Brian Kimbrell

Necrotizing soft-tissue infections

It has been more than 130 years since NSTIs were first described. Despite the development of various classification systems and progress in surgical management, these infections continue to have high mortality and pose enormous diagnostic and therapeutic challenges. For optimal outcome, treatment involves rapid institution of appropriate antibiotic coverage and early wide surgical debridement. Recovery requires aggressive resuscitation, postoperative nutritional support and wound care that is similar to the care of burn patients in many respects. The entire therapeutic process requires a well-prepared and coordinated team of health care professionals including EPs, general, orthopedic, and other specialist surgeons, infectious disease consultants, specially trained nursing staff, and physical therapists.

Multidisciplinary Approach for the Management of Complex Hepatic Injuries AAST-OIS Grades IV—V: A Prospective Study

Background: Complex hepatic injuries grades IV—V are highly lethal. The objective of this study is to assess the multidisciplinary approach for their management and to evaluate if survival could be improved with this approach. Study Design: Prospective 54-month study of all patients sustaining hepatic injuries grades IV—V managed operatively at a Level I Trauma Center. Main outcome measure: survival. Statistical analysis: univariate and stepwise logistic regression. Results: Seventy-five patients sustained penetrating (47/63%) and blunt (28/37%) injuries. Seven (9%) patients underwent emergency department thoracotomy with a mortality of 100%. Out of the 75 patients, 52 (69%) sustained grade IV, and 23 (31%) grade V. The estimated blood loss was 3,539±-3,040 ml. The overall survival was 69%, adjusted survival excluding patients requiring emergency department thoracotomy was 76%. Survival stratified to injury grade: grade IV 42/52–81%, grade V 10/23–43%. Mortality grade IV versus V injuries (p <0.002; RR 2.94; 95% CI 1.52–5.70). Risk factors for mortality: packed red blood cells transfused in operating room (p=0.024), estimated blood loss (p<0.001), dysryhthmia (p<0.0001), acidosis (p=0.051), hypothermia (p=0.04). The benefit of angiography and angioembolization indicated: 12% mortality (2/17) among those that received it versus a 36% mortality (21/58) among those that did not (p=0.074; RR 0.32; 95% CI 0.08–1.25). Stepwise logistic regression identified as significant independent predictors of outcome: estimated blood loss (p=0.0017; RR 1.24; 95% CI 1.08–1.41) and number of packed red blood cells transfused in the operating room (p=0.0358; RR 1.16; 95% CI 1.01–1.34). Conclusions: The multidisciplinary approach to the management of these severe grades of injuries appears to improve survival in these highly lethal injuries. A prospective multi-institutional study is needed to validate this approach.

Lessons learned in the management of thirteen celiac axis injuries

Objectives: Celiac axis injuries are rare. The purposes of this study were to (1) review institutional experience, (2) determine additive effect on death of associated vessel injuries, and (3) correlate mortality rates with the American Association for the Surgery of Trauma–Organ Injury Scale (AAST-OIS) for abdominal vascular injury. Methods: This was a retrospective, 132-month study (January 1992 to December 2002) of patients with celiac axis injuries. Results: Thirteen patients were included in the study. Mean revised trauma score was 5.35 ± 2.63; mean injury severity score was 25 ± 12. The mechanism was penetrating in 12 (92%) and blunt in 1 (8%); 3 of 13 had Emergency Department thoracotomy (100% mortality rate). Treatment included ligation in 11 and primary repair in 1; 1 exsanguinated. Overall survival was 5 of 13 (38%). Adjusted survival excluding patients who had Emergency Department thoracotomy was 5 of 10 patients (50%). Those surviving with isolated injuries included 57% of patients. Mortality rate versus AAST-OIS was grade III, 43% (3 of 7 patients); grade IV, 50% (1 of 2 patients); and grade V, 100% (4 of 4 patients). Conclusions: Celiac axis injuries are rare. Patients with isolated injuries have better survival rates. Mortality rate correlates well with AAST-OIS for abdominal vascular injury.

Angiographic embolization of an expanding breast hematoma after blunt trauma: a novel approach to a rare injury.

The mandatory use of seat belts has resulted in a significant reduction in the number of injuries and deaths from motor vehicle collisions.1 The number and severity of motor vehicle injuries has significantly decreased with the concomitant increased use of seat belts. Simultaneously, there has been an increase in hollow viscus, mesenteric, and soft tissue injuries from the seat belt itself.2 In women, seat belt injuries present a unique complex of potential injuries, given the location of the shoulder restraint directly over the breast. In a review of the literature, injuries to the breast range from crush to complete avulsion. We hereby present a patient in which blunt trauma to the breast resulted in an expanding hematoma with active arterial bleeding requiring angiographic embolization.

Geriatric outcomes for trauma patients in the state of Florida after the advent of a large trauma network.

BACKGROUND Florida State has one of the largest geriatric populations in the United States. However, recent data show that up to the year 2010, geriatric trauma patients were least served by designated trauma centers (TCs). One existing TC and five provisional Level 2 TCs were combined to create a large-scale trauma network (TN). The new TCs were placed in those areas with the lowest ratios of TC to residents based on census data. The aim of this study was to measure the TN impact on the population of geriatric trauma patients. METHODS Data from the Florida State Agency for Health Care Administration were used to determine mortality, length of stay, and complication rates for geriatric trauma patients (≥ 65 years). The potential effect of the TN was measured by comparing outcomes before and after the initiation of the TN. A total of 165,640 geriatric patients were evaluated. Multivariate regression methods were used to match and adjust for age, injury status (penetrating vs. nonpenetrating), sex, race, comorbidity, and injury severity (DRG International Classification of Diseases—9th Rev. Injury Severity Score). RESULTS Since the advent of the TN, an additional 1,711 geriatric patients were treated compared with the previous period. The TN was responsible 86% of these new patients. There was a temporal association with a decrease in both mortality (adjusted odds ratio, 0.90; 95% confidence interval, 0.85–0.96) and length of stay (p < 0.0001) for geriatric patients since the advent of the TN. The improved access was associated with a significant decrease in mortality in the regions serviced by the TN. CONCLUSION Geriatric patients make up a significant proportion of trauma patients within the TN. The temporal improvement in outcomes may be associated with the increased proportion of patients being treated in state-designated TCs as a result of the addition of the TN. LEVEL OF EVIDENCE Epidemiologic study, level III.

Toracotomía de emergencia: una evaluación crítica de la técnica

Resumen Objetivo Analisis de la bibliografia y del estado actual de la toracotomia de emergencia. Obtencion de los datos Revision de la bibliografia, desde las primeras experiencias en su utilizacion hasta los estudios mas recientes en el area. Resultados Desde su introduccion en la decada de los sesenta, su uso se ha extendido de forma considerable y forma parte de los protocolos de reanimacion cardiopulmonar en todos los centros de politraumatizados norteamericanos. En 42 series analizadas sobre toracotomia de emergencia se hallaron 7.035 procedimientos, de los cuales sobrevivieron 551 (7,8%). Segun el mecanismo de lesion, se realizaron 4.482 toracotomias por lesiones penetrantes, de las que sobrevivieron 500 pacientes (11,1%), y 2.193 toracotomias por lesiones contusas, de las que sobrevivieron 35 (1,6%). En las 14 series que comunicaban el pronostico neurologico se registraron 4.520 pacientes con 226 sobrevivientes (5%), de los que 34 (15%) presentaban secuelas neurologicas. Ademas, de 1.165 pacientes con lesiones cardiacas penetrantes hubo 363 (31,1%) supervivientes. Por ultimo, de 4 series sobre poblacion pediatrica se hallaron 142 pacientes, de los cuales 57 fueron por lesiones penetrantes, con una tasa de supervivencia del 12,2%. Conclusion Es una tecnica muy util para el cirujano, que debe emplearse de forma prudente y juiciosa, y con indicaciones muy estrictas, ya que su uso de forma indiscriminada lleva asociada una elevada tasa de mortalidad y morbilidad. A pesar de estos riesgos, es una maniobra util y con frecuencia la ultima esperanza para muchos pacientes que llegan a los servicios de urgencias en condiciones extremas, y debe practicarse por cirujanos apropiadamente entrenados en esta tecnica.