Transdiaphragmatic intercostal herniation in the setting of trauma

Transdiaphragmatic intercostal herniation is a rare injury that can be associated with blunt trauma. Since its first documentation within the literature in 1946, there have been less than 50 cases reported. We present a case involving a 56-year old female who presented to our Trauma Center with transdiaphragmatic intercostal herniation caused by blunt trauma from a high-velocity T-bone vehicular collision. Upon presentation, she exhibited bilateral breath sounds; however, with labored breathing, chest pain, and hypoxia. The initial chest radiograph interpretation indicated the presence of "left lower lobe infiltrates", and subsequent computed tomography imaging identified "a small lateral hernia along the left mid abdomen". After initial resuscitation, her condition deteriorated, exhibiting respiratory distress and becoming increasingly hypercarbic, requiring intubation. Review of the imaging showed disruption of the left hemidiaphragm with intrathoracic herniation of colon and stomach through the thoracic wall between the ninth and tenth ribs. Consequently, a thoracotomy was performed in the operating room, revealing a large defect between the two ribs with disruption of the intercostal muscles and inferior displacement of rib space. Lung and omentum had herniated through the disrupted rib space and the diaphragmatic rupture was attenuated anteriorly, measuring 11x6cm. After reduction of the herniated organs, a biologic porcine mesh was placed and an intermediate complex closure of the thoracic wall hernia was performed. The patient was later extubated, recovered from her injuries with no complications and was discharged. With the low incidence of transdiaphragmatic intercostal herniation, there is no standardized surgical management. Recent literature suggests that these injuries should be managed with mesh, rather than sutures only, due to high rates of recurrence. Furthermore, diaphragmatic injuries may suffer a delay in diagnosis. Therefore, a high index of suspicion should be maintained in patients with respiratory distress following a blunt trauma, with close review of computed tomography.

Early Versus Late Feeding After Percutaneous Endoscopic Gastrostomy Placement in Trauma and Burn

INTRODUCTION

Timing to resume feeds after percutaneous endoscopic gastrostomy (PEG) placement continues to vary among US trauma surgeons. The purpose of this study was to assess differences in meeting nutritional therapy goals and adverse outcomes with early versus late enteral feeding after PEG placement.

METHODS

This retrospective review included 364 trauma and burn patients who underwent PEG placement. Data included patient characteristics, time to initiate feeds, rate feeds were resumed, % feed volume goals on postoperative days 0-7, and complications. Statistical analysis was performed comparing two groups (feeds ≤ 6 h versus > 6 h) and three subgroups (< 4 h, 4-6 h, ≥ 6 h) based on data quartiles. Chi-square/Fisher's exact test, independent-samples t-test, and one-way analysis of variance were used to analyze the data.

RESULTS

Mean time to initiate feeds after PEG was 5.48 ± 4.79 h. Burn patients received early feeds in a larger proportion. A larger proportion of trauma patients received late feeds. The mean % of goal feed volume met on postoperative day 0 was higher in the early feeding group versus the late (P < 0.001). There were no differences in adverse events, even after subgroup analysis of those who received feeds < 4 h after PEG placement.

CONCLUSIONS

Patients with early initiation of feeds after PEG placement achieve a higher percentage of goals on day 0 without an increased rate of adverse events. Unfortunately, patients routinely fall short of their target tube feeding goals.

A Pediatric Cervical Spine Clearance Guideline Leads to Fewer Unnecessary Computed Tomography Scans and Decreased Radiation Exposure

OBJECTIVES

Physical examination and computed tomography (CT) are useful to rule out cervical spine injury (CSI). Computed tomography scans increase lifetime cancer risk in children from radiation exposure. Most CSI in children occur between the occiput and C4. We developed a cervical spine (C-spine) clearance guideline to reduce unnecessary CTs and radiation exposure in pediatric trauma patients.

METHODS

A pediatric C-spine clearance guideline was implemented in September 2018 at our Level 2 Pediatric Trauma Center. Guidance included CT of C1 to C4 to scan only high-yield regions versus the entire C-spine and decrease radiation dose. A retrospective cohort study was conducted comparing preguideline and postguideline of all pediatric trauma patients younger than 8 years screened for CSI from July 2017 to December 2020. Primary endpoints included the following: number of full C-spine and C1 to C4 CT scans and radiation dose. Secondary endpoints were CSI rate and missed CSI. Results were compared using χ 2 and Wilcoxon rank-sum test with P < 0.05 significant.

RESULTS

The review identified 726 patients: 273 preguideline and 453 postguideline. A similar rate of total C-spine CTs were done in both groups (23.1% vs 23.4%, P = 0.92). Full C-spine CTs were more common preguideline (22.7% vs 11.9%, P < 0.001), whereas C1 to C4 CT scans were more common post-guideline (11.5% vs 0.4%, P < 0.001). Magnetic resonance imaging utilization and CSIs identified were similar in both groups. The average radiation dose was lower postguideline (114 vs 265 mGy·cm -1 ; P < 0.001). There were no missed CSI.

CONCLUSIONS

A pediatric C-spine clearance guideline led to increasing CT of C1 to C4 over full C-spine imaging, reducing the radiation dose in children.

LEVEL OF EVIDENCE

Level IV, therapeutic.

Temperature Profiles of Sunlight-Exposed Surfaces in a Desert Climate: Determining the Risk for Pavement Burns

Plentiful sunlight and high temperatures in desert climates cause burn injuries from contact with sun-exposed surfaces. The peak temperature, times, and surfaces of greatest risk are not well described. This work recorded temperature measurements of six materials in a desert climate. Surface temperatures of asphalt, brick, concrete, sand, porous rock, and galvanized metal were measured throughout the summer, along with ambient temperature, and sunlight intensity. Samples were placed in both shade and direct sunlight for evaluation of sunlight effect. Seventy-five thousand individual measurements were obtained from March to August 2020. Maximum recorded temperatures for sunlight-exposed porous rock were 170°F, asphalt 166°F, brick 152°F, concrete 144°F, metal 144°F, and sand 143°F, measured on August 6, 2020 at 2:10 pm, when ambient temperature was 120°F and solar irradiation 940 W/m2. Sunlight-exposed materials ranged 36 to 56°F higher than shaded materials measured at the same time. The highest daily temperatures were achieved between 2:00 and 4:00 pm due to maximum solar irradiance. Contour plots of surface temperature as a function of both solar irradiation and time of day were created for all materials tested. A computational fluid dynamics model was created to validate the data and serve as a predictive model based upon temperature and sunlight inputs. This information is useful to inform the public of the risks of contact burn due to sunlight-exposed surfaces in a desert climate.

Shot through the heart: A 17-year analysis of pre-hospital and hospital deaths from penetrating cardiac injuries

BACKGROUND

Penetrating cardiac injuries (PCI) are often fatal despite rapid transport and treatment in the prehospital setting. Although many studies have identified risk factors for mortality, few studies have included non-transported field mortalities. This study analyzes penetrating cardiac injuries including hospital and coroner reports in the current era.

METHODS

Seventeen years of data were reviewed, including the trauma center (TC) registry, medical records, and coroner reports from 2000-2016. PCI were graded using American Association for the Surgery of Trauma (AAST) cardiac organ injury score (COIS). Subjects were divided into three groups: field deaths, hospital deaths, and survivors to hospital discharge. The primary outcome is survival to hospital discharge overall and among those transported to the hospital.

RESULTS

During the study period, 643 PCI patients were identified, with 52 excluded for inadequate data, leaving 591 for analysis. Mean age was 38.1 ± 17.5 years, and survivors (n=66) were significantly younger than field deaths (n=359) (32.6 ± 14.4 vs 41.1 ± 18.5, p<0.001). Stab wounds had higher survival than gunshot wounds (26.6% vs. 4.3%, p<0.001). COIS grades 4 to 6 (n=602) had lower survival than grades 1 to 3 (n=41) (8.3% vs. 39.0%, p<0.001). Survivors (n=66) had lower median COIS than patients who died in hospital (n=218) (4 vs. 5, p<0.001). Single chamber PCI had higher survival than multiple chamber PCI (13% vs. 5%, p=0.004).  The left ventricle is the most injured (n=177), and right ventricle PCI has the highest survival (p<0.001).  Of field deaths, left ventricular injuries had the highest single chamber mortality (60%), equaling multi-chamber PCI (60%).

CONCLUSIONS

Survival to both TC evaluation and hospital discharge following PCI is influenced by many factors including age, mechanism, anatomic site, and grade. Despite advances in trauma care, survival has not appreciably improved.

Skilled maneuvering: Evaluation of a young driver advanced training program

BACKGROUND

Young drivers (YDs) are disproportionately injured and killed in motor vehicle crashes throughout the United States. Nationally, YDs aged 16 to 20 years constituted nearly 9% of all traffic-related fatalities in 2018. A Nevada Advanced Driver Training (ADT) program for YDs aims to reduce YD traffic injuries and fatalities through four modules taught by professional drivers. The program modules include classroom-based didactic lessons and hands-on driving exercises intended to improve safe driving knowledge and behaviors. The overarching purpose of this study was to determine if the Nevada ADT program achieved its objectives for improving safe driving knowledge and behaviors based on program-provided data. A secondary purpose of this study was to provide recommendations to improve program efficiency, delivery, and evaluation. The findings of this study would serve as a basis to develop and evaluate future ADT interventions.

METHODS

The exploratory mixed methods outcome evaluation used secondary data collected during three weekend events in December 2018 and March 2019. The study population consisted of high school students with a driver's license or learner's permit. Pretests/posttests and preevent questionnaires on student driving history were matched and linked via personal identifiers. The pretests/posttests measured changes in knowledge of safe driving behaviors. This study used descriptive statistics, dependent samples t test, Pearson's r correlation coefficient, and χ2 (McNemar's test) with significance set at p = 0.05, 95% confidence interval. Statistical analysis was conducted using IBM SPSS version 24 (Armonk, NY). Qualitative data analysis consisted of content and thematic analysis.

RESULTS

Responses from YD participants (N = 649) were provided for analysis. Aggregate YD participant knowledge of safe driving behaviors increased from a mean of 43.9% (pretest) to 74.9% (posttest).

CONCLUSION

The program achieved its intended outcomes of improving safe driving knowledge and behaviors among its target population.

LEVEL OF EVIDENCE

Prognostic/Epidemiologic, Level V.

604 From admission to discharge: a total friction burn review from a single institution

Introduction

Most friction burns are adequately managed in an outpatient setting. However, many require hospital admission, operative excision, and extended care especially those that present at trauma or burn centers. There is a wide variance in friction burn management. Our goal is to review the etiology, management, and outcomes of such burns warranting hospitalization.

Methods

We conducted a retrospective review of all friction burns admitted to a single, American Burn Association verified burn center from January 1, 2016 to December 31, 2020. Individual chart analysis was performed using data from the hospital’s burn registry. Statistical analysis was performed using Chi-square and Wilcoxon rank-sum test with p< 0.05 being significant.

Results

Eighty-two patients met the inclusion criteria. Mean age was 35.4 years (95% CI 31.6-39.2). The overall mean Total Body Surface Area (TBSA) was 9.0 % (95% CI 7.5-10.6), and mean TBSA of 3^rd degree burns was 1.1 % (95% CI 0.6-1.7). The most common mechanism of injury was motorcycle collision (45, 55%), followed by pedestrian struck by automobile (13, 16%). Fifty-four individuals (65%) had a concomitant injury. The most common topical agent used was silver sulfadiazine (52%), followed by bacitracin (21%). Sixteen patients (20%) required ICU level of care. Twenty-eight (34%) patients required surgery for their friction burns and 15 (18%) ultimately required a split-thickness skin graft. The mean number of operations was 2.4 (95% CI 1.6-3.1).

Overall, the operative group was younger (29.9 vs 38.3 years, p=0.026), more likely to have a concomitant traumatic brain injury (25% vs 7%, p=0.027) and had a longer hospital length of stay (17.5 vs 3.9 days, p< 0.001). Both groups had a similar overall TBSA (8.5% vs 10.0%, p=0.35), but the operative group had larger surface area comprised of 3rd degree burns (3.05% vs 0.2%, p< 0.001). Eighty-one patients survived with the sole death due to massive hemoptysis.

Conclusions

Friction burns resulting in hospital admission are associated with high-energy traumatic mechanisms and concomitant injuries. Patients who need operative intervention of their burns typically require multiple procedures often culminating in a split-thickness skin graft.

Pediatric Trauma Arrival Times and the Swing Shift

BACKGROUND

Trauma center staff and trainees are often assigned to a day and night shift. However, for adult trauma, the swing shift has been found to offer superior clinical exposure compared with a standard day or night shift for trainees. We characterized patterns in pediatric trauma arrival times based on the hour, weekday, and month and studied whether or not the swing shift also maximizes exposure to hands-on experiences in managing pediatric trauma.

METHODS

We performed a retrospective review of the trauma database at our urban, level 2 pediatric trauma center. We identified all the pediatric trauma activations in the last 13 years (2006-2018). A retrospective shift log was created, which included day (7:00 am to 7:00 pm), night (7:00 pm to 7:00 am), and swing (noon to midnight) shifts. The shifts were compared using the Wilcoxon match-pairs signed rank test. Weekends data were also compared with weekdays, and comparisons were also made for pediatric patients with Injury Severity Scores (ISS) >15.

RESULTS

There were 3532 pediatric patients identified for our study. The swing shift had 1.98 times more activations than the night shift, and 1.33 more than the day shift (P < 0.001). The swing shift was also superior to both the day and night shifts for exposure to patients with Injury Severity Score greater than 15 (P < 0.001). Weekend days had 1.28 times more trauma than the weekdays (P < 0.001). Peak arrival time was between the hours of 3:00 pm and 9:00 pm, and patient age did not have an effect on this trend.

CONCLUSIONS

Experience in managing pediatric trauma patients will improve for trainees who utilize the swing shift. In addition, the hours between 3:00 pm and 9:00 pm on weekends may represent a time of particularly high likelihood of pediatric trauma arrivals, which may require extra staff and hospital resources.Level of Evidence: Therapeutic Study, Level IV.

Early feeding after percutaneous endoscopic gastrostomy tube placement in trauma and surgical intensive care patients: A retrospective cohort study

BACKGROUND

Critically ill patients experience frequent interruptions in enteral nutrition(EN). For ventilated patients who undergo percutaneous endoscopic gastrostomy tube(PEG) placement, post-procedure fasting time varies from 1-24hrs, depending on the surgeon's preference. There is no evidence to support prolonged fasting after PEG placement. This study's purpose was to determine if there is an increased complication rate associated with reduced fasting time after PEG.

METHODS

150 adult ventilated trauma and surgical ICU patients at a level I trauma center underwent PEG placement March 2015-May 2018 by one of 6 surgical intensivists. Retrospective review revealed variable post-PEG fasting practices among them: 1 started EN at 1hr, 2 at 4hrs, 2 at 6hrs, and 1 at 24hrs. Time to initiation of EN and complication rates were assessed. Patients were divided into early feeding(<4hrs) and prolonged fasting(≥4hrs) groups.

RESULTS

Median post-procedure fasting time was 5.5hrs. Complications included bleeding(2), infection(1), tube leak(1), feeding intolerance(1) and aspiration(0). The overall complication rate was 3.3%, with feeding intolerance rate 0.7% and aspiration rate 0%. There was no difference in complication rate for early feeding(3.1%) as compared to delayed feeding(3.4%) (OR 0.92, 95%CI 0.10-8.52, p = 0.7).

CONCLUSION

Complication rates following PEG placement in ventilated trauma and surgical ICU patients are low and do not change with early feeding <4hr compared to prolonged fasting ≥4hr. Early feeding after PEG is probably safe. With this data, a randomized controlled trial is underway that will provide evidence to support a more consistent practice, thus mitigating a source of EN interruption in a population vulnerable to malnutrition. This article is protected by copyright. All rights reserved.

Electronic Cigarette-Related Injuries Presenting to Five Large Burn Centers, 2015-2019

Electronic cigarettes are advertised as safer alternatives to traditional cigarettes yet cause serious injury. US burn centers have witnessed a rise in both inpatient and outpatient visits to treat thermal injuries related to their use. A multicenter retrospective chart review of American Burn Association burn registry data from 5 large burn centers was performed from January 2015 to July 2019 to identify patients with electronic cigarette-related injuries. A total of 127 patients were identified. Most sustained less than 10% total body surface area burns (mean 3.8%). Sixty-six percent sustained 2nd degree burns. Most patients (78%) were injured while using their device. Eighteen percent of patients reported spontaneous device combustion. Two patients were injured while changing their device battery, and two were injured modifying their device. Three percent were injured by second-hand mechanism. Burn injury was the most common injury pattern (100%), followed by blast injury (3.93%). Flame burns were the most common (70%) type of thermal injury; however, most patients sustained a combination-type injury secondary to multiple burn mechanisms. The most injured body region was the extremities. Silver sulfadiazine was the most common agent used in initial management of thermal injuries. Sixty-three percent of patients did not require surgery. Of the 36% requiring surgery, 43.4% required skin grafting. Multiple surgeries were uncommon. Our data recognizes electronic cigarette use as a public health problem with potential to cause thermal injury and secondary trauma. Most patients are treated on an inpatient basis although most patients treated on outpatient basis have good outcomes.

Characteristics of survivors of civilian public mass shootings: An Eastern Association for the Surgery of Trauma multicenter study

BACKGROUND

Firearm injury remains a public health crisis. Whereas there have been studies evaluating causes of death in victims of civilian public mass shootings (CPMSs), there are no large studies evaluating injuries sustained and treatments rendered in survivors. The purpose of this study was to describe these characteristics to inform ideal preparation for these events.

METHODS

A multicenter, retrospective study of CPMS survivors who were treated at designated trauma centers from July 1, 1999 to December 31, 2017, was performed. Prehospital and hospital variables were collected. Data are reported as median (25th percentile, 75th percentile interquartile range), and statistical analyses were carried out using Mann-Whitney U, χ2, and Kruskal-Wallis tests. Patients who died before discharge from the hospital were excluded.

RESULTS

Thirty-one events involving 191 patients were studied. The median number of patients seen per event was 20 (5, 106), distance to each hospital was 6 (6, 10) miles, time to arrival was 56 (37, 90) minutes, number of wounds per patient was 1 (1, 2), and Injury Severity Score was 5 (1, 17). The most common injuries were extremity fracture (37%) and lung parenchyma (14%). Twenty-nine percent of patients did not receive paramedic-level prehospital treatment. Following arrival to the hospital, 27% were discharged from the emergency department, 32% were taken directly to the operating room/interventional radiology, 16% were admitted to the intensive care unit, and 25% were admitted to the ward. Forty percent did not require advanced treatment within 12 hours. The most common operations performed within 12 hours of arrival were orthopedic (15%) and laparotomy (15%). The most common specialties consulted were orthopedics (38%) and mental health (17%).

CONCLUSION

Few CPMS survivors are critically injured. There is significant delay between shooting and transport. Revised triage criteria and a focus on rapid transport of the few severely injured patients are needed.

LEVEL OF EVIDENCE

Therapeutic/care management, level IV.

Are Self-Inflicted Stab Wounds Less Severe Than Assaults? Analysis of Injury and Severity by Intent

BACKGROUND

Although there is evidence that self-inflicted abdominal stab wounds are less severe than those from assault, it is unclear if this is true in other anatomic regions. This study compares severity and injury pattern between self-inflicted stab wounds (SISWs) and wounds from assault (ASW).

MATERIALS AND METHODS

Stab wounds from our level I trauma registry from 2013 to 2018 were reviewed. Data included age, gender, self-inflicted versus assault, psychiatric or substance use history, anatomic location, operative intervention, injury severity, length of stay, and outcomes.

RESULTS

Over the study period, 1390 patients were identified. History of psychiatric diagnoses or previous suicide attempts was more frequent in SISWs (47% versus 6.5%, P < 0.01; 35% versus 0.4%, P < 0.01). SISWs had a higher incidence of wounds to the neck and abdomen (44% versus 11%, P < 0.01; and 34% versus 26%, P = 0.02). Overall, injuries from ASW had a higher injury severity score, but more procedures were performed on SISWs (46% versus 34%, P < 0.01). SISWs to the neck were more likely to undergo procedures (26% versus 15%, P = 0.04). Median hospital charges were higher in patients with SISWs ($58.6 K versus $39.4 K, P < 0.01).

CONCLUSIONS

SISWs have a distinct pattern of injuries, more commonly to the neck and abdomen, when compared with injuries resulting from ASW. The patients with SISWs have a higher rate of procedures, longer length of stay, and higher hospital charges despite low injury severity overall.

Early Characteristics and Progression of Blunt Traumatic Aortic Injuries at a Single Level I Trauma Center

OBJECTIVES

The most widely accepted grading system for blunt traumatic aortic injury (BTAI) by the Society of Vascular Surgery (SVS) recommends endovascular repair for grade 2 and greater. Non-operative management in grade 2 injuries has been shown to be reasonable in certain circumstances. The natural history of low-grade injuries (1, 2) when managed non-operatively is not well defined.

METHODS

Utilizing our trauma registry, patients from 2013 to 2016 with blunt traumatic injury who underwent initial computed tomography were identified. Aortic pathology was graded and grouped by SVS classification. Clinical courses were reviewed for timing of interventions, repeat imaging, concurrent injuries, and outcomes. Analysis of variance and Chi-square tests of significance were utilized to compare between groups.

RESULTS

Out of 10,178 patients, we identified 32 with BTAI (grade: 1 (n = 13), 2 (n = 5), 3 (n = 3), 4 (n = 11)). High-grade injuries (3, 4) resulted only from motor vehicle, motorcycle, and pedestrian mechanisms. Initially, 9 patients (28%) required intervention, 5 (16%) were treated non-operatively, and 18 (56%) underwent repeat imaging. On repeat imaging, injuries that did not resolve remained stable and no injuries were found to progress. Of these patients, 9 (50%) required delayed intervention and 9 (50%) successfully underwent non-operative management. Patients with low-grade injuries were more likely to have successful non-operative management than those with high-grade injuries (72% vs 7%; p < 0.01).

CONCLUSIONS

While low-grade injuries generally have good outcomes, some ultimately do require delayed intervention, and short-term imaging is not reliable in identifying these cases.

Too Big, Too Small or Just Right? Why the 28 French Chest Tube Is the Best Size

BACKGROUND

Tube thoracostomy is a commonly performed procedure in trauma patients. The optimal chest tube size is unknown. This study measures chest tube drainage in a controlled laboratory setting and compares measured flowrates to those predicted by the Hagen-Poiseuille equation.

MATERIALS AND METHODS

A model of massive hemothorax was created, consisting of a basin containing synthetic blood substitute (aqueous Glycerin and Xanthan gum) and a standard pleur-evac setup at -20 cm H₂O suction. Flow measurements were calculated by measuring the time to drain 2L of blood substitute from the basin. Chest tube sizes tested were 20F, 24F, 28F, 32F, and 36F. Thoracostomy opening was modeled using custom built device that represents two ribs, with the distance between varied 2 to 12 mm. Flowrate increases were compared against predicted increases according to the Hagen-Poiseuille equation. Percent of predicted increase was calculated, both incremental increase and using 20F tube benchmark.

RESULTS

All tubes were occluded at a 2 mm thoracostomy opening. At 3 mm, 32F and 36F were occluded while smaller tubes were patent. Tubes 28F and larger exhibited high speed and consistent flowrates, even after decreasing thoracostomy opening down to 7 mm, while flowrates rapidly decreased at opening smaller than 7 mm. Smaller 24F and 20F tubes exhibited highly variable flowrates through the system. Maximum flowrates were 21.7, 36.8, 49.6, 55.6, and 61.0 mL/s for 20F-36F tubes, respectively. The incremental increase in flow ratio for increasing chest tube size was 1.69 (20F to 24F), 1.35 (24F to 28F), 1.12 (28F to 32F), and 1.10 (32F to 36F).

CONCLUSIONS

The 28F chest tube exhibited high and consistent velocity, while smaller tubes were slower and more variable. Larger tubes offered only slightly higher flowrates. The 28F is a good balance of reasonable size and high flowrate and is likely the optimal size for most clinical applications.

Outcomes in patients with gunshot wounds to the brain

Introduction

Gunshot wounds to the brain (GSWB) confer high lethality and uncertain recovery. It is unclear which patients benefit from aggressive resuscitation, and furthermore whether patients with GSWB undergoing cardiopulmonary resuscitation (CPR) have potential for survival or organ donation. Therefore, we sought to determine the rates of survival and organ donation, as well as identify factors associated with both outcomes in patients with GSWB undergoing CPR.

Methods

We performed a retrospective, multicenter study at 25 US trauma centers including dates between June 1, 2011 and December 31, 2017. Patients were included if they suffered isolated GSWB and required CPR at a referring hospital, in the field, or in the trauma resuscitation room. Patients were excluded for significant torso or extremity injuries, or if pregnant. Binomial regression models were used to determine predictors of survival/organ donation.

Results

825 patients met study criteria; the majority were male (87.6%) with a mean age of 36.5 years. Most (67%) underwent CPR in the field and 2.1% (n=17) survived to discharge. Of the non-survivors, 17.5% (n=141) were considered eligible donors, with a donation rate of 58.9% (n=83) in this group. Regression models found several predictors of survival. Hormone replacement was predictive of both survival and organ donation.

Conclusion

We found that GSWB requiring CPR during trauma resuscitation was associated with a 2.1% survival rate and overall organ donation rate of 10.3%. Several factors appear to be favorably associated with survival, although predictions are uncertain due to the low number of survivors in this patient population. Hormone replacement was predictive of both survival and organ donation. These results are a starting point for determining appropriate treatment algorithms for this devastating clinical condition.

Level of evidence

Level II.

Effect of prehospital tourniquets on resuscitation in extremity arterial trauma

Background

Timely tourniquet placement may limit ongoing hemorrhage and reduce the need for blood products. This study evaluates if prehospital tourniquet application altered the initial transfusion needs in arterial injuries when compared with a non-tourniquet control group.

Methods

Extremity arterial injuries were queried from our level I trauma center registry from 2013 to 2017. The characteristics of the cohort with prehospital tourniquet placement (TQ+) were described in terms of tourniquet use, duration, and frequency over time. These cases were matched 1:1 by the artery injured, demographics, Injury Severity Score, and mechanism of injury to patients arriving without a tourniquet (TQ-). The primary outcome was transfusion within the first 24 hours, with secondary outcomes of morbidity (rhabdomyolysis, renal failure, compartment syndrome), amputation (initial vs. delayed), and length of stay. Statistical tests included t-test and χ² for continuous and categorical variables, respectively, with p<0.05 considered as significant.

Results

Extremity arterial injuries occurred in 192 patients, with 69 (36%) having prehospital tourniquet placement for an average of 78 minutes. Tourniquet use increased over time from 9% (2013) to 62% (2017). TQ+ patients were predominantly male (81%), with a mean age of 35.0 years. Forty-six (67%) received blood transfusion within the first 24 hours. In the matched comparison (n=69 pairs), TQ+ patients had higher initial heart rate (110 vs. 100, p=0.02), frequency of transfusion (67% vs. 48%, p<0.01), and initial amputations (23% vs. 6%, p<0.01). TQ+ patients had increased frequency of initial amputation regardless of upper (n=43 pairs) versus lower (n=26 pairs) extremity involvement; however, only upper extremity TQ+ patients had increased transfusion frequency and volume. No difference was observed in morbidity, length of stay, and mortality with tourniquet use.

Discussion

Tourniquet use has increased over time in patients with extremity arterial injuries. Patients having prehospital tourniquets required a higher frequency of transfusion and initial amputation, without an increase in complications.

Level of evidence

Therapeutic study, level IV.

Selective use of pericardial window and drainage as sole treatment for hemopericardium from penetrating chest trauma

Background

Penetrating cardiac injuries (PCIs) are highly lethal, and a sternotomy is considered mandatory for suspected PCI. Recent literature suggests pericardial window (PCW) may be sufficient for superficial cardiac injuries to drain hemopericardium and assess for continued bleeding and instability. This study objective is to review patients with PCI managed with sternotomy and PCW and compare outcomes.

Methods

All patients with penetrating chest trauma from 2000 to 2016 requiring PCW or sternotomy were reviewed. Data were collected for patients who had PCW for hemopericardium managed with only pericardial drain, or underwent sternotomy for cardiac injuries grade 1-3 according to the American Association for the Surgery of Trauma (AAST) Cardiac Organ Injury Scale (OIS). The PCW+drain group was compared with the Sternotomy group using Fisher's exact and Wilcoxon rank-sum test with P<0.05 considered statistically significant.

Results

Sternotomy was performed in 57 patients for suspected PCI, including 7 with AAST OIS grade 1-3 injuries (Sternotomy group). Four patients had pericardial injuries, three had partial thickness cardiac injuries, two of which were suture-repaired. Average blood drained was 285 mL (100-500 mL). PCW was performed in 37 patients, and 21 had hemopericardium; 16 patients proceeded to sternotomy and 5 were treated with pericardial drainage (PCW+drain group). All PCW+drain patients had suction evacuation of hemopericardium, pericardial lavage, and verified bleeding cessation, followed by pericardial drain placement and admission to intensive care unit (ICU). Average blood drained was 240 mL (40-600 mL), and pericardial drains were removed on postoperative day 3.6 (2-5). There was no significant difference in demographics, injury mechanism, Revised Trauma Score exploratory laparotomies, hospital or ICU length of stay, or ventilator days. No in-hospital mortality occurred in either group.

Conclusions

Hemodynamically stable patients with penetrating chest trauma and hemopericardium may be safely managed with PCW, lavage and drainage with documented cessation of bleeding, and postoperative ICU monitoring.

Level of evidence

Therapeutic study, level IV.

Variations in institutional review board processes and consent requirements for trauma research: an EAST multicenter survey

Oversight of human subject research has evolved considerably since its inception. However, previous studies identified a lack of consistency of institutional review board (IRB) determination for the type of review required and whether informed consent is necessary, especially for prospective observational studies, which pose minimal risk of harm. We hypothesized that there is significant inter-institution variation in IRB requirements for the type of review and necessity of informed consent, especially for prospective observational trials without blood/tissue utilization. We also sought to describe investigators' and IRB members' attitudes toward the type of review and need for consent. Eastern Association for the Surgery of Trauma (EAST) and IRB members were sent an electronic survey on IRB review and informed consent requirement. We performed descriptive analyses as well as Fisher's exact test to determine differences between EAST and IRB members' responses. The response rate for EAST members from 113 institutions was 13.5%, whereas a convenience sample of IRB members from 14 institutions had a response rate of 64.4%. Requirement for full IRB review for retrospective studies using patient identifiers was reported by zero IRB member compared with 13.1% of EAST members (p=0.05). Regarding prospective observational trials without blood/tissue collection, 48.1% of EAST members reported their institutions required a full IRB review compared with 9.5% of IRB members (p=0.01). For prospective observational trials with blood/tissue collection, 80% of EAST members indicated requirement to submit a full IRB review compared with only 13.6% of IRB members (p<0.001). Most EAST members (78.6%) stated that informed consent is not ethically necessary in prospective observational trials without blood/tissue collection, whereas most IRB members thought that informed consent was ethically necessary (63.6%, p<0.001). There is significant variation in perception and practice regarding the level of review for prospective observational studies and whether informed consent is necessary. We recommend future interdisciplinary efforts between researchers and IRBs should occur to better standardize local IRB efforts.

Level of evidence

IV.

Patients with multiple traumatic amputations: An analysis of operation enduring freedom joint theatre trauma registry data

INTRODUCTION

Improvised Explosive Devices (IED) are the primary wounding mechanism for casualties in Operation Enduring Freedom. Patients can sustain devastating traumatic amputations, which are unlike injuries seen in the civilian trauma sector. This is a database analysis of the largest patient registry of multiple traumatic amputations.

METHODS

The Joint Theater Trauma Registry was queried for patients with a traumatic amputation from 2009 to 2012. Data obtained included the Injury Severity Score (ISS), Glasgow Coma Score (GCS), blood products, transfer from theatre, and complications including DVT, PE, infection (Acinetobacter and fungal), acute renal failure, and rhabdomyolysis. Comparisons were made between number of major amputations (1-4) and specific outcomes using χ² and Pearson's rank test, and multivariable logistic regression was performed for 30-day survival. Significance was considered with p<0.05.

RESULTS

We identified 720 military personnel with at least one traumatic amputation: 494 single, 191 double, 32 triple, and 3 quad amputees. Average age was 24.3 years (18-46), median ISS 24 (9-66), and GCS 15 (3-15). Tranexamic acid (TXA) was administered in 164 patients (23%) and tourniquets were used in 575 (80%). Both TXA and tourniquet use increased with increasing number of amputations (p<0.001). Average transfusion requirements (in units) were packed red blood cells (PRBC) 18.6 (0-142), fresh frozen plasma (FFP) 17.3 (0-128), platelets 3.6 (0-26), and cryoprecipitate 5.6 (0-130). Transfusion of all blood products increased with the number of amputations (p<0.001). All complications tested increased with the number of amputations except Acinetobacter infection, coagulopathy, and compartment syndrome. Transfer to higher acuity facilities was achieved in 676 patients (94%).

CONCLUSION

Traumatic amputations from blast injuries require significant blood product transfusion, which increases with the number of amputations. Most complications also increase with the number of amputations. Despite high injury severity, 94% of traumatic amputation patients who are alive upon admission to a role II/III facility will survive to transfer to facilities with higher acuity care.

Fast-track pathways in colorectal surgery

Enhanced recovery after surgery or "fast-track" pathways are a multimodal approach to the perioperative management of patients undergoing colorectal surgery designed to improve the overall quality of care. These pathways use existing evidence to streamline and standardize the perioperative management of patients to improve pain management, speed intestinal recovery, and ultimately facilitate a more rapid hospital discharge, thus minimizing complications, decreasing the use of hospital resources and health care costs, and improving overall patient care and satisfaction. Fast-track protocols are safe for patients and offer improvement in intestinal recovery and hospital discharge.

Interleukin-22: implications for liver ischemia-reperfusion injury

BACKGROUND

Ischemia-reperfusion injury (IRI) is common in general surgery and organ transplantation, and in the case of liver, it triggers proinflammatory innate immune cascade and hepatic necrosis, leading to increased incidence of early and late organ rejection. Interleukin (IL)-22, an inducible cytokine of T-cell origin and a member of the IL-10 superfamily, acts on target tissues through IL-22 receptor (IL-22R1).

METHODS

Partial hepatic warm ischemia was induced in C57Bl/6 wild-type (WT) and type 1 interferon receptor-deficient (KO) mice for 90 min followed by 6 to 24 hr of reperfusion. WT mice were treated at 30 min before the ischemia insult with recombinant IL-22 or anti-IL-22 neutralizing antibody; phosphate-buffered saline and IgG served as respective controls.

RESULTS

IL-22 was detected at 24 hr but not 6 hr of liver IRI. The expression of IL-22R1 was increased by 6 hr of reperfusion in WT but not type 1 interferon receptor KO mice that were protected from IRI. Treatment of WT mice with recombinant IL-22 decreased serum aspartate aminotransferase levels, ameliorated cardinal histological features of IR damage (Suzuki's score) and diminished leukocyte sequestration, along with the expression of IL-22R1 and pro-inflammatory cytokines. IL-22 antibody did not appreciably affect IRI but increased IL-22R1 transcription in the liver. Administration of IL-22 protein exerted hepatoprotection by STAT3 activation.

CONCLUSIONS

This is the first report investigating immune modulation by T-cell-derived IL-22 in liver injury caused by warm ischemia and reperfusion. Treatment with IL-22 protein may represent a novel therapeutic strategy to prevent liver IRI in transplant recipients.

Surgical procedures for patients receiving mechanical cardiac support

Mechanical cardiac support devices are used for patients with cardiopulmonary failure. We reviewed our institutional experience with noncardiac surgical procedures (NCPs) in patients supported by ventricular assist devices (VADs, n = 198) or extracorporeal membrane oxygenation (ECMO, n = 165) between July 1998 and June 2010. In total, 64 NCPs were performed in 55 VAD patients and 14 NCPs in 14 ECMO patients. Thirty-day mortality was higher for the VAD compared with the ECMO group (25 vs 86%; P < 0.001) and was greater for emergent compared with nonemergent procedures (58 vs 19%; P < 0.001). Excluding tracheostomy, no patients died within 30 days of a nonemergent procedure. Kaplan-Meier survival showed a trend toward worse survival after NCP in ECMO patients, but NCP did not alter survival in VAD patients. Fewer VAD patients were bridged to heart transplantation when NCP was required, and time from device implantation to transplant was significantly longer than for patients without NCP. In summary, this is the largest series of NCPs on VAD support and the only series on ECMO. Mortality is substantial for ECMO patients. Selected procedures can be performed safely in VAD patients but will delay heart transplantation.

Surgical Procedures for Patients Receiving Mechanical Cardiac Support

Mechanical cardiac support devices are used for patients with cardiopulmonary failure. We reviewed our institutional experience with noncardiac surgical procedures (NCPs) in patients supported by ventricular assist devices (VADs, n = 198) or extracorporeal membrane oxygenation (ECMO, n = 165) between July 1998 and June 2010. In total, 64 NCPs were performed in 55 VAD patients and 14 NCPs in 14 ECMO patients. Thirty-day mortality was higher for the VAD compared with the ECMO group (25 vs 86%; P < 0.001) and was greater for emergent compared with nonemergent procedures (58 vs 19%; P < 0.001). Excluding tracheostomy, no patients died within 30 days of a nonemergent procedure. Kaplan-Meier survival showed a trend toward worse survival after NCP in ECMO patients, but NCP did not alter survival in VAD patients. Fewer VAD patients were bridged to heart transplantation when NCP was required, and time from device implantation to transplant was significantly longer than for patients without NCP. In summary, this is the largest series of NCPs on VAD support and the only series on ECMO. Mortality is substantial for ECMO patients. Selected procedures can be performed safely in VAD patients but will delay heart transplantation.

Duodenal Lymphoma: A Rare and Morbid Tumor

We conducted a retrospective tumor registry review of a 36-year experience in a university center and identified 10 patients with duodenal lymphoma (five localized, five disseminated). Histologic types included diffuse large B-cell in four patients, mucosa-associated lymphoid tumor in three, and Hodgkin, follicular, and unclassified (one each). Treatments included chemotherapy in four patients, radiation therapy (RT) in two patients, Helicobacter pylori treatment in two, and observation in one. Five patients underwent operations (emergent in two, elective in three) for indications including massive bleeding in two patients, obstruction in two, or both in one. Survival for surgical group was 25 per cent at 1 year. One-year survival for nonsurgical group was 100 per cent, and all nonoperated patients lived at least 5 years, except for one who is alive 2 years after diagnosis. Surgical patients were younger and had more advanced lesions and less favorable cell types. When operation is required for bleeding or obstruction from secondary tumors in younger patients with disseminated disease, surgical challenges are formidable and survival is very limited. Tumors of less aggressive histology have far better prognosis.

Duodenal lymphoma: a rare and morbid tumor

We conducted a retrospective tumor registry review of a 36-year experience in a university center and identified 10 patients with duodenal lymphoma (five localized, five disseminated). Histologic types included diffuse large B-cell in four patients, mucosa-associated lymphoid tumor in three, and Hodgkin, follicular, and unclassified (one each). Treatments included chemotherapy in four patients, radiation therapy (RT) in two patients, Helicobacter pylori treatment in two, and observation in one. Five patients underwent operations (emergent in two, elective in three) for indications including massive bleeding in two patients, obstruction in two, or both in one. Survival for surgical group was 25 per cent at 1 year. One-year survival for nonsurgical group was 100 per cent, and all nonoperated patients lived at least 5 years, except for one who is alive 2 years after diagnosis. Surgical patients were younger and had more advanced lesions and less favorable cell types. When operation is required for bleeding or obstruction from secondary tumors in younger patients with disseminated disease, surgical challenges are formidable and survival is very limited. Tumors of less aggressive histology have far better prognosis.