Jayson D. Aydelotte

Outcomes of primary repair and primary anastomosis in war-related colon injuries.

BACKGROUND The role of primary repair (PR) of modern day war-related colon injuries remains controversial. METHODS Retrospective review of medical records of combat-wounded soldiers with colon injuries sustained during March 2003 to August 2006 was conducted. Injuries were analyzed according to location: right (n = 30), transverse (n = 13), and left (n = 24) sided colon injuries. Two-tailed Fishers Exact or chi tests were used for statistical analysis. RESULTS Seventy-seven soldiers returned to Walter Reed Army Medical Center with colon injuries suffered during Operations Enduring Freedom and Iraqi Freedom. Twelve patients with minor colon injuries were excluded. The remaining 65 patients (mean age, 28 +/- 7 years) sustained 67 colon injuries from secondary blast (n = 38); gunshot (n = 27); motor vehicle crash (n = 1) and crush injury (n = 1). Patients arrived at Walter Reed Army Medical Center 5 days (range, 2-16 days) after injury and damage control operations (n = 27, 42%), and were hospitalized for a median of 22 days (range, 1-306 days). Follow-up averaged 311 days (median, 198 days). PR was attempted in right (n = 18, 60%), transverse (n = 11, 85%), and left (n = 9, 38%) sided colon injuries. Delayed definitive treatment of colon injuries occurred in 42% of patients. Failure of repair occurred in 16% of patients and was more likely with concomitant pancreatic, stomach, splenic, diaphragm, and renal injuries. Overall morbidity for ostomy closure after primary ostomy formation was 30%, but increased to 75% for ostomy closure after primary anastomotic or repair failure. CONCLUSIONS PR of war-related colon injuries can be performed safely in selected circumstances in the absence of concomitant organ injury. Delayed anastomosis can often be performed after damage control operations once the patient stabilizes. Ostomy closure complications are more likely after anastomotic failure.

Feasibility of negative pressure wound therapy during intercontinental aeromedical evacuation of combat casualties

OBJECTIVE The objective of this study was to assess the feasibility of utilizing negative pressure wound therapy (NPWT) for the treatment of wartime soft-tissue wounds during intercontinental aeromedical evacuation. BACKGROUND Attempts to use NPWT during early phases of overseas contingency operations resulted in occasional vacuum system failures and potentially contributed to wound complications. These anecdotal episodes led to a perception that NPWT during aeromedical evacuation carried a high risk of wound complications and limited its use. As a result, NPWT was not frequently applied in the management of soft-tissue wounds before US casualty arrival in the continental United States (CONUS) for wounds sustained in the combat theaters. Concurrently, early NPWT on the traumatic wounds of host nation casualties not requiring aeromedical evacuation seemed to provide many benefits typically associated with the therapy such as decreased infection rates, earlier wound closure, and improved pain management. METHODS On a daily basis, study investigators reviewed the trauma in-patient census at Landstuhl Regional Medical Center, Germany, to identify patient candidates with soft-tissue extremity or torso wounds that required packing. Patient demographics, injuries, and previous wound treatments were recorded. Surgeons inspected wounds in the operating room and applied a NPWT dressing if deemed appropriate. NPWT was continued throughout the remainder of the patients hospitalization and also during aeromedical evacuation to CONUS. A study investigator escorted the patient during aeromedical evacuation to educate the flight crews, to record the impact on crew workload, and to troubleshoot the system if necessary. RESULTS Thirty enrolled patients with 41 separate wounds flew from Germany to CONUS with a portable NPWT system (VAC Freedom System; Kinetic Concepts Incorporated, San Antonio, TX). All 30 patients arrived at the destination facilities with intact and functional systems. No significant in-flight complications were identified, impact on flight crew workload was negligible, and subjective feedback from both flight crews and patients was uniformly positive. For 29 patients, the NPWT dressing was replaced (frequently with serial exchanges) during initial surgical treatment in CONUS; the 30th patient underwent delayed primary closure of his right forearm fasciotomy. Receiving care teams reported no complications attributable to NPWT during aeromedical evacuation. CONCLUSIONS NPWT is feasible during intercontinental aeromedical evacuation of combat casualties without an increase in wound complications or a significant impact on air crew workload. Further studies are indicated to evaluate the efficacy of NPWT in combat wounds compared with other wound care techniques.

Use of magnetic resonance cholangiopancreatography in clinical practice: Not as good as we once thought

BACKGROUND Magnetic resonance cholangiopancreatography (MRCP) is believed to be a useful tool to evaluate the biliary tree and pancreas for stones, tumors, or injuries to the ductile system. The purpose of this study was to compare the accuracy of MRCP to the gold standard, endoscopic retrograde cholangiopancreatography (ERCP), in our institution. STUDY DESIGN We performed a retrospective review of all MRCP followed by ERCP (follow-on ERCP) at a single institution over a 6-year period. Exam findings from MRCP were compared with findings on the follow-on ERCP and compared. Studies were grouped into 2 main classifications: tests being performed for patients with suspected choledocholithiasis (stone disease) and tests being performed for concerns of malignant strictures or duct injuries (non-stone disease). RESULTS A total of 81 patients had MRCPs and follow-on ERCPs in this time period. Thirty-six patients had positive findings on MRCP and ERCP for stones in the common duct system, and 14 patients had positive findings on MRCP and subsequent ERCP for masses and strictures of the common duct. Three patients had positive MRCP and ERCP findings for pancreatic duct abnormalities. The specificity and positive predictive value of MRCP were 94% and 98%, respectively. However, 13 of 28 patients had lesions identified on ERCP after a normal MRCP. The sensitivity and negative predictive value were 80% and 54%, respectively. CONCLUSIONS Magnetic resonance cholangiopancreatography was not useful in the management algorithm of either stone or non-stone disease of the biliary tree or pancreas. It should be abandoned as a diagnostic tool for work-up of biliary duct pathology.

A small amount can make a difference: a prospective human study of the paradoxical coagulation characteristics of hemothorax

BACKGROUND The evacuated hemothorax has been poorly described because it varies with time, it has been found to be incoagulable, and its potential effect on the coagulation cascade during autotransfusion is largely unknown. METHODS This is a prospective descriptive study of adult patients with traumatic chest injury necessitating tube thoracostomy. Pleural and venous samples were analyzed for coagulation, hematology, and electrolytes at 1 to 4 hours after drainage. Pleural samples were also analyzed for their effect on the coagulation cascade via mixing studies. RESULTS Thirty-four subjects were enrolled with a traumatic hemothorax. The following measured coagulation factors were significantly depleted compared with venous blood: international normalized ratio (>9 vs 1.1) (P < .001) and activated partial thromboplastin time (aPTT) (>180 vs 24.5 seconds) (P < .001). Mixing studies showed a dose-dependent increase in coagulation dilutions through 1:8 (P < .05). CONCLUSIONS An evacuated hemothorax does not vary in composition significantly with time and is incoagulable alone. Mixing studies with hemothorax plasma increased coagulation, raising safety concerns.

Thromboelastogram does not detect pre-injury anticoagulation in acute trauma patients

Purpose: Thromboelastography (TEG) has been recommended to characterize post‐traumatic coagulopathy, yet no study has evaluated the impact of pre‐injury anticoagulation (AC) on TEG variables. We hypothesized patients on pre‐injury AC have a greater incidence of coagulopathy on TEG compared to those without AC. Methods: This retrospective chart review evaluated all trauma patients admitted to an urban, level one trauma center from February 2011 to September 2014 who received a TEG within the first 24 h. Patients were classified as receiving pre‐injury AC or no AC if their documented medications prior to admission included warfarin, dabigatran, or anti‐Xa (aXa) inhibitors (apixaban or rivaroxaban). The presence of coagulopathy on TEG or conventional assays was defined by exceeding local laboratory reference standards. Results: A total of 54 patients were included (AC, n = 27 [warfarin n = 13, dabigatran n = 6, aXa inhibitor n = 8] vs. no AC, n = 27). Baseline characteristics were similar between groups, including age (72 ± 13 years vs. 72 ± 15; p = 0.85), male gender (70% vs. 74%; p = 0.76) and blunt mechanism of injury (100% vs. 100%; p = 1). There was no difference in the number of patients determined to have coagulopathy on TEG (no AC 11% vs. AC 15%; p = 0.99). Conventional tests, including the international normalized ratio (INR) and activated partial thromboplastin time (aPTT), identified coagulopathy in a high proportion of anti‐coagulated patients (no AC 22% vs. AC 85%; p < 0.01). Conclusion: TEG has limited clinical utility to evaluate the presence of pre‐injury AC. Traditional markers of drug induced coagulopathy should guide reversal decisions.

Implementation of a surgical intensive care unit service is associated with improved outcomes for trauma patients.

BACKGROUND Our trauma service recently transitioned from a pulmonary intensive care unit (ICU) service to a surgical ICU (SICU) service. We hypothesized that a newly formed SICU service could provide comparable outcomes to the existing pulmonary ICU service. A specific aim of this study was to compare outcomes of trauma patients admitted to the ICU before and after implementation of a SICU service. METHODS We performed a retrospective study of trauma patients admitted to the ICU of our urban, American College of Surgeons– verified, Level 1 trauma center during a 4-year period (2009–2012). Patients managed by the pulmonary ICU service (2009–2010) were compared with patients managed by a SICU service (2011–2012). The primary outcome was mortality, while secondary outcomes included complications (pulmonary, infectious, cardiac, and thromboembolic), hospital and ICU length of stay, ventilator days, and need for reintubation. RESULTS There were 2,253 trauma patients admitted to the ICU during the study period, 1,124 and 1,129 managed by the pulmonary ICU and SICU services, respectively. When comparing outcomes for SICU and pulmonary ICU patients, there was no difference in mortality (11% vs. 13%, p = 0.41), but patients managed by the SICU service had fewer pulmonary complications (3% vs. 6%, p < 0.001), fewer days on the ventilator (3 vs. 4, p = 0.002), and less often required reintubation after extubation (4% vs. 9%, p < 0.001). CONCLUSION Transition from a pulmonary ICU service to a SICU service at our institution was associated with no change in mortality but an improvement in pulmonary complications, ventilator days, and reintubation rates. Trauma centers currently staffed with a pulmonary ICU service should feel comfortable converting to SICU service and should expect comparable or improved outcomes for trauma patients admitted to the ICU. LEVEL OF EVIDENCE Therapeutic/care management study, level IV.

Impact of extremity amputation on combat wounded undergoing exploratory laparotomy.

BACKGROUND Combat casualties with traumatic amputations (TA) and requiring laparotomy present unique clinical challenges. The purpose of this study was to determine the association of TA on blood/blood product usage, emergency department (ED) and operating room (OR) times, and mortality in those undergoing exploratory laparotomy after combat injury. METHODS A retrospective study was performed at one combat support hospital in Iraq of patients requiring exploratory laparotomy for abdominal injury. These patients were divided into two cohorts based on the presence or absence of TA. Initial vital signs, international normalization ratio, pH, blood product usage, time in ED and OR, and mortality were compared between groups. RESULTS We reviewed 171 consecutive laparotomies performed between September 2007 and May 2008. Twenty one were identified with TA. Presenting systolic pressure, hemoglobin, platelets, international normalization ratio, and arterial pH did not differ between groups. The TA group presented more tachycardic, received more blood/blood products in ED and OR, and were more likely to meet requirements of massive transfusion. There was no difference in mortality between groups. Time in ED was shorter and time in OR was longer for the TA cohort. CONCLUSION TA with penetrating abdominal injuries are associated with increased transfusions of blood products beginning at patient arrival. Massive transfusion protocols should be activated as soon as this injury is identified. The severity of this injury pattern was only manifested by an increased heart rate at admission. TA with abdominal injury spent less time in ED and a longer time in OR; however, there was no increase in mortality.

PTSD in those who care for the injured

BACKGROUND Post Traumatic Stress Disorder (PTSD) has become a focus for the care of trauma victims, but the incidence of PTSD in those who care for injured patients has not been well studied. Our hypothesis was that a significant proportion of health care providers involved with trauma care are at risk of developing PTSD. METHODS A system-wide survey was applied using a modified version of the Primary Care PTSD Screen [PC-PTSD], a validated PTSD screening tool currently being used by the VA to screen veterans for PTSD. Pre-hospital and in-hospital care providers including paramedics, nurses, trauma surgeons, emergency medicine physicians, and residents were invited to participate in the survey. The survey questionnaire was anonymously and voluntarily performed online using the Qualtrix system. Providers screened positive if they affirmatively answered any three or more of the four screening questions and negative if they answered less than three questions with a positive answer. Respondents were grouped by age, gender, region, and profession. RESULTS 546 providers answered all of the survey questions. The screening was positive in 180 (33%) and negative in 366 (67%) of the responders. There were no differences observed in screen positivity for gender, region, or age. Pre-hospital providers were significantly more likely to screen positive for PTSD compared to the in-hospital providers (42% vs. 21%, P<0.001). Only 55% of respondents had ever received any information or education about PTSD and only 13% of respondents ever sought treatment for PTSD. CONCLUSION The results of this survey are alarming, with high proportions of healthcare workers at risk for PTSD across all professional groups. PTSD is a vastly underreported entity in those who care for the injured and could potentially represent a major problem for both pre-hospital and in-hospital providers. A larger, national study is warranted to verify these regional results.

Crash Fatality Rates After Recreational Marijuana Legalization in Washington and Colorado

Objectives To evaluate motor vehicle crash fatality rates in the first 2 states with recreational marijuana legalization and compare them with motor vehicle crash fatality rates in similar states without recreational marijuana legalization. Methods We used the US Fatality Analysis Reporting System to determine the annual numbers of motor vehicle crash fatalities between 2009 and 2015 in Washington, Colorado, and 8 control states. We compared year-over-year changes in motor vehicle crash fatality rates (per billion vehicle miles traveled) before and after recreational marijuana legalization with a difference-in-differences approach that controlled for underlying time trends and state-specific population, economic, and traffic characteristics. Results Pre-recreational marijuana legalization annual changes in motor vehicle crash fatality rates for Washington and Colorado were similar to those for the control states. Post-recreational marijuana legalization changes in motor vehicle crash fatality rates for Washington and Colorado also did not significantly differ from those for the control states (adjusted difference-in-differences coefficient = +0.2 fatalities/billion vehicle miles traveled; 95% confidence interval = −0.4, +0.9). Conclusions Three years after recreational marijuana legalization, changes in motor vehicle crash fatality rates for Washington and Colorado were not statistically different from those in similar states without recreational marijuana legalization. Future studies over a longer time remain warranted.

Group A streptococcal toxic shock syndrome secondary to necrotizing pelvic inflammatory disease in a postmenopausal woman

Group A β-hemolytic streptococcus (GAS) is well known to cause upper respiratory tract or cutaneous infections, but some more virulent species of GAS can lead to a rapidly progressive life threatening soft tissue necrotizing infection and streptococcal toxic shock syndrome (STSS). In the modern era, GAS infections within the female reproductive tract leading to STSS are unusual and are often the result of retained products of conception or intrauterine devices. This report describes a case of GAS necrotizing pelvic infection in a previously healthy menopausal woman with no obvious portal of entry. Her clinical course rapidly progressed to septic shock and multiorgan failure. She required multiple surgeries in addition to targeted antimicrobials and aggressive management of shock and organ failures. After a prolonged hospital stay, she had a full recovery.