Daniel Grabo

Emergent non-image-guided resuscitative endovascular balloon occlusion of the aorta (REBOA) catheter placement: A cadaver-based study.

BACKGROUND Emergent resuscitative endovascular balloon occlusion of the aorta (REBOA) insertion for critically injured patients in hemorrhagic shock is performed blindly with fluoroscopic imaging confirmation. The aim of this study was to determine a reliable method for initial REBOA catheter insertion with balloon deployment between the left subclavian artery takeoff and the celiac trunk (CT). METHODS Human cadaver study. External surface (sternal notch, mid-sternum, xiphoid) and intravascular (left subclavian artery [LSA], and CT) landmarks were measured from standardized left and right common femoral artery puncture sites. The landing zone (LZ, distance between LSA and CT) and margins of safety (distance from distal balloon edge to LSA and proximal balloon edge to CT) were calculated using intravascular landmarks. The probability of balloon deployment in the LZ using external landmarks was compared in univariate analysis using the Fisher exact test. RESULTS Ten cadavers were analyzed (seven males; mean body mass index, 19.4 kg/m2). Mean (SD) intravascular distances from femoral puncture sites to the LSA and CT were 54.8 (1.9) cm and 32.9 (1.9) cm. The mean (SD) LZ was 21.8 (3.8) cm. Mean (SD) surface distances from femoral puncture sites to the xiphoid, mid-sternum, and sternal notch were 31.8 (3.9) cm, 41.8 (3.3) cm, and 51.8 (3.2) cm. Inserting the catheter to a distance approximated by surface distance from the femoral puncture site to mid-sternum resulted in a 100% likelihood balloon deployment in the LZ for both sides. This was superior to the xiphoid and sternal notch (left site, p = 0.005; right site, p = 0.036; mean of both sites, p = 0.083). Using the mid-sternum landmark, the mean (SD) margins of safety to the LSA and CT were 10.7 (4.3) cm and 3.1 (3.4) cm. CONCLUSION When using the use of the mid-sternum landmark for REBOA balloon placement, the likelihood of balloon deployment in the LZ was 100% with an acceptable margin of safety.

The origin of fatal pulmonary emboli: a postmortem analysis of 500 deaths from pulmonary embolism in trauma, surgical, and medical patients

BACKGROUND The traditional theory that pulmonary emboli (PE) originate from the lower extremity has been challenged. METHODS All autopsies performed in Los Angeles County between 2002 and 2010 where PE was the cause of death were reviewed. RESULTS Of the 491 PE deaths identified, 36% were surgical and 64% medical. Venous dissection for clots was performed in 380 patients; the PE source was the lower extremity (70.8%), pelvic veins (4.2 %), and upper extremity (1.1%). No source was identified in 22.6% of patients. Body mass index (adjusted odds ratio [AOR] 1.044, 95% confidence interval [CI] 1.011 to 1.078, P = .009) and age (AOR 1.018, 95% CI 1.001 to 1.036, P = .042) were independent predictors for identifying a PE source. Chronic obstructive pulmonary disease (AOR .173, 95% CI .046 to .646, P = .009) was predictive of not identifying a PE source. CONCLUSIONS Most medical and surgical patients with fatal PE had a lower extremity source found, but a significant number had no source identified. Age and body mass index were positively associated with PE source identification. However, a diagnosis of chronic obstructive pulmonary disease was associated with no PE source identification.

Cadaveric comparison of the optimal site for needle decompression of tension pneumothorax by prehospital care providers.

BACKGROUND Computed tomographic and cadaveric studies have demonstrated needle decompression of tension pneumothorax at the fifth intercostal space (ICS), anterior axillary line (AAL) has advantages over the second ICS midclavicular line (MCL). The purpose of this study was to compare the ability of prehospital care providers to accurately decompress the chest at these two locations. METHODS Randomly selected US Navy hospital corpsmen (n = 25) underwent a standardized training session followed by timed needle decompression on unmarked fresh cadavers. A 14-gauge angiocatheter was inserted in the right and left second ICS MCL and fifth ICS AAL in a predetermined computer-generated order. Time from needle uncapping to insertion, accuracy, and ease of placement were examined. RESULTS A total of 25 corpsmen inserted 100 needles into 25 cadavers. Mean (SD) age was 25.9 (3.7) years, 72.0% were male, with 4.2 (3.2) years of experience, and 52.0% had previously deployed. A total of 60.0% had attempted decompression previously, 93.3% in a model and 6.7% in a patient. Time to decompression did not differ between the second and fifth ICS (16.8 [10.1] seconds vs. 16.9 [12.3] seconds, p = 0.438). Accuracy however was superior at the fifth ICS, with a misplacement rate of only 22.0% versus 82.0% at the second ICS (p < 0.001). The aggregate distance from the target position was also significantly greater for the second ICS (3.1 [1.7] cm vs. 1.2 [1.5] cm, p < 0.001). Insertion at the fifth ICS was rated as being easier than the second by 76.0% of providers, the same by 12.0%, and more difficult by 12.0%. CONCLUSION For prehospital care providers, the fifth ICS AAL can be localized and decompressed with a higher degree of accuracy than the traditional second ICS MCL. It is rated as easier to perform and can be done just as quickly. Based on these data, the fifth ICS AAL should be considered as an equivalent first-line position for needle decompression in patients with clinical evidence of a tension pneumothorax.

Optimal training for emergency needle thoracostomy placement by prehospital personnel: didactic teaching versus a cadaver-based training program.

BACKGROUND Tension pneumothorax can rapidly progress to cardiac arrest and death if not promptly recognized and appropriately treated. We sought to evaluate the effectiveness of traditional didactic slide-based lectures (SBLs) as compared with fresh tissue cadaver-based training (CBT) for placement of needle thoracostomy (NT). METHODS Forty randomly selected US Navy corpsmen were recruited to participate from incoming classes of the Navy Trauma Training Center at the LAC + USC Medical Center and were then randomized to one of two NT teaching methods. The following outcomes were compared between the two study arms: (1) time required to perform the procedure, (2) correct placement of the needle, and (3) magnitude of deviation from the correct position. RESULTS During the study period, a total of 40 corpsmen were enrolled, 20 randomized to SBL and 20 to CBT arms. When outcomes were analyzed, time required to NT placement was not different between the two arms. Examination of the location of needle placement revealed marked differences between the two study groups. Only a minority of the SBL group (35%) placed the NT correctly in the second intercostal space. In comparison, the majority of corpsmen assigned to the CBT group demonstrated accurate placement in the second intercostal space (75%). CONCLUSION In a CBT module, US Navy corpsmen were better trained to place NT accurately than their traditional didactic SBL counterparts. Further studies are indicated to identify the optimal components of effective simulation training for NT and other emergent interventions.

Strongyloidiasis Hyperinfection in a Patient with a History of Systemic Lupus Erythematosus

Strongyloidiasis is a parasitic disease caused by Strongyloides stercoralis, a nematode predominately endemic to tropical and subtropical regions, such as Southeast Asia. Autoinfection enables the organism to infect the host for extended periods. Symptoms, when present, are non-specific and may initially lead to misdiagnosis, particularly if the patient has additional co-morbid conditions. Immunosuppressive states place patients at risk for the Strongyloides hyperinfection syndrome (SHS), whereby the organism rapidly proliferates and disseminates within the host. Left untreated, SHS is commonly fatal. Unfortunately, the non-specific presentation of strongyloidiasis and the hyperinfection syndrome may lead to delays in diagnosis and treatment. We describe an unusual case of SHS in a 30-year-old man with a long-standing history of systemic lupus erythematosus who underwent a partial colectomy. The diagnosis was rendered on identification of numerous organisms during histologic examination of the colectomy specimen.

Splenic artery embolization versus splenectomy: Analysis for early in-hospital infectious complications and outcomes

BACKGROUND Splenic artery embolization (SAE) has gained increasing acceptance as an important adjunct in the treatment of splenic injuries. Residual immunologic function of the spleen after embolization and its consequences on early infectious complications still remain intensely debated. The purpose of this study was to compare SAE and splenectomy (SP) in terms of early in-hospital infectious complications and outcomes. METHODS Two-year retrospective Trauma Quality Improvement Program database prognostic study. Patients with grade IV to V splenic injury requiring SAE or SP were included in the final analysis. Examined variables were demographics, mechanism of injury, Abbreviated Injury Scale (AIS), Injury Severity Score, Organ Injury Scale, admission vital signs, blood transfusion in the first 24 hours, early infectious complications, and outcomes. Multivariate analysis adjusted for patient and injury-related variables was used to identify independent predictors for infectious complication and mortality. RESULTS During the study period, 4,063 patients with a grade IV to V splenic injury managed with SAE or SP were included in the study. SAE was performed in 461 (11.3%) patients. The early infectious complication rate was 23.1% in the SP group and 11.7% in the SAE group (p < 0.001). Stepwise logistic regression analysis identified age 65 years or older, Glasgow Coma Scale (GCS) score less than 9, Head AIS score of 3 or greater, SP, and blood transfusion in the first 24 hours as independent predictors for early infectious complications. The unadjusted overall mortality was 12.7% in the SP group and 5.4% in the SAE group (p < 0.001). Age 65 years or older, GCS score less than 9, hypotension, head AIS score of 3 or greater, and blood transfusion in the first 24 hours were independent risk factor for mortality. SP was not an independent risk factor in terms of mortality. Subgroup analysis in patients with isolated splenic injury showed age 65 years or older, GCS score less than 9, and blood transfusion in the first 24 hours as independent factors associated with early infection. CONCLUSION Our study supports the effectiveness of SAE in hemodynamically stable patients with a grade IV to V splenic injury. SP is associated with an increased risk of early infectious complications but is not an independent risk for mortality. LEVEL OF EVIDENCE Therapeutic study, level IV.

Resuscitative Endovascular Balloon Occlusion of the Aorta (REBOA) for Hemorrhagic Shock

This clinical practice guideline (CPG) reviews the range of accepted management approaches to profound shock and post-traumatic cardiac arrest and establishes indications for considering Resuscitative Endovascular Balloon Occlusion of the Aorta (REBOA) as a hemorrhage control adjunct. The specific management approach - within the parameters of mission, resources, and tactical situation - will depend on the casualtys physical location, mechanism and pattern of injury, and the experience level of the surgeon. The optimal management strategy is best determined by the surgeon at the bedside.

Is your graduating general surgery resident qualified to take trauma call? A 15-year appraisal of the changes in general surgery education for trauma.

BACKGROUND Trauma training in general surgery residency is undergoing an evolution. Hour restrictions, the growth of subspecialty care, and the trend toward nonoperative management have altered resident exposure to operative trauma. We sought to identify trends in resident trauma training since the inception of the 80-hour workweek. METHODS The Accreditation Council for General Medical Education Case Log Statistical Reports for Surgery was abstracted for general surgery resident trauma operative volume for the years 1999–2014. Resident trauma experience (operative caseload [OC]) was compared before inception of the 80-hour workweek (1999–2002) to after the 80-hour workweek began (2003 to current). RESULTS A trend toward decreased operative trauma for general surgery residents was observed (mean OC [before 80-hour workweek vs. 80-hour workweek], 39,252 ± 1,065.2 cases vs. 36,065 ± 1,291.8; p = 0.06). Trauma laparotomies increased (range, 5,446–9,364 cases) with corresponding decreases in vascular trauma (4,704 to 799 cases), neck explorations (1,876 to 1,370 cases), and thoracotomies (2,507 to 2,284 cases). By comparison, an increase in vascular/integrated cases was noted (mean OC [before 80-hour workweek vs. 80-hour workweek], 845 ± 44.2 vs. 1,465 ± 88.4 cases; p < 0.01). Resident deficiencies analyzed by time period (before 80-hour workweek vs. 80-hour workweek) demonstrated deficiencies in thoracic, abdominal, solid organ, and extremity-vascular trauma domains (p < 0.01 for each). Nontrauma cases were also on the decline, specifically in open thoracic, vascular, and solid organ surgery (p < 0.05 for each). Both 1- and 2-year fellowships offset deficiencies in trauma education. CONCLUSIONS Based on the data, an alarming number of graduates complete training with substantially less experience in defined trauma categories. Because of a decline in operative trauma volume, advanced fellowship training should be encouraged specifically for those interested in a career in trauma and acute care surgery.

Severe injuries associated with skiing and snowboarding: A national trauma data bank study

BACKGROUND Injuries after skiing and snowboarding accidents lead to an estimated 7,000 hospital admissions annually and present a significant burden to the health care system. The epidemiology, injury patterns, hospital resource utilization, and outcomes associated with these severe injuries need further characterization. METHODS The National Trauma Data Bank was queried for the period 2007 to 2014 for admissions with Injury Severity Score > 15 and International Classification of Diseases Codes—9th Revision codes 885.3 (fall from skis, n = 1,353) and 885.4 (fall from snowboard, n = 1,216). Demographics, emergency department data, diagnosis and procedure codes, and outcomes were abstracted from the database. RESULTS Severe (Injury Severity Score > 15) ski-associated and snowboard-associated injuries differed with respect to age distribution (median age, 38; interquartile range, 19–59 for skiers and median age, 20; interquartile range, 16–25 for snowboarders; p < 0.001) and sex (78.9% and 86.4% males, respectively, p < 0.001). Traumatic brain injury was common for both sports (56.8% of skiers vs. 46.6% of snowboarders, p < 0.001). Injuries to the spine (28.9%), chest (37.6%), and abdomen (35.0%) were also common. Eighty percent of patients used emergency medical services (50% ambulance, 30% helicopter) with a median emergency medical services transport time of 84 minutes. 50.8% of patients required interhospital transport. 43.2% of injuries required surgical intervention (21.3% orthopedic, 12.5% neurosurgical, 10.5% thoracic, 7.8% abdominal). Median hospital length of stay was 5.0 days. 60.0% of patients required intensive care unit admission with median intensive care unit length of stay 3.0 days. Overall mortality was 4.0% for skiers and 1.9% for snowboarders. CONCLUSION Severe injuries after ski and snowboard accidents are associated with significant morbidity and mortality. Differences in injury patterns, risk factors for severe injury, and resource utilization require further study. Increased resource allocation to alpine trauma systems is warranted. LEVEL OF EVIDENCE Prognostic/epidemiologic, level III.

Impact of smoking on trauma patients

BACKGROUND The harmful effects of smoking have been well-documented in the medical literature for decades. To further the support of smoking cessation, we investigate the effect of smoking on a less studied population, the trauma patient. METHODS All trauma patients admitted to the surgical intensive care unit at the LAC + University of Southern California medical center between January 2007 and December 2011 were included. Patients were stratified into two groups - current smokers and non-smokers. Demographics, admission vitals, comorbidities, operative interventions, injury severity indices, and acute physiology and chronic health evaluation (APACHE) II scores were documented. Uni- and multi-variate modeling was performed. Outcomes studied were mortality, duration of mechanical ventilation, and length of hospitalization. RESULTS A total of 1754 patients were available for analysis, 118 (6.7%) patients were current smokers. The mean age was 41.4±20.4, 81.0% male and 73.5% suffered blunt trauma. Smokers had a higher incidence of congestive heart failure (4.2% vs. 0.9%, p=0.007) and alcoholism (20.3% vs. 5.9%, p<0.001), but had a significantly lower APACHE II score. After multivariate regression analysis, there was no significant mortality difference. Patients who smoked spent more days mechanically ventilated (beta coefficient: 4.96 [1.37, 8.55, p=0.007]). CONCLUSION Smoking is associated with worse outcome in the critically ill trauma patient. On an average, smokers spent 5 days longer requiring mechanical ventilation than non-smokers.