever possible. The evidence is growing for shortening the duration of antibiotic treatment of common infections. The purpose of this clinical consensus document, created by the American Association for the Surgery of Trauma Critical Care Committee, is to synthesize the available evidence, and to provide practical recommendations. We discuss the evaluation of fever, the indications to obtain cultures including urine, blood, and respiratory specimens for diagnosis of infections, the use of procalcitonin, and the decision to initiate empiric antibiotics. We then describe the treatment of common infections, specifically ventilator-associated pneumonia, catheter-associated urinary infection, catheter-related bloodstream infection, bacteremia, surgical site infection, intra-abdominal infection, ventriculitis, and necrotizing soft tissue infection.