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Broome JM, Nordham KD, Piehl M, Tatum D, Caputo S, Belding C, De Maio VJ, Taghavi S, Jackson-Weaver O, Harris C, McGrew P, Smith A, Nichols E, Dransfield T, Rayburn D, Marino M, Avegno J, Duchesne J. Faster refill in an urban emergency medical services system saves lives: A prospective preliminary evaluation of a prehospital advanced resuscitative care bundle. J Trauma Acute Care Surg 2024; 96:702-707. [PMID: 38189675 DOI: 10.1097/ta.0000000000004239] [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: 01/09/2024]
Abstract
INTRODUCTION Military experience has demonstrated mortality improvement when advanced resuscitative care (ARC) is provided for trauma patients with severe hemorrhage. The benefits of ARC for trauma in civilian emergency medical services (EMS) systems with short transport intervals are still unknown. We hypothesized that ARC implementation in an urban EMS system would reduce in-hospital mortality. METHODS This was a prospective analysis of ARC bundle administration between 2021 and 2023 in an urban EMS system with 70,000 annual responses. The ARC bundle consisted of calcium, tranexamic acid, and packed red blood cells via a rapid infuser. Advanced resuscitative care patients were compared with trauma registry controls from 2016 to 2019. Included were patients with a penetrating injury and systolic blood pressure ≤90 mm Hg. Excluded were isolated head trauma or prehospital cardiac arrest. In-hospital mortality was the primary outcome of interest. RESULTS A total of 210 patients (ARC, 61; controls, 149) met the criteria. The median age was 32 years, with no difference in demographics, initial systolic blood pressure or heart rate recorded by EMS, or New Injury Severity Score between groups. At hospital arrival, ARC patients had lower median heart rate and shock index than controls ( p ≤ 0.03). Fewer patients in the ARC group required prehospital advanced airway placement ( p < 0.001). Twenty-four-hour and total in-hospital mortality were lower in the ARC group ( p ≤ 0.04). Multivariable regression revealed an independent reduction in in-hospital mortality with ARC (odds ratio, 0.19; 95% confidence interval, 0.05-0.68; p = 0.01). CONCLUSION Early ARC in a fast-paced urban EMS system is achievable and may improve physiologic derangements while decreasing patient mortality. Advanced resuscitative care closer to the point of injury warrants consideration. LEVEL OF EVIDENCE Therapeutic/Care Management; Level IV.
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Affiliation(s)
- Jacob M Broome
- Department of Surgery, MedStar Georgetown Washington Hospital Center, (J.M.B.) Washington DC; Department of Surgery (K.D.N., D.T., S.C., C.B., S.T., O.J.-W., C.H., P.M., J.D.), Tulane University School of Medicine, New Orleans, Louisiana; Department of Pediatrics (M.P.), and Department of Emergency Medicine (V.J.D.M.), University of North Carolina at Chapel Hill, Chapel Hill; WakeMed Health and Hospitals (M.P.), Raleigh, North Carolina; Lousiana State University Health Science Center New Orleans (A.S.); New Orleans Emergency Medical Services (E.N., T.D., D.R., M.M.); and New Orleans Health Department, New Orleans, Louisiana (J.A.)
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Sullivan TM, Sippel GJ, Gestrich-Thompson WV, Jensen AR, Burd RS. Survival bias in pediatric hemorrhagic shock: Are we misrepresenting the data? J Trauma Acute Care Surg 2024; 96:785-792. [PMID: 37752639 DOI: 10.1097/ta.0000000000004119] [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: 09/28/2023]
Abstract
BACKGROUND Studies of hemorrhage following pediatric injury often use the occurrence of transfusion as a surrogate definition for the clinical need for a transfusion. Using this approach, patients who are bleeding but die before receiving a transfusion are misclassified as not needing a transfusion. In this study, we aimed to evaluate the potential for this survival bias and to estimate its presence among a retrospective observational cohort of children and adolescents who died from injury. METHODS We obtained patient, injury, and resuscitation characteristics from the 2017 to 2020 Trauma Quality Improvement Program database of children and adolescents (younger than 18 years) who arrived with or without signs of life and died. We performed univariate analysis and a multivariable logistic regression to analyze the association between the time to death and the occurrence of transfusion within 4 hours after hospital arrival controlling for initial vital signs, injury type, body regions injured, and scene versus transfer status. RESULTS We included 6,063 children who died from either a blunt or penetrating injury. We observed that children who died within 15 minutes had lower odds of receiving a transfusion (odds ratio, 0.1; 95% confidence interval, 0.1-0.2) compared with those who survived longer. We estimated that survival bias that occurs when using transfusion administration alone to define hemorrhagic shock may occur in up to 11% of all children who died following a blunt or penetrating injury but less than 1% of all children managed as trauma activations. CONCLUSION Using the occurrence of transfusion alone may underestimate the number of children who die from uncontrolled hemorrhage early after injury. Additional variables than just transfusion administration are needed to more accurately identify the presence of hemorrhagic shock among injured children and adolescents. LEVEL OF EVIDENCE Prognostic and Epidemiological; Level III.
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MESH Headings
- Humans
- Shock, Hemorrhagic/therapy
- Shock, Hemorrhagic/mortality
- Shock, Hemorrhagic/etiology
- Shock, Hemorrhagic/diagnosis
- Child
- Female
- Male
- Retrospective Studies
- Adolescent
- Blood Transfusion/statistics & numerical data
- Child, Preschool
- Infant
- Bias
- Wounds, Penetrating/mortality
- Wounds, Penetrating/therapy
- Wounds, Penetrating/complications
- Wounds, Penetrating/diagnosis
- Wounds, Nonpenetrating/mortality
- Wounds, Nonpenetrating/therapy
- Wounds, Nonpenetrating/diagnosis
- Wounds, Nonpenetrating/complications
- Resuscitation/methods
- Resuscitation/statistics & numerical data
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Affiliation(s)
- Travis M Sullivan
- From the Division of Trauma and Burn Surgery (T.M.S., G.J.S., W.V.G.-T., R.S.B.), Children's National Hospital, Washington, DC; Department of Surgery (A.R.J.), University of California San Francisco; and Division of Pediatric Surgery (A.R.J.), UCSF Benioff Children's Hospitals, San Francisco, CA
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3
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Grisel B, Gordee A, Kuchibhatla M, Ginsberg Z, Agarwal S, Haines K. Outcomes by time-to-OR for penetrating abdominal trauma patients. Am J Emerg Med 2024; 79:144-151. [PMID: 38432154 DOI: 10.1016/j.ajem.2024.02.018] [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] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/18/2023] [Accepted: 02/09/2024] [Indexed: 03/05/2024] Open
Abstract
INTRODUCTION Time-To-OR is a critical process measure for trauma performance. However, this measure has not consistently demonstrated improvement in outcome. STUDY DESIGN Using TQIP, we identified facilities by 75th percentile time-to-OR to categorize slow, average, and fast hospitals. Using a GEE model, we calculated odds of mortality for all penetrating abdominal trauma patients, firearm injuries only, and patients with major complication by facility speed. We additionally estimated odds of mortality at the patient level. RESULTS Odds of mortality for patients at slow facilities was 1.095; 95% CI: 0.746, 1.608; p = 0.64 compared to average. Fast facility OR = 0.941; 95% CI: 0.780, 1.133; p = 0.52. At the patient-level each additional minute of time-to-OR was associated with 1.5% decreased odds of in-hospital mortality (OR 0.985; 95% CI:0.981, 0.989; p < 0.001). For firearm-only patients, facility speed was not associated with odds of in-hospital mortality (p-value = 0.61). Person-level time-to-OR was associated with 1.8% decreased odds of in-hospital mortality (OR 0.982; 95% CI: 0.977, 0.987; p < 0.001) with each additional minute of time-to-OR. Similarly, failure-to-rescue analysis showed no difference in in-hospital mortality at the patient level (p = 0.62) and 0.4% decreased odds of in-hospital mortality with each additional minute of time-to-OR at the patient level (OR 0.996; 95% CI: 0.993, 0.999; p = 0.004). CONCLUSION Despite the use of time-to-OR as a metric of trauma performance, there is little evidence for improvement in mortality or complication rate with improved time-to-OR at the facility or patient level. Performance metrics for trauma should be developed that more appropriately approximate patient outcome.
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Affiliation(s)
- Braylee Grisel
- Division of Trauma and Acute Care Surgery, Department of Surgery, Duke University Medical Center, Durham, NC, USA.
| | - Alexander Gordee
- Department of Biostatistics, Duke University School of Medicine, Durham, NC, USA.
| | | | - Zachary Ginsberg
- Division of Trauma and Acute Care Surgery, Department of Surgery, Duke University Medical Center, Durham, NC, USA.
| | - Suresh Agarwal
- Division of Trauma and Acute Care Surgery, Department of Surgery, Duke University Medical Center, Durham, NC, USA.
| | - Krista Haines
- Division of Trauma and Acute Care Surgery, Department of Surgery, Duke University Medical Center, Durham, NC, USA.
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Alcasid NJ, Banks KC, Susai CJ, Victorino GP. Early Abnormal Vital Signs Predict Poor Outcomes in Normotensive Patients Following Penetrating Trauma. J Surg Res 2024; 295:393-398. [PMID: 38070252 DOI: 10.1016/j.jss.2023.11.018] [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] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/01/2023] [Revised: 10/17/2023] [Accepted: 11/12/2023] [Indexed: 02/25/2024]
Abstract
INTRODUCTION Because trauma patients in class II shock (blood loss of 15%-30% of total blood volume) arrive normotensive, this makes the identification of shock and subsequent prognostication of outcomes challenging. Our aim was to identify early predictive factors associated with worse outcomes in normotensive patients following penetrating trauma. We hypothesize that abnormalities in initial vital signs portend worse outcomes in normotensive patients following penetrating trauma. METHODS A retrospective review was performed from 2006 to 2021 using our trauma database and included trauma patients presenting with penetrating trauma with initial normotensive blood pressures (systolic blood pressure ≥90 mmHg). We compared those with a narrow pulse pressure (NPP ≤25% of systolic blood pressure), tachycardia (heart rate ≥100 beats per minute), and elevated shock index (SI ≥ 0.8) to those without. Outcomes included mortality, intensive care unit admission, and ventilator use. Chi-squared, Mann-Whitney tests, and regression analyses were performed as appropriate. RESULTS We identified 7618 patients with penetrating injuries and normotension on initial trauma bay assessment. On univariate analysis, NPP, tachycardia, and elevated SI were associated with increases in mortality compared to those without. On multivariable logistic regression, only NPP and tachycardia were independently associated with mortality. Tachycardia and an elevated SI were both independently associated with intensive care unit admission. Only an elevated SI had an independent association with ventilator requirements, while an NPP and tachycardia did not. CONCLUSIONS Immediate trauma bay NPP and tachycardia are independently associated with mortality and adverse outcomes and may provide an opportunity for improved prognostication in normotensive patients following penetrating trauma.
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Affiliation(s)
- Nathan J Alcasid
- Department of Surgery, University of California, San Francisco- East Bay, Oakland, California.
| | - Kian C Banks
- Department of Surgery, University of California, San Francisco- East Bay, Oakland, California
| | - Cynthia J Susai
- Department of Surgery, University of California, San Francisco- East Bay, Oakland, California
| | - Gregory P Victorino
- Department of Surgery, University of California, San Francisco- East Bay, Oakland, California
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Huebinger R, Ketterer AR, Hill MJ, Mann NC, Wang RC, Montoy JCC, Osborn L, Ugalde IT. National community disparities in prehospital penetrating trauma adjusted for income, 2020-2021. Am J Emerg Med 2024; 77:183-186. [PMID: 38163413 DOI: 10.1016/j.ajem.2023.12.015] [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] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/05/2023] [Accepted: 12/07/2023] [Indexed: 01/03/2024] Open
Abstract
INTRODUCTION While Black individuals experienced disproportionately increased firearm violence and deaths during the COVID-19 pandemic, less is known about community level disparities. We sought to evaluate national community race and ethnicity differences in 2020 and 2021 rates of penetrating trauma. METHODS We linked the 2018-2021 National Emergency Medical Services Information System databases to ZIP Code demographics. We stratified encounters into majority race/ethnicity communities (>50% White, Black, or Hispanic/Latino). We used logistic regression to compare penetrating trauma for each community in 2020 and 2021 to a combined 2018-2019 historical baseline. Majority Black and majority Hispanic/Latino communities were compared to majority White communities for each year. Analyses were adjusted for household income. RESULTS We included 87,504,097 encounters (259,449 penetrating traumas). All communities had increased odds of trauma in 2020 when compared to 2018-2019, but this increase was largest for Black communities (aOR 1.4, [1.3-1.4]; White communities - aOR 1.2, [1.2-1.3]; Hispanic/Latino communities - aOR 1.1. [1.1-1.2]). There was a similar trend of increased penetrating trauma in 2021 for Black (aOR 1.2, [1.2-1.3]); White (aOR 1.2, [1.1-1.2]); Hispanic/Latino (aOR 1.1, [1.1-1.1]). Comparing penetrating trauma in each year to White communities, Black communities had higher odds of trauma in all years (2018/2019 - aOR 3.0, [3.0-3.1]; 2020 - aOR 3.3, [3.3-3.4]; 2021 - aOR 3.3, [3.2-3.2]). Hispanic/Latino also had more trauma each year but to a lesser degree (2018/2019 - aOR 2.0, [2.0-2.0]; 2020 - aOR 1.8, [1.8-1.9]; 2021 - aOR 1.9, [1.8-1.9]). CONCLUSION Black communities were most impacted by increased penetrating trauma rates in 2020 and 2021 even after adjusting for income.
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Affiliation(s)
- Ryan Huebinger
- Department of Emergency Medicine, University of New Mexico, Albuquerque, NM, United States of America.
| | - Andrew R Ketterer
- Department of Emergency Medicine, Beth Israel Deaconess Medical Center-Harvard Medical School, Boston, MA, United States of America.
| | - Mandy J Hill
- Department of Emergency Medicine, McGovern Medical School at the University of Texas Health Science Center at Houston (UTHealth), Houston, TX, United States of America.
| | - N Clay Mann
- Department of Pediatrics, University of Utah School of Medicine, Salt Lake City, UT, United States of America.
| | - Ralph C Wang
- Department of Emergency Medicine, University of California San Francisco, San Francisco, CA, United States of America.
| | - Juan Carlos C Montoy
- Department of Emergency Medicine, University of California San Francisco, San Francisco, CA, United States of America.
| | - Lesley Osborn
- Department of Emergency Medicine, University of Colorado Anschutz Medical Campus School of Medicine, Aurora, CO, United States of America.
| | - Irma T Ugalde
- Department of Emergency Medicine, McGovern Medical School at the University of Texas Health Science Center at Houston (UTHealth), Houston, TX, United States of America.
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Tucker H, Griggs JE, Gavrilovski M, Rahman S, Simpson C, Lyon RM, Hudson A. Prehospital Management of Penetrating Neck Injuries: An Evaluation of Practice. Air Med J 2024; 43:23-27. [PMID: 38154835 DOI: 10.1016/j.amj.2023.09.004] [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] [Received: 07/06/2023] [Accepted: 09/02/2023] [Indexed: 12/30/2023]
Abstract
OBJECTIVE Penetrating neck injuries (PNIs) can occur at multiple anatomic sites and involve airway, nerve, vascular, and gastrointestinal structures. They pose a unique challenge to clinicians, especially in the prehospital setting. Published guidance on the prehospital management of PNIs is limited, and there is no review of the current prehospital practice. METHODS A retrospective electronic case note review of PNIs managed within 1 UK helicopter emergency medical service (HEMS) over a 7-year period was undertaken. Data were collected on the zone of injury, mechanism of injury, prehospital times, patient demographics, prehospital interventions, and on-scene mortality. RESULTS Ninety-eight patients met the study inclusion criteria, 40% of whom had zone 2 neck injuries. Eighty-three percent were male with a mean age of 42 years. The predominant injury mechanism was interpersonal violence (51%) followed by self-harm (47%). Fifteen percent underwent prehospital emergency anesthesia, 17% underwent prehospital blood transfusion, and 30% had a hemostatic dressing applied. No patients underwent cervical spine immobilization. One percent underwent resuscitative thoracotomy. Five percent were pronounced life extinct after HEMS arrival following interventions by the HEMS team. CONCLUSION Time-critical and emergent interventions in this select patient population must be minimal and focus on optimizing care during rapid transfer to the hospital. Airway and hemorrhagic pathologies must be managed, often concomitantly. Targeted injury prevention to reduce interpersonal violence must ensue. The author group intends to devise a national Delphi and derive consensus guidelines for the management of prehospital PNIs.
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Affiliation(s)
- Harriet Tucker
- Air Ambulance Charity Kent Surrey Sussex, Surrey, United Kingdom; St George's Hospital, London, United Kingdom
| | - Joanne E Griggs
- Air Ambulance Charity Kent Surrey Sussex, Surrey, United Kingdom; School of Health Sciences, University of Surrey, Guildford, Surrey, United Kingdom.
| | - Maja Gavrilovski
- Air Ambulance Charity Kent Surrey Sussex, Surrey, United Kingdom; St Thomas' Hospital, London, United Kingdom
| | - Shah Rahman
- Air Ambulance Charity Kent Surrey Sussex, Surrey, United Kingdom
| | | | - Richard M Lyon
- Air Ambulance Charity Kent Surrey Sussex, Surrey, United Kingdom; School of Health Sciences, University of Surrey, Guildford, Surrey, United Kingdom
| | - Anthony Hudson
- Air Ambulance Charity Kent Surrey Sussex, Surrey, United Kingdom; St George's Hospital, London, United Kingdom
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Gorenshtein L, Leraas H, Eze A, Lumpkin S, Chime C, Chang D, Wischmeyer P, Agarwal S, Fernandez J, Haines KL. The Use of Parenteral Nutrition and Disparities in Its Allocation Following Traumatic Injury. J Surg Res 2024; 293:121-127. [PMID: 37738853 DOI: 10.1016/j.jss.2023.07.036] [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] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/02/2022] [Revised: 07/08/2023] [Accepted: 07/24/2023] [Indexed: 09/24/2023]
Abstract
INTRODUCTION Severe traumatic injury requires rapid and extensive deployment of resources to save the lives of the critically injured. The sequelae of traumatic injuries frequently require extensive intervention obligating patients to a complicated recovery process devoid of meaningful nutrition. In this setting, parenteral nutrition (PN) is key in enabling appropriate wound healing, recovery, and rehabilitation. We sought to examine the use of PN in adult trauma management and to highlight any disparities in the utilization of PN in adult trauma patients. METHODS We queried the 2017-2019 Trauma Quality Improvement Program (TQIP) for adult patients (aged > 18 y) who sustained blunt or penetrating traumatic injuries and received PN as part of their hospitalization. We compared time to PN administration based on demographics. We then used a multivariable logistic regression model to identify factors associated with the use of PN. We hypothesized that PN would be less commonly employed in the uninsured and minority groups. RESULTS We identified 2,449,498 patients with sufficient data for analysis. Of these, 1831 patients were treated with PN. On univariate analysis, PN patients were more commonly male (74.7% PN versus 60.2% non-PN; P < 0.001). PN use was more frequent in the Black population (24.3% PN versus 15.5% non-PN; P < 0.001) and less frequent in the White population (72.7% PN versus 81.2% non-PN; P < 0.001). PN use was also much more common among patients covered by Medicaid. Penetrating trauma was over twice as common among PN recipients relative to non-PN patients (% PN versus % non-PN). PN patients had higher injury severity scores (ISSs), more intensive care unit days, longer hospitalizations, and increased mortality compared to non-PN patients. PN patients were half as likely to discharge home and twice as likely to discharge to a long-term care facility. Multivariable analysis including age, race, trauma mechanism, primary payer, and ISS, demonstrated an association of PN use with increasing age (OR 1.01, P < 0.001), cases of penetrating trauma (odds ratio [OR], 2.47; P < 0.001), and patients with high ISS (OR, 0.1.06; P < 0.001). There was decreased use in Uninsured patient (OR, 0.54; P < 0.001). CONCLUSIONS PN use following traumatic injury is rarely required. Patients treated with PN typically have a resource-intense hospital course. More severe injuries, penetrating trauma, and increased age are more likely to result in PN use. Variations in PN use are apparent based on insurance payer, further examination into allocation of hospital and intensive care resources, as it pertains to patient socioeconomic status, is warranted in light of these findings.
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Affiliation(s)
| | - Harold Leraas
- Department of Surgery, Duke University, Durham, North Carolina.
| | - Anthony Eze
- Department of Surgery, Duke University, Durham, North Carolina
| | | | - Chinecherem Chime
- School of Medicine, Howard University College of Medicine, Washington, District of Columbia
| | - Doreen Chang
- Department of Surgery, Duke University, Durham, North Carolina
| | - Paul Wischmeyer
- Department of Surgery, Duke University, Durham, North Carolina
| | - Suresh Agarwal
- Department of Surgery, Duke University, Durham, North Carolina
| | | | - Krista L Haines
- Department of Surgery, Duke University, Durham, North Carolina
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Breeding T, Rosander A, Abella M, Martinez B, Maka P, Elkbuli A. Retrospective Study of EMS Scene Times and Mortality in Penetrating Trauma Patients: Improving Transport Standards and Patient Outcomes. Am Surg 2024; 90:46-54. [PMID: 37489560 DOI: 10.1177/00031348231191224] [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] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 07/26/2023]
Abstract
BACKGROUND This study aimed to determine the impact of emergency medical service (EMS) scene time variability on adult and pediatric trauma patient outcomes with moderate or severe penetrating injuries. METHODS This retrospective study analyzed the American College of Surgeons (ACS) Trauma Quality Improvement Program (TQIP) database between 2017 and 2020 to evaluate the relationship between EMS scene time on adult and pediatric patients with moderate to severe injuries. Primary outcomes included Dead on Arrival (DOA) to the Emergency Department (ED), ED mortality, 24-hour mortality, and in-hospital mortality. Multivariable logistic regression models were used to examine the association of each EMS scene time category and mortality. RESULTS Adult patients with 10-30 minutes of EMS scene time had increased odds of experiencing ED mortality, 24-hour mortality, and in-hospital mortality. Adults with >30 minutes of EMS scene time were more likely to be DOA to the ED. There was no significant association with mortality for patients with <10 minutes of EMS scene time. In the pediatric subset of patients, those with 10-30 minutes of EMS scene time were more likely to experience ED mortality and in-hospital mortality. CONCLUSION EMS scene times less than 10 minutes were associated with the greatest odds of survival, supporting the "load and go" theory for penetrating trauma. Our study suggests that even an EMS scene time of 10-30 minutes results in a significantly increased risk of mortality, and further efforts are needed to improve scene time through improved EMS and hospital policies.
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Affiliation(s)
- Tessa Breeding
- Dr. Kiran C. Patel College of Allopathic Medicine, NOVA Southeastern University, Fort Lauderdale, FL, USA
| | - Abigail Rosander
- Arizona College of Osteopathic Medicine, Midwestern University, Glendale, AZ, USA
| | | | - Brian Martinez
- Dr. Kiran C. Patel College of Allopathic Medicine, NOVA Southeastern University, Fort Lauderdale, FL, USA
| | - Piueti Maka
- John A. Burns School of Medicine, Honolulu, HI, USA
| | - Adel Elkbuli
- Department of Surgery, Division of Trauma and Surgical Critical Care, Orlando Regional Medical Center, Orlando, FL, USA
- Department of Surgical Education, Orlando Regional Medical Center, Orlando, FL, USA
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Krammel M, Frimmel N, Hamp T, Grassmann D, Widhalm H, Verdonck P, Reisinger C, Sulzgruber P, Schnaubelt S. Outcomes and potential for improvement in the prehospital treatment of penetrating chest injuries in a European metropolitan area: A retrospective analysis of 2009 - 2017. Injury 2024; 55:110971. [PMID: 37544864 DOI: 10.1016/j.injury.2023.110971] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/15/2023] [Revised: 07/08/2023] [Accepted: 08/01/2023] [Indexed: 08/08/2023]
Abstract
BACKGROUND Trauma is the leading cause of death in patients <45 years living in high-resource settings. However, penetrating chest injuries are still relatively rare in Europe - with an upwards trend. These cases are of particular interest to emergency medical services (EMS) due to available invasive treatment options like chest tube placement or resuscitative thoracotomy. To date, there is no sufficient data from Austria regarding penetrating chest trauma in a metropolitan area, and no reliable source to base decisions regarding further skill proficiency training on. METHODS For this retrospective observational study, we screened all trauma emergency responses of the Viennese EMS between 01/2009 and 12/2017 and included all those with a National Advisory Committee for Aeronautics (NACA) score ≥ IV (= potentially life-threatening). Data were derived from EMS mission documentations and hospital files, and for those cases with the injuries leading to cardiopulmonary resuscitation (CPR), we assessed the EMS cardiac arrest registry and consulted a forensic physician. RESULTS We included 480 cases of penetrating chest injuries of NACA IV-VII (83% male, 64% > 30 years old, 74% stab wounds, 16% cuts, 8% gunshot wounds, 56% inflicted by another party, 26% self-inflicted, 18% unknown). In the study period, the incidence rose from 1.4/100,000 to 3.5/100,000 capita, and overall, about one case was treated per week. In the cases with especially severe injury patterns (= NACA V-VII, 43% of total), (tension-)pneumothorax was the most common injury (29%). The highest mortality was seen in injuries to pulmonary vessels (100%) or the heart (94%). Fifty-eight patients (12% of total) deceased, whereas in 15 cases, the forensic physician stated survival could theoretically have been possible. However, only five of these CPR patients received at least unilateral thoracostomy. Regarding all penetrating chest injuries, thoracostomy had only been performed in eight patients. CONCLUSIONS Severe cases of penetrating chest trauma are rare in Vienna and happened about once a week between 2009 and 2017. Both incidence and case load increased over the years, and potentially life-saving invasive procedures were only reluctantly applied. Therefore, a structured educational and skill retention approach aimed at both paramedics and emergency physicians should be implemented. TRIAL REGISTRATION Retrospective analysis without intervention.
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Affiliation(s)
| | - Nikolaus Frimmel
- Dept. of Anaesthesia, General Intensive Care Medicine, and Pain Therapy, Medical University of Vienna, Vienna, Austria
| | - Thomas Hamp
- Emergency Medical Service Vienna, Vienna, Austria; Dept. of Anaesthesia, General Intensive Care Medicine, and Pain Therapy, Medical University of Vienna, Vienna, Austria
| | | | - Harald Widhalm
- Dept. of Orthopedics and Trauma Surgery, Medical University of Vienna, Vienna, Austria
| | - Philip Verdonck
- Dept. of Emergency Medicine, Antwerp University Hospital, Edegem, Belgium
| | | | - Patrick Sulzgruber
- Division of Cardiology, Dept. of Internal Medicine II, Medical University of Vienna, Vienna, Austria
| | - Sebastian Schnaubelt
- Dept. of Emergency Medicine, Antwerp University Hospital, Edegem, Belgium; Dept. of Emergency Medicine, Medical University of Vienna, Vienna, Austria.
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10
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Chang YR, Kuo LW, Hsu TA, Tee YS, Fu CY, Bajani F, Mis J, Poulakidas S, Bokhari F. The Role of Open Cardiopulmonary Resuscitation in Chest Trauma Patients with No Sign of Life: A National Trauma Data Bank Study. World J Surg 2023; 47:3107-3113. [PMID: 37740005 DOI: 10.1007/s00268-023-07180-5] [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] [Accepted: 08/26/2023] [Indexed: 09/24/2023]
Abstract
PURPOSE The effectiveness of open cardiopulmonary resuscitation (OCPR) remains controversial for trauma patients. In this current study, the role of OCPR in managing chest trauma patients is evaluated using nationwide real-world data. METHODS From 2014 to 2015, the National Trauma Data Bank was retrospectively queried for chest trauma patients with out-of-hospital cardiac arrest status. The emergency department (ED) and overall survival of patients without signs of life were analyzed. Multivariate logistic regression (MLR) analysis was performed to evaluate independent factors of mortality for the target group. Furthermore, a subset group of patients who survived after the ED were studied, focusing on the duration of survival after leaving the ED. RESULTS A total of 911 patients were enrolled in this study (OCPR vs. non-OCPR: 161 patients vs. 750 patients). The average overall mortality rate was 98.6% (N = 898). Among penetrating chest trauma patients, non-survivors in the ED had significantly higher proportions of gunshot injuries (83.9% vs. 69.7%, p = 0.001) and lower proportions of OCPR (20.7% vs. 44.4%, p < 0.001). MLR analysis showed that gunshot injuries and non-OCPR were significantly related to ED mortality in penetrating trauma patients without signs of life (odds ratio = 2.039, p = 0.006 and odds ratio = 2.900, p < 0.001, respectively). However, the overall survival rate of patients after ED survival (n = 99) was 9.9%, and only 21.2% (n = 21) of them survived more than 1 day after leaving the ED. CONCLUSION OCPR could be considered in situations where appropriate indications exist. The survival benefit was observed in critically ill patients with penetrating chest trauma who show no signs of life. By enhancing ED survival, OCPR may also contribute to overall survival improvement.
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Affiliation(s)
- Yau-Ren Chang
- Department of Trauma and Emergency Surgery, Chang Gung Memorial Hospital, Chang Gung University, 5, Fu-Hsing Street, Kwei Shan Township, Taipei, Taoyuan, Taiwan
| | - Ling-Wei Kuo
- Department of Trauma and Burn Surgery, Stroger Hospital of Cook County, Rush University, Chicago, USA
| | - Ting-An Hsu
- Department of Trauma and Emergency Surgery, Chang Gung Memorial Hospital, Chang Gung University, 5, Fu-Hsing Street, Kwei Shan Township, Taipei, Taoyuan, Taiwan
| | - Yu-San Tee
- Department of Trauma and Emergency Surgery, Chang Gung Memorial Hospital, Chang Gung University, 5, Fu-Hsing Street, Kwei Shan Township, Taipei, Taoyuan, Taiwan.
- Department of Trauma and Burn Surgery, Stroger Hospital of Cook County, Rush University, Chicago, USA.
| | - Chih-Yuan Fu
- Department of Trauma and Emergency Surgery, Chang Gung Memorial Hospital, Chang Gung University, 5, Fu-Hsing Street, Kwei Shan Township, Taipei, Taoyuan, Taiwan
- Department of Trauma and Burn Surgery, Stroger Hospital of Cook County, Rush University, Chicago, USA
| | - Francesco Bajani
- Department of Trauma and Burn Surgery, Stroger Hospital of Cook County, Rush University, Chicago, USA
| | - Justin Mis
- Department of Trauma and Burn Surgery, Stroger Hospital of Cook County, Rush University, Chicago, USA
| | - Stathis Poulakidas
- Department of Trauma and Burn Surgery, Stroger Hospital of Cook County, Rush University, Chicago, USA
| | - Faran Bokhari
- Department of Trauma and Burn Surgery, Stroger Hospital of Cook County, Rush University, Chicago, USA
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Renberg M, Dahlberg M, Gellerfors M, Rostami E, Günther M. Prehospital and emergency department airway management of severe penetrating trauma in Sweden during the past decade. Scand J Trauma Resusc Emerg Med 2023; 31:85. [PMID: 38001526 PMCID: PMC10675952 DOI: 10.1186/s13049-023-01151-4] [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] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/25/2023] [Accepted: 11/11/2023] [Indexed: 11/26/2023] Open
Abstract
BACKGROUND Prehospital tracheal intubation (TI) is associated with increased mortality in patients with penetrating trauma, and the utility of prehospital advanced airway management is debated. The increased incidence of deadly violence in Sweden warrants a comprehensive evaluation of current airway management for patients with penetrating trauma in the Swedish prehospital environment and on arrival in the emergency department (ED). METHODS This was an observational, multicenter study of all patients with penetrating trauma and injury severity scores (ISSs) ≥ 15 included in the Swedish national trauma register (SweTrau) between 2011 and 2019. We investigated the frequency and characteristics of prehospital and ED TI, including 30-day mortality and patient characteristics associated with TI. RESULT Of 816 included patients, 118 (14.5%) were intubated prehospitally, and 248 (30.4%) were intubated in the ED. Patients who were intubated prehospitally had a higher ISS, 33 (interquartile range [IQR] 25, 75), than those intubated in the ED, 25 (IQR 18, 34). Prehospital TI was associated with a higher associated mortality, OR 4.26 (CI 2.57, 7.27, p < 0.001) than TI in the ED, even when adjusted for ISS (OR 2.88 [CI 1.64, 5.14, p < 0.001]). Hemodynamic collapse (≤ 40 mmHg) and low GCS score (≤ 8) were the characteristics most associated with prehospital TI. Traumatic cardiac arrests (TCAs) occurred in 154 (18.9%) patients, of whom 77 (50%) were intubated prehospitally and 56 (36.4%) were intubated in the ED. A subgroup analysis excluding TCA showed that patients with prehospital TI did not have a higher mortality rate than those with ED TI, OR 2.07 (CI 0.93, 4.51, p = 0.068), with OR 1.39 (0.56, 3.26, p = 0.5) when adjusted for ISS. CONCLUSION Prehospital TI was associated with a higher mortality rate than those with ED TI, which was specifically related to TCA; intubation did not affect mortality in patients without cardiac arrest. Mortality was high when airway management was needed, regardless of cardiac arrest, thereby emphasizing the challenges posed when anesthesia is needed. Several interventions, including whole blood transfusions, the implementation of second-tier EMS units and measures to shorten scene times, have been initiated in Sweden to counteract these challenges.
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Affiliation(s)
- Mattias Renberg
- Department of Anesthesiology and Intensive Care, Södersjukhuset, Sjukhusbacken, 10, S1 SE-118 83, Stockholm, Sweden.
| | - Martin Dahlberg
- Department of Surgery, Södersjukhuset, Karolinska Institutet, Stockholm, Sweden
| | - Mikael Gellerfors
- Department of Perioperative Medicine and Intensive Care, Karolinska University Hospital, Stockholm, Sweden
- Rapid Response Car, Capio, Stockholm, Sweden
- Department of Physiology and Pharmacology, Karolinska Institutet, Stockholm, Sweden
- Swedish Air Ambulance (SLA), Mora, Sweden
| | - Elham Rostami
- Experimental Traumatology Unit, Department of Neuroscience, Karolinska Institutet, Stockholm, Sweden
- Department of Medical Sciences, Neurosurgery, Uppsala University, Uppsala, Sweden
| | - Mattias Günther
- Department of Anesthesiology and Intensive Care, Södersjukhuset, Sjukhusbacken, 10, S1 SE-118 83, Stockholm, Sweden
- Experimental Traumatology Unit, Department of Neuroscience, Karolinska Institutet, Stockholm, Sweden
- Department of Clinical Science and Education, Södersjukhuset, Karolinska Institutet, Stockholm, Sweden
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Paulson MW, Rossetto M, McKay JT, Bebarta VS, Flarity K, Keenan S, Schauer SG. Association of Prehospital Neck Wound Survivability and Battlefield Medical Evacuation Time in Afghanistan. Mil Med 2023; 188:185-191. [PMID: 37948214 DOI: 10.1093/milmed/usad080] [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] [Received: 12/09/2022] [Revised: 02/13/2023] [Accepted: 03/03/2023] [Indexed: 11/12/2023] Open
Abstract
INTRODUCTION The U.S. Military's Golden Hour policy led to improved warfighter survivability during the Global War on Terror. The policy's success is well-documented, but a categorical evaluation and stratification of medical evacuation (MEDEVAC) times based on combat injury is lacking. METHODS We queried the Department of Defense Joint Trauma System Prehospital Trauma Registry for casualties with documented penetrating neck trauma in Afghanistan requiring battlefield MEDEVAC from June 15, 2009, through February 1, 2021. Casualties were excluded if the time from the point of injury to reach higher level medical care was not documented, listed as zero, or exceeded 4 hours. They were also excluded if demographic data were incomplete or deemed unreliable or if their injuries occurred outside of Afghanistan.We designed a logistic regression model to test for associations in survivability, adjusting for composite injury severity score, patient age group, and type of next higher level of care reached. We then used our model to interpolate MEDEVAC times associated with 0.1%, 1%, and 10% increased risk of death for an incapacitated casualty with penetrating neck trauma. RESULTS Of 1,147 encounters, 444 casualties met inclusion criteria. Of these casualties, 430 (96.9%) survived to discharge. Interpolative analysis of our multivariable logistic regression model showed that MEDEVAC times ≥8 minutes, ≥53 minutes, and ≥196 minutes are associated with a 0.1%, 1%, and 10% increased risk of mortality from baseline, respectively. CONCLUSIONS Our data characterize the maximum MEDEVAC times associated with 0.1%, 1%, and 10% increased risk of death from baseline survivability for penetrating battlefield neck trauma in Afghanistan.
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Affiliation(s)
- Matthew W Paulson
- University of Colorado School of Medicine, Aurora, CO 80045, USA
- University of Colorado Center for COMBAT Research, University of Colorado School of Medicine, Aurora, CO 80045, USA
- Colorado National Guard Medical Detachment, Buckley Space Force Base, Aurora, CO, USA
| | - Marika Rossetto
- University of Colorado School of Medicine, Aurora, CO 80045, USA
- University of Colorado Center for COMBAT Research, University of Colorado School of Medicine, Aurora, CO 80045, USA
| | - Jerome T McKay
- University of Colorado School of Medicine, Aurora, CO 80045, USA
- Department of Biomedical Informatics, University of Colorado School of Medicine, Aurora, CO 80045, USA
| | - Vikhyat S Bebarta
- University of Colorado School of Medicine, Aurora, CO 80045, USA
- University of Colorado Center for COMBAT Research, University of Colorado School of Medicine, Aurora, CO 80045, USA
- 59th Medical Wing, JBSA Lackland, TX 78236, USA
| | - Kathleen Flarity
- University of Colorado School of Medicine, Aurora, CO 80045, USA
- University of Colorado Center for COMBAT Research, University of Colorado School of Medicine, Aurora, CO 80045, USA
| | - Sean Keenan
- University of Colorado Center for COMBAT Research, University of Colorado School of Medicine, Aurora, CO 80045, USA
- Joint Trauma System, Defense Health Agency, JBSA-Fort Sam Houston, TX 78234, USA
- Uniformed Services University of the Health Sciences, Bethesda, MD 20814, USA
| | - Steven G Schauer
- 59th Medical Wing, JBSA Lackland, TX 78236, USA
- Uniformed Services University of the Health Sciences, Bethesda, MD 20814, USA
- Department of Emergency Medicine, Brooke Army Medical Center, Fort Sam Houston, TX 78234, USA
- U.S. Army Institute of Surgical Research, JBSA-Fort Sam Houston, TX 782347, USA
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Huebinger R, Chan HK, Reed J, Mann NC, Fisher B, Osborn L. National trends in prehospital penetrating trauma in 2020 and 2021. Am J Emerg Med 2023; 72:183-187. [PMID: 37544146 DOI: 10.1016/j.ajem.2023.07.022] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [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: 06/15/2023] [Revised: 07/07/2023] [Accepted: 07/10/2023] [Indexed: 08/08/2023] Open
Abstract
OBJECTIVE Prior studies identified increased penetrating trauma rates during the earlier phase of the COVID-19 pandemic, but there is limited study of penetrating trauma rates in 2021 or at a national level. We evaluated trends in prehospital encounters for penetrating trauma in 2020 and 2021 using a national database. METHODS We conducted a retrospective analysis of the National Emergency Medicinal Services (EMS) Information System (NEMSIS) combined 2018-2021 databases of prehospital encounters. We calculated penetrating trauma yearly and monthly rates with 95% confidence; both overall and for each census region. We compared trauma rates in 2020 and 2021 to combined 2018/2019. RESULTS There were 67,457 (rate of 0.30%) penetrating traumas in 2018, 86,054 (0.30%) in 2019, 95,750 (0.37%) in 2020, and 98,040 (0.34%) in 2021. Nationally, trauma rates were higher from March 2020 to July 2021 than baseline. Penetrating trauma rates from May-December 2021 were lower than May-December of 2020. All census regions similarly had increased trauma rates during from March 2020 to July 2021. CONCLUSION We identified elevated rates of trauma on 2020 that lasted until July of 2021 that was present in all US census regions.
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Affiliation(s)
- Ryan Huebinger
- McGovern Medical School at the University of Texas Health Science Center at Houston (UTHealth), Department of Emergency Medicine, Houston, TX, United States of America; Texas Emergency Medicine Research Center, Houston, TX, United States of America.
| | - Hei Kit Chan
- McGovern Medical School at the University of Texas Health Science Center at Houston (UTHealth), Department of Emergency Medicine, Houston, TX, United States of America; Texas Emergency Medicine Research Center, Houston, TX, United States of America.
| | - Justin Reed
- Cy-Fair Fire Department, Houston, TX, United States of America.
| | - N Clay Mann
- University of Utah School of Medicine, Department of Pediatrics, Salt Lake City, UT, United States of America.
| | - Benjamin Fisher
- University of Utah School of Medicine, Department of Pediatrics, Salt Lake City, UT, United States of America.
| | - Lesley Osborn
- McGovern Medical School at the University of Texas Health Science Center at Houston (UTHealth), Department of Emergency Medicine, Houston, TX, United States of America; Texas Emergency Medicine Research Center, Houston, TX, United States of America.
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Atkins K, Schneider A, Gallaher J, Charles A. The effect of transport mode on mortality following isolated penetrating torso Trauma. Am J Surg 2023; 226:542-547. [PMID: 37453802 PMCID: PMC10528673 DOI: 10.1016/j.amjsurg.2023.06.033] [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] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/10/2023] [Revised: 06/12/2023] [Accepted: 06/26/2023] [Indexed: 07/18/2023]
Abstract
BACKGROUND Prehospital interventions may increase the time to definitive care. Compared to ground ambulance, we hypothesize improved mortality for patients with isolated, penetrating torso injuries transported via private vehicle. METHODS We reviewed the National Trauma Data Bank (2017-2021) for adults with isolated, penetrating torso injuries stratified by mechanism (stabbing vs. firearm) and transport mode (private vehicle vs. ground ambulance). We performed a multivariable logistic regression to estimate the effect of transport mode on mortality. RESULTS 48,444 patients met our inclusion criteria. Patients transported by ambulance, injured by stabbing (n = 26,633) and by firearm (n = 21,811) had adjusted odds ratios of 1.81 (95%CI 1.05-3.14, p = 0.03) and 1.66 (95%CI 1.32-2.09,p < 0.001) respectively for mortality compared to private vehicle transport. CONCLUSION Patients with penetrating torso injuries have nearly twice the odds of mortality when transported by ground ambulance than private vehicles, despite injury severity. The "scoop and run" strategy may confer a survival benefit in this population.
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Affiliation(s)
- Kathryn Atkins
- Department of Surgery, University of North Carolina at Chapel Hill, United States
| | - Andrew Schneider
- Department of Surgery, University of North Carolina at Chapel Hill, United States
| | - Jared Gallaher
- Department of Surgery, University of North Carolina at Chapel Hill, United States
| | - Anthony Charles
- Department of Surgery, University of North Carolina at Chapel Hill, United States.
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15
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Vielsmeier V, Hackenberg S, Schelzig H, Knapsis A. [Update on neck trauma]. HNO 2022; 70:724-735. [PMID: 36066623 DOI: 10.1007/s00106-022-01214-5] [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] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 07/19/2022] [Indexed: 11/26/2022]
Abstract
BACKGROUND Important organs and structures are located in the cervical region. In case of blunt and penetrating trauma, emergency situations may arise. OBJECTIVE Emergency management as well as diagnostic and therapeutic steps pertaining to neck injuries are presented. CONCLUSION Shock therapy and airway management are essential, fast management of neck injuries highly relevant.
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Affiliation(s)
- V Vielsmeier
- Klinik und Poliklinik für Hals-Nasen-Ohrenheilkunde, Universitätsklinikum Regensburg, Regensburg, Deutschland.
| | - S Hackenberg
- Klinik für Hals-Nasen-Ohrenheilkunde, Kopf- und Halschirurgie, Uniklinik RWTH Aachen, Aachen, Deutschland
| | - H Schelzig
- Klinik für Gefäß- und Endovaskularchirurgie, Universitätsklinikum Düsseldorf, Düsseldorf, Deutschland
| | - A Knapsis
- Klinik für Gefäß- und Endovaskularchirurgie, Universitätsklinikum Düsseldorf, Düsseldorf, Deutschland
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Gutierrez A, Matsushima K, Grigorian A, Schellenberg M, Inaba K. Derivation and Validation of a Score Using Prehospital Data to Identify Adults With Trauma Requiring Early Laparotomy. JAMA Netw Open 2022; 5:e2145860. [PMID: 35099548 PMCID: PMC8804917 DOI: 10.1001/jamanetworkopen.2021.45860] [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] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
Abstract
IMPORTANCE A scoring tool to identify which adults with traumatic injury will require early laparotomy could help improve prehospital triage and system readiness. OBJECTIVE To develop and validate a prediction model using prehospital information for early laparotomy following trauma. DESIGN, SETTING, AND PARTICIPANTS This retrospective cohort study analyzed data from the 2017 version of the American College of Surgeons Trauma Quality Improvement Program database. All adult patients with traumatic injury aged 18 years or older who were admitted to a US trauma center in 2017 were included. Patients were randomly assigned to a derivation or validation cohort. Data were collected and analyzed between July 2020 and September 2020. MAIN OUTCOMES AND MEASURES The primary outcome was laparotomy within 2 hours of hospital arrival. A scoring system was developed to predict early laparotomy using a logistic regression model in the derivation cohort. This was validated in the validation cohort using the area under the receiver operating characteristic curve. RESULTS A total of 379 890 US adults with traumatic injury were included; 190 264 patients were in the derivation cohort and 189 626 patients were in the validation cohort. The cohorts had the same proportion of laparotomy within 2 hours of hospital arrival (1.1%). The median (IQR) age was 32 (25-46) years in the early laparotomy group and 54 (33-72) years in the group with no early laparotomy. The early laparotomy group contained 113 776 of 188 211 (60.5%) male patients, while the group with no early laparotomy contained 1702 of 2053 (82.9%) male patients. The variable most strongly associated with early laparotomy was penetrating injury to the head, neck, torso, or extremities proximal to the elbow or knee (odds ratio, 13.47; 95% CI, 12.22-14.86) with a point value of 10 (maximum overall score 20). Other variables included in the scoring system were the male sex, a systolic blood pressure less than 90 mm Hg, a Glasgow Coma Scale of less than or equal to 13, having chest wall instability or deformity, pelvic fracture, and high-risk blunt mechanism. In the validation cohort, the C statistic of the scoring system was 0.78 (95% CI, 0.77-0.79). CONCLUSIONS AND RELEVANCE In this study, a novel scoring tool using prehospital information was derived and validated to identify which adults with traumatic injury will require laparotomy within 2 hours of hospital arrival. This tool may help trauma professionals allocate operative team resources before patient arrival.
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Affiliation(s)
- Adam Gutierrez
- Division of Acute Care Surgery, University of Southern California, Los Angeles, California
| | - Kazuhide Matsushima
- Division of Acute Care Surgery, University of Southern California, Los Angeles, California
| | - Areg Grigorian
- Division of Acute Care Surgery, University of Southern California, Los Angeles, California
| | - Morgan Schellenberg
- Division of Acute Care Surgery, University of Southern California, Los Angeles, California
| | - Kenji Inaba
- Division of Acute Care Surgery, University of Southern California, Los Angeles, California
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17
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Beattie G, Cohan CM, Tang A, Chen JY, Victorino GP. Observational management of penetrating occult pneumothoraces: Outcomes and risk factors for interval tube thoracostomy placement. J Trauma Acute Care Surg 2022; 92:177-184. [PMID: 34538828 DOI: 10.1097/ta.0000000000003415] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [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: 11/25/2022]
Abstract
BACKGROUND Guidelines for penetrating occult pneumothoraces (OPTXs) are based on blunt injury. Further understanding of penetrating OPTX pathophysiology is needed. In observational management of penetrating OPTX, we hypothesized that specific clinical and radiographic features may be associated with interval tube thoracostomy (TT) placement. Our aims were to (1) describe OPTX occurrence in penetrating chest injury, (2) determine the rate of interval TT placement in observational management and clinical outcomes compared with immediate TT placement, and (3) describe risk factors associated with failure of observational management. METHODS Penetrating OPTX patients presenting to our level 1 trauma center from 2004 to 2019 were reviewed. Occult pneumothorax was defined as a pneumothorax on chest computed tomography but not on chest radiograph. Patient groups included immediate TT placement versus observation. Clinical outcomes compared were TT duration and complications, need for additional thoracic procedures, length of stay (LOS), and disposition. Clinical and radiographic factors associated with interval TT placement were determined by multivariable regression. RESULTS Of 629 penetrating pneumothorax patients, 103 (16%) presented with OPTX. Thirty-eight patients underwent immediate TT placement, and 65 were observed. Twelve observed patients (18%) needed interval TT placement. Regardless of initial management strategy, TT placement was associated with longer LOS and more chest radiographs. Chest injury complications and outcomes were similar. Factors associated with increased odds of interval TT placement included Chest Abbreviated Injury Scale score of ≥4 (adjusted odds ratio [aOR], 7.38 [95% confidence interval, 1.43-37.95), positive pressure ventilation (aOR, 7.74 [1.07-56.06]), concurrent hemothorax (aOR, 6.17 [1.08-35.24]), and retained bullet fragment (aOR, 11.62 [1.40-96.62]) (all p < 0.05). CONCLUSION The majority of patients with penetrating OPTX can be successfully observed with improved clinical outcomes (LOS, avoidance of TT complications, reduced radiation). Interval TT intervention was not associated with risk for adverse outcomes. In patients undergoing observation, specific clinical factors (chest injury severity, ventilation) and imaging features (hemothorax, retained bullet) are associated with increased odds for interval TT placement, suggesting need for heightened awareness in these patients. LEVEL OF EVIDENCE Prognostic, level IV.
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Affiliation(s)
- Genna Beattie
- From the Department of Surgery (G.B., C.M.C., A.T., G.P.V.), University of California, San Francisco, East Bay, Oakland; Chemical Sciences Division (J.Y.C.), Lawrence Berkeley National Laboratory, Berkeley, California
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Keskey RC, Slidell MB, Bohr NL, Biermann H, Cirone J, Zakrison T, Cone J, Wilson K, Hampton D. Novel Trauma Composite Score is superior to Injury Severity Score in predicting mortality across all ages. J Trauma Acute Care Surg 2021; 91:621-626. [PMID: 34225345 DOI: 10.1097/ta.0000000000003340] [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: 11/26/2022]
Abstract
BACKGROUND Injury Severity Score (ISS) is a widely used metric for trauma research and center verification; however, it does not account for age-related physiologic parameters. We hypothesized that a novel age-based injury severity metric would better predict mortality. METHODS Adult patients (≥18 years) sustaining blunt trauma (BT) or penetrating trauma (PT) were abstracted from the 2010 to 2016 National Trauma Data Bank. Admission vitals, Glasgow Coma Scale, ISS, mechanism, and outcomes were analyzed. Patients with incomplete/non-physiologic vital signs were excluded. For each age: (1) a cut point analysis was used to determine the ISS with the highest specificity and sensitivity for predicting mortality and (2) a linear discriminant analysis was performed using ISS, ISS greater than 16, Trauma and Injury Severity Score, and Revised Trauma Scale to compare each scoring system's mortality prediction. A novel injury severity metric, the trauma component score (TCS), was developed for each age using significant (p < 0.05) variables selected from Abbreviated Injury Scale scores, Glasgow Coma Scale, vital signs, and gender. Receiver operator curves were developed and the areas under the curve were compared between the TCS and other systems. RESULTS There 777,794 patients studied (BT, 91.1%; PT, 8.9%). Blunt trauma patients were older (53.6 ± 21.3 years vs. 34.4 ± 13.8 years), had higher ISS scores (11.1 ± 8.5 vs. 8.5 ± 8.9), and lower mortality (2.9% vs. 3.4%) than PT patients (p < 0.05). When assessing the entire PT and BT cohort the optimal ISS cut point was 16. The optimal ISS was between 20 and 25 for BT younger than 70 years. For those older than 70 years, the optimal BT ISS steadily declined as age increased PT's cut point was 16 or less for all ages assessed. When the injury metrics were compared by area under the curve, our novel TCS more accurately predicted mortality across all ages in both BT and PT (p < 0.001). CONCLUSION Injury Severity Score is a poor mortality predictor in older patients and those sustaining penetrating trauma. The age-based TCS is a superior metric for mortality prediction across all ages. LEVEL OF EVIDENCE Clinical outcomes, Level IV.
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Affiliation(s)
- Robert C Keskey
- From the Department of Surgery (R.C.K., M.B.S., T.Z., J.C., K.W., D.H.), Section of Trauma and Acute Care Surgery, (T.Z., J.C., K.W., D.H.), Section of Vascular Surgery and Endovascular Therapy (N.L.B.), The University of Chicago Medicine; Department of Nursing Research and Evidence-Based Practice (N.L.B.), UChicago Medicine, Chicago, Illinois; Emory School of Medicine (H.B.), Atlanta, Georgia; Department of Surgery, Section of General Surgery (J.C.), Dartmouth-Hitchcock, Lebanon, New Hampshire; and Section of Pediatric Surgery (M.B.S.), The University of Chicago Medicine, Comer Children's Hospital, Chicago, Illinois
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Levoux J, Lafuste P, Rodriguez AM. Transcriptional analysis of mouse wounds grafted with human mesenchymal stem cells and platelets. STAR Protoc 2021; 2:100650. [PMID: 34278336 PMCID: PMC8261014 DOI: 10.1016/j.xpro.2021.100650] [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] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022] Open
Abstract
Platelet preparations are commonly used in the clinic in combination with mesenchymal stem cells (MSCs) to improve their wound healing capacity and optimize their therapeutic efficacy following their delivery into diseased tissues. To investigate the mechanisms by which platelets enhance the repair properties of MSCs, we detail a protocol using a humanized mouse model for excisional wounds to study by reverse transcription real-time PCR whether human platelets alter the therapeutic efficacy of grafted human MSCs. For complete details on the use and execution of this protocol, please refer to Levoux et al. (2021).
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Affiliation(s)
| | - Peggy Lafuste
- Univ Paris Est Creteil, INSERM, IMRB, 94010 Créteil, France
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Gaitanidis A, Sinyard RT, Nederpelt CJ, Maurer LR, Christensen MA, Mashbari H, Velmahos GC, Kaafarani HMA. Lower Mortality with Cryoprecipitate During Massive Transfusion in Penetrating but Not Blunt Trauma. J Surg Res 2021; 269:94-102. [PMID: 34537533 DOI: 10.1016/j.jss.2021.07.027] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [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: 01/16/2021] [Revised: 06/23/2021] [Accepted: 07/13/2021] [Indexed: 11/18/2022]
Abstract
BACKGROUND Balanced blood product transfusion improves the outcomes of trauma patients with exsanguinating hemorrhage, but it remains unclear whether administering cryoprecipitate improves mortality. We aimed to examine the impact of early cryoprecipitate transfusion on the outcomes of the trauma patients needing massive transfusion (MT). METHODS All MT patients 18 years or older in the 2017 Trauma Quality Improvement Program (TQIP) were retrospectively reviewed. MT was defined as the transfusion of ≥10 units of blood within 24 hours. Propensity score analysis (PSA) was used to 1:1 match then compare patients who received and those who did not receive cryoprecipitate in the first 4 hours after injury. Outcomes included in-hospital mortality, 1-day mortality, in-hospital complications and transfusion needs at 24 hours. RESULTS Of 1,004,440 trauma patients, 1,454 MT patients received cryoprecipitate and 2,920 did not. After PSA, 877 patients receiving cryoprecipitate were matched to 877 patients who did not. In-hospital mortality was lower among patients who received cryoprecipitate (49.4% v. 54.9%, P = 0.022), as was 1-day mortality. Sub-analyses showed that mortality was lower with cryoprecipitate in patients with penetrating (37.5% versus. 48%, adjusted P = 0.008), but not blunt trauma (58.5% versus. 59.8%, adjusted P = 1.000). In penetrating trauma, the cryoprecipitate group also had lower 1-day mortality (21.8% versus. 38.6%, P <0.001) and a higher rate of hemorrhage control surgeries performed within 24 hours (71.4% versus. 63.3%, P = 0.018). CONCLUSIONS Cryoprecipitate in MT is associated with improved survival in penetrating, but not blunt, trauma. Randomized trials are needed to better define the role of cryoprecipitate in MT.
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Affiliation(s)
- Apostolos Gaitanidis
- Division of Trauma, Emergency Surgery and Surgical Critical Care, Massachusetts General Hospital, Boston, Massachusetts; Center for Outcomes & Patient Safety in Surgery (COMPASS), Massachusetts General Hospital, Boston, Massachusetts
| | - Robert T Sinyard
- Division of Trauma, Emergency Surgery and Surgical Critical Care, Massachusetts General Hospital, Boston, Massachusetts
| | - Charlie J Nederpelt
- Division of Trauma, Emergency Surgery and Surgical Critical Care, Massachusetts General Hospital, Boston, Massachusetts
| | - Lydia R Maurer
- Division of Trauma, Emergency Surgery and Surgical Critical Care, Massachusetts General Hospital, Boston, Massachusetts; Center for Outcomes & Patient Safety in Surgery (COMPASS), Massachusetts General Hospital, Boston, Massachusetts
| | - Mathias A Christensen
- Division of Trauma, Emergency Surgery and Surgical Critical Care, Massachusetts General Hospital, Boston, Massachusetts
| | - Hassan Mashbari
- Division of Trauma, Emergency Surgery and Surgical Critical Care, Massachusetts General Hospital, Boston, Massachusetts; Center for Outcomes & Patient Safety in Surgery (COMPASS), Massachusetts General Hospital, Boston, Massachusetts
| | - George C Velmahos
- Division of Trauma, Emergency Surgery and Surgical Critical Care, Massachusetts General Hospital, Boston, Massachusetts
| | - Haytham M A Kaafarani
- Division of Trauma, Emergency Surgery and Surgical Critical Care, Massachusetts General Hospital, Boston, Massachusetts; Center for Outcomes & Patient Safety in Surgery (COMPASS), Massachusetts General Hospital, Boston, Massachusetts.
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De Ayala-Hillman R, Diaz-Marty C, Ramos-Meléndez E, García-Rodríguez O, Guerrios L, Rodríguez-Ortiz P. A Retrospective Cohort Study on Health Insurance: Related Disparities in Trauma Patients After Penetrating Injuries: 2000-2014. P R Health Sci J 2021; 40:120-126. [PMID: 34792925] [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] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 06/13/2023]
Abstract
OBJECTIVE Although the lack of health insurance has been linked to poor health outcomes in several diseases, this relationship is still understudied in trauma. There exist differences between the Puerto Rico health care system and that of the United States. We therefore aimed to assess mortality disparities related to insurance coverage at the Puerto Rico Trauma Hospital (PRTH). METHODS A retrospective cohort study of patients who sustained penetrating injuries (presenting at the PRTH from 2000 to 2014) was performed. Individuals were classified by their insurance status. Study variables comprised demographics, clinical characteristics and outcomes. A logistic regression analysis was performed to identify the association between health insurance status and risk of dying. RESULTS Patients with public health insurance experienced more complications than did individuals who had private health insurance (PrHI) or who were uninsured. This group had longer durations of mechanical ventilation and spent more time in the hospital than did patients who had PrHI or who were uninsured. However, uninsured patients with gunshot wounds were 54% (adjusted odds ratio = 1.54; 95% CI: 1.01, 2.36) more likely to die than were their counterparts who had PrHI. CONCLUSION Our study suggests that having health insurance could reduce a given patient mortality risk in trauma settings. More studies with larger samples are warranted to confirm these findings. If these findings hold true, then providing equitable access to health services for the entire population could prevent patients suffering trauma from having premature, preventable deaths.
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Affiliation(s)
- Rafael De Ayala-Hillman
- Department of Surgery, School of Medicine, Medical Sciences Campus, University of Puerto Rico, San Juan, Puerto Rico
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McGuinness MJ, Thompson G, Haysom S, Civil I. Nail gun injuries: not just an occupational hazard. N Z Med J 2021; 134:56-63. [PMID: 34482389] [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] [Subscribe] [Scholar Register] [Indexed: 06/13/2023]
Abstract
INTRODUCTION Nail guns are commonly used in the construction industry. They represent an occupational hazard, and in the context of mental illness can pose a threat to life. AIM To determine the number of patients admitted to Auckland City Hospital (ACH) with a nail gun injury, and to review the current New Zealand legislation surrounding nail guns. METHODS A 25-year retrospective review of patients admitted to ACH with a nail gun injury was performed by searching the ACH Trauma Registry. New Zealand legislation was reviewed. RESULTS Between 1994 and 2019, 45 patients were admitted to ACH with a nail gun injury. Two subgroups were identified: 31% with an intentional injury; 69% with an unintentional injury. All patients were male. The mean age was 36.3. Patients with an intentional injury had a higher mortality rate (21.4% vs 9.5%), Injury Severity Scores (24.2 vs 3.4) and ICU admission rate (50% vs 3%) and required more intensive post-injury care when compared to unintentional injuries. There is currently no legislation in New Zealand specifically governing the use of nail guns. Only powder-actuated nail guns require certification. CONCLUSION The continued occurrence of unintentional nail gun injuries and the high lethality of intentional injuries represent two distinct areas of concern. The Government should publish guidance aimed at improving safety and reducing the rate of intentional injury.
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Affiliation(s)
| | | | - Samuel Haysom
- Medical Student, Trauma Service, Auckland City Hospital, New Zealand
| | - Ian Civil
- General and Trauma Surgeon, Trauma Service, Auckland City Hospital, New Zealand
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Shackelford SA, Del Junco DJ, Riesberg JC, Powell D, Mazuchowski EL, Kotwal RS, Loos PE, Montgomery HR, Remley MA, Gurney JM, Keenan S. Case-control analysis of prehospital death and prolonged field care survival during recent US military combat operations. J Trauma Acute Care Surg 2021; 91:S186-S193. [PMID: 34324473 DOI: 10.1097/ta.0000000000003252] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [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
BACKGROUND Quantification of medical interventions administered during prolonged field care (PFC) is necessary to inform training and planning. MATERIALS AND METHODS Retrospective cohort study of Department of Defense Trauma Registry casualties with maximum Abbreviated Injury Scale (MAIS) score of 2 or greater and prehospital records during combat operations 2007 to 2015; US military nonsurvivors were linked to Armed Forces Medical Examiner System data. Medical interventions administered to survivors of 4 hours to 72 hours of PFC and nonsurvivors who died prehospital were compared by frequency-matching on mechanism (explosive, firearm, other), injury type (penetrating, blunt) and injured body regions with MAIS score of 3 or greater. Covariates for adjustment included age, sex, military Service, shock, Glasgow Coma Scale, transport team, MAIS and Injury Severity Score (ISS). Sensitivity analysis focused on US military subgroup with AIS/ISS assigned to nonsurvivors after autopsy. RESULTS The total inception cohort included 16,202 casualties (5,269 US military, 10,809 non-US military), 64% Afghanistan, 36% Iraq. Of US military, 734 deaths occurred within 30 days, nearly 90% occurred within 4 hours of injury. There were 3,222 casualties (1,111 US military, 2,111 non-US military) documented for prehospital care and died prehospital (691) or survived 4 hours to 72 hours of PFC (2,531). Twenty-five percent (815/3,222) received advanced airway, 18% (583) ventilatory support, 9% (281) tourniquet. Twenty-three percent (725) received blood transfusions within 24 hours. Of the matched cohort (1,233 survivors, 490 nonsurvivors), differences were observed in care (survivors received more warming, intravenous fluids, sedation, mechanical ventilation, narcotics, antibiotics; nonsurvivors received more intubations, tourniquets, intraosseous fluids, cardiopulmonary resuscitation). Sensitivity analysis focused on US military (732 survivors, 379 nonsurvivors) showed no significant differences in prehospital interventions. Without autopsy information, the ISS of nonsurvivors significantly underestimated injury severity. CONCLUSION Tourniquets, blood transfusion, airway, and ventilatory support are frequently required interventions for the seriously injured. Prolonged field care should direct resources, technology, and training to field technology for sustained resuscitation, airway, and breathing support in the austere environment. LEVEL OF EVIDENCE Prognostic, Level III.
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Affiliation(s)
- Stacy A Shackelford
- From the Joint Trauma System, Defense Health Agency (S.A.S., D.J.d.J., E.L.M., R.S.K., H.R.M., M.A.R., J.M.G., S.K.), Joint Base San Antonio Fort Sam Houston, Texas; 10th Special Forces Group (Airborne) (J.C.R.), US Army Special Operations Command, Fort Carson, Colorado; West Virginia University Heart and Vascular Institute (D.P.), Morgantown, West Virginia; USASOC Surgeon's Office (D.P.), Fort Bragg, North Carolina; Armed Forces Medical Examiner System (E.L.M.), Defense Health Agency, Dover AFB, Delaware; U.S. Army John F. Kennedy Special Warfare Center and School (P.L.), Fort Bragg, North Carolina and; US Army Institute of Surgical Research (J.M.G.), Joint Base San Antonio Fort Sam Houston, Texas
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Taghavi S, Maher Z, Goldberg AJ, Chang G, Mendiola M, Anderson C, Ninokawa S, Tatebe LC, Maluso P, Raza S, Keating JJ, Burruss S, Reeves M, Coleman LE, Shatz DV, Goldenberg-Sandau A, Bhupathi A, Spalding MC, LaRiccia A, Bird E, Noorbakhsh MR, Babowice J, Nelson MC, Jacobson LE, Williams J, Vella M, Dellonte K, Hayward TZ, Holler E, Lieser MJ, Berne JD, Mederos DR, Askari R, Okafor BU, Haut ER, Etchill EW, Fang R, Roche SL, Whittenburg L, Bernard AC, Haan JM, Lightwine KL, Norwood SH, Murry J, Gamber MA, Carrick MM, Bugaev N, Tatar A, Duchesne J, Tatum D. An Eastern Association for the Surgery of Trauma multicenter trial examining prehospital procedures in penetrating trauma patients. J Trauma Acute Care Surg 2021; 91:130-140. [PMID: 33675330 PMCID: PMC8216597 DOI: 10.1097/ta.0000000000003151] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/30/2021] [Revised: 12/01/2021] [Accepted: 03/05/2021] [Indexed: 11/25/2022]
Abstract
BACKGROUND Prehospital procedures (PHP) by emergency medical services (EMS) are performed regularly in penetrating trauma patients despite previous studies demonstrating no benefit. We sought to examine the influence of PHPs on outcomes in penetrating trauma patients in urban locations where transport to trauma center is not prolonged. We hypothesized that patients without PHPs would have better outcomes than those undergoing PHP. METHODS This was an Eastern Association for the Surgery of Trauma-sponsored, multicenter, prospective, observational trial of adults (18+ years) with penetrating trauma to the torso and/or proximal extremity presenting at 25 urban trauma centers. The impact of PHPs and transport mechanism on in-hospital mortality were examined. RESULTS Of 2,284 patients included, 1,386 (60.7%) underwent PHP. The patients were primarily Black (n = 1,527, 66.9%) males (n = 1,986, 87.5%) injured by gunshot wound (n = 1,510, 66.0%) with 34.1% (n = 726) having New Injury Severity Score of ≥16. A total of 1,427 patients (62.5%) were transported by Advanced Life Support EMS, 17.2% (n = 392) by private vehicle, 13.7% (n = 312) by police, and 6.7% (n = 153) by Basic Life Support EMS. Of the PHP patients, 69.1% received PHP on scene, 59.9% received PHP in route, and 29.0% received PHP both on scene and in route. Initial scene vitals differed between groups, but initial emergency department vitals did not. Receipt of ≥1 PHP increased mortality odds (odds ratio [OR], 1.36; 95% confidence interval [CI], 1.01-1.83; p = 0.04). Logistic regression showed increased mortality with each PHP, whether on scene or during transport. Subset analysis of specific PHP revealed that intubation (OR, 10.76; 95% CI, 4.02-28.78; p < 0.001), C-spine immobilization (OR, 5.80; 95% CI, 1.85-18.26; p < 0.01), and pleural decompression (OR, 3.70; 95% CI, 1.33-10.28; p = 0.01) had the highest odds of mortality after adjusting for multiple variables. CONCLUSION Prehospital procedures in penetrating trauma patients impart no survival advantage and may be harmful in urban settings, even when performed during transport. Therefore, PHP should be forgone in lieu of immediate transport to improve patient outcomes. LEVEL OF EVIDENCE Prognostic, level III.
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Saldarriaga LG, Palacios-Rodríguez HE, Pino LF, Hadad AG, Capre J, García A, Rodríguez-Holguín F, Salcedo A, Serna JJ, Herrera MA, Parra MW, Ordoñez CA, Kestenberg-Himelfarb A. Rectal damage control: when to do and not to do. Colomb Med (Cali) 2021; 52:e4124776. [PMID: 34188328 PMCID: PMC8216057 DOI: 10.25100/cm.v52i2.4776] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/15/2021] [Revised: 04/21/2021] [Accepted: 05/13/2021] [Indexed: 11/11/2022] Open
Abstract
Rectal trauma is uncommon, but it is usually associated with injuries in adjacent pelvic or abdominal organs. Recent studies have changed the paradigm behind military rectal trauma management, showing better morbidity and mortality. However, damage control techniques in rectal trauma remain controversial. This article aims to present an algorithm for the treatment of rectal trauma in a patient with hemodynamic instability, according to damage control surgery principles. We propose to manage intraperitoneal rectal injuries in the same way as colon injuries. The treatment of extraperitoneal rectum injuries will depend on the percentage of the circumference involved. For injuries involving more than 25% of the circumference, a colostomy is indicated. While injuries involving less than 25% of the circumference can be managed through a conservative approach or primary repair. In rectal trauma, knowing when to do or not to do it makes the difference.
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Affiliation(s)
- Luis Guillermo Saldarriaga
- Universidad del Valle, Facultad de Salud, Escuela de Medicina, Department of Surgery, Division of Trauma and Acute Care Surgery. Cali, Colombia
| | - Helmer Emilio Palacios-Rodríguez
- Universidad del Valle, Facultad de Salud, Escuela de Medicina, Department of Surgery, Division of Trauma and Acute Care Surgery. Cali, Colombia
| | - Luis Fernando Pino
- Universidad del Valle, Facultad de Salud, Escuela de Medicina, Department of Surgery, Division of Trauma and Acute Care Surgery. Cali, Colombia
- Hospital Universitario del Valle, Department of Surgery, Division of Trauma and Acute Care Surgery. Cali, Colombia
| | - Adolfo González Hadad
- Universidad del Valle, Facultad de Salud, Escuela de Medicina, Department of Surgery, Division of Trauma and Acute Care Surgery. Cali, Colombia
- Hospital Universitario del Valle, Department of Surgery, Division of Trauma and Acute Care Surgery. Cali, Colombia
- Centro Médico Imbanaco, Cali, Colombia
| | - Jessica Capre
- Fundación Valle del Lili, Department of Surgery, Division of Colorectal Surgery , Cali, Colombia
| | - Alberto García
- Universidad del Valle, Facultad de Salud, Escuela de Medicina, Department of Surgery, Division of Trauma and Acute Care Surgery. Cali, Colombia
- Fundación Valle del Lili, Department of Surgery, Division of Trauma and Acute Care Surgery, Cali, Colombia
- Universidad Icesi, Cali, Colombia
| | | | - Alexander Salcedo
- Universidad del Valle, Facultad de Salud, Escuela de Medicina, Department of Surgery, Division of Trauma and Acute Care Surgery. Cali, Colombia
- Hospital Universitario del Valle, Department of Surgery, Division of Trauma and Acute Care Surgery. Cali, Colombia
- Fundación Valle del Lili, Department of Surgery, Division of Colorectal Surgery , Cali, Colombia
- Fundación Valle del Lili, Department of Surgery, Division of Trauma and Acute Care Surgery, Cali, Colombia
| | - José Julián Serna
- Universidad del Valle, Facultad de Salud, Escuela de Medicina, Department of Surgery, Division of Trauma and Acute Care Surgery. Cali, Colombia
- Hospital Universitario del Valle, Department of Surgery, Division of Trauma and Acute Care Surgery. Cali, Colombia
- Fundación Valle del Lili, Department of Surgery, Division of Trauma and Acute Care Surgery, Cali, Colombia
- Universidad Icesi, Cali, Colombia
| | - Mario Alain Herrera
- Universidad del Valle, Facultad de Salud, Escuela de Medicina, Department of Surgery, Division of Trauma and Acute Care Surgery. Cali, Colombia
- Hospital Universitario del Valle, Department of Surgery, Division of Trauma and Acute Care Surgery. Cali, Colombia
| | - Michael W. Parra
- Broward General Level I Trauma Center, Department of Trauma Critical Care, Fort Lauderdale, FL, USA
| | - Carlos A. Ordoñez
- Universidad del Valle, Facultad de Salud, Escuela de Medicina, Department of Surgery, Division of Trauma and Acute Care Surgery. Cali, Colombia
- Fundación Valle del Lili, Department of Surgery, Division of Trauma and Acute Care Surgery, Cali, Colombia
- Universidad Icesi, Cali, Colombia
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Salcedo A, Ordoñez CA, Parra MW, Osorio JD, Leib P, Caicedo Y, Guzmán-Rodríguez M, Padilla N, Pino LF, Herrera MA, Hadad AG, Serna JJ, García A, Coccolini F, Catena F. Damage Control for renal trauma: the more conservative the surgeon, better for the kidney. Colomb Med (Cali) 2021; 52:e4094682. [PMID: 34188325 PMCID: PMC8216050 DOI: 10.25100/cm.v52i2.4682] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2022] Open
Abstract
Urologic trauma is frequently reported in patients with penetrating trauma. Currently, the computerized tomography and vascular approach through angiography/embolization are the standard approaches for renal trauma. However, the management of renal or urinary tract trauma in a patient with hemodynamic instability and criteria for emergency laparotomy, is a topic of discussion. This article presents the consensus of the Trauma and Emergency Surgery Group (CTE) from Cali, for the management of penetrating renal and urinary tract trauma through damage control surgery. Intrasurgical perirenal hematoma characteristics, such as if it is expanding or actively bleeding, can be reference for deciding whether a conservative approach with subsequent radiological studies is possible. However, if there is evidence of severe kidney trauma, surgical exploration is mandatory and entails a high probability of requiring a nephrectomy. Urinary tract damage control should be conservative and deferred, because this type of trauma does not represent a risk in acute trauma management.
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Affiliation(s)
- Alexander Salcedo
- Universidad del Valle, Facultad de Salud, Escuela de Medicina, Department of Surgery, Division of Trauma and Acute Care Surgery, Cali, Colombia
- Fundación Valle del Lili, Department of Surgery, Division of Trauma and Acute Care Surgery, Cali, Colombia
- Universidad Icesi, Cali, Colombia
- Hospital Universitario del Valle Division of Trauma and Acute Care Surgery, Department of Surgery, Cali, Colombia
| | - Carlos A Ordoñez
- Universidad del Valle, Facultad de Salud, Escuela de Medicina, Department of Surgery, Division of Trauma and Acute Care Surgery, Cali, Colombia
- Fundación Valle del Lili, Department of Surgery, Division of Trauma and Acute Care Surgery, Cali, Colombia
- Universidad Icesi, Cali, Colombia
| | - Michael W Parra
- Broward General Level I Trauma Center, Department of Trauma Critical Care, Fort Lauderdale, FL, USA
| | - José Daniel Osorio
- Universidad del Valle, Facultad de Salud, Escuela de Medicina, Department of Surgery, Division of Trauma and Acute Care Surgery, Cali, Colombia
| | | | - Yaset Caicedo
- Fundación Valle del Lili, Centro de Investigaciones Clínicas (CIC), Cali, Colombia
| | - Mónica Guzmán-Rodríguez
- Universidad de Chile, Facultad de Medicina, Instituto de Ciencias Biomédicas, Santiago de Chile, Chile
| | - Natalia Padilla
- Fundación Valle del Lili, Centro de Investigaciones Clínicas (CIC), Cali, Colombia
| | - Luis Fernando Pino
- Universidad del Valle, Facultad de Salud, Escuela de Medicina, Department of Surgery, Division of Trauma and Acute Care Surgery, Cali, Colombia
- Hospital Universitario del Valle Division of Trauma and Acute Care Surgery, Department of Surgery, Cali, Colombia
| | - Mario Alain Herrera
- Universidad del Valle, Facultad de Salud, Escuela de Medicina, Department of Surgery, Division of Trauma and Acute Care Surgery, Cali, Colombia
- Hospital Universitario del Valle Division of Trauma and Acute Care Surgery, Department of Surgery, Cali, Colombia
| | - Adolfo González Hadad
- Universidad del Valle, Facultad de Salud, Escuela de Medicina, Department of Surgery, Division of Trauma and Acute Care Surgery, Cali, Colombia
- Hospital Universitario del Valle Division of Trauma and Acute Care Surgery, Department of Surgery, Cali, Colombia
- Centro Médico Imbanaco, Cali, Colombia
| | - José Julián Serna
- Universidad del Valle, Facultad de Salud, Escuela de Medicina, Department of Surgery, Division of Trauma and Acute Care Surgery, Cali, Colombia
- Fundación Valle del Lili, Department of Surgery, Division of Trauma and Acute Care Surgery, Cali, Colombia
- Universidad Icesi, Cali, Colombia
- Hospital Universitario del Valle Division of Trauma and Acute Care Surgery, Department of Surgery, Cali, Colombia
| | - Alberto García
- Universidad del Valle, Facultad de Salud, Escuela de Medicina, Department of Surgery, Division of Trauma and Acute Care Surgery, Cali, Colombia
- Fundación Valle del Lili, Department of Surgery, Division of Trauma and Acute Care Surgery, Cali, Colombia
- Universidad Icesi, Cali, Colombia
| | - Federico Coccolini
- Pisa University Hospital, Department of General Emergency and Trauma Surgery, Pisa, Italy
| | - Fausto Catena
- Parma Maggiore Hospital, Department of Emergency Surgery, Parma, Italy
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Abstract
INTRODUCTION As the prevalence of geriatric trauma patients has increased, protocols are being developed to address the unique requirements of this demographic. However, categorical definitions for geriatric patients vary, potentially creating confusion concerning which patients should be cared for according to geriatric-specific standards. The aim of this study was to identify data-driven cut points for mortality based on age to support implementation of age-driven guidelines. METHODS Adults aged 18 to 100 years with blunt or penetrating injury were selected from 95 hospitals' trauma registries. Change point analysis techniques were used to detect inflection points in the proportion of deaths at each age. Based on these calculated points, patients were allocated into age groups, and their characteristics and outcomes were compared. Logistic regression was used to estimate risk-adjusted in-hospital mortality controlling for sex, race, Injury Severity Score, Glasgow Coma Scale, and number of comorbidities. RESULTS A total of 255,099 patients were identified (female, 45.7%; mean age, 59.3 years; mean Injury Severity Score, 8.69; blunt injury, 92.6%). Statistically significant increases in mortality rate were noted at ages 55, 77, and 82 years. Compared with the referent group (age, <55 years), adjusted odds ratios (AORs) showed increases in mortality if age 55 to 76 years (AOR, 2.42), age 77 to 81 years (AOR, 4.70), or age 82 years or older (AOR, 6.43). National Trauma Data Standard-defined comorbidities significantly increased once age surpassed 55 years, as the rate more than doubled for each of the older age categories (p < 0.001). As age increased, each group was more likely to be female, have dementia, sustain a ground level fall, and be discharged to a skilled nursing facility (p < 0.001). CONCLUSION This large multicenter analysis established a clinically and statistically significant increase in mortality at ages 55, 77, and 82 years. This research strongly suggests that trauma patients older than 55 years be considered for inclusion in geriatric trauma protocols. The other age inflection points identified (77 and 82 years) may also warrant additional specialized care considerations. LEVEL OF EVIDENCE Epidemiological study, level III; Care management, level IV.
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Affiliation(s)
- Samir M Fakhry
- From the Center for Trauma and Acute Care Surgery Research, Clinical Operations Group, HCA Healthcare, Nashville, Tennessee
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Abstract
BACKGROUND No guidelines exist for management of hemodynamically stable children with suspected hollow viscus injury. We sought to determine factors contributing to surgeon management of these patients. METHODS Surgeon members of the Eastern Association for the Surgery of Trauma and American Pediatric Surgical Association completed a survey on 3 blunt abdominal injury scenarios: (1) isolated, (2) with multisystem injury, and (3) with traumatic brain injury (TBI), and a penetrating injury scenario. Multivariable logistic regression was used to determine factors associated with initial management of observation vs. operation for blunt injury and observation vs. local wound exploration versus laparoscopy for penetrating injury. RESULTS Of 394 surgeons (response rate 22.3%), 50.3% were pediatric surgeons. For scenarios 1-3, 32.2%, 49.3%, and 60.7% of surgeons chose operation over observation, respectively. Compared to isolated blunt injury, surgeons were more likely to choose operation for patients with multisystem injury (aOR 2.20, 95%CI: 1.78-2.72) or TBI (aOR 3.60, 95%CI: 2.79-4.66). Pediatric surgeons were less likely to choose operation (aOR 0.32, 95%CI: 0.22-0.44). For penetrating injury, 39.1%, 29.5%, and 31.5% of surgeons chose observation, local wound exploration, and laparoscopy, respectively. CONCLUSIONS Large variation exists in management of hemodynamically stable children with suspected hollow viscus injury. Although patient injury characteristics account for some variation, surgeon factors such as type of surgeon also play a role. Evidence-based practice guidelines should be developed to standardize care. TYPE OF STUDY Cross-Sectional Survey. LEVEL OF EVIDENCE N/A.
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Affiliation(s)
- Elissa K Butler
- Harborview Injury Prevention & Research Center, University of Washington, 325 9th Ave Box 359960, Seattle, WA 98122, USA; Department of Surgery, University of Washington, 1959 NE Pacific Street, WA 98195, USA; Department of Surgery, SUNY Upstate Medical University, 750 East Adams Street, Syracuse, NY 13210, USA.
| | - Jonathan I Groner
- Center for Pediatric Trauma Research, Nationwide Children's Hospital, 700 Children's Drive, Columbus, OH 43205, USA; Department of Pediatric Surgery, Nationwide Children's Hospital, 700 Children's Drive, Columbus, OH 43205, USA
| | - Monica S Vavilala
- Harborview Injury Prevention & Research Center, University of Washington, 325 9th Ave Box 359960, Seattle, WA 98122, USA; Department of Anesthesiology & Pain Medicine, University of Washington, 1959 NE Pacific St, Seattle, WA 98195, USA
| | - Eileen M Bulger
- Harborview Injury Prevention & Research Center, University of Washington, 325 9th Ave Box 359960, Seattle, WA 98122, USA; Department of Surgery, University of Washington, 1959 NE Pacific Street, WA 98195, USA
| | - Frederick P Rivara
- Harborview Injury Prevention & Research Center, University of Washington, 325 9th Ave Box 359960, Seattle, WA 98122, USA; Department of Pediatrics, University of Washington, 1959 NE Pacific St, Seattle, WA 98195, USA
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Abstract
NCRP Report 156 describes soluble radionuclide retention kinetics in a wound, segregated into four retention categories: weak (W), moderate (M), strong (S), and avid (A). An alternate single-parameter model, the negative power function, t, is presented in this paper to describe the time behavior of radionuclide retention. With this mathematical description, γ is a single parameter that can be used to assign the wound retention category rapidly. Using the power function description of wound retention, the various wound categories present as straight lines on log scales with different slopes corresponding to the various retention categories. Regression analysis of average retention values in NCRP 156 shows γ = 0.735 ± 0.132, 0.514 ± 0.015, 0.242 ± 0.016, and 0.053 ± 0.023 for the weak, moderate, strong, and avid categories, respectively. A case study is presented (REAC/TS Registry case 1284) where a power function is shown to fit retention data in a Pu/Am hand wound up to 2,000 d (5.4 y) post-accident.
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Christian AB, Maithel S, Grigorian A, Kabutey NK, Dolich M, Kong A, Gambhir S, Sheehan BM, Nahmias J. Comparison of Nonoperative and Operative Management of Traumatic Penetrating Internal Jugular Vein Injury. Ann Vasc Surg 2020; 72:440-444. [PMID: 32949747 DOI: 10.1016/j.avsg.2020.08.149] [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] [Received: 04/17/2020] [Revised: 05/22/2020] [Accepted: 08/26/2020] [Indexed: 11/18/2022]
Abstract
BACKGROUND Small case series have suggested that selective nonoperative management (NOM) of penetrating internal jugular vein (IJV) injuries is safe and feasible in select patients lacking "hard signs" mandating exploration. Therefore, we sought to compare NOM to operative management (OM) of penetrating IJV injury, hypothesizing that both strategies have similar patient outcomes and mortality when patients are appropriately selected. METHODS The Trauma Quality Improvement Program (2013-2016) was queried for patients with penetrating IJV injury with an abbreviated injury scale score of the neck ≥3. Demographics and patient outcomes were compared between patients undergoing NOM and patients undergoing OM, followed by a multivariable logistic regression model to analyze the risk of mortality. RESULTS A penetrating IJV injury was identified in 188 (0.01%) patients meeting inclusion criteria, and OM was performed in 124 (66.0%) patients, whereas 64 (34.0%) patients underwent NOM. Although the OM group had a higher rate of pneumothorax (8.9% vs. 0.0%, P = 0.01), there was no difference in any other concomitant injuries or demographic data (all P > 0.05). The OM group had a higher rate of ventilator days (3 vs. 2 days, P = 0.01) but no other significant differences in morbidity or mortality (P > 0.05). After controlling for covariates, OM was associated with similar risk of mortality compared with NOM of patients with penetrating IJV injury (odds ratio 1.05, confidence interval 0.23-4.83, P = 0.95). CONCLUSIONS The NOM of penetrating IJV injuries is associated with similar risk of morbidity and mortality compared with OM, suggesting that NOM may be used in appropriately selected patients. Future research is needed to determine the ideal patients suited for NOM and to identify risk factors and outcomes associated with failure of NOM.
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Affiliation(s)
- Ashton B Christian
- Department of General Surgery, University of California, Irvine Medical Center, Orange, CA
| | - Shelley Maithel
- Department of General Surgery, University of California, Irvine Medical Center, Orange, CA
| | - Areg Grigorian
- Department of General Surgery, University of California, Irvine Medical Center, Orange, CA
| | - Nii-Kabu Kabutey
- Department of General Surgery, University of California, Irvine Medical Center, Orange, CA
| | - Matthew Dolich
- Department of General Surgery, University of California, Irvine Medical Center, Orange, CA
| | - Allen Kong
- Department of General Surgery, University of California, Irvine Medical Center, Orange, CA
| | - Sahil Gambhir
- Department of General Surgery, University of California, Irvine Medical Center, Orange, CA
| | - Brian M Sheehan
- Department of General Surgery, University of California, Irvine Medical Center, Orange, CA
| | - Jeffry Nahmias
- Department of General Surgery, University of California, Irvine Medical Center, Orange, CA.
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Tran A, Taljaard M, Abdulaziz KE, Matar M, Lampron J, Steyerberg EW, Vaillancourt C. Early identification of the need for major intervention in patients with traumatic hemorrhage: development and internal validation of a simple bleeding score. Can J Surg 2020; 63:E422-E430. [PMID: 33009903 PMCID: PMC7608708] [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] [Accepted: 12/16/2019] [Indexed: 04/08/2024] Open
Abstract
BACKGROUND Failure to rapidly identify bleeding in trauma patients leads to substantial morbidity and mortality. We aimed to develop and validate a simple bedside score for identifying bleeding patients requiring escalation of care beyond initial resuscitation. METHODS We included patients with major blunt or penetrating trauma, defined as those with an Injury Severity Score greater than 12 or requiring trauma team activation, at The Ottawa Hospital from September 2014 to September 2017. We used logistic regression for derivation. The primary outcome was a composite of the need for massive transfusion, embolization or surgery for hemostasis. We prespecified clinical, laboratory and imaging predictors using findings from our prior systematic review and survey of Canadian traumatologists. We used an AIC-based stepdown procedure based on the Akaike information criterion and regression coefficients to create a 5-variable score for bedside application. We used bootstrap internal validation to assess optimism-corrected performance. RESULTS We included 890 patients, of whom 133 required a major intervention. The main model comprised systolic blood pressure, clinical examination findings suggestive of hemorrhage, lactate level, focused assessment with sonography in trauma (FAST) and computed tomographic imaging. The C statistic was 0.95, optimism-corrected to 0.94. A simplified Canadian Bleeding (CAN-BLEED) score was devised. A score cut-off of 2 points yielded sensitivity of 97.7% (95% confidence interval [CI] 93.6 to 99.5) and specificity 73.2% (95% CI 69.9 to 76.3). An alternative version that included mechanism of injury rather than CT had lower discriminative ability (C statistic = 0.89). CONCLUSION A simple yet promising bleeding score is proposed to identify highrisk patients in need of major intervention for traumatic bleeding and determine the appropriateness of early transfer to specialized trauma centres. Further research is needed to evaluate the performance of the score in other settings, define interrater reliability and evaluate the potential for reduction of time to intervention.
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Affiliation(s)
- Alexandre Tran
- From the School of Epidemiology and Public Health, University of Ottawa, Ottawa, Ont. (Tran, Taljaard, Abdulaziz,); the Clinical Epidemiology Program, Ottawa Hospital Research Institute, Ottawa, Ont. (Taljaard, Abdulaziz, Vaillancourt); the Division of General Surgery, The Ottawa Hospital, Ottawa, Ont. (Tran, Matar, Lampron); the Department of Biomedical Data Sciences, Leiden University Medical Center, Leiden, the Netherlands (Steyerberg); the Department of Public Health, Erasmus MC, Rotterdam, the Netherlands (Steyerberg); and the Department of Emergency Medicine, University of Ottawa, Ottawa, Ont. (Vaillancourt)
| | - Monica Taljaard
- From the School of Epidemiology and Public Health, University of Ottawa, Ottawa, Ont. (Tran, Taljaard, Abdulaziz,); the Clinical Epidemiology Program, Ottawa Hospital Research Institute, Ottawa, Ont. (Taljaard, Abdulaziz, Vaillancourt); the Division of General Surgery, The Ottawa Hospital, Ottawa, Ont. (Tran, Matar, Lampron); the Department of Biomedical Data Sciences, Leiden University Medical Center, Leiden, the Netherlands (Steyerberg); the Department of Public Health, Erasmus MC, Rotterdam, the Netherlands (Steyerberg); and the Department of Emergency Medicine, University of Ottawa, Ottawa, Ont. (Vaillancourt)
| | - Kasim E Abdulaziz
- From the School of Epidemiology and Public Health, University of Ottawa, Ottawa, Ont. (Tran, Taljaard, Abdulaziz,); the Clinical Epidemiology Program, Ottawa Hospital Research Institute, Ottawa, Ont. (Taljaard, Abdulaziz, Vaillancourt); the Division of General Surgery, The Ottawa Hospital, Ottawa, Ont. (Tran, Matar, Lampron); the Department of Biomedical Data Sciences, Leiden University Medical Center, Leiden, the Netherlands (Steyerberg); the Department of Public Health, Erasmus MC, Rotterdam, the Netherlands (Steyerberg); and the Department of Emergency Medicine, University of Ottawa, Ottawa, Ont. (Vaillancourt)
| | - Maher Matar
- From the School of Epidemiology and Public Health, University of Ottawa, Ottawa, Ont. (Tran, Taljaard, Abdulaziz,); the Clinical Epidemiology Program, Ottawa Hospital Research Institute, Ottawa, Ont. (Taljaard, Abdulaziz, Vaillancourt); the Division of General Surgery, The Ottawa Hospital, Ottawa, Ont. (Tran, Matar, Lampron); the Department of Biomedical Data Sciences, Leiden University Medical Center, Leiden, the Netherlands (Steyerberg); the Department of Public Health, Erasmus MC, Rotterdam, the Netherlands (Steyerberg); and the Department of Emergency Medicine, University of Ottawa, Ottawa, Ont. (Vaillancourt)
| | - Jacinthe Lampron
- From the School of Epidemiology and Public Health, University of Ottawa, Ottawa, Ont. (Tran, Taljaard, Abdulaziz,); the Clinical Epidemiology Program, Ottawa Hospital Research Institute, Ottawa, Ont. (Taljaard, Abdulaziz, Vaillancourt); the Division of General Surgery, The Ottawa Hospital, Ottawa, Ont. (Tran, Matar, Lampron); the Department of Biomedical Data Sciences, Leiden University Medical Center, Leiden, the Netherlands (Steyerberg); the Department of Public Health, Erasmus MC, Rotterdam, the Netherlands (Steyerberg); and the Department of Emergency Medicine, University of Ottawa, Ottawa, Ont. (Vaillancourt)
| | - Ewout W Steyerberg
- From the School of Epidemiology and Public Health, University of Ottawa, Ottawa, Ont. (Tran, Taljaard, Abdulaziz,); the Clinical Epidemiology Program, Ottawa Hospital Research Institute, Ottawa, Ont. (Taljaard, Abdulaziz, Vaillancourt); the Division of General Surgery, The Ottawa Hospital, Ottawa, Ont. (Tran, Matar, Lampron); the Department of Biomedical Data Sciences, Leiden University Medical Center, Leiden, the Netherlands (Steyerberg); the Department of Public Health, Erasmus MC, Rotterdam, the Netherlands (Steyerberg); and the Department of Emergency Medicine, University of Ottawa, Ottawa, Ont. (Vaillancourt)
| | - Christian Vaillancourt
- From the School of Epidemiology and Public Health, University of Ottawa, Ottawa, Ont. (Tran, Taljaard, Abdulaziz,); the Clinical Epidemiology Program, Ottawa Hospital Research Institute, Ottawa, Ont. (Taljaard, Abdulaziz, Vaillancourt); the Division of General Surgery, The Ottawa Hospital, Ottawa, Ont. (Tran, Matar, Lampron); the Department of Biomedical Data Sciences, Leiden University Medical Center, Leiden, the Netherlands (Steyerberg); the Department of Public Health, Erasmus MC, Rotterdam, the Netherlands (Steyerberg); and the Department of Emergency Medicine, University of Ottawa, Ottawa, Ont. (Vaillancourt)
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Nasser AAH, Nederpelt C, El Hechi M, Mendoza A, Saillant N, Fagenholz P, Velmahos G, Kaafarani HMA. Every minute counts: The impact of pre-hospital response time and scene time on mortality of penetrating trauma patients. Am J Surg 2020; 220:240-244. [PMID: 31761299 DOI: 10.1016/j.amjsurg.2019.11.018] [Citation(s) in RCA: 17] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/17/2019] [Revised: 11/02/2019] [Accepted: 11/11/2019] [Indexed: 11/19/2022]
Abstract
BACKGROUND Prompt surgical control of hemorrhage is crucial in penetrating trauma patients. We aimed to study the impact of prehospital response time (PreRespT) and scene time (SceneT) on hospital mortality. METHODS Using the Trauma Quality Improvement Program (TQIP) 2010-2016 database, we identified all adults with penetrating injury. We defined PreRespT as time from EMS dispatch to scene arrival, and SceneT as time spent on scene. Univariate then multivariable logistic regression analyses were performed to study the independent correlation between PreRespT and SceneT on hospital mortality, adjusting for several covariates. RESULTS Out of a total of 1,403,470 patients, 43,467 patients were included. Multivariable analyses suggested that: 1) every minute increase in PreRespT independently correlates with a 2% increase in mortality (OR 1.02, p < 0.0001), and 2) every minute increase in SceneT independently correlates with a 1% increase in mortality (OR 1.01, p = 0.001). CONCLUSION In the penetrating injury trauma patient, PreRespT and SceneT independently correlate with hospital mortality. This data suggests that a faster PreRespT and a "scoop and run" strategy may be more beneficial in this population.
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Affiliation(s)
- Ahmed A H Nasser
- Division of Trauma, Emergency Surgery, and Surgical Critical Care, Department of Surgery, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA
| | - Charlie Nederpelt
- Division of Trauma, Emergency Surgery, and Surgical Critical Care, Department of Surgery, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA
| | - Majed El Hechi
- Division of Trauma, Emergency Surgery, and Surgical Critical Care, Department of Surgery, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA
| | - April Mendoza
- Division of Trauma, Emergency Surgery, and Surgical Critical Care, Department of Surgery, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA
| | - Noelle Saillant
- Division of Trauma, Emergency Surgery, and Surgical Critical Care, Department of Surgery, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA
| | - Peter Fagenholz
- Division of Trauma, Emergency Surgery, and Surgical Critical Care, Department of Surgery, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA
| | - George Velmahos
- Division of Trauma, Emergency Surgery, and Surgical Critical Care, Department of Surgery, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA
| | - Haytham M A Kaafarani
- Division of Trauma, Emergency Surgery, and Surgical Critical Care, Department of Surgery, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA.
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Escobar W, Guacheta P, Castillo-Cobaleda DF, Garcia-Perdomo HA. [Report on management of severe renal trauma.]. ARCH ESP UROL 2020; 73:274-280. [PMID: 32379062] [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] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/11/2023]
Abstract
OBJECTIVE To characterize the clinical condition, the type of therapeutic approach and outcome of patients with severe renal trauma (AAST: 4 and 5) treated in a tertiary hospital. Cali, Colombia. METHODS A descriptive observational study was conducted with patients older than 15 years treated between January 1, 2015 and January 1, 2019, with a diagnosis of renal trauma and renal vessel trauma. Demographic, clinical and trauma severity variables were collected. A univariate analysis was carried out with frequency tables, measures of central tendency, depending on type of intervention, associated lesions, use of blood products and severity indices. RESULTS 71 medical records were analyzed, 82% male, the average age was 25 years (range: 15-55). Regarding renal traumatic grade, 69% of the patients were grade IV and 31% grade V. Penetrating injuries were seen in 87% versus 13% of injuries due to blunt (non-penetrating) mechanism. 54% of the patients weres cored with a trauma severity index >= 25 and 51% of the patients had an abdominal trauma index <= 24. Surgical management was managed in 67% vs. 32% for non-trauma management surgical. The hospital stay was 17 days on average and 16.9% had complications. CONCLUSIONS Severe renal trauma is a frequent clinical condition in male patients between the second and third decade of life, in our environment the majority corresponds to penetrating traumas. Most cases were managed with some surgical procedure, however, with asignificant percentage of conservative management with complication rates of less than 30%, which changes the paradigm of treatment of high-grade renal trauma.
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Affiliation(s)
| | - Pedro Guacheta
- Departamento de Cirugía. Sección de Urología Universidad del Valle. Cali. Colombia
| | - Diego Fernando Castillo-Cobaleda
- Departamento de Cirugía. Sección de Urología Universidad del Valle. Cali. Colombia. Profesor Escuela de Medicina. Universidad del Valle. Cali. Colombia
| | - Herney Andrés Garcia-Perdomo
- Departamento de Cirugía. Sección de Urología Universidad del Valle. Cali. Colombia. Profesor Escuela de Medicina. Universidad del Valle. Cali. Colombia
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Lee YH, Wei WC, Chen CM, Su TW, Chu SY, Ko PJ. Iatrogenic Ureteral Injury Following Percutaneous Transabdominal Direct Sac Puncture for the Treatment of Type II Endoleak. J Vasc Interv Radiol 2020; 31:861-864. [PMID: 32305240 DOI: 10.1016/j.jvir.2020.01.006] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/17/2019] [Revised: 01/09/2020] [Accepted: 01/10/2020] [Indexed: 11/18/2022] Open
Affiliation(s)
- Yu-Hsien Lee
- Department of Medical Imaging and Intervention, Chang Gung Memorial Hospital, Chang Gung University, Linkou, Taiwan
| | - Wen-Cheng Wei
- Division of Thoracic and Cardiovascular Surgery, Department of Surgery, Chang Gung Memorial Hospital, Chang Gung University, No.5, Fusing St., Gueishan Township, Taoyuan 333, Linkou, Taiwan
| | - Chien-Ming Chen
- Department of Medical Imaging and Intervention, Chang Gung Memorial Hospital, Chang Gung University, Linkou, Taiwan
| | - Ta-Wei Su
- Division of Thoracic and Cardiovascular Surgery, Department of Surgery, Chang Gung Memorial Hospital, Chang Gung University, No.5, Fusing St., Gueishan Township, Taoyuan 333, Linkou, Taiwan
| | - Sung-Yu Chu
- Department of Medical Imaging and Intervention, Chang Gung Memorial Hospital, Chang Gung University, Linkou, Taiwan
| | - Po-Jen Ko
- Division of Thoracic and Cardiovascular Surgery, Department of Surgery, Chang Gung Memorial Hospital, Chang Gung University, No.5, Fusing St., Gueishan Township, Taoyuan 333, Linkou, Taiwan
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Feenstra FA, Aggenbach L, Rijtema G, Buunk AM, Stirler VMA. [Visual impairment following a suicide attempt with a crossbow]. Ned Tijdschr Geneeskd 2020; 164:D4397. [PMID: 32073797] [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] [Subscribe] [Scholar Register] [Indexed: 06/10/2023]
Abstract
BACKGROUND Bálint's syndrome is characterized by the triad of ocular apraxia, dorsal simultanagnosia and optic ataxia. It most commonly occurs following bilateral parieto-occipital brain injury, for which several aetiologies have been described. CASE DESCRIPTION We present a case of a 39-year-old male with penetrating brain injury following a suicide attempt with a crossbow. A CT scan of the head revealed the intracranial position of the arrow, piercing the parietal and occipital cortex from the left-parietal direction with the tip on the right parietal bone. After surgical removal of the arrow, visuospatial symptoms persisted that were consistent with Bálint's syndrome. The characteristic symptoms, patho-anatomy and treatment of this syndrome are discussed in this article. CONCLUSION The patient in this case had visual impairment following a suicide attempt with a crossbow. On the basis of neurological and neuropsychological assessments, the triad of ocular apraxia, dorsal simultanagnosia and optic ataxia was observed, characteristic of Bálint's syndrome.
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Siddiqui NA, Jawed M, Pirzada A, Ahmed M, Khan RN. Non-operative treatment of hepatic trauma: A changing paradigm. A Six year review of liver trauma patient in a single institute. J PAK MED ASSOC 2020; 70(Suppl 1):S27-S32. [PMID: 31981332] [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] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/10/2023]
Abstract
OBJECTIVE To review the managing strategies of adult patients with liver trauma in a tertiary care hospital during a six years period. METHODS The medical records of all patients admitted with a diagnosis of liver trauma from January 2012 to December 2017 in the Aga Khan University Hospital were retrospectively reviewed. The details of demographic, clinical, and outcome variables including morbidity and mortality rates were noted. RESULTS A total of 182 patients were admitted at AKUH with liver trauma between January 2012 and December 2017. Twenty-two patients were excluded according to our study criteria. Of 160 patients, 139 were male and 21 were female. One hundred twenty seven (79.4%) patients were less than 45 years of age. Most patients (89.4%) had no comorbids and 48 (44%) arrived at the hospital within 4 hours of injury. Majority, 101 (63.1%) of the patients had blunt trauma and 142 (89%) met with road accidents. A total of 109 (68.1%) patients were stable at arrival and 77 (48.1%) had abdominal signs present on examination. FAST ultrasound was done on 75 (46.9%) patients and CT scan abdomen on 145 (90.6 %) patients. Liver injuries were associated with other abdominal or systemic injuries in 139 (86.6%) patients. Low grade (Grade I & II) liver injuries were found in only 41 (25.6%) patients, with the remainder being high grade (Grade III- 41 patients, Grade IV-42 patients and Grade V-2 patients). Conservative treatment was offered to 68 (41.9%) patients, of which 57 (85.1%) remained stable and were eventually discharged. Of these, 2 expired and 3 required intervention. There were a total of 92 (57.2%) interventions done of which 60 patients were cured, 14 expired and 18 readmitted. Interventions included perihepatic packing (n=18), hepatorraphy (n=3), angioembolization (n=12) and hepatectomy (n=1). There were 16(10%) deaths in which liver haemorrhage and sepsis were the most common cause of mortality. Mean hospital stay in our study population was 8.9 days. Second admission was observed in 28 (17.5%) patients (n=28). Morbidity rate in our patients was 17.5% (n=28). The most common complication noted was that of a liver abscess, developing in 2 (1.3%) patients. Other significant problems were intra-abdominal collections (n=2) and biliary complications (n=3). Unstable haemodynamic status at arrival and prolonged stay in high dependency unit were noted to be independent risk factors for mortality. CONCLUSIONS Conservative treatment was found successful in most of our patients with an intervention rate of 57.5% and overall mortality rate of 10%. So, NOMLI can be safely offered to liver trauma patients, even in high grade injuries.
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Affiliation(s)
| | - Misaal Jawed
- Department of Surgery, Aga Khan University Hospital, Karachi, Pakistan
| | | | - Mobeen Ahmed
- Department of Surgery, Aga Khan University Hospital, Karachi, Pakistan
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Pillay V, Pillay M, Hardcastle TC. Renal trauma in a Trauma Intensive Care Unit population. S AFR J SURG 2019; 57:29-32. [PMID: 31773929] [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: 06/10/2023]
Abstract
BACKGROUND For the majority of renal injuries, non-operative management is the standard of care with nephrectomy reserved for those with severe trauma. This study in a dedicated Trauma Intensive Care Unit (TICU) population aimed to assess the outcomes of renal injuries and identify factors that predict the need for nephrectomy. METHODS Patients, older than 18 years, admitted to TICU from January 2007 to December 2014 who sustained renal injuries had data extracted from the prospectively collected Class Approved Trauma Registry (BCA207-09). Patients who underwent surgical intervention for the renal injury or received non-operative management were compared. The key variables analysed were: patient demographics, mechanism of injury, grade of renal injury, presenting haemoglobin, initial systolic blood pressure, Injury Severity Score and Renal Injury AAST Grade on CT scan in patients who did not necessarily require immediate surgery, or at surgery in those patients who needed emergency laparotomy. RESULTS There were 74 confirmed renal injuries. There were 42 low grade injuries (grade I-III) and 32 high grade injuries (5 grade IV and 27 grade V). Twenty-six (35%) had a nephrectomy: 24 with grade V injuries and 2 with grade IV injuries required nephrectomy. Six patients in the high injury grade arm had non-operative management. A low haemoglobin, low systolic blood pressure, higher injury severity score, and a high-grade renal injury, as well as increasing age were positive predictors for nephrectomy in trauma patients with renal injury. CONCLUSION Non-operative management is a viable option with favourable survival rates in lower grade injury; however, complications should be anticipated and managed accordingly. High grade injuries predict the need for surgery.
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Affiliation(s)
- V Pillay
- Department of General Surgery, University of KwaZulu-Natal, South Africa
| | - M Pillay
- Department of Virology, Inkosi Albert Luthuli Central Hospital, South Africa
| | - T C Hardcastle
- Department of Surgery, University of KwaZulu-Natal, South Africa
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Do R, Lu LQ, Strauss MB. Toxic inoculation associated with a presumptive stingray injury. Undersea Hyperb Med 2019; 46:719-722. [PMID: 31683373] [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] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/10/2023]
Abstract
INTRODUCTION Stingray spine injuries are among the most common marine animal injuries in humans. While most resolve with immersion in warm water, a few become infected and require antibiotics. We present a case report of a presumptive stingray injury that evolved to a major slough and which required prolonged healing in a patient with diabetes mellitus. Our literature review was unable to find a similarly reported case. MATERIALS A co-author was asked to evaluate and manage an ominous-appearing wound on the right foot of a diabetic. The problem developed after the individual had been wading in shallow ocean beach water. The patient's diabetic sensory neuropathy obscured the immediate association of the problem with a stingray injury, but this became the presumptive diagnosis when pain developed and necessitated that he seek medical care. FINDINGS/CLINICAL COURSE After an initial urgent care visit, increasing pain and worsening appearance of the patient's foot necessitated a visit to our emergency department. The patient was admitted the next day due to symptoms of systemic sepsis. On the fourth hospital day, a large bulla on the lateral side of the right foot was excised. This unroofed a full-thickness slough to the periosteum level of the underlying bones. Not until the 16th hospital day had enough improvement occurred to discharge the patient. Over the next 16 weeks, the wound improved, developed a vascular base and epithelialized. CONCLUSION With a dearth of literature about stingray injuries in patients with diabetes mellitus reported, our case is unique: The patient's wound course more closely resembled a toxic inoculation than the typical puncture wound-cellulitis presentations associated with stingray injuries.
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Affiliation(s)
- Ruth Do
- Long Beach Memorial Medical Center
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Pointer DT, Smith A, Slakey DP, Tatum D, Schindelar LE, Slakey AC, Duchesne J, Nichols RL. More Is Not Better: Implications of Antibiotic Practice Management Guidelines for Penetrating Trauma Hollow Viscus Injury in a Level I Trauma Center. Am Surg 2019; 85:e530-e532. [PMID: 31775982] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/10/2023]
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Cheng YC, Liu PY, Hu SY. Treating an intramuscular abscess following toothpick injury in a diabetic patient: A case report and literature review (CARE Complaint). Medicine (Baltimore) 2019; 98:e18159. [PMID: 31770260 PMCID: PMC6890348 DOI: 10.1097/md.0000000000018159] [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] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022] Open
Abstract
RATIONALE Toothpick puncture (TPP) is a penetrating injury that can result in bringing pathogens to the deep space. Such penetrating wounds are typically of pinpoint size with initial symptoms appearing subtle. Consequently, the injury itself is often neglected by patients, or is not detected during physical examinations by medical doctors. Reported complications from such injuries include osteomyelitis and septic arthritis, mostly due to delayed treatment. PATIENT CONCERNS A diabetic patient aged 83-year-old presented a 2-day history of skin redness, swelling, and tenderness over his forearm following a TPP a week earlier. Laboratory investigations showed leukocytosis with neutrophilic predominance and a high level of C-reactive protein. Before his operation, cultures of aspirated fluid from the injured site revealed the presence of Streptococcus anginosus, Streptococci viridans, Prevotella intermedia, and Pavimonas (Peptostreptococcus) micra. DIAGNOSIS Intramuscular abscess associated with toothpick injury. INTERVENTIONS Surgical irrigation with debridement and adjunctive antibiotics of ceftriaxone and clindamycin were given with a satisfactory response. Cultures of debrided tissue showed the presence of P intermedia and P (Peptostreptococcus) micra. OUTCOMES A split-thickness skin graft was done. Patient was discharged on the 30th postoperative day. LESSONS Toothpick injury, initial symptoms of which are subtle, can in some cases, lead to serious complications especially when managements are delayed. In such situations (including the present case), surgical irrigation and debridement are administrated for the eradication of infections, removal of potentially retained toothpick, and tissue cultures analyzed. Adjunctive antibiotics is recommended to combat both the aerobic and anaerobic microorganisms of the gastrointestinal tract, skin surface, and oral cavity.
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Affiliation(s)
- Yu-Cheng Cheng
- Division of Endocrinology & Metabolism, Department of Internal Medicine, Taichung City, Taiwan
| | - Po-Yu Liu
- Division of Infectious Disease, Department of Internal Medicine, Taichung Veterans General Hospital, Taichung City
- Department of Nursing, Shu-Zen Junior College of Medicine and Management, Kaohsiung City
- Rong Hsing Research Center for Translational Medicine, National Chung Hsing University
| | - Sung-Yuan Hu
- Department of Emergency Medicine, Taichung Veterans General Hospital
- School of Medicine
- Institute of Medicine, Chung Shan Medical University
- Department of Nursing, College of Health, National Taichung University of Science and Technology
- Department of Nursing, Central Taichung University of Science and Technology, Taichung City, Taiwan
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41
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Rubens JH, Ahmed OZ, Yenokyan G, Stewart D, Burd RS, Ryan LM. Mode of Transport and Trauma Activation Status in Admitted Pediatric Trauma Patients. J Surg Res 2019; 246:153-159. [PMID: 31586889 DOI: 10.1016/j.jss.2019.08.008] [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] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/19/2019] [Revised: 06/13/2019] [Accepted: 08/15/2019] [Indexed: 11/18/2022]
Abstract
BACKGROUND Injured children who arrive by self-transport to the emergency department (ED) may receive delayed or inadequate care. We studied differences in demographics, clinical characteristics, and trauma activation status for admitted pediatric trauma patients based on arrival by self-transport or Emergency Medical Services (EMS). MATERIALS AND METHODS We performed a retrospective cohort study at two level I pediatric trauma centers. INCLUSION CRITERIA <15 y old with blunt or penetrating injury. We used univariate and multivariate logistic regression analyses to determine associations between trauma activation, ED length of stay (LOS), and hospital LOS with demographic and clinical characteristics. RESULTS We identified 1161 patients: 40.1% arrived by self-transport and 59.9% by EMS. Self-transport patients were less likely to have an abnormal Glasgow Coma Scale score < 15 (2.1% versus 22.0%, P < 0.001) and Injury Severity Score > 15 (2.4% versus 11.7%, P < 0.001). Trauma activation was initiated in 52.5% of patients, occurring less often in self-transport than EMS patients (2.4% versus 86.2%, P < 0.001). Trauma activation rate was negatively associated with arrival by self-transport (odds ratio [OR] 0.001, 95% CI 0.00-0.003), positively associated with Glasgow Coma Scale <15 (OR 25.9, 95% CI 6.6-101.2) and site (OR 15.4, 95% CI 6.3-37.5) but not with Injury Severity Score >15 (OR 2.8, 95% CI 0.8-9.2). Self-transport arrival was associated with longer ED LOS (estimated regression slope 0.47, 95% CI 0.13-0.82). CONCLUSIONS Almost half of admitted pediatric trauma patients arrived by self-transport; however, trauma team activation rarely occurs for these patients. Trauma team activation may be underutilized in self-transport patients with injuries resulting in hospital admission.
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MESH Headings
- Child
- Child, Preschool
- Emergency Service, Hospital/organization & administration
- Emergency Service, Hospital/standards
- Emergency Service, Hospital/statistics & numerical data
- Facilities and Services Utilization/organization & administration
- Facilities and Services Utilization/standards
- Facilities and Services Utilization/statistics & numerical data
- Female
- Humans
- Injury Severity Score
- Length of Stay/statistics & numerical data
- Male
- Patient Admission/statistics & numerical data
- Practice Guidelines as Topic
- Practice Patterns, Physicians'/standards
- Practice Patterns, Physicians'/statistics & numerical data
- Registries/statistics & numerical data
- Retrospective Studies
- Transportation of Patients/statistics & numerical data
- Trauma Centers/organization & administration
- Trauma Centers/standards
- Trauma Centers/statistics & numerical data
- Triage/organization & administration
- Triage/standards
- Triage/statistics & numerical data
- United States
- Wounds, Nonpenetrating/diagnosis
- Wounds, Nonpenetrating/therapy
- Wounds, Penetrating/diagnosis
- Wounds, Penetrating/therapy
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Affiliation(s)
- Jessica H Rubens
- Department of Pediatrics, Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Omar Z Ahmed
- Department of Surgery, Children's National Health System, Washington, District of Columbia
| | - Gayane Yenokyan
- Department of Biostatistics, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland
| | - Dylan Stewart
- Department of Pediatrics, Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Randall S Burd
- Department of Surgery, Children's National Health System, Washington, District of Columbia
| | - Leticia M Ryan
- Department of Pediatrics, Johns Hopkins University School of Medicine, Baltimore, Maryland.
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42
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Spanyer JM, Lands HM, Kelly SC, Page PS, Yakkanti MR. Understanding Nail Gun Injuries in Orthopedics: Mechanisms and Treatment. Orthopedics 2019; 42:e410-e414. [PMID: 31408523 DOI: 10.3928/01477447-20190812-03] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/23/2018] [Accepted: 10/25/2018] [Indexed: 02/03/2023]
Abstract
Nail gun injuries are common among users, and most frequently involve the hands and lower extremities. A wide variation in costs and time are missed from work due to these injuries, and training on the proper use of nail guns has been shown to decrease workplace-related injuries. Minimal long-term disability can be expected, and orthopedic evaluations provide an opportunity to inform patients on proper use of these devices. In this article, management of nail gun injuries is discussed, including the necessity for a high suspicion for wound contamination because foreign material is often deposited with the nail, as well as treatment with debridement and antibiotics. [Orthopedics. 2019; 42(5):e410-e414.].
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43
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Hundersmarck D, Reinders Folmer E, de Borst GJ, Leenen LPH, Vriens PWHE, Hietbrink F. Penetrating Neck Injury in Two Dutch Level 1 Trauma Centres: the Non-Existent Problem. Eur J Vasc Endovasc Surg 2019; 58:455-462. [PMID: 31307866 DOI: 10.1016/j.ejvs.2019.04.020] [Citation(s) in RCA: 12] [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: 03/23/2018] [Revised: 04/16/2019] [Accepted: 04/20/2019] [Indexed: 11/26/2022]
Abstract
OBJECTIVES Penetrating neck injuries (PNIs) have a low incidence in European trauma populations. Selective non-operative management of PNI has been suggested as a safe alternative to standard surgical neck exploration, but evidence is lacking. This clinical scenario evaluates institutional PNI management, specifically the associated carotid artery injury, and compares it with current guidelines. METHODS Retrospectively, PNI patients presenting at two Dutch level 1 trauma centres from 2007 to 2015, were identified. International guidelines on PNI management were reviewed and recommendations were assessed in relation to current institutional management, and considering an illustrative case. RESULTS Two current guidelines on PNI management were reviewed. Both advocate a zone based approach; one recommends a prominent role for computed tomography angiography (CTA) scanning in stable patients, supplemented by endoscopy when indicated. A combined total of 43 PNI patients were identified over a nine year period. Haemodynamically unstable patients and patients with other hard signs (i.e. active bleeding, expanding haematoma, air/saliva leak, massive subcutaneous emphysema) received immediate exploration (n = 9). Haemodynamically stable patients and those responding to resuscitation (transient responders) had a CTA scan (n = 31). Three asymptomatic patients were treated conservatively, and had an uncomplicated clinical course regarding the PNI. In 10 of 14 patients who received surgical exploration, a significant vascular or aerodigestive injury was found and repaired (71%). All patients treated conservatively after CTA scanning had an uncomplicated clinical course regarding the PNI (n = 17). Six patients with penetrating carotid artery injury underwent primary arterial reconstruction, of whom five survived. CONCLUSIONS This clinical scenario evaluates institutional management in two trauma centres for PNI and associated carotid artery injury, and compares it to current guidelines. In comparison with guideline recommendations, CTA scanning and the so called "No zone" approach appears to have assumed a more prominent role in management of PNI.
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Affiliation(s)
- Dennis Hundersmarck
- Department of Surgery, University Medical Centre Utrecht, Utrecht, the Netherlands; Department of Vascular Surgery, University Medical Centre Utrecht, Utrecht, the Netherlands.
| | | | - Gert J de Borst
- Department of Vascular Surgery, University Medical Centre Utrecht, Utrecht, the Netherlands
| | - Luke P H Leenen
- Department of Surgery, University Medical Centre Utrecht, Utrecht, the Netherlands
| | | | - Falco Hietbrink
- Department of Surgery, University Medical Centre Utrecht, Utrecht, the Netherlands
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44
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Hundersmarck D, van Koperen PJ, Leenen LPH, de Borst GJ, Houwert RM, Hietbrink F. [Not Available]. NEDERLANDS TIJDSCHRIFT VOOR GENEESKUNDE 2019; 163:D2879. [PMID: 31424702] [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] [Subscribe] [Scholar Register] [Indexed: 06/10/2023]
Abstract
Penetrating neck injuries (PNIs) as a result of stabbing or deliberate self-harm are complex and potentially life-threatening. Nowadays, selective non-operative management of PNI has become common practice. Diagnostic and treatment algorithms originating from high-volume trauma centres in South-Africa and North-America are used in Dutch clinical practice. Three patients that sustained a PNI are discussed. Two patients, aged 61 and 37, only had mild signs on physical examination that justified additional diagnostic investigations. In the first patient, a penetrating oesophageal injury was found and repaired. The latter had a partial Horner syndrome as a result of PNI, no underlying injuries were found. One patient, aged 57, was haemodynamically unstable and therefore received immediate surgical exploration of the neck. A penetrating injury of the jugular vein was discovered and repaired. A summary of literature and guidelines is presented for the benefit of Dutch physicians that may be confronted with these complex injuries.
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Affiliation(s)
- Dennis Hundersmarck
- Universitair Medisch Centrum Utrecht, afd. Heelkunde, Utrecht
- Contact: D. Hundersmarck
| | | | - Loek P H Leenen
- Universitair Medisch Centrum Utrecht, afd. Heelkunde, Utrecht
| | - Gert J de Borst
- Universitair Medisch Centrum Utrecht, afd. Heelkunde, Utrecht
| | | | - Falco Hietbrink
- Universitair Medisch Centrum Utrecht, afd. Heelkunde, Utrecht
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45
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Abstract
Doxey RJ. You're the flight surgeon: Ehlers-Danlos syndrome. Aerosp Med Hum Perform. 2019; 90(6):583-586.
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46
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van Adrichem DC, Ratering MRHA, Rashid SM, Jusabani MA, Poppe VE, Mwaitele HA, Massawe HH, Howlett WP, Moshi HI, Dekker MCJ. Penetrating spinal cord injury causing paraplegia in a bird hunter in rural Tanzania. Spinal Cord Ser Cases 2019; 5:49. [PMID: 31632707 PMCID: PMC6786419 DOI: 10.1038/s41394-019-0195-7] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/16/2019] [Revised: 05/03/2019] [Accepted: 05/05/2019] [Indexed: 11/08/2022] Open
Abstract
Introduction Cultural and socioeconomic factors influence the risk of sustaining a Traumatic Spinal Cord Injury (TSCI). The standard of management and rehabilitation available to TSCI patients differs greatly between high-income and low-income countries. Case presentation We report a 17-year-old male bird hunter, with no prior medical history, presenting with paraplegia and sensory loss from the xiphoid process down after being struck by an arrow in the left lateral side of the neck. Discussion Penetrating neck injuries are potentially life threatening because of the complex arrangement of vital structures in the neck. Management of spinal cord trauma resulting from such injuries in low-resource settings is challenging.
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Affiliation(s)
| | | | - Sakina Mehboob Rashid
- Department of General Surgery, Kilimanjaro Christian Medical Centre, Moshi, Tanzania
| | - Mubashir Alavi Jusabani
- Department of Orthopaedics and Traumatology, Kilimanjaro Christian Medical Centre, Moshi, Tanzania
| | | | | | - Honest Herman Massawe
- Department of Orthopaedics and Traumatology, Kilimanjaro Christian Medical Centre, Moshi, Tanzania
| | | | | | - Marieke Cornelia Johanna Dekker
- Department of Orthopaedics and Traumatology, Kilimanjaro Christian Medical Centre, Moshi, Tanzania
- Department of Internal Medicine, Kilimanjaro Christian Medical Centre, Moshi, Tanzania
- Department of Paediatrics and Child Health, Kilimanjaro Christian Medical Centre, Moshi, Tanzania
- Department of Neurology, Radboudumc Nijmegen, Nijmegen, Netherlands
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47
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Watts S, Smith JE, Gwyther R, Kirkman E. Closed chest compressions reduce survival in an animal model of haemorrhage-induced traumatic cardiac arrest. Resuscitation 2019; 140:37-42. [PMID: 31077754 DOI: 10.1016/j.resuscitation.2019.04.048] [Citation(s) in RCA: 24] [Impact Index Per Article: 4.8] [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: 01/23/2019] [Revised: 04/09/2019] [Accepted: 04/28/2019] [Indexed: 11/18/2022]
Abstract
Closed chest compressions (CCC) are recommended for medical cardiac arrest, but there is little evidence to support their inclusion for traumatic cardiac arrest (TCA). This laboratory study evaluated CCC following haemorrhage-induced TCA and whether resuscitation with blood improved survival compared to saline. The study was conducted with the authority of UK Animals (Scientific Procedures) Act 1986 (received institutional ethical approval and a Home Office Licence) using 39 terminally anesthetised, instrumented, juvenile Large White pigs. Following baseline measurements, animals underwent captive bolt injury to the right thigh and controlled haemorrhage (30% blood volume). Sixty minutes later there was a further haemorrhage to a MAP of 20 mmHg. The randomised resuscitation protocol was initiated within 5 min: CCC (Group 1); IV whole blood (Group 2); IV 0.9% saline (Group 3); IV whole blood + CCC (Group 4); and IV saline + CCC (Group 5). Fluid was administered as 3 × 10 ml/kg boluses using the Belmont® Rapid Infuser. The LUCAS™ II Chest Compression System delivered CCC. Primary Outcome was attainment of return of spontaneous circulation (ROSC MAP ≥ 50 mmHg) at Study End (fifteen minutes post-resuscitation) and secondary outcomes included haemodynamics. Mortality (MAP≤10 mmHg) was significantly higher in Group 1 compared to Groups 2 and 3 (P < 0.0001). Resuscitation with whole blood was significantly better than saline (P = 0.0069), no animals in Group 3 attained ROSC. The addition of chest compressions to fluid resuscitation resulted in a significantly worse outcome with saline resuscitation (P = 0.0023) but not with whole blood (P = 0.4411). Cardiovascular variables at the end of the Resuscitation Phase and Study End were significantly worse for Group 5 compared to Group 3. Some significant differences were present at the end of the Resuscitation Phase for Group 4 versus Group 2 but these differences were no longer present by Study End. CCC were associated with increased mortality and compromised haemodynamics compared to intravenous fluid resuscitation. Whole blood resuscitation was better than saline.
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Affiliation(s)
- Sarah Watts
- CBR Division, Dstl Porton Down, Salisbury, Wiltshire, SP4 0JQ, UK.
| | - Jason E Smith
- Academic Department of Military Emergency Medicine, Royal Centre for Defence Medicine, Birmingham, UK; Emergency Department, Derriford Hospital, Plymouth, UK
| | - Robert Gwyther
- CBR Division, Dstl Porton Down, Salisbury, Wiltshire, SP4 0JQ, UK
| | - Emrys Kirkman
- CBR Division, Dstl Porton Down, Salisbury, Wiltshire, SP4 0JQ, UK
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48
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Haines E, Fairbrother H, Pade KH. Points & Pearls: Evaluation and management of pediatric patients with penetrating trauma to the torso. Pediatr Emerg Med Pract 2019; 16:e1-e2. [PMID: 31038892] [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] [Subscribe] [Scholar Register] [Indexed: 06/09/2023]
Abstract
Children with penetrating trauma to the torso require careful evaluation of the chest, abdomen, pelvis, and genital structures for system-specific injuries that may contribute to rapid decompensation and influence the order of emergent resuscitation. Care of the injured child and the effect on clinical outcomes starts in the prehospital setting, with hemorrhage control and IV fluid resuscitation. The evaluation and disposition of the patient in the ED will depend on the mechanism of injury and the severity of trauma. This issue reviews the diagnostic evaluation and management of pediatric patients with penetrating injuries to the torso. [Points & Pearls is a digest of Pediatric Emergency Medicine Practice.]
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Affiliation(s)
- Elizabeth Haines
- Associate Professor, Associate Division Chief, Pediatric Emergency Medicine, Ronald O. Perelman Department of Emergency Medicine at NYU Langone Health, New York, NY
| | - Hilary Fairbrother
- Director of Undergraduate Medical Education, Associate Professor, McGovern Medical School at the University of Texas Health Science Center at Houston, Houston, TX
| | - Kathryn H. Pade
- Pediatric Emergency Medicine Ultrasound Fellow, Department of Emergency Medicine, Stanford University School of Medicine, Lucile Packard Children’s Hospital, Palo Alto, CA
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49
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Haines E, Fairbrother H. Evaluation and management of pediatric patients with penetrating trauma to the torso. Pediatr Emerg Med Pract 2019; 16:1-24. [PMID: 31033268] [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] [Subscribe] [Scholar Register] [Received: 02/01/2019] [Accepted: 02/10/2019] [Indexed: 06/09/2023]
Abstract
Children with penetrating trauma to the torso require careful evaluation of the chest, abdomen, pelvis, and genital structures for system-specific injuries that may contribute to rapid decompensation and influence the order of emergent resuscitation. Care of the injured child and the effect on clinical outcomes starts in the prehospital setting, with hemorrhage control and IV fluid resuscitation. The evaluation and disposition of the patient in the ED will depend on the mechanism of injury and the severity of trauma. This issue reviews the diagnostic evaluation and management of pediatric patients with penetrating injuries to the torso.
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Affiliation(s)
- Elizabeth Haines
- Associate Professor, Associate Division Chief, Pediatric Emergency Medicine, Ronald O. Perelman Department of Emergency Medicine at NYU Langone Health, New York, NY
| | - Hilary Fairbrother
- Director of Undergraduate Medical Education, Associate Professor, McGovern Medical School at the University of Texas Health Science Center at Houston, Houston, TX
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50
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Cull J, Riggs R, Riggs S, Byham M, Witherspoon M, Baugh N, Metcalf A, Kitchens D, Manning B. Development of Trauma Level Prediction Models Using Emergency Medical Service Vital Signs to Reduce Over- and Undertriage Rates in Penetrating Wounds and Falls of the Elderly. Am Surg 2019; 85:524-529. [PMID: 31126367] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/09/2023]
Abstract
Determining triage activation levels in geriatric patients who fall (GF), and patients with penetrating wounds can be difficult and inaccurate, resulting in excessive overtriage (OT) and undertriage (UT) rates. We developed trauma activation prediction models using field data to predict with greater accuracy trauma activation level and triage rates consistent with the ACS recommendations. Using data from the 2014 National Trauma Data Bank, we created binary regression equations for each type of injury (GF and penetrating wounds). The 2014 data were randomized and divided into two halves. The first half for each injury type was used to generate prediction models, whereas the second half of the 2014 data were combined with 2013 and 2015 National Trauma Data Bank data for model verification. Binary regression equations were generated from vital signs collected by EMS. A Cribari grid with ISS ≥ 15 was used to determine the appropriateness of activation level. Chi-square analysis was used to determine significant differences between OT, UT, and accuracy predictions. Using our triage models, we were able to obtain UT rates of less than 4 per cent for GF with OT rates of less than 40 per cent, UT rates less than 4.1 per cent and OT of less than 50 per cent for patients with gunshot wounds, and UT rates less than 4 per cent and OT rates less than 25 per cent for patients who had stab wounds. Our developed trauma level prediction models enable health providers to predict trauma activation levels that can result in OT and UT rates in the recommended ranges by the ACS.
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