Joseph D. Love

Damage-control resuscitation increases successful nonoperative management rates and survival after severe blunt liver injury.

BACKGROUND Nonoperative multidisciplinary management for severe (American Association for the Surgery of Trauma Grades IV and V) liver injury has been used for two decades. We have previously shown that Damage Control Resuscitation (DCR) using low-volume, balanced resuscitation improves survival of severely injured trauma patients; however, little attention has been paid to organ-specific outcomes. We wanted to determine if implementation of DCR has improved survival and successful nonoperative management after severe blunt liver injury. METHODS A retrospective study was performed on all adult trauma patients with severe blunt liver injury who were admitted from 2005 to 2011. Patients were divided into pre-DCR (2005–2008) and DCR (2009–2011) groups. Patients who died before leaving the emergency department (ED) were excluded. Outcomes (resuscitation products used, survival, and length of stay) were then compared by univariate and multivariate analyses. RESULTS Between 2005 and 2011, 29,801 adult trauma patients were admitted, and 1,412 (4.7%) experienced blunt liver injury. Of these, 244 (17%) sustained Grade IV and V injuries, with 206 patients surviving to leave the ED. The pre-DCR group (2005–2008) was composed of 108 patients, and the DCR group (2009–2011) had 98 patients. The groups were not different in demographics as well as prehospital and ED vital signs or Injury Severity Score (ISS). No change in operative or interventional radiology techniques occurred in this time frame. The DCR cohort had an increase in successful nonoperative management (from 54% to 74%, p < 0.01) as well as a reduction in initial 24-hour packed red blood cell (median, from 13 U to 6.5 U; p < 0.01), plasma (median, from 13 U to 8 U; p < 0.01), and crystalloid (median, from 5,800 mL to 4,100 mL; p < 0.01) administration. The DCR treatment was associated with improved survival, from 73% to 94% (p < 0.01). CONCLUSION In patients with severe blunt liver injury, DCR was associated with less crystalloid and blood product use, a higher successful nonoperative management rate, and improved survival. Resuscitation technique may improve outcomes after severe liver injury. LEVEL OF EVIDENCE Therapeutic/care management, level III.

Operative fixation of rib fractures after blunt trauma: A practice management guideline from the Eastern Association for the Surgery of Trauma

BACKGROUND Rib fractures are identified in 10% of all injury victims and are associated with significant morbidity (33%) and mortality (12%). Significant progress has been made in the management of rib fractures over the past few decades, including operative reduction and internal fixation (rib ORIF); however, the subset of patients that would benefit most from this procedure remains ill-defined. The aim of this project was to develop evidence-based recommendations. METHODS Population, intervention, comparison, and outcome (PICO) questions were formulated for patients with and without flail chest. Outcomes of interest included mortality, duration of mechanical ventilation (DMV), hospital and intensive care unit (ICU) length of stay (LOS), incidence of pneumonia, need for tracheostomy, and pain control. A systematic review and meta-analysis of currently available evidence was performed per the Grading of Recommendations Assessment, Development, and Evaluation methodology. RESULTS Twenty-two studies were identified and analyzed. These included 986 patients with flail chest, of whom 334 underwent rib ORIF. Rib ORIF afforded lower mortality; shorter DMV, hospital LOS, and ICU LOS; and lower incidence of pneumonia and need for tracheostomy. The data quality was deemed very low, with only three prospective randomized trials available. Analyses for pain in patients with flail chest and all outcomes in patients with nonflail chest were not feasible due to inadequate data. CONCLUSION In adult patients with flail chest, we conditionally recommend rib ORIF to decrease mortality; shorten DMV, hospital LOS, and ICU LOS; and decrease incidence of pneumonia and need for tracheostomy. We cannot offer a recommendation for pain control, or any of the outcomes in patients with nonflail chest with currently available data. LEVEL OF EVIDENCE Systematic review/meta-analysis, level III.

Safety and Appropriateness of Tourniquets in 105 Civilians.

Abstract Background: The United States military considers tourniquets to be effective for controlling bleeding from major limb trauma. The purpose of this study was to assess whether tourniquets are safely applied to the appropriate civilian patient with major limb trauma of any etiology. Methods: Following IRB approval, patients arriving to a level-1 trauma center between October 2008 and May 2013 with a prehospital (PH) or emergency department (ED) tourniquet were reviewed. Cases were assigned the following designations: absolute indication (operation within 2 hours for limb injury, vascular injury requiring repair/ligation, or traumatic amputation); relative indication (major musculoskeletal/soft-tissue injury requiring operation 2–8 hours after arrival, documented large blood loss); and non-indicated. Patients with absolute or relative indications for tourniquet placement were defined as indicated, while the remaining were designated as non-indicated. Complications potentially associated with tourniquets, including amputation, acute renal failure, compartment syndrome, nerve palsies, and venous thromboembolic events, were adjudicated by orthopedic, hand or trauma surgical staff. Univariate analysis was performed to compare patients with indicated versus non-indicated tourniquet placement. Results: A total of 105 patients received a tourniquet for injuries sustained via sharp objects, i.e., glass or knives (32%), motor vehicle collisions (30%), or other mechanisms (38%). A total of 94 patients (90%) had indicated tourniquet placement; 41 (44%) of which had a vascular injury. Demographics, mechanism, transport, and vitals were similar between patients that had indicated or non-indicated tourniquet placement. 48% of the indicated tourniquets placed PH were removed in the ED, compared to 100% of the non-indicated tourniquets (p < 0.01). The amputation rate was 32% among patients with indicated tourniquet placement (vs. 0%; p = 0.03). Acute renal failure (3.2 vs. 0%, p = 0.72), compartment syndrome (2.1 vs. 0%, p = 0.80), nerve palsies (5.3 vs. 0%; p = 0.57), and venous thromboembolic events (9.1 vs. 8.5%; p = 0.65) and were similar in patients that had indicated compared to non-indicated tourniquet placement. After adjudication, no complication was a result of tourniquet use. Conclusion: The current study suggests that PH and ED tourniquets are used safely and appropriately in civilians with major limb trauma that occur via blunt and penetrating mechanisms.

Control the damage: morbidity and mortality after emergent trauma laparotomy.

BACKGROUND Damage control laparotomy (DCL) is performed for physiologically deranged patients. Recent studies suggest overutilization of DCL, which may be associated with potentially iatrogenic complications. METHODS We conducted a retrospective study of trauma patients over a 2-year period that underwent an emergent laparotomy and received preoperative blood products. The group was divided into definitive laparotomy and DCL. RESULTS A total of 237 received were included: 78 in definitive laparotomy group, 144 in the DCL group, and 15 who died in the operating room. The DCL group was more severely injured and required more transfusions. After propensity score matching, DCL was associated with an 18% increase in hospital mortality, a 13% increase in ileus, and a 7% increase in enteric suture line failure, an 11% increase in fascial dehiscence, and a 19% increase in superficial surgical site infection. CONCLUSIONS The potential overuse of DCL unnecessarily exposes patients to increased morbidity and mortality.

The trauma center is too late: Major limb trauma without a pre-hospital tourniquet has increased death from hemorrhagic shock

BACKGROUND To date, no civilian studies have demonstrated that pre-hospital (PH) tourniquets improve survival. We hypothesized that late, trauma center (TC) tourniquet use would increase death from hemorrhagic shock compared to early (PH) placement. METHODS All patients arriving to a Level 1, urban TC between October 2008 and January 2016 with a tourniquet placed before (T-PH) or after arrival to the TC (T-TC) were evaluated. Cases were assigned the following designations: indicated (absolute indication [vascular injury requiring repair/ligation, operation within 2 hours for extremity injury, or traumatic amputation] or relative indication [major musculoskeletal/soft tissue injury requiring operation 2–8 hours after arrival, documented large blood loss]) or non-indicated. Outcomes were death from hemorrhagic shock, physiology upon arrival to the TC, and massive transfusion requirements. After univariate analysis, logistic regression was carried out to assess independent predictors of death from hemorrhagic shock. RESULTS A total of 306 patients received 326 tourniquets for injuries to 157 upper and 147 lower extremities. Two hundred eighty-one (92%) had an indication for placement. Seventy percent of patients had a blunt mechanism of injury. T-TC patients arrived with a lower systolic blood pressure (SBP, 101 [86, 123] vs. 125 [100, 145] mm Hg, p < 0.001), received more transfusions in the first hour of arrival (55% vs. 34%, p = 0.02), and had a greater mortality from hemorrhagic shock (14% vs. 3.0%, p = 0.01). When controlling for year of admission, mechanism of injury and shock upon arrival (SBP ⩽90 mm Hg or HR ≥120 bpm or base deficit ⩽ 4) indicated T-TC had a 4.5-fold increased odds of death compared to T-PH (OR 4.5, 95% CI 1.23–16.4, p = 0.02). CONCLUSIONS Waiting until TC arrival to control hemorrhage with a tourniquet was associated with worsened blood pressure and increased transfusion within the first hour of arrival. In routine civilian trauma patients, delaying to T-TC was associated with 4.5-fold increased odds of mortality from hemorrhagic shock. LEVEL OF EVIDENCE Level IV.

Stapled versus hand-sewn: A prospective emergency surgery study. An American Association for the Surgery of Trauma multi-institutional study

BACKGROUND Data from the trauma patient population suggests handsewn (HS) anastomoses are superior to stapled (ST). A recent retrospective study in emergency general surgery (EGS) patients had similar findings. The aim of the current study was to evaluate HS and ST anastomoses in EGS patients undergoing urgent/emergent operations. METHODS The study was sponsored by the American Association for the Surgery of Trauma Multi-Institutional Studies Committee. Patients undergoing urgent/emergent bowel resection for EGS pathology were prospectively enrolled from July 22, 2013 to December 31, 2015. Patients were grouped by HS/ST anastomoses, and variables were collected. The primary outcome was anastomotic failure. Similar to other studies, anastomotic failure was evaluated at the anastomosis level. Multivariable logistic regression was performed controlling for age and risk factors for anastomotic failure. RESULTS Fifteen institutions enrolled a total of 595 patients with 649 anastomoses (253 HS and 396 ST). Mean age was 61 years, 51% were men, 7% overall mortality. Age and sex were the same between groups. The overall anastomotic failure rate was 12.5%. The HS group had higher lactate, lower albumin, and were more likely to be on vasopressors. Hospital and intensive care unit days, as well as mortality, were greater in the HS group. Anastomotic failure rates and operative time were equivalent for HS and ST. On multivariate regression, the presence of contamination at initial resection (odds ratio, 1.965; 95% confidence interval, 1.183–3.264) and the patient being managed with open abdomen (odds ratio, 2.529; 95% confidence interval, 1.492–4.286) were independently associated with anastomotic failure, while the type of anastomosis was not. CONCLUSION EGS patients requiring bowel resection and anastomosis are at high risk for anastomotic failure. The current study illustrates an apparent bias among acute care surgeons to perform HS techniques in higher-risk patients. Despite the individualized application of technique for differing patient populations, the risk of anastomotic failure was equivalent when comparing HS and ST anastomoses. LEVEL OF EVIDENCE Therapeutic study, level II.

Tort Reform Is Associated with More Medical Board Complaints and Disciplinary Actions

BACKGROUND Previous reports have confirmed that comprehensive tort reform in Texas (enacted in 2003) was associated with fewer lawsuits and less litigation-associated cost. We hypothesized that complaints to the Texas Medical Board (TMB) increased after tort reform. STUDY DESIGN To test this hypothesis, we compared complaints, investigations, disciplinary actions, and penalties against physicians before and after comprehensive state tort reform measures were adopted. Data were obtained from the TMB for a 15-year period (1996 to 2010). RESULTS When comparing the period before tort reform (1996 to 2002) with the period after tort reform (2004 to 2010), TMB complaints increased 13%; investigations opened increased 33%, disciplinary actions increased 96%, license revocations or surrenders increased 47%, and financial penalties increased 367%. All of these increases were statistically significant (p ≤ 0.01). CONCLUSIONS After tort reform in Texas, the total number of complaints, investigations, disciplinary decisions, license revocations or surrenders, and financial penalties from the TMB significantly increased. In Texas, tort reform was accompanied by legislatively directed, enhanced oversight and activity of the authority (TMB) charged with regulation of the medical profession.

Predicting and enhancing American Board of Surgery In-Training Examination performance: does writing questions really help?

BACKGROUND The generative learning model posits that individuals remember content they have generated better than materials created by others. The goals of this study were to evaluate question generation as a study method for the American Board of Surgery In-Training Examination (ABSITE) and determine whether practice test scores and other data predict ABSITE performance. METHODS Residents (n = 206) from 6 general surgery programs were randomly assigned to one of the two study conditions. One group wrote questions for practice examinations. All residents took 2 practice examinations. RESULTS There was not a significant effect of writing questions on ABSITE score. Practice test scores, United States Medical Licensing Examination Step 1 scores, and previous ABSITE scores were significantly correlated with ABSITE performance. CONCLUSIONS The generative learning model was not supported. Performance on practice tests and other data can be used for early identification of residents at risk of performing poorly on the ABSITE.

Admission Rapid Thrombelastography (rTEG®) Values Predict Resuscitation Volumes and Patient Outcomes After Thermal Injury

In trauma, admission rapid thrombelastography (rTEG) has been shown to predict in-hospital thromboembolic events, guide treatment of coagulopathy, and identify likely to require large volume resuscitations. We sought to evaluate the use of rTEG in describing the coagulation status of major burn patients at admission and assess whether rTEG values predicted resuscitation volumes and patient outcomes. This is a retrospective study of all patients admitted to our Burn intensive care unit between January 2010 and December 2012. We excluded those with < 15% TBSA burns, < 18 years of age, and with concomitant injuries requiring admission to the Trauma intensive care unit. Previously published and validated cut points for hypocoagulable (activated clotting time ≥ 128; k-time ≥ 2.5; angle ≤ 60; mA ≤ 55; LY30 ≥ 3%) and hypercoagulable (mA ≥ 65) rTEG values were used. Supra-normal burn resuscitation was defined as ≥ 5.0 mL/kg/TBSA. Statistical analyses were conducted using STATA 13.1. Sixty-five patients met inclusion with a median age of 45 years, 74% male and 49% white. Median TBSA was 38% with 14% having third-degree burns. Sixty percentage of patients were hypercoagulable on admission, while 24% were hypocoagulable. rTEG values predicted increased 24-hour resuscitation volumes, as well as plasma and platelet transfusions (P < 0.05). Controlling for age, TBSA, and base deficit, admission rTEG ≥ 128 predicted a 5-fold increased likelihood of supra-normal resuscitation. In addition, an angle < 60 predicted in-hospital mortality. While the majority of severely burned patients arrive hypercoagulable, one-quarter are hypocoagulable and have increased resuscitation and transfusion requirements. Moreover, those with admission activated clotting time ≥ 128 are at 5-fold increased risk of supra-normal resuscitation.

Inguinal Hernia Repair Using 3D Printed Surgical Instruments in the Cadaveric Model: A Feasibility Study

Background: 3D printing is an additive manufacturing process allowing the creation of solid objects directly from computer aided design (CAD). Design and fabrication of 3D printed surgical instruments has previously been performed with results indicating relevance to real surgical procedures. This study expands on previous work and investigates the feasibility of performing a cadaveric inguinal hernia repair using 3D printed surgical instruments. Methods: A CAD software package was used to design a general surgical set including hemostats, needle driver, scalpel handle, retractors and forceps. The digital models were manufactured on a 3D printer and used to perform a standard inguinal hernia repair on a human cadaver. Results: An acceptable inguinal hernia repair including mesh placement was successfully performed on a human cadaver using standard surgical techniques. Conclusions: General surgical procedures such as an inguinal hernia repair are feasible using 3D printed surgical instruments.