David V. Shatz

Optimal positioning for emergent needle thoracostomy: a cadaver-based study.

BACKGROUND Needle thoracostomy is an emergent procedure designed to relieve tension pneumothorax. High failure rates because of the needle not penetrating into the thoracic cavity have been reported. Advanced Trauma Life Support guidelines recommend placement in the second intercostal space, midclavicular line using a 5-cm needle. The purpose of this study was to evaluate placement in the fifth intercostal space, midaxillary line, where tube thoracostomy is routinely performed. We hypothesized that this would result in a higher successful placement rate. METHODS Twenty randomly selected unpreserved adult cadavers were evaluated. A standard 14-gauge 5-cm needle was placed in both the fifth intercostal space at the midaxillary line and the traditional second intercostal space at the midclavicular line in both the right and left chest walls. The needles were secured and thoracotomy was then performed to assess penetration into the pleural cavity. The right and left sides were analyzed separately acting as their own controls for a total of 80 needles inserted into 20 cadavers. The thickness of the chest wall at the site of penetration was then measured for each entry position. RESULTS A total of 14 male and 6 female cadavers were studied. Overall, 100% (40 of 40) of needles placed in the fifth intercostal space and 57.5% (23 of 40) of the needles placed in the second intercostal space entered the chest cavity (p < 0.001); right chest: 100% versus 60.0% (p = 0.003) and left chest: 100% versus 55.0% (p = 0.001). Overall, the thickness of the chest wall was 3.5 cm ± 0.9 cm at the fifth intercostal space and 4.5 cm ± 1.1 cm at the second intercostal space (p < 0.001). Both right and left chest wall thicknesses were similar (right, 3.6 cm ± 1.0 cm vs. 4.5 cm ± 1.1 cm, p = 0.007; left, 3.5 ± 0.9 cm vs. 4.4 cm ± 1.1 cm, p = 0.008). CONCLUSIONS In a cadaveric model, needle thoracostomy was successfully placed in 100% of attempts at the fifth intercostal space but in only 58% at the traditional second intercostal position. On average, the chest wall was 1 cm thinner at this position and may improve successful needle placement. Live patient validation of these results is warranted.

Radiologic Evaluation of Alternative Sites for Needle Decompression of Tension Pneumothorax

OBJECTIVE To compare the distance to be traversed during needle thoracostomy decompression performed at the second intercostal space (ICS) in the midclavicular line (MCL) with the fifth ICS in the anterior axillary line (AAL). DESIGN Patients were separated into body mass index (BMI) quartiles, with BMI calculated as weight in kilograms divided by height in meters squared. From each BMI quartile, 30 patients were randomly chosen for inclusion in the study on the basis of a priori power analysis (n = 120). Chest wall thickness on computed tomography at the second ICS in the MCL was compared with the fifth ICS in the AAL on both the right and left sides through all BMI quartiles. SETTING Level I trauma center. PATIENTS Injured patients aged 16 years or older evaluated from January 1, 2009, to January 1, 2010, undergoing computed tomography of the chest. RESULTS A total of 680 patients met the study inclusion criteria (81.5% were male and mean age was 41 years [range, 16-97 years]). Of the injuries sustained, 13.2% were penetrating, mean (SD) Injury Severity Score was 15.5 (10.3), and mean BMI was 27.9 (5.9) (range, 15.4-60.7). The mean difference in chest wall thickness between the second ICS at the MCL and the fifth ICS at the AAL was 12.9 mm (95% CI, 11.0-14.8; P < .001) on the right and 13.4 mm (95% CI, 11.4-15.3; P < .001) on the left. There was a stepwise increase in chest wall thickness across all BMI quartiles at each location of measurement. There was a significant difference in chest wall thickness between the second ICS at the MCL and the fifth ICS at the AAL in all quartiles on both the right and the left. The percentage of patients with chest wall thickness greater than the standard 5-cm decompression needle was 42.5% at the second ICS in the MCL and only 16.7% at the fifth ICS in the AAL. CONCLUSIONS In this computed tomography-based analysis of chest wall thickness, needle thoracostomy decompression would be expected to fail in 42.5% of cases at the second ICS in the MCL compared with 16.7% at the fifth ICS in the AAL. The chest wall thickness at the fifth ICS AAL was 1.3 cm thinner on average and may be a preferred location for needle thoracostomy decompression.

Decreased mortality after prehospital interventions in severely injured trauma patients.

BACKGROUND We test the hypothesis that prehospital interventions (PHIs) performed by skilled emergency medical service providers during ground or air transport adversely affect outcome in severely injured trauma patients. METHODS Consecutive trauma activations (March 2012 to June 2013) transported from the scene by air or ground emergency medical service providers were reviewed. PHI was defined as intubation, needle decompression, tourniquet, cricothyroidotomy, or advanced cardiac life support. RESULTS In 3,733 consecutive trauma activations (71% blunt, 25% penetrating, 4% burns), age was 39 years, 74% were male, Injury Severity Score (ISS) was 5, and Glasgow Coma Score (GCS) was 15, with 32% traumatic brain injury (TBI) and 7% overall mortality. Those who received PHI (n = 130, 3.5% of the trauma activations) were more severely injured: ISS (26 vs. 5), GCS (3 vs. 15), TBI (57% vs. 31%), Revised Trauma Score (RTS, 5.45 vs. 7.84), Trauma and Injury Severity Score (TRISS, 1.32 vs. 4.89), and mortality (56% vs. 5%) were different (all p < 0.05) than those who received no PHI. Air crews transported 22% of the patients; more had TBI, blunt injury, high ISS, and long prehospital times (all p < 0.05), but mortality was similar to those transported by ground. In the most severely injured patients with signs of life who received a PHI, the ISS, prehospital times, and proportions of TBI, blunt trauma, and air transport were similar, but mortality was significantly lower (43% vs. 23%, p= 0.021). CONCLUSION In our urban trauma system, PHIs are associated with a lower incidence of mortality in severely injured trauma patients and do not delay transport to definitive care. LEVEL OF EVIDENCE Prognostic/epidemiologic study, level III; therapeutic study, level IV.

Patterns of maxillofacial injuries in powered watercraft collisions.

Because of the widespread popularity of water sports, plastic and reconstructive surgeons can expect to manage an increasing number of injuries associated with these activities, particularly those related to powered watercraft vehicles. Although seat belts for motorists and helmets for motorcyclists may be efficacious, such devices currently do not serve a similar role in powered watercraft sports. In this study, a retrospective chart review of 194 consecutive patients who presented to the University of Miami/Jackson Memorial Hospital (Level I trauma center) as a result of powered watercraft collisions is presented. The purpose of this investigation was to assess the incidence, cause, demographics, and available management options for head and neck injuries secondary to powered watercraft. Identified were 194 patients who presented because of watersports-related injuries during the period January 1, 1991, through December 31, 1996. From this group, 81 patients (41.8 percent) sustained injuries directly attributable to powered watercraft collisions, including 41 personal watercraft collisions (50.6 percent), 39 boat collisions (48.1 percent), and 1 airboat collision (1.2 percent). The patient population, as expected, tended to be young and male with an average age of 29 years (range, 8 to 64 years old). Interestingly, 41 of the patients (50.6 percent) who presented to this trauma center as a result of powered watercraft collisions also sustained associated head and neck trauma. Of 74 injuries 24 were facial fractures (32.4 percent), 18 were facial lacerations (24.3 percent), 14 were closed head injuries (18.9 percent), 8 were skull fractures (10.8 percent), 4 were scalp lacerations (5.4 percent), 4 were C-spine fractures (5.4 percent), 1 was an ear laceration (1.4 percent), and 1 was a fatality (1.4 percent). Le Fort fractures were the most commonly identified facial fracture in this series. The number of these injuries seen in hospital emergency rooms will most likely increase in the future as the popularity of water-related recreational activities becomes even more widespread. Based on these findings, it is strongly recommended that future efforts be directed toward the prevention of these injuries through patient education and the eventual development of efficacious and safe protective equipment.

Mechanical ventilation weaning and extubation after spinal cord injury: a Western Trauma Association multicenter study.

BACKGROUND Respiratory failure after acute spinal cord injury (SCI) is well recognized, but data defining which patients need long-term ventilator support and criteria for weaning and extubation are lacking. We hypothesized that many patients with SCI, even those with cervical SCI, can be successfully managed without long-term mechanical ventilation and its associated morbidity. METHODS Under the auspices of the Western Trauma Association Multi-Center Trials Group, a retrospective study of patients with SCI at 14 major trauma centers was conducted. Comprehensive injury, demographic, and outcome data on patients with acute SCI were compiled. The primary outcome variable was the need for mechanical ventilation at discharge. Secondary outcomes included the use of tracheostomy and development of acute lung injury and ventilator-associated pneumonia. RESULTS A total of 360 patients had SCI requiring mechanical ventilation. Sixteen patients were excluded for death within the first 2 days of hospitalization. Of the 344 patients included, 222 (64.5%) had cervical SCI. Notably, 62.6% of the patients with cervical SCI were ventilator free by discharge. One hundred forty-nine patients (43.3%) underwent tracheostomy, and 53.7% of them were successfully weaned from the ventilator, compared with an 85.6% success rate among those with no tracheostomy (p < 0.05). Patients who underwent tracheostomy had significantly higher rates of ventilator-associated pneumonia (61.1% vs. 20.5%, p < 0.05) and acute lung injury (12.8% vs. 3.6%, p < 0.05) and fewer ventilator-free days (1 vs. 24 p < 0.05). When controlled for injury severity, thoracic injury, and respiratory comorbidities, tracheostomy after cervical SCI was an independent predictor of ventilator dependence with an associated 14-fold higher likelihood of prolonged mechanical ventilation (odds ratio, 14.1; 95% confidence interval, 2.78–71.67; p < 0.05). CONCLUSION While many patients with SCI require short-term mechanical ventilation, the majority can be successfully weaned before discharge. In patients with SCI, tracheostomy is associated with major morbidity, and its use, especially among patients with cervical SCI, deserves further study. LEVEL OF EVIDENCE Prognostic study, level III

Western Trauma Association Critical Decisions in Trauma: Diagnosis and management of esophageal injuries

This is a recommended management algorithm from the Western Trauma Association addressing the diagnostic evaluation and management of esophageal injuries in adult patients. Because there is a paucity of published prospective randomized clinical trials that have generated Class I data, the recommendations herein are based primarily on published observational studies and expert opinion of Western Trauma Association members. The algorithms and accompanying comments represent a safe and sensible approach that can be followed at most trauma centers. We recognize that there will be patient, personnel, institutional, and situational factors that may warrant or require deviation from the recommended algorithm. We encourage institutions to use this guideline to formulate their own local protocols.The algorithm contains letters at decision points; the corresponding paragraphs in the text elaborate on the thought process and cite pertinent literature. The annotated algorithm is intended to (a) serve as a quick bedside reference for clinicians; (b) foster more detailed patient care protocols that will allow for prospective data collection and analysis to identify best practices; and (c) generate research projects to answer specific questions concerning decision making in the management of adults with esophageal injuries.

Probable cause in helicopter emergency medical services crashes: what role does ownership play?

BACKGROUND The National Transportation Safety Board (NTSB) ranks helicopter emergency medical services (HEMS) as one of the most perilous occupations in the United States, with improvements in its safety of highest priority. As many injured patients are transported by helicopter, this is of particular concern to the trauma community. The use of HEMS is associated with a heightened degree of inherent risk. We hypothesized that this risk is not uniform and varies with the entity providing HEMS, specifically, commercial versus public safety providers. METHODS The NTSB accident database was queried to identify all HEMS-involved events for the 15-year period 1998 to 2012. The NTSB investigation report was reviewed to obtain crash details including probable cause. These were analyzed on the basis of HEMS ownership. Statistical analyses were performed using analysis of variance and Fisher’s exact test as appropriate. RESULTS During the study period, 139 (6.8%) of 2,040 crashes involved HEMS and occurred across 134 cities in 37 states, killing 120 and seriously injuring 146. Of these, 118 involved commercial, 14 not-for-profit, and 7 public safety HEMS. Analyzed in 5-year blocks, no decrease in crash incidence was seen (p = 0.7, analysis of variance). Human and pilot errors were significantly more common among commercial HEMS compared with public safety HEMS (91 of 118 vs. 2 of 7, p = 0.013, and 75 of 116 vs. 1 of 7, p = 0.017, Fisher’s exact test). Conditions for which training was not adequate, limited resources, inadequate equipment, and the undertaking of suboptimal trips were identified as key factors. Trauma patients were involved in 34 transports (24.5%), with a fatal or serious outcome in 68 crew/patients on 12 flights. CONCLUSION Potentially preventable human and pilot error–related HEMS crashes are significantly more frequent among commercial compared with public safety providers. Deficiencies in training, reduced availability of equipment and resources, as well as questionable flight selection seem to play a key role. LEVEL OF EVIDENCE Epidemiologic study, level III.

Western Trauma Association Critical Decisions in Trauma: Management of pelvic fracture with hemodynamic instability—2016 updates

S ince the publication of the 2008 Western Trauma Association algorithm for the management of pelvic fracture with hemodynamic instability, the approach in general has not changed, but several components of the approach have come into sharper focus, and a new component is gaining some traction in a few centers (Fig. 1). This manuscript is an interim update to recognize some of the changes. The accompanying graphic is marked where it differs from the 2008 algorithm, and explanatory text follows. Pelvic ring injuries range from low-energy pubic ramus fractures to high-energy unstable patterns that can result in hemodynamic instability. The Young and Burgess system identified injury patterns correlating with the direction of the applied force. This classification system described four pelvic injury patterns: anterior posterior compression (APC), lateral compression (LC), vertical shear (VS), and combined injuries. LC and APC injuries are further classified into progressively numbered stages from I to III, which represent increasing displacement and severity of injury. The internal iliac vasculature and the presacral venous plexus are located just anterior to the

Western Trauma Association Critical Decisions in Trauma: Management of adult blunt splenic trauma - 2016 updates

This is an updated position article from members of the Western Trauma Association (WTA). It includes recommendations for the management of blunt splenic injury in adult trauma patients based on literature available since the last WTA position article in 2008.1 There remain no prospective randomized

Management of rib fractures: A Western Trauma Association Critical Decisions algorithm

This is a recommended management algorithm from the Western Trauma Association addressing the management of adult patients with rib fractures. Because there is a paucity of published prospective randomized clinical trials that have generated Class I data, these recommendations are based primarily on published observational studies and expert opinion of Western Trauma Association members. The algorithm and accompanying comments represent a safe and sensible approach that can be followed at most trauma centers. We recognize that there will be patient, personnel, institutional, and situational factors that may warrant or require deviation from the recommended algorithm. We encourage institutions to use this as a guideline to develop their own local protocols.