Lance Stuke

Damage control resuscitation in combination with damage control laparotomy: a survival advantage.

BACKGROUND Damage control laparotomy (DCL) improves outcomes when used in patients with severe hemorrhage. Correction of coagulopathy with close ratio resuscitation while limiting crystalloid forms a new methodology known as damage control resuscitation (DCR). We hypothesize a survival advantage in DCL patients managed with DCR when compared with DCL patients managed with conventional resuscitation efforts (CRE). METHODS This study is a 4-year retrospective study of all DCL patients who required >or=10 units of packed red blood cells (PRBC) during surgery. A 2-year period after institution of DCR (DCL and DCR) was compared with the preceding 2 years (DCL and CRE). Univariate analysis of continuous data was done with Students t test followed by multiple logistic regression. RESULTS One Hundred twenty-four and 72 patients were managed during the DCL and CRE and DCL and DCR time periods, respectively. Baseline patient characteristics of age, Injury Severity Score, % penetrating, blood pressure, hemoglobin, base deficit, and INR were similar between groups. There was no difference in quantity of intraoperative PRBC utilization between DCL and CRE and DCL and DCR study periods: 21.7 units versus 25.5 units (p = 0.53); however, when compared with DCL and CRE group, patients in the DCL and DCR group received less intraoperative crystalloids, 4.7 L versus 14.2 L (p = 0.009); more fresh frozen plasma (FFP), 18.2 versus 6.4 (p = 0.002); a closer FFP to PRBC ratio, 1 to 1.2 versus 1 to 4.2 (p = 0.002); platelets to PRBC ratio, 1:2.3 versus 1:5.9 (0.002); shorter mean trauma intensive care unit length of stay, 11 days versus 20 days (p = 0.01); and greater 30-day survival, 73.6% versus 54.8% (p < 0.009). The addition of DCR to DCL conveyed a survival benefit (odds ratio; 95% confidence interval: 0.19 (0.05-0.33), p = 0.005). CONCLUSION This is the first civilian study that analyses the impact of DCR in patients managed with DCL. During the DCL and DCR study period more PRBC, FFP, and platelets with less crystalloid solution was used intraoperatively. DCL and DCR were associated with a survival advantage and shorter trauma intensive care unit length of stay in patients with severe hemorrhage when compared with DCL and CRE.

Hemostatic resuscitation during surgery improves survival in patients with traumatic-induced coagulopathy.

BACKGROUND Although hemostatic resuscitation with a 1:1 ratio of fresh-frozen plasma (FFP) to packed red blood cells (PRBC) after severe hemorrhage has been shown to improve survival, its benefit in patients with traumatic-induced coagulopathy (TIC) after >10 units of PRBC during operation has not been elucidated. We hypothesized that a survival benefit would occur when early hemostatic resuscitation was used intraoperatively after injury in patients with TIC. METHODS A 7-year retrospective study of patients with emergency department diagnosis of TIC after transfusion of >10 units of PRBC in the operating room. TIC was defined as initial emergency department international normalized ratio > 1.2, prothrombin time > 16 seconds, and partial thromboplastin time > 50 seconds. Patients were divided into FFP:PRBC ratios of 1:1, 1:2, 1:3, and 1:4. Patients with diagnosis of TIC who received transfusion of both FFP and PRBC during surgery were included. Other variables evaluated included age, gender, mechanism of injury, initial base deficit, mean operative time, trauma intensive care unit length of stay (TICU LOS) and Injury Severity Score. The primary outcome measure evaluated was the impact of the early FFP:PRBC ratio on mortality. RESULTS Four hundred thirty-five patients underwent emergency operations postinjury and received FFP with >10 units of PRBC in the operating room; 135 (31.0%) of these patients had TIC and 53 died (39.5% mortality). Mean operative time was 137 minutes (SD +/- 49). There were no differences with regard to age, gender, mechanism of injury, initial base deficit, or Injury Severity Score among all groups. A significant difference in mortality was found in patients who received >10 units of PRBC when FFP:PRBC ratio was 1:1 versus 1:4 (28.2% vs. 51.1%, p = 0.03). Intermediate mortality rates were noted in patients with 1:2 and 1:3 ratios (38% and 40%, respectively). From a linear regression model, 13 days of increased TICU LOS was observed among 1:4 group compared with 1:1 group (p < 0.01). CONCLUSION TIC is common after severe injury and is associated with a high mortality in patients transfused with >10 units of PRBC during surgery. Early hemostatic resuscitation during first hours after injury improves survival with shorter TICU LOS in patients with TIC.

Effect of Alcohol on Glasgow Coma Scale in Head-Injured Patients

Objective:Almost 50% of traumatic brain-injured (TBI) patients are alcohol intoxicated. The Glasgow Coma Scale (GCS) is frequently used to direct diagnostic and therapeutic decisions in these patients. It is commonly assumed that alcohol intoxication reduces GCS, thus limiting its utility in intoxicated patients. The purpose of this study was to test the hypothesis that the presence of blood alcohol has a clinically significant impact on GCS in TBI patients. Methods:The National Trauma Data Bank of the American College of Surgeons was queried (1994–2003). Patients 18 to 45 years of age with blunt injury mechanism, whose GCS in the emergency department, survival status, anatomic severity of TBI (Head Abbreviated Injury Score [AIS]), and blood alcohol testing status were known, were included. GCS of patients who tested positive for alcohol (n = 55,732) was compared with GCS of patients who tested negative (n = 53,197), stratified by head AIS. Results:Groups were similar in age (31 ± 8 vs. 30 ± 8 years), Injury Severity Score (ISS; 12 ± 11 vs. 12 ± 11), systolic blood pressure in the ED (131 ± 25 vs. 134 ± 25 mm Hg), TRISS (Trauma Injury Severity Score; probability of survival (94% ± 16% vs. 95% ± 15%), and actual survival (96% vs. 96%). When stratified by anatomic severity of TBI, the presence of alcohol did not lower GCS by more than 1 point in any head AIS group (GCS in alcohol-positive vs. alcohol-negative patients; AIS 1 = 13.9 ± 2.8 vs. 14.3 ± 2.3; AIS 2 = 13.4 ± 3.2 vs. 14.1 ± 2.4; AIS 3 = 11.1 ± 4.7 vs. 11.6 ± 4.6; AIS 4 = 9.8 ± 4.9 vs. 10.4 ± 4.9; AIS 5 = 5.5 ± 3.8 vs. 5.9 ± 4.1, AIS 6: 3.4 ± 1.1 vs. 3.8 ± 2.8). Conclusion:Alcohol use does not result in a clinically significant reduction in GCS in trauma patients. Attributing low GCS to alcohol intoxication in TBI patients may delay necessary diagnostic and therapeutic interventions.

Restrictive fluid resuscitation in combination with damage control resuscitation: time for adaptation.

BACKGROUND Damage control resuscitation (DCR) conveys a survival advantage in patients with severe hemorrhage. The role of restrictive fluid resuscitation (RFR) when used in combination with DCR has not been elucidated. We hypothesize that RFR, when used with DCR, conveys an overall survival benefit for patients with severe hemorrhage. METHODS This is a retrospective analysis from January 2007 to May 2011 at a Level I trauma center. Inclusion criteria included penetrating torso injuries, systolic blood pressure less than or equal to 90 mm Hg, and managed with DCR and damage control surgery (DCS). There were two groups according to the quantity of fluid before DCS: (1) standard fluid resuscitation (SFR) greater than or equal to 150 mL of crystalloid; (2) RFR less than 150 mL of crystalloid. Demographics and outcomes were analyzed. RESULTS Three hundred seven patients were included. Before DCS, 132 (43%) received less than 150 mL of crystalloids, grouped under RFR; and 175 (57%) received greater than or equal to 150 mL of crystalloids, grouped under SFR. Demographics and initial clinical characteristics were similar between the study groups. Compared with the SFR group, RFR patients received less fluid preoperatively (129 mL vs. 2,757 mL; p < 0.001), exhibited a lower intraoperative mortality (9% vs. 32%; p < 0.001), and had a shorter hospital length of stay (13 vs. 18 days; p = 0.02). Patients in the SFR group had a lower trauma intensive care unit mortality (5 vs. 12%; p = 0.03) but exhibited a higher overall mortality. Patients receiving RFR demonstrated a survival benefit, with an odds ratio for mortality of 0.69 (95% confidence interval, 0.37–0.91). CONCLUSION To the best of our knowledge, this is the first civilian study that analyzes the impact of RFR in patients managed with DCR. Its use in conjunction with DCR for hypotensive trauma patients with penetrating injuries to the torso conveys an overall and early intraoperative survival benefit. LEVEL OF EVIDENCE Therapeutic study, level IV.

Prehospital spine immobilization for penetrating trauma--review and recommendations from the Prehospital Trauma Life Support Executive Committee.

Spine immobilization in trauma patients suspected of having a spinal injury has been a cornerstone of prehospital treatment for decades. Current practices are based on the belief that a patient with an injured spinal column can deteriorate neurologically without immobilization. Most treatment protocols do not differentiate between blunt and penetrating mechanisms of injury. Current Emergency Medical Service (EMS) protocols for spinal immobilization of penetrating trauma are based on historic practices rather than scientific merits. Although blunt spinal column injuries will occasionally produce unstable vertebral injuries, which may result in subsequent neurologic propagation if not managed appropriately in the field, this has not been demonstrated to be the case with penetrating trauma.1 Patients with penetrating trauma have different management priorities than those with blunt mechanisms. In patients with penetrating wounds of the head and neck, cervical collars hinder provider assessment of the neck for evolving injuries, tissue edema, subcutaneous emphysema, hematoma development or expansion, and tracheal deviation— with many of these injuries often identified only after removal of the cervical collar.2,3 Airway management is a significant issue in the penetrating trauma population who have had their cervical spine immobilized by prehospital personnel. Endotracheal intubation is more difficult in patients with cervical immobilization.4 More attempts at intubation occur in patients with cervical spine immobilization than occur without, and there is a higher incidence of esophageal intubation and tube dislodgement in this group.5 In the case of penetrating injuries, delays in transport prolong the time before patients receive the prompt surgical care needed to arrest hemorrhage. Even with experienced prehospital providers, spine immobilization is time consuming. The time required for experienced emergency medical technicians to properly immobilize a cervical spine has been reported to be 5.64 minutes ( 1.49 minutes).6 This scene delay can be catastrophic for a patient with penetrating trauma requiring urgent surgical intervention for airway compromise or hemorrhage. Studies have demonstrated that cervical collars increase intracranial pressure in patients with head injuries.7–9 The mechanism for this rise in intracranial pressure is unknown but has been postulated to be due to jugular venous compression by the cervical collar.10 Finally, no study has demonstrated that penetrating trauma can produce an unstable spine injury. Progression of spinal cord injury has not been demonstrated to occur following penetrating trauma, which has a different mechanism of injury from blunt trauma. The PreHospital Trauma Life Support (PHTLS) program is a national and international educational effort sponsored jointly by the National Association of Emergency Medical Technicians and the American College of Surgeons Committee on Trauma. The Executive Committee of PHTLS is comprised of surgeons, emergency physicians, and paramedics. The mission of PHTLS is to further the knowledge of prehospital providers of all levels in the management of victims of trauma. To that end, PHTLS publishes textbooks and offers educational courses for prehospital providers at both basic and advanced levels of training. The PHTLS program was modeled after the American College of Surgeons Committee on Trauma Advanced Trauma Life Support course for physicians.

Hydrofluoric acid burns: A 15-year experience

Hydrofluoric acid (HF) is a strong inorganic acid commonly used in many domestic and industrial settings. It is one of the most common chemical burns encountered in a burn center and frequently engenders controversy in its management. We report our 15 year experience with management of HF burns. We reviewed our experience from 1990 to 2005 for patients admitted with HF burns. Primary treatment was with calcium gluconate gel. Arterial infusion of calcium and fingernail removal were reserved for unrelenting symptoms. There were 7944 acute burn admissions to our center during this study period, 204 of which were chemical burns. HF burns comprised 17% of these chemical burn admissions (35 patients). All were men, with a mean burn size of 2.1 ± 1.5% (range, 1–6%) and hospital stay of 1.6 ± 0.7 days (range, 0–3 days). The most common seasonal time of injury was in the summer. Twelve patients (34%) were admitted to the intensive care unit for a total of 14 intensive care unit days, primarily for arterial infusions. Ventilator support was not required in any patient. No electrolyte abnormalities occurred. All burns were either partial thickness or small full thickness with no operative intervention required and no deaths. The upper extremity was most commonly involved (29 patients, 83%). The most common cause was air conditioner cleaner (8 patients, 23%). HF is a common cause of chemical burns. Although hospital admission is usually required for vigorous treatment and pain control, burn size is usually small and does not cause electrolyte abnormalities, significant morbidity, or death.

Risk factors for cervical spine injury

INTRODUCTION The early recognition of cervical spine injury remains a top priority of acute trauma care. Missed diagnoses can lead to exacerbation of an existing injury and potentially devastating consequences. We sought to identify predictors of cervical spine injury. METHODS Trauma registry records for blunt trauma patients cared for at a Level I Trauma Centre from 1997 to 2002 were examined. Cervical spine injury included all cervical dislocations, fractures, fractures with spinal cord injury, and isolated spinal cord injuries. Univariate and adjusted odds ratios (ORs) were calculated to identify potential risk factors. Variables and two-way interaction terms were subjected to multivariate analysis using backward conditional stepwise logistic regression. RESULTS Data from 18,644 patients, with 55,609 injuries, were examined. A total of 1255 individuals (6.7%) had cervical spine injuries. Motor Vehicle Collision (MVC) (odds ratio (OR) of 1.61 (1.26, 2.06)), fall (OR of 2.14 (1.63, 2.79)), age <40 (OR of 1.75 (1.38-2.17)), pelvic fracture (OR of 9.18 (6.96, 12.11)), Injury Severity Score (ISS) >15 (OR of 7.55 (6.16-9.25)), were all significant individual predictors of cervical spine injury. Neither facial fracture nor head injury alone were associated with an increased risk of cervical spine injury. Significant interactions between pelvic fracture and fall and pelvic fracture and head injury were associated with a markedly increased risk of cervical spine (OR 19.6 (13.1, 28.8)) and (OR 27.2 (10.0-51.3)). CONCLUSIONS MVC and falls were independently associated with cervical spine injury. Pelvic fracture and fall and pelvic fracture and head injury, had a greater than multiplicative interaction and high risk for cervical spine injury, warranting increased vigilance in the evaluation of patients with this combination of injuries.

Survival of a patient with trauma-induced mucormycosis using an aggressive surgical and medical approach

BACKGROUND Mucormycosis is a deadly angioinvasive fungal infection that is increasing in incidence. Gastrointestinal and abdominal involvement is rare, has higher mortality rates, and is frequently diagnosed late. METHODS We report a patient who sustained multiple gunshot wounds to the chest and abdomen and subsequently developed omental and hepatic mucormycosis. He underwent 14 abdominal washouts and several liver debridements, and he received combination therapy with amphotericin B and micafungin. RESULTS The patient survived the disease, with negative cultures and pathology at the last washout, and underwent skin grafting. He is clinically improved and remains on oral antifungals as an outpatient. CONCLUSIONS Mucormycosis should be considered in trauma patients with persistent signs of infection after lavage and antibiotics, especially when necrosis or atypical wound presentations are noted. Approaches such as ours using aggressive surgical management and intensive antifungal administration should be instituted once the diagnosis is suspected.

Not all mechanisms are created equal: a single-center experience with the national guidelines for field triage of injured patients.

BACKGROUND Trauma systems use prehospital evaluation of anatomic and physiologic criteria and mechanism of injury (MOI) to determine trauma center need (TCN). MOI criteria are established nationally in a collaborative effort between the Centers for Disease Control and Prevention and the American College of Surgeons’ Committee on Trauma and have been revised several times, most recently in 2011. Controversy exists as to which MOI criteria truly predict TCN. We review our single-center experience with past and present National Trauma Triage Criteria to determine which MOI predict TCN. METHODS The trauma registry of an urban Level I trauma center was reviewed from 2001 to 2011 for all patients meeting only MOI criteria. Patients meeting any anatomic and physiologic criteria were excluded. TCN was defined as death, Injury Severity Score (ISS) of greater than 15, emergency department transfusion, intensive care unit admission, need for laparotomy/thoracotomy/vascular surgery within 24 hours of arrival, pelvic fracture, 2 or more proximal long bone fractures, or neurosurgical intervention during admission. Logistic regression analysis was used to identify which MOI predict TCN. RESULTS A total of 3,569 patients were transported to our trauma center who met only MOI criteria and had the MOI recorded in the registry; 821 MOI patients (23%) were identified who met our definition of TCN. Significant predictors of TCN included death in the same passenger compartment, ejection from vehicle, extrication time of more than 20 minutes, fall from more than 20 feet, and pedestrian thrown/runover. Criteria not meeting TCN include vehicle intrusion, rollover motor vehicle collision, speed of more than 40 mph, injury from autopedestrian/autobicycle of more than 5 mph, and both of the motorcycle crash (MCC) criteria. CONCLUSION With the exception of vehicle intrusion and MCC, the new National Trauma Triage Criteria accurately predicts TCN. In addition, extrication time of more than 20 minutes was a positive predictor of TCN in our system. Elimination of the vehicle intrusion and MCC criteria and reevaluation of extrication time merits further study. LEVEL OF EVIDENCE Prognostic and epidemiologic, level III.

Comparison of the Prehospital Trauma Life Support recommendations and the German national guideline on treatment of patients with severe and multiple injuries.

BACKGROUND The Prehospital Trauma Life Support (PHTLS) concept is well established throughout the world. The aim is to improve prehospital care for patients with major trauma. In 2011, a German Level 3 (S3) evidence- and consensus-based guideline on the treatment of patients with severe and multiple injuries was published. The scope of this study was the systematic comparison between the educational content of the worldwide PHTLS concept and the German S3 Guideline. METHODS A total of 62 key recommendations of the German S3 Guideline were compared with the content of the English PHTLS manual (eighth edition). Depending on the level of agreement, the recommendations were categorized as (1) agreement, (2) minor variation, or (3) major variation. Comparison was done via a rating system by a number of international experts in the field of out-of-hospital trauma care. The Delphi method was used to get the final statements by indistinct or board-ranged ratings. RESULTS Overall, there was no conformity in 12%. In 68% a total agreement and in 88% conformity with slight differences of minor variations were found between the key recommendations of the guideline and the PHTLS manual. The PHTLS primary assessment has a large conformity for the following individual priorities: airway, 92%; breathing, 92%; circulation, 63%; disability, 100%; exposure, 89%. CONCLUSIONS According to our comparison, the PHTLS manual is largely compatible with the German S3 Guideline from 2011. The 12% divergent statements concern mainly fluid resuscitation. Minor deviations in the prehospital care are due to a national guideline with an emergency medical service with emergency physicians (S3 Guideline) and a global PHTLS concept.