Donald H. Jenkins

Damage control resuscitation: the new face of damage control.

Juan C. Duchesne, MD, FACS, FCCP, Norman E. McSwain, Jr., MD, FACS, Bryan A. Cotton, MD, FACS, John P. Hunt, MD, MPH, FACS, Jeff Dellavolpe, MD, Kelly Lafaro, MD, MPH, Alan B. Marr, MD, FACS, Earnest A. Gonzalez, MD, FACS, Herb A. Phelan, MD, FACS, Tracy Bilski, MD, FACS, Patrick Greiffenstein, MD, James M. Barbeau, MD, JD, Kelly V. Rennie, MD, Christopher C. Baker, MD, FACS, Karim Brohi, MD, FRCS, FRCA, Donald H. Jenkins, MD, FACS, and Michael Rotondo, MD, FACS

A Reduction in Clot Formation Rate and Strength Assessed by Thrombelastography Is Indicative of Transfusion Requirements in Patients With Penetrating Injuries

BACKGROUND Bleeding is a major cause of death in patients with traumatic injuries. Recently, thrombelastography (TEG) has been suggested as an additional means of evaluating coagulation in trauma patients. We hypothesized that TEG data would aid in defining the coagulopathy of trauma in patients with penetrating traumatic injuries. METHODS A retrospective study was performed of patients (n = 44) with penetrating injuries admitted to a combat support hospital during a 2-month period in 2004. Recorded data included standard laboratory data, TEG parameters, and blood product use in the first 24 hours after admission. Values were compared with clinically accepted ranges and those obtained from the Haemoscope Corporation. RESULTS At admission, International Normalization Ratio, prothrombin time, and partial thromboplastin time were increased in 39% (>or=1.5), 31% (>16 seconds), and 37% (>40 seconds) of patients, respectively, suggesting hypocoagulation, but these variables did not correlate with the use of blood products (p > 0.05). TEG values obtained within 24 hours of admission (6 hours +/- 5.7 hours; median of 4.5 hours) demonstrated hypocoagulation based on delayed propagation of the clot (increased K time and reduced alpha-angle) and decreased clot strength (reduced maximal amplitude [MA]). MA correlated (r = 0.57, p < 0.01) with blood product use as well as platelet count (r = 0.61, p < 0.01). Patients with reduced MA (n = 23) used more blood products and had reduced platelet counts and hematocrit. CONCLUSION Thrombelastography was a more accurate indicator of blood product requirements in our patient population than prothrombin time, partial thromboplastin time, and International Normalization Ratio. Thrombelastography enhanced by platelet count and hematocrit can guide blood transfusion requirements.

Complications After Fasciotomy Revision and Delayed Compartment Release in Combat Patients

BACKGROUND Incomplete or delayed fasciotomies are associated with muscle necrosis and death in civilian trauma. Combat explosions severely damage tissue and distort normal anatomy making fasciotomies challenging. Rapid air evacuation may delay treatment of patients with evolving extremity compartment syndrome. We investigated the impact of fasciotomy revision and delayed compartment release on combat casualties after air evacuation. METHODS A retrospective review was performed of combat casualties who underwent fasciotomies in Iraq, Afghanistan, or at Landstuhl Regional Medical Center between January 1, 2005 and August 31, 2006. Outcomes were rates of muscle excision, major amputation, and mortality. RESULTS A total of 336 patients underwent 643 fasciotomies. Most were to the lower leg (49%) and forearm (23%). Patients who underwent a fasciotomy revision had higher rates of muscle excision (35% vs. 9%, p < 0.01) and mortality (20% vs. 6%, p < 0.01) than those who did not receive a revision. The anterior and deep compartments of the lower leg were the most commonly unopened. Patients who underwent fasciotomy after evacuation had higher rates of muscle excision (25% vs. 11%), amputation (31 vs. 15%), and mortality (19% vs. 5%) than patients who received their fasciotomies in the combat theater (p < 0.01). Patients who underwent revisions or delayed fasciotomies had higher Injury Severity Score and larger burns as well as lower systolic blood pressure, acidosis, and more pressor use during air evacuation. These patients also received more blood products at Landstuhl Regional Medical Center. CONCLUSION Fasciotomy revision was associated with a fourfold increase in mortality. The most common revision procedures were extension of fascial incisions and opening new compartments. The most commonly unopened compartment was the anterior compartment of the lower leg. Patients who underwent delayed fasciotomies had twice the rate of major amputation and a threefold higher mortality.

Improved characterization of combat injury

BACKGROUND Combat injury patterns differ from civilian trauma in that the former are largely explosion-related, comprising multiple mechanistic and fragment injuries and high-kinetic-energy bullets. Further, unlike civilians, U.S. armed forces combatants are usually heavily protected with helmets and Kevlar body armor with ceramic plate inserts. Searchable databases providing actionable, statistically valid knowledge of body surface entry wounds and resulting organ injury severity are essential to understanding combat trauma. METHODS Two tools were developed to address these unique aspects of combat injury: (1) the Surface Wound Mapping (SWM) database and Surface Wound Analysis Tool (SWAT) software that were developed to generate 3D density maps of point-of-surface wound entry and resultant anatomic injury severity; and (2) the Abbreviated Injury Scale (AIS) 2005-Military that was developed by a panel of military trauma surgeons to account for multiple injury etiology from explosions and other high-kinetic- energy weapons. Combined data from the Joint Theater Trauma Registry, Navy/Marine Combat Trauma Registry, and the Armed Forces Medical Examiner System Mortality Trauma Registry were coded in AIS 2005-Military, entered into the SWM database, and analyzed for entrance site and wounding path. RESULTS When data on 1,151 patients, who had a total of 3,500 surface wounds and 12,889 injuries, were entered into SWM, surface wounds averaged 3.0 per casualty and injuries averaged 11.2 per casualty. Of the 3,500 surface wounds, 2,496 (71%) were entrance wounds with 6,631 (51%) associated internal injuries, with 2.2 entrance wounds and 5.8 associated injuries per casualty (some details cannot be given because of operational security). Crude deaths rates were calculated using Maximum AIS-Military. CONCLUSION These new tools have been successfully implemented to describe combat injury, mortality, and distribution of wounds and associated injuries. AIS 2005-Military is a more precise assignment of severity to military injuries. SWM has brought data from all three combat registries together into one analyzable database. SWM and SWAT allow visualization of wounds and associated injuries by region on a 3D model of the body.

Impact of joint theater trauma system initiatives on battlefield injury outcomes

INTRODUCTION The US military forces developed and implemented the Joint Theater Trauma System (JTTS) and Joint Theater Trauma Registry (JTTR) using US civilian trauma system models with the intent of improving outcomes after battlefield injury. METHODS The purpose of this analysis was to elaborate the impact of the JTTS. To quantify these achievements, the JTTR captured mechanism, acute physiology, diagnostic, therapeutic, and outcome data on 23,250 injured patients admitted to deployed US military treatment facilities from July 2003 through July 2008 for analysis. Comparative analysis to civilian trauma systems was done using the National Trauma Data Bank (NTDB). RESULTS In contrast to civilian trauma systems with an 11.1% rate of penetrating injury, 68.3% of battlefield wounds were by penetrating mechanism. In the analyzed cohort, 23.3% of all patients had an Injury Severe Score (ISS) > or = 16, which is similar to the civilian rate of 22.4%. In the military injury population, 66% of injuries were combat-related. In addition, in the military injury group, 21.8% had metabolic evidence of shock with a base deficit > or = 5, 29.8% of patients required blood transfusion, and 6.4% of the total population of combat casualties required massive transfusion (>10 U red blood cells/24 hours). With this complex and severely injured population of battlefield injuries, the JTTS elements were used to recognize and remedy more than 60 trauma system issues requiring leadership and advocacy, education, research, and alterations in clinical care. Of particular importance to the trauma system was the implementation and tracking of performance improvement indicators and the dissemination of 27 evidence-based clinical practice guidelines (CPGs). In particular, the damage control resuscitation guideline was associated with a decrease in mortality in the massively transfused from 32% pre-CPG to 21% post-CPG. As evidence of the effectiveness of the JTTS, a mortality rate of 5.2% after battlefield hospital admission is comparable to a case fatality rate of 4.3% reported in an age-matched cohort from the NTDB. CONCLUSIONS JTTS initiatives contributed to improved survival after battlefield injury. The JTTS has set the standard of trauma care for the modern battlefield using contemporary systems-based methodologies.

Joint Theater Trauma System implementation of burn resuscitation guidelines improves outcomes in severely burned military casualties.

BACKGROUND Between March 2003 and June 2007, our burn center received 594 casualties from the conflicts in Iraq and Afghanistan. Ongoing acute burn resuscitation as severely burned casualties are evacuated over continents is very challenging. To help standardize care, burn resuscitation guidelines (BRG) were devised along with a burn flow sheet (BFS) and disseminated via the new operational Joint Theater Trauma System to assist deployed providers. METHODS After the BRG was implemented in January 2006, BRF data were prospectively collected in consecutive military casualties with >30% total body surface area (TBSA) burns (BRG Group). Baseline demographic data and fluid requirements for the first 24 hours of the burn resuscitation were collected from the BFS. Percentage full thickness TBSA burns, presence of inhalation injury, injury severity score, resuscitation-related abdominal compartment syndrome, and mortality were collected from our database. Individual charts were reviewed to determine the presence of extremity fasciotomies and myonecrosis. These results were compared with consecutive military casualties admitted during the 2-year- period before the system-wide implementation of the BRG (control group). RESULTS One hundred eighteen military casualties with burns >30% TBSA were admitted between January 2003 and June 2007, with n = 56 in the BRG group and n = 62 in the control group. The groups were different in age, but similar in %TBSA, %full thickness, presence of inhalation injury, and injury severity score. There was no difference in the rate of extremity fasciotomies or the incidence of myonecrosis between groups. CONCLUSIONS The composite endpoint of abdominal compartment syndrome and mortality was significantly lower in the BRG group compared with the control group (p = 0.03). Implementation of the BRG and system-wide standardization of burn resuscitation improved outcomes in severely burned patients. Utilization of the joint theater trauma system to implement system-wide guidelines is effective and can help improve outcomes.

Trauma hemostasis and oxygenation research position paper on remote damage control resuscitation: definitions, current practice, and knowledge gaps.

ABSTRACT The Trauma Hemostasis and Oxygenation Research Network held its third annual Remote Damage Control Resuscitation Symposium in June 2013 in Bergen, Norway. The Trauma Hemostasis and Oxygenation Research Network is a multidisciplinary group of investigators with a common interest in improving outcomes and safety in patients with severe traumatic injury. The network’s mission is to reduce the risk of morbidity and mortality from traumatic hemorrhagic shock, in the prehospital phase of resuscitation through research, education, and training. The concept of remote damage control resuscitation is in its infancy, and there is a significant amount of work that needs to be done to improve outcomes for patients with life-threatening bleeding secondary to injury. The prehospital phase of resuscitation is critical in these patients. If shock and coagulopathy can be rapidly identified and minimized before hospital admission, this will very likely reduce morbidity and mortality. This position statement begins to standardize the terms used, provides an acceptable range of therapeutic options, and identifies the major knowledge gaps in the field.

Infections in combat casualties during Operations Iraqi and Enduring Freedom.

BACKGROUND Infections are a common acute and chronic complication of combat-related injuries; however, no systematic attempt to assess infections associated with US combat-related injuries occurring in Iraq and Afghanistan has been conducted. The Joint Theater Trauma Registry (JTTR) has been established to collect injury specific medical data from casualties in Iraq and Afghanistan. METHODS We reviewed the JTTR for the identification of infectious complications (IC) using International Classification of Diseases, 9th Revision (ICD-9) coding during two phases of the wars, before and after the end of the major ground operations in Iraq (19 March-May 31, 2003 and June 1, 2003-December 31, 2006). ICD-9 codes were combined into two categories; anatomic or clinical syndrome and pathogen. An IC was defined as the presence of ICD-9 codes that included both anatomic or clinical syndrome and a pathogen. RESULTS There were 425 patients evaluated in phase I and 684 in phase II with approximately one third having an IC. The most common anatomic or clinical syndrome codes were skin or wound followed by lung, and the most common pathogen code was gram-negative bacteria. The site of injury had varying rates of IC: spine or back (53%), head or neck (44%), torso (43%), and extremity (35%). Injury Severity Score and certain mechanisms of injury (explosive device, bomb, and landmine) were associated with an IC on multivariate analysis (p < 0.01). CONCLUSION Infections are common after combat-related injuries. Although the JTTR can provide general information regarding infections, improved data capture and more specific clinical information is necessary to improve overall combat-related injury infection care.

Guidelines for the prevention of infection after combat-related injuries.

Management of combat-related trauma is derived from skills and data collected in past conflicts and civilian trauma, and from information and experience obtained during ongoing conflicts. The best methods to prevent infections associated with injuries observed in military combat are not fully established. Current methods to prevent infections in these types of injuries are derived primarily from controlled trials of elective surgery and civilian trauma as well as retrospective studies of civilian and military trauma interventions. The following guidelines integrate available evidence and expert opinion, from within and outside of the US military medical community, to provide guidance to US military health care providers (deployed and in permanent medical treatment facilities) in the diagnosis, treatment, and prevention of infections in those individuals wounded in combat. These guidelines may be applicable to noncombat traumatic injuries under certain circumstances. Early wound cleansing and surgical debridement, antibiotics, bony stabilization, and maintenance of infection control measures are the essential components to diminish or prevent these infections. Future research should be directed at ideal treatment strategies for prevention of combat-related injury infections, including investigation of unique infection control techniques, more rapid diagnostic strategies for infection, and better defining the role of antimicrobial agents, including the appropriate spectrum of activity and duration.

Independent Predictors of Enteric Fistula and Abdominal Sepsis After Damage Control Laparotomy: Results From the Prospective AAST Open Abdomen Registry

IMPORTANCE Enterocutaneous fistula (ECF), enteroatmospheric fistula (EAF), and intra-abdominal sepsis/abscess (IAS) are major challenges for surgeons caring for patients undergoing damage control laparotomy after trauma. OBJECTIVE To determine independent predictors of ECF, EAF, or IAS in patients undergoing damage control laparotomy after trauma, using the AAST Open Abdomen Registry. DESIGN The AAST Open Abdomen registry of patients with an open abdomen following damage control laparotomy was used to identify patients who developed ECF, EAF, or IAS and to compare these patients with those without these complications. Univariate analyses were performed to compare these groups of patients. Variables from univariate analyses differing at P < .20 were entered into a stepwise logistic regression model to identify independent risk factors for ECF, EAF, or IAS. SETTING Fourteen level I trauma centers. PARTICIPANTS A total of 517 patients with an open abdomen following damage control laparotomy. MAIN OUTCOMES AND MEASURES Complication of ECF, EAF, or IAS. RESULTS More patients in the ECF/EAF/IAS group than in the group without these complications underwent bowel resection (63 of 111 patients [57%] vs 133 of 406 patients [33%]; P < .001). Within the first 48 hours after surgery, the ECF/EAF/IAS group received more colloids (P < .03) and total fluids (P < .03) than did the group without these complications. The ECF/EAF/IAS group underwent almost twice as many abdominal reexplorations as did the group without these complications (mean [SD] number, 4.1 [4.1] vs 2.2 [3.4]; P < .001). After multivariate analysis, the independent predictors of ECF/EAF/IAS were a large bowel resection (adjusted odds ratio [AOR], 3.56 [95% CI, 1.88-6.76]; P < .001), a total fluid intake at 48 hours of between 5 and 10 L (AOR, 2.11 [95% CI, 1.15-3.88]; P = .02) or more than 10 L (AOR, 1.93 [95% CI, 1.04-3.57]; P = .04), and an increasing number of reexplorations (AOR, 1.14 [95% CI, 1.06-1.21]; P < .001). CONCLUSIONS AND RELEVANCE Large bowel resection, large-volume fluid resuscitation, and an increasing number of abdominal reexplorations were statistically significant predictors of ECF, EAF, or IAS in patients with an open abdomen after damage control laparotomy.