Paula Ferrada

Transthoracic focused rapid echocardiographic examination: real-time evaluation of fluid status in critically ill trauma patients.

BACKGROUND A transthoracic focused rapid echocardiographic evaluation (FREE) was developed to answer specific questions about treatment direction regarding the use of fluid versus ionotropes in trauma patients. Our objective was to evaluate the clinical utility of the information obtained by this diagnostic test. METHODS The FREE was performed by an ultrasonographer or an intensivist and interpreted by a surgical intensivist using a full service portable echo machine (Vivid i; GE Healthcare). The clinical team ordering the examination was surveyed before and after the test was performed. RESULTS During a 9-month study period, the FREE was performed in 53 patients admitted to our trauma critical care units. In 80% of patients, an estimated ejection fraction was obtained. Moderate and severe left ventricular dysfunction was diagnosed in 56% of patients, and right heart dysfunction was found in 25% of the patients. Inferior vena cava (IVC) diameter and IVC respiratory variation was visualized in 80% of patients. In 87% (46 of 53), the FREE was able to answer the clinical question asked by the primary team. Strikingly, in 54% of patients, the plan of care was modified as a result of the FREE examination. CONCLUSIONS IVC diameter and IVC respiratory variation was able to be obtained in the majority of cases, giving an estimate of fluid status. Estimation of ejection fraction was useful in guiding the treatment plan regarding the requirement of fluid boluses versus ionotropic support. We conclude that the FREE can provide meaningful data in difficult to image critically ill trauma patients.

Findings of a randomized controlled trial using limited transthoracic echocardiogram (LTTE) as a hemodynamic monitoring tool in the trauma bay

BACKGROUND We hypothesize that limited transthoracic echocardiogram (LTTE) is a useful tool to guide therapy during the initial phase of resuscitation in trauma patients. METHODS All highest-level alert patients with at least one measurement of systolic blood pressure less than 100 mm Hg, a mean arterial pressure less than 60 mm Hg, and/or a heart rate greater than 120 beats per minute who arrived to the trauma bay (TB) were randomized to have either LTTE performed (LTTEp) or not performed (non-LTTE) as part of their initial evaluation. Images were stored, and results were reported regarding contractility (good vs. poor), fluid status (empty inferior vena cava [hypovolemic] vs. full inferior vena cava [not hypovolemic]), and pericardial effusion (present vs. absent). Time from TB to operating room, intravenous fluid administration, blood product requirement, intensive care unit admission, and mortality were examined in both groups. RESULTS A total of 240 patients were randomized. Twenty-five patients were excluded since they died upon arrival to the TB, leaving 215 patients in the study. Ninety-two patients were in the LTTEp group with 123 patients in the non-LTTE group. The LTTEp and non-LTTE groups were similar in age (38 years vs. 38.8 years, p = 0.75), Injury Severity Score (ISS) (19.2 vs. 19.0, p = 0.94), Revised Trauma Score (RTS) (5.5 vs. 6.0, p = 0.09), lactate (4.2 vs. 3.6, p = 0.14), and mechanism of injury (p = 0.44). Strikingly, LTTEp had significantly less intravenous fluid than non-LTTE patients (1.5 L vs. 2.5 L, p < 0.0001), less time from TB to operating room (35.6 minutes vs. 79.1 min, p = 0.0006), higher rate of intensive care unit admission (80.4% vs. 67.2%, p = 0.04), and a lower mortality rate (11% vs. 19.5%, p = 0.09). Mortality differences were particularly evident in the traumatic brain injury patients (14.7% in LTTEp vs. 39.5% in non-LTTE, p = 0.03). CONCLUSION LTTE is a useful guide for therapy in hypotensive trauma patients during the early phase of resuscitation. LEVEL OF EVIDENCE Therapeutic study, level II.

A, B, C, D, echo: limited transthoracic echocardiogram is a useful tool to guide therapy for hypotension in the trauma bay--a pilot study.

BACKGROUND Limited transthoracic echocardiogram (LTTE) has been introduced as a technique to direct resuscitation in intensive care unit (ICU) patients. Our hypothesis is that LTTE can provide meaningful information to guide therapy for hypotension in the trauma bay. METHODS LTTE was performed on hypotensive patients in the trauma bay. Views obtained included parasternal long and short, apical, and subxyphoid. Results were reported regarding contractility (good vs. poor), fluid status (flat inferior vena cava [hypovolemia] vs. fat inferior vena cava [euvolemia]), and pericardial effusion (present vs. absent). Need for surgery, ICU admission, Focused Assessment with Sonography for Trauma examination results, and change in therapy as a consequence of LTTE findings were examined. Data were collected prospectively to evaluate the utility of this test. RESULTS A total of 148 LTTEs were performed in consecutive patients from January to December 2011. Mean age was 46 years. Admission diagnosis was 80% blunt trauma, 16% penetrating trauma, and 4% burn. Subxyphoid window was obtained in all patients. Parasternal and apical windows were obtained in 96.5% and 11%, respectively. Flat inferior vena cava was associated with an increased incidence of ICU admission (p < 0.0076) and therapeutic operation (p < 0.0001). Of the 148 patients, 27 (18%) had LTTE results indicating euvolemia. The diagnosis in these cases was head injury (n = 14), heart dysfunction (n = 5), spinal shock (n = 4), pulmonary embolism (n = 3), and stroke (n = 1). Of the patients, 121 had LTTE results indicating hypovolemia. Twenty-eight hypovolemic patients had a negative or inconclusive Focused Assessment with Sonography for Trauma examination finding (n = 18 penetrating, n = 10 blunt), with 60% having blood in the abdomen confirmed by surgical exploration or computed tomographic scan. Therapy was modified as a result of LTTE in 41% of cases. Strikingly, in patients older than 65 years, LTTE changed therapy in 96% of cases. CONCLUSION LTTE is a useful tool to guide therapy in hypotensive patients in the trauma bay. LEVEL OF EVIDENCE Diagnostic study, level III.

WSES guidelines for management of Clostridium difficile infection in surgical patients

In the last two decades there have been dramatic changes in the epidemiology of Clostridium difficile infection (CDI), with increases in incidence and severity of disease in many countries worldwide. The incidence of CDI has also increased in surgical patients. Optimization of management of C difficile, has therefore become increasingly urgent. An international multidisciplinary panel of experts prepared evidenced-based World Society of Emergency Surgery (WSES) guidelines for management of CDI in surgical patients.

A multi-institutional analysis of prehospital tourniquet use

BACKGROUND Recent military studies demonstrated an association between prehospital tourniquet use and increased survival. The benefits of this prehospital intervention in a civilian population remain unclear. The aims of our study were to evaluate tourniquet use in the civilian population and to compare outcomes to previously published military experience. We hypothesized that incorporation of tourniquet use in the civilian population will result in an overall improvement in mortality. METHODS This is a preliminary multi-institutional retrospective analysis of prehospital tourniquet (MIA-T) use of patients admitted to nine urban Level 1 trauma centers from January 2010 to December 2013. Patient demographics and mortality from a previous military experience by Kragh et al. (Ann Surg. 2009;249:1–7) were used for comparison. Patients younger than 18 years or with nontraumatic bleeding requiring tourniquet application were excluded. Data were analyzed using a two-tailed unpaired Student’s t test with p < 0.05 as significant. RESULTS A total of 197 patients were included. Tourniquets were applied effectively in 175 (88.8%) of 197 patients. The average Injury Severity Score (ISS) for MIA-T versus military was 11 ± 12.5 versus 14 ± 10.5, respectively (p = 0.02). The overall mortality and limb amputation rates for the MIA-T group were significantly lower than previously seen in the military population at 6 (3.0%) of 197 versus 22 (11.3%) of 194 (p = 0.002) and 37 (18.8%) of 197 versus 97 (41.8%) of 232 (p = 0.0001), respectively. CONCLUSION Our study is the largest evaluation of prehospital tourniquet use in a civilian population to date. We found that tourniquets were applied safely and effectively in the civilian population. Adaptation of this prehospital intervention may convey a survival benefit in the civilian population. LEVEL OF EVIDENCE Epidemiologic study, level V.

Limited transthoracic echocardiogram: so easy any trauma attending can do it.

BACKGROUND Limited transthoracic echocardiogram (LTTE) represents an attractive alternative to formal transthoracic echocardiogram (TTE), because it does not require an echocardiogram machine. Our hypothesis is that trauma attendings can learn LTTE effectively with minimal training. METHODS Seven attendings at a Level I trauma center received didactic and hands-on training in LTTE and performed this test on hypotensive patients to evaluate for contractility, fluid status, and pericardial effusion. Therapy to improve perfusion (administration of fluids, ionotropes, or vasopressors) was guided by LTTE findings. Perfusion status was determined by serum lactate level before and 6 hours after LTTE. Findings were compared with cardiology-performed TTE. RESULTS Range of postresidency training was 1 year to 29 years. LTTE teaching entailed 70 minutes of didactics and 25 minutes of hands-on. In all, 52 LTTEs were performed; two patients were excluded due to blunt trauma arrest. Age ranged from 22 years to 89 years with an average of 55 years. Admission diagnosis was blunt trauma (n = 34), penetrating trauma (n = 3), and intra-abdominal sepsis (n = 13). Average time for LTTE was 4 minutes 38 seconds. Cardiology-performed TTE was obtained in all patients, and correlation with LTTE was 100%. A total of 37 patients received intravenous fluid, 9 received vasopressors, and 4 received ionotropes as guided by LTTE findings, with lactate reduction in all patients (p < 0.00001). Attendings scored a mean of 88% in a written test after training. CONCLUSIONS Trauma attendings can successfully learn LTTE with minimal training and use the technique as a resuscitation tool in the hypotensive patient.

Endoscopic retrograde cholangiopancreatography is an effective treatment for bile leak after severe liver trauma.

BACKGROUND Biliary leak after severe hepatic trauma is a complex problem requiring multidisciplinary care. We report on our experience with endoscopic management of posttraumatic bile leaks and clarify the role of endoscopic retrograde cholangiopancreatography (ERCP). METHODS A retrospective analysis was performed on all patients who sustained liver injury and underwent ERCP from September 2003 to September 2009. Patients who had associated biliary leak were identified. Patient demographics, injury characteristics, liver operations, endoscopic treatment, and success of endoscopic intervention were reviewed. Liver injury was managed in an interdisciplinary fashion, including immediate or delayed operation or angiography or both for primary or adjunctive hemostasis. ERCP with stenting and sphincterotomy was used to treat biliary fistulae. Sequelae of liver injury including biloma or other perihepatic fluid collection were also managed by computed tomography scan-guided or ultrasound-guided drainage. RESULTS A total of 26 patients underwent ERCP for the management of biliary fistula as a result of severe hepatic trauma. There were 14 (54%) blunt injuries. In every patient (100%), ERCP with stenting and sphincterotomy was successful in controlling bile leak. All patients eventually had removal of stents and drains, with resolution of leak. Two patients had concomitant treatment of associated pancreatic ductal injury. CONCLUSION ERCP is useful as both a diagnostic and therapeutic tool for the safe treatment of biliary ductal injuries after severe liver trauma and should be part of a multidisciplinary treatment algorithm.

Timing and type of surgical treatment of Clostridium difficile-associated disease: A practice management guideline from the Eastern Association for the Surgery of Trauma

BACKGROUND Clostridium difficile infection is the leading cause of nosocomial diarrhea in the United States; however, few patients will develop fulminant C. difficile–associated disease (CDAD), necessitating an urgent operative intervention. Mortality for patients who require operative intervention is very high, up to 80% in some series. Since there is no consensus in the literature regarding the best operative treatment for this disease, we sought to answer the following: PICO [population, intervention, comparison, and outcome] Question 1: In adult patients with CDAD, does early surgery compared with late surgery, as defined by the need for vasopressors, decrease mortality? PICO Question 2: In adult patients with CDAD, does total abdominal colectomy (TAC) compared with other types of surgical intervention decrease mortality? METHODS A subcommittee of the Practice Management Guideline Committee of the Eastern Association for the Surgery of Trauma conducted a systematic review and meta-analysis for the selected questions. RevMan software was used to generate forest plots. Grading of Recommendations, Assessment, Development and Evaluations methodology was used to rate the quality of the evidence, using GRADEpro software to create evidence tables. RESULTS Reduction in mortality was significantly associated with early surgery, with a risk ratio (RR) of 0.5 (95% confidence interval [CI], 0.35–0.72). The quality of evidence was rated “moderate.” Considering only the first procedure performed, mortality seemed to trend higher for TAC, with an RR of 1.11 (95% CI, 0.69–1.80). Considering only the actual procedure performed, the point estimate switched sides, showing a trend toward decreased mortality with TAC (RR, 0.86; 95% CI, 0.56–1.31). The quality of evidence was rated “very low.” CONCLUSION We strongly recommend that adult patients with CDAD undergo early surgery, before the development of shock and need for vasopressors. We conditionally recommend total or subtotal colectomy (vs. partial colectomy or other surgery) when the diagnosis of The Centers for Disease Control and Prevention is known.

Nonoperative Management of Blunt Abdominal Trauma: Have We Gone Too Far?

BACKGROUND The paradigm shift in the management of blunt abdominal trauma has been to become less invasive with both diagnostic tools and management. Avoidance of a laparotomy with its short-term and long-term risks is of obvious benefit to the patient. METHOD Review of the pertinent literature. RESULTS Most blunt hepatic and splenic injuries are managed nonoperatively. Management of blunt splenic injury with observation and organ preservation will avoid the lifelong risk of overwhelming postsplenectomy infection. However, what are the risks? Does nonoperative management simply delay laparotomy? The answer is no. The pendulum has swung too far toward observation. Most patients with blunt hepatic injury, irrespective of the grade, are hemodynamically stable and can be observed. On the other hand, high-grade injury (IV and V) often necessitates operation or management of complications by interventional radiology or gastroenterology procedures. When hepatic injury necessitates laparotomy because of hemodynamic instability, the operation is technically challenging, with a significant risk of death. As shown by large studies, the risk of failure of nonoperative management of blunt splenic injury includes preventable deaths. Factors in such deaths include inappropriate clinical decision-making, false-negative diagnostic studies, and initial misreading of computed tomography scans. CONCLUSION Safe nonoperative management requires adherence to cardinal surgical principles, examination and re-examination of the patient, and fastidious clinical judgment.

Use of limited transthoracic echocardiography in patients with traumatic cardiac arrest decreases the rate of nontherapeutic thoracotomy and hospital costs.

Limited transthoracic echocardiography (LTTE) has been introduced as a hemodynamic tool for trauma patients. The aim of this study was to evaluate the utility of LTTE during the evaluation of nonsurviving patients who presented to the trauma bay with traumatic cardiac arrest.