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Noorbakhsh S, Wagner V, Arientyl V, Orlin S, Koganti D, Fransman RB, Bishop ES, Castater CA, Nguyen J, De Leon Castro A, Davis MA, Smith RN, Todd SR, Sciarretta JD. Pancreaticoduodenectomy in high-grade pancreatic and duodenal trauma. Injury 2024; 55:111721. [PMID: 39084919 DOI: 10.1016/j.injury.2024.111721] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/21/2024] [Revised: 06/07/2024] [Accepted: 07/05/2024] [Indexed: 08/02/2024]
Abstract
INTRODUCTION High-grade pancreaticoduodenal injuries are highly morbid and may require complex surgical management. Pancreaticoduodenectomy (Whipple procedure) is sometimes utilized in the management of these injuries, but guidelines on its use are lacking. This paper aims to present our 14-year experience in management of high-grade pancreaticoduodenal injuries at our busy, urban trauma center. METHODS A retrospective review was performed on patients (ages >15 years) presenting with high-grade (AAST-OIS Grades IV and V) injuries to the pancreas or duodenum at our Southeastern Level 1 trauma center. Inclusion criteria included high-grade injury and requirement of Whipple procedure based on surgeon discretion. Patients were divided into two groups: (1) those who underwent Whipple procedures during the index operation and (2) Whipple candidates. Whipple candidates included patients who received Whipples in a staged fashion or who would have benefited from the procedure but either died or were salvaged to another procedure. Demographics, injury patterns, management, and outcomes were compared. Primary outcome was survival to discharge. RESULTS Of 66,272 trauma patients in this study period, 666 had pancreatic or duodenal injuries, and 20 met inclusion criteria. Of these, 6 had Whipples on the index procedure and 14 were Whipple candidates (among whom 7 had staged Whipples, 6 died before completing a Whipple, and 1 was salvaged). Median (IQR) age was 28 (22.75-40) years. Patients were 85 % male, 70 % Black. GSWs comprised 95 % of injuries. All patients had at least one concomitant injury, most commonly major vascular injury (75 %), colonic injury (65 %), and hepatic injury (60 %). In-hospital mortality among Whipple patients was 15 %. CONCLUSIONS Complex pancreaticoduodenal injuries requiring pancreaticoduodenectomy are rare but life-threatening. In such patients, hemorrhage was the leading cause of death in the first 24 h. Approximately half underwent damage control surgery with staged Whipple Procedures. However, pancreaticoduodenectomy at the initial operation is feasible in highly selective patients, depending on the extent of injury, physiologic status, and resuscitation.
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Affiliation(s)
- Soroosh Noorbakhsh
- Emory University School of Medicine, 2015 Uppergate Dr, Atlanta, GA, 30307, United States; Grady Memorial Hospital, 80 Jesse Hill Jr Dr SE, Atlanta, GA, 30303, United States.
| | - Victoria Wagner
- Emory University School of Medicine, 2015 Uppergate Dr, Atlanta, GA, 30307, United States; Grady Memorial Hospital, 80 Jesse Hill Jr Dr SE, Atlanta, GA, 30303, United States
| | - Vanessa Arientyl
- Emory University School of Medicine, 2015 Uppergate Dr, Atlanta, GA, 30307, United States; Grady Memorial Hospital, 80 Jesse Hill Jr Dr SE, Atlanta, GA, 30303, United States
| | - Stormy Orlin
- Mercer University School of Medicine, 1550 College St, Macon, GA, 31207, United States
| | - Deepika Koganti
- Emory University School of Medicine, 2015 Uppergate Dr, Atlanta, GA, 30307, United States; Grady Memorial Hospital, 80 Jesse Hill Jr Dr SE, Atlanta, GA, 30303, United States
| | - Ryan B Fransman
- Emory University School of Medicine, 2015 Uppergate Dr, Atlanta, GA, 30307, United States; Grady Memorial Hospital, 80 Jesse Hill Jr Dr SE, Atlanta, GA, 30303, United States
| | - Elliot S Bishop
- Emory University School of Medicine, 2015 Uppergate Dr, Atlanta, GA, 30307, United States; Grady Memorial Hospital, 80 Jesse Hill Jr Dr SE, Atlanta, GA, 30303, United States
| | - Christine A Castater
- Grady Memorial Hospital, 80 Jesse Hill Jr Dr SE, Atlanta, GA, 30303, United States; Morehouse School of Medicine, 720 Westview Dr SW, Atlanta, GA, 30310, United States
| | - Jonathan Nguyen
- Grady Memorial Hospital, 80 Jesse Hill Jr Dr SE, Atlanta, GA, 30303, United States; Morehouse School of Medicine, 720 Westview Dr SW, Atlanta, GA, 30310, United States
| | | | - Millard A Davis
- Emory University School of Medicine, 2015 Uppergate Dr, Atlanta, GA, 30307, United States; Grady Memorial Hospital, 80 Jesse Hill Jr Dr SE, Atlanta, GA, 30303, United States
| | - Randi N Smith
- Emory University School of Medicine, 2015 Uppergate Dr, Atlanta, GA, 30307, United States; Grady Memorial Hospital, 80 Jesse Hill Jr Dr SE, Atlanta, GA, 30303, United States
| | - S Rob Todd
- Grady Memorial Hospital, 80 Jesse Hill Jr Dr SE, Atlanta, GA, 30303, United States
| | - Jason D Sciarretta
- Emory University School of Medicine, 2015 Uppergate Dr, Atlanta, GA, 30307, United States; Grady Memorial Hospital, 80 Jesse Hill Jr Dr SE, Atlanta, GA, 30303, United States
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Anatoliyovych IL, Yuriyovych OU, Valentynovych OH. Surgical treatment features of liver gunshot wound with a dumdum bullet (expanding bullet). Int J Emerg Med 2022; 15:57. [PMID: 36217126 PMCID: PMC9549613 DOI: 10.1186/s12245-022-00460-2] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/01/2022] [Accepted: 09/27/2022] [Indexed: 12/03/2022] Open
Abstract
Introduction Liver injury is one of the most common abdominal traumas. The causes of military activity related injuries are gunshot wounds (up to 60–70%), while in peacetime—closed blunt abdominal trauma (up to 45–55%). The overall mortality is up to 40–60% and has higher rates in the group of wartime injury, among the male population over 65 years old and of low social status. Presentation of the case We report the management of a clinical case of a 34-year-old man with thoracoabdominal dumdum’s bullet trauma in the case of which damage control tactics were applied in cooperation between two clinics in conditions of active hostilities. Discussions Treatment of patients with abdominal injuries should be guided by the principles of damage control. This tactic requires stabilization of the patient's condition at the initial stage, followed by the completion of the final volume of surgical treatment in a compensated state of the patient. Liver injuries represent an ideal model for the application of damage control surgery in wartime settings and require close coordination between clinics that perform primary and delayed surgical interventions. Minimizing the volume of surgical intervention at the stage of primary control of bleeding due to liver damage provides the most optimal immediate results in conditions of a hemodynamically unstable patients, simultaneous admission of a large number of wounded, and a limited clinic resource. Conclusion This surgical history research is an example of the effectively organized and coordinated work of two clinics such as National Military Medical Clinical Center “Main Military Clinical Hospital” and Shalimov National Institute of Surgery and Transplantation, based on the principle of damage control in conditions of active hostilities.
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Affiliation(s)
| | | | - Oleksandr Hrynenko Valentynovych
- National Institute of Surgery and Transplantation named after O.O. Shalimov NAMS of Ukraine, Kyiv, Ukraine. .,Department of Liver Transplantation and Surgery, Shalimov National Institute of Surgery and Transplantation, 30 Heroiv Sevastopolya Str., Kyiv, 03680, Ukraine.
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Luo Y, He X, Geng L, Ouyang R, Xu Y, Liang Y, Wu J, Zhang H, Ye Z, Zou R, Wu Q, Chai C. Diagnosis and treatment of traumatic duodenal rupture in children. BMC Gastroenterol 2022; 22:61. [PMID: 35151250 PMCID: PMC8840068 DOI: 10.1186/s12876-022-02136-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/08/2021] [Accepted: 02/01/2022] [Indexed: 11/10/2022] Open
Abstract
Background The purpose of this study was to investigate the diagnosis and treatment experience of traumatic duodenal ruptures in children. Methods Clinical data were collected from four children suffering from a traumatic duodenal rupture who were admitted to and treated by our hospital from January 2012 to December 2020. The early diagnosis and treatment, surgical plan, postoperative management, complications, and prognosis of each child were analyzed. The key points and difficulties of the diagnosis and treatment for this type of injury are summarized. Results One child had an extreme infection caused by drug-resistant bacteria, which resulted in severe complications, including wound infection, dehiscence, and an intestinal fistula. One child developed an anastomotic stenosis after the duodenostomy, which improved following an endoscopic balloon dilatation. The other two children had no relevant complications after their operations. All four patients were cured and discharged from hospital. The average hospital stay was 48.25 ± 26.89 days. The follow-up period was 0.5 to 1 year. No other complications occurred, and all children had a positive prognosis. Conclusions The early identification of a duodenal rupture is essential, and surgical exploration should be carried out proactively. The principles of damage-control surgery should be followed as much as possible during the operation. Multidisciplinary cooperation and management are both important to reduce the occurrence of postoperative complications and improve cure rates.
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Willms A, Güsgen C, Schwab R, Lefering R, Schaaf S, Lock J, Kollig E, Jänig C, Bieler D. Status quo of the use of DCS concepts and outcome with focus on blunt abdominal trauma : A registry-based analysis from the TraumaRegister DGU®. Langenbecks Arch Surg 2021; 407:805-817. [PMID: 34611749 DOI: 10.1007/s00423-021-02344-0] [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: 04/20/2021] [Accepted: 09/28/2021] [Indexed: 10/20/2022]
Abstract
INTRODUCTION Damage control surgery (DCS) is a standardized treatment concept in severe abdominal injury. Despite its evident advantages, DCS bears the risk of substantial morbidity and mortality, due to open abdomen therapy (OAT). Thus, identifying the suitable patients for that approach is of utmost importance. Furthermore, little is known about the use of DCS and the related outcome, especially in blunt abdominal trauma. METHODS Patients recorded in the TraumaRegister DGU® from 2008 to 2017, and with an Injury Severity Score (ISS) ≥ 9 and an abdominal injury with an Abbreviated Injury Scale (AIS) score ≥ 3 were included in that registry-based analysis. Patients with DCS and temporary abdominal closure (TAC) were compared with patients who were treated with a laparotomy and primary closure (non-DCS) and those who did receive non-operative management (NOM). Following descriptive analysis, a matched-pairs study was conducted to evaluate differences and outcomes between DCS and non-DCS group. Matching criteria were age, abdominal trauma severity, and hemodynamical instability at the scene. RESULTS The injury mechanism was predominantly blunt (87.1%). Of the 8226 patients included, 2351 received NOM, 5011 underwent laparotomy and primary abdominal closure (non-DCS), and 864 were managed with DCS. Thus, 785 patient pairs were analysed. The rate of hepatic injuries AIS > 3 differed between the groups (DCS 50.3% vs. non-DCS 18.1%). DCS patients had a higher ISS (p = 0.023), required more significant volumes of fluids, more catecholamines, and transfusions (p < 0.001). More DCS patients were in shock at the accident scene (p = 0.022). DCS patients had a higher number of severe hepatic (AIS score ≥ 3) and gastrointestinal injuries and more vascular injuries. Most severe abdominal injuries in non-DCS patients were splenic injuries (AIS, 4 and 5) (52.1% versus 37.9%, p = 0.004). CONCLUSION DCS is a strategy used in unstable trauma patients, severe hepatic, gastrointestinal, multiple abdominal injuries, and mass transfusions. The expected survival rates were achieved in such extreme trauma situations.
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Affiliation(s)
- Arnulf Willms
- Department of General, Visceral and Thoracic Surgery, German Armed Forces Central Hospital of Koblenz, Rübenacher Str. 170, 56072, Koblenz, Germany
| | - Christoph Güsgen
- Department of General, Visceral and Thoracic Surgery, German Armed Forces Central Hospital of Koblenz, Rübenacher Str. 170, 56072, Koblenz, Germany.
| | - Robert Schwab
- Department of General, Visceral and Thoracic Surgery, German Armed Forces Central Hospital of Koblenz, Rübenacher Str. 170, 56072, Koblenz, Germany
| | - Rolf Lefering
- Institute for Research in Operative Medicine, Witten/Herdecke University, Cologne, Germany
| | - Sebastian Schaaf
- Department of General, Visceral and Thoracic Surgery, German Armed Forces Central Hospital of Koblenz, Rübenacher Str. 170, 56072, Koblenz, Germany
| | - Johan Lock
- Department of General, Transplantation, Vascular and Paediatric Surgery, University Hospital of Würzburg, VisceralWürzburg, Germany
| | - Erwin Kollig
- Department of Orthopaedics, Trauma Surgery, Reconstructive Surgery, Hand Surgery, Plastic Surgery, and Burn Medicine, German Armed Forces Central Hospital, Koblenz, Germany
| | - Christoph Jänig
- Department of Anesthesiology and Intensive Care, German Armed Forces Central Hospital, Koblenz, Germany
| | - Dan Bieler
- Department of Orthopaedics, Trauma Surgery, Reconstructive Surgery, Hand Surgery, Plastic Surgery, and Burn Medicine, German Armed Forces Central Hospital, Koblenz, Germany.,Department of Orthopaedics and Trauma Surgery, Heinrich Heine University Medical School, Düsseldorf, Germany
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Critical decision points in the management of acute trauma: a practical review. Int Anesthesiol Clin 2021; 59:1-9. [PMID: 33560038 DOI: 10.1097/aia.0000000000000317] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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Bae M, Jeon CH, Kwon H, Kim JH, Choi SU, Song S. Evaluation of Zone 2 Thoracic Endovascular Aortic Repair Performed with and without Prophylactic Embolization of the Left Subclavian Artery in Patients with Traumatic Aortic Injury. Korean J Radiol 2021; 22:577-583. [PMID: 33543841 PMCID: PMC8005354 DOI: 10.3348/kjr.2020.0989] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/06/2020] [Revised: 11/03/2020] [Accepted: 11/10/2020] [Indexed: 11/15/2022] Open
Abstract
OBJECTIVE To report the authors' experience in performing thoracic endovascular aortic repair (TEVAR) for zone 2 lesions after traumatic aortic injury (TAI). MATERIALS AND METHODS This retrospective review included 10 patients who underwent zone 2 TEVAR after identification of aortic isthmus injury by CT angiography (CTA) upon arrival at the emergency room of a regional trauma center from 2016 to 2019. Patients were classified into two groups: those who underwent left subclavian artery (LSA) embolization concurrently with the main TEVAR procedure, and those in whom LSA embolization was not performed during the main procedure, but was planned as a bailout treatment if type II endoleak was noted on follow-up CTA images. Pre-procedural and procedure-related factors and post-procedure prognosis were compared between the groups. RESULTS There were no differences in pre-procedural factors, occurrence of endoleaks, and post-procedure prognosis (including mortality) between patients in the two groups. The duration of the procedure was shorter in the non-LSA embolization group (61 minutes vs. 27 minutes, p = 0.012). During follow-up, type II endoleak did not occur in either group. CONCLUSION Delaying preventative LSA embolization until stabilization of the patient would be desirable when performing zone 2 TEVAR for TAI, in the absence of endoleak on the completion aortography image taken after complete deployment of the stent graft.
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Affiliation(s)
- Miju Bae
- Department of Thoracic and Cardiovascular Surgery, Pusan National University Hospital, Busan, Korea.,Biomedical Research Institute, Pusan National University Hospital, Busan, Korea
| | - Chang Ho Jeon
- Biomedical Research Institute, Pusan National University Hospital, Busan, Korea.,Department of Radiology, Pusan National University Hospital, Busan, Korea.
| | - Hoon Kwon
- Biomedical Research Institute, Pusan National University Hospital, Busan, Korea.,Department of Radiology, Pusan National University Hospital, Busan, Korea
| | - Jin Hyeok Kim
- Department of Radiology, Pusan National University Yangsan Hospital, Yangsan, Korea
| | - Seon Uoo Choi
- Department of Thoracic and Cardiovascular Surgery, Kosin University Gospel Hospital, Kosin University College of Medicine, Busan, Korea
| | - Seunghwan Song
- Department of Thoracic and Cardiovascular Surgery, Pusan National University Hospital, Busan, Korea.,Biomedical Research Institute, Pusan National University Hospital, Busan, Korea
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Dattatri R, Jain VK, Iyengar K, Vaishya R, Garg R. Anaesthetic considerations in polytrauma patients. J Clin Orthop Trauma 2021; 12:50-57. [PMID: 33716428 PMCID: PMC7920205 DOI: 10.1016/j.jcot.2020.10.022] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/29/2020] [Revised: 10/09/2020] [Accepted: 10/12/2020] [Indexed: 02/07/2023] Open
Abstract
Trauma remains a major public health concern due to the high cost, associated morbidity, and mortality both in developed and developing countries. Management of polytrauma patients has advanced and improved over the last few decades with a better understanding of the pathophysiology of shock, resuscitation, and hemodynamic changes. Anaesthesia and application of anaesthetic principles have consequently evolved and can be applied in polytrauma patients throughout their journey of treatment beginning from pre-hospital care, emergency department resuscitation, surgical procedures, and rehabilitation. Providing immediate pain relief is an important component in the management of these patients. Performing peripheral nerve blocks in the pre-hospital setting when feasible or on arrival in the emergency room provides rapid pain relief, better patient co-operation, decreases the risk of chronic pain syndromes. This narrative evaluates the role of anaesthesia and anaesthesiologists in the management of polytrauma patients. The authors performed a thorough review of the literature using various databased of Medline, PubMed, Embase, and Google Scholar. The relevant papers were also searched manually from the cross-referencing of retrieved papers. Full papers published in English till September 25, 2020 were included for this review. The keywords included 'trauma', 'difficult airway', 'anaesthesia', 'fluid and blood', 'monitoring', 'critical care', 'resuscitation' and 'surgery' in various combinations. The holistic management of trauma victims requires a multidisciplinary time-based approach for an optimal outcome. The management starts from assessment and simultaneous management for the optimization of the trauma victim from the first point of contact itself. The anaesthetic technique of choice in the perioperative management of trauma patients depends on different factors such as neurological status, cardiovascular stability, type and duration of surgery, coagulation status. Regional techniques are to be used whenever possible due to the beneficial effects observed with these techniques. Various important aspects are being discussed in subsequent sections.
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Affiliation(s)
- Rohini Dattatri
- Department of Onco-Anaesthesiology and Palliative Medicine, Dr BRAIRCH, All India Institute of Medical Sciences, New Delhi, 110029, India
| | - Vijay Kumar Jain
- Department of Orthopaedics, Atal Bihari Vajpayee Institute of Medical Sciences, Dr Ram Manohar Lohia Hospital, New Delhi, 110001, India
| | | | - Raju Vaishya
- Department of Orthopaedics, Indraprastha Apollo Hospital, Sarita Vihar, Mathura Road, New Delhi, 110076, India
| | - Rakesh Garg
- Department of Onco-Anaesthesia and Palliative Medicine, Dr BRAIRCH, All India Institute of Medical Sciences, New Delhi, 110029, India
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Asim M, Amin F, El-Menyar A. Multiple organ dysfunction syndrome: Contemporary insights on the clinicopathological spectrum. Qatar Med J 2020; 2020:22. [PMID: 33628712 PMCID: PMC7884906 DOI: 10.5339/qmj.2020.22] [Citation(s) in RCA: 14] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/05/2020] [Accepted: 03/03/2020] [Indexed: 12/27/2022] Open
Abstract
Multiorgan dysfunction syndrome (MODS) remains a major complication and challenge to treat patients with critical illness in different intensive care unit settings. The exact mechanism and pathophysiology of MODS is complex and remains unexplored. We reviewed the literature from January 2011 to August 2019 to analyze the underlying mechanisms, prognostic factors, MODS scoring systems, organ systems dysfunctions, and the management of MODS. We used the search engines PubMed, MEDLINE, Scopus, and Google Scholar with the keywords "multiple organ dysfunction syndrome," "intensive care units," "multiorgan failure," "MODS scoring system," and "MODS management." The initial search yielded 3550 abstracts, of which 91 articles were relevant to the scope of the present article. A better understanding of a disease course will help differentiate the signs of an intense inflammatory response from the early onset of sepsis and minimize the inappropriate use of medications. This, in turn, will promote organtargeted therapy and prevent occurrence and progression of MODS.
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Affiliation(s)
- Mohammad Asim
- Department of Surgery, Clinical Research, Trauma Surgery Section, Hamad General Hospital, Doha, Qatar
| | - Farhana Amin
- Sri Ramaswamy Memorial Medical College Hospital & Research Center, Tamil Nadu, India
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Spahn DR, Bouillon B, Cerny V, Duranteau J, Filipescu D, Hunt BJ, Komadina R, Maegele M, Nardi G, Riddez L, Samama CM, Vincent JL, Rossaint R. The European guideline on management of major bleeding and coagulopathy following trauma: fifth edition. Crit Care 2019; 23:98. [PMID: 30917843 PMCID: PMC6436241 DOI: 10.1186/s13054-019-2347-3] [Citation(s) in RCA: 699] [Impact Index Per Article: 139.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/12/2018] [Accepted: 02/06/2019] [Indexed: 12/24/2022] Open
Abstract
BACKGROUND Severe traumatic injury continues to present challenges to healthcare systems around the world, and post-traumatic bleeding remains a leading cause of potentially preventable death among injured patients. Now in its fifth edition, this document aims to provide guidance on the management of major bleeding and coagulopathy following traumatic injury and encourages adaptation of the guiding principles described here to individual institutional circumstances and resources. METHODS The pan-European, multidisciplinary Task Force for Advanced Bleeding Care in Trauma was founded in 2004, and the current author group included representatives of six relevant European professional societies. The group applied a structured, evidence-based consensus approach to address scientific queries that served as the basis for each recommendation and supporting rationale. Expert opinion and current clinical practice were also considered, particularly in areas in which randomised clinical trials have not or cannot be performed. Existing recommendations were re-examined and revised based on scientific evidence that has emerged since the previous edition and observed shifts in clinical practice. New recommendations were formulated to reflect current clinical concerns and areas in which new research data have been generated. RESULTS Advances in our understanding of the pathophysiology of post-traumatic coagulopathy have supported improved management strategies, including evidence that early, individualised goal-directed treatment improves the outcome of severely injured patients. The overall organisation of the current guideline has been designed to reflect the clinical decision-making process along the patient pathway in an approximate temporal sequence. Recommendations are grouped behind the rationale for key decision points, which are patient- or problem-oriented rather than related to specific treatment modalities. While these recommendations provide guidance for the diagnosis and treatment of major bleeding and coagulopathy, emerging evidence supports the author group's belief that the greatest outcome improvement can be achieved through education and the establishment of and adherence to local clinical management algorithms. CONCLUSIONS A multidisciplinary approach and adherence to evidence-based guidance are key to improving patient outcomes. If incorporated into local practice, these clinical practice guidelines have the potential to ensure a uniform standard of care across Europe and beyond and better outcomes for the severely bleeding trauma patient.
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Affiliation(s)
- Donat R. Spahn
- Institute of Anaesthesiology, University of Zurich and University Hospital Zurich, Raemistrasse 100, CH-8091 Zurich, Switzerland
| | - Bertil Bouillon
- Department of Trauma and Orthopaedic Surgery, Cologne-Merheim Medical Centre (CMMC), University of Witten/Herdecke, Ostmerheimer Strasse 200, D-51109 Cologne, Germany
| | - Vladimir Cerny
- Department of Anaesthesiology, Perioperative Medicine and Intensive Care, J.E. Purkinje University, Masaryk Hospital, Usti nad Labem, Socialni pece 3316/12A, CZ-40113 Usti nad Labem, Czech Republic
- Centre for Research and Development, University Hospital Hradec Kralove, Hradec Kralove, Czech Republic, Sokolska 581, CZ-50005 Hradec Kralove, Czech Republic
- Department of Anaesthesiology and Intensive Care Medicine, Faculty of Medicine in Hradec Kralove, Charles University, Simkova 870, CZ-50003 Hradec Kralove, Czech Republic
- Department of Anaesthesia, Pain Management and Perioperative Medicine, QE II Health Sciences Centre, Dalhousie University, Halifax, 10 West Victoria, 1276 South Park St, Halifax, NS B3H 2Y9 Canada
| | - Jacques Duranteau
- Department of Anaesthesia and Intensive Care, Hôpitaux Universitaires Paris Sud, University of Paris XI, Faculté de Médecine Paris-Sud, 78 rue du Général Leclerc, F-94275 Le Kremlin-Bicêtre Cedex, France
| | - Daniela Filipescu
- Department of Cardiac Anaesthesia and Intensive Care, C. C. Iliescu Emergency Institute of Cardiovascular Diseases, Sos Fundeni 256-258, RO-022328 Bucharest, Romania
| | - Beverley J. Hunt
- King’s College and Departments of Haematology and Pathology, Guy’s and St Thomas’ NHS Foundation Trust, Westminster Bridge Road, London, SE1 7EH UK
| | - Radko Komadina
- Department of Traumatology, General and Teaching Hospital Celje, Medical Faculty Ljubljana University, SI-3000 Celje, Slovenia
| | - Marc Maegele
- Department of Trauma and Orthopaedic Surgery, Cologne-Merheim Medical Centre (CMMC), Institute for Research in Operative Medicine (IFOM), University of Witten/Herdecke, Ostmerheimer Strasse 200, D-51109 Cologne, Germany
| | - Giuseppe Nardi
- Department of Anaesthesia and ICU, AUSL della Romagna, Infermi Hospital Rimini, Viale Settembrini, 2, I-47924 Rimini, Italy
| | - Louis Riddez
- Department of Surgery and Trauma, Karolinska University Hospital, S-171 76 Solna, Sweden
| | - Charles-Marc Samama
- Hotel-Dieu University Hospital, 1, place du Parvis de Notre-Dame, F-75181 Paris Cedex 04, France
| | - Jean-Louis Vincent
- Department of Intensive Care, Erasme University Hospital, Université Libre de Bruxelles, Route de Lennik 808, B-1070 Brussels, Belgium
| | - Rolf Rossaint
- Department of Anaesthesiology, University Hospital Aachen, RWTH Aachen University, Pauwelsstrasse 30, D-52074 Aachen, Germany
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Smith SE, Hamblin SE, Dennis BM. Effect of Neuromuscular Blocking Agents on Sedation Requirements in Trauma Patients with an Open Abdomen. Pharmacotherapy 2019; 39:271-279. [PMID: 30672000 DOI: 10.1002/phar.2225] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/31/2023]
Abstract
The appropriate level of sedation in patients with an open abdomen following damage control laparotomy (DCL) is debated. Chemical paralysis with neuromuscular blocking agents (NMBAs) has been used to decrease time to abdominal closure. We sought to evaluate the effect of NMBA use on sedation requirements in patients with an open abdomen and to determine the effect of sedation on patient outcomes. A retrospective cohort study was conducted at an American College of Surgeons' verified level 1 trauma center. Adult trauma patients who underwent DCL between 2009 and 2015 were included. Patients with an intensive care unit length of stay of less than 48 hours and those who died before abdominal closure were excluded. The NMBA+ group received continuous NMBA within 24 hours of DCL; the NMBA- group did not. The primary outcome was cumulative sedation dose during the 7 days following DCL. Secondary outcomes included Richmond Agitation-Sedation Scale (RASS) score, mechanical ventilation-free days, and delirium-coma-free days. Delirium-coma-free days were analyzed with linear regression. A total of 222 patients were included (NMBA+ 125; NMBA- 97). Demographics were similar between groups including age, Injury Severity Score, and mechanism of injury. The median time to closure in the overall cohort was 2 days (interquartile range [IQR] 1-2 days). Propofol and fentanyl were the primary sedatives used. The NMBA+ group received higher cumulative doses of propofol (NMBA+ 5405 mg, IQR 3103-10,573 mg; NMBA- 3601 mg, IQR 1605-6887 mg; p=0.007), but not of fentanyl. Time to abdominal closure, but not NMBA use, was associated with a higher cumulative propofol dose on multivariate analysis. The NMBA+ group had significantly lower RASS scores on the first 3 days following DCL. Mechanical ventilation-free days (NMBA+ 20 days vs NMBA- 18 days, p=0.960) and delirium-coma-free days (NMBA+ 18 days vs NMBA- 18 days, p=0.610) were similar between the groups. On linear regression, cumulative propofol dose was associated with fewer delirium-coma-free days (β-coefficient -0.007, 95% confidence interval -0.015 to -0.003). In trauma patients managed with DCL, higher cumulative sedative doses were administered in patients who received adjunctive NMBA, although NMBA therapy was not associated with a higher cumulative propofol dose on multivariate analysis. Consideration must be given to the potential effect of sedation on delirium and awakening following DCL.
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Affiliation(s)
- Susan E Smith
- Department of Pharmaceutical Services, Vanderbilt University Medical Center, Nashville, Tennessee
| | - Susan E Hamblin
- Department of Pharmaceutical Services, Vanderbilt University Medical Center, Nashville, Tennessee
| | - Bradley M Dennis
- Division of Trauma and Surgical Critical Care, Vanderbilt University Medical Center, Nashville, Tennessee
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Madani T, El Alouani EM, Mhammdi Y, Kharmaz M, El Ouadghiri M, Lahlou A, Omar LM, El Bardouni A, Mahfoud M, Berrada MS. [Role of Trauma Damage Control Orthopaedic in polytraumas: a case of pelvic disjunction associated with hip dislocation with vascular injury]. Pan Afr Med J 2017; 27:122. [PMID: 28904652 PMCID: PMC5567943 DOI: 10.11604/pamj.2017.27.122.8699] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/22/2015] [Accepted: 04/03/2016] [Indexed: 11/14/2022] Open
Abstract
La connaissance de la physiopathologie du traumatisé grave et les conséquences hémodynamiques et inflammatoires de la prise en charge chirurgicale initiale a amené de nombreux chirurgiens à modifier leur approche du traitement des polytraumatisé graves avec lésions du bassin ou des membres en intégrant les principes d'un traitement séquentiel ou Trauma Damage Control Orthopédique (TDCO).Nous rapportons le cas d'une patiente victime d'un accident de la voie publique, admise dans un tableau d'état de choc avec un disjonction du bassin associée à une luxation de la hanche compliquée d'une lésion vasculaire du même membre. Nous avons agit selon les concepts du TDCO en privilégiant une fixation externe du bassin après réduction de la luxation. La rapidité de notre conduite a permis une revascularisation précoce du membre tout en évitant les complications hémodynamiques et inflammatoires de la chirurgie à ciel ouvert.
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Affiliation(s)
- Tarik Madani
- Service de Chirurgie Orthopédique et Traumatologique du Centre Hospitalier Universitaire de Rabat, Maroc
| | - El Mehdi El Alouani
- Service de Chirurgie Orthopédique et Traumatologique du Centre Hospitalier Universitaire de Rabat, Maroc
| | - Younes Mhammdi
- Service de Chirurgie Orthopédique et Traumatologique du Centre Hospitalier Universitaire de Rabat, Maroc
| | - Mohammed Kharmaz
- Service de Chirurgie Orthopédique et Traumatologique du Centre Hospitalier Universitaire de Rabat, Maroc
| | - Mohamed El Ouadghiri
- Service de Chirurgie Orthopédique et Traumatologique du Centre Hospitalier Universitaire de Rabat, Maroc
| | - Abdou Lahlou
- Service de Chirurgie Orthopédique et Traumatologique du Centre Hospitalier Universitaire de Rabat, Maroc
| | - Lamrani Moulay Omar
- Service de Chirurgie Orthopédique et Traumatologique du Centre Hospitalier Universitaire de Rabat, Maroc
| | - Ahmed El Bardouni
- Service de Chirurgie Orthopédique et Traumatologique du Centre Hospitalier Universitaire de Rabat, Maroc
| | - Mustapha Mahfoud
- Service de Chirurgie Orthopédique et Traumatologique du Centre Hospitalier Universitaire de Rabat, Maroc
| | - Mohamed Saleh Berrada
- Service de Chirurgie Orthopédique et Traumatologique du Centre Hospitalier Universitaire de Rabat, Maroc
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Initial management of complex hand injuries in military or austere environments: how to defer and prepare for definitive repair? INTERNATIONAL ORTHOPAEDICS 2017; 41:1771-1775. [DOI: 10.1007/s00264-017-3439-9] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Received: 10/31/2016] [Accepted: 03/06/2017] [Indexed: 10/19/2022]
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13
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Beckman M, Paul J, Neideen T, Weigelt JA. Role of the Open Abdomen in Critically Ill Patients. Crit Care Clin 2017; 32:255-64. [PMID: 27016166 DOI: 10.1016/j.ccc.2015.12.003] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
An open abdomen is common used in critically ill patients to temporize permanent abdominal closure. The most common reason for leaving the abdomen open by reopening a laparotomy, not closing, or creating a fresh laparotomy is the abdominal compartment syndrome. The open abdomen technique is also used in damage control operations and intra-abdominal sepsis. Negative pressure wound therapy may be associated with better outcomes than other temporary abdominal closure techniques. The open abdomen is associated with many early and late complications, including infections, gastrointestinal fistulas, and ventral hernias. Clinicians should be vigilant regarding the development of these complications.
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Affiliation(s)
- Marshall Beckman
- Division of Trauma Surgery and Critical Care, Department of Surgery, Medical College of Wisconsin, 9200 West Wisconsin Avenue, Milwaukee, WI 53226, USA
| | - Jasmeet Paul
- Division of Trauma Surgery and Critical Care, Department of Surgery, Medical College of Wisconsin, 9200 West Wisconsin Avenue, Milwaukee, WI 53226, USA
| | - Todd Neideen
- Division of Trauma Surgery and Critical Care, Department of Surgery, Medical College of Wisconsin, 9200 West Wisconsin Avenue, Milwaukee, WI 53226, USA
| | - John A Weigelt
- Division of Trauma Surgery and Critical Care, Department of Surgery, Medical College of Wisconsin, 9200 West Wisconsin Avenue, Milwaukee, WI 53226, USA.
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14
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Rossaint R, Bouillon B, Cerny V, Coats TJ, Duranteau J, Fernández-Mondéjar E, Filipescu D, Hunt BJ, Komadina R, Nardi G, Neugebauer EAM, Ozier Y, Riddez L, Schultz A, Vincent JL, Spahn DR. The European guideline on management of major bleeding and coagulopathy following trauma: fourth edition. Crit Care 2016; 20:100. [PMID: 27072503 PMCID: PMC4828865 DOI: 10.1186/s13054-016-1265-x] [Citation(s) in RCA: 597] [Impact Index Per Article: 74.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/03/2016] [Accepted: 03/11/2016] [Indexed: 12/13/2022] Open
Abstract
BACKGROUND Severe trauma continues to represent a global public health issue and mortality and morbidity in trauma patients remains substantial. A number of initiatives have aimed to provide guidance on the management of trauma patients. This document focuses on the management of major bleeding and coagulopathy following trauma and encourages adaptation of the guiding principles to each local situation and implementation within each institution. METHODS The pan-European, multidisciplinary Task Force for Advanced Bleeding Care in Trauma was founded in 2004 and included representatives of six relevant European professional societies. The group used a structured, evidence-based consensus approach to address scientific queries that served as the basis for each recommendation and supporting rationale. Expert opinion and current clinical practice were also considered, particularly in areas in which randomised clinical trials have not or cannot be performed. Existing recommendations were reconsidered and revised based on new scientific evidence and observed shifts in clinical practice; new recommendations were formulated to reflect current clinical concerns and areas in which new research data have been generated. This guideline represents the fourth edition of a document first published in 2007 and updated in 2010 and 2013. RESULTS The guideline now recommends that patients be transferred directly to an appropriate trauma treatment centre and encourages use of a restricted volume replacement strategy during initial resuscitation. Best-practice use of blood products during further resuscitation continues to evolve and should be guided by a goal-directed strategy. The identification and management of patients pre-treated with anticoagulant agents continues to pose a real challenge, despite accumulating experience and awareness. The present guideline should be viewed as an educational aid to improve and standardise the care of the bleeding trauma patients across Europe and beyond. This document may also serve as a basis for local implementation. Furthermore, local quality and safety management systems need to be established to specifically assess key measures of bleeding control and outcome. CONCLUSIONS A multidisciplinary approach and adherence to evidence-based guidance are key to improving patient outcomes. The implementation of locally adapted treatment algorithms should strive to achieve measureable improvements in patient outcome.
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Affiliation(s)
- Rolf Rossaint
- />Department of Anaesthesiology, University Hospital Aachen, RWTH Aachen University, Pauwelsstrasse 30, 52074 Aachen, Germany
| | - Bertil Bouillon
- />Department of Trauma and Orthopaedic Surgery, Witten/Herdecke University, Cologne-Merheim Medical Centre, Ostmerheimer Strasse 200, 51109 Cologne, Germany
| | - Vladimir Cerny
- />Department of Anaesthesiology, Perioperative Medicine and Intensive Care, J.E. Purkinje University, Masaryk Hospital, Usti nad Labem, Socialni pece 3316/12A, 40113 Usti nad Labem, Czech Republic
- />Department of Research and Development, Charles University in Prague, Faculty of Medicine in Hradec Kralove, Sokolska 581, 50005 Hradec Kralove, Czech Republic
- />Department of Anaesthesiology and Intensive Care, Charles University in Prague, Faculty of Medicine in Hradec Kralove, Sokolska 581, 50005 Hradec Kralove, Czech Republic
- />Department of Anaesthesia, Pain Management and Perioperative Medicine, Dalhousie University, Halifax, QE II Health Sciences Centre, 10 West Victoria, 1276 South Park St., Halifax, NS B3H 2Y9 Canada
| | - Timothy J. Coats
- />Emergency Medicine Academic Group, University of Leicester, University Road, Leicester, LE1 7RH UK
| | - Jacques Duranteau
- />Department of Anaesthesia and Intensive Care, Hôpitaux Universitaires Paris Sud, University of Paris XI, Faculté de Médecine Paris-Sud, 78 rue du Général Leclerc, 94275 Le Kremlin-Bicêtre, Cedex France
| | - Enrique Fernández-Mondéjar
- />Servicio de Medicina Intensiva, Complejo Hospitalario Universitario de Granada, ctra de Jaén s/n, 18013 Granada, Spain
| | - Daniela Filipescu
- />Department of Cardiac Anaesthesia and Intensive Care, C. C. Iliescu Emergency Institute of Cardiovascular Diseases, Sos Fundeni 256-258, 022328 Bucharest, Romania
| | - Beverley J. Hunt
- />King’s College, Departments of Haematology, Pathology and Lupus, Guy’s and St Thomas’ NHS Foundation Trust, Westminster Bridge Road, London, SE1 7EH UK
| | - Radko Komadina
- />Department of Traumatology, General and Teaching Hospital Celje, Oblakova 5, 3000 Celje, Slovenia
| | - Giuseppe Nardi
- />Shock and Trauma Centre, S. Camillo Hospital, Viale Gianicolense 87, 00152 Rome, Italy
| | - Edmund A. M. Neugebauer
- />Faculty of Health - School of Medicine, Witten/Herdecke University, Ostmerheimer Strasse 200, Building 38, 51109 Cologne, Germany
| | - Yves Ozier
- />Division of Anaesthesia, Intensive Care and Emergency Medicine, Brest University Hospital, Boulevard Tanguy Prigent, 29200 Brest, France
| | - Louis Riddez
- />Department of Surgery and Trauma, Karolinska University Hospital, 171 76 Solna, Sweden
| | - Arthur Schultz
- />Ludwig Boltzmann Institute for Experimental and Clinical Traumatology, Lorenz Boehler Trauma Centre, Donaueschingenstrasse 13, 1200 Vienna, Austria
| | - Jean-Louis Vincent
- />Department of Intensive Care, Erasme University Hospital, Université Libre de Bruxelles, Route de Lennik 808, 1070 Brussels, Belgium
| | - Donat R. Spahn
- />Institute of Anaesthesiology, University of Zurich and University Hospital Zurich, Raemistrasse 100, 8091 Zurich, Switzerland
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Giannoudi M, Harwood P. Damage control resuscitation: lessons learned. Eur J Trauma Emerg Surg 2016; 42:273-82. [PMID: 26847110 PMCID: PMC4886149 DOI: 10.1007/s00068-015-0628-3] [Citation(s) in RCA: 36] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/07/2015] [Accepted: 12/25/2015] [Indexed: 02/05/2023]
Abstract
BACKGROUND Damage control resuscitation describes an approach to the early care of very seriously injured patients. The aim is to keep the patient alive whilst avoiding interventions and situations that risk worsening their situation by driving the lethal triad of hypothermia, coagulopathy and acidosis or excessively stimulating the immune-inflammatory system. It is critical that the concepts and practicalities of this approach are understood by all those involved in the early management of trauma patients. This review aims to summarise this and discusses current knowledge on the subject. INTERVENTIONS Damage control resuscitation forms part of an overall approach to patient care rather than a specific intervention and has evolved from damage control surgery. It is characterised by early blood product administration, haemorrhage arrest and restoration of blood volume aiming to rapidly restore physiologic stability. The infusion of large volumes of crystalloid is no longer appropriate, instead the aim is to replace lost blood and avoid dilution and coagulopathy. In specific situations, permissive hypotension may also be of benefit, particularly in patients with severe haemorrhage from an arterial source. As rapid arrest of haemorrhage is so important, team-based protocols that deliver patients rapidly but safely, via CT scan where appropriate, to operating theatres or interventional radiology suites form a critical part of this process. CONCLUSIONS Given that interventions are so time dependent in the severely injured, it is likely that by further improving trauma systems and protocols, improvements in outcome can still be made. Further research work in this area will allow us to target these approaches more accurately to those patients who can benefit most.
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Affiliation(s)
- M Giannoudi
- Leeds General Infirmary, Clarendon Wing, Level A, Great George Street, Leeds, West Yorkshire, LS1 3EX, UK
| | - P Harwood
- Leeds General Infirmary, Clarendon Wing, Level A, Great George Street, Leeds, West Yorkshire, LS1 3EX, UK.
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Ratio-driven resuscitation predicts early fascial closure in the combat wounded. J Trauma Acute Care Surg 2016; 79:S188-92. [PMID: 26406429 DOI: 10.1097/ta.0000000000000741] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
BACKGROUND Operation Iraqi Freedom and Operation Enduring Freedom have seen the highest rates of combat casualties since Vietnam. These casualties often require massive transfusion (MT) and immediate surgical attention to control hemorrhage. Clinical practice guidelines dictate ratio-driven resuscitation (RDR) for patients requiring MT. With the transition from crystalloid to blood product resuscitation, we have seen fewer open abdomens in combat casualties. We sought to determine the effect RDR has on achieving early definitive abdominal fascial closure in combat casualties undergoing exploratory laparotomy. METHODS Records of 1,977 combat casualties admitted to a single US military hospital from April 2003 to December 2011 were reviewed. Patients receiving an MT and laparotomy in theater constituted the study cohort. The cohort was divided into RDR, defined as a ratio of 0.8-U to 1.2-U packed red blood cells to 1-U fresh frozen plasma, and No-RDR groups. Age, injury patterns, mechanism of injury, injury severity, blood products, number of laparotomies, and days to fascial closure were collected. Assessed outcomes were number of days (early ≤ 2 days) and number of laparotomies to achieve fascial closure. RESULTS The mean age of the study cohort (n = 172) was 24.0 years, and mean Injury Severity Score (ISS) was 24.8. Improvised explosive device blast was the most common mechanism of injury (74.4%). The cohort was divided into RDR patients (n = 73) and no RDR (n = 99). There was no difference in mean age, mean ISS, or rate of nontherapeutic exploratory laparotomies between the groups. RDR patients had a significantly lower abdominal injury rate (34.2% vs. 72.7%, p < 0.01), had fewer laparotomies (2.7 vs. 4.3, p = 0.003), and achieved primary fascial closure faster (2.4 days vs. 7.2 days, p = 0.004). On multivariate analysis, RDR (2.74; 95% confidence interval, 1.44-5.2) was an independent predictor for early fascial closure. CONCLUSION Adherence to RDR guidelines resulted in significantly decreased number of abdominal operations and was identified as an independent predictor for early fascial closure. Further investigation is warranted to validate these findings. LEVEL OF EVIDENCE Therapeutic study, level III.
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Chatrath V, Khetarpal R, Ahuja J. Fluid management in patients with trauma: Restrictive versus liberal approach. J Anaesthesiol Clin Pharmacol 2015; 31:308-16. [PMID: 26330707 PMCID: PMC4541175 DOI: 10.4103/0970-9185.161664] [Citation(s) in RCA: 51] [Impact Index Per Article: 5.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/02/2023] Open
Abstract
Trauma is a leading cause of death worldwide, and almost 30% of trauma deaths are due to blood loss. A number of concerns have been raised regarding the advisability of the classic principles of aggressive crystalloid resuscitation in traumatic hemorrhagic shock. Some recent studies have shown that early volume restoration in certain types of trauma before definite hemostasis may result in accelerated blood loss, hypothermia, and dilutional coagulopathy. This review discusses the advances and changes in protocols in fluid resuscitation and blood transfusion for treatment of traumatic hemorrhage shock. The concept of low volume fluid resuscitation also known as permissive hypotension avoids the adverse effects of early aggressive resuscitation while maintaining a level of tissue perfusion that although lower than normal, is adequate for short periods. Permissive hypotension is part of the damage control resuscitation strategy, which targets the conditions that exacerbate hemorrhage. The elements of this strategy are permissive hypotension, minimization of crystalloid resuscitation, control of hypothermia, prevention of acidosis, and early use of blood products to minimize coagulopathy.
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Affiliation(s)
- Veena Chatrath
- Department of Anaesthesia and Critical Care, Government Medical College, Amritsar, Punjab, India
| | - Ranjana Khetarpal
- Department of Anaesthesia and Critical Care, Government Medical College, Amritsar, Punjab, India
| | - Jogesh Ahuja
- Department of Anaesthesia and Critical Care, Government Medical College, Amritsar, Punjab, India
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18
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Identifying the bleeding trauma patient: predictive factors for massive transfusion in an Australasian trauma population. J Trauma Acute Care Surg 2013; 75:359-64. [PMID: 24089108 DOI: 10.1097/ta.0b013e31829e2248] [Citation(s) in RCA: 20] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
BACKGROUND Military and civilian data would suggest that hemostatic resuscitation results in improved outcomes for exsanguinating patients. However, identification of those patients who are at risk of significant hemorrhage is not clearly defined. We attempted to identify factors that would predict the need for massive transfusion (MT) in an Australasian trauma population, by comparing those trauma patients who did receive massive transfusion with those who did not. METHODS Between 1985 and 2010, 1,686 trauma patients receiving at least 1 U of packed red blood cells were identified from our prospectively maintained trauma registry. Demographic, physiologic, laboratory, injury, and outcome variables were reviewed. Univariate analysis determined significant factors between those who received MT and those who did not. A predictive multivariate logistic regression model with backward conditional stepwise elimination was used for MT risk. Statistical analysis was performed using SPSS PASW. RESULTS MT patients had a higher pulse rate, lower Glasgow Coma Scale (GCS) score, lower systolic blood pressure, lower hemoglobin level, higher Injury Severity Score (ISS), higher international normalized ratio (INR), and longer stay. Initial logistic regression identified base deficit (BD), INR, and hemoperitoneum at laparotomy as independent predictive variables. After assigning cutoff points of BD being greater than 5 and an INR of 1.5 or greater, a further model was created. A BD greater than 5 and either INR of 1.5 or greater or hemoperitoneum was associated with 51 times increase in MT risk (odds ratio, 51.6; 95% confidence interval, 24.9-95.8). The area under the receiver operating characteristic curve for the model was 0.859. CONCLUSION From this study, a combination of BD, INR, and hemoperitoneum has demonstrated good predictability for MT. This tool may assist in the determination of those patients who might benefit from hemostatic resuscitation. LEVEL OF EVIDENCE Prognostic study, level III.
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19
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Bograd B, Rodriguez C, Amdur R, Gage F, Elster E, Dunne J. Use of Damage Control and the Open Abdomen in Combat. Am Surg 2013. [DOI: 10.1177/000313481307900813] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Despite the well-documented use of damage control laparotomy (DCL) in civilian trauma, its use has not been well described in the combat setting. Therefore, we sought to document the use of DCL and to investigate its effect on patient outcome. Prospective data were collected on 1603 combat casualties injured between April 2003 and January 2009. One hundred seventy patients (11%) underwent an exploratory laparotomy (ex lap) in theater and comprised the study cohort. DCL was defined as an abbreviated ex lap resulting in an open abdomen. Patients were stratified by age, Injury Severity Score (ISS), Glasgow Coma Score (GCS), mechanism of injury, and blood product administration. Multivariate regression analyses were used to determine risks factors for intensive care unit length of stay (ICU LOS), hospital length of stay (HLOS), and the need for DCL. Mean age of the cohort was 24 ± 5 years, ISS was 21 ± 11, and 94 per cent sustained penetrating injury. Patients with DCL comprised 50.6 per cent (n = 86) of the study cohort and had significant increases in ICU admission ( P < 0.001), ICU LOS ( P < 0.001), HLOS ( P < 0.05), ventilator days ( P < 0.001), abdominal complications ( P < 0.05), but not mortality ( P = 0.65) compared with patients without DCL. When compared with the non-DCL group, patients undergoing DCL required significantly more blood products (packed red blood cells, fresh-frozen plasma, platelets, and cryoprecipitate; P < 0.001). Multivariate regression analyses revealed blood transfusion and GCS as significant risk factors for DCL ( P < 0.05). Patients undergoing DCL had increased complications and resource use but not mortality compared with patients not undergoing DCL. The need for combat DCL may be different compared with civilian use. Prospective studies to evaluate outcomes of DCL are warranted.
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Affiliation(s)
- Benjamin Bograd
- Department of Surgery, Walter Reed National Military Medical Center, Department Bethesda, Maryland; the
| | - Carlos Rodriguez
- Department of Surgery, Walter Reed National Military Medical Center, Department Bethesda, Maryland; the
| | - Richard Amdur
- Department of Surgery, George Washington University, Washington, DC
| | - Fred Gage
- Department of Surgery, Walter Reed National Military Medical Center, Department Bethesda, Maryland; the
| | - Eric Elster
- Department of Surgery, Walter Reed National Military Medical Center, Department Bethesda, Maryland; the
- Department of Surgery, Uniformed Services University of the Health Sciences, Bethesda, Maryland
| | - James Dunne
- Department of Surgery, Uniformed Services University of the Health Sciences, Bethesda, Maryland
- Department of Surgery, George Washington University, Washington, DC
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20
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Spahn DR, Bouillon B, Cerny V, Coats TJ, Duranteau J, Fernández-Mondéjar E, Filipescu D, Hunt BJ, Komadina R, Nardi G, Neugebauer E, Ozier Y, Riddez L, Schultz A, Vincent JL, Rossaint R. Management of bleeding and coagulopathy following major trauma: an updated European guideline. Crit Care 2013; 17:R76. [PMID: 23601765 PMCID: PMC4056078 DOI: 10.1186/cc12685] [Citation(s) in RCA: 692] [Impact Index Per Article: 62.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/02/2013] [Revised: 03/26/2013] [Accepted: 04/02/2013] [Indexed: 12/16/2022] Open
Abstract
INTRODUCTION Evidence-based recommendations are needed to guide the acute management of the bleeding trauma patient. When these recommendations are implemented patient outcomes may be improved. METHODS The multidisciplinary Task Force for Advanced Bleeding Care in Trauma was formed in 2005 with the aim of developing a guideline for the management of bleeding following severe injury. This document represents an updated version of the guideline published by the group in 2007 and updated in 2010. Recommendations were formulated using a nominal group process, the Grading of Recommendations Assessment, Development and Evaluation (GRADE) hierarchy of evidence and based on a systematic review of published literature. RESULTS Key changes encompassed in this version of the guideline include new recommendations on the appropriate use of vasopressors and inotropic agents, and reflect an awareness of the growing number of patients in the population at large treated with antiplatelet agents and/or oral anticoagulants. The current guideline also includes recommendations and a discussion of thromboprophylactic strategies for all patients following traumatic injury. The most significant addition is a new section that discusses the need for every institution to develop, implement and adhere to an evidence-based clinical protocol to manage traumatically injured patients. The remaining recommendations have been re-evaluated and graded based on literature published since the last edition of the guideline. Consideration was also given to changes in clinical practice that have taken place during this time period as a result of both new evidence and changes in the general availability of relevant agents and technologies. CONCLUSIONS A comprehensive, multidisciplinary approach to trauma care and mechanisms with which to ensure that established protocols are consistently implemented will ensure a uniform and high standard of care across Europe and beyond.
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Affiliation(s)
- Donat R Spahn
- Institute of Anaesthesiology, University Hospital Zurich, Rämistrasse 100, CH-8091 Zurich, Switzerland
| | - Bertil Bouillon
- Department of Trauma and Orthopaedic Surgery, University of Witten/Herdecke, Cologne-Merheim Medical Centre, Ostmerheimerstrasse 200, D-51109 Cologne, Germany
| | - Vladimir Cerny
- Faculty of Medicine in Hradec Králové, Department of Anaesthesiology and Intensive Care Medicine, University Hospital Hradec Králové, CZ-50005 Hradec Králové, Czech Republic
- Dalhousie University, Department of Anesthesia, Pain Management and Perioperative Medicine, Halifax, NS B3H 4R2, Canada
| | - Timothy J Coats
- Accident and Emergency Department, University of Leicester, Infirmary Square, Leicester LE1 5WW, UK
| | - Jacques Duranteau
- Department of Anaesthesia and Intensive Care, University of Paris XI, Faculté de Médecine Paris-Sud, 63 rue Gabriel Péri, F-94276 Le Kremlin-Bicêtre, France
| | - Enrique Fernández-Mondéjar
- Department of Emergency and Critical Care Medicine, University Hospital Virgen de las Nieves, ctra de Jaén s/n, E-18013 Granada, Spain
| | - Daniela Filipescu
- Department of Cardiac Anaesthesia and Intensive Care, C. C. Iliescu Emergency Institute of Cardiovascular Diseases, Sos Fundeni 256-258, RO-022328 Bucharest, Romania
| | - Beverley J Hunt
- Guy's and St Thomas' Foundation Trust, Westminster Bridge Road, London, SE1 7EH, UK
| | - Radko Komadina
- Department of Traumatology, General and Teaching Hospital Celje, SI-3000 Celje, Slovenia
| | - Giuseppe Nardi
- Shock and Trauma Centre, S. Camillo Hospital, Viale Gianicolense 87, I-00152 Rome, Italy
| | - Edmund Neugebauer
- Institute for Research in Operative Medicine (IFOM), Witten/Herdecke University, Campus Cologne, Ostmerheimerstrasse 200, D-51109 Cologne, Germany
| | - Yves Ozier
- Division of Anaesthesia, Intensive Care and Emergency Medicine, Brest University Hospital, Boulevard Tanguy Prigent, F-29200 Brest, France
| | - Louis Riddez
- Department of Surgery and Trauma, Karolinska University Hospital, S-171 76 Solna, Sweden
| | - Arthur Schultz
- Ludwig-Boltzmann-Institute for Experimental and Clinical Traumatology, Lorenz Boehler Trauma Centre, Donaueschingenstrasse 13, A-1200 Vienna, Austria
| | - Jean-Louis Vincent
- Department of Intensive Care, Erasme University Hospital, Université Libre de Bruxelles, Route de Lennik 808, B-1070 Brussels, Belgium
| | - Rolf Rossaint
- Department of Anaesthesiology, University Hospital Aachen, RWTH Aachen University, Pauwelsstrasse 30, D-52074 Aachen, Germany
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