Edward B. Lineen

Biologic dressing in burns.

Advances in cellular biology and knowledge in wound healing and growth factors have given us a wide variety of choices to attack the problem of the complex burn wound. Split-thickness skin grafting with autograft is at present the standard of care. It, however, is not an ideal substitute and frequently is not available for full-burn coverage. This article will review honey, human amnion, xenograft, allograft, cultured epithelial autograft, and various engineered commercial products for use in the biologic treatment of burn wounds.

Value of computed tomographic angiography in neck and extremity pediatric vascular trauma

PURPOSE We sought to define the sensitivity and specificity of computed tomographic angiography (CTA) in pediatric vascular injuries. METHODS All neck and extremity CTAs performed in pediatric patients at a level 1 trauma center were reviewed from 2001 to 2007. RESULTS Overall, 78 patients were identified with an average age of 15.0 +/- 4.0 (0-18 years). Males outnumbered females 3.6:1. CTA was performed for 41 penetrating and 37 blunt traumas. Most penetrating injuries were due to missile wounds (71%) or stab wounds (17%). Eleven major vascular injuries resulted from penetrating trauma. For penetrating trauma, CTA was 100% sensitive and 93% specific. CTA for penetrating trauma had a positive predictive value (PPV) of 85% and negative predictive value (NPV) of 100%. Most blunt injuries were due to motor vehicle accidents (57%), followed by pedestrian hit by car (27%). Eight major vascular injuries resulted from blunt trauma. For blunt trauma, CTA was 88% sensitive and 100% specific. CTA for blunt trauma had a PPV of 100% and an NPV of 97%. The accuracy for penetrating and blunt trauma was 95% and 97%, respectively. CONCLUSIONS CTA is highly sensitive, specific, and accurate for pediatric neck and extremity vascular trauma.

Surveillance and Early Management of Deep Vein Thrombosis Decreases Rate of Pulmonary Embolism in High-Risk Trauma Patients

BACKGROUND Venous duplex ultrasound (VDU) is the modality of choice for surveillance of venous thromboembolism (VTE), but there is controversy about its appropriate implementation as a screening method. We hypothesize that VDU surveillance in trauma patients at high risk for VTE decreases the rate of pulmonary embolism (PE). STUDY DESIGN One thousand two hundred and eighty-two trauma ICU admissions were screened with Greenfields Risk Assessment Profile from August 2011 to September 2014. Four hundred and two patients were identified as high risk for VTE (Risk Assessment Profile ≥10). Those who received weekly VDU to evaluate for deep vein thrombosis (n = 259 [64%]) were compared with those who did not (n = 143 [36%]). Parametric data are reported as mean ± SD and nonparametric data are reported as median (interquartile range). Statistical significance was determined at an α level of 0.05. RESULTS The overall study population was 47 ± 19 years old and 75% were male, 78% of injuries were blunt mechanism, Injury Severity Score was 28 ± 13, Risk Assessment Profile was 14 ± 4, and mortality was 14.3%. Deep vein thrombosis rate was 11.6% (n = 30) in the surveillance group vs 2.1% (n = 3) in the non-surveillance group (p < 0.001). Deep vein thromboses detected in the surveillance group were managed with systemic anticoagulation (43%) or with IVC filter placement (57%). In the surveillance group, the PE rate was 1.9% (n = 5) vs 7.0% (n = 10) in the non-surveillance group (p = 0.014). CONCLUSIONS Trauma patients at high risk for VTE and who received VDU surveillance and early management of deep vein thrombosis have decreased rates of pulmonary embolism.

Trauma surgeon mortality rates correlate with surgeon time at institution

BACKGROUND Trauma centers have been created to bring traumatized patients together with experienced surgeons. We reviewed our outcomes to determine if mortality rates for high Injury Severity Scores (>or= 35) correlate with surgeon experience at our trauma center. STUDY DESIGN Using our prospectively collected database, we compared our results with mean mortality for high-volume American College of Surgeon-certified trauma centers reporting to the National Trauma Data Bank. Mortality rates for our 11 trauma surgeons were correlated with years of experience as faculty surgeons at our institution during a 2-year period. Statistical analysis was done with chi-square or weighted linear regression; significance was defined as p < 0.05. RESULTS Our trauma center mortality rates were significantly below the mean rates of National Trauma Data Bank at all levels of injury (chi-square, p < 0.05). Despite this success, there was a significant correlation between years of experience as a surgeon at our institution and improved outcomes for patients with an Injury Severity Score >or= 35 (weighted linear regression, p < 0.05). It took, on average, 7.9 years of experience at our trauma center to reach benchmark mortality rates. CONCLUSIONS Mortality rates for severely injured patients correlate significantly with surgeon experience at our institution. The training process does not end with fellowship or surgical residency, and surgeons new to an institution should be closely monitored and mentored to minimize mortality rates of severely injured patients. Even at a very high volume trauma center with overall results substantially better than mean expected survival, we can demonstrate that experience makes a difference.

Anti-Xa Guided Enoxaparin Thromboprophylaxis Reduces Rate Of Deep Venous Thromboembolism In High-Risk Trauma Patients.

BACKGROUND Appropriate prophylaxis against venous thromboembolism (VTE) remains undefined. This study evaluated an anti-Xa–guided enoxaparin thromboprophylaxis (TPX) protocol on the incidence of VTE in high-risk trauma patients based on Greenfield’s Risk Assessment Profile (RAP) score. METHODS This is a retrospective observational study of patients admitted to a trauma intensive care unit over a 12-month period. Patients were included if they received anti-Xa–guided enoxaparin TPX. Dosage was adjusted to a prophylactic peak anti-Xa level of 0.2 to 0.4 IU/mL. Subgroup analysis was performed on high-risk patients (RAP score ≥10) who received lower-extremity duplex ultrasound surveillance for deep vein thrombosis (DVT). Data are expressed as mean ± SD. Significance was assessed at p < 0.05. RESULTS One hundred thirty-one patients received anti-Xa–guided enoxaparin TPX. Four patients were excluded for age or acute VTE on admission. Fifty-six patients with RAP score of ≥10 and surveillance duplex evaluations were included in the subgroup analysis with mean age 43 ± 20 years, Injury Severity Score of 25 ± 10, and RAP score of 16 ± 4. Prophylactic anti-Xa levels were initially achieved in 34.6% of patients. An additional 25.2% required 40 to 60 mg twice daily to reach prophylactic levels; 39.4% never reached prophylactic levels. Weight, body mass index, ISS, and RAP score were significantly higher with subprophylactic anti-Xa levels. One patient developed bleeding complications (0.8%). No patient developed intracerebral bleeding or heparin-induced thrombocytopenia. Nine VTE events occurred in the high-risk subgroup, including four DVT (7.1%), all asymptomatic, and five pulmonary emboli (8.9%). The historical rate of DVT in similar patients (ISS 31 ± 12 and RAP score 16 ± 5) was 20.5%, a significant decrease (p = 0.031). Mean chest Abbreviated Injury Scale scores were significantly higher for patients developing pulmonary emboli than DVT, 3.0 ± 1.1 vs. 0.0 (p < 0.001). CONCLUSIONS Mean chest Abbreviated Injury Scale score was higher in patients developing pulmonary embolism. Increased weight, body mass index, ISS, and RAP score are associated with subprophylactic anti-Xa levels. Anti-Xa–guided enoxaparin dosing reduced the rate of DVT from 20.5% to 7.1% in high-risk trauma patients. LEVEL OF EVIDENCE Therapeutic study, level IV.

Risk of pulmonary embolism with repair or ligation of major venous injury following penetrating trauma

BACKGROUND There are many benefits of repair over ligation of major venous injuries (MVIs) following penetrating trauma, but the risk of pulmonary embolism (PE) is not well defined. We hypothesized that rates of PE are comparable between repair and ligation of MVI. METHODS All penetrating trauma patients with MVI requiring an operation from 2003 to 2012 (n = 158) were retrospectively reviewed. Propensity scores were based on a logistic regression model using patient and injury characteristics. A 1:1 fixed ratio nearest neighbor matching was performed to compare outcomes of the repair and ligation cohorts. Data are reported as mean ± SD if parametric, or median (interquartile range) if not, and compared using a t test, Mann-Whitney U-test, &khgr;2, or Fisher’s exact test, as appropriate. RESULTS The population was 89% male, age 32 ± 12 years, 74% gunshot wound, Injury Severity Score of 19 ± 13, length of stay of 9 (18) days, 3.8% PE, and a mortality of 21.5%. Repair was performed in 37% (n = 59), ligation was performed in 60% (n = 94), and 3% required both. With ligation versus repair, ligation patients were generally more critically injured; 48-hour survival was 78% versus 93% (p = 0.0083), initial Glasgow Coma Scale (GCS) score was 12 ± 5 versus 14 ± 3 (p = 0.003), initial base excess was −9 ± 8 versus −5 ± 5 mEq/L (p = 0.003), more packed red blood cells were transfused (12 (14) U vs. 9 (12) U; p = 0.032), and major arterial injury was more likely (86% vs. 42%, p < 0.001), but the PE rate was identical (5.9%) in propensity-matched cohorts. In those who developed a PE, all were receiving standard thromboprophylaxis. CONCLUSION Following penetrating trauma, the risk of PE between repair and ligation of MVI is comparable. LEVEL OF EVIDENCE Epidemiologic study, level III.

Association of Anti–Factor Xa–Guided Dosing of Enoxaparin With Venous Thromboembolism After Trauma

Importance The efficacy of anti–factor Xa (anti-Xa)–guided dosing of thromboprophylaxis after trauma remains controversial. Objective To assess whether dosing of enoxaparin sodium based on peak anti-Xa levels is associated with the venous thromboembolism (VTE) rate after trauma. Design, Setting, and Participants Retrospective review of 950 consecutive adults admitted to a single level I trauma intensive care unit for more than 48 hours from December 1, 2014, through March 31, 2017. Within 24 hours of admission, these trauma patients were screened with the Greenfield Risk Assessment Profile (RAP) (possible score range, 0-46). Patients younger than 18 years and those with VTE on admission were excluded, resulting in a study population of 792 patients. Exposures The control group received fixed doses of either heparin sodium, 5000 U 3 times a day, or enoxaparin sodium, 30 mg twice a day. The adjustment cohort initially received enoxaparin sodium, 30 mg twice a day. A peak anti-Xa level was drawn 4 hours after the third dose. If the anti-Xa level was 0.2 IU/mL or higher, no adjustment was made. If the anti-Xa level was less than 0.2 IU/mL, each dose was increased by 10 mg. The process was repeated up to a maximum dose of 60 mg twice a day. Main Outcomes and Measures Rates of VTE were measured. Venous duplex ultrasonography and computed tomographic angiography were used for diagnosis. Results The study population comprised 792 patients with a mean (SD) age of 46 (19) years and was composed of 598 men (75.5%). The control group comprised 570 patients, was older, and had a longer time to thromboprophylaxis initiation. The adjustment group consisted of 222 patients, was more severely injured, and had a longer hospital length of stay. The mean (SD) RAP scores were 9 (4) for the control group and 9 (5) for the adjustment group (P = .28). The VTE rates were similar for both groups (34 patients [6.0%] vs 15 [6.8%]; P = .68). Prophylactic anti-Xa levels were reached in 119 patients (53.6%) in the adjustment group. No difference in VTE rates was observed between those who became prophylactic and those who did not (7 patients [5.9%] vs 8 [7.8%]; P = .58). To control for confounders, 132 patients receiving standard fixed-dose enoxaparin were propensity matched to 84 patients receiving dose-adjusted enoxaparin. The VTE rates remained similar between the control and adjustment groups (3 patients [2.3%] vs 3 [3.6%]; P = .57). Conclusions and Relevance Rates of VTE were not reduced with anti-Xa–guided dosing, and almost half of the patients never reached prophylactic anti-Xa levels; achieving those levels did not decrease VTE rates. Thus, other targets, such as platelets, may be necessary to optimize thromboprophylaxis after trauma.

Analysis of water sports injuries admitted to a pediatric trauma center: a 13 year experience

BackgroundUnintentional injury is the leading cause of death in children and adolescents. Injuries occurring during boating and recreational water sports are poorly described in the literature. Herein, we compare injuries from water sports to those resulting from motor vehicle collisions, which are better described in existing literature.MethodsA retrospective review of 1935 consecutive pediatric trauma patients, as defined by age < 18 years, admitted to a single level-1 pediatric trauma center between January 2000 and August 2013 was performed. Patients were divided into two cohorts based on the mechanism of injury: water sports injury (WSI) or motor vehicle collision (MVC). Demographics, injury descriptors, and outcomes were reviewed for each patient. Categorical variables were compared by Chi square or Fisher’s exact test, and continuous by t test or Mann–Whitney U test. Parametric data are reported as mean ± standard deviation and nonparametric as median (interquartile range). Significance was set at alpha level 0.05.ResultsA total of 18 pediatric patients were admitted for WSI and 615 for MVC during the study period. Among those with WSI, mean age was 12 ± 4 years, mean Injury Severity Score (ISS) was 11 ± 10, and mean Revised Trauma Score (RTS) was 7.841(IQR 6.055–7.841). 44% of WSI occurred by personal watercraft (Jet Ski, WaveRunner), 39% by boat, and 17% by other means (e.g., diving, tubing, kite surfing). Overall, the most common WSI included skin/soft-tissue lacerations (59%), head injury/concussion (33%), tendon/ligament lacerations (28%), and extremity fractures (28%). Compared to 615 patients admitted for MVC, age, sex, race, Glasgow Coma Scale, ISS, RTS, spleen and liver laceration rates, neurosurgical consultation, ICU admission, ICU and total length of stay, and mortality were similar. Patients with WSI were more likely to be tourists (44% vs. 5%, p < 0.001). Those with WSI showed a significantly higher requirement for any surgical intervention (61% vs. 15%, p = 0.001). The rate of open fracture (28% vs. 6%, p = 0.006) and, subsequently, orthopedic procedures (39% vs. 17%, p = 0.027) were also higher in the WSI group.ConclusionOverall, water sports injuries are similar in in-hospital mortality to motor vehicle collisions. They are more likely to result in penetrating trauma and more likely to require surgical intervention. Primary and secondary prevention strategies should specifically target personal watercraft usage and tourist populations.

Closed (Blunt) Compared to Open (Penetrating) Pulmonary Contusion–A National Trauma Data Bank Review

Results: A total of 12,884 patients with pulmonary contusions were identified. The closed pulmonary contusion was present in 12,329 patients, open pulmonary contusion in 555 patients. Patients with closed pulmonary contusions were older with a mean age of 38.00 ± 22.23 versus 30.58 ± 12.88. Patients with closed pulmonary contusion had a higher injury severity score (ISS) 21.60 ± 0.22 versus 18.64 ± 1.08, p = 0.001. Closed pulmonary contusion was associated with increased ventilator days 3.09 ± 0.13, p = 0.052, intensive care unit (ICU) days 5.11 ± 0.15 versus 4.01 ± 0.69, p = 0.003 and hospital length of stay 0.65 ± 0.25 versus 9.37 ± 0.99, p = 0.032.

A Weaning Protocol for Venovenous Extracorporeal Membrane Oxygenation With a Review of the Literature: VV ECMO WEANING PROTOCOL

Several articles have discussed the weaning process for venoarterial extracorporeal membrane oxygenation; however, there is no published report to outline a standardized approach for weaning a patient from venovenous extracorporeal membrane oxygenation (ECMO). This complex process requires an organized approach and a thorough understanding of ventilator management and ECMO physiology. The purpose of this article is to describe the venovenous ECMO weaning protocol used at our institution as well as provide a review of the literature.