Ultrasound-Guided Serratus Anterior Plane Block (SAPB) Improves Pain Control in Patients With Rib Fractures.

OBJECTIVES: The serratus anterior plane block (SAPB) is an ultrasound-guided compartment block; limited data suggest that it can decrease pain in patients with rib fractures or chest wall pain. We sought to determine the effect of SAPB on pain and incentive spirometry (IS) maximal vital capacity in adult patients with rib fractures. METHODS: We enrolled a prospective sample of adult patients with at least two unilateral rib fractures who were being admitted for pain control. SAPB was performed by trained emergency physicians. Patients reported pain on an 11-point Numeric Rating Scale at rest and during IS, before, 15, and 60 minutes after SAPB. RESULTS: Mean pain scores decreased by 1.8 (SD 2.17, 95% confidence interval [CI]: 0.79-2.81) at 15 minutes and 2.5 (SD 2.69, 95% CI: 1.24-3.76) at 60 minutes. Compared to pre-block pain scores during IS, mean pain scores decreased by 1.95 (SD 1.99, 95% CI: 1.02-2.88) at 15 minutes and 2.4 (SD 2.42, 95% CI: 1.27-3.53) at 60 minutes. Mean maximum vital capacity increased by 232 mL (SD 406, 95% CI: 36-427) at 60 minutes. Zero SAPB-attributable complications were identified in the 24 hours post-enrollment. CONCLUSIONS: In patients with multiple rib fractures, SAPB reduced pain scores at rest and during IS, and increased maximal vital capacity. The SABP may be a safe and effective modality for pain control in trauma patients with multiple rib fractures.

Venous thromboembolism prophylaxis in the trauma intensive care unit: an American Association for the Surgery of Trauma Critical Care Committee Clinical Consensus Document.

Venous thromboembolism (VTE) is a potential sequela of injury, surgery, and critical illness. Patients in the Trauma Intensive Care Unit are at risk for this condition, prompting daily discussions during patient care rounds and routine use of mechanical and/or pharmacologic prophylaxis measures. While VTE rightfully garners much attention in clinical patient care and in the medical literature, optimal strategies for VTE prevention are still evolving. Furthermore, trauma and surgical patients often have real or perceived contraindications to prophylaxis that affect the timing of preventive measures and the consistency with which they can be applied. In this Clinical Consensus Document, the American Association for the Surgery of Trauma Critical Care Committee addresses several practical clinical questions pertaining to specific or unique aspects of VTE prophylaxis in critically ill and injured patients.

Transdiaphragmatic Chest Wall Herniation.

BACKGROUND: The combination of traumatic simultaneous diaphragmatic rupture and chest wall herniation remains rare, with 42 cases of traumatic transdiaphragmatic intercostal hernia (TDIH) reported in the literature since 1946. An accurate count of cases is difficult to obtain, as TDIH nomenclature has been variable.1-5 Risk factors for traumatic TDIH are not well established. As these injuries are uncommon, best management techniques have yet to be established. Reported repair techniques include primary closure, closure with mesh, and implantation of prosthetic or autologous material. We present our single-center series of 7 patients, the largest reported to our knowledge, and discuss the challenges of repairing these difficult injuries. METHODS: After obtaining institutional review board approval, data were abstracted from the electronic medical record on all adults who underwent evaluation and treatment for traumatic TDIH between July 2014 and January 2019. RESULTS: Of the 7 cases of traumatic TDIH, 6 patients developed TDIH secondary to cough; the seventh patient presented with chronic chest wall pain after an episode of heavy lifting. All patients were obese or overweight. Pain and a "popping sensation" were the most common presenting symptoms. All patients underwent operative intervention with primary repair of the diaphragm and suture approximation of the ribs. 3 patients had onlay mesh repair of the chest wall and/or abdominal wall. 1 patient had plating of his rib fracture. 3 patients had a recurrence of the intercostal portion of the hernia No patients have undergone reoperation thus far. DISCUSSION: While previously thought to more commonly occur on the left side due to the protective effects of the diaphragm,2 the majority in this series had right-sided injuries. Herniation through the ninth-10th interspace remains the most common location.4 Computed tomography imaging should be used for diagnosis and operative planning. It is best to manage these hernias acutely to re-establish normal anatomy. Mesh may be required in delayed reconstructions of if the chest wall cannot be re-approximated. Rib plating should be considered in cases of instability or flail. High rates of complications are not unexpected given the complicated and rare nature of the injury. Given the high rate of intercostal hernia recurrence, it is likely that mesh repair or should be more often used in the treatment of this injury.

Risk of Harm Associated With Using Rapid Sequence Induction Intubation and Positive Pressure Ventilation in Patients With Hemorrhagic Shock.

Based on limited published evidence, physiological principles, clinical experience, and expertise, the author group has developed a consensus statement on the potential for iatrogenic harm with rapid sequence induction (RSI) intubation and positive-pressure ventilation (PPV) on patients in hemorrhagic shock. "In hemorrhagic shock, or any low flow (central hypovolemic) state, it should be noted that RSI and PPV are likely to cause iatrogenic harm by decreasing cardiac output." The use of RSI and PPV leads to an increased burden of shock due to a decreased cardiac output (CO)2 which is one of the primary determinants of oxygen delivery (DO2). The diminishing DO2 creates a state of systemic hypoxia, the severity of which will determine the magnitude of the shock (shock dose) and a growing deficit of oxygen, referred to as oxygen debt. Rapid accumulation of critical levels of oxygen debt results in coagulopathy and organ dysfunction and failure. Spontaneous respiration induced negative intrathoracic pressure (ITP) provides the pressure differential driving venous return. PPV subsequently increases ITP and thus right atrial pressure. The loss in pressure differential directly decreases CO and DO2 with a resultant increase in systemic hypoxia. If RSI and PPV are deemed necessary, prior or parallel resuscitation with blood products is required to mitigate post intervention reduction of DO2 and the potential for inducing cardiac arrest in the critically shocked patient.

Surgical adjuncts to noncompressible torso hemorrhage as tools for patient blood management.

Despite the tremendous advances and successes in the care of combat casualties over the past 15 years of war, noncompressible torso hemorrhage (NCTH) remains the most likely source of potentially preventable death (approx. 25%) on the battlefield. This is also likely true for civilian victims of blunt and penetrating trauma. Various devices and therapeutic interventions have been, and are being, developed in an attempt to reduce morbidity and mortality for patients with NCTH. Examples include the use of prehospital blood and blood products, tranexamic acid, specially designed tourniquets for junctional hemorrhage control, retrograde endovascular balloon occlusion of the aorta, intracavity foam, expandable hemostatic sponges, and intravascular nanoparticles to suspended animation. Although each of these modalities offer the potential to staunch uncontrolled hemorrhage until an injured patient is able to reach definitive surgical care, further research and advances must be made to further reduce trauma morbidity and mortality and to identify those technologies and modalities that are best suited to rapid movement to the front lines of combat casualty care as well as to emergency medical personnel dealing with civilian trauma victims. The surgical adjuncts for NCTH discussed may all be considered as potential tools for patient blood management programs. If effective they offer the possibility of reduce hemorrhage and blood product exposure and improved patient outcomes.

Noncardiac Surgical Procedures After Left Ventricular Assist Device Implantation.

As left ventricular assist devices (LVADs) are increasingly used for patients with end-stage heart failure, the need for noncardiac surgical procedures (NCSs) in these patients will continue to rise. We examined the various types of NCS required and its outcomes in LVAD patients requiring NCS. The National Inpatient Sample Database was examined for all patients implanted with an LVAD from 2007 to 2010. Patients requiring NCS after LVAD implantation were compared to all other patients receiving an LVAD. There were 1,397 patients undergoing LVAD implantation. Of these, 298 (21.3%) required 459 NCS after LVAD implantation. There were 153 (33.3%) general surgery procedures, with abdominal/bowel procedures (n = 76, 16.6%) being most common. Thoracic (n = 141, 30.7%) and vascular (n = 140, 30.5%) procedures were also common. Patients requiring NCS developed more wound infections (9.1 vs. 4.6%, p = 0.004), greater bleeding complications (44.0 vs. 24.8%, p < 0.001) and were more likely to develop any complication (87.2 vs. 82.0%, p = 0.001). On multivariate analysis, the requirement of NCSs (odds ratio: 1.45, 95% confidence interval: 0.95-2.20, p = 0.08) was not associated with mortality. Noncardiac surgical procedures are commonly required after LVAD implantation, and the incidence of complications after NCS is high. This suggests that patients undergoing even low-risk NCS should be cared at centers with treating surgeons and LVAD specialists.

Non-Vitamin K Antagonist Oral Anticoagulants: The Clinician's New Challenge.

Millions of US patients are prescribed oral anticoagulants. Traditionally, oral anticoagulation was achieved with vitamin K antagonists (VKAs). In recent years, non-VKA oral anticoagulants (NOACs) have emerged that provide an effective and convenient alternative to VKAs. These agents possess very different pharmacologic properties from what the medical community has grown accustom to with the VKAs. Thus, a new knowledge base is required for NOACs. One particular challenge with the NOACs is the lack of specific reversal agent, resulting in difficulties correcting the coagulopathy induced by these drugs when needed. A review of the current literature is presented to assist clinicians in gaining knowledge of the NOACs to care for patients.

The evil of good is better: Making the case for basic life support transport for penetrating trauma victims in an urban environment.

BACKGROUND: Controversy remains over the ideal way to transport penetrating trauma victims in an urban environment. Both advance life support (ALS) and basic life support (BLS) transports are used in most urban centers. METHODS: A retrospective cohort study was conducted at an urban Level I trauma center. Victims of penetrating trauma transported by ALS, BLS, or police from January 1, 2008, to November 31, 2013, were identified. Patient survival by mode of transport and by level of care received was analyzed using logistic regression. RESULTS: During the study period, 1,490 penetrating trauma patients were transported by ALS (44.8%), BLS (15.6%), or police (39.6%) personnel. The majority of injuries were gunshot wounds (72.9% for ALS, 66.8% for BLS, 90% for police). Median transport minutes were significantly longer for ALS (16 minutes) than for BLS (14.5 minutes) transports (p = 0.012). After adjusting for transport time and Injury Severity Score (ISS), among victims with an ISS of 0 to 30, there was a 2.4-fold increased odds of death (95% confidence interval [CI], 1.3-4.4) if transported by ALS as compared with BLS. With an ISS of greater than 30, this relationship did not exist (odds ratio, 0.9; 95% CI, 0.3-2.7). When examined by type of care provided, patients with an ISS of 0 to 30 given ALS support were 3.7 times more likely to die than those who received BLS support (95% CI, 2.0-6.8). Among those with an ISS of greater than 30, no relationship was evident (odds ratio, 0.9; 95% CI, 0.3-2.7). CONCLUSION: Among penetrating trauma victims with an ISS of 30 or lower, an increased odds of death was identified for those treated and/or transported by ALS personnel. For those with an ISS of greater than 30, no survival advantage was identified with ALS transport or care. Results suggest that rapid transport may be more important than increased interventions. LEVEL OF EVIDENCE: Therapeutic study, level IV.

Pertussis vaccination in adult trauma patients: Are we missing an opportunity?

INTRODUCTION: Trauma centers commonly administer tetanus prophylaxis to patients sustaining open wounds. In the United States, there are different vaccinations available for adult administration: tetanus/diphtheria toxoid (Td) or tetanus/reduced diphtheria and acellular pertussis (Tdap). The importance of the Tdap preparation lies in its vaccination against pertussis while providing tetanus immunity. Vaccination against pertussis is paramount for disease prevention. In recent decades, there has been a steady rise in pertussis cases. This epidemic increase caused the Centers for Disease Control and Prevention (CDC) Advisory Committee on Immunization Practices (ACIP) to recommend the routine use of Tdap when tetanus prophylaxis is indicated. OBJECTIVES: The aim of this study was to gather data on which formulation of tetanus vaccination is currently being given to adult trauma patients. We hoped to increase awareness of the expanded recommendations for vaccination against pertussis when tetanus prophylaxis is indicated, thus providing patients with protection against pertussis. METHODS: An institutional review board exempt, web-based, nationwide survey was sent to adult trauma center coordinators that could be located via an Internet search. Questions included trauma center level designation, number of trauma evaluations per year, zip code, hospital description (university, university affiliated, or community), and which vaccination is given for adults <65 years and those ≥65. At the conclusion of the survey, hyperlinks to the CDC ACIP recommendations were provided as an educational tool. RESULTS: A total of 718 emails were successfully sent and 439 (61%) completed surveys were returned. Level 4/5 centers had the highest compliance rates for those patients between ages 18 and 64 (93%), followed by level 2/3 (87%), and then level 1 centers (57%). Among all centers, the use of Tdap was lower in the ≥65 year group. Level 2 trauma centers were the most compliant with this age group (61%) followed by level 4/5 (57%) and level 1 (43%) centers. CONCLUSION: With the increase in pertussis cases, vaccination remains crucial to prevention. The CDC recommendations for Tdap have existed for adults <65 years since 2005 and those ≥65 years since 2012. However, many adult trauma centers do not adhere to the current CDC ACIP guidelines for tetanus/pertussis vaccination. In particular, level 1 trauma centers and those classified as university hospitals have the lowest rate of compliance with these recommendations. Through this survey, trauma centers were educated on current recommendations. Increased vaccination of trauma patients with Tdap should improve protection against this virulent pathogen.

Examining Noncardiac Surgical Procedures in Patients on Extracorporeal Membrane Oxygenation.

As extracorporeal membrane oxygenation (ECMO) is increasingly used for patients with cardiac and/or pulmonary failure, the need for noncardiac surgical procedures (NCSPs) in these patients will continue to increase. This study examined the NCSP required in patients supported with ECMO and determined which variables affect outcomes. The National Inpatient Sample Database was examined for patients supported with ECMO from 2007 to 2010. There were 563 patients requiring ECMO during the study period. Of these, 269 (47.8%) required 380 NCSPs. There were 149 (39.2%) general surgical procedures, with abdominal exploration/bowel resection (18.2%) being most common. Vascular (29.5%) and thoracic procedures (23.4%) were also common. Patients requiring NCSP had longer median length of stay (15.5 vs. 9.2 days, p = 0.001), more wound infections (7.4% vs. 3.7%, p = 0.02), and more bleeding complications (27.9% vs. 17.3%, p = 0.01). The incidences of other complications and inpatient mortality (54.3% vs. 58.2%, p = 0.54) were similar. On logistic regression, the requirement of NCSPs was not associated with mortality (odds ratio [OR]: 0.91, 95% confidence interval [CI]: 0.68-1.23, p = 0.17). However, requirement of blood transfusion was associated with mortality (OR: 1.70, 95% CI: 1.06-2.74, p = 0.03). Although NCSPs in patients supported with ECMO does not increase mortality, it results in increased morbidity and longer hospital stay.

Blood far forward: Time to get moving!

In planning for future contingencies, current problems often crowd out historical perspective and planners often turn to technological solutions to bridge gaps between desired outcomes and the reality of recent experience. The US Military, North Atlantic Treaty Organization, and other allies are collectively taking stock of 10-plus years of medical discovery and rediscovery of combat casualty care after the wars in Iraq and Afghanistan. There has been undeniable progress in the treatment of combat wounded during the course of the conflicts in Southwest Asia, but continued efforts are required to improve hemorrhage control and provide effective prehospital resuscitation that treats both coagulopathy and shock. This article presents an appraisal of the recent evolution in medical practice in historical context and suggests how further gains in far forward resuscitation might be achieved using existing technology and methods based on whole-blood transfusion while research on new approaches continues.

Noncardiac surgery in patients on mechanical circulatory support.

This study examined outcomes in patients with left ventricular assist device (LVAD) and extracorporeal membrane oxygenation (ECMO) requiring noncardiac surgical procedures and identified factors that influence outcomes. All patients with mechanical circulatory support (MCS) devices at our institution from 2002 to 2013 undergoing noncardiac surgical procedures were reviewed. There were 148 patients requiring MCS during the study period, with 40 (27.0%) requiring 62 noncardiac surgical procedures. Of these, 29 (72.5%) had implantable LVAD and 11 (27.5%) were supported with ECMO. The two groups were evenly matched with regard to age (53.6 vs. 54.5 years, p = 0.87), male sex (71.4 vs. 45.5%, p = 0.16), and baseline creatinine (1.55 vs. 1.43 mg/dl, p = 0.76). Patients on ECMO had greater demand for postoperative blood products (0.8 vs. 2.8 units of packed red blood cells, p = 0.002) and greater postoperative increase in creatinine (0.07 vs. 0.44 mg/dl, p = 0.047). Median survival was markedly worse in ECMO patients. Factors associated with mortality included ECMO support, history of biventricular assist device, and postoperative blood transfusion. Preoperative aspirin was associated with survival. These findings demonstrate the importance of careful surgical hemostasis and minimizing perioperative blood transfusions in patients on MCS undergoing noncardiac surgical procedures. In addition, low-dose antiplatelet therapy should be continued perioperatively.

"Permissive hypoventilation" in a swine model of hemorrhagic shock.

BACKGROUND: Many penetrating trauma patients in severe hemorrhagic shock receive positive pressure ventilation (PPV) upon transport to definitive care, either by intubation (INT) or bag-valve mask (BVM). Using a swine hemorrhagic shock model that simulates penetrating trauma, we proposed that severely injured patients may have better outcomes with "permissive hypoventilation," where manual breaths are not given and oxygen is administrated passively via face mask (FM). We hypothesized that PPV has harmful physiologic effects in severe low-flow states and that permissive hypoventilation would result in better outcomes. METHODS: The carotid arteries of Yorkshire pigs were cannulated with a 14-gauge catheter. One group of animals (n = 6) was intubated and manually ventilated, a second received PPV via BVM (n = 7), and a third group received 100% oxygen via FM (n = 6). After placement of a Swan-Ganz catheter, the carotid catheters were opened, and the animals were exsanguinated. The primary end point was time until death. Secondary end points included central venous pressure, cardiac output, lactate levels, serum creatinine, CO2 levels, and pH measured in 10-minute intervals. RESULTS: Average survival time in the FM group (50.0 minutes) was not different from the INT (51.1 minutes) and BVM groups (48.5 minutes) (p = 0.84). Central venous pressure was higher in the FM group as compared with the INT 10 minutes into the shock phase (8.3 mm Hg vs. 5.2 mm Hg, p = 0.04). Drop in cardiac output (p < 0.001) and increase in lactate (p < 0.05) was worse in both PPV groups throughout the shock phase. Creatinine levels were higher in both PPV groups (p = 0.04). The FM group was more hypercarbic and acidotic than the two PPV groups during the shock phase (p < 0.001). CONCLUSION: Although permissive hypoventilation leads to respiratory acidosis, it results in less hemodynamic suppression and better perfusion of vital organs. In severely injured penetrating trauma patients, consideration should be given to immediate transportation without PPV.

Trauma hemostasis and oxygenation research position paper on remote damage control resuscitation: definitions, current practice, and knowledge gaps.

The Trauma Hemostasis and Oxygenation Research Network held its third annual Remote Damage Control Resuscitation Symposium in June 2013 in Bergen, Norway. The Trauma Hemostasis and Oxygenation Research Network is a multidisciplinary group of investigators with a common interest in improving outcomes and safety in patients with severe traumatic injury. The network's mission is to reduce the risk of morbidity and mortality from traumatic hemorrhagic shock, in the prehospital phase of resuscitation through research, education, and training. The concept of remote damage control resuscitation is in its infancy, and there is a significant amount of work that needs to be done to improve outcomes for patients with life-threatening bleeding secondary to injury. The prehospital phase of resuscitation is critical in these patients. If shock and coagulopathy can be rapidly identified and minimized before hospital admission, this will very likely reduce morbidity and mortality. This position statement begins to standardize the terms used, provides an acceptable range of therapeutic options, and identifies the major knowledge gaps in the field.