Trauma Research

Stephen L Barnes MD FACS

Professor of Surgery & Anesthesia
Chief, Division of Acute Care Surgery
University of Missouri School of Medicine
One in 5 trauma deaths potentially salvageable
Chest Injuries and Death from Hemorrhage
Methodology of most studies Bad
Benefit of HEMS could not be determined
5 studies Benefit ; 4 Studies No Benefit
Needs standardized reporting structures
Faster inter-facility transport times
HEMS offered no mortality benefit
Must Identify which patients gain benefit
1,555,944 Subjects
Age > 65
SBP < 110 more sensitive, less
specific
10 fold increase in mortality
Recommend SBP < 110 mmHg
as highest level of Alert for
Triage Resource Utilization
NTDB 11-12
ISS > 15
ICU Admit
Urgent OR
ED Death
AUC for SBP < 110
AUC for SBP < 90
PCC with FFP
Not on Warfarin
Rapid reversal of TIC
Reduced overall
need for blood
products
PRBCs
FFP
Reduced Overall
Cost
TXA admin within 3
hours of injury
Reduce mortality
No increase in
Thrombotic events
No Benefit in
patients with isolated
TBI
2009-2013
1032 eligible patients
Age > 15
Excluded those with < 3% lysis on TEG LY-30
Note: Faculty chose not to give to 90% of patients who met criteria
So for the remaining 103 patients no mortality benefit???
Conclusions:
Use of rFVIIa in the
early management of
TBI is not associated
with improvement in
mortality or morbidity
and may negatively
impact recovery and
functional status
Multicenter Trial
11 Level 1 TCs
4284 patients
129 rFVIIa within 24
hours
Older male patients
More Warfarin use
Higher ISS and Head
AIS

Conclusions:
Rate of aerodigestive
injury is low
Routine bronchoscopy,
esophagoscopy not
warranted
Selective workup
Single Center 2007-
2012
9,946 patients
258 (2.6%)
pneumomediastinum
4 (1.6%) with
Aerodigestive injuries
ROC Consortium
19 EMS Systems
10 Hospitals
6 Regions
192 patients
Crystalloid for SBP <
70 or no radial pulse
Controlled Resuscitation may offer early survival
advantage
CR Group
1 liter difference in crystalloid
resuscitation
Mortality 3% CR vs 18% in SR in
blunt trauma
No mortality differences in
penetrating trauma
Chemoprophylaxis at 24 hours with stable CT
Not associated with intra cranial bleeding
Reduced DVT rates
Must be on a strict protocol
Glutamine Bad:
1223 vented adult
patients with multi-organ
failure
No subgroups
suggested a reduced
mortality with
supplementation
Glutamine Good:
26 studies - 2484 pts
1997-2013
Reduced in hospital
mortality
Shortened LOS
Improves outcomes in
critically ill patients
HCUP Inpatient
Sample 1994-2010
29,409 adult Spleens
14,704 adult livers
Cost and LOS analysis
Conclusions:
Non-operative solid
organ injury
management has
resulted in a substantial
decrease in expenditure
and LOS while
improving mortality
Conclusions:
Need for splenectomy after 24 hours successful non-
operative management is rare.
No additional interventions are warranted for Grade I
injuries
Grade II-V injuries warrant close observation 10-14 days
CT to Follow healing is not indicated unless symptoms
383 patients 366 discharged with a spleen
Only admit blush on admission CT was associated with delayed
splenectomy
24 USA patients
72 RT patients



REBOA feasible, controls
non-compressible
hemorrhage and improves
survival compared to RT
52 Japan patients
100% blunt
ISS 47.5
Survival 29.2%
REBOA is feasible and
should improve
survivorship
Serious limb ischemia
complications
619 patient
2 or more rib fxs
Protocol based care
Shorter LOS
Fewer Vent days
Lower mortality with
matched probability
of survival
Aggressive pain
control / pulm toilet
Operative Fixation of
MRF
Reduced DMV
Reduced ICU-LOS
Reduced Pneumonia
Reduced Chest Tube
duration
No difference in mortality
20% observation failure
rate
Conservative
management is
reasonable
Follow-up CT scan can
be helpful
Higher ISS more likely to
fail

Both Diagnostic &
Therapeutic Laparoscopy
outperformed Celiotomy
Shorter LOS
Fewer wound complications
No missed injuries
Laparoscopy initial
procedure of choice in stable
penetrating trauma

Race, ethnicity, sex , socioeconomic status no role
Septicemia number one readmission cause
Advancing Age decreased risk
Comorbidities increase risk
Elderly men and women with co morbidities
Sustain Falls after discharge
Co morbidities a contributor
Medication changes (narcotics) may contribute
Trauma Research
In
Missouri
Not necessarily inclusive
Only included what was sent to me
prior to deadline
The Role of Biomarker Expression in Triaging
Patients with Traumatic Brain Injury
Project Aims
To determine acute cytokine
and suppressor of cytokine
signaling (SOCS) expression
in the CSF and peripheral
blood collected from patients
with cerebral edema

To determine whether
differential SOCS expression
correlates with brain injury
status and patient outcomes
Study Information
Identify patients at risk with
post concussive syndrome and
develop a serum test to
determine when they may
resume normal activity

Daily sampling of blood and
CSF for 10 days
Principal Investigators:
Stephen Barnes, MD and
Jacob Quick, MD
Gene Expression of STAT3, SOCS3, and
Members of the TLR Pathway in the Peripheral
Blood of Hemorrhagic Shock Patients
Project Aims
To determine the time after
injury when gene expression
levels are maximized to
measure levels of STAT3,
SOC3 and members of the
TLR3 and TLR4 pathway
To determine the correlation
between gene expression
levels of STAT3, SOC3, and
members of the TLR3 and
TLR4 pathway of hemorrhagic
shock patients and patient
outcomes
Study Information
Sampling of peripheral and
arterial blood at the time of
admission and for 4
consecutive days after
admission in hemorrhagic
shock patients

Principal Investigators:
Stephen Barnes, MD and Chris
Nelson, MD

Combat Casualty Training Consortium (CCTC)
Project Aims

To conduct a direct
comparison study of two
training methodologies
(inanimate vs. live tissue) and
develop scientific evidence of
the differences and impact on
achievement of learning
objectives, between the
training approaches
Study Information

Funded by Department of
Defense
Coordinating site and
collaborating with University of
South Florida, University of
Central Florida, and University
of Alabama
Principal Investigator:
Stephen Barnes, MD
Presumptive Antibiotics in Tube Thoracostomy
for Traumatic Hemopneumothorax
Project Aims

To determine if presumptive
antibiotics in tube
thoracostomy for traumatic
hemopneumothorax reduce
the incidence of empyema and
pneumonia because there is
insufficient evidence to support
such claim
Study Information
Prospective data collection

AAST Multicenter Study

Collaborative study with Grant
Medical Center, Columbus,
Ohio

Principal Investigator:
Salman Ahmad, MD
PFA vs TEG Determining Anti-Platelet Effects
Project Aims

Compare accuracy of platelet
function assay (PFA) and
thromboelastography-platelet
mapping (TEG-PM) in
detecting anti-platelet effects
Evaluate cost difference
between PFA and TEG-PM
Evaluate time required for
results to be available
Study Information


One year retrospective data
collection

Principal Investigators:
Salman Ahmad, MD and
Ashley Bartels, MD
Observational Study of Trauma Patients on
Novel Oral Anticoagulants
Project Aims
Identify injury patterns
associated with use of oral
anticoagulants
Document outcomes following
injury in patients on oral
anticoagulants
Assess the hypocoagulable
profile of anti-coagulated
patients on novel oral agents
using both traditional
measures such as PT, aPTT,
and INR as well as TEG
Study Information
Prospective data collection

AAST Multicenter Study

Collaborative study with
University of California, San
Diego

Principal Investigator:
Jacob Quick, MD

Optimal Management of Pancreatic Trauma
Project Aims
Determine if drainage alone is
adequate for the management
of AAST Grade 1-2 pancreatic
injuries
Determine if drainage alone
can be sufficient for the
management of AAST Grade
3-5 pancreatic injuries
Determine if endoscopic
pancreatic stenting improves
outcomes in AAST Grade 3-5
pancreatic injuries
Study Information
Retrospective data collection
of 7 years

AAST Multicenter Study

Collaborative study with
University of Utah

Principal Investigator:
Salman Ahmad, MD

COMPASS (CareGuide to Observe Muscle
oxygenation and pH as an Alert to Shock and
trauma Severity)
Project Aims
To observe changes in muscle
oxygen saturation and muscle
pH in relation to other
physiological measurements
(BP, SpO2, lactate, arterial and
venous SO2)
To observe changes in muscle
oxygen saturation and muscle
pH values in response to
intervention including fluid
resuscitation, vasoactive drug
adjustment and transfusion

Study Information
Clinical, observational trial
using the noninvasive Multi-
Parameter Mobile CareGuide
Oximeter to collect SmO2 and
pHm
Validate if SmO2 and pHm are
potentially early indicators of
deterioration of health status
and response to treatment
Principal Investigator:
Jeffrey Coughenour, MD
Can the Cervical Spine be Clinically Cleared in
Awake and Alert Blunt Trauma Patients with
Distracting Injuries?
Project Aims
To assess the sensitivity and
efficacy of clinical examination
for screening of cervical spine
injury in awake and alert blunt
trauma patients with
distracting injuries
To evaluate missed injuries
and potential complications
associated with clinical
clearance of the cervical spine
injury in awake and alert blunt
trauma patients with
distracting injuries

Study Information
Prospective data collection

AAST Multicenter Study

Collaborative study with
University of South Alabama
Medical Center

Principal Investigator:
Jacob Quick, MD

Panaceas Glass: A Novel, Hands-Free
Communication System for Secure Mass
Casualty Disaster Triage
Project Aims
To test the deployment of a
proof-of-concept
communication system using a
hands-free device with the
ability to share audio and video
across a secure, self-
contained, ruggedized, an ad
hoc Wi-Fi mesh network
To test the system in a mass
casualty triage simulation
Study Information
The Panaceas Glass system
sets up its own battery-
powered Wi-Fi network within
field triage area to substitute
for communication system loss

Principal Investigators:
Salman Ahmad, MD and
Ashley Bartels, MD
Project Aims Study Information
To examine the efficacy
of CroFab antivenin after
Agkistrodon bites in
patients from Southwest
Missouri and Northern
Arkansas
10 year retrospective
review study
Study compared tissue
loss and need for
surgical intervention
Principal Investigator(s):
Kenneth Larson, MD
Crotalidae Fab Antivenin for the Management
of Tissue Loss after Agkistrodon Bites
Project Aims Study Information
Here we identified the first
strains of clinical bacteria
expressing silver-resistance at
a level that could significantly
impact healthcare and the use
of silver in medical devices
These Enterobacteriaceae
isolates were capable of
luxuriant growth at
exceedingly high silver
concentrations
Major Implications for Burn
and Wound Management
Clinically Isolated
Bacteria
Collaborative study
with Missouri State
University
Principal Investigator(s):
Phillip Finley, PhD
Plasmid-mediated Silver Resistance in
Clinical Bacteria
Project Aims Study Information
To examine impact of
early ethical consultation
for trauma and burn
patients
4 year retrospective chart
review
Hope to gain a better
understanding on when to
involve ethical consults for
end of life decisions
Principal Investigator(s):
Robert Saylor, MD; Cindy
Austin, MS
Ethical Consult and Hospital Length of Stay
Project Aims Study Information
Preliminary data has
shown an up regulation
of pro-inflammatory
proteins in diabetic
wounds
This project is looking at
the expression of these
proteins over time
Grant funded study from
the Diabetes Action
Research and Education
Foundation
Collaborative study with
Saint Louis University
Principal Investigator(s):
Phillip Finley, PhD
Aberrant Cytokine Expression during Diabetic
Burn and Wound Healing
Project Aims Study Information
To examine the role of
certain neruopeptides
and receptors during
soft tissue injury
including burn and
wound healing
Translational study: Lab
and animal findings to
patient injuries
Collaborative study with
Missouri State
University
Principal Investigator(s):
Bharat Shah, MD; Kara Walker,
PA; Phillip Finley, PhD
Neuropeptide Expression in Soft Tissue Injury
Project Aims Study Information
To examine a number of
different commercially
available burn and
wound dressings
comparing different
outcome measures
Randomized clinical
outcome study

Principal Investigator(s):
Kenneth Larson, MD
Burn & Wound Dressing Comparison
Project Aims Study Information
Multiple studies
examining different
preventative programs
and methods to
decrease HAIs in part
with a focus on surgical
site infections
Clinical based studies
Efficacy and
determination of best-
practice procedures
Principal Investigator(s):
Multiple studies
Alex Hoover, MD
William Sistrunk, MD

Healthcare Associated Infections
Project Aims Study Information
To examine distress in
critical care Physicians
and Nurses at Mercy
Including burnout,
compassion fatigue, job
satisfaction, turnover
intent, moral distress,
and learned helplessness
119 physicians & 211 nurses
from all specialties
Increase the awareness on
the impact of psychological
states, situations causing
the most distress (futile
care) and predictors of at-
risk staff
Principal Investigator(s):
Cindy Austin, MS; Robert Saylor,
MD
Evaluation of Moral Distress, Professional Quality of
Life, & Learned Helplessness in Physicians & Nurses
Potential Projects under Evaluation
Research Project Principal Investigator(s):
Pradaxa (Dabigatran) Robert Johnson, MD - Sponsored
Prospective evaluation of CroFab Kenneth Larson, MD - Sponsored
Multicenter Trials Robert Johnson, MD et al.
Delayed Splenic Bleed after Trauma General and Trauma Surgery Group
Emergent Operative Liver Injuries
Surgical Repair for Blunt Aortic Trauma
Microbiome analysis in burn/wounds Robert Johnson, MD; Phillip Finley, PhD
Matt Si mpson MD
CHEST TRAUMA


HOSPITAL BASED
STUDIES
Purpose
To examine the patient
method of arrival
comparing outcomes of
the patient arriving by
air, ground ambulance
and private vehicle.

Study Information
A hospital based study
Study the outcomes of
the TCD comparing the
outcomes to the
method of arrival (to
include trauma, stroke
and STEMI patients)
Principal Investigator:
Dr. Matt Brandt
HOSPITAL OUTCOMES FOR THE TCD
PATIENT
Purpose
Examine patient
outcomes in the
traumatically injured
patient receiving TXA in
the pre-hospital setting
Study Information
Retrospective review
study
Prehospital patients
meeting criteria to
receive TXA comparing
blood utilization of those
who receive TXA in the
prehospital environment
to those who do not
receive
TRANEXAMIC ACID FOR TRAUMA
ASSOCIATED HEMORRHAGE
Purpose
Study the effects of the
pediatric trauma
patient in the trauma
bay with the utilization
of child life

Study Information
3 year review
Compare the pediatric
patient/family
experience with the
presence of Child Life
in the trauma bay to
the experience of the
patient/family in the
absence of Child Life
during resuscitation
UTILIZATION OF CHILD LIFE IN THE
TRAUMA BAY
Purpose
Evaluation patients
undergoing rib fixation
and examining patient
outcomes

Study Information
A retrospective review of
the following on patients
undergoing rib fixation:
Timing of fixation
Ventilator days following
fixation
ICU days following fixation
Hospital length of stay
Principal investigator:
Dr. Timothy Woods
RIB FIXATION IN THE PATIENT
SUSTAINING THORACIC INJURIES
Purpose
The purpose is to allow
patients with high
potential for falls to be
identified and
opportunities to be
created for patient
safety
Study Information
Retrospective chart
review
2-stage process
Stage 1 creation of falls
scale identifying
medications known to
increase fall risks
Stage 2 retrospective
evaluation of the developed
medication scale sensitivity
and specificity.
IDENTIFICATION OF PATIENTS AT RISK FOR
FALLS BASED ON MEDICATION REGIMEN
CLINICAL TRIALS
Purpose
To examine the
efficacy, safety,
tolerability and
pharmacokinetics of
the SUN13837 injection
for 28 days
Study Information
Multicenter,
randomized, double-
blind study
For patients with
complete or incomplete
C3-C8 injuries
Principal investigator
Dr. Charles Mace
SUN13837 FOR ACUTE SPINAL CORD
INJURIES
Purpose
A clinical study
evaluating the reversal
of the anticoagulant
effects of dabigatran by
IV administration of
idarucizumba
Study Information
Multicenter case series
clinical study
Study evaluating the
effects of patients with
uncontrolled bleeding
or requiring emergency
surgery or procedures
receiving dabigatran.
Principal investigator:
Dr. Timothy Woods
IV ADMINISTRATION OF BI 6555075 TO
PATIENTS
Purpose
Evaluation of the safety
and efficacy of BAY 41-
6551 as adjunctive
therapy in intubated
and mechanically-
ventilated patients with
gram negative
pneumonia


Study Information
A prospective,
randomized, double-
blind multicenter study
Study of the effects of
the therapy in the
critical care patient
Principal investigator:
Dr. Robin Trotman

ADMINISTRATION OF BAY 41- 6551 TO
INTUBATED/VENTILATED PATIENTS WITH
PNEUMONIA