Amy J. Goldberg

Emergency Department Thoracotomy: Still Useful After Abdominal Exsanguination?

BACKGROUND Although literature regarding emergency department thoracotomy (EDT) outcome after abdominal exsanguination is limited, numerous reports have documented poor EDT survival in patients with anatomic injuries other than cardiac wounds. As a result, many trauma surgeons consider prelaparotomy EDT futile for patients dying from intra-abdominal hemorrhage. Our primary study objective was to prove that prelaparotomy EDT is beneficial to patients with exsanguinating abdominal hemorrhage. METHODS A retrospective review of 237 consecutive EDTs for penetrating injury (2000-2006) revealed 50 patients who underwent EDT for abdominal exsanguination. Age, gender, injury mechanism and location, field and emergency department (ED) signs of life, prehospital time, initial ED cardiac rhythm, vital signs, Glasgow Coma Score, blood transfusion requirements, predicted mortality, primary abdominal injuries, and the need for temporary abdominal closure were analyzed. The primary study endpoint was neurologically intact hospital survival. RESULTS The 50 patients who underwent prelaparotomy EDT for abdominal exsanguination were largely young (mean, 27.3 +/- 8.2 years) males (94%) suffering firearm injuries (98%). Patients presented with field (84%) and ED signs of life (78%) after a mean prehospital time of 21.2 +/- 9.8 minutes. Initial ED cardiac rhythms were variable and Glasgow Coma Score was depressed (mean, 4.2 +/- 3.2). Eight (16%) patients survived hospitalization, neurologically intact. Of these eight, all were in hemorrhagic shock because of major abdominal vascular (75%) or severe liver injuries (25%) and all required massive blood transfusion (mean, 28.6 +/- 17.3 units) and extended intensive care unit length of stay (mean, 36.3 +/- 25.7 days). CONCLUSIONS Despite critical injuries, 16% survived hospitalization, neurologically intact, after EDT for abdominal exsanguination. Our results suggest that prelaparotomy EDT provides survival benefit to penetrating trauma victims dying from intra-abdominal hemorrhage.

Emergency Department Thoracotomy for Penetrating Injuries of the Heart and Great Vessels: An Appraisal of 283 Consecutive Cases From Two Urban Trauma Centers

BACKGROUND Historically, patients with penetrating cardiac injuries have enjoyed the best survival after emergency department thoracotomy (EDT), but further examination of these series reveals a preponderance of cardiac stab wound (SW) survivors with only sporadic cardiac gunshot wound (GSW) survivors. Our primary study objective was to determine which patients requiring EDT for penetrating cardiac or great vessel (CGV) injury are salvageable. METHODS All patients who underwent EDT for penetrating CGV injuries in two urban, level I trauma centers during 2000 to 2007 were retrospectively reviewed. Demographics, injury (mechanism, anatomic injury), prehospital care, and physiology (signs of life [SOL], vital signs, and cardiac rhythm) were analyzed with respect to hospital survival. RESULTS The study population (n = 283) comprised young (mean age, 27.1 years +/- 10.1 years) men (96.1%) injured by gunshot (GSW, 88.3%) or SWs (11.7%). Patients were compared by injury mechanism and number of CGV wounds with respect to survival (SW, 24.2%; GSW, 2.8%; p < 0.001; single, 9.5%; multiple, 1.4%; p = 0.003). Three predictors-injury mechanism, ED SOL, and number of CGV wounds-were then analyzed alone and in combination with respect to hospital survival. Only one patient (0.8%) with multiple CGV GSW survived EDT. CONCLUSION When the cumulative impact of penetrating injury mechanism, ED SOL, and number of CGV wounds was analyzed together, we established that those sustaining multiple CGV GSWs (regardless of ED SOL) were nearly unsalvageable. These results indicate that when multiple CGV GSWs are encountered after EDT, further resuscitative efforts may be terminated without limiting the opportunity for survival.

Outcomes after emergency department thoracotomy for penetrating cardiac injuries: a new perspective.

Previous reports have described penetrating cardiac injuries as the anatomic injury with the greatest opportunity for emergency department thoracotomy (EDT) survival. We hypothesize that actual survival rates are lower than that initially reported. A retrospective review of our EDT experience was performed. Data collected included injury mechanism and location, presence of measurable ED vital signs, initial ED cardiac rhythm, GCS, method of transportation, and survival. Logistic regression analysis identified predictors of survival. Ninety-four of 237 patients presented penetrating cardiac injuries after EDT. Eighty-nine patients (95%) were males. Measurable ED vital signs were present in 15 patients (16%). Cardiac injuries were caused by GSW in 82 patients (87%) and SW in 12 patients (13%). Fifteen patients (16%) survived EDT and were taken to the operating room, while eight patients (8%) survived their entire hospitalization. All survivors were neurologically intact. Survival rates were 5% for GSW and 33% for SW. Mechanism of injury (SW), prehospital transportation by police, higher GCS, sinus tachycardia, and measurable ED vital signs were associated with improved survival. In urban trauma centers where firearm injuries are much more common than stabbings, the presence of a penetrating cardiac injury may no longer be considered a predictor of survival after EDT.

Pancreatic injury in damage control laparotomies : Is pancreatic resection safe during the initial laparotomy?

OBJECTIVES While damage control (DC) techniques such as the rapid control of exsanguinating haemorrhage and gastrointestinal contamination have improved survival in severely injured patients, the optimal pancreatic injury management strategy in these critically injured patients requiring DC is uncertain. We sought to characterise pancreatic injury patterns and outcomes to better determine optimal initial operative management in the DC population. MATERIALS AND METHODS A two-centre, retrospective review of all patients who sustained pancreatic injury requiring DC in two urban trauma centres during 1997-2004 revealed 42 patients. Demographics and clinical characteristics were analysed. Study groups based on operative management (pack+/-drain vs. resection) were compared with respect to clinical characteristics and hospital outcomes. RESULTS The 42 patients analysed were primarily young (32.8+/-16.2 years) males (38/42, 90.5%) who suffered penetrating (30/42, 71.5%) injuries of the pancreas and other abdominal organs (41/42, 97.6%). Of the 12 patients who underwent an initial pancreatic resection (11 distal pancreatectomies, 1 pancreaticoduodenectomy), all distal pancreatectomies were performed in entirety during the initial laparotomy while pancreaticoduodenectomy reconstruction was delayed until subsequent laparotomy. Comparing the pack+/-drain and resection groups, no difference in mechanism, vascular injury, shock, ISS, or complications was revealed. Mortality was substantial (packing only, 70%; packing with drainage, 25%, distal pancreatectomy, 55%, pancreaticoduodenectomy, 0%) in the study population. CONCLUSIONS The presence of shock or major vascular injury dictates the extent of pancreatic operative intervention. While pancreatic resection may be required in selected damage control patients, packing with pancreatic drainage effectively controls both haemorrhage and abdominal contamination in patients with life-threatening physiological parameters and may lead to improved survival. Increased mortality rates in patients who were packed without drainage suggest that packing without drainage is ineffective and should be abandoned.

Stress training for the surgical resident

BACKGROUND Much effort in surgical education is placed on the development of clinical judgment and technical proficiency. However, little focus is placed on the management of stress associated with surgical performance. The inability to manage stress may lead to poor patient care, attrition from residency, and surgeon burnout. METHODS A blinded, matched, comparison group study to evaluate the efficacy of an educational program designed to improve surgical resident performance during stressful scenarios was conducted. The experimental group (n = 11) participated in stress training sessions, whereas the control group (n = 15) did not. Both groups then completed a simulation during which stress was evaluated using objective and subjective measures, and resident performance was graded using a standardized checklist. RESULTS Performance checklist scores were 5% higher in the experimental group than the control group (P = .54). No change existed in anxiety state according to the State Trait Anxiety Inventory (P = .34) or in heart rate under stress (P = .17) between groups. CONCLUSIONS There was a trend toward improved performance scoring but no difference in anxiety levels after stress training. However, 91% of residents rated the stress training as valuable.

Life after near death: Long-term outcomes of emergency department thoracotomy survivors

BACKGROUND: Predictors of hospital survival after emergency department thoracotomy (EDT) are well established, but little is known of long‐term outcomes after hospital survival. Our primary study objective was to analyze the long‐term social, cognitive, functional, and psychological outcomes in EDT survivors. METHODS: Review of our Level I trauma center registry (2000–2010) revealed that 37 of 448 patients survived hospitalization after EDT. Demographics and clinical characteristics were analyzed. After attempts to contact survivors, 21 patients or caretakers were invited to an outpatient study evaluation; 16 were unreachable (none of whom were present in the Social Security Death Index). Study evaluation included demographic and social data and an outpatient multidisciplinary assessment with validated scoring instruments (Mini‐Mental Status Exam, Glasgow Outcome Scores, Timed Get‐Up and Go Test, Functional Independence Measure Scoring, SF‐36 Health Survey, and civilian posttraumatic stress disorder checklist). RESULTS: After extended hospitalization (43 ± 41 days), disposition varied (home, 62%; rehabilitation, 32%; skilled nursing facility, 6%), but readmission was common (33%) in the 37 EDT hospital survivors. Of the 21 contacted, 16 completed the study evaluation, 2 had died, 1 remained in a comatose state, and 2 were available by telephone only. While unemployment (75%), daily alcohol (50%), and drug use (38%) were common, of the 16 patients who underwent the comprehensive, multidisciplinary outpatient assessment after a median of 59 months following EDT, 75% had normal cognition and returned to normal activities, 81% were freely mobile and functional, and 75% had no evidence of posttraumatic stress disorder upon outpatient screening. CONCLUSION: Despite the common belief that EDT survivors often live with severe neurologic or functional impairment, we have found that most of our sampled EDT survivors had no evidence of long‐term impairment. It is our hope that these results are considered by physicians making life or death decisions regarding the “futility” of EDT in our most severely injured patients. LEVEL OF EVIDENCE: Prognostic and epidemiologic study, level III.

A comparison of Injury Severity Score and New Injury Severity Score after penetrating trauma: a prospective analysis

BACKGROUND The Injury Severity Score (ISS) has been validated in numerous studies and has become one of the most common trauma scoring systems since its inception. The ISS equation was later modified to create the New Injury Severity Score (NISS). By using the three most severe injuries regardless of body region, the NISS seems well suited to describe patients of penetrating trauma, where injuries often cluster within a single body region. We hypothesized that NISS would better predict outcomes than ISS in penetrating trauma patients. METHODS An analysis (June 2008 to March 2009) of all severely injured (length of hospital stay ≥ 48 hours, intensive care unit admission, interhospital transfer, or death) penetrating trauma patients revealed final study sample of 256 patients. ISS and NISS were compared as predictors for both mortality and complications through area under the receiver operating characteristic curve, Hanley-McNeil test, multiple-variable logistic regression, and Hosmer-Lemeshow goodness-of-fit test analysis. RESULTS Of 256 study patients, 195 (76.2%) survived until discharge. The mean (ISS, 21.7 ± 21.1 vs. NISS, 27.4 ± 22.0; p < 0.001) and median (ISS, 14.0 vs. NISS, 21.0) ISS was lower than those of the NISS. Overall, 173 patients (67.6%) had discordant scores with 26% and 43% having scores greater than 25 (ISS and NISS, respectively, p < 0.01). The mortality area under the curve (AUC) for NISS was greater than the AUC for ISS in all penetrating patients (0.930 vs. 0.885, p = 0.008), those with penetrating torso injuries (NISS, 0.934 vs. ISS, 0.881, p < 0.001), and those with severe (score > 25) injuries (NISS, 0.845 vs. ISS, 0.761, p < 0.001). In patients surviving for more than 48 hours, the complications AUC for NISS was also greater than the AUC for ISS (NISS, 0.838 vs. ISS, 0.784; p = 0.023). CONCLUSION The NISS outperformed ISS as a predictor of both mortality and complications in civilian penetrating trauma patients. These results indicate that NISS is a superior scoring system for patients with penetrating injuries. LEVEL OF EVIDENCE Prognostic study, level III.

HIV and hepatitis in an urban penetrating trauma population: unrecognized and untreated.

BACKGROUND Despite limited prospective data, it is commonly believed that human immunodeficiency virus (HIV) and hepatitis infections are widespread in the penetrating trauma population, placing healthcare workers at risk for occupational exposure. Our primary study objective was to measure the prevalence of HIV (anti-HIV), hepatitis B (HB surface antigen [HBsAg]), and hepatitis C virus (anti-HCV) in our penetrating trauma population. METHODS We prospectively analyzed penetrating trauma patients admitted to Temple University Hospital between August 2008 and February 2010. Patients (n = 341) were tested with an oral swab for anti-HIV and serum evaluated for HBsAg and anti-HCV. Positives were confirmed with western blot, neutralization immunoassay, and reverse transcription polymerase chain reaction, respectively. Demographics, risk factors, and clinical characteristics were analyzed. RESULTS Of 341 patients, 4 patients (1.2%) tested positive for anti-HIV and 2 had a positive HBsAg (0.6%). Hepatitis C was the most prevalent measured infection as anti-HCV was detected in 26 (7.6%) patients. Overall, 32 (9.4%) patients were tested positive for anti-HIV, HBsAg, or anti-HCV. Twenty-eight (75%) of these patients who tested positive were undiagnosed before study enrollment. When potential risk factors were analyzed, age (odds ratio, 1.07, p = 0.031) and intravenous drug use (odds ratio 14.4, p < 0.001) independently increased the likelihood of anti-HIV, HBsAg, or anti-HCV-positive markers. CONCLUSIONS Greater than 9% of our penetrating trauma study population tested positive for anti-HIV, HBsAg, or anti-HCV although patients were infrequently aware of their seropositive status. As penetrating trauma victims frequently require expedient, invasive procedures, universal precautions are essential. The prevalence of undiagnosed HIV and hepatitis in penetrating trauma victims provides an important opportunity for education, screening, and earlier treatment of this high-risk population.

Follow-up after asymptomatic penetrating thoracic injury: 3 hours is enough.

BACKGROUND Patients with asymptomatic penetrating thoracic injuries routinely undergo chest radiographs (CXRs) upon emergency department (ED) arrival, and then 6 hours later to exclude delayed pneumothorax (PTX) or hemothorax (HTX). Although previous reports indicate that up to 12% (mean, 3%) of asymptomatic penetrating thoracic injuries are complicated by delayed PTX or HTX, we hypothesized that these events would be detectable after only 3 hours of observation. The purpose of this study was to compare the incidence of delayed thoracic injury at 3 hours and 6 hours using standard CXR. METHODS A prospective trial of asymptomatic patients with penetrating thoracic injuries was conducted during 36 months. CXRs were performed upon arrival (supine, AP), and at 3 hours (upright, PA/lateral) and 6 hours (upright, PA/lateral). Patients with either injuries detected on initial CXR or cardiopulmonary symptoms were excluded. Findings from 3 hour and 6 hour CXRs were compared. Assuming a delayed PTX or HTX rate of 3%, the probability of detecting at least one delayed event between 3 hours and 6 hours in 100 patients is 95.25%. RESULTS Of 648 patients with penetrating thoracic injuries, 100 patients both met inclusion criteria and completed the study. Patients were predominantly young (32.5 years +/- 13.3 years [mean +/- SD]) men (75% men) with stab wounds (75% stab wounds, 25% gunshot wounds). The mean length of stay for patients discharged from the ED was 8.8 hours +/- 2.6 hours. Although two patients developed a PTX between arrival and 3 hours, none developed after 3 hours. Patient charges, hospital costs, and radiation exposure were calculated for patients in our proposed study protocol, totaling

Pathogenesis and outcomes of traumatic injuries of the esophagus

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