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Matta R, Keihani S, Hebert K, Horns JJ, Nirula R, McCrum M, McCormick BJ, Gross JA, Joyce RP, Rogers DM, Wang SS, Hagedorn JC, Selph JP, Sensenig RL, Moses RA, Dodgion CM, Gupta S, Mukherjee K, Majercik S, Broghammer JA, Schwartz I, Elliott SP, Breyer BN, Baradaran N, Zakaluzny S, Erickson BA, Miller BD, Askari R, Carrick MM, Burks FN, Norwood S, Myers JB. PROPOSED REVISION OF THE AMERICAN ASSOCIATION FOR SURGERY OF TRAUMA RENAL TRAUMA ORGAN INJURY SCALE: SECONDARY ANALYSIS OF THE MULTI-INSTITUTIONAL GENITOURINARY TRAUMA STUDY. J Trauma Acute Care Surg 2024:01586154-990000000-00628. [PMID: 38319246 DOI: 10.1097/ta.0000000000004232] [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: 02/07/2024]
Abstract
BACKGROUND This study updates the American Association for Surgery of Trauma (AAST) Organ Injury Scale (OIS) for renal trauma using evidence-based criteria for bleeding control intervention. METHODS This was a secondary analysis of a multi-center retrospective study including patients with high grade renal trauma from 7 Level-1 trauma centers from 2013-2018. All eligible patients were assigned new renal trauma grades based on revised criteria. The primary outcome used to measure injury severity was intervention for renal bleeding. Secondary outcomes included intervention for urinary extravasation, units of packed red blood cells (PRBCs) transfused within 24 hours, and mortality. To test the revised grading system, we performed mixed effect logistic regression adjusted for multiple baseline demographic and trauma covariates. We determined the area under the receiver-operator curve (AUC) to assess accuracy of predicting bleeding interventions from the revised grading system and compared this to 2018 AAST organ injury scale. RESULTS based on the 2018 OIS grading system, we included 549 patients with AAST Grade III-V injuries and CT scans (III: 52% (n = 284), IV: 45% (n = 249), and V: 3% (n = 16)). Among these patients, 89% experienced blunt injury (n = 491) and 12% (n = 64) underwent intervention for bleeding. After applying the revised grading criteria, 60% (n = 329) of patients were downgraded and 4% (n = 23) were upgraded; 2.8% (n = 7) downgraded from grade V to IV, and 69.5% (n = 173) downgraded from IV to III. The revised renal trauma grading system demonstrated improved predictive ability for bleeding interventions (2018 AUC = 0.805, revised AUC = 0.883; p = 0.001) and number of units of PRBCs transfused. When we removed urinary injury from the revised system, there was no difference in its predictive ability for renal hemorrhage intervention. CONCLUSIONS A revised renal trauma grading system better delineates the need for hemostatic interventions than the current AAST OIS renal trauma grading system. LEVEL OF EVIDENCE II.
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Affiliation(s)
- Rano Matta
- Division of Urology, Department of Surgery, University of Toronto, Toronto, ON, Canada
| | - Sorena Keihani
- Department of Surgery, University of Utah, Salt Lake City, UT, USA
| | - Kevin Hebert
- Department of Surgery, Louisiana State University Health Shreveport, Shreveport, LA, USA
| | - Joshua J Horns
- Department of Surgery, University of Utah, Salt Lake City, UT, USA
| | - Raminder Nirula
- Department of Surgery, University of Utah, Salt Lake City, UT, USA
| | - Marta McCrum
- Department of Surgery, University of Utah, Salt Lake City, UT, USA
| | | | - Joel A Gross
- Department of Radiology, Harborview Medical Center, University of Washington, Seattle, WA, USA
| | - Ryan P Joyce
- NYU Grossman School of Medicine, New York, NY, USA
| | - Douglas M Rogers
- Department of Radiology, University of Utah Salt Lake City, UT, USA
| | | | - Judith C Hagedorn
- Department of Urology, Harborview Medical Center, University of Washington, Seattle, Washington
| | - J Patrick Selph
- Department of Urology, University of Alabama at Birmingham, Birmingham, Alabama
| | - Rachel L Sensenig
- Division of Trauma, Department of Surgery, Cooper University Hospital, Camden, NJ, USA
| | - Rachel A Moses
- Department of Surgery, Section of Urology, Dartmouth Hitchcock Medical Center, Lebanon, New Hampshire
| | | | - Shubham Gupta
- Department of Urology, Case Western Reserve University, Cleveland, OH, USA
| | - Kaushik Mukherjee
- Division of Acute Care Surgery, Loma Linda University Medical Center, Loma Linda, CA, USA
| | - Sarah Majercik
- Division of Trauma and Surgical Critical Care, Intermountain Medical Center, Murray, UT, USA
| | | | - Ian Schwartz
- Department of Urology, Hennepin County Medical Center, University of Minnesota, Minneapolis, MN, USA
| | - Sean P Elliott
- Department of Urology, University of Minnesota, Minneapolis, MN, USA
| | - Benjamin N Breyer
- Department of Urology, University of California - San Francisco, San Francisco, CA, USA
| | - Nima Baradaran
- Department of Urology, The Ohio State University Wexner Medical Center, Columbus, OH, USA
| | - Scott Zakaluzny
- Division of Trauma, Acute Care Surgery, and Surgical Critical Care, Department of Surgery, University of California Davis Medical Center, Sacramento, CA, USA
| | | | - Brandi D Miller
- Department of Urology, Detroit Medical Center, Detroit, MI, USA
| | - Reza Askari
- Division of Trauma, Department of Surgery, Brigham and Women's Hospital, Boston, MA, USA
| | | | - Frank N Burks
- Department of Urology, Oakland University William Beaumont School of Medicine, Royal Oak, MI, USA
| | - Scott Norwood
- Department of Surgery, UT Health Tyler, Tyler, TX, USA
| | - Jeremy B Myers
- Department of Surgery, University of Utah, Salt Lake City, UT, USA
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Keihani S, Putbrese BE, Rogers DM, Zhang C, Nirula R, Luo-Owen X, Mukherjee K, Morris BJ, Majercik S, Piotrowski J, Dodgion CM, Schwartz I, Elliott SP, DeSoucy ES, Zakaluzny S, Sherwood BG, Erickson BA, Baradaran N, Breyer BN, Fick CN, Smith BP, Okafor BU, Askari R, Miller B, Santucci RA, Carrick MM, Kocik JF, Hewitt T, Burks FN, Heilbrun ME, Myers JB. The associations between initial radiographic findings and interventions for renal hemorrhage after high-grade renal trauma: Results from the Multi-Institutional Genitourinary Trauma Study. J Trauma Acute Care Surg 2019; 86:974-982. [PMID: 31124895 DOI: 10.1097/ta.0000000000002254] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/23/2022]
Abstract
BACKGROUND Indications for intervention after high-grade renal trauma (HGRT) remain poorly defined. Certain radiographic findings can be used to guide the management of HGRT. We aimed to assess the associations between initial radiographic findings and interventions for hemorrhage after HGRT and to determine hematoma and laceration sizes predicting interventions. METHODS The Genitourinary Trauma Study is a multicenter study including HGRT patients from 14 Level I trauma centers from 2014 to 2017. Admission computed tomography scans were categorized based on multiple variables, including vascular contrast extravasation (VCE), hematoma rim distance (HRD), and size of the deepest laceration. Renal bleeding interventions included angioembolization, surgical packing, renorrhaphy, partial nephrectomy, and nephrectomy. Mixed-effect Poisson regression was used to assess the associations. Receiver operating characteristic analysis was used to define optimal cutoffs for HRD and laceration size. RESULTS In the 326 patients, injury mechanism was blunt in 81%. Forty-seven (14%) patients underwent 51 bleeding interventions, including 19 renal angioembolizations, 16 nephrectomies, and 16 other procedures. In univariable analysis, presence of VCE was associated with a 5.9-fold increase in risk of interventions, and each centimeter increase in HRD was associated with 30% increase in risk of bleeding interventions. An HRD of 3.5 cm or greater and renal laceration depth of 2.5 cm or greater were most predictive of interventions. In multivariable models, VCE and HRD were significantly associated with bleeding interventions. CONCLUSION Our findings support the importance of certain radiographic findings in prediction of bleeding interventions after HGRT. These factors can be used as adjuncts to renal injury grading to guide clinical decision making. LEVEL OF EVIDENCE Prognostic and Epidemiological Study, Level III and Therapeutic/Care Management, Level IV.
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Affiliation(s)
- Sorena Keihani
- From the Division of Urology, Department of Surgery (S.K., J.B.M.), Department of Radiology (B.E.P., D.M.R.), Division of Epidemiology, Department of Internal Medicine (C.Z.), Department of Surgery (R.N.), University of Utah, Salt Lake City, Utah; Division of Acute Care Surgery (X. L-O, K.M), Loma Linda University Medical Center, Loma Linda, California; Division of Trauma and Surgical Critical Care (B.J.M., S.M), Intermountain Medical Center, Murray, Utah; Department of Urology (J.P.), Department of Surgery (C.M.D.), University of Wisconsin, Milwaukee, Wisconsin; Department of Urology (I.S., S.P.E.), Hennepin County Medical Center, University of Minnesota, Minneapolis, Minnesota; Department of Surgery (E.S.D.); Division of Trauma, Acute Care Surgery, and Surgical Critical Care, Department of Surgery (S.Z.), University of California Davis Medical Center, Sacramento, California; Department of Urology (B.G.S., BA.E), University of Iowa, Iowa City, Iowa; Department of Urology (N.B., B.N.B.), University of California-San Francisco, San Francisco, California; Division of Trauma and Surgical Critical Care (C.N.F., B.P.S), Hospital of the University of Pennsylvania, Philadelphia, Pennsylvania; Division of Trauma, Department of Surgery (B.U.O., R.A.), Brigham and Women's Hospital, Boston, Massachusetts; Department of Urology (B.M., R.A.S), Detroit Medical Center, Detroit, Michigan; Medical City Plano (M.M.C.), Plano; Department of Surgery (J.F.K.), East Texas Medical Center, Tyler, Texas; Department of Urology (T.H., F.N.B.), Oakland University William Beaumont School of Medicine, Royal Oak, Michigan; Department of Radiology and Imaging Sciences (M.E.H.), Emory University Hospital, Atlanta, Georgia
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Grabo DJ, Seery JM, Bradley M, Zakaluzny S, Kearns MJ, Fernandez N, Tadlock M. Prevention of Deep Venous Thromboembolism. Mil Med 2019; 183:133-136. [PMID: 30189059 DOI: 10.1093/milmed/usy072] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/21/2016] [Indexed: 11/12/2022] Open
Abstract
The nature of many combat wounds puts patients at a high risk of developing deep venous thrombosis (DVT) and pulmonary embolism (PE), which fall under the broader disease category of venous thromboembolism (VTE). In addition to the hypercoagulable state induced by trauma, massive injuries to the extremities, prolonged immobility, and long fixed wing transport times to higher echelons of care are unique risk factors for venous thromboembolism in the combat-injured patient. These risk factors mandate aggressive prophylaxis for DVT and PE that can effectively be achieved by the use of lower extremity sequential compression devices and low dose unfractionated heparin or low molecular weight heparin. In addition, inferior vena cava filters are often used for PE prophylaxis when chemical DVT prophylaxis fails or is contraindicated. The following Department of Defense (DoD) Joint Trauma System (JTS) Clinical Practice Guideline (CPG) discusses the current recommendations for the prevention of DVT and PE including the use of inferior vena cava filters (IVCFs).
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Affiliation(s)
- Daniel J Grabo
- Joint Trauma System, 3698 Chambers Pass, Joint Base San Antonio, Fort Sam Houston, TX
| | - Jason M Seery
- Joint Trauma System, 3698 Chambers Pass, Joint Base San Antonio, Fort Sam Houston, TX
| | - Matthew Bradley
- Joint Trauma System, 3698 Chambers Pass, Joint Base San Antonio, Fort Sam Houston, TX
| | - Scott Zakaluzny
- Joint Trauma System, 3698 Chambers Pass, Joint Base San Antonio, Fort Sam Houston, TX
| | - Michel J Kearns
- Joint Trauma System, 3698 Chambers Pass, Joint Base San Antonio, Fort Sam Houston, TX
| | - Nathanial Fernandez
- Joint Trauma System, 3698 Chambers Pass, Joint Base San Antonio, Fort Sam Houston, TX
| | - Matthew Tadlock
- Joint Trauma System, 3698 Chambers Pass, Joint Base San Antonio, Fort Sam Houston, TX
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Monchal T, Martin MJ, Antevil JL, Bennett DR, DeVries WC, Zakaluzny S, Ricca RL, Tien H, Mullenix PS, Stockinger ZT. Emergency Resuscitative Thoracotomy in the Combat or Operational Environment. Mil Med 2019; 183:92-97. [PMID: 30189054 DOI: 10.1093/milmed/usy117] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/05/2018] [Indexed: 11/15/2022] Open
Abstract
Resuscitative thoracotomy has been extensively described in the civilian trauma literature and has a high mortality rate, due largely to the nature of the injuries leading to arrest. The survival rates are generally highest (10-30%) for penetrating truncal injuries and patients who arrive with vital signs and proceed to arrest or who have impending arrest. They are significantly lower (less than 5%) for blunt trauma victims, particularly those who arrest in the field or during transport (1% or less). In addition, the likelihood of survival with intact neurologic function is significantly lower than the overall survival rates, particularly for blunt trauma victims and for prehospital arrest.
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Affiliation(s)
- Tristan Monchal
- Joint Trauma System, 3698 Chambers Pass, Joint Base San Antonio, Fort Sam Houston, TX
| | - Matthew J Martin
- Joint Trauma System, 3698 Chambers Pass, Joint Base San Antonio, Fort Sam Houston, TX
| | - Jared L Antevil
- Joint Trauma System, 3698 Chambers Pass, Joint Base San Antonio, Fort Sam Houston, TX
| | - Donald R Bennett
- Joint Trauma System, 3698 Chambers Pass, Joint Base San Antonio, Fort Sam Houston, TX
| | - William C DeVries
- Joint Trauma System, 3698 Chambers Pass, Joint Base San Antonio, Fort Sam Houston, TX
| | - Scott Zakaluzny
- Joint Trauma System, 3698 Chambers Pass, Joint Base San Antonio, Fort Sam Houston, TX
| | - Robert L Ricca
- Joint Trauma System, 3698 Chambers Pass, Joint Base San Antonio, Fort Sam Houston, TX
| | - Homer Tien
- Joint Trauma System, 3698 Chambers Pass, Joint Base San Antonio, Fort Sam Houston, TX.,Canadian Forces Health Services
| | - Philip S Mullenix
- Joint Trauma System, 3698 Chambers Pass, Joint Base San Antonio, Fort Sam Houston, TX
| | - Zsolt T Stockinger
- Joint Trauma System, 3698 Chambers Pass, Joint Base San Antonio, Fort Sam Houston, TX
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Keihani S, Moses R, Xu Y, Putbrese B, Rogers D, Luo-Owen X, Mukherjee K, Morris B, Majercik S, Piotrowski J, Dodgion C, Sherwood B, Erickson B, Schwartz I, Elliott S, DeSoucy E, Zakaluzny S, Baradaran N, Breyer B, Smith B, Miller B, Santucci R, Carrick M, Kocik J, Hewitt T, Burks F, Heilbrun M, Hotaling J, Presson A, Nirula R, Myers J. MP25-18 IMAGING FINDINGS ASSOCIATED WITH RENAL BLEEDING INTERVENTIONS AFTER HIGH-GRADE RENAL TRAUMA: RESULTS FROM THE AMERICAN ASSOCIATION FOR SURGERY OF TRAUMA (AAST) GENITO-URINARY TRAUMA STUDY. J Urol 2018. [DOI: 10.1016/j.juro.2018.02.855] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
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Beyer C, Zakaluzny S, Humphries M, Shatz D. Multidisciplinary Management of Blunt Renal Artery Injury with Endovascular Therapy in the Setting of Polytrauma: A Case Report and Review of the Literature. Ann Vasc Surg 2017; 38:318.e11-318.e16. [DOI: 10.1016/j.avsg.2016.05.130] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/02/2016] [Revised: 05/04/2016] [Accepted: 05/25/2016] [Indexed: 11/16/2022]
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Varga S, Smith J, Minneti M, Carey J, Zakaluzny S, Noguchi T, Demetriades D, Talving P. Central venous catheterization using a perfused human cadaveric model: application to surgical education. J Surg Educ 2015; 72:28-32. [PMID: 25129205 DOI: 10.1016/j.jsurg.2014.07.005] [Citation(s) in RCA: 22] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 05/01/2014] [Revised: 06/24/2014] [Accepted: 07/08/2014] [Indexed: 06/03/2023]
Abstract
OBJECTIVE The purpose of this article is to present a unique training model using a perfused human cadaver for central line placement training with the ultimate goal of reducing central venous catheter mechanical complications. DESIGN The applicability of the fresh tissue cadaver model for central line placement was assessed using a 10-item questionnaire with a 5-point Likert-type scale. Respondents were asked to rate their opinions as strongly agree, agree, neutral, disagree, or strongly disagree. SETTING All participants received a didactic lecture followed by supervised practice on a commercially available simulator. The students were then relocated to the Fresh Tissue Dissection Laboratory where they practiced central vein catheterization on a fresh perfused human cadaver. PARTICIPANTS Course participants included 87 physicians from various medical specialties at different stages of training. RESULTS Results of the survey demonstrated that 91% of the participating physicians found the perfused cadaveric model to be a true simulation of conditions that exist in live patients, and 98% reported that the use of this model promoted acquisition of technical skills. CONCLUSION The integration of central line placement training on perfused cadavers into residency and fellowship training provides an unparalleled realistic simulation to participants. Further study is needed to assess whether realistic simulation translates into objective end points such as decreased mechanical complications.
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Affiliation(s)
- Stephen Varga
- Trauma and Acute Care Surgery, Surgical Critical Care, Department of Surgery, San Antonio Military Medical Center, San Antonio, Texas.
| | - Jennifer Smith
- Los Angeles County and University of Southern California Medical Center Fresh Tissue Dissection Laboratory, Los Angeles, California
| | - Michael Minneti
- Los Angeles County and University of Southern California Medical Center Fresh Tissue Dissection Laboratory, Los Angeles, California
| | - Joseph Carey
- Los Angeles County and University of Southern California Medical Center Fresh Tissue Dissection Laboratory, Los Angeles, California
| | - Scott Zakaluzny
- Los Angeles County and University of Southern California Medical Center Fresh Tissue Dissection Laboratory, Los Angeles, California
| | - Thomas Noguchi
- Los Angeles County and University of Southern California Medical Center Fresh Tissue Dissection Laboratory, Los Angeles, California
| | - Demetrios Demetriades
- Los Angeles County and University of Southern California Medical Center Fresh Tissue Dissection Laboratory, Los Angeles, California
| | - Peep Talving
- Los Angeles County and University of Southern California Medical Center Fresh Tissue Dissection Laboratory, Los Angeles, California
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Abstract
Over the history of surgery, the management of abdominal gunshot wounds in the stable evaluable patient without peritonitis has evolved. While non-operative management has been widely accepted and employed for the management of abdominal stab wounds, recently it has been deemed a safe option for abdominal gunshot wounds as well. Selective non-operative management of penetrating abdominal trauma in the appropriate setting has been shown to decrease the rate of nontherapeutic laparotomy as well as the cost and total length of hospital stay, and potentially decrease short- and long-term morbidity. This review examines the background support for non-operative management of abdominal gunshot wounds while discussing patient evaluation, selection, and clinical management.
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Affiliation(s)
- Stephen Varga
- Division of Trauma and Surgical Critical Care, University of Southern California, Los Angeles, CA, USA
| | - Scott Zakaluzny
- Division of Trauma and Surgical Critical Care, University of Southern California, Los Angeles, CA, USA
| | - Kenji Inaba
- Division of Trauma and Surgical Critical Care, University of Southern California, Los Angeles, CA, USA
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