Karim Fikry

Hemostatic and pharmacologic resuscitation: results of a long-term survival study in a swine polytrauma model.

BACKGROUND We have previously demonstrated that valproic acid (VPA), a histone deacetylase inhibitor, and spray-dried plasma (SDP) improve early survival after lethal hemorrhage and polytrauma, but their effect on long-term survival and organ function remains untested. METHODS Yorkshire swine (n=27; 6-8/group) underwent a protocol simulating different phases of trauma care: (1) prehospital-rib fracture, soft-tissue injury, hemorrhage (50% blood volume), 30 minutes of shock, and infusion of 0.9% saline (3× shed blood); (2) early hospital/treatment-grade IV liver (partial amputation of the median lobe) and grade V splenic (transection of spleen into three pieces) injuries to simulate rupture of contained hematomas, followed by 30 minutes of uncontrolled hemorrhage. Animals were treated with (a) Hextend (6% hetastarch), (b) fresh whole blood (FWB), (c) SDP, and (d) VPA (300 mg/kg) plus Hextend. VPA was given during the prehospital phase, and the volumes of Hextend, FWB and SDP (reconstituted in water) matched shed blood; (3) repair/resuscitation-liver injury was controlled by suture control of the transected edge, and splenic injury was treated by partial splenectomy; 1 hour after repair of injuries, surviving animals were fully resuscitated with packed red blood cells; and (4) monitoring-survival was monitored for 7 days (primary endpoint), and blood samples were drawn serially to measure organ function. RESULTS Only 25% of the Hextend-treated animals survived. Addition of VPA improved survival to only 50% (p=0.28), whereas treatment with SDP and FWB increased survival significantly to 83% and 100%, respectively (p<0.05). Surviving animals showed no long-term organ dysfunction, postoperative hemorrhage, and delayed complications. CONCLUSIONS In a clinically relevant lethal polytrauma model, administration of SDP significantly improves survival without any long-term organ dysfunction or complications.

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

BACKGROUND In 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. METHODS This 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. RESULTS Sixteen 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). CONCLUSION The 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.

Presenting blood pressure in traumatic brain injury: a bimodal distribution of death.

BACKGROUND Recent research explores the relationship between vital signs on arrival to the emergency department and early outcomes. This work has not included traumatic brain injury (TBI). We aimed to evaluate the relationship of the initial emergency department systolic blood pressure (EDSBP) with outcome. METHODS By using the National Trauma Data Bank (v7), we analyzed patients older than 16 years with isolated moderate to severe blunt TBI. TBI was defined by International Classification of Diseases--9th Rev diagnosis codes and Abbreviated Injury Scale scores. We determined mortality rates while controlling for age, gender, race, payment type, and injury severity using logistic regression. Survival analysis was performed to determine 3-day survival rates. Scores and rates were plotted against EDSBP. RESULTS A total of 7,238 patients were included in the analysis. Plots of adverse outcomes versus EDSBP demonstrated bimodal distributions. The mortality curve had one inflection point at EDSBP 120 mm Hg, indicating higher mortality when blood pressures were lower than this threshold. Another inflection began at EDSBP 140 mm Hg. The mortality rate was 21% when EDSBP was <120 mm Hg, 9% when it was between 120 mm Hg and 140 mm Hg, and 19% when EDSBP was ≥140 mm Hg. Multivariate analysis demonstrated that patients presenting with an EDSBP of <120 mm Hg and ≥140 mm Hg were 2.7 (95% confidence interval =2.13,3.48) and 1.6 (95% confidence interval =1.32,1.96) times more likely to die, respectively, than those who presented with a EDSBP of 120 mm Hg to 140 mm Hg. CONCLUSIONS Mortality in moderate to severe TBI has a bimodal distribution. Like hypotension, hypertension at hospital admission seems to be associated with increased mortality in TBI, even after controlling for other factors.

Successful Selective Nonoperative Management of Abdominal Gunshot Wounds Despite Low Penetrating Trauma Volumes

OBJECTIVE To determine whether selective nonoperative management of abdominal gunshot wounds (AGSW) is safe in trauma centers with a low volume of penetrating trauma. DESIGN Retrospective study. SETTING Academic level 1 trauma center with approximately 10% penetrating trauma. PATIENTS All patients with anterior and posterior AGSW (January 1, 1999, through December 31, 2009), excluding tangential injuries, transfers, and deaths in the emergency department. Patients with hemodynamic instability or peritonitis received an urgent laparotomy. The remaining patients had selective nonoperative management. A delayed laparotomy was offered for worsening symptoms or worrisome computed tomography findings. MAIN OUTCOME MEASURES Hospital stay, complications, and mortality. RESULTS Of 125 AGSW patients, 38 (30%) were initially managed by selective nonoperative management (25 of 99 anterior and 13 of 26 posterior AGSW patients). Seven selective nonoperative management patients received delayed laparotomy as late as 11 hours after admission. At the end, 30 of the 125 patients (24%) were successfully managed without an operation (20 of 99 anterior and 10 of 26 posterior AGSW patients). There were no predictors of delayed laparotomy and no complications or mortality attributed to it. Ten patients (8%) had a nontherapeutic laparotomy, and 3 of them developed complications. CONCLUSIONS Selective nonoperative management of AGSW is feasible and safe in trauma centers with low penetrating trauma volumes. Nearly 1 in 4 AGSW patients does not need a laparotomy, and nontherapeutic laparotomies are associated with complications. The volume of AGSW per se should not be an excuse for routine laparotomies. These data become particularly important because penetrating trauma volumes are decreasing around the country.

Emergent cricothyroidotomies for trauma: training considerations

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 for trauma occur in the emergency department (ED), they are usually performed by surgeons. METHODS We conducted a retrospective analysis of all emergent cricothyroidotomies for trauma presentations performed at 2 large level I 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 analyzed. Patients had a mean age of 50 years, 80% were male, and 90% presented as a result of 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 an 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 with in-hospital procedures (P < .0001). CONCLUSIONS (1) Prehospital cricothyroidotomy results in serious complications. (2) Despite the ubiquitous presence of EM physicians in the ED, all cricothyroidotomies were performed by a surgeon, which may present opportunities for training improvement.

Predictors of Bleeding From Stable Pelvic Fractures

HYPOTHESIS Stable pelvic fractures (SPFs) that do not need operative fixation are only infrequently associated with significant bleeding (SigBleed). Our hypothesis is that simple indicators, easily detectable at the bedside, can alert the clinician about the likelihood of bleeding and the need for closer monitoring or early intervention in patients with SPFs. DESIGN Retrospective review of medical records. SETTING Academic level 1 trauma center. PATIENTS The medical records of patients with SPFs admitted to our academic level 1 trauma center from January 1, 2002, to June 30, 2007, were reviewed. Stable pelvic fractures were defined as fractures not requiring external or internal fixation. SigBleed was defined as the need for blood transfusion and/or intervention for bleeding control within the first 24 hours after admission. The patients were divided into group A, which included patients without SigBleed; group B, which included patients with SigBleed of a nonpelvic cause; and group C, which included patients with SigBleed caused by the SPF. The 3 groups were compared by univariate and multivariate analysis. MAIN OUTCOME MEASURE Significant bleeding from SPFs. RESULTS Of 391 patients with SPFs, 280 (72%) were in group A, 90 (23%) were in group B, and 21 (5%) were in group C. Compared with group A patients, those in group C were older and had a lower hematocrit and systolic blood pressure on admission. They also had longer hospital stays and a higher mortality. The following independent predictors of SigBleed from SPF were identified: hematocrit of 30% or lower (odds ratio [OR], 43.93; 95% confidence interval [CI], 9.78-197.32; P < .001); presence of pelvic hematoma on computed tomographic scan (OR, 39.37; 95% CI, 4.58-338.41; P < .001); and systolic blood pressure of 90 mm Hg or lower (OR, 18.352; 95% CI, 1.98-169.87; P = .01). When all independent predictors were present, 100% of the patients had SigBleed; when all were absent, no one had SigBleed. CONCLUSIONS The incidence of SigBleed due to SPFs is low (5% in this study) and independently predicted by an admission hematocrit of 30% or lower, the presence of a pelvic hematoma on computed tomographic scan, and systolic blood pressure of 90 mm Hg or lower.

MDCT quantification is the dominant parameter in decision–making regarding chest tube drainage for stable patients with traumatic pneumothorax

It is commonly believed that the size of a pneumothorax is an important determinant of treatment decision, in particular regarding whether chest tube drainage (CTD) is required. However, the volumetric quantification of pneumothoraces has not routinely been performed in clinics. In this paper, we introduced an automated computer-aided volumetry (CAV) scheme for quantification of volume of pneumothoraces in chest multi-detect CT (MDCT) images. Moreover, we investigated the impact of accurate volume of pneumothoraces in the improvement of the performance in decision-making regarding CTD in the management of traumatic pneumothoraces. For this purpose, an occurrence frequency map was calculated for quantitative analysis of the importance of each clinical parameter in the decision-making regarding CTD by a computer simulation of decision-making using a genetic algorithm (GA) and a support vector machine (SVM). A total of 14 clinical parameters, including volume of pneumothorax calculated by our CAV scheme, was collected as parameters available for decision-making. The results showed that volume was the dominant parameter in decision-making regarding CTD, with an occurrence frequency value of 1.00. The results also indicated that the inclusion of volume provided the best performance that was statistically significant compared to the other tests in which volume was excluded from the clinical parameters. This study provides the scientific evidence for the application of CAV scheme in MDCT volumetric quantification of pneumothoraces in the management of clinically stable chest trauma patients with traumatic pneumothorax.

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.

Tegaderm™ Trauma in the Operating Room

955 October 2013 A 49-YR-OLD female nonsmoker developed shortness of breath, cough, and dyspnea on exertion after partial thyroidectomy. Computed tomography of the chest revealed emphysematous changes, bronchiectasis, and increasing pulmonary infiltrates with lympadenopathy. In addition, she was noted to have abnormal skin laxity with pendulous folds of her chin and eyes. An endobronchial biopsy was scheduled. After induction of anesthesia, her eyes were protected with TegadermTM Transparent Dressing (3M, St. Paul, MN). On emergence, the TegadermTM dressing was removed with shearing of the underlying skin and active bleeding (see fig.). Skin was also abraded at the site of the electrocardiography leads (inset). Dermatology consultation led to the diagnosis of acquired cutis laxa (ACL). ACL is characterized by abnormal elastic fibers resulting in loose, redundant, hypoelastic skin. It has an insidious onset, most commonly in adulthood, and may be associated with a variety of malignancies, infections, inflammatory and connective tissue diseases, and drugs.2 Systemic involvement includes pulmonary, cardiovascular, gastrointestinal, and skeletal systems. The most serious complication is cor pulmonale resulting from progressive pulmonary emphysema. There is no definitive treatment for ACL. Preserving skin integrity is one of the challenges in caring for patients with ACL or similar skin conditions. Use of lubricant eye ointment to protect the eyes against corneal abrasion, nonadhesive head dressings, and clip-on pulse oximeter has been suggested in analogous fragile skin disorders.3 In addition to the importance of positioning, padding, and skin integrity, an understanding of the systemic manifestations associated with skin diseases such as ACL is crucial for the anesthesiologist, as they can be life threatening.