A. Britton Christmas

Vasopressor use after initial damage control laparotomy increases risk for anastomotic disruption in the management of destructive colon injuries

BACKGROUND Management of destructive colon injuries during damage control (DC) laparotomy is debated. The authors reviewed a single institutions experience with destructive colon injuries to identify risk factors for anastomotic failure after colon reconstruction. METHODS The authors identified all trauma patients sustaining destructive colon injuries between 2002 and 2011 from their medical centers trauma registry. Anastomotic leak was defined as suture or staple line disruption or enteral fistula formation. RESULTS Of 171 identified patients, 68 had DC procedures, 41 (60%) had subsequent anastomoses performed during the same hospitalization, and 27 (40%) were diverted. The colon anastomotic leak rate in patients who underwent DC laparotomy was higher than in patients who were reconstructed at the primary operation in a non-DC setting (17% vs 6%, P = .09). The use of vasopressors after the initial DC operation more than quadrupled the leak rate to 50% (P = .02). CONCLUSIONS Colonic anastomotic disruptions yield deadly consequences, and diversion rather than anastomosis should be used in patients who require vasopressor support after the initial DC procedure.

Vena cava filter retrieval in therapeutically anticoagulated patients.

BACKGROUND Vena cava filters (VCFs) are indicated in patients with active venous thromboembolism and are a contraindication to therapeutic anticoagulation. When patients can be anticoagulated, VCFs can be removed; however, patients often have anticoagulation discontinued during the retrieval procedure, leaving them at risk for pulmonary embolism (PE). The authors evaluated their experience with retrieving VCFs in therapeutically anticoagulated patients. METHODS Data from a prospectively collected database of patients with VCFs placed between January 2005 and September 2007 were reviewed. The retrievals in therapeutically anticoagulated patients (international normalized ratio, 2.0-3.4) were performed using a strict protocol, including preretrieval and postretrieval cavograms. All retrievals were performed in the operating room, and patients were discharged home the same day and examined within 7 to 14 days. Descriptive statistics including means and counts were calculated. RESULTS One hundred thirteen VCF removals occurred during the study period; 62 were attempted on anticoagulated patients (42 male and 20 female patients; mean age, 36.5 years). Thirty-five patients (56%) had VCFs placed for prophylaxis, 22 (35%) had deep venous thromboses or PEs but had contraindications to anticoagulation, and 5 (8%) were on anticoagulation, which was discontinued perioperatively for major surgical operations. The mean time the filters were in place was 153.7 days (range, 22-684 days). No extravasation was seen on postretrieval cavography. Eight of 62 removal attempts in anticoagulated patients were unsuccessful. One patient had a postoperative pneumothorax that was successfully managed without intervention. There were no operative bleeding complications, and no hematomas or contusions were seen at follow-up. CONCLUSIONS The retrieval of VCFs in therapeutically anticoagulated patients can be performed without complication. Given the perioperative risk for PE, anticoagulation should not be discontinued for VCF retrieval.

Prevention of fall-related injuries in the elderly: an eastern association for the surgery of trauma practice management guideline

BACKGROUND Fall-related injuries among the elderly (age 65 and older) are the cause of nearly 750,000 hospitalizations and 25,000 deaths per year in the United States, yet prevention research is lagging. Using the Grading of Recommendations Assessment, Development, and Evaluation (GRADE) methodology, the Eastern Association for the Surgery of Trauma produced this practice management guideline to answer the following injury prevention–related population, intervention, comparator, outcomes (PICO) questions: PICO 1: Should bone mineral–enhancing agents be used to prevent fall-related injuries in the elderly? PICO 2: Should hip protectors be used to prevent fall-related injuries in the elderly? PICO 3: Should exercise programs be used to prevent fall-related injuries in the elderly? PICO 4: Should physical environment modifications be used to prevent fall-related injuries in the elderly? PICO 5: Should risk factor screening be used to prevent fall-related injuries in the elderly? PICO 6: Should multiple interventions tailored to the population or individual be used to prevent fall-related injuries in the elderly? METHODS A comprehensive search and review of all the available literature was performed. We used the GRADE methodology to assess the breadth and quality of the data specific to our PICO questions. RESULTS We reviewed 50 articles that met our inclusion and exclusion criteria as they applied to our PICO questions. CONCLUSION Given the data constraints, we offer the following suggestions and recommendations: PICO 1: We conditionally recommend vitamin D and calcium supplementation for frail elderly individuals. PICO 2: We conditionally recommend hip protectors for frail elderly individuals, in the appropriate environment. PICO 3: We conditionally recommend evidence-based exercise programs for frail elderly individuals. PICO 4: We conditionally recommend physical environment modification for frail elderly people. PICO 5: We conditionally recommend frailty screening for the elderly. PICO 6: We strongly recommend risk stratification with targeted comprehensive risk-reduction strategies tailored to particular high-risk groups. LEVEL OF EVIDENCE Systematic review, level III.

Impact of common crystalloid solutions on resuscitation markers following Class I hemorrhage: A randomized control trial.

BACKGROUND Resuscitation after hemorrhage with crystalloid solutions can lead to marked acidosis and iatrogenically worsen the lethal triad. The effect of differing solutions on base deficit and lactate has been sparsely prospectively studied in humans. We sought to quantify the effect of normal saline (NS) and lactated Ringer’s (LR) resuscitation in voluntary blood donors as a model for Class I hemorrhage. METHODS A prospective randomized control trial was conducted in conjunction with blood drives. Donors were randomized to receive no intravenous fluid (noIVF), 2-L NS, or 2-L LR after blood donation of 500 mL. Lactate and base deficit were measured before and after fluid administration using an iSTAT. The mean laboratory values were compared between groups first using a global test followed by pairwise testing between groups using the Wilcoxon rank-sum and Kruskal-Wallis tests. The Bonferroni correction was used and a statistical significance of p < 0.0167 was set. RESULTS A total of 157 patients completed the study. The mean (SD) age was 39.2 (12.7), and 65.0% were female. Patients in each group lost equivalent amounts of total blood volume, and a similar amount was replaced in the crystalloid group (p > 0.0167). Donors had comparable increases in lactate and base deficit after donation regardless of the group (p > 0.0167). After resuscitation with 2-L crystalloid, the lactate level increased higher in the LR group than in the noIVF or the NS group (1.36 mmol/L vs. 1.00 mmol/L vs. 1.54 mmol/L, p < 0.0001). In addition, the resuscitation base deficit increased in the NS group more than in the noIVF or LR group (−0.65 vs. −3.06 vs. −0.34, p < 0.0001). CONCLUSION This study is one of the first human studies to prospectively demonstrate quantifiable differences in base deficit and lactate by type of crystalloid resuscitation. LR resuscitation elevated lactate levels, and NS negatively affected the base deficit. These findings are critical to the interpretation of trauma patient resuscitation with crystalloid solutions. LEVEL OF EVIDENCE Therapeutic study, level II.

Definitive laparoscopic repair of penetrating injuries to the colon and small intestine: a case report.

Several case reports and small series have documented the feasibility of therapeutic laparoscopy for traumatic liver, splenic, and diaphragmatic injuries. A multicenter report of laparoscopies for trauma by Zantut et al. documented only three gastrostomies repaired laparoscopically with no small bowel or colon injuries repaired. We present a laparoscopic repair of small bowel and colon injuries caused by a gunshot wound.

Motor Vehicle Collision-Related Injuries in the Elderly: An Eastern Association for the Surgery of Trauma Evidence-Based Review of Risk Factors and Prevention.

Advancements in car and road safety in the US have led to a drop in the number of overall fatalities per million miles traveled in recent decades. However, elderly individuals (aged 65 and older) remain more likely to die or be severely injured due to motor vehicle collisions (MVCs) than younger people. As the elderly population continues to grow, the number of elderly injured by MVCs is also expected to increase. In this article, the authors investigate MVC-related injury prevention strategies aimed at elderly drivers and pedestrians. An evidence-based review of risk factors and prevention is conducted. The authors determine that injury prevention research is lagging and they recommend further research to strengthen future evidence-based guidelines.

Failure of lorazepam to treat alprazolam withdrawal in a critically ill patient

Management of sedation in the critical care unit is an ongoing challenge. Benzodiazepines have been commonly used as sedatives in critically ill patients. The pharmacokinetic and pharmacodynamic properties that make benzodiazepines effective and safe in critical care sedation include rapid onset of action and decreased respiratory depression. Alprazolam is a commonly used benzodiazepine that is prescribed for anxiety and panic disorders. It is frequently prescribed in the outpatient setting. Its use has been reported to result in a relatively high rate of dependence and subsequent withdrawal symptoms. Symptoms of alprazolam withdrawal can be difficult to recognize and treat in the critical care setting. In addition, other benzodiazepines may also be ineffective in treating alprazolam withdrawal. We present a case of alprazolam withdrawal in a critically ill trauma patient who failed treatment with lorazepam and haloperidol. Subsequent replacement with alprazolam resulted in significant improvement in the patients medication use and clinical status.

Mopeds: The legal Loophole for Repeat Driving While Intoxicated Offenders

BACKGROUND Mopeds have less stringent licensing laws than automobiles. Moped operators in motorized vehicle collisions (MVCs) exhibit significantly higher rates of driving while intoxicated (DWI) and higher blood alcohol levels than automobile or motorcycle operators. This study evaluates the public safety issue of DWI recidivism among moped operators. METHODS Moped operators evaluated after MVCs were identified from 2007 to 2009. Demographics, hospital data, and Department of Motor Vehicles records were reviewed. RESULTS Sixty-five moped operators were evaluated. Thirty-two (49%) had a positive blood alcohol level, 29 (45%) had a previous DWI, and 21 (72%) of those were repeat offenders. Twenty-five (38%) had a revoked license at the time of injury. Of these, 19 (76%) incurred multiple revocations. Twenty-two (34%) showed prior charges of driving with a revoked license (DWRL), with 15 (68%) incurring multiple DWRL charges. CONCLUSIONS Moped operators are often intoxicated at the time of injury and represent a public safety hazard. The majority are recidivists with multiple alcohol-related traffic charges. Current laws allow repeat offenders the sustained opportunity to operate motorized vehicles. Re-evaluation of current moped laws is needed to keep habitual offenders off the road.

Removal of erythropoietin from anaemia trauma practice guideline does not increase red blood cell transfusions and decreases hospital utilization costs.

INTRODUCTION We previously demonstrated that utilization of erythropoietin (r-EPO) did not significantly reduce blood utilization in trauma patients. We undertook this study to analyze blood utilization 1 year after r-EPO removal from our trauma service anaemia practice management guideline. METHODS Electronic records of patients admitted to the trauma service were retrospectively reviewed for units of packed red blood cells (pRBCs) transfused and for units of r-EPO administered 12 months before the initiation of an anaemia practice guideline (PRE), 12 months during the use of an anaemia guideline (GUIDE), and 12 months following removal of r-EPO from the guideline (POST). Hospital acquisition cost was also reviewed for the respective time periods. Nominal data were analyzed using chi-squared or Fishers exact tests, and interval data were compared using ANOVA followed by Tukeys test where appropriate. Results were considered significant for P<0.05. RESULTS Over the 3-year study period, 4881 patients were admitted to the trauma service and included in this study. The hospital length of stay, intensive care unit length of stay, and units of pRBC transfused were similar among all three groups. Group I (PRE) received a total of 228 doses of r-EPO at a cost of

Hospital-based violence intervention programs targeting adult populations: an Eastern Association for the Surgery of Trauma evidence-based review

102,600. Group II (GUIDE) received a total of 410 doses at a cost of