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Background and Objective: Penetrating cardiac trauma is rare but can cause life-threatening complications. Survival is dependent on prompt diagnosis and treatment. Given the low incidence and life-threatening implications, it is difficult to study in large prospective studies. The current literature regarding penetrating cardiac trauma comes primarily from large, experienced trauma centers and military sources. Understanding the history, current literature and even expert opinion can help with effectively treating injury promptly to maximize survival after penetrating cardiac trauma. We aimed to review the etiology and history of penetrating cardiac trauma. We review the prehospital treatment and initial diagnostic modalities. We review the incisional approaches to treatment including anterolateral thoracotomy, median sternotomy and subxiphoid window. The repair of atrial, ventricular and coronary injuries are also addressed in our review. The purpose of this paper is to perform a narrative review to better describe the history, etiology, presentation, and management of penetrating cardiac trauma. Methods: A narrative review was preformed synthesizing literature from MEDLINE and bibliographic review from identified publications. Studies were included based on relevance without exclusion to time of publication or original publication language. Key Content and Findings: Sonographic identification of pericardial fluid can aid in diagnosis of patients too unstable for CT. Anterolateral thoracotomy should be used for emergent repairs and initial stabilization. A median sternotomy can be used for more stable patients with known injuries. Carefully placed mattress sutures can be useful for repair of injuries surrounding coronary vessels to avoid devascularization. Conclusions: Penetrating cardiac trauma is life threatening and requires prompt workup and treatment. Trauma algorithms should continue to refine and be clear on which patients should undergo an emergency department (ED) thoracotomy, median sternotomy and further imaging.
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BACKGROUND: "Academic surgeon" describes a member of a medical school department of surgery, but this term does not fully define the important role of such physician-scientists in advancing surgical science through translational research and innovation. METHODS: The curriculum vitae and self-descriptive vignettes of the records of achievement of seven surgeons possessing documented records of academic leadership, innovation, and dissemination of knowledge were reviewed. RESULTS: Out analysis yielded seven attributes of the archetypal academic surgeon: 1) identifies complex clinical problems ignored or thought unsolvable by others, 2) becomes an expert, 3) innovates to advance treatment, 4) observes outcomes to further improve and innovate, 5) disseminates knowledge and expertise, 6) asks important questions to further improve care, and 7) trains the next generation of surgeons and scientists. CONCLUSION: Although alternative pathways to innovation and academic contribution also exist, the academic surgeon typically devotes years of careful observation, analysis, and iterative investigation to identify and solve challenging or unexplored clinical problems, ideally leverages resources available in academic medical centers to support these endeavors.
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Docentes Médicos , Especialidades Quirúrgicas , Investigación Biomédica Traslacional , Especialidades Quirúrgicas/educación , Estados UnidosRESUMEN
BACKGROUND: Hemorrhagic shock is responsible for one third of trauma related deaths. We hypothesized that intraoperative hypotensive resuscitation would improve survival for patients undergoing operative control of hemorrhage following penetrating trauma. METHODS: Between July 1, 2007, and March 28, 2013, penetrating trauma patients aged 14 years to 45 years with a systolic blood pressure of 90 mm Hg or lower requiring laparotomy or thoracotomy for control of hemorrhage were randomized 1:1 based on a target minimum mean arterial pressure (MAP) of 50 mm Hg (experimental arm, LMAP) or 65 mm Hg (control arm, HMAP). Patients were followed up 30 days postoperatively. The primary outcome of mortality; secondary outcomes including stroke, myocardial infarction, renal failure, coagulopathy, and infection; and other clinical data were analyzed between study arms using univariate and Kaplan-Meier analyses. RESULTS: The trial enrolled 168 patients (86 LMAP, 82 HMAP patients) before early termination, in part because of clinical equipoise and futility. Injuries resulted from gunshot wounds (76%) and stab wounds (24%); 90% of the patients were male, and the median age was 31 years. Baseline vitals, laboratory results, and injury severity were similar between groups. Intraoperative MAP was 65.5 ± 11.6 mm Hg in the LMAP group and 69.1 ± 13.8 mm Hg in the HMAP group (p = 0.07). No significant survival advantage existed for the LMAP group at 30 days (p = 0.48) or 24 hours (p = 0.27). Secondary outcomes were similar for the LMAP and HMAP groups: acute myocardial infarction (1% vs. 2%), stroke (0% vs. 3%), any renal failure (15% vs. 12%), coagulopathy (28% vs. 29%), and infection (59% vs. 58%) (p > 0.05 for all). Acute renal injury occurred less often in the LMAP than in HMAP group (13% vs. 30%, p = 0.01). CONCLUSION: This study was unable to demonstrate that hypotensive resuscitation at a target MAP of 50 mm Hg could significantly improve 30-day mortality. Further study is necessary to fully realize the benefits of hypotensive resuscitation. LEVEL OF EVIDENCE: Therapeutic study, level II.
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Hemorragia/cirugía , Hipotensión/terapia , Cuidados Intraoperatorios/métodos , Laparotomía , Resucitación/métodos , Toracotomía , Heridas Penetrantes/cirugía , Adolescente , Adulto , Femenino , Hemorragia/mortalidad , Mortalidad Hospitalaria , Humanos , Masculino , Persona de Mediana Edad , Estudios Prospectivos , Tasa de Supervivencia , Resultado del Tratamiento , Heridas Penetrantes/mortalidadRESUMEN
BACKGROUND: Traumatic injuries to peripheral arterial vessels are increasingly managed with endovascular techniques. Early small series have suggested that endovascular therapy is feasible and decreases operative blood loss, but these data are limited. The purpose of this study was to evaluate the feasibility and outcomes of endovascular management of nonaortic arterial trauma. MATERIALS AND METHODS: We reviewed records of traumatic nonaortic arterial injuries presenting at an urban level 1 trauma center from December 2009-July 2013. Patients undergoing treatment in interventional radiology and patients whose injuries occurred >72 h before presentation were excluded. Demographics, indicators of injury severity, operative blood loss, transfusion requirements, and clinical outcome were compared between patients undergoing endovascular and open management using appropriate inferential statistics. RESULTS: During the study period, 17 patients underwent endovascular interventions and 20 had open surgery. There were 19 upper extremity and/or thoracic outlet arterial injuries, 15 lower extremity injuries and 11 pelvic injuries. Endovascular cases were completed using a vascular imaging C-arm in a standard operating room. Estimated blood loss during the primary procedure was significantly lower with endovascular management (150 versus 825 cc, P < 0.001). No differences were observed between cohorts in age, injury severity score, intensive care unit length of stay, arterial pH, transfusion requirements, inpatient complication rate, or mortality. CONCLUSIONS: Our experience with endovascular management demonstrates its feasibility with commonly available tools. Operative blood loss may be significantly decreased using endovascular techniques. Further study is needed to refine patient selection criteria and to define long-term outcomes.
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Arterias/lesiones , Pérdida de Sangre Quirúrgica/estadística & datos numéricos , Procedimientos Endovasculares/estadística & datos numéricos , Complicaciones Posoperatorias/epidemiología , Lesiones del Sistema Vascular/cirugía , Adulto , Arterias/cirugía , Estudios de Factibilidad , Femenino , Humanos , Masculino , Persona de Mediana Edad , Estudios Retrospectivos , Texas/epidemiología , Resultado del Tratamiento , Adulto JovenRESUMEN
BACKGROUND: Damage-control resuscitation is the prevailing trauma resuscitation technique that emphasizes early and aggressive transfusion with balanced ratios of red blood cells (RBCs), plasma (FFP), and platelets (Plt) while minimizing crystalloid resuscitation, which is a departure from Advanced Trauma Life Support (ATLS) guidelines. It is unclear whether the newer approach is superior to the approach recommended by ATLS. QUESTIONS/PURPOSES: With these recent changes pervading resuscitation protocols, we performed a systematic review to determine if the shift in trauma resuscitation from ATLS guidelines to damage control resuscitation has improved mortality in patients with penetrating injuries. METHODS: A systematic search of PubMed, the Cochrane Library, and the Current Controlled Trials Register was performed for studies comparing mortality in massively transfused penetrating trauma patients receiving either balanced ratios of blood transfusion per damage control resuscitation tenets or undergoing an alternate blood volume resuscitation strategy. Studies were deemed appropriate for inclusion if they had a Newcastle-Ottawa Scale score of 6 or greater as well as at least 30% penetrating trauma. Twenty studies that reported on a total of 12,154 patients were included. RESULTS: Transfusion ratios varied widely, with 1:1 and 1:2 ratios of FFP:RBC most often defined as high ratios for purposes of comparison with other low ratio groups. Fourteen of 20 studies found significantly lower 30-day mortality when higher transfusion ratios of FFP, RBC, and/or Plt were used; six of 20 studies found mortality to be similar between higher and lower transfusion ratios. CONCLUSIONS: Patients with penetrating injuries who require massive transfusion should be transfused early using balanced ratios of RBC, FFP, and Plt. Randomized, controlled trials are needed to determine optimal ratios for transfusion.
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Atención de Apoyo Vital Avanzado en Trauma/métodos , Resucitación/métodos , Heridas por Arma de Fuego/terapia , Heridas Penetrantes/terapia , Transfusión Sanguínea/métodos , Humanos , Centros Traumatológicos , Resultado del TratamientoRESUMEN
BACKGROUND: For nearly a decade, our center performed thromboelastograms (TEGs) to analyze coagulation profiles, allowing rapid data-driven blood component therapy. After consensus recommendations for massive transfusion protocols (MTPs), we implemented an MTP in October 2009 with 1:1:1 ratio of blood (red blood cells [RBC]), plasma (fresh-frozen plasma [FFP]), and platelets. We hypothesized that TEG-directed resuscitation is equivalent to MTP resuscitation. METHODS: All patients receiving 6 units (U) or more of RBC in the first 24 hours for 21 months before and after MTP initiation in an urban Level I trauma center were examined. Demographics, mechanism of injury (MOI), Injury Severity Score (ISS), 24-hour volume of RBC, FFP, platelets, crystalloid, and 30-day mortality were compared, excluding patients with traumatic brain injuries. Variables were analyzed using Student's t-test and χ2 or Fisher's exact test. RESULTS: For the preMTP group, there were 165 patients. In the MTP group, there were 124 patients. There were no significant differences in ISS, age, or sex. PreMTP patients with 6U or more RBC had significantly more penetrating MOI (p = 0.017), whereas preMTP patients with 10U or more RBC had similar MOIs. All patients received less crystalloid after MTP adoption (p < 0.001). There was no difference in volume of blood products or mortality in patients receiving 6U or more RBC. Blunt trauma MTP patients who received 10U or more RBC received more FFP (p = 0.02), with no change in mortality. Penetrating trauma patients who received 10U or more RBC received a similar volume of FFP; however, mortality increased from 54.1% for MTP versus 33.3% preMTP (p = 0.04). CONCLUSION: TEG-directed resuscitation is equivalent to standardized MTP for patients receiving 6U or more RBC and for blunt MOI patients receiving 10U or more RBC. MTP therapy worsened mortality in penetrating MOI patients receiving 10U or more RBC, indicating a continued need for TEG-directed therapy. A 1:1:1 strategy may not be adequate in all patients. LEVEL OF EVIDENCE: Therapeutic study, level IV.
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Transfusión Sanguínea/métodos , Resucitación/métodos , Tromboelastografía , Heridas Penetrantes/terapia , Adulto , Protocolos Clínicos , Transfusión de Eritrocitos/métodos , Femenino , Humanos , Puntaje de Gravedad del Traumatismo , Masculino , Transfusión de Plaquetas/métodos , Estudios Retrospectivos , Tromboelastografía/métodosRESUMEN
A recent large civilian randomized controlled trial on the use of tranexamic acid (TXA) for trauma reported important survival benefits. Subsequently, successful use of TXA for combat casualties in Afghanistan was also reported. As a result of these promising studies, there has been growing interest in the use of TXA for trauma. Potential adverse effects of TXA have also been reported. A US Department of Defense committee conducted a review and assessment of knowledge gaps and research requirements regarding the use of TXA for the treatment of casualties that have experienced traumatic hemorrhage. We present identified knowledge gaps and associated research priorities. We believe that important knowledge gaps exist and that a targeted, prioritized research effort will contribute to the refinement of practice guidelines over time.
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Antifibrinolíticos/uso terapéutico , Hemorragia/prevención & control , Ácido Tranexámico/uso terapéutico , Heridas y Lesiones/tratamiento farmacológico , Antifibrinolíticos/farmacología , Humanos , Complicaciones Posoperatorias/inducido químicamente , Ensayos Clínicos Controlados Aleatorios como Asunto , Investigación , Factores de Riesgo , Convulsiones/inducido químicamente , Trombosis/inducido químicamente , Ácido Tranexámico/farmacología , Heridas y Lesiones/cirugíaAsunto(s)
Oclusión con Balón/métodos , Procedimientos Endovasculares/métodos , Hipotensión/diagnóstico , Lesiones del Sistema Vascular/terapia , Heridas Penetrantes/terapia , Adolescente , Adulto , Anciano , Angiografía/métodos , Arteria Axilar/diagnóstico por imagen , Arteria Axilar/lesiones , Estudios de Cohortes , Femenino , Estudios de Seguimiento , Humanos , Hipotensión/terapia , Puntaje de Gravedad del Traumatismo , Masculino , Persona de Mediana Edad , Estudios Prospectivos , Medición de Riesgo , Arteria Subclavia/diagnóstico por imagen , Arteria Subclavia/lesiones , Traumatismos Torácicos/diagnóstico por imagen , Traumatismos Torácicos/terapia , Resultado del Tratamiento , Lesiones del Sistema Vascular/diagnóstico por imagen , Heridas Penetrantes/diagnóstico por imagenRESUMEN
Blunt abdominal aortic injury (BAAI) is a rare and lethal injury requiring surgical management. Injury patterns can be complex and surgical strategy should accommodate specific case circumstances. Endovascular solutions appear appropriate and preferred in certain cases of BAAI, which, however, may not be applicable due to device limitations in regard to patient anatomy and limited operating room capability. However, endovascular therapy can be pursued with limited fluoroscopy capability and consumable availability providing a solution that is expeditious and effective for select cases of BAAI.
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Aorta Abdominal/cirugía , Implantación de Prótesis Vascular , Procedimientos Endovasculares , Lesiones del Sistema Vascular/cirugía , Heridas no Penetrantes/cirugía , Accidentes de Tránsito , Adulto , Aorta Abdominal/diagnóstico por imagen , Aorta Abdominal/lesiones , Aortografía/métodos , Humanos , Masculino , Cinturones de Seguridad/efectos adversos , Tomografía Computarizada por Rayos X , Resultado del Tratamiento , Lesiones del Sistema Vascular/diagnóstico por imagen , Lesiones del Sistema Vascular/etiología , Heridas no Penetrantes/diagnóstico por imagen , Heridas no Penetrantes/etiologíaRESUMEN
PURPOSE: To describe the use of custom fenestrated endografts to preserve left subclavian artery (SCA) flow when requiring coverage during endovascular repair of blunt aortic injury (BAI). CASE REPORT: A 39-year-old male involved in a motor vehicle accident sustained injuries including intracranial hemorrhage, BAI, and extremity fractures. Immediate neurosurgical intervention was required. Once neurologically stabilized, endovascular repair was performed with a commercially available device modified with a custom fenestration to preserve flow into the left SCA. Serial follow-up CT angiography (CTA) demonstrates satisfactory repair with prograde left SCA flow and no evidence of endoleak. CONCLUSION: Left SCA coverage is often required for successful endovascular repair of BAI. A subgroup of patients who undergo left SCA coverage will require revascularization. The use of custom fenestrated endografts for preserving left SCA during thoracic endovascular aortic repair (TEVAR) for BAI is an innovative and feasible option in patients who require revascularization.
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Aneurisma Falso/cirugía , Aorta Torácica/cirugía , Aneurisma de la Aorta Torácica/cirugía , Implantación de Prótesis Vascular/instrumentación , Prótesis Vascular , Procedimientos Endovasculares/instrumentación , Stents , Arteria Subclavia , Lesiones del Sistema Vascular/cirugía , Heridas no Penetrantes/cirugía , Accidentes de Tránsito , Adulto , Aneurisma Falso/diagnóstico por imagen , Aneurisma Falso/etiología , Aneurisma Falso/fisiopatología , Aorta Torácica/diagnóstico por imagen , Aorta Torácica/lesiones , Aorta Torácica/fisiopatología , Aneurisma de la Aorta Torácica/diagnóstico por imagen , Aneurisma de la Aorta Torácica/etiología , Aneurisma de la Aorta Torácica/fisiopatología , Aortografía/métodos , Humanos , Masculino , Diseño de Prótesis , Flujo Sanguíneo Regional , Arteria Subclavia/diagnóstico por imagen , Arteria Subclavia/fisiopatología , Tomografía Computarizada por Rayos X , Resultado del Tratamiento , Lesiones del Sistema Vascular/diagnóstico por imagen , Lesiones del Sistema Vascular/etiología , Lesiones del Sistema Vascular/fisiopatología , Heridas no Penetrantes/diagnóstico por imagen , Heridas no Penetrantes/etiología , Heridas no Penetrantes/fisiopatologíaRESUMEN
BACKGROUND: Trauma is a leading cause of death worldwide and is thus a major public health concern. Previous studies have shown that limiting the amount of fluids given by following a strategy of permissive hypotension during the initial resuscitation period may improve trauma outcomes. This study examines the clinical outcomes from the first 90 patients enrolled in a prospective, randomized controlled trial of hypotensive resuscitation, with the primary aim of assessing the effects of a limited transfusion and intravenous (IV) fluid strategy on 30-day morbidity and mortality. METHODS: Patients in hemorrhagic shock who required emergent surgery were randomized to one of the two arms of the study for intraoperative resuscitation. Those in the experimental (low mean arterial pressure [LMAP]) arm were managed with a hypotensive resuscitation strategy in which the target mean arterial pressure (MAP) was 50 mm Hg. Those in the control (high MAP [HMAP]) arm were managed with standard fluid resuscitation to a target MAP of 65 mm Hg. Patients were followed up for 30 days. Intraoperative fluid requirements, mortality, postoperative complications, and other clinical data were prospectively gathered and analyzed. RESULTS: Patients in the LMAP group received a significantly less blood products and total i.v. fluids during intraoperative resuscitation than those in the HMAP group. They had significantly lower mortality in the early postoperative period and a nonsignificant trend for lower mortality at 30 days. Patients in the LMAP group were significantly less likely to develop immediate postoperative coagulopathy and less likely to die from postoperatively bleeding associated with coagulopathy. Among those who developed coagulopathy in both groups, patients in the LMAP group had significantly lower international normalized ratio than those in the HMAP group, indicating a less severe coagulopathy. CONCLUSIONS: Hypotensive resuscitation is a safe strategy for use in the trauma population and results in a significant reduction in blood product transfusions and overall IV fluid administration. Specifically, resuscitating patients with the intent of maintaining a target minimum MAP of 50 mm Hg, rather than 65 mm Hg, significantly decreases postoperative coagulopathy and lowers the risk of early postoperative death and coagulopathy. These preliminary results provide convincing evidence that support the continued investigation and use of hypotensive resuscitation in the trauma setting.