Andreas Larentzakis

The initial response to the Boston marathon bombing: lessons learned to prepare for the next disaster.

Objective:We discuss the strengths of the medical response to the Boston Marathon bombings that led to the excellent outcomes. Potential shortcomings were recognized, and lessons learned will provide a foundation for further improvements applicable to all institutions. Background:Multiple casualty incidents from natural or man-made incidents remain a constant global threat. Adequate preparation and the appropriate alignment of resources with immediate needs remain the key to optimal outcomes. Methods:A collaborative effort among Bostons trauma centers (2 level I adult, 3 combined level I adult/pediatric, 1 freestanding level I pediatric) examined the details and outcomes of the initial response. Each center entered its respective data into a central database (REDCap), and the data were analyzed to determine various prehospital and early in-hospital clinical and logistical parameters that collectively define the citywide medical response to the terrorist attack. Results:A total of 281 people were injured, and 127 patients received care at the participating trauma centers on that day. There were 3 (1%) immediate fatalities at the scene and no in-hospital mortality. A majority of the patients admitted (66.6%) suffered lower extremity soft tissue and bony injuries, and 31 had evidence for exsanguinating hemorrhage, with field tourniquets in place in 26 patients. Of the 75 patients admitted, 54 underwent urgent surgical intervention and 12 (22%) underwent amputation of a lower extremity. Conclusions:Adequate preparation, rapid logistical response, short transport times, immediate access to operating rooms, methodical multidisciplinary care delivery, and good fortune contributed to excellent outcomes.

Tourniquet use at the Boston Marathon bombing: Lost in translation

BACKGROUND The Boston Marathon bombing was the first major, modern US terrorist event with multiple, severe lower extremity injuries. First responders, including trained professionals and civilian bystanders, rushed to aid the injured. The purpose of this review was to determine how severely bleeding extremity injuries were treated in the prehospital setting in the aftermath of the Boston Marathon bombing. METHODS A database was created and populated by all the Boston Level I trauma centers following the Boston Marathon bombing. Data regarding specific injuries, extremities affected, demographics, prehospital interventions (including tourniquet types), and outcomes were extracted. RESULTS Of 243 injured, 152 patients presented to the emergency department within 24 hours. Of these 152 patients, there were 66 (63.6% female) experiencing at least one extremity injury, with age ranging from younger than 15 years to 71 years, and with a median Injury Severity Score (ISS) of 10 (range, 1–38). Of the 66 injured patients, 4 had upper limbs affected, 56 had injuries on the lower limbs only, and 6 had combined upper and lower limbs affected. The extremity Abbreviated Injury Scale (AIS) scores had a median of 3 (range, 1–4). There were 17 lower extremity traumatic amputations in 15 patients. In addition, there were 10 patients with 12 lower extremities experiencing major vascular injuries. Of 66 injured patients, 29 patients had recognized extremity exsanguination at the scene. In total, 27 tourniquets were applied: 16 of 17 traumatic amputations, 5 of 12 lower extremities with major vascular injuries, and 6 additional limbs with major soft tissue injury. All tourniquets were improvised, and no commercial, purpose-designed tourniquets were identified. Among all 243 patients, mortality was 0%. CONCLUSION After the Boston Marathon bombings, extremity exsanguination at the point of injury was either left untreated or treated with an improvised tourniquet in the prehospital environment. An effective, prehospital extremity hemorrhage control posture should be translated to all civilian first responders in the United States and should mirror the military’s posture toward extremity bleeding control. The prehospital response to extremity exsanguination after the Boston Marathon bombing demonstrates that our current practice is an approach, lost in translation, from the battlefield to the homeland. LEVEL OF EVIDENCE Epidemiologic study, level V.

Opening Pandora's box: understanding the nature, patterns, and 30-day outcomes of intraoperative adverse events.

BACKGROUNDnLittle evidence exists regarding the characteristics of intraoperative adverse events (iAEs).nnnMETHODSnAdministrative data, the American College of Surgeons - National Surgical Quality Improvement Project, and systematic review of operative reports were used to confirm iAEs in abdominal surgery patients. Standard American College of Surgeons - National Surgical Quality Improvement Project data were supplemented with variables including injury type/organ, phase of operation, adhesions, repair type, and intraoperative consultations.nnnRESULTSnTwo hundred twenty-seven iAEs (187 patients) were confirmed in 9,292 patients. Most common injuries were enterotomies during intestinal surgery (68%) and vessel injuries during hepatopancreaticobiliary surgery (61%); 108 iAEs (48%) specifically occurred during adhesiolysis. A third of the iAEs required organ/tissue resection or complex reconstruction. Because of iAEs, 20 intraoperative consults (11%) were requested and 9 of the 66 (16%) laparoscopic cases were converted to open. Thirty-day mortality and morbidity were 6% and 58%, respectively. The complications included perioperative transfusions (36%), surgical site infection (19%), systemic sepsis (13%), and failure to wean off the ventilator (12%).nnnCONCLUSIONSniAEs commonly occur in reoperative cases requiring lysis of adhesions and possibly lead to increased patient morbidity. Understanding iAEs is essential to prevent their occurrence and mitigate their adverse effects.

The financial impact of intraoperative adverse events in abdominal surgery.

BACKGROUNDnLittle evidence currently exists regarding the clinical or financial impact of intraoperative adverse events (iAEs). We sought to study the additional health care charges attributable to the occurrence of an iAE.nnnMETHODSnThe administrative and ACS-NSQIP databases at our tertiary academic medical center were linked for all patients undergoing abdominal surgery (January 2007-October 2012). The ICD-9-CM-based Patient Safety Indicator accidental puncture/laceration was used to screen the linked database for potential iAEs. All iAEs were confirmed subsequently through standardized review of all flagged medical records. Multivariate analyses controlling for demographics, comorbidities/laboratory values, procedure type, and approach and complexity of surgery were performed to assess the increase in health care charges independently predicted by the occurrence of iAEs.nnnRESULTSnOf 9,111 patients, 183 were confirmed to have iAEs. Patients in the iAE group had higher median total charges (

Efficacy of a prehospital self-expanding polyurethane foam for noncompressible hemorrhage under extreme operational conditions.

27,169 [IQR, 17,302-44,952] vs

Morbidity related to concomitant adhesions in abdominal surgery

13,312 [IQR, 8,586-22,012]; P < .001), direct charges (

Association Between Ratio of Fresh Frozen Plasma to Red Blood Cells During Massive Transfusion and Survival Among Patients Without Traumatic Injury

17,808 [IQR, 11,520-28,930] vs

Peer-to-peer physician feedback improves adherence to blood transfusion guidelines in the surgical intensive care unit.

8,738 [IQR, 5,686-14,227]; P < .001) and indirect charges (

Human dose confirmation for self-expanding intra-abdominal foam: A translational, adaptive, multicenter trial in recently deceased human subjects.

9,396 [IQR, 5,932-16,144] vs

Is CT Angiography of the Head Useful in the Management of Traumatic Brain Injury

4,568 [IQR, 2,887-7,824]; P < .001) when compared with patients without iAEs. Multivariate analyses demonstrated that iAEs independently predict an increase in total hospitalization charges by 41% (95% CI, 30-52%; P < .001). Specifically, the direct, indirect, operating room, laboratory/radiology, and alimentation/medical therapy charges increased by 42, 39, 27, 54, and 48%, respectively (all P < .001).nnnCONCLUSIONnIn addition to the morbidity incurred by patients, the occurrence of an iAE is associated with major additional health care charges. In an era of value-based health care, understanding and preventing iAEs can lead to major cost savings alongside improvements in patient safety and surgical quality.