Nathan T. Mowery

The management of the open abdomen in trauma and emergency general surgery: part 1-damage control.

BACKGROUND The open abdomen technique, after both military and civilian trauma, emergency general or vascular surgery, has been used in some form for the past 30 years. There have been several hundred citations on the indications and the management of the open abdomen. Eastern Association for the Surgery of Trauma practice management committee convened a study group to organize the worlds literature for the management of the open abdomen. This effort was divided into two parts: damage control and the management of the open abdomen. Only damage control is presented in this study. Part 1 is divided into indications for the open abdomen, temporary abdominal closure, staged abdominal repair, and nutrition support of the open abdomen. METHODS A literature review was performed for more than 30 years. Prospective and retrospective studies were included. The reviews and case reports were excluded. Of 1,200 articles, 95 were selected. Seventeen surgeons reviewed the articles with four defined criteria. The Eastern Association for the Surgery of Trauma primer was used to grade the evidence. RESULTS There was only one level I recommendation. A patient with documented abdominal compartment syndrome should undergo decompressive laparotomy. CONCLUSION The open abdomen technique remains a heroic maneuver in the care of the critically ill trauma or surgical patient. For the best outcomes, a protocol for the indications, temporary abdominal closure, staged abdominal reconstruction, and nutrition support should be in place.

Guidelines for Management of Small Bowel Obstruction

STATEMENT OF THE PROBLEMThe description of patients presenting with small bowel obstruction (SBO) dates back to the third or fourth century, when early surgeons created enterocutaneous fistulas to relieve a bowel obstruction. Despite this success with operative therapy, the nonoperative management o

Practice management guidelines for management of hemothorax and occult pneumothorax.

STATEMENT OF THE PROBLEMThoracic trauma is a notable cause of morbidity and mortality in American trauma centers, where 25% of traumatic deaths are related to injuries sustained within the thoracic cage.1 Chest injuries occur in ∼60% of polytrauma cases; therefore, a rough estimate of the occurrence

Prospective Trial of Angiography and Embolization for All Grade III to V Blunt Splenic Injuries: Nonoperative Management Success Rate Is Significantly Improved

BACKGROUND Nonoperative management (NOM) of blunt splenic injury is well accepted. Substantial failure rates in higher injury grades remain common, with one large study reporting rates of 19.6%, 33.3%, and 75% for grades III, IV, and V, respectively. Retrospective data show angiography and embolization can increase salvage rates in these severe injuries. We developed a protocol requiring referral of all blunt splenic injuries, grades III to V, without indication for immediate operation for angiography and embolization. We hypothesized that angiography and embolization of high-grade blunt splenic injury would reduce NOM failure rates in this population. STUDY DESIGN This was a prospective study at our Level I trauma center as part of a performance-improvement project. Demographics, injury characteristics, and outcomes were compared with historic controls. The protocol required all stable patients with grade III to V splenic injuries be referred for angiography and embolization. In historic controls, referral was based on surgeon preference. RESULTS From January 1, 2010 to December 31, 2012, there were 168 patients with grades III to V spleen injuries admitted; NOM was undertaken in 113 (67%) patients. The protocol was followed in 97 patients, with a failure rate of 5%. Failure rate in the 16 protocol deviations was 25% (p = 0.02). Historic controls from January 1, 2007 to December 31, 2009 were compared with the protocol group. One hundred and fifty-three patients with grade III to V injuries were admitted during this period, 80 (52%) patients underwent attempted NOM. Failure rate was significantly higher than for the protocol group (15%, p = 0.04). CONCLUSIONS Use of a protocol requiring angiography and embolization for all high-grade spleen injuries slated for NOM leads to a significantly decreased failure rate. We recommend angiography and embolization as an adjunct to NOM for all grade III to V splenic injuries.

Emergency department length of stay is an independent predictor of hospital mortality in trauma activation patients

BACKGROUND The early resuscitation occurs in the emergency department (ED) where intensive care unit protocols do not always extend and monitoring capabilities vary. Our hypothesis is that increased ED length of stay (LOS) leads to increased hospital mortality in patients not undergoing immediate surgical intervention. METHODS We examined all trauma activation admissions from January 2002 to July 2009 admitted to the Trauma Service (n = 3,973). Exclusion criteria were as follows: patients taken to the operating room within the first 2 hours of ED arrival, nonsurvivable brain injury, and ED deaths. Patients spending >5 hours in the ED were not included in the analysis because of significantly lower acuity and mortality. RESULTS Patients spent a mean of 3.2 hours ± 1 hour in the ED during their initial evaluation. Hospital mortality increases for each additional hour a patient spends in the ED, with 8.3% of the patients staying in the ED between 4 hours and 5 hours ultimately dying (p = 0.028). ED LOS measured in minutes is an independent predictor of mortality (odds ratio, 1.003; 95% confidence interval, 1.010-1.006; p = 0.014) when accounting for Injury Severity Score, Revised Trauma Score, and age. Linear regression showed that a longer ED LOS was associated with anatomic injury pattern rather than physiologic derangement. CONCLUSION In this patient population, a longer ED LOS is associated with an increased hospital mortality even when controlling for physiologic, demographic, and anatomic factors. This highlights the importance of rapid progression of patients through the initial evaluation process to facilitate placement in a location that allows implementation of early goal directed trauma resuscitation.

Stress insulin resistance is a marker for mortality in traumatic brain injury.

BACKGROUND Both hyper- and hypoglycemia have been associated with poor outcome in traumatic brain injury (TBI). Neither the risks nor benefit of tight glucose control (goal range, 80-110 mg/dL) have been documented in the TBI population. OBJECTIVE To analyze whether densely collected blood glucose data, using a computerized algorithm, to maintain tight glycemic control will reveal significant differences in blood glucose control between survivors and nonsurvivors in patients with TBI. METHODS From October 2005 to April 2006, all ventilated, critically ill surgical patients with TBI Abbreviated Injury Scale score of >or=3 were placed on an automated, euglycemia protocol with every 2-hour blood glucose sampling. Mortalities within 24 hours were excluded. The protocol calculates the insulin rate using a linear equation (rate = blood glucose - 60[M]). M is an adapting multiplier and used here as a marker for insulin resistance (IR). RESULTS Of 1,636 trauma intensive care unit admissions 160 patients, (median Injury Severity Score 34, mortality 13.1%) had 10,071 samples collected. Median glucose 115.6 mg/dL, with 41% of values between 80 and 110 mg/dL, 81% between 80 and 150 mg/dL, and 0.3% <40 mg/dL. The median blood glucose was statistically different but not clinically different among the patients who lived and died (114; interquartile range, 109-132 vs. 118; 111-136, p = 0.01). The median insulin dose was a unit per hour higher among the patient who died (4.2; 2.7-5.9 vs. 3.2; 2.4-5.0, p = 0.006). A logistic regression model demonstrated insulin rate (odds ratio 0.736, 95% confidence interval, 0.549-0.985, p = 0.039) to be the only independent predictor of mortality among the measures of blood glucose control. CONCLUSION Nonsurvivors with TBI have significantly higher markers of IR (insulin rate and multiplier). Markers of glucose control (median glucose, hypoglycemic episodes, and the percentage of values in range) did not differ clinically among groups. Despite this stress IR, tight glycemic control appears possible and safe with low levels of hypoglycemic episodes in the TBI population.

Cardiac uncoupling and heart rate variability are associated with intracranial hypertension and mortality: a study of 145 trauma patients with continuous monitoring.

BACKGROUND A noninvasive tool reflecting intracranial hypertension (ICH) should prompt early invasive monitoring and reduce secondary injury after traumatic brain injury. We hypothesized that integer heart rate variability (HRV) may be associated with rises in intracranial pressure (ICP); changes in HRV may precede changes in ICP; and both increases in ICP and cardiac uncoupling (low HRV) predict mortality. METHODS Of 14,330 consecutive trauma admissions, 291 of these patients had an injury requiring intracranial monitoring. Of these patients 145 had simultaneous HRV and ICP monitoring with a Camino monitor. ICP and heart rate (HR) data were matched and divided into 5-minute intervals (N = 117,956, representing 24.4 million HR and ICP data points). In each interval, the median ICP, and SD of HR (HRSD5) were calculated. Cardiac uncoupling was defined as an interval with HRSD5 between 0.3 bpm and 0.6 bpm. Cardiac uncoupling was compared between ICP categories using the Wilcoxon Rank-Sum test, and logistic regression was used to assess the continuous relationship between ICP and risk of uncoupling. RESULTS Cardiac uncoupling increases as ICP increases (p < 0.001). Uncoupling nearly doubles when comparing acceptable ICP (<20 mm Hg, 11% uncoupled) to ICH (31-50 mm Hg, 18% uncoupled), with uncoupling = 13% in the intermediate group (ICP 21-30 mm Hg). This trend continues at the level of malignant ICH (>50 mm Hg, 22% uncoupled). CONCLUSION Cardiac uncoupling increases as ICP increases. Both cardiac uncoupling and ICH predict mortality. Cardiac uncoupling may precede ICH but is not yet an indication for invasive monitoring.

The American Association for the Surgery of Trauma grading scale for 16 emergency general surgery conditions: Disease-specific criteria characterizing anatomic severity grading.

Abstract The American Association for the Surgery of Trauma (AAST) Committee on Patient Assessment has previously published a uniform system for describing anatomic severity for Emergency General Surgery (EGS) diseases and applied these to 16 specific EGS disease processes: appendicitis, breast infections, acute cholecystitis, acute diverticulitis of the colon, esophageal perforation, hernias (internal or abdominal wall), infectious colitis, intestinal obstruction, intestinal arterial ischemia of the bowel, acute pancreatitis, pelvic inflammatory disease, perforated peptic ulcer disease, perirectal abscess, pleural space infection, skin and soft tissue infections, and surgical site infections. Standardized definitions of categorizing these diseases will be essential for risk adjustment and comparing patient outcomes among different centers. We now report on the final construct for the data dictionaries including clinical, imaging, operative, and pathologic criteria to correspond with each grade of each EGS disease. The data dictionaries are based on review of the literature, examination of existing grading systems, and discussion with expert consensus. Level V - Expert opinion STUDY TYPE: Current Opinion or Special Report.

An innovative approach to predict the development of adult respiratory distress syndrome in patients with blunt trauma.

BACKGROUND Pulmonary contusion (PC) is a common injury associated with blunt chest trauma. Complications such as pneumonia and adult respiratory distress syndrome (ARDS) occur in up to 50% of patients with PC. The ability to predict which PC patients are at increased risk of developing complications would be of tremendous clinical utility. In this study, we test the hypothesis that a novel method that objectively measures percent PC can be used to identify patients at risk to develop ARDS after injury. METHODS Patients with unilateral or bilateral PC with an admission chest computed tomographic angiogram were identified from the trauma registry. Demographic, infectious, and outcome data were collected. Percent PC was determined on admission chest computed tomography using our novel semiautomated, attenuation-defined computer-based algorithm, in which the lung was segmented with minimal manual editing. Factors contributing to the development of ARDS were identified by both univariate and multivariable logistic regression analyses. ARDS was defined as PaO2/FiO2 ratio of less than 200 with diffuse bilateral infiltrates on chest radiograph with no evidence of congestive heart failure. RESULTS Quantifying percent PC from our objective computer-based approach proved successful. We found that a contusion size of 24% of total lung volume or greater was most significant at predicting ARDS, which occurred in 78% of these patients. Such patients also had a significantly higher incidence of pneumonia when compared with those with contusions less than 24%. The specificity of contusion size of 24% or greater was 94%, although sensitivity was 37%; positive predictive value was 78%, and negative predictive value was 72%. CONCLUSION We developed and describe a software-based methodology to accurately measure the size of lung contusion in patients of blunt trauma. In our analyses, contusions of 24% or greater most significantly predict the development of ARDS. Such an objective approach can identify patients with PC who are at increased risk for developing respiratory complications before they happen. Further research is needed to use this novel methodology as a means to prevent posttraumatic lung injury in patients with blunt trauma. LEVEL OF EVIDENCE Prognostic/epidemiologic study, level III; diagnostic study, level IV.

Severe hypoglycemia while on intensive insulin therapy is not an independent predictor of death after trauma.

BACKGROUND Fear of the adverse effects of hypoglycemia has limited the widespread application of intensive insulin therapy (goal, 80-110 mg/dL) in the trauma population. We hypothesized that severe hypoglycemia (SH; <or=40 mg/dL) was not an independent predictor of mortality in the trauma population. METHODS An analysis of critically ill trauma patients treated with intensive insulin therapy from November 2005 to May 2008 was performed. The primary outcomes of interest were any episode of SH (<40 mg/dL) and all-cause inhospital mortality. Multivariate logistic regression was used to estimate the independent relationship between hypoglycemia and death. RESULTS : Fifty-seven thousand two hundred eighty-four data entries (1,824 patients) from the euglycemia protocol were analyzed (mortality = 16.0%). Median glucose was 119 mg/dL, with 43% of values between 80 mg/dL and 110 mg/dL, 81% between 80 mg/dL and 150 mg/dL, and 0.3% <40 mg/dL. There were 126 severe hypoglycemic episodes in 111 patients (6.1% of the patients). Multivariate logistic regression revealed that SH was not independently associated with death after adjusting for other known risk factors (odds ratio, 1.244; 95% confidence interval, 0.853-1.816; p = 0.257). CONCLUSION Hypoglycemia may be an unavoidable byproduct of tight glucose control with 6.1% of the patients experiencing a severe hypoglycemic event (<40 mg/dL). Hypoglycemia is not an independent predictor of death. Hypoglycemia is a statistical probability of time spent on protocol rather than an event leading to death. These data suggest that lower glucose ranges should be targeted in the trauma population without fear of hypoglycemias adverse effect on mortality.