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Radding S, Harfouche MN, Dhillon NK, Ko A, Hawley KL, Kundi R, Maddox JS, Radowsky JS, DuBose JJ, Feliciano DV, Kozar RA, Scalea TM. A pseudo-dilemma: Are we over-diagnosing and over-treating traumatic splenic intraparenchymal pseudoaneurysms? J Trauma Acute Care Surg 2024; 96:313-318. [PMID: 37599423 DOI: 10.1097/ta.0000000000004117] [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: 08/22/2023]
Abstract
BACKGROUND Splenic embolization for traumatic vascular abnormalities in stable patients is a common practice. We hypothesize that modern contrast-enhanced computed tomography (CT) over diagnoses posttraumatic splenic vascular lesions, such as intraparenchymal pseudoaneurysms (PSA) that may not require embolization. METHODS We reviewed the experience at our high-volume center with endovascular management of blunt splenic injuries from January 2016 to December 2021. Multidisciplinary review was used to compared initial CT findings with subsequent angiography, analyzing management and outcomes of identified vascular lesions. RESULTS Of 853 splenic injuries managed overall during the study period, 255 (29.9%) underwent angiography of the spleen at any point during hospitalization. Vascular lesions were identified on 58% of initial CTs; extravasation (12.2%) and PSA (51.0%). Angiography was performed a mean of 22 hours after admission, with 38% done within 6 hours. Embolization was performed for 90.5% (231) of patients. Among the 130 patients with PSA on initial CT, 36 (27.7%) had no visible lesion on subsequent angiogram. From the 125 individuals who did not have a PSA identified on their initial CT, 67 (54%) had a PSA seen on subsequent angiography. On postembolization CT at 48 hours to 72 hours, persistently perfused splenic PSAs were seen in 41.0% (48/117) of those with and 22.2% (2/9) without embolization. Only one of 24 (4.1%) patients with PSA on angiography observed without embolization required delayed splenectomy, whereas 6.9% (16/231) in the embolized group had splenectomy at a mean of 5.5 ± 4 days after admission. CONCLUSION There is a high rate of discordance between CT and angiographic identification of splenic PSAs. Even when identified at angiogram and embolized, close to half will remain perfused on follow-up imaging. These findings question the use of routine angioembolization for all splenic PSAs. LEVEL OF EVIDENCE Therapeutic/Care Management; Level IV.
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Affiliation(s)
- Sydney Radding
- From the Department of Surgery (S.R.), Virginia Commonwealth University, Richmond, VA; R Adams Cowley Shock Trauma Center (M.N.H., N.K.D., K.L.H., R.K., J.S.M., J.S.R., D.V.F., R.A.K., T.M.S.), University of Maryland Medical System, Baltimore, Maryland; Department of Surgery (A.K.), Stanford University, Stanford, California; and Department of Surgery (J.J.DB.), University of Texas at Austin, Austin, Texas
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2
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Angus AA, July LN, McCarthy PM, Shepard ND, Rall JM, Radowsky JS. Testing and Evaluation of a Novel Hemostatic Matrix in a Swine Junctional Hemorrhage Model. J Surg Res 2023; 291:452-458. [PMID: 37523895 DOI: 10.1016/j.jss.2023.06.040] [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: 03/02/2023] [Revised: 06/07/2023] [Accepted: 06/25/2023] [Indexed: 08/02/2023]
Abstract
INTRODUCTION In an ongoing effort to improve survival and reduce blood loss from hemorrhagic injuries on the battlefield, new hemostatic dressings continue to be developed. This study aimed to determine the efficacy of a novel silicon dioxide-based hemostatic matrix (HM) and compare it with the current military standard Quikclot Combat Gauze (QCG) utilizing a lethal femoral artery injury model. MATERIALS AND METHODS The femoral arteries of 20 anesthetized swine were isolated, and an arteriotomy was performed. After a 45 s free bleed, the wound was treated with either HM or QCG (n = 10 per group). Following a 60-min observation period, ipsilateral leg manipulations and angiography were performed. Animal survival, hemostasis, blood loss, exothermic reaction, and femoral artery patency were analyzed. RESULTS Despite a volumetric size discrepancy between the two products tested, the survival rate was similar between the two groups (80% HM, 90% QCG, n = 10, P = 0.588). Immediate hemostasis was obtained in 50% of HM animals and 40% of QCG animals. There was no difference in total blood loss recorded between the two groups (P = 0.472). Femoral artery patency rates following ipsilateral leg manipulations were similar between the two groups (50% HM, 33% QCG, P = 0.637), with no contrast extravasation in HM-treated wounds (0% HM, 33% QCG, P = 0.206). There was no significant difference in either pretreatment or posttreatment laboratory values, and there were no exothermic reactions in either group. CONCLUSIONS The SiOxMed HM demonstrated comparable hemostatic efficacy to QCG. The tested form of HM may be appropriate for surgical or topical hemostasis applications, and with further product development, it could be used for battlefield trauma implementation.
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Affiliation(s)
- Andrew A Angus
- Department of Surgery, Brooke Army Medical Center, JBSA-Fort Sam Houston, Texas
| | - Lindsey N July
- Department of Surgery, Brooke Army Medical Center, JBSA-Fort Sam Houston, Texas; DHA Joint Trauma System, JBSA-Fort Sam Houston, Texas
| | - Patrick M McCarthy
- Department of Surgery, Brooke Army Medical Center, JBSA-Fort Sam Houston, Texas
| | - Nola D Shepard
- Office of the Chief Scientist, 59th Medical Wing, JBSA-Lackland, Texas
| | - Jason M Rall
- Office of the Chief Scientist, 59th Medical Wing, JBSA-Lackland, Texas
| | - Jason S Radowsky
- Department of Surgery, Brooke Army Medical Center, JBSA-Fort Sam Houston, Texas; Division of General Surgery, Walter Reed National Military Medical Center, Bethesda, Maryland.
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Keller BA, Skubic J, Betancourt-Garcia M, Ignacio RC, Radowsky JS, Tyroch AH, Lascano CP, Joseph B, Stewart C, Moore FO, Costantini TW, Rizzo JA, Paul JS, Galindo RM, Silva A, Coimbra R, Berndtson AE. Understanding the burden of traumatic injuries at the United States-Mexico border: A scoping review of the literature. J Trauma Acute Care Surg 2023; 95:276-284. [PMID: 36872517 DOI: 10.1097/ta.0000000000003920] [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: 03/07/2023]
Abstract
ABSTRACT The US-Mexico border is the busiest land crossing in the world and faces continuously increasing numbers of undocumented border crossers. Significant barriers to crossing are present in many regions of the border, including walls, bridges, rivers, canals, and the desert, each with unique features that can cause traumatic injury. The number of patients injured attempting to cross the border is also increasing, but significant knowledge gaps regarding these injuries and their impacts remain. The purpose of this scoping literature review is to describe the current state of trauma related to the US-Mexico border to draw attention to the problem, identify knowledge gaps in the existing literature, and introduce the creation of a consortium made up of representatives from border trauma centers in the Southwestern United States, the Border Region Doing Research on Trauma Consortium. Consortium members will collaborate to produce multicenter up-to-date data on the medical impact of the US-Mexico border, helping to elucidate the true magnitude of the problem and shed light on the impact cross-border trauma has on migrants, their families, and the US health care system. Only once the problem is fully described can meaningful solutions be provided.
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Affiliation(s)
- Benjamin A Keller
- From the Department of Surgery (B.A.K., R.C.I.), Division of Pediatric Surgery, Rady Children's Hospital, San Diego, California; Department of Surgery (J.S., A.S.), University of Texas Rio Grande Valley, Edinburg, Texas; Department of Trauma (J.S., M.B.-G.), DHR Health, Edinburg, Texas; Department of Trauma and Acute Care Surgery (J.S.R., J.A.R.), Brooke Army Medical Center, JBSA Fort Sam Houston, San Antonio, Texas; Department of Surgery (A.H.T.), Texas Tech University Health Sciences Center, El Paso, Texas; Department of Surgery (C.P.L.), South Texas Health System, McAllen, Texas; Department of Surgery (B.J., C.S.), University of Arizona-Tucson, Tucson, Arizona; Department of Surgery (F.O.M.), John Peter Smith Health, Fort Worth, Texas; Department of Surgery (T.W.C., A.E.B.), Division of Trauma, Surgical Critical Care, Burns, and Acute Care Surgery, University of California San Diego, San Diego, California; Department of Surgery (J.S.P.), Division of Acute Care Surgery, University of New Mexico, Albuquerque, New Mexico; Department of Surgery (R.M.G.), University of Texas Rio Grande Valley, Harlingen, Texas; and Department of Surgery (R.C.), Riverside University Health System Medical Center, Loma Linda University, Loma Linda, California
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4
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Kenney CL, Nelson AR, Fahey RA, Roubik DJ, How RA, Radowsky JS, Sams VG, Schauer SG, Rizzo JA. EFFECTS OF SARS COVID-19 POSITIVITY STATUS ON VENOUS THROMBOSIS AND PULMONARY EMBOLISM RATES IN TRAUMA PATIENTS. Shock 2023; 59:599-602. [PMID: 36809212 DOI: 10.1097/shk.0000000000002097] [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: 02/23/2023]
Abstract
ABSTRACT Introduction : COVID-19-induced coagulopathy (CIC) can increase the risk of thromboembolism without underlying clotting disorders, even when compared with other respiratory viruses. Trauma has a known association with hypercoagulability. Trauma patients with concurrent COVID-19 infection potentially have an even greater risk of thrombotic events. The purpose of this study was to evaluate venous thromboembolism (VTE) rates in trauma patients with COVID-19. Methods : This study reviewed all adult patients (≥18 years of age) admitted to the Trauma Service from April through November 2020 for a minimum of 48 hours. Patients were grouped based off COVID-19 status and compared for inpatient VTE chemoprophylaxis regimen, thrombotic complications defined as deep vein thrombosis, pulmonary embolism, myocardial infarction, and cerebrovascular accident, intensive care unit (ICU) length of stay, hospital length of stay, and mortality. Results : A total of 2,907 patients were reviewed and grouped into COVID-19-positive (n = 110) and COVID-19-negative (n = 2,797) groups. There was no difference in terms of receiving deep vein thrombosis chemoprophylaxis or type, but a longer time to initiation in the positive group ( P = 0.0012). VTE occurred in 5 (4.55%) positive and 60 (2.15%) negative patients without a significant difference between the groups, as well as no difference in type of VTE observed. Mortality was higher ( P = 0.009) in the positive group (10.91%). Positive patients had longer median ICU LOS ( P = 0.0012) and total LOS ( P < 0.001). Conclusion : There were no increased rates of VTE complications between COVID-19-positive and -negative trauma patients, despite a longer time to initiation of chemoprophylaxis in the COVID-19-positive group. COVID-19-positive patients had increased ICU LOS, total LOS, and mortality, which are likely due to multifactorial causes but primarily related to their underlying COVID-19 infection.
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Affiliation(s)
| | - Austin R Nelson
- Uniformed Services University of Health Sciences, Bethesda, Maryland
| | - Ryan A Fahey
- Brooke Army Medical Center, Fort Sam Houston, Texas
| | | | | | - Jason S Radowsky
- Uniformed Services University of Health Sciences, Bethesda, Maryland
| | | | | | - Julie A Rizzo
- Uniformed Services University of Health Sciences, Bethesda, Maryland
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5
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Schweickhardt SK, Sams VG, Radowsky JS, Sobieszczyk MJ, Marcus JE, Sobieszczyk MJ, Medicine P&CC, Marcus JE, Disease I. Infections complicating extracorporeal membrane oxygenation in patients with traumatic injuries. Injury 2023; 54:405-408. [PMID: 36450617 DOI: 10.1016/j.injury.2022.11.048] [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] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/09/2022] [Revised: 11/19/2022] [Accepted: 11/21/2022] [Indexed: 11/25/2022]
Abstract
INTRODUCTION Extracorporeal Membrane Oxygenation (ECMO) has increasing utility in adult patients with traumatic injuries. There is currently limited data on the pathogens complicating a trauma patient's ECMO course, making empiric antibiotic decisions difficult. This study aims to characterize the types of infection among patients with traumatic injuries on ECMO. METHODS A chart review was performed on all trauma patients at Brooke Army Medical Center receiving ECMO between February 2013 and July 2021. Charts were reviewed to identify pathogens by culture site as well as time to infection following cannulation. RESULTS Twenty-one trauma patients underwent ECMO during the study period. The majority of patients were men (90%) with a median age of 30 [IQR 27-38], and a median ECMO course of 9.8 days [IQR 3.9-14.1]. Motor vehicle crashes (81%) accounted for the majority of mechanisms of injury. Of the 24 infections, the majority were respiratory (n = 13, 58/1000 ECMO days) followed by skin and soft tissue (n = 6, 26/1000 ECMO days), blood stream (n = 4, 18/1000 ECMO days), and urinary tract (n = 1, 5/1000 ECMO days). Gram-negative bacteria were the most commonly isolated organism from all sites and at all time periods following cannulation. Multi-drug resistant organisms accounted for 35% (n = 9) of infections and were independent of time from cannulation. DISCUSSION/CONCLUSION This is the first study to describe infections in trauma patients requiring ECMO support. We observed majority Gram-negative infections regardless of culture site or time after cannulation. Thus, with infection in this population, empiric antibiotics should have broad spectrum coverage of Gram-negative organisms.
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Affiliation(s)
- Samantha K Schweickhardt
- Uniformed Services University of the Health Sciences, 4301 Jones Bridge Road, Bethesda, MD 20814, United States
| | - Valerie G Sams
- Uniformed Services University of the Health Sciences, 4301 Jones Bridge Road, Bethesda, MD 20814, United States; Department of Surgery, Brooke Army Medical Center, 3551 Roger Brooke Drive, JBSA Ft. Sam Houston, San Antonio, TX 78234, United States
| | - Jason S Radowsky
- Uniformed Services University of the Health Sciences, 4301 Jones Bridge Road, Bethesda, MD 20814, United States; Department of Surgery, Brooke Army Medical Center, 3551 Roger Brooke Drive, JBSA Ft. Sam Houston, San Antonio, TX 78234, United States
| | - Michal J Sobieszczyk
- Uniformed Services University of the Health Sciences, 4301 Jones Bridge Road, Bethesda, MD 20814, United States; Department of Medicine, Brooke Army Medical Center, 3551 Roger Brooke Drive, JBSA Ft. Sam Houston, San Antonio, TX 78234, United States
| | - Joseph E Marcus
- Uniformed Services University of the Health Sciences, 4301 Jones Bridge Road, Bethesda, MD 20814, United States; Department of Medicine, Brooke Army Medical Center, 3551 Roger Brooke Drive, JBSA Ft. Sam Houston, San Antonio, TX 78234, United States.
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Braverman MA, Smith AA, Ciaraglia AV, Radowsky JS, Schauer SG, Sams VG, Greebon LJ, Shiels MD, Jonas RB, Ngamsuntikul S, Waltman E, Epley E, Rose T, Bynum JA, Cap AP, Eastridge BJ, Stewart RM, Jenkins DH, Nicholson SE. The regional whole blood program in San Antonio, TX: A 3-year update on prehospital and in-hospital transfusion practices for traumatic and non-traumatic hemorrhage. Transfusion 2022; 62 Suppl 1:S80-S89. [PMID: 35748675 DOI: 10.1111/trf.16964] [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] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/06/2022] [Revised: 05/16/2022] [Accepted: 05/17/2022] [Indexed: 11/30/2022]
Abstract
Low titer type O Rh-D + whole blood (LTO + WB) has become a first-line resuscitation medium for hemorrhagic shock in many centers around the World. Showing early effectiveness on the battlefield, LTO + WB is used in both the pre-hospital and in-hospital settings for traumatic and non-traumatic hemorrhage resuscitation. Starting in 2018, the San Antonio Whole Blood Collaborative has worked to provide LTO + WB across Southwest Texas, initially in the form of remote damage control resuscitation followed by in-hospital trauma resuscitation. This program has since expanded to include pediatric trauma resuscitation, obstetric hemorrhage, females of childbearing potential, and non-traumatic hemorrhage. The objective of this manuscript is to provide a three-year update on the successes and expansion of this system and outline resuscitation challenges in special populations.
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Affiliation(s)
| | - Allison A Smith
- Department of Surgery, UT Health San Antonio, San Antonio, Texas, USA
| | | | - Jason S Radowsky
- Department of Trauma and Acute Care Surgery, Brooke Army Medical Center, JBSA Fort Sam Houston, San Antonio, Texas, USA
| | - Steven G Schauer
- Department of Emergency Medicine, Brooke Army Medical Center, JBSA Fort Sam Houston, San Antonio, Texas, USA.,United States Army Institute of Surgical Research, JBSA Fort Sam Houston, San Antonio, Texas, USA
| | - Valerie G Sams
- Department of Trauma and Acute Care Surgery, Brooke Army Medical Center, JBSA Fort Sam Houston, San Antonio, Texas, USA
| | - Leslie J Greebon
- Department of Pathology, UT Health San Antonio, San Antonio, Texas, USA
| | | | | | | | | | - Eric Epley
- Southwest Texas Regional Advisory Council, San Antonio, Texas, USA
| | - Tracee Rose
- Southwest Texas Regional Advisory Council, San Antonio, Texas, USA
| | - James A Bynum
- United States Army Institute of Surgical Research, JBSA Fort Sam Houston, San Antonio, Texas, USA
| | - Andre P Cap
- United States Army Institute of Surgical Research, JBSA Fort Sam Houston, San Antonio, Texas, USA
| | - Brian J Eastridge
- Department of Surgery, UT Health San Antonio, San Antonio, Texas, USA
| | - Ronald M Stewart
- Department of Surgery, UT Health San Antonio, San Antonio, Texas, USA
| | - Donald H Jenkins
- Department of Surgery, UT Health San Antonio, San Antonio, Texas, USA
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7
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Kemp Bohan PM, McCarthy PM, Wall ME, Adams AM, Chick RC, Forcum JE, Radowsky JS, How RA, Sams VG. Safety and efficacy of low-titer O whole blood resuscitation in a civilian level I trauma center. J Trauma Acute Care Surg 2021; 91:S162-S168. [PMID: 34039931 DOI: 10.1097/ta.0000000000003289] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [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: 02/01/2023]
Abstract
BACKGROUND Military experience has shown low-titer O whole blood (LTOWB) to be safe and beneficial in the resuscitation of hemorrhaging trauma patients. However, few civilian centers use LTOWB for trauma resuscitation. We evaluated the early experience and safety of a LTOWB program at a level 1 civilian trauma center. METHODS We retrospectively reviewed our trauma registry from January 2018 to June 2020 for patients admitted in shock (defined as ≥1 of the following: heart rate, >120 beats per minute; systolic blood pressure, <90 mm Hg; or shock index, >0.9) who received blood products within 24 hours. Patients were grouped by resuscitation provided: LTOWB (group 1), component therapy (CT; group 2), and LTOWB-CT (group 3). Safety, outcomes, and variables associated with LTOWB transfusion and mortality were analyzed. RESULTS 216 patients were included: 34 in Group 1, 95 in Group 2, and 87 in Group 3. Patientsreceiving LTOWB were more commonly male (p<0.001) and had a penetrating injury (p=0.005). Groups 1 and 3 had higher median ISS scores compared to Group 2 (19 and 20 vs 17; p=0.01). Group 3 received more median units of blood product in the first 4h (p<0.001) and in the first 24h (p<0.001). There was no difference between groups in 24h mortality or transfusion-related complications (all p>0.05). Arrival ED SBP was associated with LTOWB transfusion (odds ratio [OR] 0.98, 95% confidence interval [CI] 0.95-1.00, p=0.03). ED lactate was independently associated with 24h mortality. (OR 1.27, CI 1.02-1.58, p=0.03). LTOWB transfusion was not associated with mortality (p=0.49). Abstract. CONCLUSION Severely injured patients received LTOWB-CT and more overall product units but had similar 24 h mortality when compared with the LTOWB or CT groups. No increase in transfusion-related complications was seen after LTOWB transfusion. Low-titer O whole blood should be strongly considered in the resuscitation of trauma patients at civilian centers. LEVEL OF EVIDENCE Retrospective, therapeutic, level IV.
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Affiliation(s)
- Phillip M Kemp Bohan
- From the Department of Surgery (P.M.K.B., P.M.M., A.M.A., R.C.C.), Brooke Army Medical Center, Fort Sam Houston, Texas; Uniformed Services University of the Health Sciences (M.E.W.), Bethesda, Maryland; and Department of Trauma and Acute Care Surgery (J.E.F., J.S.R., R.A.H., V.G.S.), Brooke Army Medical Center, Fort Sam Houston, Texas
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8
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Radowsky JS, Mazzeffi MM, Deatrick KB, Galvagno SM, Parker BM, Tabatabai A, Madathil RJ, Kaczorowski DJ, Rabinowitz RP, Herr DL, Scalea T, Menaker J. Intoxication and overdose should not preclude veno-venous extracorporeal membrane oxygenation. Perfusion 2020; 36:839-844. [DOI: 10.1177/0267659120963938] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
Introduction Acute intoxication (AI) related morbidity and mortality are increasing in the United States. For patients with severe respiratory failure in the setting of an acute ingestion, veno-venous extracorporeal membrane oxygenation (VV ECMO) can provide salvage therapy. The purpose of this study was to evaluate outcomes in patients with overdose-related need for VV ECMO. Methods: We performed a retrospective review of all patients admitted to a specialty VV ECMO unit between August 2014 and August 2018. Patients were stratified by those whose indication for VV ECMO was directly related to an acute ingestion (alcohol, illicit drug, or prescription drug overdose) and those with unrelated diagnoses. Demographics, pre-cannulation clinical characteristics, ECMO parameters, and outcomes data was collected and analyzed with parametric and non-parametric statistics as indicated. Results: 189 patients were enrolled with 27 (14%) diagnosed with AI. Patients requiring VV ECMO for an AI were younger, had lower median BMI and PaO2/FiO2, and higher RESP scores than non-AI patients (p = 0.002, 0.01, 0.03 and 0.01). There was no difference in pre-cannulation pH, lactate, or SOFA scores between the two groups (p = 0.24, 0.5, 0.6). There was no difference in survival to discharge (p = 0.95). Among survivors, there was no difference in ECMO time or hospital stay (p = 0.24, 0.07). Conclusion: We demonstrate no survival difference for patients with and without an AI-related need for VV ECMO. AI patients should be supported with VV ECMO when traditional therapies fail despite potential stigma against acceptance on referral.
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Affiliation(s)
- Jason S Radowsky
- Department of Surgery, University of Maryland School of Medicine, Baltimore, MD, USA
- Program in Trauma, R Adams Cowley Shock Trauma Center, Baltimore, MD, USA
| | - Michael M Mazzeffi
- Department of Anesthesiology, University of Maryland School of Medicine, Baltimore, MD, USA
| | - K Barry Deatrick
- Department of Surgery, University of Maryland School of Medicine, Baltimore, MD, USA
- Division of Cardiac Surgery, University of Maryland School of Medicine, Baltimore, MD, USA
| | - Samuel M Galvagno
- Program in Trauma, R Adams Cowley Shock Trauma Center, Baltimore, MD, USA
- Department of Anesthesiology, University of Maryland School of Medicine, Baltimore, MD, USA
| | - Brandon M Parker
- Department of Surgery, University of Maryland School of Medicine, Baltimore, MD, USA
- Program in Trauma, R Adams Cowley Shock Trauma Center, Baltimore, MD, USA
| | - Ali Tabatabai
- Program in Trauma, R Adams Cowley Shock Trauma Center, Baltimore, MD, USA
- Department of Medicine, University of Maryland School of Medicine, Baltimore, MD, USA
| | - Ronson J Madathil
- Department of Surgery, University of Maryland School of Medicine, Baltimore, MD, USA
- Division of Cardiac Surgery, University of Maryland School of Medicine, Baltimore, MD, USA
| | - David J Kaczorowski
- Department of Surgery, University of Maryland School of Medicine, Baltimore, MD, USA
- Division of Cardiac Surgery, University of Maryland School of Medicine, Baltimore, MD, USA
| | - Ronald P Rabinowitz
- Program in Trauma, R Adams Cowley Shock Trauma Center, Baltimore, MD, USA
- Department of Medicine, University of Maryland School of Medicine, Baltimore, MD, USA
| | - Daniel L Herr
- Program in Trauma, R Adams Cowley Shock Trauma Center, Baltimore, MD, USA
- Department of Medicine, University of Maryland School of Medicine, Baltimore, MD, USA
| | - Thomas Scalea
- Department of Surgery, University of Maryland School of Medicine, Baltimore, MD, USA
- Program in Trauma, R Adams Cowley Shock Trauma Center, Baltimore, MD, USA
| | - Jay Menaker
- Department of Surgery, University of Maryland School of Medicine, Baltimore, MD, USA
- Program in Trauma, R Adams Cowley Shock Trauma Center, Baltimore, MD, USA
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9
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Larabee SM, Radowsky JS, Zhu G, Papadimitriou J, Stein D. Giant adrenal pseudocyst in trauma patient. Trauma 2020. [DOI: 10.1177/1460408619881540] [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: 11/17/2022]
Abstract
Adrenal pseudocysts are a subclass of adrenal cysts frequently found as incidentalomas. Here, we present the case of a 67-year-old man with an adrenal pseudocyst suspicious for hemorrhage after a fall who was urgently transferred to a tertiary care trauma center for care.
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Affiliation(s)
- Shannon M Larabee
- Department of Surgery, University of Maryland School of Medicine, Baltimore, MD, USA
| | - Jason S Radowsky
- Program in Trauma, R Adams Cowley Shock Trauma Center, University of Maryland School of Medicine, Baltimore, MD, USA
| | - Guangjing Zhu
- Department of Pathology, University of Maryland School of Medicine, Baltimore, MD, USA
| | - John Papadimitriou
- Department of Pathology, University of Maryland School of Medicine, Baltimore, MD, USA
| | - Deborah Stein
- Program in Trauma, R Adams Cowley Shock Trauma Center, University of Maryland School of Medicine, Baltimore, MD, USA
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10
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Radowsky JS, DuBose JJ, Scalea TM, Miller C, Floccare DJ, Sikorski RA, MacKenzie CF, Hu P, Rock P, Galvagno SM. Handheld Tissue Oximetry for the Prehospital Detection of Shock and Need for Lifesaving Interventions: Technology in Search of an Indication? Air Med J 2019; 38:276-280. [PMID: 31248537 DOI: 10.1016/j.amj.2019.03.014] [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] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/06/2018] [Revised: 02/28/2019] [Accepted: 03/27/2019] [Indexed: 06/09/2023]
Abstract
Improved prehospital methods for assessing the need for lifesaving interventions (LSIs) are needed to gain critical lead time in the care of the injured. We hypothesized that threshold values using prehospital handheld tissue oximetry would detect occult shock and predict LSI requirements. This was a prospective observational study of adult trauma patients emergently transported by helicopter. Patients were monitored with a handheld tissue oximeter (InSpectra Spot Check; Hutchinson Technology Inc, Hutchinson, MN), continuous vital signs, and 21 laboratory measurements obtained both in the field with a portable analyzer and at the time of admission. Shock was defined as base excess ≥ 4 or lactate > 3 mmol/L. Eighty-eight patients were enrolled with a median Injury Severity Score of 16 (interquartile range, 5-29). The median hemoglobin saturation in the capillaries, venules, and arterioles (StO2) value for all patients was 82% (interquartile range, 76%-87%; range, 42%-98%). StO2 was abnormal (< 75%) in 18 patients (20%). Eight were hypotensive (9%) and had laboratory-confirmed evidence of occult shock. StO2 correlated poorly with shock threshold laboratory values (r = -0.17; 95% confidence interval, -0.33 to 1.0; P = .94). The area under the receiver operating curve was 0.51 (95% confidence interval, 0.39-0.63) for StO2 < 75% and laboratory-confirmed shock. StO2 was not associated with LSI need on admission when adjusted for multiple covariates, nor was it independently associated with death. Handheld tissue oximetry was not sensitive or specific for identifying patients with prehospital occult shock. These results do not support prehospital StO2 monitoring despite its inclusion in several published guidelines.
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Affiliation(s)
- Jason S Radowsky
- R Adams Cowley Shock Trauma Center, University of Maryland School of Medicine, Baltimore, MD
| | - Joseph J DuBose
- Center for Sustainment for Trauma and Readiness Skills, Baltimore, MD
| | - Thomas M Scalea
- R Adams Cowley Shock Trauma Center, University of Maryland School of Medicine, Baltimore, MD
| | | | - Douglas J Floccare
- Maryland Institute for Emergency Medical Services Systems, Baltimore, MD
| | - Robert A Sikorski
- Department of Anesthesiology and Critical Care Medicine, Johns Hopkins University School of Medicine, Baltimore, MD
| | - Colin F MacKenzie
- Department of Anesthesiology, University of Maryland School of Medicine, Baltimore, MD
| | - Peter Hu
- Department of Anesthesiology, University of Maryland School of Medicine, Baltimore, MD
| | - Peter Rock
- Department of Anesthesiology, University of Maryland School of Medicine, Baltimore, MD
| | - Samuel M Galvagno
- R Adams Cowley Shock Trauma Center, University of Maryland School of Medicine, Baltimore, MD.
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11
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Radowsky JS, Neely R, Forsberg JA, Lisboa FA, Dente CJ, Elster EA, Crane NJ. Preclosure spectroscopic differences between healed and dehisced traumatic wounds. PLoS One 2018; 13:e0204453. [PMID: 30261011 PMCID: PMC6160065 DOI: 10.1371/journal.pone.0204453] [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] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/06/2018] [Accepted: 09/07/2018] [Indexed: 11/18/2022] Open
Abstract
BACKGROUND The complexity and severity of traumatic wounds in military and civilian trauma demands improved wound assessment, before, during, and after treatment. Here, we explore the potential of 3 charge-coupled device (3CCD) imaging values to distinguish between traumatic wounds that heal following closure and those that fail. Previous studies demonstrate that normalized 3CCD imaging values exhibit a high correlation with oxygen saturation and allow for comparison of values between diverse clinical settings, including utilizing different equipment and lighting. METHODS We screened 119 patients at Walter Reed National Military Medical Center and at Grady Memorial Hospital with at least one traumatic extremity wound of ≥ 75 cm2. We collected images of each wound during each débridement surgery for a total of 66 patients. An in-house written computer application selected a region of interest in the images, separated the pixel color values, calculated relative values, and normalized them. We followed patients until the enrolled wounds were surgically closed, quantifying the number of wounds that dehisced (defined as wound failure or infection requiring return to the operating room after closure) or healed. RESULTS Wound failure occurred in 20% (19 of 96) of traumatic wounds. Normalized intensity values for patients with wounds that healed successfully were, on average, significantly different from values for patients with wounds that failed (p ≤ 0.05). Simple thresholding models and partial least squares discriminant analysis models performed poorly. However, a hierarchical cluster analysis model created with 17 variables including 3CCD data, wound surface area, and time from injury predicts wound failure with 76.9% sensitivity, 76.5% specificity, 76.6% accuracy, and a diagnostic odds ratio of 10.8 (95% confidence interval: 2.6-45.9). CONCLUSIONS Imaging using 3CCD technology may provide a non-invasive and cost-effective method of aiding surgeons in deciding if wounds are ready for closure and could potentially decrease the number of required débridements and hospital days. The process may be automated to provide real-time feedback in the operating room and clinic. The low cost and small size of the cameras makes this technology attractive for austere and shipboard environments where space and weight are at a premium.
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Affiliation(s)
- Jason S. Radowsky
- Department of Surgery, Uniformed Services University of the Health Sciences and Walter Reed National Military Medical Center (USUHS-Walter Reed Surgery), Bethesda, Maryland, United States of America
- * E-mail:
| | - Romon Neely
- Department of Surgery, Uniformed Services University of the Health Sciences and Walter Reed National Military Medical Center (USUHS-Walter Reed Surgery), Bethesda, Maryland, United States of America
| | - Jonathan A. Forsberg
- Orthopaedics, USUHS-Walter Reed Surgery, Walter Reed National Military Medical Center, Bethesda, Maryland, United States of America
- Orthopaedics, Johns Hopkins University, Baltimore, Maryland, United States of America
| | - Felipe A. Lisboa
- Department of Surgery, Uniformed Services University of the Health Sciences and Walter Reed National Military Medical Center (USUHS-Walter Reed Surgery), Bethesda, Maryland, United States of America
- Regenerative Medicine Department, Naval Medical Research Center, Silver Spring, Maryland, United States of America
- Surgical Critical Care Initiative, Uniformed Services University of the Health Sciences, Bethesda, Maryland, United States of America
| | - Christopher J. Dente
- Surgical Critical Care Initiative, Uniformed Services University of the Health Sciences, Bethesda, Maryland, United States of America
- Department of Surgery, Emory University School of Medicine, Atlanta, Georgia, United States of America
- Trauma/Surgical Critical Care, Grady Memorial Hospital, Atlanta, Georgia, United States of America
| | - Eric A. Elster
- Department of Surgery, Uniformed Services University of the Health Sciences and Walter Reed National Military Medical Center (USUHS-Walter Reed Surgery), Bethesda, Maryland, United States of America
- Regenerative Medicine Department, Naval Medical Research Center, Silver Spring, Maryland, United States of America
- Surgical Critical Care Initiative, Uniformed Services University of the Health Sciences, Bethesda, Maryland, United States of America
| | - Nicole J. Crane
- Department of Surgery, Uniformed Services University of the Health Sciences and Walter Reed National Military Medical Center (USUHS-Walter Reed Surgery), Bethesda, Maryland, United States of America
- Regenerative Medicine Department, Naval Medical Research Center, Silver Spring, Maryland, United States of America
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12
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Radowsky JS, Rodriguez CJ, Wind GG, Elster EA. A Surgeon's Guide to Obtaining Hemorrhage Control in Combat-Related Dismounted Lower Extremity Blast Injuries. Mil Med 2016; 181:1300-1304. [DOI: 10.7205/milmed-d-15-00324] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022] Open
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13
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Radowsky JS, Brown TS, Lisboa FA, Rodriguez CJ, Forsberg JA, Elster EA. Serum Inflammatory Cytokine Markers of Invasive Fungal Infection in Previously Immunocompetent Battle Casualties. Surg Infect (Larchmt) 2015; 16:526-32. [PMID: 26110227 DOI: 10.1089/sur.2013.124] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Abstract
BACKGROUND Invasive fungal infection (IFI) is described increasingly in individuals experiencing high-energy military trauma. Hallmarks of successful treatment involve aggressive surgical debridement and early initiation of systemic antimicrobial therapy. Currently, intravenous anti-fungal therapy commences based on appearance of wounds and patient's clinical course. Whereas some clinical protocols exist to predict which critically injured patients should receive anti-fungal therapies, there are no established serum markers associated with IFI. Our hypothesis is that serum inflammatory cytokines exist that can assist in identifying individuals at risk for IFI. METHODS This is a retrospective case control study at a single institution. Nine patients with IFI (Saksenaea vasiformis, Fusarium sp., Graphium sp., Scedosporium sp., Aspergillus sp., Mucor sp., and Alternaria sp.) after battlefield trauma were matched to nine individuals with similar injury patterns whose laboratory results were negative for IFI. The combination of serum inflammatory cytokines from the first and second debridements was examined with multiplex platform proteomic analysis. We defined statistical significance as a two-tailed α<0.05 after adjusting for multiple comparisons using the false discovery rate method. This model was refined further with correlation-based filter selection and the area under the curve of the receiver operating characteristics (AUROC) was tested. RESULTS Both groups had similar Injury Severity Scores (ISS) (mean±standard deviation [SD]) (26.8±15.5 vs. 29.2±16.8, p=0.766). Elevated RANTES (regulated on activation, normal T cell expressed and secreted) alone (10,492.8±4,450.1 vs. 5,333.3±4,162.2, p=0.006) correlated with IFI. Also, the combination of persistent elevations in RANTES, interleukin (IL)-2R, and IL-15 was a robust model for predicting IFI with the AUROC being 0.9. CONCLUSIONS Elevation in serum cytokines, particularly RANTES, correlated with IFI in this small group of patients. This demonstrates the potential of future rapid serum testing for early initiation and guidance of anti-fungal therapies.
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Affiliation(s)
- Jason S Radowsky
- 1 Department of General Surgery, Walter Reed National Military Medical Center, Bethesda , Maryland.,2 Naval Medical Research Center , Regenerative Medicine Department, Silver Spring, Maryland.,4 Norman M. Rich Department of Surgery, Uniformed Services University of the Health Sciences , Bethesda, Maryland
| | - Trevor S Brown
- 2 Naval Medical Research Center , Regenerative Medicine Department, Silver Spring, Maryland.,5 Surgical Critical Care Initiative (SC2i), Uniformed Services University of the Health Sciences , Department of Surgery, Bethesda, Maryland
| | - Felipe A Lisboa
- 2 Naval Medical Research Center , Regenerative Medicine Department, Silver Spring, Maryland.,4 Norman M. Rich Department of Surgery, Uniformed Services University of the Health Sciences , Bethesda, Maryland.,5 Surgical Critical Care Initiative (SC2i), Uniformed Services University of the Health Sciences , Department of Surgery, Bethesda, Maryland
| | - Carlos J Rodriguez
- 1 Department of General Surgery, Walter Reed National Military Medical Center, Bethesda , Maryland.,4 Norman M. Rich Department of Surgery, Uniformed Services University of the Health Sciences , Bethesda, Maryland
| | - Jonathan A Forsberg
- 2 Naval Medical Research Center , Regenerative Medicine Department, Silver Spring, Maryland.,3 Department of Orthopaedic Surgery, Walter Reed National Military Medical Center, Bethesda , Maryland.,5 Surgical Critical Care Initiative (SC2i), Uniformed Services University of the Health Sciences , Department of Surgery, Bethesda, Maryland
| | - Eric A Elster
- 1 Department of General Surgery, Walter Reed National Military Medical Center, Bethesda , Maryland.,2 Naval Medical Research Center , Regenerative Medicine Department, Silver Spring, Maryland.,4 Norman M. Rich Department of Surgery, Uniformed Services University of the Health Sciences , Bethesda, Maryland.,5 Surgical Critical Care Initiative (SC2i), Uniformed Services University of the Health Sciences , Department of Surgery, Bethesda, Maryland
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Abstract
BACKGROUND The clinical importance of extrathyroidal extension (ETE) on outcome of papillary thyroid cancer (PTC), particularly with respect to disease extending to the surgical margin is not well established. This study assessed the importance of surgical margin and extrathyroidal invasion relative to local control of disease and oncologic outcome. METHODS A retrospective analysis of a prospective institutional endocrine database was conducted on 276 patients with PTC treated between 1955 and 2004 to determine the impact of margin-negative resection (n=199, 72%), disease up to within 1 mm of surgical margin (n=19, 7%), microscopic (n=39, 14%), and gross (n=19, 7%) ETE. Data were compared with Fisher's exact test or analysis of variance (ANOVA). RESULTS Median follow-up was 3.1-6.8 years per study group (disease-free survival, range 1-37 years). The proportion of those with age >45 years, prior radiation exposure, distant metastasis at presentation, and those undergoing total thyroidectomy was not significantly different between groups. Tumor size and multifocality correlated with extent of local disease, which in turn was significantly associated with regional nodal disease at time of primary operation as well as prevalence of persistence of disease after multimodality therapy. Extent of local disease correlated significantly with subsequent clinical recurrence after a disease-free period (p=0.006); however, recurrence rates were not significantly different between negative and close (≤1 mm) margin resection. CONCLUSION Oncological outcome correlates with the extent of extrathyroidal invasion. Outcome is worse in patients with gross extrathyroidal disease extension than in those with microscopic local invasion apparent on histopathological assessment. However, the risk of clinical recurrence appears similar between patients undergoing margin-negative and "close margin" resection.
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Affiliation(s)
- Jason S Radowsky
- 1 Department of Surgery, Walter Reed National Military Medical Center , Bethesda, Maryland
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Radowsky JS, Helou LB, Howard RS, Solomon NP, Stojadinovic A. Racial disparities in voice outcomes after thyroid and parathyroid surgery. Surgery 2012; 153:103-10. [PMID: 22862898 DOI: 10.1016/j.surg.2012.06.001] [Citation(s) in RCA: 21] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/21/2011] [Accepted: 06/04/2012] [Indexed: 11/17/2022]
Abstract
BACKGROUND There is evidence that the outcomes of head and neck surgery may differ across racial and ethnic groups. Vocal changes related to the operation are an anticipated risk of thyroidectomy and parathyroidectomy. Race-specific voice outcomes after thyroid and parathyroid operations have not been reported. Therefore, our aim was to examine the potential disparity in voice outcomes between white and black patients after thyroid or parathyroid operations. PATIENTS AND METHODS Eighty-seven patients (59 white and 28 black) were included in a prospective observational trial. Subjects were evaluated before operation, and 2 weeks, 3 months, and 6 months postoperatively using a comprehensive battery of functional voice assessments of voice characteristics. The association of race with voice outcomes over time was evaluated with generalized linear models. RESULTS Aside from volume of pathologic specimen (black, 117.5 cm3 vs. white, 43.2 cm3; P = .004), presence of multinodular goiter (black, 32.1% vs. white, 6.8%; P = .004) or Hashimoto's thyroiditis (black, 3.6% vs. white, 28.8%; P = .009), there were no differences between racial groups. Blacks were more likely than whites to have negative voice outcomes (odds ratio, 2.6; 95% confidence interval, 1.1-6.2; P = .034] throughout the postoperative period, especially at 6 months (black, 25% vs. white, 4%; P = .018). This finding was related principally to divergent scores on the voice-related quality-of-life scale, the voice handicap index. CONCLUSION We observed greater rates of self-reported, negative voice outcomes among blacks than whites after thyroid or parathyroid operations. The precise mechanism for this disparity has not been described. The observed racial disparity in self-perceived voice impairment in this study merits further investigation.
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Affiliation(s)
- Jason S Radowsky
- Department of Surgery, Walter Reed National Military Medical Center, Bethesda, MD 2088, USA.
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Radowsky JS, Baines L, Howard RS, Shriver CD, Buckenmaier CC, Stojadinovic A. Pain Ratings by Patients and Their Providers of Radionucleotide Injection for Breast Cancer Lymphatic Mapping. Pain Med 2012; 13:670-6. [DOI: 10.1111/j.1526-4637.2012.01374.x] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
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Radowsky JS, Strawn AA, Sherwood J, Braden A, Liston W. Invasive mucormycosis and aspergillosis in a healthy 22-year-old battle casualty: case report. Surg Infect (Larchmt) 2011; 12:397-400. [PMID: 22004440 DOI: 10.1089/sur.2010.065] [Citation(s) in RCA: 23] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Abstract
BACKGROUND Invasive mucormycosis or aspergillosis is a life-threatening infection. The disease typically occurs in immunocompromised patients (e.g., those with diabetes mellitus or burns) but is rarely serious in otherwise-healthy young trauma patients. METHODS Case report and literature review. RESULTS A previously-healthy 22-year-old United States Marine who sustained large soft tissue injuries in support of Operation Enduring Freedom underwent multiple operations in theater to stabilize his wounds. He was evacuated first to Landstuhl Regional Medical Center in Germany and thence to the National Naval Medical Center in Maryland, where appropriate antifungal therapies were initiated and wide débridements were undertaken without success. His clinical status deteriorated, and he died. Tissue examination revealed systemic invasive mucormycosis and aspergillosis. CONCLUSION The suspicion of invasive fungal infections must be tested early if intervention is to be curative.
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Affiliation(s)
- Jason S Radowsky
- Department of Surgery, Walter Reed National Military Medical Center, 8901 Rockville Pike, Bethesda, MD 20889-5600, USA.
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