Stephen Luk

Selective hepatic arterial embolization of grade IV and V blunt hepatic injuries: an extension of resuscitation in the nonoperative management of traumatic hepatic injuries.

BACKGROUND Recognizing the significant mortality and complications inherent in the operative management of blunt hepatic injuries, hepatic arterial embolization was evaluated as a bridge between operative and nonoperative interventions in patients defined as hemodynamically stable only with continuous resuscitation. METHODS Seven of 11 patients with grade IV or V hepatic injuries identified by computed tomography underwent hepatic arterial embolization. A prospective evaluation of hepatic embolization based on subsequent hemodynamic parameters was assessed by matched-pair analysis. A summary of this study populations demographic data and outcomes is presented, including age, Glasgow Coma Scale score, Injury Severity Score, Revised Trauma Score, computed tomography grade, intensive care unit and hospital length of stay, transfusion requirements, complications, and mortality. RESULTS No statistical difference was demonstrated between pre-embolization and postembolization hemodynamics and volume requirements. After embolization, however, continuous resuscitation was successfully reduced to maintenance fluids. Hepatic embolization was the definitive therapy for all seven patients who underwent embolization. CONCLUSION Results of this preliminary investigation suggest that hepatic arterial embolization is a viable alternative bridging the therapeutic options of operative and nonoperative intervention for a subpopulation of patients with hepatic injury.

Follow-up survey of participants attending the Advanced Trauma Operative Management (ATOM) Course.

BACKGROUND The ATOM Course was developed to educate surgeons about the surgical management of penetrating injuries. Its goals are to improve knowledge, self-confidence, and technical competence. METHODS ATOM participants completed a 25-item questionnaire to assess self-efficacy (SE) for advanced trauma operative management before and immediately after taking the ATOM course. On follow-up, questionnaires were sent to ATOM participants. One was a 7-item survey to assess the value of the ATOM course to surgical practice. Another was the 25-item questionnaire to assess SE. RESULTS Four items on the survey to assess the value of ATOM had mean scores > or = 4.0 and 3 had mean scores > 3.6. All had modes of 4.0 or greater. For all items, most respondents selected the agree options indicating positive assessments of the ATOM course to their surgical practice. For SE, the pre-ATOM mean SE score was 3.88 and the immediate post ATOM mean SE score was 4.57 (p < 0.05). The follow-up mean SE score was 4.47 indicating maintenance of SE (p > 0.05). CONCLUSIONS Follow-up data from ATOM participants indicate that respondents believe the ATOM course improved their ability to identify and repair traumatic injuries. They report they use the techniques and knowledge learned in ATOM and confidence remains high after the ATOM course. ATOM is well received as an effective teaching strategy for surgical education for the management of penetrating injuries.

Prehospital blood transfusion versus crystalloid alone in the air medical transport of trauma patients.

INTRODUCTION Differences in prehospital resuscitation measures and outcomes of trauma patients transported by two air medical programs were assessed comparing the prehospital administration of crystalloid only (Group A) with the administration of 2 liters of crystalloid followed by blood (Group B). METHODS A 1-year retrospective review of flight and hospital records of patients taken to Level I trauma centers by two separate air medical programs was completed. Physiologic variables, total fluids infused, and flight times were compared. RESULTS Thirty-one patients (Group A) received crystalloids in flight, and 17 patients received in-flight blood (Group B). No statistical differences were found between the two groups when comparing age, ISS, PS, RTS, GCS, survival, and total fluid volume. Group B had statistically greater mean flight times compared with Group A (P < .05). A difference was demonstrated between groups A and B in pH and HCO3 measurements (P < .05), with Group B presenting in a more acidotic state on admission to the hospital. CONCLUSION Patients with lengthy flight times, despite the administration of blood products, presented to the trauma center more acidotic than trauma patients receiving only crystalloid. The true impact of blood products on outcome could not be demonstrated because of statistical differences in flight times between the groups. A multicenter study matching flight times, head injury status, and flight type of assess benefit of prehospital utilization of blood products is warranted.

Outcome assessment of physiologic and clinical predictors of survival in patients after traumatic injury with a trauma score less than 5.

OBJECTIVE To define those physiologic and clinical variables that have a positive or negative predictive value in discriminating survivors from nonsurvivors with traumatic injuries and a Trauma Score of 5 or less. METHODS A retrospective review of 2,622 trauma patients transported by an air medical service from the scene of injury to a Level I trauma center was performed. Demographic, physiologic, and clinical variables were evaluated. RESULTS One hundred thirty-six patients were studied; 14 patients survived trauma resuscitation. Survivors had statistically significant improvement in the Glasgow Coma Scale from the field to arrival in the emergency room. Revised Trauma Score, probability of survival, pulse, respiratory rate, cardiac rhythm, central nervous system activity, and signs of life were statistically more favorable in survivors. CONCLUSION In patients who survived to discharge, signs of central nervous system activity in the field was a positive predictor of survival, and severe head injury served as a negative predictor of survival.

Advanced Trauma Operative Management Course: Participant Survey

BackgroundThe Advanced Trauma Operative Management (ATOM) course uses standardized porcine simulation to teach the repair of penetrating trauma. It is offered in 26 sites in the United States, Canada, Africa, the Middle East, and Japan. The purpose of the present study was to query ATOM participants regarding their perceptions of the value and influence of the ATOM course on knowledge, confidence, and skill to repair penetrating injuries.MethodsAn anonymous, voluntary survey was posted on the Internet at surveymonkey.com. E-mail notification was sent to all 1,001 ATOM participants through May 2008. Items requested agreement/disagreement on a 5-point Likert scale and space for comments. Agreement indicated positive perceptions of ATOM.ResultsA total of 962 surgeons received the request to complete the survey; 444 ATOM participants from 36 states and 17 countries participated, for a response rate of 46%. Range of agreement with all of the items was 75.4–99.0%. Results include the following: 78.9% (95% CI, 74.7–82.6%) can identify injuries more quickly; 80.7% (95% CI, 76.6–84.3%) have a more organized operative approach; 81.1% (95% CI, 77.0–84.6%) can control bleeding more quickly; 86.1% (95% CI, 82.4–89.2%) can control injuries more effectively; 86.4% (95% CI, 82.7–89.4%) are more competent trauma surgeons; 87.0% are more confident (95% CI, 83.4–89.9%), and 89.2% are more knowledgeable (95% CI, 85.8–91.8%) about repairing penetrating injuries; 99% (95% CI, 97.4–99.7%) said ATOM is worthwhile. Overall, 87.4% of the comments were positive.ConclusionsParticipants worldwide perceive that ATOM is worthwhile and helps surgeons improve knowledge, confidence, and skill in repairing penetrating injuries.

Traumatic colon injury in damage control laparotomy - A multicenter trial: Is it safe to do a delayed anastomosis?

Background Delayed colonic anastomosis after damage control laparotomy (DCL) is an alternative to colostomies during a single laparotomy (SL) in high-risk patients. However, literature suggests increased colonic leak rates up to 27% with DCL, and various reported risk factors. We evaluated our regional experience to determine if delayed colonic anastomosis was associated with worse outcomes. Methods A multicenter retrospective cohort study was performed across three Level I trauma centers encompassing traumatic colon injuries from January 2006 through June 2014. Patients with rectal injuries or mortality within 24 hours were excluded. Patient and injury characteristics, complications, and interventions were compared between SL and DCL groups. Regional readmission data were utilized to capture complications within 6 months of index trauma. Results Of 267 patients, 69% had penetrating injuries, 21% underwent DCL, and the mortality rate was 4.9%. Overall, 176 received primary repair (26 in DCL), 90 had resection and anastomosis (28 in DCL), and 26 had a stoma created (10 end colostomies and 2 loop ileostomies in DCL). Thirty-five of 56 DCL patients had definitive colonic repair subsequent to their index operation. DCL patients were more likely to be hypotensive; require more resuscitation; and suffer acute kidney injury, pneumonia, adult respiratory distress syndrome, and death. Five enteric leaks (1.9%) and three enterocutaneous fistulas (ECF, 1.1%) were identified, proportionately distributed between DCL and SL (p = 1.00, p = 0.51). No difference was seen in intraperitoneal abscesses (p = 0.13) or surgical site infections (SSI, p = 0.70) between cohorts. Among SL patients, pancreas injuries portended an increased risk of intraperitoneal abscesses (p = 0.0002), as did liver injuries in DCL patients (p = 0.06). Conclusions DCL was not associated with increased enteric leaks, ECF, SSI, or intraperitoneal abscesses despite nearly two-thirds having delayed repair. Despite this being a multicenter study, it is underpowered, and a prospective trial would better demonstrate risks of DCL in colon trauma. Level of Evidence Therapeutic study, level IV.