H.B. Alam

Quikclot use in trauma for hemorrhage control: Case series of 103 documented uses

BACKGROUNDnLocal hemostatics have recently been introduced for field use to control external hemorrhage. The objective of this report is to describe the initial clinical experience with QuikClot, a zeolite that works by absorbing water and concentrating coagulation factors to stop bleeding in a series of patients.nnnMETHODSnDocumented cases using a self-reporting survey sheet submitted by the users and first-hand detailed interviews with the users when possible.nnnRESULTSnThere were 103 documented cases of QuikClot use: 69 by the US military in Iraq, 20 by civilian trauma surgeons and 14 by civilian first responders. There were 83 cases involving application to external wounds and 20 cases of intracorporeal use by military and civilian surgeons. All field applications by first responders were successful in controlling hemorrhage. The overall efficacy rate was 92% with eight cases of ineffectiveness noted by physicians in morbid patients with massive injuries when the QuikClot was used as a last resort. These reported failures were thought to be a result of the coagulopathic state of the patient from massive resuscitation or the inability to get the product directly to the source of hemorrhage. When the QuikClot was applied on responsive patients, the heat generated by the exothermic reaction caused mild to severe pain and discomfort. There were three cases of burns caused by the heat generated by the QuikClot application with one case requiring skin grafting. There was one major complication from intracorporeal use caused by scar formation from a foreign body reaction.nnnCONCLUSIONSnQuikClot has been effectively used by a wide range of providers in the field and hospital to control hemorrhage.

Pain as an indication for rib fixation: a bi-institutional pilot study.

BACKGROUNDnIn trauma patients, open reduction and internal fixation of rib fractures remain controversial. We hypothesized that patients who have open reduction and internal fixation of rib fractures would experience less pain compared with controls and thus require fewer opiates. Further, we hypothesized that improved pain control would result in fewer pulmonary complications and decreased length of stay.nnnMETHODSnThis is a retrospective bi-institutional matched case-control study. Cases were matched 1:2 by age, injury severity Score, chest abbreviated injury severity score, head abbreviated injury severity score, pulmonary contusion score, and number of fractured ribs. The daily total doses of analgesic drugs were converted to equianalgesic intravenous morphine doses, and the primary outcome was inpatient narcotic administration.nnnRESULTSnSixteen patients between July 2005 and June 2009 underwent rib fixation in 5 ± 3 days after injury using an average of 3 (1-5) metallic plates. Morphine requirements decreased from 110 mg ± 98 mg preoperatively to 63 ± 57 mg postoperatively (p = 0.01). There were no significant differences between cases and controls in the mean morphine dose (79 ± 63 vs. 76 ± 55 mg, p = 0.65), hospital stay (18 ± 12 vs. 16 ± 11 days, p = 0.67), intensive care unit stay (9 ± 8 vs. 7 ± 10 days, p = 0.75), ventilation days (7 ± 8 vs. 6 ± 10, p = 0.44), and pneumonia rates (31% vs. 38%, p = 0.76).nnnCONCLUSIONnThe need for analgesia was significantly reduced after rib fixation in patients with multiple rib fractures. However, no difference in outcomes was observed when these patients were compared with matched controls in this pilot study. Further study is required to investigate these preliminary findings.

Fifty-Four Emergent Cricothyroidotomies: Are Surgeons Reluctant Teachers?

Background Emergent cricothyroidotomy remains an uncommon, but life-saving, core procedural training requirement for emergency medicine (EM) physician training. We hypothesized that, although most cricothyroidotomies occur in the emergency department (ED), they are rarely performed by EM physicians. Methods We conducted a retrospective analysis of all emergent cricothyroidotomies performed at two large level one trauma centers over 10 years. Operators and assistants for all procedures were identified, as well as mechanism of injury and patient demographics were examined. Results Fifty-four cricothyroidotomies were performed. Patients were: mean age of 50, 80% male and 90% blunt trauma. The most common primary operator was a surgeon (n = 47, 87%), followed by an Emergency Medical Services (EMS) provider (n = 6, 11%) and a EM physician (n = 1, 2%). In all cases, except those performed by EMS, the operator or assistant was an attending surgeon. All EMS procedures resulted in serious complications compared to in-hospital procedures (p < 0.0001). Conclusions 1. Pre-hospital cricothyroidotomy results in serious complications. 2. Despite the ubiquitous presence of emergency medicine physicians in the ED, all cricothyroidotomies were performed by a surgeon, which may represent a serious emergency medicine training deficiency.

Case records of the Massachusetts General Hospital. Case 31-2009. A 26-year-old man with abdominal distention and shock.

Dr. Jeffrey S. Ustin (Trauma, Emergency Surgery, and Surgical Critical Care): A 26year-old man was admitted to this hospital because of abdominal distention and shock. The patient had been well until the evening before admission, when mild abdominal pain developed, shortly after he had eaten five or six frankfurters. The pain gradually increased overnight, and nausea developed the next day. In the evening of the day of admission, his parents found him unresponsive, with coffee-grounds material emanating from his mouth. They called emergency medical services. On examination, he was obtunded, with agonal respirations. The trachea was intubated without medications, and supplemental oxygen was administered by means of an anesthesia bag attached to the endotracheal tube; the patient was transported to another hospital. On examination in the emergency department, the femoral pulse rate was 150 beats per minute, and the respiratory rate 24 breaths per minute; the blood pressure could not be measured. Twenty-two minutes after arrival, during insertion of a central intravenous catheter, the patient became pulseless, and cardiopulmonary resuscitation (CPR) was begun. Within 12 minutes, the blood pressure was 87/70 mm Hg and compressions were stopped. Screening of the urine for toxins was negative. Laboratory-test results are shown in Tables 1 and 2. He began to awaken, and fentanyl and vecuronium were administered. A nasogastric tube was inserted, and brown material (200 to 300 ml) was aspirated. Levofloxacin and metronidazole were administered intravenously. Computed tomography (CT) of the abdomen and pelvis reportedly showed markedly dilated loops of bowel, without free air or evidence of obstruction or volvulus, and CT scans of the chest and head were normal. Two hours 40 minutes after arrival, the patient was transferred to this hospital by helicopter. The blood pressure during transfer ranged between 79 and 116 mm Hg systolic and between 34 and 50 mm Hg diastolic, and the pulse was 125 beats per minute. Four intravenous catheters were in place. The patient arrived at this hospital 47 minutes later. The patient’s history was obtained from his family. The patient had had increasCase 31-2009: A 26-Year-Old Man with Abdominal Distention and Shock

Low degree of formal education and musical experience predict degree of music-induced stress reduction in relatives and friends of patients: a single-center, randomized controlled trial.

Objective:To determine the factors that may predict music-induced relaxation in friends and family of patients in the emergency department. Background:It remains unclear to date which demographic and experiential factors predict the effectiveness of music-induced relaxation. Furthermore, in-hospital stressors for friends and family of patients rather than patients themselves are underresearched and deserve in-depth investigation to improve this groups experience in health care environments. Methods:A total of 169 relatives and friends of patients in the emergency department–waiting area completed a series of questionnaires, including the Spielberger State-Trait Anxiety Inventory (STAI), the Music Experience Questionnaire (MEQ), and a demographic survey. They were then randomly assigned to either Case Group (1 hour in the waiting area with classical music in the background) or Control Group (1 hour with no music) before completing a second, identical copy of the STAI to measure change from baseline. Data were analyzed for associations between music intervention, change in STAI scores, MEQ scores, and demographic characteristics. Results:Participants who underwent the music intervention experienced a 9.8% decrease in overall mean State Anxiety, whereas those in the Control Group experienced no change over time (P = 0.001). Higher education significantly inversely correlated with the effectiveness of music intervention: participants with no formal education beyond high school showed a greater overall mean decrease in State Anxiety than those with a college education or beyond in response to classical music (P = 0.006). Furthermore, MEQ scores indicated that the Social Uplift scale (a measure of ones tendency to be uplifted in a group-oriented manner by music) was highly predictive of the effectiveness of music intervention. Conclusions:Music is an effective and inexpensive means of reducing anxiety in friends and family of patients, who are underresearched in medicine. Moreover, low educational attainment and tendency to respond positively to music in a group setting can predict the effectiveness of music-induced relaxation.

Novel Pharmacological Treatment Attenuates Septic Shock and Improves Long-Term Survival

Background. We have demonstrated previously that suberoylanilide hydroxamic acid (SAHA), a histone deacetylase inhibitor, improves survival in a lipopolysaccharide-induced lethal model of endotoxemia. The goal of this study was to investigate the impact of SAHA on survival in a more clinically relevant model of cecal ligation and puncture (CLP)-induced septic shock and to elucidate changes in cytokine responses and organ injury. Methods. C57BL/6J mice were subjected to CLP, and 1 hour later were given intraperitoneally either SAHA dissolved in dimethyl sulfoxide or dimethyl sulfoxide only. Survival was monitored for 10 days. In a second study, livers were harvested for evaluation of acute liver injury, and peritoneal fluid and blood samples were collected for cytokine assays. In addition, RAW264.7 and bone marrowderived macrophages were used to assess effects of SAHA on cytokine responses. Results. SAHA-treated animals displayed a substantial improvement in survival. In addition, SAHA also attenuated cytokine levels in blood and peritoneal fluid compared with vehicle animals, as well as in culture supernatant of macrophages stimulated with bacterial components (lipopolysaccharide or Pam3CSK4). Moreover, SAHA-treated animals showed a substantial decrease in acute liver injury. Conclusion. SAHA treatment improves survival, decreases ‘‘cytokine storm,’’ and prevents distant organ damage in a lethal septic model. (Surgery 2013;154:206-13.)