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Mehl SC, Vogel AM, Glasgow AE, Moody S, Kotagal M, Williams RF, Kayton ML, Alberto EC, Burd RS, Schroeppel TJ, Baerg JE, Munoz A, Rothstein WB, Boomer LA, Campion EM, Robinson C, Nygaard RM, Richardson CJ, Garcia DI, Streck CJ, Gaffley M, Petty JK, Greenwell C, Pandya S, Waters AM, Russell RT, Yorkgitis BK, Mull J, Pence J, Santore MT, MacArthur TA, Klinkner DB, Safford SD, Trevilian T, Cunningham M, Black C, Rea J, Spurrier RG, Jensen AR, Farr BJ, Mooney DP, Ketha B, Dassinger MS, Goldenberg-Sandau A, Roman JS, Jenkins TM, Falcone RA, Polites SF. Prevalence and Outcomes of High versus Low Ratio Plasma to Red Blood Cell Resuscitation in a Multi-Institutional Cohort of Severely Injured Children. J Trauma Acute Care Surg 2024:01586154-990000000-00661. [PMID: 38497936 DOI: 10.1097/ta.0000000000004301] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/19/2024]
Abstract
BACKGROUND The benefit of targeting high ratio fresh frozen plasma (FFP):red blood cell (RBC) transfusion in pediatric trauma resuscitation is unclear as existing studies are limited to patients who retrospectively met criteria for massive transfusion. The purpose of this study is to evaluate the use of high ratio FFP:RBC transfusion and the association with outcomes in children presenting in shock. METHODS A post-hoc analysis of a 24-institution prospective observational study (4/2018-9/2019) of injured children <18 years with elevated age-adjusted shock index was performed. Patients transfused within 24 hours were stratified into cohorts of low (<1:2) or high (>1:2) ratio FFP:RBC. Nonparametric Kruskal-Wallis and chi-square were used to compare characteristics and mortality. Competing risks analysis was used to compare extended (≥75th percentile) ventilator, intensive care, and hospital days while accounting for early deaths. RESULTS Of 135 children with median (IQR) age 10 (5,14) years and weight 40 (20,64) kg, 85 (63%) received low ratio transfusion and 50 (37%) high ratio despite similar activation of institutional massive transfusion protocols (MTP; low-38%, high-46%, p = .34). Most patients sustained blunt injuries (70%). Median injury severity score was greater in high ratio patients (low-25, high-33, p = .01); however, hospital mortality was similar (low-24%, high-20%, p = .65) as was the risk of extended ventilator, ICU, and hospital days (all p > .05). CONCLUSION Despite increased injury severity, patients who received a high ratio of FFP:RBC had comparable rates of mortality. These data suggest high ratio FFP:RBC resuscitation is not associated with worst outcomes in children who present in shock. MTP activation was not associated with receipt of high ratio transfusion, suggesting variability in MTP between centers. LEVEL OF EVIDENCE Prospective cohort study, Level II.
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Affiliation(s)
- Steven C Mehl
- Baylor College of Medicine, Texas Children's Hospital, Houston, TX
| | - Adam M Vogel
- Baylor College of Medicine, Texas Children's Hospital, Houston, TX
| | | | - Suzanne Moody
- Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio; University of Cincinnati College of Medicine, Cincinnati, Ohio
| | - Meera Kotagal
- Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio; University of Cincinnati College of Medicine, Cincinnati, Ohio
| | | | - Mark L Kayton
- Department of Surgery, K. Hovnanian Children's Hospital at Jersey Shore University Medical Center, Hackensack-Meridian Health Network, Neptune, New Jersey
| | | | | | | | | | | | - William B Rothstein
- Children's Hospital of Richmond, Virginia Commonwealth University, Richmond, Virginia
| | - Laura A Boomer
- Children's Hospital of Richmond, Virginia Commonwealth University, Richmond, Virginia
| | | | | | | | | | - Denise I Garcia
- The Medical University of South Carolina, Charleston, South Carolina
| | | | - Michaela Gaffley
- Wake Forest University School of Medicine, Brenner Children's Hospital, Winston-Salem, North Carolina
| | - John K Petty
- Wake Forest University School of Medicine, Brenner Children's Hospital, Winston-Salem, North Carolina
| | | | | | | | | | - Brian K Yorkgitis
- College of Medicine, University of Florida - Jacksonville, Jacksonville, Florida
| | - Jennifer Mull
- College of Medicine, University of Florida - Jacksonville, Jacksonville, Florida
| | | | | | | | | | - Shawn D Safford
- University of Pittsburgh Medical Center, Harrisburg, Pennsylvania
| | - Tanya Trevilian
- Carilion Children's Hospital, Carilion Roanoke Memorial Hospital, Roanoke, Virginia
| | - Megan Cunningham
- Baylor College of Medicine, Texas Children's Hospital, Houston, TX
| | - Christa Black
- ProMedica Toledo and Toledo Children's Hospital, Toledo, Ohio
| | - Jessica Rea
- Children's Hospital Los Angeles, Los Angeles, California
| | | | - Aaron R Jensen
- Benioff Children's Hospital, University of California San Francisco, San Francisco, California
| | | | | | - Bavana Ketha
- Arkansas Children's Hospital, Little Rock, Arkansas
| | | | | | | | - Todd M Jenkins
- Mayo Clinic, Mayo Eugenio Litta Children's Hospital, Rochester, Minnesota
| | - Richard A Falcone
- Mayo Clinic, Mayo Eugenio Litta Children's Hospital, Rochester, Minnesota
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Santos J, Delaplain PT, Tay-Lasso E, Biffl WL, Schaffer KB, Sundel M, Ghneim M, Costantini TW, Santorelli JE, Switzer E, Schellenberg M, Keeley JA, Kim DY, Wang A, Dhillon NK, Patel D, Campion EM, Robinson CK, Kartiko S, Quintana MT, Estroff JM, Kirby KA, Grigorian A, Nahmias J. Development and Validation of a Novel Hollow Viscus Injury Prediction Score for Abdominal Seatbelt Sign: A Pacific Coast Surgical Association Multicenter Study. J Am Coll Surg 2023; 237:826-833. [PMID: 37703489 DOI: 10.1097/xcs.0000000000000863] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 09/15/2023]
Abstract
BACKGROUND High-quality CT can exclude hollow viscus injury (HVI) in patients with abdominal seatbelt sign (SBS) but performs poorly at identifying HVI. Delay in diagnosis of HVI has significant consequences necessitating timely identification. STUDY DESIGN This multicenter, prospective observational study conducted at 9 trauma centers between August 2020 and October 2021 included adult trauma patients with abdominal SBS who underwent abdominal CT before surgery. HVI was determined intraoperatively and physiologic, examination, laboratory, and imaging findings were collected. Least absolute shrinkage and selection operator- and probit regression-selected predictor variables and coefficients were used to assign integer points for the HVI score. Validation was performed by comparing the area under receiver operating curves (AUROC). RESULTS Analysis included 473 in the development set and 203 in the validation set. The HVI score includes initial systolic blood pressure <110 mmHg, abdominal tenderness, guarding, and select abdominal CT findings. The derivation set has an AUROC of 0.96, and the validation set has an AUROC of 0.91. The HVI score ranges from 0 to 17 with score 0 to 5 having an HVI risk of 0.03% to 5.36%, 6 to 9 having a risk of 10.65% to 44.1%, and 10 to 17 having a risk of 58.59% to 99.72%. CONCLUSIONS This multicenter study developed and validated a novel HVI score incorporating readily available physiologic, examination, and CT findings to risk stratify patients with an abdominal SBS. The HVI score can be used to guide decisions regarding management of a patient with an abdominal SBS and suspected HVI.
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Affiliation(s)
- Jeffrey Santos
- From the Division of Trauma, Burns, Critical Care & Acute Care Surgery, Department of Surgery, University of California, Irvine, Orange, CA (Santos, Delaplain, Tay-Lasso, Grigorian, Nahmias)
| | - Patrick T Delaplain
- From the Division of Trauma, Burns, Critical Care & Acute Care Surgery, Department of Surgery, University of California, Irvine, Orange, CA (Santos, Delaplain, Tay-Lasso, Grigorian, Nahmias)
- Department of Surgery, Boston Children's Hospital/Harvard Medical System, Boston, MA (Delaplain)
| | - Erika Tay-Lasso
- From the Division of Trauma, Burns, Critical Care & Acute Care Surgery, Department of Surgery, University of California, Irvine, Orange, CA (Santos, Delaplain, Tay-Lasso, Grigorian, Nahmias)
| | - Walter L Biffl
- Trauma Department, Scripps Memorial Hospital La Jolla, La Jolla, CA (Biffl, Schaffer)
| | - Kathryn B Schaffer
- Trauma Department, Scripps Memorial Hospital La Jolla, La Jolla, CA (Biffl, Schaffer)
| | - Margaret Sundel
- Program in Trauma, R Adams Cowley Shock Trauma Center, University of Maryland School of Medicine, Baltimore, MD (Sundel, Ghneim)
| | - Mira Ghneim
- Program in Trauma, R Adams Cowley Shock Trauma Center, University of Maryland School of Medicine, Baltimore, MD (Sundel, Ghneim)
| | - Todd W Costantini
- Division of Trauma, Surgical Critical Care, Burns and Acute Care Surgery, University of California San Diego School of Medicine, San Diego, CA (Costantini, Santorelli)
| | - Jarrett E Santorelli
- Division of Trauma, Surgical Critical Care, Burns and Acute Care Surgery, University of California San Diego School of Medicine, San Diego, CA (Costantini, Santorelli)
| | - Emily Switzer
- Division of Acute Care Surgery, LAC+USC Medical Center, University of Southern California, Los Angeles, CA (Switzer, Schellenberg)
| | - Morgan Schellenberg
- Division of Acute Care Surgery, LAC+USC Medical Center, University of Southern California, Los Angeles, CA (Switzer, Schellenberg)
| | - Jessica A Keeley
- Division of Trauma/Acute Care Surgery/Surgical Critical Care, Harbor-UCLA Medical Center, Torrance, CA (Keeley, Kim)
| | - Dennis Y Kim
- Division of Trauma/Acute Care Surgery/Surgical Critical Care, Harbor-UCLA Medical Center, Torrance, CA (Keeley, Kim)
| | - Andrew Wang
- Department of Surgery, Cedars-Sinai Medical Center, Los Angeles, CA (Want, Dhillon, Patel)
| | - Navpreet K Dhillon
- Department of Surgery, Cedars-Sinai Medical Center, Los Angeles, CA (Want, Dhillon, Patel)
| | - Deven Patel
- Department of Surgery, Cedars-Sinai Medical Center, Los Angeles, CA (Want, Dhillon, Patel)
| | - Eric M Campion
- Department of Surgery, Denver Health Medical Center, Denver, CO (Campion, Robinson)
| | - Caitlin K Robinson
- Department of Surgery, Denver Health Medical Center, Denver, CO (Campion, Robinson)
| | - Susan Kartiko
- Department of Surgery, The George Washington University School of Medicine & Health Sciences, Washington, DC (Kartiko, Quintana, Estroff)
| | - Megan T Quintana
- Department of Surgery, The George Washington University School of Medicine & Health Sciences, Washington, DC (Kartiko, Quintana, Estroff)
| | - Jordan M Estroff
- Department of Surgery, The George Washington University School of Medicine & Health Sciences, Washington, DC (Kartiko, Quintana, Estroff)
| | - Katharine A Kirby
- Center for Statistical Consulting, Department of Statistics, University of California Irvine, Irvine, CA (Kirby)
| | - Areg Grigorian
- From the Division of Trauma, Burns, Critical Care & Acute Care Surgery, Department of Surgery, University of California, Irvine, Orange, CA (Santos, Delaplain, Tay-Lasso, Grigorian, Nahmias)
| | - Jeffry Nahmias
- From the Division of Trauma, Burns, Critical Care & Acute Care Surgery, Department of Surgery, University of California, Irvine, Orange, CA (Santos, Delaplain, Tay-Lasso, Grigorian, Nahmias)
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3
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Dhanasekara CS, Marschke B, Morris E, Bashrum BS, Shrestha K, Richmond R, Dissanaike S, Ko A, Tennakoon L, Campion EM, Wood FC, Brandt M, Ng G, Regner J, Keith SL, Mcnutt MK, Kregel H, Gandhi R, Schroeppel T, Margulies DR, Hashim Y, Herrold J, Goetz M, Simpson L, Xuan-Lan D. Anastomotic leak rates after repair of mesenteric bucket-handle injuries: A multi-center retrospective cohort study. Am J Surg 2023; 226:770-775. [PMID: 37270399 DOI: 10.1016/j.amjsurg.2023.05.032] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/24/2023] [Revised: 05/22/2023] [Accepted: 05/25/2023] [Indexed: 06/05/2023]
Abstract
BACKGROUND Primary aim was to assess the relative risk (RR) of anastomotic leak (AL) in intestinal bucket-handle (BH) compared to non-BH injury. METHODS Multi-center study comparing AL in BH from blunt trauma 2010-2021 compared to non-BH intestinal injuries. RR was calculated for small bowel and colonic injury using R. RESULTS AL occurred in 20/385 (5.2%) of BH vs. 4/225 (1.8%) of non-BH small intestine injury. AL was diagnosed 11.6 ± 5.6 days from index operation in small intestine BH and 9.7 ± 4.3 days in colonic BH. Adjusted RR for AL was 2.32 [0.77-6.95] for small intestinal and 4.83 [1.47-15.89] for colonic injuries. AL increased infections, ventilator days, ICU & total length of stay, reoperation, and readmission rates, although mortality was unchanged. CONCLUSION BH carries a significantly higher risk of AL, particularly in the colon, than other blunt intestinal injuries.
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Affiliation(s)
| | - Brianna Marschke
- Department of Surgery, Texas Tech University Health Sciences Center, Lubbock, TX, USA
| | - Erin Morris
- Department of Surgery, Texas Tech University Health Sciences Center, Lubbock, TX, USA
| | - Bryan S Bashrum
- Department of Surgery, Texas Tech University Health Sciences Center, Lubbock, TX, USA
| | - Kripa Shrestha
- Department of Surgery, Texas Tech University Health Sciences Center, Lubbock, TX, USA
| | - Robyn Richmond
- Department of Surgery, Texas Tech University Health Sciences Center, Lubbock, TX, USA
| | - Sharmila Dissanaike
- Department of Surgery, Texas Tech University Health Sciences Center, Lubbock, TX, USA.
| | - Ara Ko
- Department of Surgery, Stanford University School of Medicine, Palo Alto, CA, USA
| | - Lakshika Tennakoon
- Department of Surgery, Stanford University School of Medicine, Palo Alto, CA, USA
| | - Eric M Campion
- Department of Surgery, Denver Health Medical Center, Denver, CO, USA
| | - Frank C Wood
- Department of Surgery, University of Oklahoma Health Sciences Center, Oklahoma City, OK, USA
| | - Maggie Brandt
- Department of Surgery, University of Oklahoma Health Sciences Center, Oklahoma City, OK, USA
| | - Grace Ng
- Department of Surgery, Texas Tech University Health Sciences Center, El Paso, TX, USA
| | - Justin Regner
- Department of Surgery, Baylor Scott and White Health, Temple, TX, USA
| | - Stacey L Keith
- Department of Surgery, Baylor Scott and White Health, Temple, TX, USA
| | - Michelle K Mcnutt
- Department of Surgery, University of Texas Health Sciences Center at Houston, Houston, TX, USA
| | - Heather Kregel
- Department of Surgery, University of Texas Health Sciences Center at Houston, Houston, TX, USA
| | - Rajesh Gandhi
- Department of Surgery, JPS Health Network, Ft. Worth, TX, USA
| | - Thomas Schroeppel
- Department of Surgery, UCHealth, Memorial Hospital, Colorado Springs, CO, USA
| | - Daniel R Margulies
- Department of Surgery, Cedars-Sinai Medical Center, Los Angeles, CA, USA
| | - Yassar Hashim
- Department of Surgery, Cedars-Sinai Medical Center, Los Angeles, CA, USA
| | - Joseph Herrold
- Department of Surgery, University of Maryland School of Medicine, Baltimore, MD, USA
| | - Mallory Goetz
- Department of Surgery, University of Maryland School of Medicine, Baltimore, MD, USA
| | - LeRone Simpson
- McAllen Medical Center Trauma Department, McAllen, TX, USA
| | - Doan Xuan-Lan
- McAllen Medical Center Trauma Department, McAllen, TX, USA
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4
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Wham C, Morin T, Sauaia A, McIntyre R, Urban S, McVaney K, Cohen M, Cralley A, Moore EE, Campion EM. Prehospital ETCO 2 is predictive of death in intubated and non-intubated patients. Am J Surg 2023; 226:886-890. [PMID: 37563074 DOI: 10.1016/j.amjsurg.2023.07.033] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/24/2023] [Revised: 07/18/2023] [Accepted: 07/22/2023] [Indexed: 08/12/2023]
Abstract
BACKGROUND Prehospital identification of shock in trauma patients lacks accurate markers. Low end tidal carbon dioxide (ETCO2) correlates with mortality in intubated patients. The predictive value of ETCO2 obtained by nasal capnography cannula (NCC) is unknown. We hypothesized that prehospital ETCO2 values obtained by NCC and in-line ventilator circuit (ILVC) would be predictive of mortality. METHODS This was a prospective, observational, multicenter study. ETCO2 values were collected by a NCC or through ILVC. AUROCs were compared with prehospital systolic blood pressure (SBP) and shock index (SI). The Youden index defined optimal cutoffs. RESULTS Of 550 enrolled patients, 487 (88.5%) had ETCO2 measured through an NCC. Median age was 37 (27-52) years; 76.5% were male; median ISS was 13 (5-22). Mortality was 10.4%. Minimum prehospital ETCO2 significantly predicted mortality with an AUROC of 0.76 (CI 0.69-0.84; Youden index = 22 mmHg), outperforming SBP with an AUROC of 0.68; (CI 0.62-0.74, p = 0.04) and shock index with an AUROC of 0.67 (CI 0.59-0.74, p = 0.03). CONCLUSION Prehospital ETCO2 measured by non-invasive NCC or ILVC may be predictive of mortality in injured patients.
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Affiliation(s)
- Courtney Wham
- Denver Health Medical Center, Department of Emergency Medicine, Denver Paramedics, United States.
| | - Theresa Morin
- Ernest E. Moore Shock Trauma Center at Denver Health, Department of Surgery, United States.
| | - Angela Sauaia
- University of Colorado, School of Public Health (AS), United States.
| | - Robert McIntyre
- University of Colorado Anschutz, Department of Surgery, United States.
| | - Shane Urban
- University of Colorado Anschutz, Department of Surgery, United States.
| | - Kevin McVaney
- Denver Health Medical Center, Department of Emergency Medicine, Denver Paramedics, United States.
| | - Mitchell Cohen
- University of Colorado Anschutz, Department of Surgery, United States.
| | - Alexis Cralley
- Ernest E. Moore Shock Trauma Center at Denver Health, Department of Surgery, United States.
| | - Ernest E Moore
- Ernest E. Moore Shock Trauma Center at Denver Health, Department of Surgery, United States.
| | - Eric M Campion
- Ernest E. Moore Shock Trauma Center at Denver Health, Department of Surgery, United States.
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5
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Grossman H, Dhanasekara CS, Shrestha K, Marschke B, Morris E, Richmond R, Ko A, Tennakoon L, Campion EM, Wood FC, Brandt M, Ng G, Regner JL, Keith SL, McNutt MK, Kregel H, Gandhi RR, Schroeppel TJ, Margulies DR, Hashim YM, Herrold J, Goetz M, Simpson L, Doan XL, Dissanaike S. Rates and risk factors for anastomotic leak following blunt trauma-associated bucket handle intestinal injuries: a multicenter study. Trauma Surg Acute Care Open 2023; 8:e001178. [PMID: 38020867 PMCID: PMC10668238 DOI: 10.1136/tsaco-2023-001178] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/19/2023] [Accepted: 10/13/2023] [Indexed: 12/01/2023] Open
Abstract
Objectives The risk factors for anastomotic leak (AL) after resection and primary anastomosis for traumatic bucket handle injury (BHI) have not been previously defined. This multicenter study was conducted to address this knowledge gap. Methods This is a multicenter retrospective study on small intestine and colonic BHIs from blunt trauma between 2010 and 2021. Baseline patient characteristics, risk factors, presence of shock and transfusion, operative details, and clinical outcomes were compared using R. Results Data on 395 subjects were submitted by 12 trauma centers, of whom 33 (8.1%) patients developed AL. Baseline details were similar, except for a higher proportion of patients in the AL group who had medical comorbidities such as diabetes, hypertension, and obesity (60.6% vs. 37.3%, p=0.015). AL had higher rates of surgical site infections (13.4% vs. 5.3%, p=0.004) and organ space infections (65.2% vs. 11.7%, p<0.001), along with higher readmission and reoperation rates (48.4% vs. 9.1%, p<0.001, and 39.4% vs. 11.6%, p<0.001, respectively). There was no difference in intensive care unit length of stay or mortality (p>0.05). More patients with AL were discharged with an ostomy (69.7% vs. 7.3%, p<0.001), and the mean duration until ostomy reversal was 5.85±3 months (range 2-12.4 months). The risk of AL significantly increased when the initial operation was a damage control procedure, after adjusting for age, sex, injury severity, presence of one or more comorbidities, shock, transfusion of >6 units of packed red blood cells, and site of injury (adjusted RR=2.32 (1.13, 5.17)), none of which were independent risk factors in themselves. Conclusion Damage control surgery performed as the initial operation appears to double the risk of AL after intestinal BHI, even after controlling for other markers of injury severity. Level of evidence III.
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Affiliation(s)
- Holly Grossman
- Department of Surgery, Texas Tech University Health Sciences Center, Lubbock, Texas, USA
| | | | - Kripa Shrestha
- Department of Surgery, Texas Tech University Health Sciences Center, Lubbock, Texas, USA
| | - Brianna Marschke
- Department of Surgery, Texas Tech University Health Sciences Center, Lubbock, Texas, USA
| | - Erin Morris
- Department of Surgery, Texas Tech University Health Sciences Center, Lubbock, Texas, USA
| | - Robyn Richmond
- Department of Surgery, Texas Tech University Health Sciences Center, Lubbock, Texas, USA
| | - Ara Ko
- Department of Surgery, Stanford Medicine, Stanford, California, USA
| | | | - Eric M Campion
- Department of Surgery, Denver Health Medical Center, Denver, Colorado, USA
| | - Frank C Wood
- Department of Surgery, The University of Oklahoma Health Sciences Center, Oklahoma City, Oklahoma, USA
| | - Maggie Brandt
- Department of Surgery, The University of Oklahoma Health Sciences Center, Oklahoma City, Oklahoma, USA
| | - Grace Ng
- Department of Surgery, Texas Tech University Health Sciences Center El Paso, El Paso, Texas, USA
| | - Justin L Regner
- Department of Surgery, Baylor Scott & White Medical Center Temple, Temple, Texas, USA
| | - Stacey L Keith
- Department of Surgery, Baylor Scott & White Medical Center Temple, Temple, Texas, USA
| | - Michelle K McNutt
- Department of Surgery, University of Texas Health Science Center at Houston, Houston, Texas, USA
| | - Heather Kregel
- Department of Surgery, University of Texas Health Science Center at Houston, Houston, Texas, USA
| | - Rajesh R Gandhi
- Department of Surgery, JPS Health Network, Fort Worth, Texas, USA
| | | | - Daniel R Margulies
- Department of Surgery, Cedars-Sinai Medical Center, Los Angeles, California, USA
| | - Yassar M Hashim
- Department of Surgery, Cedars-Sinai Medical Center, Los Angeles, California, USA
| | - Joseph Herrold
- Department of Surgery, University of Maryland, Baltimore, Maryland, USA
| | - Mallory Goetz
- Department of Surgery, University of Maryland, Baltimore, Maryland, USA
| | - LeRone Simpson
- Department of Surgery, McAllen Medical Center, McAllen, Texas, USA
| | - Xuan-Lan Doan
- Department of Surgery, McAllen Medical Center, McAllen, Texas, USA
| | - Sharmila Dissanaike
- Department of Surgery, Texas Tech University Health Sciences Center, Lubbock, Texas, USA
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6
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MacArthur TA, Vogel AM, Glasgow AE, Moody S, Kotagal M, Williams RF, Kayton ML, Alberto EC, Burd RS, Schroeppel TJ, Baerg JE, Munoz A, Rothstein WB, Boomer LA, Campion EM, Robinson C, Nygaard RM, Richardson CJ, Garcia DI, Streck CJ, Gaffley M, Petty JK, Ryan M, Pandya S, Russell RT, Yorkgitis BK, Mull J, Pence J, Santore MT, Klinkner DB, Safford SD, Trevilian T, Jensen AR, Mooney DP, Ketha B, Dassinger MS, Goldenberg-Sandau A, Falcone RA, Polites SF. Crystalloid volume is associated with short-term morbidity in children with severe traumatic brain injury: An Eastern Association for the Surgery of Trauma multicenter trial post hoc analysis. J Trauma Acute Care Surg 2023; 95:78-86. [PMID: 37072882 DOI: 10.1097/ta.0000000000004013] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 04/20/2023]
Abstract
OBJECTIVE This study examined differences in clinical and resuscitation characteristics between injured children with and without severe traumatic brain injury (sTBI) and aimed to identify resuscitation characteristics associated with improved outcomes following sTBI. METHODS This is a post hoc analysis of a prospective observational study of injured children younger than 18 years (2018-2019) transported from the scene, with elevated shock index pediatric-adjusted on arrival and head Abbreviated Injury Scale score of ≥3. Timing and volume of resuscitation products were assessed using χ 2t test, Fisher's exact t test, Kruskal-Wallis, and multivariable logistic regression analyses. RESULTS There were 142 patients with sTBI and 547 with non-sTBI injuries. Severe traumatic brain injury patients had lower initial hemoglobin (11.3 vs. 12.4, p < 0.001), greater initial international normalized ratio (1.4 vs. 1.1, p < 0.001), greater Injury Severity Score (25 vs. 5, p < 0.001), greater rates of ventilator (59% vs. 11%, p < 0.001) and intensive care unit (ICU) requirement (79% vs. 27%, p < 0.001), and more inpatient complications (18% vs. 3.3%, p < 0.001). Severe traumatic brain injury patients received more prehospital crystalloid (25% vs. 15%, p = 0.008), ≥1 crystalloid boluses (52% vs. 24%, p < 0.001), and blood transfusion (44% vs. 12%, p < 0.001) than non-sTBI patients. Among sTBI patients, receipt of ≥1 crystalloid bolus (n = 75) was associated with greater ICU need (92% vs. 64%, p < 0.001), longer median ICU (6 vs. 4 days, p = 0.027) and hospital stay (9 vs. 4 days, p < 0.001), and more in-hospital complications (31% vs. 7.5%, p = 0.003) than those who received <1 bolus (n = 67). These findings persisted after adjustment for Injury Severity Score (odds ratio, 3.4-4.4; all p < 0.010). CONCLUSION Pediatric trauma patients with sTBI received more crystalloid than those without sTBI despite having a greater international normalized ratio at presentation and more frequently requiring blood products. Excessive crystalloid may be associated with worsened outcomes, including in-hospital mortality, seen among pediatric sTBI patients who received ≥1 crystalloid bolus. Further attention to a crystalloid sparing, early transfusion approach to resuscitation of children with sTBI is needed. LEVEL OF EVIDENCE Therapeutic/Care Management; Level IV.
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Affiliation(s)
- Taleen A MacArthur
- Department of Surgery, Division of Pediatric Surgery (T.A.M., A.E.G., D.B.K., S.F.P.), Mayo Clinic, Rochester, Minnesota; Department of Pediatric Surgery (A.M.V.), Texas Children's Hospital, Houston, Texas; Division of Pediatric General and Thoracic Surgery (S.M., M.K., R.A.F.), Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio; Department of Surgery (R.F.W.), Le Bonheur Children's Hospital, Memphis, Tennessee; Jersey Shore University Medical Center (M.L.K.), Hackensack-Meridian Health Network, Neptune, New Jersey; Department of Pediatric Surgery (E.C.A., R.S.B.), Children's National Hospital, Washington, DC; UCHealth Memorial Hospital (T.J.S.), Pediatric Surgery, Colorado Springs, Colorado; Division of Pediatric Surgery (J.E.B., A.M.), Loma Linda University, Loma Linda, California; Department of Surgery, Virginia Commonwealth University (W.B.R., L.A.B.), Children's Hospital of Richmond, Richmond, Virginia; Department of Surgery (E.M.C., C.R.), Denver Health Medical Center, Denver, Colorado; Department of Surgery (R.M.N., C.J.R.), Hennepin Healthcare, Minneapolis, Minnesota; Department of Surgery (D.I.G., C.J.S.), The Medical University of South Carolina, Charleston, South Carolina; Department of Surgery (M.G., J.K.P.), Wake Forest Baptist Medical Center, Brenner Children's Hospital, Winston-Salem, North Carolina; Department of Surgery (M.R., S.P.), Children's Health Dallas, Dallas, Texas; Department of Pediatric Surgery, (R.T.R.), Children's of Alabama, Birmingham, Alabama; Department of Surgery (B.K.Y., J.M.), College of Medicine, University of Florida Jacksonville, Jacksonville, Florida; Department of Surgery (J.P.), Dayton Children's Hospital, Dayton, Ohio; Department of Surgery (M.T.S.), Children's Healthcare of Atlanta, Atlanta, Georgia; Department of Surgery (S.D.S., T.T.), Carilion Children's Hospital, Carilion Roanoke Memorial Hospital, Roanoke, Virginia; Department of Surgery (A.R.J.), Benioff Children's Hospital, University of California San Francisco, San Francisco, California; Department of Pediatric Surgery (D.P.M.), Boston Children's Hospital, Boston, Massachusetts; Department of Surgery (B.K., M.S.D.), Arkansas Children's Hospital, Little Rock, Arkansas; and Department of Surgery (A.G.-S.), Cooper University Hospital, Camden, New Jersey
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7
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Eitel AP, Moore EE, Sauaia A, Kelher MR, Vigneshwar NG, Bartley MG, Handley JB, Burlew CC, Campion EM, Fox CJ, Lawless RA, Pieracci FM, Platnick KB, Moore HB, Cohen MJ, Silliman CC. A proposed clinical coagulation score for research in trauma-induced coagulopathy. J Trauma Acute Care Surg 2023; 94:798-802. [PMID: 36805626 PMCID: PMC10205655 DOI: 10.1097/ta.0000000000003874] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/22/2023]
Abstract
BACKGROUND Trauma-induced coagulopathy (TIC) has been the subject of intense study for greater than a century, and it is associated with high morbidity and mortality. The Trans-Agency Consortium for Trauma-Induced Coagulopathy, funded by the National Health Heart, Lung and Blood Institute, was tasked with developing a clinical TIC score, distinguishing between injury-induced bleeding from persistent bleeding due to TIC. We hypothesized that the Trans-Agency Consortium for Trauma-Induced Coagulopathy clinical TIC score would correlate with laboratory measures of coagulation, transfusion requirements, and mortality. METHODS Trauma activation patients requiring a surgical procedure for hemostasis were scored in the operating room (OR) and in the first ICU day by the attending trauma surgeon. Conventional and viscoelastic (thrombelastography) coagulation assays, transfusion requirements, and mortality were correlated to the coagulation scores using the Cochran-Armitage trend test or linear regression for numerical variables. RESULTS Increased OR TIC scores were significantly associated with abnormal conventional and viscoelastic measurements, including hyperfibrinolysis incidence, as well as with higher mortality and more frequent requirement for massive transfusion ( p < 0.0001 for all trends). Patients with OR TIC score greater than 3 were more than 31 times more likely to have an ICU TIC score greater than 3 (relative risk, 31.6; 95% confidence interval, 12.7-78.3; p < 0.0001). CONCLUSION A clinically defined TIC score obtained in the OR reflected the requirement for massive transfusion and mortality in severely injured trauma patients and also correlated with abnormal coagulation assays. The OR TIC score should be validated in multicenter studies. LEVEL OF EVIDENCE Prognostic and Epidemiological; Level IV.
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Affiliation(s)
- Andrew P. Eitel
- Univerity of Washington Medicine, Department of Anesthesiology and Pain Medicine, Seattle, WA
| | - Ernest E. Moore
- University of Colorado Anschutz Medical Campus, School of Medicine, Department of Surgery, Aurora, CO
- Denver Health Medical Center, Trauma Surgery, Denver, CO
| | - Angela Sauaia
- University of Colorado Anschutz Medical Campus, School of Public Health, Aurora, CO
| | - Marguerite R Kelher
- University of Colorado Anschutz Medical Campus, School of Medicine, Department of Surgery, Aurora, CO
- Vitalant Research Institute, Denver, CO
| | - Navin G. Vigneshwar
- University of Colorado Anschutz Medical Campus, School of Medicine, Department of Surgery, Aurora, CO
| | - Matthew G. Bartley
- University of Colorado Anschutz Medical Campus, School of Medicine, Department of Surgery, Aurora, CO
| | - Jamie B. Handley
- University of Colorado Anschutz Medical Campus, School of Medicine, Department of Surgery, Aurora, CO
| | - Clay C. Burlew
- University of Colorado Anschutz Medical Campus, School of Medicine, Department of Surgery, Aurora, CO
| | | | - Charles J. Fox
- University of Maryland, School of Medicine, Department of Surgery, Baltimore, MD
| | | | | | - Kenneth B. Platnick
- University of Colorado Anschutz Medical Campus, School of Medicine, Department of Surgery, Aurora, CO
| | - Hunter B. Moore
- University of Colorado Anschutz Medical Campus, School of Medicine, Department of Surgery, Aurora, CO
| | - Mitchell J. Cohen
- University of Colorado Anschutz Medical Campus, School of Medicine, Department of Surgery, Aurora, CO
| | - Christopher C. Silliman
- University of Colorado Anschutz Medical Campus, School of Medicine, Department of Surgery, Aurora, CO
- Vitalant Research Institute, Denver, CO
- University of Colorado Anschutz Medical Campus, School of Medicine, Department of Pediatrics, Aurora, CO
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8
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Lee JS, Khan AD, Quinn CM, Colborn K, Patel DC, Barmparas G, Margulies DR, Waller CJ, Kallies KJ, Fitzsimmons AJ, Kothari SN, Raines AR, Mahnken H, Dunn J, Zier L, McIntyre RC, Urban S, Coleman JR, Campion EM, Burlew CC, Schroeppel TJ. Patient characteristics and diagnostic tests associated with syncopal falls: A Southwestern surgical congress multicenter study. Am J Surg 2022; 224:1374-1379. [PMID: 35940931 DOI: 10.1016/j.amjsurg.2022.07.018] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/25/2022] [Revised: 07/01/2022] [Accepted: 07/20/2022] [Indexed: 12/14/2022]
Abstract
BACKGROUND Patients suspected of syncope frequently undergo laboratory and imaging studies to determine the etiology of the syncope. Variability exists in these workups across institutions. The purpose of this study was to evaluate the utilization and diagnostic yield of these workups and the patient characteristics associated with syncopal falls. METHODS A multi-institutional retrospective review was performed on adult patients admitted after a fall between 1/2017-12/2018. Syncopal falls were compared to non-syncopal falls. RESULTS 4478 patients were included. There were 795 (18%) patients with a syncopal fall. Electrocardiogram, troponin, echocardiogram, CT angiography (CTA), and carotid ultrasound were more frequently tested in syncope patients compared to non-syncope patients. Syncope patients had higher rates of positive telemetry/Holter monitoring, CTAs, and electroencephalograms. CONCLUSION Patients who sustain syncopal falls frequently undergo diagnostic testing without a higher yield to determine the etiology of syncope.
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Affiliation(s)
- Janet S Lee
- Department of Trauma and Acute Care Surgery, UCHealth Memorial Hospital, Colorado Springs, CO, USA; Department of Surgery, University of Colorado Anschutz Medical Campus, Aurora, CO, USA.
| | - Abid D Khan
- Department of Surgery, Division of Trauma and Acute Care Surgery, University of Chicago, Chicago, IL, USA.
| | - Christopher M Quinn
- Department of Surgery, University of Colorado Anschutz Medical Campus, Aurora, CO, USA; Surgical Outcomes and Applied Research, University of Colorado Anschutz Medical Campus, Aurora, CO, USA.
| | - Kathryn Colborn
- Department of Surgery, University of Colorado Anschutz Medical Campus, Aurora, CO, USA; Surgical Outcomes and Applied Research, University of Colorado Anschutz Medical Campus, Aurora, CO, USA.
| | - Deven C Patel
- Department of Surgery, Cedars-Sinai Medical Center, Los Angeles, CA, USA.
| | - Galinos Barmparas
- Department of Surgery, Cedars-Sinai Medical Center, Los Angeles, CA, USA.
| | - Daniel R Margulies
- Department of Surgery, Cedars-Sinai Medical Center, Los Angeles, CA, USA.
| | | | - Kara J Kallies
- Department of Medical Research, Gundersen Health System, La Crosse, WI, USA.
| | - Alec J Fitzsimmons
- Department of Medical Research, Gundersen Health System, La Crosse, WI, USA.
| | - Shanu N Kothari
- Department of General Surgery, Prisma Health, Greenville, SC, USA.
| | - Alexander R Raines
- Department of Surgery, University of Oklahoma Health Science Center, Oklahoma City, OK, USA.
| | - Heidi Mahnken
- Department of Surgery, University of Oklahoma Health Science Center, Oklahoma City, OK, USA.
| | - Julie Dunn
- Department of Trauma and Acute Care Surgery, UCHealth Medical Center of the Rockies, Loveland, CO, USA.
| | - Linda Zier
- Department of Trauma and Acute Care Surgery, UCHealth Medical Center of the Rockies, Loveland, CO, USA.
| | - Robert C McIntyre
- Department of Surgery, University of Colorado Anschutz Medical Campus, Aurora, CO, USA.
| | - Shane Urban
- Department of Surgery, University of Colorado Anschutz Medical Campus, Aurora, CO, USA.
| | - Julia R Coleman
- Department of Surgery, University of Colorado Anschutz Medical Campus, Aurora, CO, USA; Department of Surgery, Denver Health Medical Center, Denver, CO, USA.
| | - Eric M Campion
- Department of Surgery, Denver Health Medical Center, Denver, CO, USA.
| | - Clay C Burlew
- Department of Surgery, Denver Health Medical Center, Denver, CO, USA.
| | - Thomas J Schroeppel
- Department of Trauma and Acute Care Surgery, UCHealth Memorial Hospital, Colorado Springs, CO, USA.
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Werner NL, Moore EE, Hoehn M, Lawless R, Coleman JR, Freedberg M, Heelan AA, Platnick KB, Cohen MJ, Coleman JJ, Campion EM, Fox CJ, Mauffrey C, Cralley A, Pieracci FM, Burlew CC. Inflate and pack! Pelvic packing combined with REBOA deployment prevents hemorrhage related deaths in unstable pelvic fractures. Injury 2022; 53:3365-3370. [PMID: 36038388 DOI: 10.1016/j.injury.2022.07.025] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/10/2022] [Revised: 06/07/2022] [Accepted: 07/15/2022] [Indexed: 02/02/2023]
Abstract
INTRODUCTION Resuscitative endovascular balloon occlusion of the aorta (REBOA) is advocated for hemorrhage control in pelvic fracture patients in shock. We evaluated REBOA in patients undergoing preperitoneal pelvic packing (PPP) for pelvic fracture-related hemorrhage. METHODS Retrospective, single-institution study of unstable pelvic fractures (hemodynamic instability despite 2 units of red blood cells (RBCs) and fracture identified on x-ray). Management included the placement of a Zone III REBOA in the emergency department (ED) for systolic blood pressure <80 mmHg. All PPP patients were included and analyzed for injury characteristics, transfusion requirements, outcomes and complications. Additionally, patients who received REBOA (REBOA+) were compared to those that did not (REBOA-). RESULTS During the study period (January 2015 - January 2019), 652 pelvic fracture patients were admitted; 78 consecutive patients underwent PPP. Median RBCs at PPP completion compared to 24 h post-packing were 11 versus 3 units (p<0.05). Median time to operation was 45 min. After PPP, 7 (9%) patients underwent angioembolization. Mortality was 14%. No mortalities were due to ongoing pelvic fracture hemorrhage or physiologic exhaustion; all were a withdrawal of life sustaining support, most commonly due to neurologic insults (TBI/fat emboli = 6, stroke/spinal cord injury = 3). REBOA+ patients (n = 31) had a significantly higher injury severity score (45 vs 38, p<0.01) and higher heart rate (130 vs 118 beats per minute, p = 0.04) than REBOA-. The systolic blood pressure, base deficit, and number of RBCs transfused in the ED, and time spent in the ED were similar between groups. REBOA+ had a higher median transfusion of RBCs at PPP completion (11 units vs 5 units, p<0.01) but similar RBC transfusion in the 24 h after PPP (2 vs 1 units, p = 0.27). Mortality, pelvic infection, and ICU length of stay was not different between these cohorts. CONCLUSION PPP with REBOA was utilized in more severely injured patients with greater physiologic derangements. Although REBOA patients required greater transfusion requirements, there were no deaths due to acute pelvic hemorrhage. This suggests the combination of REBOA with PPP provides life-saving hemorrhage control in otherwise devastating injuries.
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Affiliation(s)
- Nicole L Werner
- Denver Health Medical Center, 777 Bannock Street, MC 0206, Denver, CO 80204 United States of America.
| | - Ernest E Moore
- Denver Health Medical Center, 777 Bannock Street, MC 0206, Denver, CO 80204 United States of America
| | - Melanie Hoehn
- Denver Health Medical Center, 777 Bannock Street, MC 0206, Denver, CO 80204 United States of America
| | - Ryan Lawless
- Denver Health Medical Center, 777 Bannock Street, MC 0206, Denver, CO 80204 United States of America
| | - Julia R Coleman
- Denver Health Medical Center, 777 Bannock Street, MC 0206, Denver, CO 80204 United States of America
| | - Mari Freedberg
- Denver Health Medical Center, 777 Bannock Street, MC 0206, Denver, CO 80204 United States of America
| | - Alicia A Heelan
- Denver Health Medical Center, 777 Bannock Street, MC 0206, Denver, CO 80204 United States of America
| | - K Barry Platnick
- Denver Health Medical Center, 777 Bannock Street, MC 0206, Denver, CO 80204 United States of America
| | - Mitchell J Cohen
- Denver Health Medical Center, 777 Bannock Street, MC 0206, Denver, CO 80204 United States of America
| | - Jamie J Coleman
- Denver Health Medical Center, 777 Bannock Street, MC 0206, Denver, CO 80204 United States of America
| | - Eric M Campion
- Denver Health Medical Center, 777 Bannock Street, MC 0206, Denver, CO 80204 United States of America
| | - Charles J Fox
- Denver Health Medical Center, 777 Bannock Street, MC 0206, Denver, CO 80204 United States of America
| | - Cyril Mauffrey
- Denver Health Medical Center, 777 Bannock Street, MC 0206, Denver, CO 80204 United States of America
| | - Alexis Cralley
- Denver Health Medical Center, 777 Bannock Street, MC 0206, Denver, CO 80204 United States of America
| | - Fredric M Pieracci
- Denver Health Medical Center, 777 Bannock Street, MC 0206, Denver, CO 80204 United States of America
| | - Clay Cothren Burlew
- Denver Health Medical Center, 777 Bannock Street, MC 0206, Denver, CO 80204 United States of America
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Delaplain PT, Tay-Lasso E, Biffl WL, Schaffer KB, Sundel M, Behdin S, Ghneim M, Costantini TW, Santorelli JE, Switzer E, Schellenberg M, Keeley JA, Kim DY, Wang A, Dhillon NK, Patel D, Campion EM, Robinson CK, Kartiko S, Quintana MT, Estroff JM, Kirby KA, Nahmias J. Excluding Hollow Viscus Injury for Abdominal Seat Belt Sign Using Computed Tomography. JAMA Surg 2022; 157:771-778. [PMID: 35830194 DOI: 10.1001/jamasurg.2022.2770] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/18/2023]
Abstract
Importance Abdominal seat belt sign (SBS) has historically entailed admission and observation because of the diagnostic limitations of computed tomography (CT) imaging and high rates of hollow viscus injury (HVI). Recent single-institution, observational studies have questioned the utility of this practice. Objective To evaluate whether a negative CT scan can safely predict the absence of HVI in the setting of an abdominal SBS. Design, Setting, and Participants This prospective, observational cohort study was conducted in 9 level I trauma centers between August 2020 and October 2021 and included adult trauma patients with abdominal SBS. Exposures Inclusion in the study required abdominal CT as part of the initial trauma evaluation and before any surgical intervention, if performed. Results of CT scans were considered positive if they revealed any of the following: abdominal wall soft tissue contusion, free fluid, bowel wall thickening, mesenteric stranding, mesenteric hematoma, bowel dilation, pneumatosis, or pneumoperitoneum. Main Outcomes and Measures Presence of HVI diagnosed at the time of operative intervention. Results A total of 754 patients with abdominal SBS had an HVI prevalence of 9.2% (n = 69), with only 1 patient with HVI (0.1%) having a negative CT (ie, none of the 8 a priori CT findings). On bivariate analysis comparing patients with and without HVI, there were significant associations between each of the individual CT scan findings and the presence of HVI. The strongest association was found with the presence of free fluid, with a more than 40-fold increase in the likelihood of HVI (odds ratio [OR], 42.68; 95% CI, 20.48-88.94; P < .001). The presence of free fluid also served as the most effective binary classifier for presence of HVI (area under the receiver operator characteristic curve [AUC], 0.87; 95% CI, 0.83-0.91). There was also an association between a negative CT scan and the absence of HVI (OR, 41.09; 95% CI, 9.01-727.69; P < .001; AUC, 0.68; 95% CI, 0.66-0.70). Conclusions and Relevance The prevalence of HVI among patients with an abdominal SBS and negative findings on CT is extremely low, if not zero. The practice of admitting and observing all patients with abdominal SBS should be reconsidered when a high-quality CT scan is negative, which may lead to significant resource and cost savings.
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Affiliation(s)
- Patrick T Delaplain
- Division of Trauma, Burns, & Surgical Critical Care, University of California, Irvine
| | - Erika Tay-Lasso
- Division of Trauma, Burns, & Surgical Critical Care, University of California, Irvine
| | - Walter L Biffl
- Trauma Department, Scripps Memorial Hospital La Jolla, La Jolla, California
| | - Kathryn B Schaffer
- Trauma Department, Scripps Memorial Hospital La Jolla, La Jolla, California
| | - Margaret Sundel
- Program in Trauma, R Adams Cowley Shock Trauma Center, University of Maryland School of Medicine, Baltimore
| | - Samar Behdin
- Program in Trauma, R Adams Cowley Shock Trauma Center, University of Maryland School of Medicine, Baltimore
| | - Mira Ghneim
- Program in Trauma, R Adams Cowley Shock Trauma Center, University of Maryland School of Medicine, Baltimore
| | - Todd W Costantini
- Division of Trauma, Surgical Critical Care, Burns and Acute Care Surgery, University of California San Diego School of Medicine, San Diego
| | - Jarrett E Santorelli
- Division of Trauma, Surgical Critical Care, Burns and Acute Care Surgery, University of California San Diego School of Medicine, San Diego
| | - Emily Switzer
- Los Angeles County + USC Medical Center, Division of Acute Care Surgery, University of Southern California, Los Angeles
| | - Morgan Schellenberg
- Los Angeles County + USC Medical Center, Division of Acute Care Surgery, University of Southern California, Los Angeles
| | - Jessica A Keeley
- Division of Trauma/Acute Care Surgery/Surgical Critical Care, Harbor-UCLA Medical Center, Torrance, California
| | - Dennis Y Kim
- Division of Trauma/Acute Care Surgery/Surgical Critical Care, Harbor-UCLA Medical Center, Torrance, California
| | - Andrew Wang
- Department of Surgery, Cedars-Sinai Medical Center, Los Angeles, California
| | - Navpreet K Dhillon
- Department of Surgery, Cedars-Sinai Medical Center, Los Angeles, California
| | - Deven Patel
- Department of Surgery, Cedars-Sinai Medical Center, Los Angeles, California
| | - Eric M Campion
- Department of Surgery, Denver Health Medical Center, Denver, Colorado
| | | | - Susan Kartiko
- Department of Surgery, The George Washington University School of Medicine & Health Sciences, Washington, DC
| | - Megan T Quintana
- Department of Surgery, The George Washington University School of Medicine & Health Sciences, Washington, DC
| | - Jordan M Estroff
- Department of Surgery, The George Washington University School of Medicine & Health Sciences, Washington, DC
| | - Katharine A Kirby
- Center for Statistical Consulting, Department of Statistics, University of California, Irvine
| | - Jeffry Nahmias
- Division of Trauma, Burns, & Surgical Critical Care, University of California, Irvine
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Campion EM, Cralley A, Sauaia A, Buchheit RC, Brown AT, Spalding MC, LaRiccia A, Moore S, Tann K, Leskovan J, Camazine M, Barnes SL, Otaibi B, Hazelton JP, Jacobson LE, Williams J, Castillo R, Stewart NJ, Elterman JB, Zier L, Goodman M, Elson N, Miner J, Hardman C, Kapoen C, Mendoza AE, Schellenberg M, Benjamin E, Wakam GK, Alam HB, Kornblith LZ, Callcut RA, Coleman LE, Shatz DV, Burruss S, Linn AC, Perea L, Morgan M, Schroeppel TJ, Stillman Z, Carrick MM, Gomez MF, Berne JD, McIntyre RC, Urban S, Nahmias J, Tay E, Cohen M, Moore EE, McVaney K, Burlew CC. Prehospital end-tidal carbon dioxide is predictive of death and massive transfusion in injured patients: An Eastern Association for Surgery of Trauma multicenter trial. J Trauma Acute Care Surg 2022; 92:355-361. [PMID: 34686640 DOI: 10.1097/ta.0000000000003447] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
BACKGROUND Prehospital identification of the injured patient likely to require emergent care remains a challenge. End-tidal carbon dioxide (ETCO2) has been used in the prehospital setting to monitor respiratory physiology and confirmation of endotracheal tube placement. Low levels of ETCO2 have been demonstrated to correlate with injury severity and mortality in a number of in-hospital studies. We hypothesized that prehospital ETCO2 values would be predictive of mortality and need for massive transfusion (MT) in intubated patients. METHODS This was a retrospective multicenter trial with 24 participating centers. Prehospital, emergency department, and hospital values were collected. Receiver operating characteristic curves were created and compared. Massive transfusion defined as >10 U of blood in 6 hours or death in 6 hours with at least 1 U of blood transfused. RESULTS A total of 1,324 patients were enrolled. ETCO2 (area under the receiver operating characteristic curve [AUROC], 0.67; confidence interval [CI], 0.63-0.71) was better in predicting mortality than shock index (SI) (AUROC, 0.55; CI, 0.50-0.60) and systolic blood pressure (SBP) (AUROC, 0.58; CI, 0.53-0.62) (p < 0.0005). Prehospital lowest ETCO2 (AUROC, 0.69; CI, 0.64-0.75), SBP (AUROC, 0.75; CI, 0.70-0.81), and SI (AUROC, 0.74; CI, 0.68-0.79) were all predictive of MT. Analysis of patients with normotension demonstrated lowest prehospital ETCO2 (AUROC, 0.66; CI, 0.61-0.71), which was more predictive of mortality than SBP (AUROC, 0.52; CI, 0.47-0.58) or SI (AUROC, 0.56; CI, 0.50-0.62) (p < 0.001). Lowest prehospital ETCO2 (AUROC, 0.75; CI, 0.65-0.84), SBP (AUROC, 0.63; CI, 0.54-0.74), and SI (AUROC, 0.64; CI, 0.54-0.75) were predictive of MT in normotensive patients. ETCO2 cutoff for MT was 26 mm Hg. The positive predictive value was 16.1%, and negative predictive value was high at 98.1%. CONCLUSION Prehospital ETCO2 is predictive of mortality and MT. ETCO2 outperformed traditional measures such as SBP and SI in the prediction of mortality. ETCO2 may outperform traditional measures in predicting need for transfusion in occult shock. LEVEL OF EVIDENCE Diagnostic test, level III.
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Affiliation(s)
- Eric M Campion
- From the Department of Surgery (E.M.C., A.C., M. Cohen, E.E.M., C.C.B.), Denver Health Medical Center, Denver, Colorado; School of Public Health (A.S.), University of Colorado, Aurora, Colorado; Department of Surgery (R.C.B., A.T.B.), Erlanger Health System, Chattanooga, Tennessee; Department of Surgery (M.C.S., A.L.), Grant Medical Center, Columbus, Ohio; Department of Surgery (S.M., K.T.), Wakemed, Raleigh, North Carolina; Department of Surgery (J.L.), Mercy Health, Toledo, Ohio; Department of Surgery (M. Camazine, S.L.B.), University of Missouri Health Care, Columbia, Missouri; Department of Surgery (B.O., J.P.H.), Penn State Health, Hershey, Pennsylvania; Department of Surgery (L.E.J., J.W.), Ascension, Indianapolis, Indiana; Department of Surgery (R.C., N.J.S.), St. Lukes University Health Network, Bethlehem, Pennsylvania; Department of Surgery (J.B.E., L.Z.), UCHealth Medical Center of the Rockies, Loveland, Colorado; Department of Surgery (M.G., N.E.), University of Cincinnati, Cincinnati, Ohio; Department of Surgery (J.M., C.H.), Premier Health Miami Valley, Dayton, Ohio; Department of Surgery (C.K., A.E.M.), Massachusetts General Hospital, Boston, Massachusetts; USC Medical Center, University of Southern California (M.S., E.B.), Los Angeles, California; Department of Surgery (G.K.W., H.B.A.), University of Michigan, Ann Arbor, Michigan; Department of Surgery (L.Z.K., R.A.C.), Zuckerberg San Francisco General Hospital, University of California, San Francisco, San Francisco, California; Department of Surgery (L.E.C., D.V.S.), University of California, Davis, Sacramento, California; Department of Surgery (S.B., A.C.L.), Loma Linda University Health, Loma Linda, California; Department of Surgery (L.P., M.M.), Penn Medicine, Philadelphia, Pennsylvania; Department of Surgery (T.J.S., Z.S.), UCHealth Memorial Hospital, Springs Colorado, Colorado; Department of Surgery (M.M.C.), Medical City Plano, Plano, Texas; Department of Surgery (M.F.G., J.D.B.), Broward Health, Ft. Lauderdale, Florida; Department of Surgery (R.C.M., S.U.), University of Colorado Anschutz, Aurora, Colorado; University of California, Irvine (J.N., E.T.), Irvine, CA; and Denver Paramedics, Department of Emergency Medicine (K.M.), Denver Health Medical Center, Denver, Colorado
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Fischer PE, Gestring ML, Sagraves SG, Michaels HN, Patel B, Dodd J, Campion EM, VanderKolk WE, Bulger EM. The national trauma triage protocol: how EMS perspective can inform the guideline revision. Trauma Surg Acute Care Open 2022; 7:e000879. [PMID: 35128069 PMCID: PMC8768919 DOI: 10.1136/tsaco-2021-000879] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/27/2021] [Accepted: 12/31/2021] [Indexed: 11/21/2022] Open
Abstract
Objectives The Field Triage Guidelines (FTG) support emergency medical service (EMS) decisions regarding the most appropriate transport destination for injured patients. While the components of the algorithm are largely evidenced-based, the stepwise approach was developed with limited input from EMS providers. FTG are only useful if they can easily be applied by the field practitioner. We sought to gather end-user input on the current guidelines from a broad group of EMS stakeholders to inform the next revision of the FTG. Methods An expert panel composed an end-user feedback tool. Data collected included: demographics, EMS agency type, geographic area of respondents, use of the current FTG, perceived utility, and importance of each step in the algorithm (1: physiologic, 2: anatomic, 3 mechanistic, 4: special populations). The American College of Surgeons Committee on Trauma (ACS COT), in partnership with several key organizations, distributed the tool to reach as many providers as possible. Results 3958 responses were received (82% paramedics/emergency medical technicians, 9% physicians, 9% other). 94% responded directly to scene emergency calls and 4% were aeromedical providers. Steps 2 and 3 were used in 95% of local protocols, steps 1 and 4 in 90%. Step 3 was used equally in protocols across all demographics; however, step 1 was used significantly more in the air medical services than ground EMS (96% vs 88%, p<0.05). Geographic variation was demonstrated in FTG use based on the distance to a trauma center, but step 3 (not step 1) drove the majority of the decisions. This point was reinforced in the qualitative data with the comment, “I see the wreck before I see the patient.” Conclusion The FTG are widely used by EMS in the USA. The stepwise approach is useful; however, mechanism (not physiological criteria) drives most of the decisions and is evaluated first. Revision of the FTG should consider the experience of the end-users. Level of evidence V.
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Affiliation(s)
- Peter E Fischer
- Department of Surgery, The University of Tennessee Health Science Center, Memphis, Tennessee, USA
| | - Mark L Gestring
- Department of Surgery, University of Rochester, Rochester, New York, USA
| | - Scott G Sagraves
- Department of Surgery, Baylor Scott and White Central Texas, Temple, Texas, USA
| | - Holly N Michaels
- Committee on Trauma, American College of Surgeons, Chicago, Illinois, USA
| | - Bhavin Patel
- Committee on Trauma, American College of Surgeons, Chicago, Illinois, USA
| | - Jimm Dodd
- Committee on Trauma, American College of Surgeons, Chicago, Illinois, USA
| | - Eric M Campion
- Department of Surgery, Denver Health, Denver, Colorado, USA
| | - Wayne E VanderKolk
- Department of Surgery, West Michigan Surgical Specialists, Grand Rapids, Michigan, USA
| | - Eileen M Bulger
- Department of Surgery, University of Washington, Seattle, Washington, USA
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13
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Cralley AL, Burlew CC, Fox CJ, Pieracci FM, Platnick KBK, Campion EM, Cohen MJ, Moore EE, Lawless RA. An Unencumbered Acute Care Surgeon Improves Delivery of Emergent Surgical Care for Cholecystectomy Patients. JSLS 2022; 26:JSLS.2022.00045. [PMID: 36212183 PMCID: PMC9521635 DOI: 10.4293/jsls.2022.00045] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022] Open
Abstract
Introduction: Many patients utilize the Emergency Room (ER) for primary care, resulting in overburdened ERs, strained resources, and delays in care. To combat this, many centers have adopted a Trauma/Acute Care Surgery (TACS) service providing specialty surgeons whose primary work is the unencumbered surgical availability to emergency surgery patients. To evaluate our programs’ efficacy, we investigated cholecystectomies as a common urgent procedure representative of services provided. We hypothesized that the adoption of a TACS service would result in improved access to care as evidence by decreased ER visits prior to cholecystectomy, improved time to cholecystectomy, and decreased hospital length of stay (LOS). Methods: All patients that underwent urgent cholecystectomy from January 1, 2018 to December 31, 2018 were reviewed. The unencumbered TACS surgeon was implemented on July 1, 2018. Prior ER visits involving biliary symptoms, time from admission to cholecystectomy, and hospital LOS were compared. Results: Of the 322 urgent cholecystectomies over the study period, 165 were performed prior and 157 following adoption of the TACS structure. The average number of ER visits for biliary symptoms prior to cholecystectomy decreased from 1.4 to 1.2 (p = 0.01). Time from admission to cholecystectomy was 28.3 hours and 27.3 hours respectively (p = 0.74). Average LOS decreased following the restructure (3.1 vs 2.5 days; p = 0.03). Conclusion: Implementation of an unencumbered TACS surgeon managing urgent surgical disease improves access to and delivery of surgical services for cholecystectomy patients in a safety net, level one trauma center. Further research is necessary to determine potential improvements in hospital cost and patient satisfaction.
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Affiliation(s)
- Alexis L. Cralley
- Department of Surgery, Denver Health Medical Center, Denver, Colorado
| | - Clay C. Burlew
- Department of Surgery, Denver Health Medical Center, Denver, Colorado.,Department of Surgery, University of Colorado, Aurora, Colorado
| | - Charles J. Fox
- Department of Surgery, University of Maryland School of Medicine, Baltimore, Maryland
| | - Fredric M. Pieracci
- Department of Surgery, Denver Health Medical Center, Denver, Colorado.,Department of Surgery, University of Colorado, Aurora, Colorado
| | - K. Barry K. Platnick
- Department of Surgery, Denver Health Medical Center, Denver, Colorado.,Department of Surgery, University of Colorado, Aurora, Colorado
| | - Eric M. Campion
- Department of Surgery, Denver Health Medical Center, Denver, Colorado.,Department of Surgery, University of Colorado, Aurora, Colorado
| | - Mitchell J. Cohen
- Department of Surgery, Denver Health Medical Center, Denver, Colorado.,Department of Surgery, University of Colorado, Aurora, Colorado
| | - Ernest E. Moore
- Department of Surgery, Denver Health Medical Center, Denver, Colorado.,Department of Surgery, University of Colorado, Aurora, Colorado
| | - Ryan A. Lawless
- Department of Surgery, Denver Health Medical Center, Denver, Colorado.,Department of Surgery, University of Colorado, Aurora, Colorado
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14
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Hadley JB, Coleman JR, Moore EE, Lawless R, Burlew CC, Platnick B, Pieracci FM, Hoehn MR, Coleman JJ, Campion EM, Cohen MJ, Cralley A, Eitel AP, Bartley M, Vigneshwar N, Sauaia A, Fox CJ. Strategies for successful implementation of resuscitative endovascular balloon occlusion of the aorta in an urban Level I trauma center. J Trauma Acute Care Surg 2021; 91:295-301. [PMID: 33783417 PMCID: PMC8375411 DOI: 10.1097/ta.0000000000003198] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
BACKGROUND The rationale for resuscitative endovascular balloon occlusion of the aorta (REBOA) is to control life-threatening subdiaphragmatic bleeding and facilitate resuscitation; however, incorporating this into the resuscitative practices of a trauma service remains challenging. The objective of this study is to describe the process of successful implementation of REBOA use in an academic urban Level I trauma center. All REBOA procedures from April 2014 through December 2019 were evaluated; REBOA was implemented after surgical faculty attended a required and internally developed Advanced Endovascular Strategies for Trauma Surgeons course. Success was defined by sustained early adoption rates. METHODS An institutional protocol was published, and a REBOA supply cart was placed in the emergency department with posters attached to depict technical and procedural details. A focused professional practice evaluation was utilized for the first three REBOA procedures performed by each faculty member, leading to internal privileging. RESULTS Resuscitative endovascular balloon occlusion of the aorta was performed in 97 patients by nine trauma surgeons, which is 1% of the total trauma admissions during this time. Each surgeon performed a median of 12 REBOAs (interquartile range, 5-14). Blunt (77/97, 81%) or penetrating abdominopelvic injuries (15/97, 15%) comprised the main injury mechanisms; 4% were placed for other reasons (4/97), including ruptured abdominal aortic aneurysms (n = 3) and preoperatively for a surgical oncologic resection (n = 1). Overall survival was 65% (63/97) with a steady early adoption trend that resulted in participation in a Department of Defense multicenter trial. CONCLUSION Strategies for how departments adopt new procedures require clinical guidelines, a training program focused on competence, and a hospital education and privileging process for those acquiring new skills. LEVEL OF EVIDENCE Therapeutic, level V.
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Affiliation(s)
- Jamie B Hadley
- From Department of Surgery, University of Colorado School of Medicine (J.B.H., J.R.C., A.P.E., M.B., N.V., C.J.F.); and Department of Surgery, Denver Health Medical Center (E.E.M., R.L., C.C.B., B.P., F.M.P., M.R.H., J.J.C., E.M.C., M.J.C., A.S., A.C.), Denver, Colorado
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15
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Barmparas G, Alhaj Saleh A, Huang R, Eaton BC, Bruns BR, Raines A, Bryant C, Crane CE, Scherer EP, Schroeppel TJ, Moskowitz E, Regner JL, Frazee R, Campion EM, Bartley M, Mortus JR, Ward J, Margulies DR, Dissanaike S. Empiric antifungals do not decrease the risk for organ space infection in patients with perforated peptic ulcer. Trauma Surg Acute Care Open 2021; 6:e000662. [PMID: 34079912 PMCID: PMC8137227 DOI: 10.1136/tsaco-2020-000662] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/17/2020] [Revised: 02/24/2021] [Accepted: 04/24/2021] [Indexed: 12/29/2022] Open
Abstract
Introduction Infection control in patients with perforated peptic ulcers (PPU) commonly includes empiric antifungals (AF). We investigated the variation in the use of empiric AF and explored the association between their use and the subsequent development of organ space infection (OSI). Methods This was a secondary analysis of a multicenter, case–control study of patients treated for PPU at nine institutions between 2011 and 2018. Microbiology and utilization of empiric AF, defined as AF administered within 24 hours from the index surgery, were recorded. Patients who received empiric AF were compared with those who did not. The primary outcome was OSI and secondary outcome was OSI with growth of Candida spp. A logistic regression was used to adjust for differences between the two cohorts. Results A total of 554 patients underwent a surgical procedure for PPU and had available timing of AF administration. The median age was 57 years and 61% were male. Laparoscopy was used in 24% and omental patch was the most common procedure performed (78%). Overall, 239 (43%) received empiric AF. There was a large variation in the use of empiric AF among participating centers, ranging from 25% to 68%. The overall incidence of OSI was 14% (77/554) and was similar for patients who did or did not receive empiric AF. The adjusted OR for development of OSI for patients who received empiric AF was 1.04 (95% CI 0.64 to 1.70), adjusted p=0.86. The overall incidence of OSI with growth of Candida spp was 5% and was similar for both groups (adjusted OR 1.29, 95% CI 0.59 to 2.84, adjusted p=0.53). Conclusion For patients undergoing surgery for PPU, the use of empiric AF did not yield any significant clinical advantage in preventing OSI, even those due to Candida spp. Use of empiric AF in this setting is unnecessary. Study type Original article, case series. Level of evidence III.
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Affiliation(s)
- Galinos Barmparas
- Department of Surgery, Cedars-Sinai Medical Center, Los Angeles, California, USA
| | - Adel Alhaj Saleh
- Department of Surgery, Texas Tech University Health Sciences Center School of Medicine-Lubbock Campus, Lubbock, Texas, USA
| | - Raymond Huang
- Department of Surgery, Cedars-Sinai Medical Center, Los Angeles, California, USA
| | - Barbara C Eaton
- Department of Surgery, R Adams Cowley Shock Trauma Center, Baltimore, Maryland, USA
| | - Brandon R Bruns
- Department of Surgery, R Adams Cowley Shock Trauma Center, Baltimore, Maryland, USA
| | - Alexander Raines
- Department of Surgery, The University of Oklahoma Health Sciences Center, Oklahoma City, Oklahoma, USA
| | - Cressilee Bryant
- Department of Surgery, The University of Oklahoma Health Sciences Center, Oklahoma City, Oklahoma, USA
| | - Christopher E Crane
- Department of Surgery, University of Texas Health San Antonio, San Antonio, Texas, USA
| | - Elizabeth P Scherer
- Department of Surgery, University of Texas Health San Antonio, San Antonio, Texas, USA
| | - Thomas J Schroeppel
- Department of Surgery, University of Colorado, Colorado Springs, Colorado, USA
| | - Eliza Moskowitz
- Department of Surgery, University of Colorado, Colorado Springs, Colorado, USA
| | - Justin L Regner
- Department of Surgery, Baylor Scott and White Health, Temple, Texas, USA
| | - Richard Frazee
- Department of Surgery, Baylor Scott and White Health, Temple, Texas, USA
| | - Eric M Campion
- Department of Surgery, Denver Health Medical Center, Denver, Colorado, USA
| | - Matthew Bartley
- Department of Surgery, Denver Health Medical Center, Denver, Colorado, USA
| | - Jared R Mortus
- Michael E. DeBakey Department of Surgery, Baylor College of Medicine, Houston, Texas, USA
| | - Jeremy Ward
- Michael E. DeBakey Department of Surgery, Baylor College of Medicine, Houston, Texas, USA
| | - Daniel R Margulies
- Department of Surgery, Cedars-Sinai Medical Center, Los Angeles, California, USA
| | - Sharmila Dissanaike
- Department of Surgery, Texas Tech University Health Sciences Center School of Medicine-Lubbock Campus, Lubbock, Texas, USA
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16
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Carmichael H, Samuels JM, Jamison EC, Bol KA, Coleman JJ, Campion EM, Velopulos CG. Finding the elusive trauma denominator: Feasibility of combining data sets to quantify the true burden of firearm trauma. J Trauma Acute Care Surg 2021; 90:466-470. [PMID: 33105286 DOI: 10.1097/ta.0000000000003005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Abstract
BACKGROUND Evidence guiding firearm injury prevention is limited by current data collection infrastructure. Trauma registries (TR) omit prehospital deaths and underestimate the burden of injury. In contrast, the National Violent Death Reporting System (NVDRS) tracks all firearm deaths including prehospital fatalities, excluding survivors. This is a feasibility study to link these data sets through collaboration with our state public health department, aiming to better estimate the burden of firearm injury and assess comparability of data. METHODS We reviewed all firearm injuries in our Level I TR from 2011 to 2017. We provided the public health department with in-hospital deaths, which they linked to NVDRS using patient identifiers and time of injury/death. The NVDRS collates information about circumstances, incident type, and wounding patterns from multiple sources including death certificates, autopsy records, and legal proceedings. We considered only subjects with injury location in a single urban county to best estimate in-hospital and prehospital mortality. RESULTS Of 168 TR deaths, 166 (99%) matched to NVDRS records. Based on data linkages, we estimate 320 prehospital deaths, 184 in-hospital deaths, and 453 survivors for a total of 957 firearm injuries. For the matched patients, there was near-complete agreement regarding simple demographic variables (e.g., age and sex) and good concordance between incident types (suicide, homicide, etc.). However, agreement in wounding patterns between NVDRS and TR varied. CONCLUSION We demonstrate the feasibility of linking TR and NVDRS data with good concordance for many variables, allowing for good estimation of the trauma denominator. Standardized data collection methods in one data set could improve methods used by the other, for example, training NVDRS abstractors to utilize Abbreviated Injury Scale designations for injury patterns. Such data integration holds immediate promise for guiding prevention strategies. LEVEL OF EVIDENCE Epidemiological study, level IV.
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Affiliation(s)
- Heather Carmichael
- From the University of Colorado (H.C., J.M.S., C.G.V.), Aurora; Colorado Department of Public Health and Environment (E.C.J., K.A.B.), Health Statistics and Evaluation Branch; and Department of Surgery (J.J.C., E.M.C.), Denver Health Medical Center, Denver, Colorado
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17
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Schwed AC, Wagenaar A, Reppert AE, Gore AV, Pieracci FM, Platnick KB, Lawless RA, Campion EM, Coleman JJ, Cohen MJ, Moore EE, Burlew CC. Trust the FAST: Confirmation that the FAST examination is highly specific for intra-abdominal hemorrhage in over 1,200 patients with pelvic fractures. J Trauma Acute Care Surg 2021; 90:137-142. [PMID: 32976327 DOI: 10.1097/ta.0000000000002947] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
BACKGROUND Use of the focused assessment with sonography for trauma (FAST) examination in patients with pelvic fractures has been reported as unreliable. We hypothesized that FAST is a reliable method for detecting clinically significant intra-abdominal hemorrhage in patients with pelvic fractures. METHODS All patients with pelvic fractures over a 10-year period were reviewed at a Level I trauma center. The predictive ability of FAST was assessed by calculating the sensitivity, specificity, positive predictive value and negative predictive value against the criterion standard of either computed tomography (CT) or laparotomy findings. The FAST examination was considered "false negative" if findings at laparotomy indicated traumatic intra-abdominal hemorrhage. Likewise, the FAST examination was considered "false positive" if either CT or findings at laparotomy indicated no intra-abdominal hemorrhage. Hemodynamic instability scores were calculated for all patients. RESULTS There were 1,456 patients with pelvic fractures and an initial FAST reviewed; 1,219 (83.7%) underwent FAST and either CT or operative exploration. Median age was 43 years (interquartile range, 26-56 years) and mean Injury Severity Score was 18.5 ± 12.3. The sensitivity and specificity for FAST in this group of patients with pelvic fracture was 85.4% and 98.1%, respectively. The positive predictive value and negative predictive value were 78.4% and 98.8%, respectively. Of 21 patients with a false-positive FAST, 15 (71.4%) were confirmed with a negative CT scan, and 6 (28.6%) underwent laparotomy without findings of intra-abdominal hemorrhage. Of 13 patients with a false-negative FAST, all were identified with positive findings at the time of laparotomy. The specificity of the FAST examination remained high regardless of hemodynamic instability score grade. CONCLUSION The false positive rate of FAST examination for intra-abdominal hemorrhage is 1.1%. These data suggest that a positive FAST in this clinical scenario should be considered to represent intra-abdominal fluid. This series contradicts prior reports that FAST is unreliable in patients with pelvic fracture. LEVEL OF EVIDENCE Diagnostic, level III.
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Affiliation(s)
- Alexander C Schwed
- From the Department of Surgery (A.C.S., A.V.G., F.M.P., K.B.P., R.A.L., E.M.C., J.J.C., E.E.M., C.C.B.), Denver Health Medical Center, Denver, Colorado; Department of Anesthesia (A.W.), Brigham and Women's Hospital, Harvard University, Boston, Massachussets; and Department of Surgery (A.E.R.), University of Colorado, Aurora, Colorado
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18
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Alhaj Saleh A, Esquivel EC, Lung JT, Eaton BC, Bruns BR, Barmparas G, Margulies DR, Raines A, Bryant C, Crane CE, Scherer EP, Schroeppel TJ, Moskowitz E, Regner J, Frazee R, Campion EM, Bartley M, Mortus J, Ward J, Almekdash MH, Dissanaike S. Laparoscopic omental patch for perforated peptic ulcer disease reduces length of stay and complications, compared to open surgery: A SWSC multicenter study. Am J Surg 2019; 218:1060-1064. [PMID: 31537324 DOI: 10.1016/j.amjsurg.2019.09.002] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/15/2019] [Revised: 08/24/2019] [Accepted: 09/03/2019] [Indexed: 12/12/2022]
Abstract
RCTs showed benefits in Lap repair of perforated peptic ulcer (PPU). The SWSC Multi-Center Trials Group sought to evaluate whether Lap omental patch repairs compared to Open improved outcomes in PPU in general practice. Data was collected from 9 SWSC Trial Group centers. Demographics, operative time, 30-day complications, length of stay and mortality were included. 461 PATIENTS: Open in 311(67%) patients, Lap in 132(28%) with 20(5%) patients converted from Lap to Open. Groups were similar at baseline. Significant variability was found between centers in their utilization of Lap (0-67%). Complications at 30 days were lower in Lap (18.5% vs. 27.5%, p < 0.05) as was unplanned re-operation (4.7% vs 14%, p < 0.05). Lap reduced LOS (6 vs 8 days, p < 0.001). Ileus was more in Lap (42% vs 18 p < 0.001) operative time was 14 min higher in Lap(p < 0.01) and admission to OR time was 4 h higher in Lap(<0.05). No significant difference readmission or mortality. Our results suggest Lap should be considered a first-line option in suitable PPU patients requiring omental patch repair in centers that have the capacity and resources 24/7.
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Affiliation(s)
- Adel Alhaj Saleh
- Department of Surgery, Texas Tech University Health Sciences Center, Lubbock, TX, USA
| | - Esteban C Esquivel
- Department of Surgery, Texas Tech University Health Sciences Center, Lubbock, TX, USA
| | - John T Lung
- Department of Surgery, Texas Tech University Health Sciences Center, Lubbock, TX, USA
| | - Barbara C Eaton
- Department of Surgery, University of Maryland Medical System, Baltimore, MD, USA
| | - Brandon R Bruns
- Department of Surgery, University of Maryland Medical System, Baltimore, MD, USA
| | - Galinos Barmparas
- Department of Surgery, Cedars-Sinai Medical Center, Los Angeles, CA, USA
| | - Daniel R Margulies
- Department of Surgery, Cedars-Sinai Medical Center, Los Angeles, CA, USA
| | - Alexander Raines
- Department of Surgery, Oklahoma University Health Sciences Center, Oklahoma City, OK, USA
| | - Cressilee Bryant
- Department of Surgery, Oklahoma University Health Sciences Center, Oklahoma City, OK, USA
| | - Christopher E Crane
- Department of Surgery, University of Texas Health Science Center, San Antonio, TX, USA
| | - Elizabeth P Scherer
- Department of Surgery, University of Texas Health Science Center, San Antonio, TX, USA
| | - Thomas J Schroeppel
- Department of Surgery, UCHealth Memorial Hospital Center, Colorado Springs, CO, USA
| | - Eliza Moskowitz
- Department of Surgery, UCHealth Memorial Hospital Center, Colorado Springs, CO, USA
| | - Justin Regner
- Department of Surgery, Baylor Scott and White Health, Temple, TX, USA
| | - Richard Frazee
- Department of Surgery, Baylor Scott and White Health, Temple, TX, USA
| | - Eric M Campion
- Department of Surgery, Department of Surgery, Denver Health Medical Center, Denver, CO, USA
| | - Matthew Bartley
- Department of Surgery, Department of Surgery, Denver Health Medical Center, Denver, CO, USA
| | - Jared Mortus
- Department of Surgery, Baylor College of Medicine, Ben Taub, TX, USA
| | - Jeremy Ward
- Department of Surgery, Baylor College of Medicine, Ben Taub, TX, USA
| | - Mhd Hasan Almekdash
- Clinical Research Institute, Texas Tech University Health Sciences Center, Lubbock, TX, USA
| | - Sharmila Dissanaike
- Department of Surgery, Texas Tech University Health Sciences Center, Lubbock, TX, USA.
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20
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Affiliation(s)
- Jason S. Haukoos
- Department of Emergency Medicine, Denver Health Medical Center, Denver, Colorado
- Division of Paramedic, Denver Health Medical Center, Denver, Colorado
- Department of Emergency Medicine, University of Colorado School of Medicine, Aurora
- Department of Epidemiology, Colorado School of Public Health, Aurora
| | - Eric M. Campion
- Department of Surgery, Denver Health Medical Center, Denver, Colorado
- Department of Surgery, University of Colorado School of Medicine, Aurora
| | - Peter T. Pons
- Department of Emergency Medicine, Denver Health Medical Center, Denver, Colorado
- Division of Paramedic, Denver Health Medical Center, Denver, Colorado
- Department of Emergency Medicine, University of Colorado School of Medicine, Aurora
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21
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Moskowitz E, Campion EM, Burlew CC, Helmkamp LJ, Peltz ED, Gansar BL, McIntyre RC. Obstruction reduction: Use of water-soluble contrast challenge to differentiate between partial and complete small bowel obstruction. Am J Surg 2019; 218:913-917. [PMID: 30910130 DOI: 10.1016/j.amjsurg.2019.02.034] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/19/2018] [Revised: 01/23/2019] [Accepted: 02/13/2019] [Indexed: 10/27/2022]
Abstract
Differentiating SBO that will resolve conservatively from those requiring surgery remains challenging. Water-soluble contrast administration may be diagnostic and therapeutic. Our study evaluated use of a WSC challenge protocol. We hypothesize that protocol use discriminates between surgical SBO and obstructions which can be managed non-operatively. Demographics, prior surgeries, time to operation, complications, and LOS were analyzed. 108 patients were admitted with SBO. 13% underwent immediate laparotomy with concern for bowel compromise; these had a median LOS of 8.5 days. 91 received WSC protocol. Of these, 77% had contrast passage to the colon. Of the 48 in whom contrast passed between 0 and 12 h, LOS was 2 days. Of the 22 patients in whom contrast passed between 12 and 24 h, LOS was 4.5 days. 21 had failure of contrast passage; 18 of those underwent surgery after 24 h as a result. Of the 21 patients who failed WSC challenge, median LOS was 8 days. WSC protocol implementation facilitates early recognition of partial from complete obstruction and may decrease LOS. Our findings warrant further evaluation with a multicenter trial.
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Affiliation(s)
- Eliza Moskowitz
- Department of Surgery, University of Colorado School of Medicine, Aurora, CO, USA; Department of Surgery, Denver Health Medical Center, USA
| | - Eric M Campion
- Department of Surgery, University of Colorado School of Medicine, Aurora, CO, USA; Department of Surgery, Denver Health Medical Center, USA.
| | - Clay Cothren Burlew
- Department of Surgery, University of Colorado School of Medicine, Aurora, CO, USA; Department of Surgery, Denver Health Medical Center, USA
| | - Laura J Helmkamp
- Adult and Child Consortium for Health Outcomes Research and Delivery Science (ACCORDS), University of Colorado School of Medicine and Children's Hospital Colorado, USA
| | - Erik D Peltz
- Department of Surgery, University of Colorado School of Medicine, Aurora, CO, USA
| | - Brittany L Gansar
- Department of Surgery, University of Colorado School of Medicine, Aurora, CO, USA
| | - Robert C McIntyre
- Department of Surgery, University of Colorado School of Medicine, Aurora, CO, USA
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22
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Howard BM, Kornblith LZ, Christie SA, Conroy AS, Nelson MF, Campion EM, Callcut RA, Calfee CS, Lamere BJ, Fadrosh DW, Lynch S, Cohen MJ. Characterizing the gut microbiome in trauma: significant changes in microbial diversity occur early after severe injury. Trauma Surg Acute Care Open 2017; 2:e000108. [PMID: 29766103 PMCID: PMC5877916 DOI: 10.1136/tsaco-2017-000108] [Citation(s) in RCA: 58] [Impact Index Per Article: 8.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/03/2017] [Revised: 06/15/2017] [Accepted: 06/26/2017] [Indexed: 01/25/2023] Open
Abstract
Background Recent studies have demonstrated the vital influence of commensal microbial communities on human health. The central role of the gut in the response to injury is well described; however, no prior studies have used culture-independent profiling techniques to characterize the gut microbiome after severe trauma. We hypothesized that in critically injured patients, the gut microbiome would undergo significant compositional changes in the first 72 hours after injury. Methods Trauma stool samples were prospectively collected via digital rectal examination at the time of presentation (0 hour). Patients admitted to the intensive care unit (n=12) had additional stool samples collected at 24 hours and/or 72 hours. Uninjured patients served as controls (n=10). DNA was extracted from stool samples and 16S rRNA-targeted PCR amplification was performed; amplicons were sequenced and binned into operational taxonomic units (OTUs; 97% sequence similarity). Diversity was analyzed using principle coordinates analyses, and negative binomial regression was used to determine significantly enriched OTUs. Results Critically injured patients had a median Injury Severity Score of 27 and suffered polytrauma. At baseline (0 hour), there were no detectable differences in gut microbial community diversity between injured and uninjured patients. Injured patients developed changes in gut microbiome composition within 72 hours, characterized by significant alterations in phylogenetic composition and taxon relative abundance. Members of the bacterial orders Bacteroidales, Fusobacteriales and Verrucomicrobiales were depleted during 72 hours, whereas Clostridiales and Enterococcus members enriched significantly. Discussion In this initial study of the gut microbiome after trauma, we demonstrate that significant changes in phylogenetic composition and relative abundance occur in the first 72 hours after injury. This rapid change in intestinal microbiota represents a critical phenomenon that may influence outcomes after severe trauma. A better understanding of the nature of these postinjury changes may lead to the ability to intervene in otherwise pathological clinical trajectories. Level of evidence III Study type Prognostic/epidemiological
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Affiliation(s)
- Benjamin M Howard
- Department of Surgery, San Francisco General Hospital, University of California San Francisco, California, USA
| | - Lucy Z Kornblith
- Department of Surgery, San Francisco General Hospital, University of California San Francisco, California, USA
| | - Sabrinah A Christie
- Department of Surgery, San Francisco General Hospital, University of California San Francisco, California, USA
| | - Amanda S Conroy
- Department of Surgery, San Francisco General Hospital, University of California San Francisco, California, USA
| | - Mary F Nelson
- Department of Surgery, San Francisco General Hospital, University of California San Francisco, California, USA
| | - Eric M Campion
- Department of Surgery, Denver Health and Hospital Authority, University of Colorado, Denver, Colorado, USA
| | - Rachael A Callcut
- Department of Surgery, San Francisco General Hospital, University of California San Francisco, California, USA
| | - Carolyn S Calfee
- Division of Pulmonary and Critical Care Medicine, Departments of Medicine and Anesthesia, University of California San Francisco, California, USA
| | - Brandon J Lamere
- Division of Gastroenterology, Department of Medicine, University of California San Francisco, California, USA
| | - Douglas W Fadrosh
- Division of Gastroenterology, Department of Medicine, University of California San Francisco, California, USA
| | - Susan Lynch
- Division of Gastroenterology, Department of Medicine, University of California San Francisco, California, USA
| | - Mitchell Jay Cohen
- Department of Surgery, Denver Health and Hospital Authority, University of Colorado, Denver, Colorado, USA
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Campion EM, Croyle C, French AJ, Burlew CC, Lawless RA, Platnick BK, Cohen MJ, Fox CJ, Moore EE, Pieracci FM. Introduction of a Novel Rib Fracture Admission Protocol Decreases Time to Surgical Intensive Care Unit SICU Admission. J Am Coll Surg 2017. [DOI: 10.1016/j.jamcollsurg.2017.07.1021] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
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Pearcy C, Almahmoud K, Jackson T, Hartline C, Cahill A, Spence L, Kim D, Olatubosun O, Todd SR, Campion EM, Burlew CC, Regner J, Frazee R, Michaels D, Dissanaike S, Stewart C, Foley N, Nelson P, Agrawal V, Truitt MS. Risky business? Investigating outcomes of patients undergoing urgent laparoscopic appendectomy on antithrombotic therapy. Am J Surg 2017; 214:1012-1015. [PMID: 28982518 DOI: 10.1016/j.amjsurg.2017.08.035] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/20/2017] [Revised: 07/31/2017] [Accepted: 08/08/2017] [Indexed: 12/17/2022]
Abstract
INTRODUCTION The literature regarding outcomes in patients on irreversible antithrombotic therapy (IAT) undergoing urgent laparoscopic appendectomy is limited. The aim of this multicenter retrospective study was to examine the impact of prehospital IAT on outcomes in this population. METHODS From 2010 to 2014, seven institutions from the Southwest Surgical Multicenter Trials (SWSC MCT) group conducted a retrospective study to evaluate the clinical course of all patients on IAT who underwent urgent/emergent laparoscopic appendectomy. The IAT+ group was subdivided into IAT+ (Aspirin only) and IAT+ (Aspirin-Plavix). These groups were matched 1:1 to controls. The primary outcomes were estimated blood loss (EBL) and transfusion requirement. Secondary outcomes included infections (SSI - Surgical Site Infection, DSI - Deep Space Infection, and OSI - Organ Space Infection), hospital length of stay (HLOS), complications, 30-day readmissions, and mortality. RESULTS Out of the 2903 patients included in the study, 287 IAT+ patients were identified and matched in a 1:1 ratio to 287 IAT-patients. In the IAT+ vs IAT-analysis, no significant differences in EBL (p = 1.0), transfusion requirement during the preoperative (p = 0.5), intraoperative (p = 0.3) or postoperative periods (p = 0.5), infectious complications (SSI; p = 1.0, DSI; p = 1.0, and OSI; p = 0.1), overall complications (p = 0.3), HLOS (p = 0.7), 30-day readmission (p = 0.3), or mortality (p = 0.1) were noted. Similarly, outcomes in the IAT+ (Aspirin only) and IAT+ (Aspirin-Plavix) subgroups failed to demonstrate any significant differences when compared to controls. CONCLUSIONS Our analysis suggests that IAT is not associated with worse outcomes in urgent/emergent laparoscopic appendectomy. Prehospital use of IAT should not be used to delay laparoscopic appendectomy.
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Affiliation(s)
- Christopher Pearcy
- Department of Graduate Medical Education, Department of Surgery, Methodist Dallas Health System, Dallas, TX, USA
| | - Khalid Almahmoud
- Department of Graduate Medical Education, Department of Surgery, Methodist Dallas Health System, Dallas, TX, USA
| | - Theresa Jackson
- Department of Graduate Medical Education, Department of Surgery, Methodist Dallas Health System, Dallas, TX, USA
| | - Cassie Hartline
- Department of Graduate Medical Education, Department of Surgery, Methodist Dallas Health System, Dallas, TX, USA
| | - Anthony Cahill
- Department of Graduate Medical Education, Department of Surgery, Methodist Dallas Health System, Dallas, TX, USA
| | - Lara Spence
- Department of Graduate Medical Education, Department of Surgery, Harbor-UCLA Medical Center, Torrance, CA, USA
| | - Dennis Kim
- Department of Graduate Medical Education, Department of Surgery, Harbor-UCLA Medical Center, Torrance, CA, USA
| | - Oluwabukola Olatubosun
- Department of Graduate Medical Education, Department of Surgery, Baylor College of Medicine, Houston, TX, USA
| | - S Rob Todd
- Department of Graduate Medical Education, Department of Surgery, Baylor College of Medicine, Houston, TX, USA
| | - Eric M Campion
- Department of Graduate Medical Education, Department of Surgery, University of Colorado, Aurora, CO, USA
| | - Clay Cothren Burlew
- Department of Graduate Medical Education, Department of Surgery, University of Colorado, Aurora, CO, USA
| | - Justin Regner
- Department of Graduate Medical Education, Department of Surgery, Baylor Scott and White Health - Central Texas, Temple, TX, USA
| | - Richard Frazee
- Department of Graduate Medical Education, Department of Surgery, Baylor Scott and White Health - Central Texas, Temple, TX, USA
| | - David Michaels
- Department of Graduate Medical Education, Department of Surgery, Texas Tech Health Sciences Center, Lubbock, TX, USA
| | - Sharmila Dissanaike
- Department of Graduate Medical Education, Department of Surgery, Texas Tech Health Sciences Center, Lubbock, TX, USA
| | - Collin Stewart
- Department of Graduate Medical Education, Department of Surgery, University of Nevada - Mountain View Surgery Residency, Las Vegas, NV, USA
| | - Neal Foley
- Department of Graduate Medical Education, Department of Surgery, University of Nevada - Mountain View Surgery Residency, Las Vegas, NV, USA
| | - Paul Nelson
- Department of Graduate Medical Education, Department of Surgery, University of Nevada - Mountain View Surgery Residency, Las Vegas, NV, USA
| | - Vaidehi Agrawal
- Clinical Research Institution, Methodist Dallas Health System, Dallas, TX, USA
| | - Michael S Truitt
- Department of Graduate Medical Education, Department of Surgery, Methodist Dallas Health System, Dallas, TX, USA.
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Campion EM, Juillard C, Knudson MM, Dicker R, Cohen MJ, Mackersie R, Campbell AR, Callcut RA. Reconsidering the Resources Needed for Multiple Casualty Events: Lessons Learned From the Crash of Asiana Airlines Flight 214. JAMA Surg 2017; 151:512-7. [PMID: 26764565 DOI: 10.1001/jamasurg.2015.5107] [Citation(s) in RCA: 23] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022]
Abstract
IMPORTANCE To date, a substantial portion of multiple casualty incident literature has focused exclusively on prehospital and emergency department resources needed for optimal disaster response. Thus, inpatient resources required to care for individuals injured in multiple casualty events are not well described. OBJECTIVE To highlight the resources beyond initial emergency department triage needed for multiple casualty events, using one of the largest commercial aviation disasters in modern US history as a case study. DESIGN, SETTING, AND PARTICIPANTS Prospective case series of injured individuals treated at an urban level I trauma center following the crash of Asiana Airlines flight 214 on July 6, 2013. This analysis was conducted between June 1, 2014, and December 1, 2015. EXPOSURE Commercial jetliner crash. MAIN OUTCOMES AND MEASURES Medical records, imaging data, nursing overtime, blood bank records, and trauma registry data were analyzed. Disaster logs, patient injuries, and blood product data were prospectively collected during the incident. RESULTS Among 307 people aboard the flight, 192 were injured; 63 of the injured patients were initially evaluated at San Francisco General Hospital and Trauma Center (the highest number at any of the receiving medical facilities; age range, 4-74 years [23 were aged <17 years and 3 were aged >60 years]; median injury severity score of 19 admitted patients, 9 [range, 9-45]), including the highest number of critically injured patients (10 of 12). Despite the high impact of the crash, only 3 persons (<1%) died, including 1 in-hospital death. Among the 63 patients, 32 (50.8%) underwent a computed tomographic imaging study, with imaging of the abdomen and pelvis being the most common. Sixteen of the 32 patients undergoing computed tomography (50.0%) had a positive finding on at least 1 scan. Nineteen patients had major injuries and required admission, with 5 taken directly from the emergency department to the operating room. The most frequent injury was spinal fracture (13 patients). In the first 48 hours, 15 operations were performed and 117 total units of blood products were transfused. A total of 370 nursing overtime hours were required to treat the injured patients on the day of the event. CONCLUSIONS AND RELEVANCE Proper disaster preparedness requires attention to hospital-level needs beyond initial emergency department triage. The Asiana Airlines flight 214 crash highlights the need to plan for high use of advanced imaging, blood products, operating room availability, nursing resources, and management of inpatient hospital beds.
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Affiliation(s)
- Eric M Campion
- University of California, San Francisco, San Francisco General Hospital and Trauma Center, San Francisco
| | - Catherine Juillard
- University of California, San Francisco, San Francisco General Hospital and Trauma Center, San Francisco
| | - M Margaret Knudson
- University of California, San Francisco, San Francisco General Hospital and Trauma Center, San Francisco
| | - Rochelle Dicker
- University of California, San Francisco, San Francisco General Hospital and Trauma Center, San Francisco
| | - Mitchell J Cohen
- University of California, San Francisco, San Francisco General Hospital and Trauma Center, San Francisco
| | - Robert Mackersie
- University of California, San Francisco, San Francisco General Hospital and Trauma Center, San Francisco
| | - Andre R Campbell
- University of California, San Francisco, San Francisco General Hospital and Trauma Center, San Francisco
| | - Rachael A Callcut
- University of California, San Francisco, San Francisco General Hospital and Trauma Center, San Francisco
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Dunn RH, Jackson T, Burlew CC, Pieracci FM, Fox C, Cohen M, Campion EM, Lawless R, Mauffrey C. Fat emboli syndrome and the orthopaedic trauma surgeon: lessons learned and clinical recommendations. Int Orthop 2017; 41:1729-1734. [PMID: 28555248 DOI: 10.1007/s00264-017-3507-1] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 04/19/2017] [Accepted: 05/07/2017] [Indexed: 11/24/2022]
Abstract
PURPOSE Fat emboli syndrome is a rare but well-described complication of long-bone fractures classically characterised by a triad of respiratory failure, mental status changes and petechial rash. In this paper, we present the case of a patient who sustained bilateral femoral fractures and subsequently developed FES. Our aim was to review and summarise the current literature regarding the pathophysiology and management of fat emboli syndrome (FES) and propose an algorithm for treating patients with bilateral femoral fractures to reduce the risk of FES. METHODS A literature analysis was performed to determine implications in the clinical setting. RESULTS Currently, there exists little high-quality evidence to guide the orthopaedic surgeon in identifying patients at highest risk of FES or in preventing FES in patients with multiple long-bone fractures. However, the literature does suggest that the risk is directly related to the volume of marrow displaced and inversely related to both the time to fracture stabilisation and the respiratory reserve of the patient. Based on these correlations, we propose an algorithm for treating patients with bilateral femoral fractures, taking into consideration haemodynamic and pulmonary stability. CONCLUSIONS Our algorithm for managing bilateral femoral fractures prioritises early stabilisation with external fixation, staged intramedullary nailing and conversion to plate fixation if FES develops. This protocol is meant to be the basis of future investigations of optimal treatment strategies.
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Affiliation(s)
- Robin Hall Dunn
- Department of Orthopedics, University of Colorado School of Medicine, 12631 E. 17th Avenue, Mail Stop B202, Aurora, CO, 80045, USA
| | - Trevor Jackson
- Department of Orthopedics, University of Colorado School of Medicine, 12631 E. 17th Avenue, Mail Stop B202, Aurora, CO, 80045, USA
| | - Clay Cothren Burlew
- Department of surgery, Denver Health Medical Center, 777 Bannock Street, Denver, CO, 80204, USA
| | - Fredric M Pieracci
- Department of surgery, Denver Health Medical Center, 777 Bannock Street, Denver, CO, 80204, USA
| | - Charles Fox
- Department of surgery, Denver Health Medical Center, 777 Bannock Street, Denver, CO, 80204, USA
| | - Mitchell Cohen
- Department of surgery, Denver Health Medical Center, 777 Bannock Street, Denver, CO, 80204, USA
| | - Eric M Campion
- Department of surgery, Denver Health Medical Center, 777 Bannock Street, Denver, CO, 80204, USA
| | - Ryan Lawless
- Department of surgery, Denver Health Medical Center, 777 Bannock Street, Denver, CO, 80204, USA
| | - Cyril Mauffrey
- Department of Orthopaedic Surgery, Denver Health Medical Center, 777 Bannock Street, Denver, CO, 80204, USA.
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Geddes AE, Burlew CC, Wagenaar AE, Biffl WL, Johnson JL, Pieracci FM, Campion EM, Moore EE. Expanded screening criteria for blunt cerebrovascular injury: a bigger impact than anticipated. Am J Surg 2016; 212:1167-1174. [PMID: 27751528 DOI: 10.1016/j.amjsurg.2016.09.016] [Citation(s) in RCA: 87] [Impact Index Per Article: 10.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/19/2016] [Revised: 09/02/2016] [Accepted: 09/02/2016] [Indexed: 11/17/2022]
Abstract
BACKGROUND We implemented expanded screening criteria for blunt cerebrovascular injuries (BCVIs) in an attempt to capture the remaining 20% of patients not historically identified with earlier protocols. We hypothesized that these expanded criteria would capture the additional 20% of BCVI patients not previously identified. METHODS Screening criteria for BCVI were expanded in 2011 after identifying new injury patterns. The study population included 4 years prior (2007 to 2010; classic) and following (2011 to 2014; expanded) implementation of expanded criteria. RESULTS BCVIs were identified in 386 patients: 150 during the classic period (2.36% incidence) and 236 in the expanded period (2.99% incidence). In the expanded period, 155 patients were imaged based on classic screening criteria, 62 on expanded criteria (21 complex skull fractures, 20 upper rib fractures, 6 mandible fractures, 2 scalp degloving, 1 great vessel injury, and 12 combination), and 19 for other injuries and symptoms. CONCLUSIONS There was a significant increase in the identification of BCVI following the adoption of expanded screening criteria, resulting in a substantial reduction of missed injuries. Expanded criteria should be adopted when screening for BCVI.
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Affiliation(s)
- Andrea E Geddes
- Department of Surgery, Denver Health Medical Center, University of Colorado, School of Medicine, 777 Bannock Street, Denver, CO 80204, USA
| | - Clay Cothren Burlew
- Department of Surgery, Denver Health Medical Center, University of Colorado, School of Medicine, 777 Bannock Street, Denver, CO 80204, USA.
| | - Amy E Wagenaar
- Department of Surgery, Denver Health Medical Center, University of Colorado, School of Medicine, 777 Bannock Street, Denver, CO 80204, USA
| | - Walter L Biffl
- Department of Surgery, Denver Health Medical Center, University of Colorado, School of Medicine, 777 Bannock Street, Denver, CO 80204, USA
| | - Jeffrey L Johnson
- Department of Surgery, Denver Health Medical Center, University of Colorado, School of Medicine, 777 Bannock Street, Denver, CO 80204, USA
| | - Fredric M Pieracci
- Department of Surgery, Denver Health Medical Center, University of Colorado, School of Medicine, 777 Bannock Street, Denver, CO 80204, USA
| | - Eric M Campion
- Department of Surgery, Denver Health Medical Center, University of Colorado, School of Medicine, 777 Bannock Street, Denver, CO 80204, USA
| | - Ernest E Moore
- Department of Surgery, Denver Health Medical Center, University of Colorado, School of Medicine, 777 Bannock Street, Denver, CO 80204, USA
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Callcut RA, Wakam G, Conroy AS, Kornblith LZ, Howard BM, Campion EM, Nelson MF, Mell MW, Cohen MJ. Discovering the truth about life after discharge: Long-term trauma-related mortality. J Trauma Acute Care Surg 2016; 80:210-7. [PMID: 26606176 PMCID: PMC4731245 DOI: 10.1097/ta.0000000000000930] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
Abstract
BACKGROUND Outcome after traumatic injury has typically been limited to the determination at time of discharge or brief follow-up. This study investigates the natural history of long-term survival after trauma. METHODS All highest-level activation patients prospectively enrolled in an ongoing cohort study from 2005 to 2012 were selected. To allow for long-term follow-up, patients had to be enrolled at least 1 year before the latest available data from the National Death Index (NDI, 2013). Time and cause of mortality was determined based on death certificates. Survival status was determined by the latest date of either care in our institution or NDI query. Kaplan-Meier curves were created stratified for Injury Severity Score (ISS). Survival was compared with estimated actuarial survival based on age, sex, and race. RESULTS A total of 908 highest-level activation patients (median ISS, 18) were followed up for a median 1.7 years (interquartile range 1.0-2.9; maximum, 9.8 years). Survival data were available on 99.8%. Overall survival was 73% (663 of 908). For those with at least 2-year follow-up, survival was only 62% (317 of 509). Severity of injury predicted long-term survival (p < 0.0001) with those having ISS of 25 or greater with the poorest outcome (57% survival at 5 years). For all ISS groups, survival was worse than predicted actuarial survival (p < 0.001). When excluding early deaths (≤30 days), observed survival was still significantly lower than estimated actuarial survival (p < 0.002). Eighteen percent (44 of 245 deaths) of all deaths occurred after 30 days. Among late deaths, 53% occurred between 31 days and 1 year after trauma. Trauma-related mortality was the leading cause of postdischarge death, accounting for 43% of the late deaths. CONCLUSION Postdischarge deaths represent a significant percentage of total trauma-related mortality. Despite having "survived" to leave the hospital, long-term survival was worse than predicted actuarial survival, suggesting that the mortality from injury does not end at "successful" hospital discharge. LEVEL OF EVIDENCE Prognostic study, level III.
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Affiliation(s)
- Rachael A. Callcut
- Department of Surgery, San Francisco General Hospital, University of California, San Francisco
| | - Glenn Wakam
- Department of Surgery, San Francisco General Hospital, University of California, San Francisco
| | - Amanda S. Conroy
- Department of Surgery, San Francisco General Hospital, University of California, San Francisco
| | - Lucy Z. Kornblith
- Department of Surgery, San Francisco General Hospital, University of California, San Francisco
| | - Benjamin M. Howard
- Department of Surgery, San Francisco General Hospital, University of California, San Francisco
| | - Eric M. Campion
- Department of Surgery, Denver Health Medical Center and the University of Colorado School of Medicine, Denver, CO
| | - Mary F. Nelson
- Department of Surgery, San Francisco General Hospital, University of California, San Francisco
| | - Matthew W. Mell
- Department of Surgery, Stanford University, Stanford, California
| | - Mitchell J. Cohen
- Department of Surgery, San Francisco General Hospital, University of California, San Francisco
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Campion EM, Pritts TA, Dorlac WC, Nguyen AQ, Fraley SM, Hanseman D, Robinson BRH. Implementation of a military-derived damage-control resuscitation strategy in a civilian trauma center decreases acute hypoxia in massively transfused patients. J Trauma Acute Care Surg 2013; 75:S221-7. [PMID: 23883912 DOI: 10.1097/ta.0b013e318299d59b] [Citation(s) in RCA: 21] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/22/2023]
Abstract
BACKGROUND Recent military experience supports a paradigm shift in shock resuscitation to damage-control resuscitation (DCR), which emphasizes a plasma-rich and crystalloid-poor approach to resuscitation. The effect of DCR on hypoxia after massive transfusion is unknown. We hypothesized that implementation of a military-derived DCR strategy in a civilian setting would lead to decreased acute hypoxia. METHODS A DCR strategy was implemented in 2007. We retrospectively reviewed patients receiving trauma surgeon operative intervention and 10 or more units of packed red blood cells (pRBCs) within 24 hours of injury at an adult Level I trauma center from 2001 to 2010. Demographic data, blood requirements, and PaO₂/FIO₂ ratios were analyzed. To evaluate evolving resuscitation strategies, we fit linear trend models to continuous variables and tested their slopes for statistical significance. RESULTS Two hundred sixteen patients met the study criteria, with a mean age of 35 ± 1.1 years and Injury Severity Score (ISS) of 31 ± 9.0. Of the patients, 80% were male, and 52% sustained penetrating injuries. Overall mortality was 32%. Overall mean pRBC and fresh frozen plasma (FFP) units infused in 24 hours were 23.2 ± 1.1 and 18.6 ± 1.1, respectively. Trends for patient age, sex, mechanism of injury, ISS, highest positive end-expiratory pressure, and mean total pRBC transfused over 24 hours were not statistically different from zero. An increasing trend in FFP and platelets transfused during the first 24 hours (p < 0.0001, p = 0.04, respectively) and a decrease in the pRBC/FFP ratio (p < 0.0001) were found. The amount of crystalloid infused during the initial 24 hours decreased with time (p < 0.0001). The lowest PaO₂/FIO₂ ratio recorded during the initial 24 hours increased during the study period (p = 0.01), indicating a statistically significant reduction in hypoxia. CONCLUSION A military-derived DCR strategy can be implemented in the civilian setting. DCR led to significant increases in FFP transfusion, decreases in crystalloid use, and acute hypoxia.
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Affiliation(s)
- Eric M Campion
- Institute for Military Medicine, Department of Surgery, University of Cincinnati, Cincinnati, Ohio, USA
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Goodman MD, Makley AT, Campion EM, Friend LAW, Lentsch AB, Pritts TA. Preinjury alcohol exposure attenuates the neuroinflammatory response to traumatic brain injury. J Surg Res 2013; 184:1053-8. [PMID: 23721933 DOI: 10.1016/j.jss.2013.04.058] [Citation(s) in RCA: 40] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/15/2013] [Revised: 04/13/2013] [Accepted: 04/24/2013] [Indexed: 10/26/2022]
Abstract
BACKGROUND Traumatic brain injury (TBI) initiates a neuroinflammatory response that increases the risk of TBI-related mortality. Acute alcohol intoxication at the time of TBI is associated with improved survival. Ethanol is recognized as a systemic immunomodulator that may also impart neuroprotection. The effects of alcohol on TBI-induced neuroinflammation, however, are unknown. We hypothesized that ethanol treatment prior to TBI may provide neuroprotection by diminishing the neuroinflammatory response to injury. MATERIALS AND METHODS Mice underwent gavage with ethanol (EtOH) or water (H2O) prior to TBI. Animals were subjected to blunt TBI or sham injury (Sham). Posttraumatic rapid righting reflex (RRR) and apnea times were assessed. Cerebral and serum samples were analyzed by ELISA for inflammatory cytokine levels. Serum neuron-specific enolase (NSE), a biomarker of injury severity, was also measured. RESULTS Neurologic recovery from TBI was more rapid in H2O-treated mice compared with EtOH-treated mice. However, EtOH/TBI mice had a 4-fold increase in RRR time compared with EtOH/Sham, whereas H2O/TBI mice had a 15-fold increase in RRR time compared with H2O/Sham. Ethanol intoxication at the time of TBI significantly increased posttraumatic apnea time. Preinjury EtOH treatment was associated with reduced levels of proinflammatory cytokines IL-6, KC, MCP-1, and MIP-1α post TBI. NSE was significantly increased post injury in the H2O/TBI group compared with H2O/Sham but was not significantly reduced by EtOH pretreatment. CONCLUSIONS Alcohol treatment prior to TBI reduces the local neuroinflammatory response to injury. The decreased neurologic and inflammatory impact of TBI in acutely intoxicated patients may be responsible for improved clinical outcomes.
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Affiliation(s)
- Michael D Goodman
- Department of Surgery, Institute for Military Medicine, University of Cincinnati College of Medicine, Cincinnati, Ohio.
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Makley AT, Belizaire R, Campion EM, Goodman MD, Sonnier DI, Friend LA, Schuster RM, Bailey SR, Johannigman JA, Dorlac WC, Lentsch AB, Pritts TA. Simulated aeromedical evacuation does not affect systemic inflammation or organ injury in a murine model of hemorrhagic shock. Mil Med 2012; 177:911-6. [PMID: 22934369 DOI: 10.7205/milmed-d-11-00385] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022] Open
Abstract
Hemorrhagic shock is a primary injury amongst combat casualties. Aeromedical evacuation (AE) of casualties exposes patients to a hypobaric, hypoxic environment. The effect of this environment on the host response to hemorrhagic shock is unknown. In the present study, we sought to determine the effect of simulated AE on systemic inflammation and organ injury using a murine model of hemorrhagic shock. Mice underwent femoral artery cannulation and were hemorrhaged for 60 minutes. Mice were then resuscitated with a 1:1 ratio of plasma:packed red blood cells. At 1 or 24 hours after resuscitation, mice were exposed to a 5-hour simulated AE or remained at ground level (control). Serum was analyzed for cytokine concentrations and organs were assessed for neutrophil accumulation and vascular permeability. Mice in the simulated AE groups demonstrated reduced arterial oxygen saturation compared to ground controls. Serum cytokine concentrations, neutrophil recruitment, and vascular permeability in the lung, ileum, and colon in the simulated AE groups were not different from the ground controls. Our results demonstrate that mice exposed to simulated AE following hemorrhagic shock do not exhibit worsened systemic inflammation or organ injury compared to controls. The data suggest that AE has no adverse effect on isolated hemorrhagic shock.
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Affiliation(s)
- Amy T Makley
- Department of Surgery, Institute for Military Medicine, University of Cincinnati, 231 Albert Sabin Way, Mail Location 0558, Cincinnati, OH 45267-0558, USA
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Campion EM, Goodman MD, Makley AT, Lentsch AB, Pritts TA. Treatment with ethanol after traumatic brain injury decreases cerebral MIP-1alpha and serum neuron specific enolase in mice. J Am Coll Surg 2010. [DOI: 10.1016/j.jamcollsurg.2010.06.132] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/19/2022]
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Arbabi S, Campion EM, Hemmila MR, Barker M, Dimo M, Ahrns KS, Niederbichler AD, Ipaktchi K, Wahl WL. Beta-Blocker Use is Associated With Improved Outcomes in Adult Trauma Patients. ACTA ACUST UNITED AC 2007; 62:56-61; discussion 61-2. [PMID: 17215733 DOI: 10.1097/ta.0b013e31802d972b] [Citation(s) in RCA: 93] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
BACKGROUND Beta-adrenoreceptor blocker (beta-blocker) therapy may improve outcomes in surgical patients by decreasing cardiac oxygen consumption and hypermetabolism. Because beta-blockers can lower the systemic blood pressure and cerebral perfusion pressure, there is concern regarding their use in patients with head injury. However, beta-blockers may protect beta-receptor rich brain cells by attenuating cerebral oxygen consumption and metabolism. We hypothesized that beta-blockers are safe in trauma patients, even if they have suffered a significant head injury. METHODS Using pharmacy and trauma registry data of a Level I trauma center, we identified a cohort of trauma patients who received beta-blockers during their hospital stay (beta-cohort). Trauma admissions who did not receive beta-blockers were in the control cohort. beta-blocker status, in combination with other variables associated with mortality, were placed in a stepwise multivariate logistic regression to identify independent predictors of fatal outcome. RESULTS In all, 303 (7%) of 4,117 trauma patients received beta-blockers. In the beta-cohort, 45% of patients were on beta-blockers preinjury. The most common reason to initiate beta-blocker therapy was blood pressure (60%) and heart rate (20%) control. The overall mortality rate was 5.6% and head injury was considered to be the major cause of death. After adjusting for age, Injury Severity Scale score, blood pressure, Glasgow Coma Scale score, respiratory status, and mechanism of injury, the odds ratio for fatal outcome was 0.3 (p < 0.001) for beta-cohort as compared with control. Decreased risk of fatal outcome was more pronounced in patients with a significant head injury. CONCLUSIONS beta-blocker therapy is safe and may be beneficial in selected trauma patients with or without head injury. Further studies looking at beta-blocker therapy in trauma patients and their effect on cerebral metabolism are warranted.
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Affiliation(s)
- Saman Arbabi
- Harborview Medical Center, University of Washington, Seattle, WA 98104, USA.
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