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Martin GE, Johnson M, Veile R, Friend LA, Elterman JB, Johannigman JA, Pritts TA, Goodman MD, Makley AT. Effects of Early Altitude Exposure on the Open Abdomen After Laparotomy in Trauma. Mil Med 2020; 184:e460-e467. [PMID: 30839078 DOI: 10.1093/milmed/usz034] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/28/2018] [Revised: 10/25/2018] [Accepted: 02/12/2019] [Indexed: 11/14/2022] Open
Abstract
INTRODUCTION While damage control surgery and resuscitation techniques have revolutionized the care of injured service members who sustain severe traumatic hemorrhage, the physiologic and inflammatory consequences of hemostatic resuscitation and staged abdominal surgery in the face of early aeromedical evacuation (AE) have not been investigated. We hypothesized that post-injury AE with an open abdomen would have significant physiologic and inflammatory consequences compared to AE with a closed abdomen. MATERIALS AND METHODS Evaluation of resuscitation and staged abdominal closure was performed using a murine model of hemorrhagic shock with laparotomy. Mice underwent controlled hemorrhage to a systolic blood pressure of 25 mmHg and received either no resuscitation, blood product resuscitation, or Hextend resuscitation to a systolic blood pressure of either 50 mmHg (partial resuscitation) or 80 mmHg (complete resuscitation). Laparotomies were either closed prior to AE (closed abdomens) or left open during AE (open abdomens) and subsequently closed. AE was simulated with a 1-hour exposure to a hypobaric hypoxic environment at 8,000 feet altitude. Mice were euthanized at 0, 4, or 24 hours following AE. Serum was collected and analyzed for physiologic variables and inflammatory cytokine levels. Samples of lung and small intestine were collected for tissue cytokine and myeloperoxidase analysis as indicators of intestinal inflammation. Survival curves were also performed. RESULTS Unresuscitated mice sustained an 85% mortality rate from hemorrhage and laparotomy, limiting the assessment of the effect of simulated AE in these subgroups. Overall survival was similar among all resuscitated groups regardless of the presence of hypobaric hypoxia, type of resuscitation, or abdominal closure status. Simulated AE had no observed effects on acid/base imbalance or the inflammatory response as compared to ground level controls. All mice experienced both metabolic acidosis and an acute inflammatory response after hemorrhage and injury, represented by an initial increase in serum interleukin (IL)-6 levels. Furthermore, mice with open abdomens had an elevated inflammatory response with increased levels of serum IL-10, serum tumor necrosis factor alpha, intestinal IL-6, intestinal IL-10, and pulmonary myeloperoxidase. CONCLUSION These results demonstrate the complex interaction of AE and temporary or definitive abdominal closure after post-injury laparotomy. Contrary to our hypothesis, we found that AE in those animals with open abdomens is relatively safe with no difference in mortality compared to those with closed abdomens. However, given the physiologic and inflammatory changes observed in animals with open abdomens, further evaluation is necessary prior to definitive recommendations regarding the safety or downstream effects of exposure to AE prior to definitive abdominal closure.
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Affiliation(s)
- Grace E Martin
- Department of Surgery, College of Medicine, University of Cincinnati, Section of General Surgery, OH.,Department of Surgery, Institute for Military Medicine, University of Cincinnati, 231 Albert Sabin Way, Cincinnati, OH
| | - Mark Johnson
- Department of Surgery, College of Medicine, University of Cincinnati, Section of General Surgery, OH.,Department of Surgery, Institute for Military Medicine, University of Cincinnati, 231 Albert Sabin Way, Cincinnati, OH
| | - Rose Veile
- Department of Surgery, College of Medicine, University of Cincinnati, Section of General Surgery, OH.,Department of Surgery, Institute for Military Medicine, University of Cincinnati, 231 Albert Sabin Way, Cincinnati, OH
| | - Lou Ann Friend
- Department of Surgery, College of Medicine, University of Cincinnati, Section of General Surgery, OH.,Department of Surgery, Institute for Military Medicine, University of Cincinnati, 231 Albert Sabin Way, Cincinnati, OH
| | - Joel B Elterman
- Department of Surgery, College of Medicine, University of Cincinnati, Section of General Surgery, OH.,Department of Surgery, Institute for Military Medicine, University of Cincinnati, 231 Albert Sabin Way, Cincinnati, OH
| | - Jay A Johannigman
- Department of Surgery, College of Medicine, University of Cincinnati, Section of General Surgery, OH.,Department of Surgery, Institute for Military Medicine, University of Cincinnati, 231 Albert Sabin Way, Cincinnati, OH
| | - Timothy A Pritts
- Department of Surgery, College of Medicine, University of Cincinnati, Section of General Surgery, OH.,Department of Surgery, Institute for Military Medicine, University of Cincinnati, 231 Albert Sabin Way, Cincinnati, OH
| | - Michael D Goodman
- Department of Surgery, College of Medicine, University of Cincinnati, Section of General Surgery, OH.,Department of Surgery, Institute for Military Medicine, University of Cincinnati, 231 Albert Sabin Way, Cincinnati, OH
| | - Amy T Makley
- Department of Surgery, College of Medicine, University of Cincinnati, Section of General Surgery, OH.,Department of Surgery, Institute for Military Medicine, University of Cincinnati, 231 Albert Sabin Way, Cincinnati, OH
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Cardi M, Ibrahim K, Alizai SW, Mohammad H, Garatti M, Rainone A, Di Marzo F, La Torre G, Paschetto M, Carbonari L, Mingarelli V, Mingoli A, Sica GS, Sibio S. Injury patterns and causes of death in 953 patients with penetrating abdominal war wounds in a civilian independent non-governmental organization hospital in Lashkargah, Afghanistan. World J Emerg Surg 2019; 14:51. [PMID: 31832085 PMCID: PMC6868865 DOI: 10.1186/s13017-019-0272-z] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/17/2019] [Accepted: 10/17/2019] [Indexed: 11/10/2022] Open
Abstract
Background Management of penetrating abdominal war injuries centers upon triage, echeloned care, and damage control. A civilian hospital based in a war zone can rarely rely upon these principles because it normally has limited resources and lacks rapid medical evacuation. We designed this study to describe organ injury patterns and factors related to mortality in patients with penetrating abdominal war injuries in a civilian hospital in an active war zone in Afghanistan, examine how these findings differ from those in a typical military setting, and evaluate how they might improve patients’ care. Methods We reviewed the records of all patients admitted at the Lashkargah “Emergency” hospital with penetrating abdominal injuries treated from January 2006 to December 2016. Demographic and clinical data were recorded; univariate and multivariate analyses were used to identify variables significantly associated with death. Results We treated 953 patients for penetrating abdominal injury. The population was mainly civilian (12.1% women and 21% under 14). Mean age was 23 years, and patients with blast injuries were younger than in the other groups. The mechanism of injury was bullet injury in 589 patients, shell injury in 246, stab wound in 97, and mine injury in 21. The most frequent abdominal lesion was small bowel injury (46.3%). Small and large bowel injuries were the most frequent in the blast groups, stomach injury in stab wounds. Overall mortality was 12.8%. Variables significantly associated with death were age > 34 years, mine and bullet injury, length of stay, time since injury > 5 h, injury severity score > 17, and associated injuries. Conclusions Epidemiology and patterns of injury in a civilian hospital differ from those reported in a typical military setting. Our population is mainly civilian with a significant number of women and patients under 14 years. BI are more frequent than blast injuries, and gastrointestinal injuries are more common than injuries to solid organs. In this austere setting, surgeons need to acquire a wide range of skills from multiple surgical specialties. These findings might guide trauma and general surgeons treating penetrating abdominal war wounds to achieve better care and outcome.
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Affiliation(s)
- Maurizio Cardi
- Emergency NGO Medical Division, Lashkargah Hospital, Lashkargah, Afghanistan.,2Dipartimento di Chirurgia "P. Valdoni", Sapienza Università di Roma, Viale del Policlinico155, 00161 Rome, Italy
| | - Khushal Ibrahim
- Emergency NGO Medical Division, Lashkargah Hospital, Lashkargah, Afghanistan
| | - Shah Wali Alizai
- Emergency NGO Medical Division, Lashkargah Hospital, Lashkargah, Afghanistan
| | - Hamayoun Mohammad
- Emergency NGO Medical Division, Lashkargah Hospital, Lashkargah, Afghanistan
| | - Marco Garatti
- Emergency NGO Medical Division, Lashkargah Hospital, Lashkargah, Afghanistan.,Chirurgia Generale, Fondazione Poliambulanza, Istituto Ospedaliero, Via Bissolati 57, Brescia, Italy
| | - Antonio Rainone
- Emergency NGO Medical Division, Lashkargah Hospital, Lashkargah, Afghanistan
| | - Francesco Di Marzo
- 4Chirurgia Generale, Ospedale Versilia, Via Aurelia 335, 55041 Lido di Camaiore, LU Italy
| | - Giuseppe La Torre
- 5Dipartimento di Sanità Pubblica e Malattie Infettive, Sapienza Università di Roma, Viale del Policlinico155, 00161 Rome, Italy
| | - Michela Paschetto
- Emergency NGO Medical Division, Lashkargah Hospital, Lashkargah, Afghanistan
| | - Ludovica Carbonari
- 2Dipartimento di Chirurgia "P. Valdoni", Sapienza Università di Roma, Viale del Policlinico155, 00161 Rome, Italy
| | - Valentina Mingarelli
- 2Dipartimento di Chirurgia "P. Valdoni", Sapienza Università di Roma, Viale del Policlinico155, 00161 Rome, Italy
| | - Andrea Mingoli
- 2Dipartimento di Chirurgia "P. Valdoni", Sapienza Università di Roma, Viale del Policlinico155, 00161 Rome, Italy
| | - Giuseppe S Sica
- 6Dipartimento di Chirurgia, Università Tor Vergata, Viale Oxford 81, 00133 Rome, Italy
| | - Simone Sibio
- Emergency NGO Medical Division, Lashkargah Hospital, Lashkargah, Afghanistan
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Abstract
OBJECTIVE To determine utilization and accuracy of focused assessment with sonography for trauma (FAST) and computed tomography (CT) in a mature military trauma system to inform service provision for future conflicts. BACKGROUND FAST and CT scans undertaken by attending radiologists contribute to surgical decision making for battlefield casualties at the Joint Force, Role 3 Medical Treatment Facility at Camp Bastion (R3), Afghanistan. METHODS Registry data for abdominally injured casualties treated at R3 from July to November 2012 were matched to radiological and surgical records to determine diagnostic accuracy for FAST and CT and their influence on casualty management. RESULTS A total of 468 casualties met inclusion criteria, of whom 85.0% underwent FAST and 86.1% abdominal CT; 159 (34.0%) had abdominal injuries. For detection of intra-abdominal injury, FAST sensitivity (Sn) was 0.56, specificity (Sp) 0.98, positive predictive value (PPV) 0.87, negative predictive value (NPV) 0.90, and accuracy (Acc) 0.89. For CT, Sn was 0.99, Sp 0.99, PPV 0.96, NPV 1.00, and Acc 0.99. Forty-six solid organ injuries were identified in 38 patients by CT; 17 were managed nonoperatively. A further 61 patients avoided laparotomy after CT confirmed extra-abdominal wounds only. The negative laparotomy rate was 3.9%. CONCLUSIONS FAST and CT contribute to triage, guide surgical management, and reduce nontherapeutic laparotomy. When imaging is available, these data challenge current doctrine about inadvisability of nonoperative management of abdominal injury after combat trauma.
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A Prospective Observational Study of Abdominal Injury Management in Contemporary Military Operations. Ann Surg 2015; 261:765-73. [DOI: 10.1097/sla.0000000000000657] [Citation(s) in RCA: 28] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
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Watson JDB, Aden JK, Engel JE, Rasmussen TE, Glasgow SC. Risk factors for colostomy in military colorectal trauma: A review of 867 patients. Surgery 2014; 155:1052-61. [DOI: 10.1016/j.surg.2014.01.010] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/03/2013] [Accepted: 01/31/2014] [Indexed: 10/25/2022]
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Turégano-Fuentes F, Pérez-Diaz D, Sanz-Sánchez M, Alfici R, Ashkenazi I. Abdominal blast injuries: different patterns, severity, management, and prognosis according to the main mechanism of injury. Eur J Trauma Emerg Surg 2014; 40:451-60. [PMID: 26816240 DOI: 10.1007/s00068-014-0397-4] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/16/2014] [Accepted: 03/17/2014] [Indexed: 11/30/2022]
Abstract
PURPOSE To review the frequency, different patterns, anatomic severity, management, and prognosis of abdominal injuries in survivors of explosions, according to the main mechanism of injury. METHODS A MEDLINE search was conducted from January 1982 to August 2013, including the following MeSH terms: blast injuries, abdominal injuries. EMBASE was also searched, with the same entries. Abdominal blast injuries (ABIs) have been defined as injuries resulting not only from the effects of the overpressure on abdominal organs, but also from the multimechanistic effects and projectile fragments resulting from the blast. Special emphasis was placed on the detailed assessment of ABIs in patients admitted to GMUGH (Gregorio Marañón University General Hospital) after the Madrid 2004 terrorist bombings, and in patients admitted to HYMC (Hillel Yaffe Medical Centre) in Hadera (Israel) following several bombing episodes. The anatomic severity of injuries was assessed by the abdominal component of the AIS, and the overall anatomic severity of casualties was assessed by means of the NISS. RESULTS Abdominal injuries are not common in survivors of terrorist explosions, although they are a frequent finding in those immediately killed. Primary and tertiary blast injuries have predominated in survivors from explosions in enclosed spaces reported outside of Israel. In contrast, secondary blast injuries causing fragmentation wounds were predominant in suicide bombings in open and/or semi-confined spaces, mainly in Israel, and also in military conflicts. Multiple perforations of the ileum seem to be the most common primary blast injury to the bowel, but delayed bowel perforations are rare. Secondary blast injuries carry the highest anatomic severity and mortality rate. Most of the deaths assessed occurred early, with hemorrhagic shock from penetrating fragments as the main contributing factor. The negative laparotomy rate has been very variable, with higher rates reported, in general, from civilian hospitals attending a large number of casualties. CONCLUSIONS The pattern, severity, management, and prognosis of ABI vary considerably, in accordance with the main mechanism of injury.
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Affiliation(s)
- F Turégano-Fuentes
- General and Emergency Surgery Service, University General Hospital Gregorio Marañón, Madrid, Spain.
| | - D Pérez-Diaz
- General and Emergency Surgery Service, University General Hospital Gregorio Marañón, Madrid, Spain.
| | - M Sanz-Sánchez
- General and Emergency Surgery Service, University General Hospital Gregorio Marañón, Madrid, Spain.
| | - R Alfici
- General Surgery B Service, Hillel Yaffe Medical Centre, Hadera, Israel.
| | - I Ashkenazi
- General Surgery B Service, Hillel Yaffe Medical Centre, Hadera, Israel
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Sharrock AE, Midwinter M. Damage control - trauma care in the first hour and beyond: a clinical review of relevant developments in the field of trauma care. Ann R Coll Surg Engl 2013; 95:177-83. [PMID: 23827287 DOI: 10.1308/003588413x13511609958253] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022] Open
Abstract
INTRODUCTION Trauma provision in the UK is a topic of interest. Regional trauma networks and centres are evolving and research is blossoming, but what bearing does all this have on the care that is delivered to the individual patient? This article aims to provide an overview of key research concepts in the field of trauma care, to guide the clinician in decision making in the management of major trauma. METHODS The Ovid MEDLINE(®), EMBASE™ and PubMed databases were used to search for relevant articles on haemorrhage control, damage control resuscitation and its exceptions, massive transfusion protocols, prevention and correction of coagulopathy, acidosis and hypothermia, and damage-control surgery. FINDINGS A wealth of research is available and a broad range has been reviewed to summarise significant developments in trauma care. Research has been categorised into disciplines and it is hoped that by considering each, a tailored management plan for the individual trauma patient will evolve, potentially improving patient outcome.
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Affiliation(s)
- A E Sharrock
- Vascular Surgery Department, Salisbury District Hospital, Odstock Road, Salisbury, Wiltshire, SP2 8BJ, UK.
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