Victor Joe

A Survey of Mechanical Ventilator Practices Across Burn Centers in North America.

Burn injury introduces unique clinical challenges that make it difficult to extrapolate mechanical ventilator (MV) practices designed for the management of general critical care patients to the burn population. We hypothesize that no consensus exists among North American burn centers with regard to optimal ventilator practices. The purpose of this study is to examine various MV practice patterns in the burn population and to identify potential opportunities for future research. A researcher designed, 24-item survey was sent electronically to 129 burn centers. The &khgr;2, Fisher’s exact, and Cochran–Mantel–Haenszel tests were used to determine if there were significant differences in practice patterns. We analyzed 46 questionnaires for a 36% response rate. More than 95% of the burn centers reported greater than 100 annual admissions. Pressure support and volume assist control were the most common initial MV modes used with or without inhalation injury. In the setting of Berlin defined mild acute respiratory distress syndrome (ARDS), ARDSNet protocol and optimal positive end-expiratory pressure were the top ventilator choices, along with fluid restriction/diuresis as a nonventilator adjunct. For severe ARDS, airway pressure release ventilation and neuromuscular blockade were the most popular. The most frequently reported time frame for mechanical ventilation before tracheostomy was 2 weeks (25 of 45, 55%); however, all respondents reported in the affirmative that there are certain clinical situations where early tracheostomy is warranted. Wide variations in clinical practice exist among North American burn centers. No single ventilator mode or adjunct prevails in the management of burn patients regardless of pulmonary insult. Movement toward American Burn Association–supported, multicenter studies to determine best practices and guidelines for ventilator management in burn patients is prudent in light of these findings.

A Case of Argyria and Acute Leukopenia Associated with the Use of an Antimicrobial Soft Silicone Foam Dressing.

Silver has had an important role in preventing burn-related infections for decades. Relatively few side effects is one factor that has led to its wide spread use. Here, the authors present the first case of argyria, acute leukopenia, and possibly acute kidney injury associated with the use of a silver-containing soft silicone foam dressing. A 56-year-old female was transferred to the burn center with an exfoliating skin condition involving 70% TBSA diagnosed as toxic epidermal necrolysis associated with trimethoprim/sulfamethoxazole. On presentation she appeared to have clinical sepsis and was started on vancomycin and piperacillin/tazobactam. Clinical sepsis resolved within several days. Initial wound care consisted of daily topical double antibiotic and 3% bismuth tribromophenate petroleum gauze. After several days, the wounds were covered with a silver-containing soft silicone foam dressing. After 7 days, the leukocyte count declined from 18,000 to 600/cm3. Silver toxicity was suspected and the dressings removed. Initial serum silver level was 190 and 249 &mgr;g/L 1 week later. The leukocyte level normalized within 7 days. Over the following days and weeks, the patient’s skin began to show blue-gray coloration consistent with argyria. The patient subsequently developed acute kidney injury requiring hemodialysis and multiple organ failure. Although controversy exists about the causal relationship between silver-containing dressings and leukopenia, the authors believe that this case represents a case of acute leukopenia and argyria from the use of a silver-containing soft silicone foam dressing. It may have been a contributing factor to the development of acute kidney injury as well.

Blunt cerebrovascular injury incidence, stroke-rate, and mortality with the expanded Denver criteria

Background: Blunt carotid and vertebral artery injury, collectively termed blunt cerebrovascular injury occur in less than 1% of blunt traumas. Conventional indications for screening miss up to 20% of blunt cerebrovascular injuries. Therefore, the expanded Denver criteria were created in 2012. We hypothesized the introduction of the expanded Denver criteria would lead to an increase in the national detection of blunt cerebrovascular injury with a subsequent decrease in stroke rate. Methods: The National Trauma Data Bank was queried for blunt trauma admissions. Patients were divided into 2 groups: pre–expanded Denver criteria (2007–2011) or post–expanded Denver criteria era (2013–2015). The primary endpoint was the incidence of blunt cerebrovascular injury, which was used as a surrogate for detection. Results: There were 10,183 blunt cerebrovascular injuries with 5,364 blunt cerebrovascular injuries in the pre–expanded Denver criteria group (0.19%) and 4,819 blunt cerebrovascular injuries in the post–expanded Denver criteria group (0.22%; P < .001). The stroke‐rate in the post–expanded Denver criteria was significantly higher (9.2% vs 5.5%; OR 2.73, CI 2.29–3.25, P < .001). The strongest associated injury with blunt cerebrovascular injury was skull‐base fracture (OR 3.61, CI 3.46–3.77, P < .001). Conclusion: The detection of blunt cerebrovascular injury has increased by 16% since the publication of the expanded Denver criteria. Skull‐base fracture is the strongest traumatic risk factor for blunt cerebrovascular injury. Although detection may have increased, the stroke‐rate nearly doubled in the post‐eDC era. This warrants future research.

Epidemiology of Burn Injuries and Burn Care

The science of epidemiology is of great importance, as the patterns of burn injury can lead to more concentrated efforts for both prevention and treatment. The goal of this chapter is not to attempt an exhaustive review of burn epidemiology, but rather to utilize some basic epidemiologic data to convey several important points that strengthen the premise and purpose of this book. These data will demonstrate the following: 1. Burns remain a significant mechanism of injury. 2. Most burns are nonfatal and are minor in terms of size (i.e., total body surface area). 3. Knowledge of the common causes and circumstances of burn injuries provides a greater understanding of the patterns sustained by each specific etiology, as well as providing targets for burn prevention in our local communities. 4. General surgeons have a role in the treatment of burn injuries, but they need to recognize those injuries that require referral to a burn center.

Use of laparoscopic colectomy increasing in trauma: comparison of laparoscopic vs. open colectomy

Laparoscopy accounts for > 70% of general surgical cases. Given the increased use of laparoscopy in emergent colorectal disease, we hypothesized that there would be an increased use of laparoscopic colectomy (LC) in trauma patients. In addition, we hypothesized increased length of stay (LOS) and mortality in trauma patients undergoing open colectomy (OC) vs. LC. This was a retrospective analysis using the National Trauma Data Bank (2008–2015). We included adult patients undergoing LC or OC. A multivariable logistic regression model was used for determining risk of LOS and mortality. We identified 19,788 (96.8%) patients undergoing OC and 644 (3.2%) who underwent LC. There was a 21-fold increased number of patients that underwent LC over the study period (p < 0.05), with approximately 119 per 10,000 trauma patients undergoing LC. The most common operation was a laparoscopic right hemicolectomy (27.5%). LC patients had a lower median injury severity score (ISS) (16 vs. 17, p < 0.001). There was no difference in LOS (p = 0.14) or mortality (p = 0.44) between the two groups. This remained true in patients with isolated colorectal injury. The use of LC has increased 21-fold from 2008 to 2015, with laparoscopic right hemicolectomy being the most common procedure performed. There was no difference in LOS, in-hospital complications, or mortality between the two groups. We suggest that LC should be considered in stable adult trauma patients undergoing colectomy. However, future prospective research is needed to help determine which trauma patients may benefit from LC.

Cirrhosis increases complication rate and overall mortality in patients with traumatic lung injury

Introduction Hepatic cirrhosis is associated with an increased mortality in trauma. However, the association between cirrhosis and outcomes in traumatic lung injury has not been investigated. We hypothesize that cirrhosis adversely affects mortality and increases complications after traumatic lung injury. Methods A retrospective analysis of the National Trauma Data Bank was performed between 2007 and 2015. Patients ≥ 18 years of age with traumatic lung injury were identified and grouped by the presence or absence of cirrhosis. Patients that died in the emergency department or those with a severe (grade > 3) abbreviated injury scale for head trauma were excluded. The primary outcome was mortality. Results Out of 6,774,260 patients, 578,883 (8.5%) presented with traumatic lung injury. Of these, 1971 (0.3%) had a concomitant diagnosis of cirrhosis. The cirrhotic group was significantly older (median age, 56 versus 42 years, p < 0.001) and more likely to be hypotensive on admission (9.3% versus 6.7%, p < 0.001). There was no difference in injury severity score (p > 0.05). Patients with cirrhosis had a significantly longer median length of stay (12.5 versus 8.8 days, p < 0.001), rates of acute kidney injury (7.6% versus 1.4%, p < 0.001), acute respiratory distress syndrome (7.3% versus 2.9%, p < 0.001), pneumonia (12.9% versus 5.9%, p < 0.001), and overall mortality (20.6% versus 5.6%, p < 0.001). After adjusting for significant covariates, cirrhosis (OR = 6.26, 95% CI = 5.49–7.14, p < 0.001) was found to be an independent risk factor for mortality in patients with traumatic lung injury. Conclusion Cirrhosis in patients with traumatic lung injury is associated with more than a sixfold higher risk of mortality and increased rates of complications such as acute kidney injury and acute respiratory distress syndrome. While much focus has been on increased mortality of cirrhosis in patients with concomitant abdominal solid organ or traumatic brain injury, our study suggests cirrhosis with traumatic lung injury to possibly be an even worse prognosticator.

National analysis of testicular and scrotal trauma in the USA

Background To provide a descriptive analysis of scrotal and testicular trauma in the USA. Additionally, we hypothesized that motorcycle collision would have a higher association with scrotal or testicular trauma and subsequent scrotal or testicular operation, compared to a bicycle collision. Methods The National Trauma Data Bank (2007–2015) was queried to identify adult male patients with scrotal or testicular trauma. A multivariable logistic regression analysis was performed. Results A total of 8,030 patients (0.23%) had scrotal/testicular injury, with 44.6% involved in blunt trauma. A penetrating mechanism occurred in 50.5% of cases, with assault by firearm (75.8%) being the most common. The median age of the patients was 31 years and the median injury severity score was 8. Most had isolated scrotal or testicular trauma (74.5%), with 48.3% requiring scrotal or testicular operation, most commonly repair of laceration (37.3%). Patients involved in a motorcycle collision had higher risk for scrotal/testicular trauma (OR=5.40, CI=4.40–6.61, p=0.0004) and subsequent scrotal/testicular surgery (OR=4.93, CI=3.82–6.36, p=0.0005), compared to bicycle collision. Conclusion Scrotal or testicular trauma is rare but occurs most commonly after assault by firearm. Most patients only have isolated scrotal or testicular trauma, but nearly half require subsequent scrotal or testicular operation. Trauma patients presenting after a motorcycle collision have a higher association of scrotal or testicular trauma and subsequent surgery when compared to those involved in a bicycle collision.

Black Race and Body Mass Index Are Risk Factors for Rhabdomyolysis and Acute Kidney Injury in Trauma

Abstract Purpose: Obesity has been shown in a single-center study to be a risk factor for rhabdomyolysis. More recently, sickle cell trait, known to be more prevalent in blacks, has been shown to be a risk factor for rhabdomyolysis. We hypothesized that in trauma patients, black race and a higher body mass index (BMI) are associated with risk for rhabdomyolysis and acute kidney injury (AKI). Materials and Methods: The National Trauma Data Bank (NTDB) was queried (2013–2015) to identify patients age ≥18 years and grouped by BMI: normal (18.5–24.99 kg/m2), underweight (16.5–18.49 kg/m2), overweight (25–29.99 kg/m2), obese (30–34.99 kg/m2), severely obese (35–39.99 kg/m2), and morbidly obese (≥40 kg/m2). A multivariable logistic regression model was used to assess whether a higher BMI or black race was associated with rhabdomyolysis or AKI. Results: After adjusting for covariates, severe obesity (odds ratio (OR) = 1.42, confidence interval (CI) = 1.01–1.99, p < .001), morbid obesity (OR = 1.46, CI = 1.04–2.06, p < .001), and black race (OR = 1.52, CI = 1.24–1.88, p < .001) were associated with higher risk for rhabdomyolysis. Patients that were overweight (OR = 1.17, CI = 1.11–1.24, p < .001), obese (OR = 1.32, CI = 1.24–1.41, p < .001), severely obese (OR = 1.72, CI = 1.59–1.86, p < .001), morbidly obese (OR = 1.77, CI = 1.64–1.92, p < .001), or black (OR = 1.31, CI = 1.24–1.38, p < .001) were associated with higher risk for AKI. Conclusions: Black race was associated with an increased risk of rhabdomyolysis as well as AKI in trauma. BMI ≥25 kg/m2 was associated with increased risk for AKI with the morbidly obese having the highest risk. BMI ≥35 kg/m2 was found to be associated with increased risk of rhabdomyolysis. Future studies should investigate the role for routine screening of these high-risk populations and other potential associated factors such as adherence to weight-based fluid resuscitation.

Association of Heparin-Induced Thrombocytopenia With Bacterial Infection in Trauma Patients

Association of Heparin-Induced Thrombocytopenia With Bacterial Infection in Trauma Patients Heparin-induced thrombocytopenia (HIT) is a rare complication that has been reported to occur in 0.36% of trauma patients and is caused by antibody formation to complexes between heparin and platelet-factor 4 (PF4), leading to platelet activation and subsequent thrombosis.1,2 An earlier report demonstrated that PF4 can bind to bacteria, inducing an autoimmune response similar to the major antigen in HIT.3 We hypothesized that trauma patients with HIT have a higher incidence of bacterial infection during their hospitalization compared with patients without HIT. In addition, we provide a descriptive analysis of HIT in trauma patients.

Risk of hysterectomy and salpingectomy or oophorectomy compared to repair after pelvic gynecologic trauma

PurposePelvic gynecologic trauma (PGT) includes injury to the uterus, ovaries or fallopian tubes. We hypothesized Injury Severity Score (ISS) ≥ 25, hypotension on admission and age ≥ 51 (average age for menopause) would be independent risk factors for resection compared to repair.MethodsA retrospective analysis of the National Trauma Data Bank was performed between 2007 and 2015.ResultsOf 2,040,235 female patients, 1938 (< 0.1%) presented with PGT with the majority sustaining injury to the ovary or fallopian tubes (52.9%). Most patients were managed nonoperatively (77.1 vs 22.9%). On multivariable analysis, in patients with injury to the uterus, ISS ≥ 25 (OR 3.52, CI 1.67–7.48, p < 0.05) was associated with higher risk for hysterectomy compared to repair. In patients with injury to the ovaries or fallopian tubes, gunshot wound (OR 3.73, CI 1.43–9.68, p < 0.05) was associated with a higher risk for salpingectomy or oophorectomy compared to repair. Age ≥ 51 and hypotension on admission were not independent risk factors for resection in patients with PGT. Operative treatment was associated with a lower risk for mortality in patients with an injury to the uterus (OR 0.27, CI 0.14–0.51, p < 0.001) or ovaries/fallopian tubes (OR 0.37, CI 0.19–0.72, p < 0.001) compared to those managed nonoperatively.ConclusionIn the largest study reported, PGT occurred in < 0.1% of traumas involving women. Patients with ISS ≥ 25 have higher risk for hysterectomy compared to repair. Gunshot injuries have higher risk for salpingectomy or oophorectomy compared to repair. Hypotension on arrival or age ≥ 51 are not independent risk factors for resection in PGT. Operative management is associated with lower risk of mortality in PGT patients.