Forest R. Sheppard

The majority of US combat casualty soft-tissue wounds are not infected or colonized upon arrival or during treatment at a continental US military medical facility.

BACKGROUNDnThe microbiology of war wounds has changed as medicine and warfare have evolved. This study was designed to determine the microbial flora and bacterial quantification of present-day war wounds in US troops from Iraq and Afghanistan upon arrival at the National Naval Medical Center (NNMC).nnnMETHODSnPatients with extremity combat wounds treated with a vacuum-assisted wound closure device were enrolled in study. Wounds were biopsied every 48 to 72 hours with quantitative microbiology performed on all biopsies.nnnRESULTSnTwo hundred forty-two wound biopsies from 34 patients; 167 (69%) showed no growth, and 75 (31%) showed positive growth. The incidence of any bacterial isolation from biopsies weekly from the time of injury was 28% (first), 31% (second), and 37% (≥third). Acinetobacter baumannii was the most prevalent isolate.nnnCONCLUSIONSnMost soft-tissue wounds from Iraq and Afghanistan do not have significant bacterial burden upon arrival to and during initial treatment at NNMC. Improved evaluation of combat wound microbiology at all levels of care is warranted to determine shifts in microbiology and to impact care practices.

Mechanisms of early trauma-induced coagulopathy: The clot thickens or not?

Abstract Traumatic-induced coagulopathy (TIC) is a hemostatic disorder that is associated with significant bleeding, transfusion requirements, morbidity and mortality. A disorder similar or analogous to TIC was reported around 70 years ago in patients with shock, hemorrhage, burns, cardiac arrest or undergoing major surgery, and the condition was referred to as a “severe bleeding tendency,” “defibrination syndrome,” “consumptive disorder,” and later by surgeons treating US Vietnam combat casualties as a “diffuse oozing coagulopathy.” In 1982, Moore’s group termed it the “bloody vicious cycle,” others “the lethal triad,” and in 2003 Brohi and colleagues introduced “acute traumatic coagulopathy” (ATC). Since that time, early TIC has been cloaked in many names and acronyms, including a “fibrinolytic form of disseminated intravascular coagulopathy (DIC).” A global consensus on naming is urgently required to avoid confusion. In our view, TIC is a dynamic entity that evolves over time and no single hypothesis adequately explains the different manifestations of the coagulopathy. However, early TIC is not DIC because an increased thrombin-generating potential in vitro does not imply a clinically relevant thrombotic state in vivo as early TIC is characterized by excessive bleeding, not thrombosis. DIC with its diffuse anatomopathologic fibrin deposition appears to be a latter phase progression of TIC associated with unchecked inflammation and multiple organ dysfunction.

Evaluation of lyophilized platelets as an infusible hemostatic agent in experimental non‐compressible hemorrhage in swine

Summary.u2002 Introduction:u2002Human lyophilized platelets hold promise as a novel hemostatic infusion agent for the control of traumatic hemorrhage. Rehydrated, lyophilized platelets (Stasix) were investigated as an infusible hemostatic agent in experimental non‐compressible hemorrhage, using a porcine liver injury model. Methods:u2002Yorkshire swine underwent a grade III liver injury and uncontrolled bleeding. After 15u2003min, animals were infused with Stasix (nu2003=u200310) or normal saline vehicle (nu2003=u200310). At 2u2003h, the liver was repaired, and the animals were monitored for another4u2003h. Resuscitation, including blood transfusion, was administered during the hospital phase. Laboratory data, including arterial blood gas, complete blood count, thromboelastography (TEG), and coagulation parameters, were collected. All animals underwent necropsy with complete histopathologic examination. Results:u2002Overall survival in the Stasix group [8/10 (80%)] was significantly higher than in the control group [2/10 (20%)] (Pu2003=u20030.023). Mean total blood loss index (gu2003kg−1) was lower in Stasix‐treated animals (22.2u2003±u20033.5) than in control animals (34.7u2003±u20033.4) (Pu2003=u20030.019). Hemodynamic parameters were improved in the Stasix group, and a trend towards higher hemoglobin and lower lactate was observed. Coagulation and TEG parameters were not different between the groups. One surviving animal in the Stasix group had evidence of thrombi on necropsy. Conclusions:u2002This is the first reported study to evaluate rehydrated, lyophilized platelets as an infusible hemostatic agent for non‐compressible hemorrhage. Stasix improved survival and reduced blood loss in a liver injury porcine model. However, evidence of thrombotic complications warrants further investigation prior to human use in the setting of traumatic hemorrhage.

Incidence of Pulmonary Embolus in Combat Casualties With Extremity Amputations and Fractures

BACKGROUNDnThe objective of this retrospective study was to determine the incidence of pulmonary embolism (PE) in casualties of wartime extremity wounds and specifically in casualties with a trauma-associated amputation.nnnMETHODSnRecords of all combat-wounded evacuated and admitted between March 1, 2003, and December 31, 2007, were retrospectively reviewed. Continuous and categorical variables were studied with the Students t test, Fishers exact test or χ² test; multivariate analysis was performed using a stepwise regression logistic model.nnnRESULTSnA total of 1,213 records were reviewed; 263 casualties met the inclusion criteria. One hundred three (41.5%) had amputations and 145 (58.5%) had long-bone fractures not requiring amputation. The observed rate of PE in these 263 casualties was 5.7%. More casualties with amputations, 10 (3.7%), developed PE than those with long-bone fractures in the absence of amputation, 5 (1.9%) (p = 0.045). Casualties with bilateral lower extremity trauma-associated amputations had a significantly higher incidence of PE compared with those sustaining a single amputation (p = 0.023), and the presence of bilateral lower extremity amputations was an independent risk factor for development of a PE (p = 0.007, odds ratio 5.9) (univariate and multivariate analysis, respectively).nnnCONCLUSIONnThe cumulative incidence of PE was 5.7%. The incidence of PE is significantly higher with trauma-associated amputation than with extremity long-bone fracture without amputation. Bilateral amputations, multiple long-bone fractures, and pelvic fractures are independent risk factors for the development of PE. The use of aggressive prophylaxis, deep venous thrombosis screening with ultrasound, and use of prophylactic inferior vena cava filters should be considered in this patient population.

Inflammatory Response Is Associated with Critical Colonization in Combat Wounds

BACKGROUNDnModern combat- or blast-related injuries are characterized by devastatingly massive zones of injury that violate soft tissue, bone, and neurovascular structures. In our translational research program, we have determined that healing of traumatic combat wounds is dependent on the immune response. Although the majority of combat wounds are not critically colonized with bacteria, there exists a correlation between critical colonization and the concentration of inflammatory cytokines and chemokines measured in wound effluent or patient serum.nnnMETHODSnPatients with penetrating extremity wounds sustained during combat operations were studied prospectively, being followed for 30 days after definitive wound closure. Surgical debridement was repeated every 48-72u2009h until wound closure at the discretion of the attending surgeon. Serum, wound effluent, and wound bed tissue biopsy were collected at each debridement. Serum and wound effluent were analyzed with a multiplex assay for cytokines, chemokines, and inflammatory proteases, whereas wound tissue was assessed for microbial colonization via quantitative cultures. Correlations between serum and effluent cytokines and chemokines and the degree of tissue colonization were evaluated.nnnRESULTSnSamples from 154 debridements in 38 wounds from 25 male patients were investigated. Many of the patients sustained multi-system trauma (mean Injury Severity Score 21±12 points) and were critically ill (mean Acute Physiology and Chronic Health Evaluation II score 7±5 points). Healing failure occurred in 23.7% of wounds. A marked inflammatory profile, including increased serum and wound effluent cytokines and chemokines, was associated with the extent of critical colonization.nnnCONCLUSIONSnThe correlation between systemic and local inflammatory cytokines and quantitative culture suggests that the interplay between the systemic response to injury and the local wound environment is a determinant of outcome. This relationship remains ill defined and requires further investigation in both clinical and pre-clinical studies. A biomarker panel reflective of colonization may provide clinically useful, objective criteria indicating when wound closure is appropriate for successful healing.

Hypothermia and hemostasis in severe trauma: A new crossroads workshop report

OBJECTIVE The hypothermia and hemostasis in severe trauma (HYPOSTAT): a new crossroads workshop was convened to evaluate the interplay among hypothermia, hemostasis, and severe trauma/hemorrhage. Trauma is the major cause of death in young individuals in the United States, with uncontrolled hemorrhage representing the major cause of preventable deaths. DATA SOURCES This workshop organized by the National Heart, Lung, and Blood Institute and the US Army Medical Research and Material Command as a forum for exchange of ideas among experts from diverse fields. The specific workshop goals were to (1) identify state-of-the-art and needs in knowledge of biology of hypothermia and hemostasis in the setting of significant traumatic injury; (2) provide an interdisciplinary forum to enhance knowledge regarding early detection of traumatic shock and monitoring of the level and effect of controlled hypothermia in severe trauma settings; and (3) identify future research directions of the role of therapeutic-oriented hypothermia and hemostasis in trauma with severe blood loss. STUDY SELECTION Not applicable. DATA EXTRACTION Expert opinion and literature review. CONCLUSION This document provides a summary of the expert opinion and highlights the recommendations that came out of the discussions at this workshop to guide scientific efforts in basic, translational, and clinical research in this area.

Emergent management of postpartum hemorrhage for the general and acute care surgeon

BackgroundPostpartum hemorrhage is one of the rare occasions when a general or acute care surgeon may be emergently called to labor and delivery, a situation in which time is limited and the stakes high. Unfortunately, there is generally a paucity of exposure and information available to surgeons regarding this topic: obstetric training is rarely found in contemporary surgical residency curricula and is omitted nearly completely from general and acute care surgery literature and continuing medical education.MethodsThe purpose of this manuscript is to serve as a topic specific review for surgeons and to present a surgeon oriented management algorithm. Medline and Ovid databases were utilized in a comprehensive literature review regarding the management of postpartum hemorrhage and a management algorithm for surgeons developed based upon a collaborative panel of general, acute care, trauma and obstetrical surgeons review of the literature and expert opinion.ResultsA stepwise approach for surgeons of the medical and surgical interventions utilized to manage and treat postpartum hemorrhage is presented and organized into a basic algorithm.ConclusionThe manuscript should promote and facilitate a more educated, systematic and effective surgeon response and participation in the management of postpartum hemorrhage.

Combat Wound Initiative Program

The Combat Wound Initiative (CWI) program is a collaborative, multidisciplinary, and interservice public-private partnership that provides personalized, state-of-the-art, and complex wound care via targeted clinical and translational research. The CWI uses a bench-to-bedside approach to translational research, including the rapid development of a human extracorporeal shock wave therapy (ESWT) study in complex wounds after establishing the potential efficacy, biologic mechanisms, and safety of this treatment modality in a murine model. Additional clinical trials include the prospective use of clinical data, serum and wound biomarkers, and wound gene expression profiles to predict wound healing/failure and additional clinical patient outcomes following combat-related trauma. These clinical research data are analyzed using machine-based learning algorithms to develop predictive treatment models to guide clinical decision-making. Future CWI directions include additional clinical trials and study centers and the refinement and deployment of our genetically driven, personalized medicine initiative to provide patient-specific care across multiple medical disciplines, with an emphasis on combat casualty care.