Lauren Turco

Penetrating Bihemispheric Traumatic Brain Injury: A Collective Review of Gunshot Wounds to the Head

BACKGROUND Head injuries that cross midline structures of the brain are bihemispheric. Other terms have been used to describe such injuries, but bihemispheric is the most accurate and should be standard nomenclature. Bihemispheric head injuries are associated with greater mortality and morbidity than other penetrating traumatic brain injuries (TBIs). Currently, there is a tendency to manage severe gunshot wounds (GSWs) to the head nonoperatively, despite reports of improved outcome in military patients treated aggressively. Thus, controversy exists in the management of civilian TBI. METHODS PubMed was searched for query terms, and PRISMA guidelines were used. Studies were selected by relevance and inclusion of data regarding etiology, diagnosis, and management of bihemispheric TBI. Case reports, studies not in English, and records lacking information on mechanism or bihemispheric injuries were excluded. RESULTS Thirteen studies were included and most contained level IV evidence. The mean mortality rate of all head GSWs was 62% in adults and 32% in children. Bihemispheric GSWs had greater mortality rates of 82% in adults and 60% in children. There was a larger proportion of self-inflicted injury in studies with greater rates of bihemispheric injuries. CONCLUSIONS Bihemispheric injuries have greater mortality rates than other penetrating TBI. Violation of midline brain structures such as the diencephalon and mesencephalon, increased rate of self-inflicted wounds, and lack of a standard management algorithm may increase the lethality of these injuries. Although bihemispheric injuries historically have been considered nonsalvageable, an aggressive surgical approach has been shown to improve outcomes, particularly in the military population.

Penetrating injuries to the duodenum: An analysis of 879 patients from the National Trauma Data Bank, 2010 to 2014

BACKGROUND Despite wide belief that the duodenal Organ Injury Scale has been validated, this has not been reported in the published literature. Based on clinical experience, we hypothesize that the American Association for Surgery of Trauma Organ Injury Scale (AAST-OIS) for duodenal injuries can independently predict mortality. Our objectives were threefold: (1) describe the national profile of penetrating duodenal injuries, (2) identify predictors of morbidity and mortality, and (3) validate the duodenum AAST-OIS as a statistically significant predictor of mortality. METHODS Using the Abbreviated Injury Scale 2005 and International Classification of Diseases—9th Rev.—Clinical Modification (ICD-9-CM) E-codes, we identified 879 penetrating duodenal trauma patients from the National Trauma Data Bank between 2010 and 2014. We controlled patient-level covariates of age, biological sex, systolic blood pressure (SBP), Glasgow Coma Scale (GCS) score, pulse, Injury Severity Score (ISS), and Organ Injury Scale (OIS) grade. We estimated multivariable generalized linear mixed models to account for the nesting of patients within trauma centers. RESULTS Our results indicated an overall mortality rate of 14.4%. Approximately 10% of patients died within 24 hours of admission, of whom 76% died in the first 6 hours. Patients averaged approximately five associated injuries, 45% of which involved the liver and colon. Statistically significant independent predictors of mortality were firearm mechanism, SBP, GCS, pulse, ISS, and AAST-OIS grade. Specifically, odds of death were decreased with 10 mm Hg higher admission SBP (13% decreased odds), one point higher GCS (14.4%), 10-beat lower pulse (8.2%), and 10-point lower ISS (51.0%). CONCLUSION This study is the first to report the national profile of penetrating duodenal injuries. Using the National Trauma Data Bank, we identified patterns of injury, predictors of outcome, and validated the AAST-OIS for duodenal injuries as a statistically significant predictor of morbidity and mortality. LEVEL OF EVIDENCE Epidemiologic/Prognostic, level IV.

Trauma to the Superior Mesenteric Artery and Superior Mesenteric Vein: A Narrative Review of Rare but Lethal Injuries

Mesenteric vessels, including the superior mesenteric artery (SMA) and vein (SMV), provide and drain the rich blood supply of the midgut and hindgut. SMA and SMV injuries are rare and often lethal. Clinical management of these injuries is not well established, but treatment options include operative, non-operative, and endovascular strategies. A narrative review of the literature was conducted using MEDLINE Complete-EBSCO. Relevant studies, specifically those focusing on diagnosis and management of SMA and SMV injuries, were selected. Only original reports and collected series were selected to prevent duplication of cases. A search of the literature for mesenteric arterial injuries yielded 87 studies. Vessel-specific breakdown of the studies yielded 40 with SMA injuries and 41 with SMV injuries. These searches were winnowed to 26 individual studies, which were included in this collective review. Limitations of this study are similar to all narrative literature reviews: the dependence on previously published research and availability of references as outlined in our methodology. Although historically rare, mesenteric vessel injuries are seen with increasing incidence and continue to present a challenge to trauma surgeons due to their daunting mortality rates. Currently, universal treatment guidelines do not exist, but the various options for their management have been extensively reviewed in the literature.

Trauma pneumonectomy: A narrative review

PURPOSE Thoracic injuries are common in both blunt and penetrating trauma. Most thoracic injuries are managed non-operatively, approximately 7-20% undergo thoracotomy. Of the injuries requiring thoracotomy, 1-6% ultimately require pulmonary resection. Wedge resection and lobectomies are well-studied in the literature; however, there is a paucity regarding reports on total pneumonectomy in the setting of trauma. Our objectives were to summarize the evidence supporting the role of trauma pneumonectomy (TP) in the current era and reiterate that despite the associated morbidity and mortality TP is justified in selective cases. METHODS A review of the worlds literature was conducted following standard guidelines. Inclusion criteria included those studies reviewing blunt and penetrating trauma to the lungs in adults (age greater than 15 year) that reported mortality rates and outcome measures. RESULTS The PubMed search yielded 713 studies. Of these, 14 studies included pertinent information on TP. Studies included in this review were published from 1985 to 2017 and involved patient data that was collected from 1972 to 2014. Mortality ranged from 50% to 100% (median 63%; mean 68%). CONCLUSION In the setting of severe thoracic trauma, pulmonary resection may be necessary. Less aggressive techniques are options in a stable patient; however, in the setting of ongoing hemorrhage, TP should be considered and expediently conducted. The role of damage control thoracic surgery and related techniques is vitally important in these patients to improve the significant mortality of trauma pneumonectomy.

Treatment of Methamphetamine withdrawal in trauma patients

Background: Methamphetamine use has increased in the United States over the past several decades. Similarly, an increasing number of trauma patients are testing positive for methamphetamine, which impacts hospital resources and length of stay, particularly in intensive care units. Treatment of methamphetamine-positive patients has not been well defined in the medical literature. Methods: A systematic literature search was conducted to identify a treatment algorithm and medications used in methamphetamine-intoxication and withdrawal. PRISMA guidelines were followed in the search and classification of the available literature. Inclusion criteria were defined as “any peer-reviewed study that reported results regarding the management and treatment of withdrawal from methamphetamine. All studies that were published in English were initially identified and screened for inclusion. However, due to the paucity of published reports on this subject, all sources were reviewed. Results: The literature search yielded 329 publications, of which 22 were included in this systematic literature review. A total of 12 randomized trials, 6 animal models and 1 consensus recommendation by the WHO met inclusion criteria. 3 other studies were used as additional reference and supportive evidence. A proposed treatment algorithm for managing methamphetamine withdrawal was not identified. A consensus regarding treatment of methamphetamine-positive patients does not currently exist in the literature. Few drugs have shown any clinical efficacy in managing methamphetamine-withdrawal. However, some drugs indicated potential benefits in animal models. Most prominently, n-acetylcysteine, bupropion, and dextroamphetamine, might be beneficial for use in the acute and long-term management of methamphetamine withdrawal. Limitations: The greatest limitation was the lack of available Level I, II, and III studies in the medical literature. Reports that are published include mostly subjective experiences. Conclusions: The current methamphetamine epidemic impacts medical care and resources at trauma centers in the United States. A consensus regarding treatment of methamphetamine-positive patients, including medicinal agents and timing of their administration is lacking. Additional studies are needed to identify an effective treatment algorithm. Correspondence to: Bradley J Phillips, Vice Chairman of Surgery – Surgical Research, Associate Professor of Surgery, Department of Surgery, Department of Clinical and Translational Science, Creighton University School of Medicine Creighton University Medical Center, 601 North 30th Street, Suite 3701, Omaha, NE 68131-2137, USA, Tel: 402-717-4909; Fax: 402-717-6068; E-mail: Bradley. Phillips@alegent.org