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Berg A, Lyons NB, Badami A, Reynolds J, Pizano L, Pust GD, Meizoso J, Namias N, Yeh DD. Statistical Power of Randomized Controlled Trials in Trauma Surgery. J Am Coll Surg 2023; 237:731-736. [PMID: 37417653 DOI: 10.1097/xcs.0000000000000800] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 07/08/2023]
Abstract
BACKGROUND Our purpose was to conduct a bibliometric study investigating the prevalence of underpowered randomized controlled trials (RCTs) in trauma surgery. STUDY DESIGN A medical librarian conducted a search of RCTs in trauma published from 2000 to 2021. Data extracted included study type, sample size calculation, and power analyses. Post hoc calculations were performed using a power of 80% and an alpha level of 0.05. A CONSORT checklist was then tabulated from each study as well as a fragility index for studies with statistical significance. RESULTS In total 187 RCTs from multiple continents and 60 journals were examined. A total of 133 (71%) were found to have "positive" findings consistent with their hypothesis. When evaluating their methods, 51.3% of articles did not report how they calculated their intended sample size. Of those that did, 25 (27%) did not meet their target enrollment. When examining post hoc power, 46%, 57%, and 65% were adequately powered to detect small, medium, and large effect sizes, respectively. Only 11% of RCTs had complete adherence with CONSORT reporting guidelines and the average CONSORT score was 19 out of 25. For positive superiority trials with binary outcomes, the fragility index median (interquartile range) was 2 (2 to 8). CONCLUSIONS A concerningly large proportion of recently published RCTs in trauma surgery do not report a priori sample size calculations, do not meet enrollment targets, and are not adequately powered to detect even large effect sizes. There exists opportunity for improvement of trauma surgery study design, conduct, and reporting.
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Affiliation(s)
- Arthur Berg
- From the Department of Trauma and Surgical Critical Care, Jackson Memorial Hospital, Miami, FL (Berg, Lyons, Badami, Reynolds, Pizano, Pust, Meizoso, Namias)
| | - Nicole B Lyons
- From the Department of Trauma and Surgical Critical Care, Jackson Memorial Hospital, Miami, FL (Berg, Lyons, Badami, Reynolds, Pizano, Pust, Meizoso, Namias)
| | - Abbasali Badami
- From the Department of Trauma and Surgical Critical Care, Jackson Memorial Hospital, Miami, FL (Berg, Lyons, Badami, Reynolds, Pizano, Pust, Meizoso, Namias)
| | - John Reynolds
- From the Department of Trauma and Surgical Critical Care, Jackson Memorial Hospital, Miami, FL (Berg, Lyons, Badami, Reynolds, Pizano, Pust, Meizoso, Namias)
| | - Louis Pizano
- From the Department of Trauma and Surgical Critical Care, Jackson Memorial Hospital, Miami, FL (Berg, Lyons, Badami, Reynolds, Pizano, Pust, Meizoso, Namias)
| | - Gerd Daniel Pust
- From the Department of Trauma and Surgical Critical Care, Jackson Memorial Hospital, Miami, FL (Berg, Lyons, Badami, Reynolds, Pizano, Pust, Meizoso, Namias)
| | - Jonathan Meizoso
- From the Department of Trauma and Surgical Critical Care, Jackson Memorial Hospital, Miami, FL (Berg, Lyons, Badami, Reynolds, Pizano, Pust, Meizoso, Namias)
| | - Nicholas Namias
- From the Department of Trauma and Surgical Critical Care, Jackson Memorial Hospital, Miami, FL (Berg, Lyons, Badami, Reynolds, Pizano, Pust, Meizoso, Namias)
| | - Daniel Dante Yeh
- and the Department of Trauma and Surgical Critical Care, Denver Health, Denver, CO (Yeh)
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Schulman CI, Namias N, Pizano L, Rodriguez-Menocal L, Aickara D, Guzman W, Candanedo A, Maranda E, Beirn A, Badiavas EV. The effect of mesenchymal stem cells improves the healing of burn wounds: a phase 1 dose-escalation clinical trial. Scars Burn Heal 2022; 8:20595131211070783. [PMID: 35781931 PMCID: PMC9247372 DOI: 10.1177/20595131211070783] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/01/2022] Open
Abstract
Background Stem cell therapy holds promise to improve healing and stimulate tissue
regeneration after burn injury. Preclinical evidence has supported this;
however, clinical studies are lacking. We examined the application of bone
marrow-derived mesenchymal stem cells (BM-MSC) to deep second-degree burn
injuries using a two-dose escalation protocol. Methods Ten individuals aged 18 years or older with deep second-degree burn wounds
were enrolled. The first five patients were administered 2.5 × 10³
BM-MSC/cm2 to their wounds. After safety of the initial dose
level was assessed, a second group of five patients was treated with a
higher concentration of 5 × 10³ allogeneic BM-MSC/cm2. Safety was
assessed clinically and by evaluating cytokine levels in mixed recipient
lymphocyte/donor BM-MSC reactions (INFγ, IL-10 and TNFα). At each visit, we
performed wound measurements and assessed wounds using a Patient and
Observer Scar Assessment Scale (POSAS). Results All patients responded well to treatment, with 100% closure of wounds and
minimal clinical evidence of fibrosis. No adverse reactions or evidence of
rejection were observed for both dose levels. Patients receiving the first
dose concentration had a wound closure rate of 3.64 cm2/day.
Patients receiving the second dose concentration demonstrated a wound
closure rate of 10.47 cm2/day. The difference in healing rates
between the two groups was not found to be statistically significant
(P = 0.17). Conclusion BM-MSC appear beneficial in optimising wound healing in patients with deep
second-degree burn wounds. Adverse outcomes were not observed when
administering multiple doses of allogeneic BM-MSC. Lay Summary Thermal injuries are a significant source of morbidity and mortality,
constituting 5%–20% of all injuries and 4% of all deaths. Despite overall
improvements in the management of acutely burned patients, morbidities
associated with deeper burn injuries remain commonplace. Burn patients are
too often left with significant tissue loss, scarring and contractions
leading to physical loss of function and long-lasting psychological and
emotional impacts. In previous studies, we have demonstrated the safety and efficacy of
administering bone marrow-derived mesenchymal stem cells (BM-MSC) to chronic
wounds with substantial improvement in healing and evidence of tissue
regeneration. In this report, we have examined the application of BM-MSC to
deep second-degree burn injuries in patients. The aim of the present phase I/II clinical trial was to examine the safety
and efficacy of administering allogeneic BM-MSC to deep second-degree burns.
We utilised two different dose levels at concentrations 2.5 × 103
and 5 × 103 cells/cm2. Patients with deep
second-degree burn wounds up to 20% of the total body surface area were
eligible for treatment. Allogeneic BM-MSC were applied to burn wounds
topically or by injection under transparent film dressing <7 days after
injury. Patients were followed for at least six months after treatment. Using two dose levels allowed us to gain preliminary information as to
whether different amounts of BM-MSC administered to burn wounds will result
in significant differences in safety/ clinical response. Once the safety and
dose-response analysis were completed, we evaluated the efficacy of
allogeneic stem cell therapy in the treatment of deep second-degree burn
wounds. In this study, we examined the role of allogeneic BM-MSC treatment in
patients with deep second-degree burn injuries, in a dose-dependent manner.
No significant related adverse events were reported. Safety was evaluated
both clinically and by laboratory-based methods. Efficacy was assessed
clinically through evidence of re-pigmentation, hair follicle restoration
and regenerative change. While these findings are encouraging, more studies
will be needed to better establish the benefit of BM-MSC in the treatment of
burn injuries.
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Affiliation(s)
- Carl I Schulman
- Department of Surgery, Ryder Trauma Center, University of Miami School of Medicine, Miami, FL, USA
| | - Nicholas Namias
- Department of Surgery, Ryder Trauma Center, University of Miami School of Medicine, Miami, FL, USA
| | - Louis Pizano
- Department of Surgery, Ryder Trauma Center, University of Miami School of Medicine, Miami, FL, USA
| | - Luis Rodriguez-Menocal
- Department of Dermatology and Cutaneous Surgery. Leonard M Miller School of Medicine, University of Miami, Interdisciplinary Stem Cell Institute, Miami, FL, USA
| | - Divya Aickara
- Department of Dermatology and Cutaneous Surgery. Leonard M Miller School of Medicine, University of Miami, Interdisciplinary Stem Cell Institute, Miami, FL, USA
| | - Wellington Guzman
- Department of Surgery, Ryder Trauma Center, University of Miami School of Medicine, Miami, FL, USA
| | - Ambar Candanedo
- Department of Surgery, Ryder Trauma Center, University of Miami School of Medicine, Miami, FL, USA
| | - Eric Maranda
- Department of Dermatology and Cutaneous Surgery. Leonard M Miller School of Medicine, University of Miami, Interdisciplinary Stem Cell Institute, Miami, FL, USA
| | - Audrey Beirn
- Department of Dermatology and Cutaneous Surgery. Leonard M Miller School of Medicine, University of Miami, Interdisciplinary Stem Cell Institute, Miami, FL, USA
| | - Evangelos V Badiavas
- Department of Dermatology and Cutaneous Surgery. Leonard M Miller School of Medicine, University of Miami, Interdisciplinary Stem Cell Institute, Miami, FL, USA
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Rosa R, Arheart KL, Depascale D, Cleary T, Kett DH, Namias N, Pizano L, Fajardo-Aquino Y, Munoz-Price LS. Environmental Exposure to Carbapenem-Resistant Acinetobacter baumannii as a Risk Factor for Patient Acquisition of A. baumannii. Infect Control Hosp Epidemiol 2016; 35:430-3. [DOI: 10.1086/675601] [Citation(s) in RCA: 24] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/03/2022]
Abstract
We aimed to determine the association between environmental exposure to carbapenem-resistant Acinetobacter baumannii and the subsequent risk of acquiring this organism. Patients exposed to a contaminated hospital environment had 2.77 times the risk of acquiring carbapenem-resistant A. baumannii than did unexposed patients (relative risk, 2.77 [95% confidence interval, 1.50–5.13]; P = .002).
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Munoz-Price LS, Carling P, Cleary T, Fajardo-Aquino Y, DePascale D, Jimenez A, Hughes M, Namias N, Pizano L, Kett DH, Arheart K. Control of a two-decade endemic situation with carbapenem-resistant Acinetobacter baumannii: electronic dissemination of a bundle of interventions. Am J Infect Control 2014; 42:466-71. [PMID: 24773784 DOI: 10.1016/j.ajic.2013.12.024] [Citation(s) in RCA: 24] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/30/2013] [Revised: 12/24/2013] [Accepted: 12/30/2013] [Indexed: 11/30/2022]
Abstract
BACKGROUND Our institution continued to experience a hyperendemic situation with carbapenem-resistant Acinetobacter baumannii despite a bundle of interventions. We aim to describe the effect of the subsequent implementation of electronic dissemination of the weekly findings of a bundle of interventions. METHODS This was a quasiexperimental study performed at a 1,500-bed, public, teaching hospital. From January 2011 to March 2012, weekly electronic communications were sent to the hospital leadership and intensive care units (ICUs). These communications aimed to describe, interpret, and package the findings of the previous week's active surveillance cultures, environmental cultures, environmental disinfection, and hand cultures. Additionally, action plans based on these findings were shared with recipients. RESULTS During 42 months and 1,103,900 patient-days, we detected 438 new acquisitions of carbapenem-resistant A baumannii. Hospital wide, the rate of acquisition decreased from 5.13 ± 0.39 to 1.93 ± 0.23 per 10,000 patient-days, during the baseline and postintervention periods, respectively (P < .0001). This effect was also observed in the medical and trauma ICUs, with decreased rates from 67.15 ± 10.56 to 17.4 ± 4.6 (P < .0001) and from 55.9 ± 8.95 to 14.71 ± 4.45 (P = .0004), respectively. CONCLUSION Weekly and systematic dissemination of the findings of a bundle of interventions was successful in decreasing the rates of carbapenem-resistant A baumannii across a large public hospital.
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Affiliation(s)
- L Silvia Munoz-Price
- Department of Medicine, University of Miami Miller School of Medicine, Miami, FL; Department of Public Health Sciences, University of Miami Miller School of Medicine, Miami, FL; Department of Anesthesiology, University of Miami Miller School of Medicine, Miami, FL; Jackson Health System, Miami, FL.
| | | | - Timothy Cleary
- Department of Pathology, University of Miami Miller School of Medicine, Miami, FL
| | | | | | | | | | - Nicholas Namias
- Department of Anesthesiology, University of Miami Miller School of Medicine, Miami, FL; Jackson Health System, Miami, FL; Department of Surgery, University of Miami Miller School of Medicine, Miami, FL
| | - Louis Pizano
- Jackson Health System, Miami, FL; Department of Surgery, University of Miami Miller School of Medicine, Miami, FL
| | - Daniel H Kett
- Department of Medicine, University of Miami Miller School of Medicine, Miami, FL
| | - Kristopher Arheart
- Department of Public Health Sciences, University of Miami Miller School of Medicine, Miami, FL; Division of Statistics, University of Miami Miller School of Medicine, Miami, FL
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Meizoso J, Namias N, Pepe A, Schulman C, Pizano L, McKenney M. QS379. CT Utilization Is Not Predicted by Severity of Illness, But Does Show Cultural Disparity, in Minimally Injured Blunt Trauma Patients. J Surg Res 2009. [DOI: 10.1016/j.jss.2008.11.689] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/21/2022]
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McCullough MC, Namias N, Schulman C, Gomez E, Manning R, Goldberg S, Pizano L, Ward GC. Incidence of hepatic dysfunction is equivalent in burn patients receiving oxandrolone and controls. J Burn Care Res 2007; 28:412-20. [PMID: 17438485 DOI: 10.1097/bcr.0b013e318053d257] [Citation(s) in RCA: 14] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
Oxandrolone has been shown to improve lean muscle mass in patients with burns. Hepatic dysfunction is a known side effect of treatment with oxandrolone. The purpose of this study was to examine the incidence of hepatic dysfunction in our series of burn patients receiving oxandrolone. Fourteen patients who received oxandrolone (5 mg, n = 8; 10 mg, n = 6) were identified from our prospectively collected burn database. The records of 61 control patients also were reviewed. Demographics such as age, comorbidities, and burn size were recorded. The incidence of hepatic dysfunction was determined by the presence of abnormal liver function tests. The study and control groups were similar in age and burn size. Two of the eight (25%) oxandrolone patients receiving 5 mg and four of the six (67%) oxandrolone patients receiving 10 mg had evidence of hepatic dysfunction. Twenty six of the 61 (43%) control patients had evidence of hepatic dysfunction (P = NS). There appears no significant increased incidence of hepatic dysfunction in burn patients who received oxandrolone compared to those who did not.
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Affiliation(s)
- Mona C McCullough
- University ofMiami-Miller School ofMedicine, DeWitt Daughtry Family Department of Surgery, Division of Burns, Miami, Florida, USA
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de Moya MA, Seaver C, Spaniolas K, Inaba K, Nguyen M, Veltman Y, Shatz D, Alam HB, Pizano L. Occult Pneumothorax in Trauma Patients: Development of an Objective Scoring System. ACTA ACUST UNITED AC 2007; 63:13-7. [PMID: 17622863 DOI: 10.1097/ta.0b013e31806864fc] [Citation(s) in RCA: 54] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/23/2022]
Abstract
BACKGROUND The incidence of occult pneumothorax (OPTX) has dramatically increased since the widespread use of computed tomography (CT) scanning. The OPTX is defined as a pneumothorax not identified on plain chest X-ray but detected by CT scan. The overall reported incidence is about 5% to 8% of all trauma patients. We conducted a 5-year review of our OPTX incidence and asked if an objective score could be developed to better quantify the OPTX. This in turn may guide the practitioner with the decision to observe these patients. METHODS This is a retrospective review of all trauma patients in a Level I university trauma center during a 5-year period. The patients were identified by a query of all pneumothoraces in our trauma registry. Those X-ray results were then reviewed to identify those who had OPTX. After developing an OPTX score on a small number, we retrospectively scored 50 of the OPTXs by taking the largest perpendicular distance in millimeters from the chest wall of the largest air pocket. We then added 10 or 20 to this if the OPTX was either anterior/posterior or lateral, respectively. RESULTS A total of 21,193 trauma patients were evaluated and 1,295 patients with pneumothoraces (6.1%) were identified. Of the 1,295 patients with pneumothoraces, 379 (29.5%) OPTXs were identified. The overall incidence of OPTX was 1.8%: 95.7% occurred after blunt trauma, 222 (59%) of the OPTX patients had chest tubes and of the remaining 157 without chest tubes, 27 (17%) were on positive pressure ventilation. Of the 50 studies selected for scoring, the average score was 28.5. The average score for those with chest tubes was 34. The average score for those without chest tubes was 21. The positive predictive value for need of chest tube if the score was >30 was 78% and the negative predictive value if the score was <20 was 70%. Area under the receiver operator characteristic curve was 0.72, which was significant with p < 0.007. CONCLUSIONS The OPTX score could quantify the size of the OPTX allowing the practitioner to better define a "small" pneumothorax. The management of OPTX is not standardized and further study using a more objective classification may assist the surgeon's decision-making. The application of a scoring system may also decrease unnecessary insertion of chest tubes for small OPTXs and is currently being prospectively validated.
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Affiliation(s)
- Marc A de Moya
- Department of Surgery, University of Miami/Ryder Trauma Center, Miami, FL, USA.
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8
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Inaba K, Munera F, McKenney MG, Rivas L, Marecos E, de Moya M, O'Keeffe T, Pizano L, Cohn S. The nonoperative management of penetrating internal jugular vein injury. J Vasc Surg 2006; 43:77-80. [PMID: 16414392 DOI: 10.1016/j.jvs.2005.09.012] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/23/2005] [Accepted: 09/08/2005] [Indexed: 10/25/2022]
Abstract
OBJECTIVE The objective of this study was to review the outcome of nonoperative treatment for penetrating internal jugular vein (IJ) injuries in a continuous series of prospectively identified, hemodynamically stable patients. METHODS All penetrating neck injuries assessed from February 1, 2004, to August 31, 2004, were prospectively identified. Patients without an indication for urgent neck exploration underwent diagnostic assessment with multislice helical computed tomographic angiography with or without vascular ultrasonography. All IJ injuries with no other indication for surgical exploration were treated nonoperatively. All patients were discharged home and followed up for a minimum of 1 week to document outcomes. RESULTS From 51 neck injuries penetrating the platysma, 7 required urgent neck exploration, during which 2 IJ injuries were ligated. Forty-four patients underwent multislice helical computed tomographic angiography. Eight IJ injuries (two gunshot wounds and six stab wounds) with no other indication for neck exploration were identified and managed nonoperatively. One external wound was in zone 1, five were in zone 2, one was in zone 3, and one traversed all three zones. The average length of stay was 4.5 days. At follow-up, ranging from 1 week to 5 months, all patients were asymptomatic, and no patient required delayed operation for IJ injury. CONCLUSIONS In hemodynamically stable patients with no other indication for exploration, the nonoperative management of penetrating jugular vein injuries should be considered as a safe alternative.
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Affiliation(s)
- Kenji Inaba
- Department of Surgery, Ryder Trauma Center, Miami, FL, USA.
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Tekin A, Namias N, O'Keeffe T, Pizano L, Lynn M, Prater-Varas R, Quintana OD, Borges L, Ishii M, Lee S, Lopez P, Lessner-Eisenberg S, Alvarez A, Ellison T, Sapnas K, Lefton J, Ward CG. A burn mass casualty event due to boiler room explosion on a cruise ship: preparedness and outcomes. Am Surg 2005; 71:210-5. [PMID: 15869134] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/02/2023]
Abstract
The purpose of this study was to review our experience with a mass casualty incident resulting from a boiler room steam explosion aboard a cruise ship. Experience with major, moderate, and minor burns, steam inhalation, mass casualty response systems, and psychological sequelae will be discussed. Fifteen cruise ship employees were brought to the burn center after a boiler room explosion on a cruise ship. Eleven were triaged to the trauma resuscitation area and four to the surgical emergency room. Seven patients were intubated for respiratory distress or airway protection. Six patients had >80 per cent burns with steam inhalation, and all of these died. One of the 6 patients had 99 per cent burns with steam inhalation and died after withdrawal of support within the first several hours. All patients with major burns required escharotomy on arrival to trauma resuscitation. One patient died in the operating room, despite decompression by laparotomy for abdominal compartment syndrome and pericardiotomy via thoracotomy for cardiac tamponade. Four patients required crystalloid, 20,000 mls/m2-27,000 ml/m2 body surface area (BSA) in the first 48 hours to maintain blood pressure and urine output. Three of these four patients subsequently developed abdominal compartment syndrome and died in the first few days. The fourth patient of this group died after 26 days due to sepsis. Five patients had 13-20 per cent bums and four patients had less than 10 per cent burns. Two of the patients with 20 per cent burns developed edema of the vocal cords with mild hoarseness. They improved and recovered without intubation. The facility was prepared for the mass casualty event; having just completed a mass casualty drill several days earlier. Twenty-six beds were made available in 50 minutes for anticipated casualties. Fifteen physicians reported immediately to the trauma resuscitation area to assist in initial stabilization. The event occurred at shift change; thus, adequate support personnel were instantaneously to hand. Our mass casualty preparation proved useful in managing this event. Most of the patients who survived showed signs of post-traumatic stress syndrome, which was diagnosed and treated by the burn center psychology team. Despite our efforts at treating large burns (>80%) with steam inhalation, mortality was 100 per cent. Fluid requirements far exceeded those predicted by the Parkland (Baxter) formula. Abdominal compartment syndrome proved to be a significant complication of this fluid resuscitation. A coordinated effort by the facility and preparation for mass casualty events are needed to respond to such events.
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Affiliation(s)
- Akin Tekin
- University of Miami/Jackson Memorial Burn Center, Miami, Florida, USA
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Tekin A, Namias N, O'Keeffe T, Pizano L, Lynn M, Prater-Varas R, Quintana OD, Borges L, Ishii M, Lee S, Lopez P, Lessner-Eisenberg S, Alvarez A, Ellison T, Sapnas K, Lefton J, Ward CG. A Burn Mass Casualty Event Due to Boiler Room Explosion on a Cruise Ship: Preparedness and Outcomes. Am Surg 2005. [DOI: 10.1177/000313480507100307] [Citation(s) in RCA: 15] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
The purpose of this study was to review our experience with a mass casualty incident resulting from a boiler room steam explosion aboard a cruise ship. Experience with major, moderate, and minor burns, steam inhalation, mass casualty response systems, and psychological sequelae will be discussed. Fifteen cruise ship employees were brought to the burn center after a boiler room explosion on a cruise ship. Eleven were triaged to the trauma resuscitation area and four to the surgical emergency room. Seven patients were intubated for respiratory distress or airway protection. Six patients had >80 per cent burns with steam inhalation, and all of these died. One of the 6 patients had 99 per cent burns with steam inhalation and died after withdrawal of support within the first several hours. All patients with major burns required escharotomy on arrival to trauma resuscitation. One patient died in the operating room, despite decompression by laparotomy for abdominal compartment syndrome and pericardiotomy via thoracotomy for cardiac tamponade. Four patients required crystalloid, 20,000 mls/m2–27,000 ml/m2 body surface area (BSA) in the first 48 hours to maintain blood pressure and urine output. Three of these four patients subsequently developed abdominal compartment syndrome and died in the first few days. The fourth patient of this group died after 26 days due to sepsis. Five patients had 13–20 per cent burns and four patients had less than 10 per cent burns. Two of the patients with 20 per cent burns developed edema of the vocal cords with mild hoarseness. They improved and recovered without intubation. The facility was prepared for the mass casualty event, having just completed a mass casualty drill several days earlier. Twenty-six beds were made available in 50 minutes for anticipated casualties. Fifteen physicians reported immediately to the trauma resuscitation area to assist in initial stabilization. The event occurred at shift change; thus, adequate support personnel were instantaneously to hand. Our mass casualty preparation proved useful in managing this event. Most of the patients who survived showed signs of post-traumatic stress syndrome, which was diagnosed and treated by the burn center psychology team. Despite our efforts at treating large burns (>80%) with steam inhalation, mortality was 100 per cent. Fluid requirements far exceeded those predicted by the Parkland (Baxter) formula. Abdominal compartment syndrome proved to be a significant complication of this fluid resuscitation. A coordinated effort by the facility and preparation for mass casualty events are needed to respond to such events.
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Affiliation(s)
- Akin Tekin
- University of Miami/Jackson Memorial Burn Center, Miami, Florida
| | - Nicholas Namias
- University of Miami/Jackson Memorial Burn Center, Miami, Florida
| | - Terence O'Keeffe
- University of Miami/Jackson Memorial Burn Center, Miami, Florida
| | - Louis Pizano
- University of Miami/Jackson Memorial Burn Center, Miami, Florida
| | - Mauricio Lynn
- University of Miami/Jackson Memorial Burn Center, Miami, Florida
| | | | | | - Leda Borges
- University of Miami/Jackson Memorial Burn Center, Miami, Florida
| | - Mary Ishii
- University of Miami/Jackson Memorial Burn Center, Miami, Florida
| | - Seong Lee
- University of Miami/Jackson Memorial Burn Center, Miami, Florida
| | - Peter Lopez
- University of Miami/Jackson Memorial Burn Center, Miami, Florida
| | | | - Angel Alvarez
- University of Miami/Jackson Memorial Burn Center, Miami, Florida
| | - Tom Ellison
- University of Miami/Jackson Memorial Burn Center, Miami, Florida
| | - Katherine Sapnas
- University of Miami/Jackson Memorial Burn Center, Miami, Florida
| | - Jennifer Lefton
- University of Miami/Jackson Memorial Burn Center, Miami, Florida
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