Thromboelastography Use to Guide Resuscitation and Antivenom Administration after Gaboon Viper Bite.

The Gaboon viper (Bitis gabonica) is an exotic snake native to sub-Saharan Africa. Gaboon viper venom is an extremely toxic hemotoxin, causing severe coagulopathy and local tissue necrosis. These are not aggressive snakes and therefore bites involving humans are rare and there is not a substantial amount of literature documenting how to manage these injuries and resultant coagulopathies. We report a 29-year-old male presenting 3 hours after a Gaboon viper envenomation resulting in coagulopathy requiring massive resuscitation and multiple doses of antivenom. The patient received various blood products based on thromboelastography (TEG) and also underwent early continuous renal replacement therapy (CRRT) to assist in correction of severe acidosis and acute renal failure. The combination of TEG to guide resuscitation, administration of antivenom, and early implementation of CRRT allowed our team to correct venom-induced consumptive coagulopathy and ultimately allow the patient to survive following this extremely deadly Gaboon viper envenomation.

The Trauma Activation Review Committee: Response to Undertriage During a Period of Rapid Growth at a Level II Trauma Center.

Trauma triage criteria are constantly being refined for improved identification of severely injured patients. When errors occur, they should be tracked, and triage criteria adjusted to minimize these events. Two time periods of trauma registry data at a single rural level II trauma center were retrospectively compared to evaluate demographics, injuries, and outcomes to identify triage errors. In 300 activated trauma patients during 2011, overtriage was 23% and undertriage was 3.7%. In 1035 activated trauma patients during 2019, overtriage was 20.5% and undertriage was 2.2%. Mortality decreased over time overall. In 2019, Trauma I patients were older, spent more time on the ventilator, and in the ICU (all P < .001). Trauma II patients were also older, had lower ISS, hospital days, and ventilator days (all P < .001). During rapid growth, evaluation of overtriage and undertriage can provide useful feedback for hospital staff to refine triage choices and improve patient outcomes.

Coronavirus-Associated Coagulopathy After Trauma.

Coronavirus disease 2019 (COVID-19) is linked with a hypercoagulable state called COVID-19-associated coagulopathy (CAC). Due to elevated levels of factor VIII and fibrinogen as well as inflammation-linked hyperviscosity of blood, the risk for venous thromboembolism is increased in patients who have CAC. We report the case of a patient with recent COVID-19 infection and no other past medical history who presented after a motorcycle collision with left middle and distal femur fractures, who underwent retrograde intramedullary nailing, and then developed immediate massive bilateral pulmonary emboli. The patient was treated with tissue plasminogen activator administration via bilateral pulmonary artery thrombolysis catheters without improvement, and was then placed on venoarterial extracorporeal membrane oxygenation for subsequent cardiogenic shock. During a 58-day hospital stay, the patient recovered and was discharged with a good long-term prognosis. In this report, we discuss CAC, the role of surgical critical care in the management of the disease, and issues specific to this patient's disease process and treatment.

Implementation of a Surgical Intensivist Model Increases Palliative Care Consultation in the Care of Trauma ICU Patients.

OBJECTIVE: This study investigated patient outcomes of care before and after transitioning to a surgical intensivist-led trauma-intensive care unit (ICU) team. The intensivist team provided daily multidisciplinary rounds and continuity of care. Prior to an intensivist model, general surgeons cared for trauma patients admitted to the unit. METHODS: Outcomes of 1,078 trauma patients, admitted to the ICU at a Level II trauma center, under care of general surgeons (1/2011-8/2012, n = 449) were retrospectively compared with care managed by a surgical intensivist team (1/2013-5/2015, n = 629) by Pearson Chi-squared and Wilcoxon tests. A multivariable logistic regression technique was used to control for covariates. Demographics and injury severity were analyzed. The primary outcome was ICU mortality. The secondary outcomes were length of stay (LOS), ventilator-free and ICU-free days, and ICU readmission rate. Other data collected included palliative care consultation. Results: There were no statistically significant differences in ICU mortality (P = 0.055), hospital LOS (P = 0.481), ventilator-free days (P = 0.174), or ICU readmission rate (P = 0.587). The surgical intensivist team consulted palliative care more frequently (4.0% vs 13.5%, P < 0.001), while managing more trauma patients who were older than 65 years (P < 0.001) with lower Glasgow Coma Scale (P = 0.048) and higher injury severity (P = 0.025) and abbreviated injury scale (P < 0.001) scores. DISCUSSION: There were no differences in outcomes. However, incorporating palliative care consultation in the ICU is essential in the support of critically ill patients and their families. These data demonstrate that a surgical intensivist team utilized palliative care more often in the management of trauma patients admitted to the ICU.

Decreasing Incisional Hernia by Teaching 4:1 Suture to Wound Length Ratio Early in Surgical Education.

OBJECTIVE: Incisional hernia formation has become a major burden for our healthcare system. One factor that has been shown to reduce incisional hernia rates that can be impacted on by the surgeon is the ability to achieve a 4:1 suture to wound length ratio. The purpose of this study is to evaluate whether a focused educational program for surgical residents can help improve laparotomy closures and be successful in achieving 4:1 suture to wound length ratios. DESIGN: Following Institutional Review Board approval, consecutive abdominal wall closures were reviewed from December 2013 to July 2016. S:W length ratios were calculated in all cases and after 100 cases a formal audit of success and risk factors for not achieving a 4:1 ratio was performed followed by a formal resident education on laparotomy closure. The ability to achieve a 4:1 ratio for the first 100 cases following resident education was then compared to the 100 patients preceding the education with a p-value of <0.05 considered significant. RESULTS: Two hundred patients underwent midline laparotomy with S:W length ratio calculated. In the first 100 patients, 76% of patients received a 4:1 S:W closure. Following resident education, this improved to 90% in the second 100 patients (p = 0.0083). Among patients where 2 residents performed the abdominal closure, 50% got an adequate 4:1 closure. This improved to 92% for the second 100 patients (p = 0.016). CONCLUSION: A 4:1 S:W length ratio is a simple technique that has been proven to decrease incisional hernia. It requires no additional cost and can easily be implemented into practice. The act of formal resident education and measuring suture tails to calculate a S:W ratio on each case holds surgeons accountable and improves success rate of achieving a 4:1 ratio.

Analysis of Helicopter-Transported Trauma Patients at a Regional Trauma Center.

Our medical center's regional helicopter emergency medical service (HEMS) serves southeastern North Carolina. Judicious HEMS use is vital to ensure that the resource is available for critically injured patients and to reduce morbidity and mortality by providing timely access to definitive care. We reviewed HEMS use, clinical outcomes, and overtriage rates. The data included airlifted trauma patients from January 2004 to December 2012. Of 1210 total patients, 733 were flown directly from the scene (FS) and 477 from referring hospitals (FH). The HEMS catchment area was a 100-mile radius of our trauma center. FS patients were younger and sustained more motor vehicle collisions. FH patients were older and sustained more falls. FS patients required more hospital resources including longer ventilator requirements, intensive care unit (ICU) stay, and hospital stay. For all HEMS patients, there was 92.2 per cent blunt injury, 47.5 per cent required Trauma I or II activation, 31 per cent required mechanical ventilation, and 50 per cent required ICU care. 59.5 per cent of HEMS trauma patients were critically injured (defined as requiring either immediate surgical intervention, immediate ICU admission, or immediate death). The overtriage rate was 1.8 per cent. The emergency department mortality rate was 2.3 per cent and the ultimate mortality rate was 7.5 per cent. Most of the airlifted trauma patients were critically injured, and therefore, HEMS transport was appropriate. However, overtriage was low, suggesting high incidence of undertriage. There should be a lower threshold for HEMS use for trauma patients in our region. More research is needed to determine ideal overtriage and undertriage rates.

Platelet transfusion does not improve outcomes in patients with brain injury on antiplatelet therapy.

INTRODUCTION: Platelet dysfunction following traumatic brain injury (TBI) is associated with worse outcomes. The efficacy of platelet transfusion to reverse antiplatelet medication (APM) remains unknown. Thrombelastography platelet mapping (TEG-PM) assesses platelet function. We hypothesize that platelet transfusion can reverse the effects of APM but does not improve outcomes following TBI. METHODS: An observational study at six US trauma centres was performed. Adult patients on APM with CT evident TBI after blunt injury were enrolled. Demographics, brain CT and TEG-PM results before/after platelet transfusion, length of stay (LOS), and injury severity score (ISS) were abstracted. RESULTS: Sixty six patients were enrolled (89% aspirin, 50% clopidogrel, 23% dual APM) with 23 patients undergoing platelet transfusion. Transfused patients had significantly higher ISS and admission CT scores. Platelet transfusion significantly reduced platelet inhibition due to aspirin (76.0 ± 30.2% to 52.7 ± 31.5%, p < 0.01), but had a non-significant impact on clopidogrel-associated inhibition (p = 0.07). Platelet transfusion was associated with longer length of stay (7.8 vs. 3.5 days, p < 0.01), but there were no differences in mortality. CONCLUSION: Platelet transfusion significantly decreases platelet inhibition due to aspirin but is not associated with change in outcomes in patients on APM following TBI.

Development, Implementation, and Outcomes of a Delirium Protocol in the Surgical Trauma Intensive Care Unit.

BACKGROUND: Delirium in the critically ill is associated with increased mortality, length of stay (LOS), and prolonged cognitive dysfunction. Existing guidelines provide no recommendation for use of combination nonpharmacological and pharmacological prevention protocols or use of antipsychotic medications for the prevention or treatment of delirium. OBJECTIVE: This study evaluated the impact of implementing a delirium treatment protocol on the number of delirium-free days experienced by acutely delirious patients in the surgical trauma intensive care unit (STICU). METHODS: This retrospective, institutional review board-approved, pre-implementation (PRE) versus post-implementation (POST) cohort evaluated delirious patients admitted to the STICU. Patients were evaluated based on the duration of delirium. Secondary end points included ICU LOS, amount of atypical and typical antipsychotic medication used, amount of analgesia and sedation used, and adverse drug events associated with antipsychotics. RESULTS: Of the 593 evaluated, 89 patients were included (38 PRE vs 51 POST). Implementation of a delirium protocol reduced the number of delirious days, 8.2 ± 5.7 days PRE versus 4.5 ± 4.4 days POST; P = 0.001. ICU LOS in surviving patients and use of concomitant medications, intravenous morphine equivalents, and propofol were significantly reduced in the POST group. CONCLUSION: The implementation of a delirium protocol with nonpharmacological and pharmacological interventions had an impact on STICU patients experiencing acute delirium by significantly increasing delirium-free days and reducing the ICU LOS, in addition to decreased administration of concomitant medications.