Ernest E. Moore

Western trauma association (WTA) critical decisions in trauma: Management of adult blunt splenic trauma

This is a position article from members of the Western Trauma Association (WTA). Because there are no prospective randomized trials, the algorithm (Fig. 1) is based on the expert opinion of WTA members and published observational studies. We recognize that variability in decision making will continue. We hope this management algorithm will encourage institutions to develop local protocols based on the resources that are available and local expert consensus opinion to apply the safest, most reliable management strategies for their patients. What works at one institution may not work at another. The algorithm contains letters A through K, which corresponds to lettered text. This text is intentionally concise and its purpose is to navigate the reader through the algorithm and to identify and discuss the gray zones in the logic of this decision making. This annotated algorithm is intended to (a) serve as a quick reference for bedside clinicians, (b) foster more detailed patient care protocols that will allow for prospective collection of data to identify best practices, and (c) generate research projects to answer specific questions concerning decision making in the management of adult blunt splenic trauma.

Portal triad injuries

OBJECTIVE Injuries to the portal triad are a rare and complex challenge in trauma surgery. The purpose of this review is to better characterize the incidence, lethality, and successful management schemes used to treat these injuries. DESIGN A retrospective review of the experience of eight academic level I trauma centers over a combined 62 years. RESULTS A retrospective review of the experience of eight anatomical structures of the portal hepatis: 118 injuries to the anatomical structures of the portal hepatis: 55 extrahepatic portal vein injuries, 28 extrahepatic arterial injuries, and 35 injuries to the extrahepatic biliary tree. Sixty-nine percent of the injuries were by penetrating mechanism and 31% were by blunt mechanism. All patients had associated injuries with a mean Injury Severity Score of 34 in blunt trauma patients. Overall mortality was 51%, rising to 80% in patients with combination injuries. Sixty-six percent of deaths occurred in the operating room, primarily from exsanguination; 18% of deaths occurred within 48 hours of injury from refractory shock, coagulopathy, or cardiac arrest; 16% occurred late. Ten percent of patients undergoing portal vein ligation survived, compared to 58% managed by primary repair. Survival after hepatic artery ligation was 42%, compared to 14% after primary repair. Survival after biliary-enteric anastomosis as treatment of extrahepatic bile duct injury was 89%, compared to 50% after primary repair and 100% after ligation of lobar bile duct injuries. Missed bile duct injuries had a high (75%) severe complication rate. CONCLUSIONS Injuries to the anatomical structures of the portal triad are rare and often lethal. Intraoperative exsanguination is the primary cause of death, and hemorrhage control should be the first priority. Bile duct injuries should be identified by intraoperative cholangiography and repaired primarily or by enteric anastomosis; lobar bile ducts can be managed by ligation.

Western trauma association critical decisions in trauma: management of pelvic fracture with hemodynamic instability.

SUMMARY Patients with hemodynamic instability and pelvic frac-ture remain a significant challenge in management. A mul-tidisciplinary approach has been shown to have the bestoutcomes. The algorithm outlined above represents the ef-forts of the Western Trauma Association Critical Decisions inTrauma Ad Hoc Committee based on the best evidence avail-able and expert opinion. Prospective validation of this algo-rithm is recommended. REFERENCES 1. Moreno C, Moore EE, Rosenberger A, Cleveland HC. Hemorrhageassociated with major pelvic fracture: a multispecialty challenge. J Trauma. 1986;26:987–994.2. Smith W, Williams A, Agudelo J, et al. Early predictors of mortalityin hemodynamically unstable pelvis fractures. J Orthop Trauma. 2007;21:31–37.3. Cothren CC, Osborn PM, Moore EE, Morgan SJ, Johnson JL, SmithWR. Preperitonal pelvic packing for hemodynamically unstablepelvic fractures: a paradigm shift. J Trauma. 2007;62:834–839;discussion 839–842.4. Gilliland MD, Ward RE, Barton RM, Miller PW, Duke JH. Factorsaffecting mortality in pelvic fractures.

Acute ethanol intoxication increases the risk of infection following penetrating abdominal trauma

Acute alcohol (ETOH) intoxication as a risk factor for infection in trauma victims to our knowledge has not been previously reported. To determine if ETOH intoxication increases infection risk we examined data from 365 patients with penetrating abdominal trauma who were enrolled in a multi-center antibiotic study. Ninety-four patients sustained an injury to a hollow viscus. To separate acute from chronic ETOH effects, infections were divided into two categories: (1) trauma related; infections caused by bacterial contamination at the time of injury, while blood alcohol level (BAL) was elevated. (2) nosocomial; infections caused by bacteria acquired during hospital stay, after BAL had normalized. A BAL > or = 200 mg/dL was associated with a 2.6-fold increase in trauma-related infections. There was no association between BAL and subsequent nosocomial infection. Since infection rates for intoxicated patients were not higher after BAL had normalized, acute rather than chronic effects of ETOH appear to be responsible.

Goal Directed Resuscitation in the Prehospital Setting: A Propensity Adjusted Analysis

BACKGROUND: The scope of prehospital (PH) interventions has expanded recently—not always with clear benefit. PH crystalloid resuscitation has been challenged, particularly in penetrating trauma. Optimal PH crystalloid resuscitation strategies remain unclear in blunt trauma as does the influence of PH hypotension. The objective was to characterize outcomes for PH crystalloid volume in patients with and without PH hypotension. METHODS: Data were obtained from a multicenter prospective study of blunt injured adults transported from the scene with ISS > 15. Subjects were divided into HIGH (>500 mL) and LOW (<=500 mL) PH crystalloid groups. Propensity‐adjusted regression determined the association of PH crystalloid group with mortality and acute coagulopathy (admission International Normalized Ratio, >1.5) in subjects with and without PH hypotension (systolic blood pressure [SBP], <90 mm Hg) after controlling for confounders. RESULTS: Of 1,216 subjects, 822 (68%) received HIGH PH crystalloid and 616 (51%) had PH hypotension. Initial base deficit and ISS were similar between HIGH and LOW crystalloid groups in subjects with and without PH hypotension. In subjects without PH hypotension, HIGH crystalloid was associated with an increase in the risk of mortality (hazard ratio, 2.5; 95% confidence interval [95% CI], 1.3–4.9; p < 0.01) and acute coagulopathy (odds ratio [OR], 2.2; 95% CI, 1.01–4.9; p = 0.04) but not in subjects with PH hypotension. HIGH crystalloid was associated with correction of PH hypotension on emergency department (ED) arrival (OR, 2.02; 95% CI, 1.06–3.88; p = 0.03). The mean corrected SBP in the ED was 104 mm Hg. Each 1 mm Hg increase in ED SBP was associated with a 2% increase in survival in subjects with PH hypotension (OR, 1.02; 95% CI, 1.01–1.03; p < 0.01). CONCLUSION: In severely injured blunt trauma patients, PH crystalloid more than 500 mL was associated with worse outcome in patients without PH hypotension but not with PH hypotension. HIGH crystalloid was associated with corrected PH hypotension. This suggests that PH resuscitation should be goal directed based on the presence or absence of PH hypotension. LEVEL OF EVIDENCE: Therapeutic study, level III.

Inflammation and the host response to injury, a large-scale collaborative project: Patient-oriented research core-standard operating procedures for clinical care VII-guidelines for antibiotic administration in severely injured patients

When the clinical decision to treat a critically ill patient with antibiotics has been made, one must attempt to identify the site of infection based on clinical signs and symptoms, laboratory or diagnostic radiology studies. Identification of site requires, examination of patient, inspection of all wounds, chest radiograph, and calculation of clinical pulmonary infection score if ventilated, obtaining blood cultures, urinalysis, and line change if clinical suspicion of central venous catheter (CVC) source. If it is impossible to identify site, obtain cultures from all accessible suspected sites and initiate empiric, broad spectrum antibiotics. If likely site can be identified answer these questions: Is intra-abdominal site suspected? Is pulmonary source of infection suspected? Is skin, skin structure or soft tissue site suspected? If yes, does the patient have clinical signs suspicion for necrotizing soft tissue infection (NSTI)? Is a CVC infection suspected? Risk factors for more complicated infections are discussed and specific antibiotic recommendations are provided for each type and severity of clinical infection. Decision to continue, discontinue and/or alter antibiotic/antimicrobial treatment should be based on the clinical response to treatment, diagnostic or interventional findings, and culture and sensitivity data, bearing in mind that not all patients with infections will have positive cultures because of limitations of specimen handling, microbiology laboratory variations, time between specimen acquisition and culture, or presence of effective antibiotics at the time that specimens were obtained. It should also be noted that not all patients with increased temperature/WBC have an infection. Discontinuation of antibiotics is appropriate if cultures and other diagnostic studies are negative.