Noncitrated whole blood is optimal for evaluation of postinjury coagulopathy with point-of-care rapid thrombelastography.

INTRODUCTION: Progressive postinjury coagulopathy has become the fundamental rationale for damage control surgery, and the decision to abort operative intervention must occur prior to overt laboratory confirmation of coagulopathy. Current coagulation testing is most commonly performed for monitoring anticoagulation therapy, the results are delayed, and the applicability of these tests in the trauma setting is questionable. Point-of-care (POC) rapid thrombelastography (r-TEG) provides real time analysis of thrombostatic function, which may allow for accurate, goal directed therapy. The test differs from standard thrombelastography (TEG) because the clotting process and subsequent analysis is accelerated by the addition of tissue factor to the whole blood sample, but is limited by the requirement that the analysis be performed within 4 min of blood draw to prevent clot formation. Consequently, citrated specimens have been proposed to obviate this time limitation. We hypothesized that the speed of r-TEG analysis following tissue factor addition to citrated blood might compromise accurate determinations compared with noncitrated whole blood. Additionally, we sought to compare the use of r-TEG with conventional coagulation tests in analysis of postinjury coagulopathy. METHODS: We conducted a retrospective study of severely injured patients entered into our trauma database between January and June 2008 who were at risk for postinjury coagulopathy. Patients needed simultaneous conventional coagulation (INR, fibrinogen, platelet count) and r-TEG specimens with either fresh or citrated whole blood for inclusion in the study. kappa-Statistics were used to determine the agreement between the tests in predicting hypocoagulability. McNemar's chi(2) tests were used to compare theoretical blood product administration between r-TEG and conventional coagulation tests for noncitrated specimens. Therapeutic transfusion triggers were: INR (>1.5) and r-TEG ACT (>125 s) for FFP administration; fibrinogen (<133 mg/dL) and alpha-angle (<63 degrees ) for cryoprecipitate; and platelet count (<100K) and maximum amplitude (MA) (<52 mm) for aphaeresis platelets. Statistical significance was established as P<0.05 using two-sided tests. RESULTS: Forty-four patients met the inclusion criteria. kappa-Values (correlation) were higher in noncitrated versus citrated specimens for all comparisons between conventional and r-TEG tests, indicating better performance of r-TEG with the noncitrated specimens. FFP would have been administered to significantly more patients based on conventional transfusion triggers (61.5% by INR transfusion triggers versus 26.9% by r-TEG-ACT triggers, P=0.003). There was no statistically significant difference in potential cryoprecipitate or aphaeresis platelet administration. CONCLUSION: POC r-TEG is superior when performed with uncitrated versus citrated whole blood for evaluation of postinjury coagulation status. As a real time measure of total thrombostatic function, our preliminary data suggest that r-TEG may effectively guide transfusion therapy and result in reduced FFP administration compared with conventional coagulation tests.

Lower extremity compartment syndrome in the acute care surgery paradigm: safety lessons learned.

BACKGROUND: Prompt diagnosis and decompression of acute lower extremity compartment syndrome (LECS) in the multisystem injured patient is essential to avoid the devastating complications of progressive tissue necrosis and amputation. Despite collaborative trauma and orthopedic management of these difficult cases, significant delays in diagnosis and treatment occur. Periodic system review of our trauma and orthopedic data for complications of LECS led us to hypothesize that delayed diagnosis and limb loss were potentially preventable events in our trauma center. SETTING: Academic level 1 trauma center. METHODS: We performed a prospective review of our trauma registry for all cases of LECS over a 7 year period (2/98-10/2005). Variables reviewed included demographics, injury patterns, tissue necrosis, amputation and mortality. RESULTS: Eighty-three (10 female, 73 male) cases were reviewed. Mean age = 33.3 years (range 1-78). Mean ISS = 19.4, GCS = 12.5. Five (6.0%) had amputations; 7 (8.4%) died. Fractures occurred in 68.7% (n = 57), and vascular injuries were present in 38.6% (n = 32). In 7 patients (8.4%), a delayed compartment release resulted in muscle necrosis requiring multiple debridements, subsequent wound closure problems, and long term disability. Of note, none of these patients had prior compartment pressure measurements. Furthermore, 6 patients (7%) had superficial peroneal nerve transections as complications of their fasciotomy. CONCLUSION: In the multisystem injured patient, LECS remains a major diagnostic and treatment challenge with significant risks of limb loss as well as complications from decompressive fasciotomy. These data underscore the importance of routine surveillance for LECS. In addition, a thorough knowledge of regional anatomy is essential to avoid technical morbidity.

Management of maxillofacial injuries with severe oronasal hemorrhage: a multicenter perspective.

BACKGROUND: Airway establishment and hemorrhage control may be difficult to achieve in patients with massive oronasal bleeding from maxillofacial injuries. This study was formulated to develop effective algorithms for managing these challenging injuries. METHODS: Trauma registries from nine trauma centers were queried over a 7-year period for injuries with abbreviated injury scale face >/= 3 and transfusion of >/=3 units of blood within 24 hours. Patients in whom no significant bleeding was attributed to maxillofacial trauma were excluded. Patient demographics, injury severity measures, airway management, hemostatic procedures, and outcome were analyzed. RESULTS: Ninety patients were identified. Median injury severity scores for 60 blunt trauma patients was 34 versus 17 for 30 patients with penetrating wounds (p < 0.05). Initial airway management was by endotracheal intubation in 72 (80%) patients. Emergent cricothyrotomy and tracheostomy were necessary in 7 (8%) and 5 (6%) patients, respectively. Seventeen (57%) patients with penetrating wounds were taken directly to the operating room for airway control and initial efforts at hemostasis versus 12 (20%) patients with blunt trauma (p < 0.05). Anterior or posterior or both packing alone controlled bleeding in only 29% of patients in whom it was used. Transarterial embolization (TAE) was used in 12 (40%) patients with penetrating injuries and 20 (33%) patients with blunt trauma. TAE was successful for definitive control of hemorrhage in 87.5% of patients. Overall mortality rate was 24.4%, with 6 (7%) deaths directly attributable to maxillofacial injuries. CONCLUSIONS: Initial airway control was achieved by endotracheal intubation in most patients. Patients with penetrating wounds were more frequently taken directly to the operating room for airway management and initial efforts at hemostasis. Patients with blunt trauma were much more likely to have associated injuries which affected treatment priorities. TAE was highly successful in controlling hemorrhage.

Hepatic Trauma.

Hepatic injuries are one of the most common abdominal injuries following either blunt or penetrating trauma. CT scanning has revolutionized the treatment algorithm for these patients. The majority of patients are successfully treated with nonoperative management, but surgeons should have a clear understanding of the indications for operative intervention. An array of techniques including operative, interventional, and endoscopic, are often required for management of advanced grade hepatic injuries.

Practice patterns and outcomes of retrievable vena cava filters in trauma patients: an AAST multicenter study.

BACKGROUND: The purpose of this study is to describe practice patterns and outcomes of posttraumatic retrievable inferior vena caval filters (R-IVCF). METHODS: A retrospective review of R-IVCFs placed during 2004 at 21 participating centers with follow up to July 1, 2005 was performed. Primary outcomes included major complications (migration, pulmonary embolism [PE], and symptomatic caval occlusion) and reasons for failure to retrieve. RESULTS: Of 446 patients (69% male, 92% blunt trauma) receiving R-IVCFs, 76% for prophylactic indications and 79% were placed by interventional radiology. Excluding 33 deaths, 152 were Gunter-Tulip (G-T), 224 Recovery (R), and 37 Optease (Opt). Placement occurred 6 +/- 8 days after admission and retrieval at 50 +/- 61 days. Follow up after discharge (5.7 +/- 4.3 months) was reported in 51%. Only 22% of R-IVCFs were retrieved. Of 115 patients in whom retrieval was attempted, retrieval failed as a result of technical issues in 15 patients (10% of G-T, 14% of R, 27% of Opt) and because of significant residual thrombus within the filter in 10 patients (6% of G-T, 4% of R, 46% Opt). The primary reason R-IVCFs were not removed was because of loss to follow up (31%), which was sixfold higher (6% to 44%, p = 0.001) when the service placing the R-IVCF was not directly responsible for follow up. Complications did not correlate with mechanism, injury severity, service placing the R-IVCF, trauma volume, use of anticoagulation, age, or sex. Three cases of migration were recorded (all among R, 1.3%), two breakthrough PE (G-T 0.6% and R 0.4%) and six symptomatic caval occlusions (G-T 0, R 1%, Opt 11%) (p < 0.05 Opt versus both G-T and R). CONCLUSION: Most R-IVCFs are not retrieved. The service placing the R-IVCF should be responsible for follow up. The Optease was associated with the greatest incidence of residual thrombus and symptomatic caval occlusion. The practice patterns of R-IVCF placement and retrieval should be re-examined.

Pelvic actinomycosis: a case report.

BACKGROUND: Pelvic actinomycosis is rare but can manifest with multiple presentations. CASE: A 28-year-old woman, gravida 4, para 2, conceived with a Paraguard intrauterine device (IUD) (FEI Products LLC, North Tonawanda, New York) in place. The IUD had been present for 2 years. The patient presented with an incomplete abortion at 6 weeks' gestation, and the IUD was removed. Two and one-half months later the patient presented with signs and symptoms of pelvic inflammatory disease and underwent hospitalization and exploratory laparotomy. The pathology specimen revealed diffuse actinomycosis involving the tube and ovary, appendix, and bowel mucosa. A Pap smear 3 months earlier had revealed Actinomyces. CONCLUSION: Actinomyces has been associated with IUD use and may present even after removal of the IUD. Pelvic actinomycosis is rare, and removal of the IUD may not be adequate treatment. If a patient presents with symptoms of infection, early diagnosis and aggressive antibiotics may prevent further complications.

The role of the lung in postinjury multiple organ failure.

BACKGROUND: Postinjury multiple organ failure (MOF) is a result of a dysfunctional inflammatory response to severe injury and shock. Acute lung injury is thought to promote further organ dysfunction by the systemic release of inflammatory mediators from injured lung tissue. Although clinical evidence supports this model, a clear understanding of the relationship between lung dysfunction and multiple organ failure has yet to be defined. We hypothesized that respiratory dysfunction is an early obligate event in the progression of postinjury MOF. METHODS: Data were collected prospectively on 1,344 trauma patients at risk for postinjury MOF. Inclusion criteria were age greater than 16 years, trauma intensive care unit admission, Injury Severity Score greater than 15, and survival longer than 48 hours. Isolated head injuries and head injuries with an extracranial abbreviated injury score of less than 2 were excluded. Daily physiologic and laboratory data were collected through surgical intensive care unit day 28 and clinical events were recorded thereafter until death or hospital discharge. Organ failure was characterized using the Denver MOF scale. RESULTS: Organ dysfunction was observed in 1,011 (75%) of 1,344 patients. Lung dysfunction was observed in 951 (94%) patients with 1 or more organ dysfunctions and 598 (99%) of 605 patients with 2 or more organ dysfunctions. Lung dysfunction preceded heart, liver, and kidney dysfunction by an average of 0.6 +/- 0.2 days, 4.8 +/- 0.2 days, and 5.5 +/- 0.5 days, respectively. The severity of lung dysfunction correlated with the severity of heart, liver, and kidney dysfunction, and the number of other dysfunctional organ systems. CONCLUSIONS: Postinjury respiratory dysfunction is an obligate event that precedes heart, liver, and kidney failure. The severity of other organ dysfunction is related directly to the severity of respiratory dysfunction. These data implicate lung dysfunction as central to the promotion of pathogenic inflammation and the development of postinjury MOF.

A 12-year prospective study of postinjury multiple organ failure: has anything changed?

HYPOTHESIS: The incidence and severity of postinjury multiple organ failure (MOF) has decreased over the last decade. DESIGN: A prospective 12-year inception cohort study ending December 31, 2003. SETTING: Regional academic level I trauma center. PATIENTS: One thousand three hundred forty-four trauma patients at risk for postinjury MOF. Inclusion criteria were aged older than 15 years, admission to the trauma intensive care unit, an Injury Severity Score higher than 15, and survival for more than 48 hours after injury. Isolated head injuries were excluded from this study. Previously identified risk factors for postinjury MOF were age, Injury Severity Score, and receiving a blood transfusion within 12 hours of injury. MAIN OUTCOME MEASURES: Multiple organ failure was defined by a Denver MOF score of 4 or more for longer than 48 hours after injury. Multiple organ failure severity was defined by the maximum daily MOF score and the number of MOF free days within the first 28 postinjury days. RESULTS: Multiple organ failure was diagnosed in 339 (25%) of 1244 patients. The mean age and Injury Severity Scores increased and the use of blood transfusion during resuscitation decreased over the 12-year study period. After adjusting for age, injury severity, and amount of blood transfused during resuscitation, there was a decreased incidence of MOF over the study period. Of the patients who developed MOF, there was a decrease in disease severity and duration as measured by the maximum daily MOF score and the MOF free days. Although the overall mortality rate remained constant, the MOF-specific mortality decreased. CONCLUSIONS: The incidence, severity, and attendant mortality of postinjury MOF decreased over the last 12 years despite an increased MOF risk. Improvements in MOF outcomes can be attributed to improvements in trauma and critical care and are associated with decreased use of blood transfusion during resuscitation.

The academic trauma center is a model for the future trauma and acute care surgeon.

BACKGROUND: Strategies to prevent the extinction of the trauma surgeon have focused on increasing the operative potential by including nontrauma general surgery emergencies. Although providing comprehensive emergent surgical care by the trauma service may seem novel, our institution has embraced this concept for the past 25 years. Recent discussions on the future of trauma surgery stimulated us to review our experience as a possible model for the future trauma and acute care surgeon. METHODS: We reviewed operative logs for 2002 and 2003 at our urban academic Level I trauma center. Six surgeons participate equally in call that covers trauma and nontrauma general surgical, thoracic, and vascular emergencies. Cases were classified as trauma, emergent, urgent, or according to the patient's clinical condition. The primary procedure for each operation was classified according to the American Board of Surgery Case Reporting System. RESULTS: We performed 4,082 operations during the study period, of which 8% were trauma, 11% were emergent, 40% were urgent, and 41% were elective. Abdominal and alimentary procedures accounted for 53% of all operations. Vascular, thoracic, and head and neck procedures accounted for 22%, 14%, and 9% of procedures, respectively. CONCLUSION: To resurrect our discipline, we must reclaim and expand our operative potential and be relieved of our excessive night and weekend burden of serving as housestaff for the neurosurgeons, orthopedic surgeons, and interventional radiologists. The trauma surgeon can effectively manage trauma and acute care surgery emergencies including thoracic and vascular conditions. Education of the future trauma and acute care surgeon must include specialty training in thoracic and vascular surgery.

Intubation alone does not mandate trauma surgeon presence on patient arrival to the emergency department.

BACKGROUND: Current American College of Surgeons Committee on Trauma criteria for major resuscitation include prehospital respiratory compromise or obstruction and/or intubation and mandate an attending trauma surgeon's presence on patient's arrival to the emergency department (ED). A substantial number of trauma patients arrive intubated, with no other physiologic compromise. We hypothesized that field or ED intubation in the absence of other major criteria does not require trauma surgeon presence on patient arrival. METHODS: Data were collected from our trauma registry on all injured patients intubated in the field or on arrival to the ED over a 30-month period ending in June 2003. Patients meeting other American College of Surgeons Committee on Trauma criteria (systolic blood pressure < 90 mm Hg; gunshot wound to the neck, chest, or abdomen; and unstable patient transfers) were excluded. RESULTS: During this period, 7,645 trauma patients were admitted to the ED; 834 were intubated, of whom 489 (59%) had no other criteria for major resuscitation. One was pronounced dead, 6 were admitted to the ward, 415 (85%) were admitted to the intensive care unit, and 67 (14%) were transferred directly to the operating room. Twenty-two (4%) required nonorthopedic or nonneurosurgical procedures, 11 (2%) of which were for hemorrhage control. Twelve of 16 stab wounds (75%) required emergent operation, 7 (44%) of which were for hemorrhage control. In contrast, 8 (3%) of 244 motor vehicle crashes required emergent operation, 4 (2%) of which were for hemorrhage control. CONCLUSION: Intubated patients with central stab wounds represent a high-risk group and should mandate trauma surgeon presence on patient arrival. Excluding stab wounds, field or ED intubation alone rarely requires emergent surgical decision-making. Therefore, field or ED intubation alone should not mandate trauma surgeon presence on patient arrival.

Multiple organ dysfunction during resuscitation is not postinjury multiple organ failure.

HYPOTHESIS: Multiple organ dysfunction (MOD) within 48 hours of injury is a reversible physiologic response to tissue injury and resuscitation. DESIGN: A prospective 10-year inception cohort study ending September 2003. SETTING: Regional academic level I trauma center. PATIENTS: One thousand two hundred seventy-seven consecutive trauma patients at risk for postinjury multiple organ failure (MOF). Inclusion criteria were being 16 years and older, being admitted to the trauma intensive care unit, having an Injury Severity Score higher than 15, and surviving more than 48 hours after injury. Isolated head injuries were excluded. INTERVENTIONS: None. MAIN OUTCOME MEASURES: Development of postinjury MOD as defined by a Denver MOF score of 4 or higher within 48 hours of injury and MOF as defined by a Denver MOF score of 4 or higher more than 48 hours after injury. RESULTS: Postinjury MOD and MOF were diagnosed in 209 (16%) and 300 (23%) patients, respectively. Age, Injury Severity Score, and 12-hour blood transfusion requirements were significantly higher among patients who developed MOD and MOF. Of the 209 patients who developed MOD, 134 (64%) progressively developed MOF while 75 (36%) had MOD resolve within 48 hours. CONCLUSION: Multiple organ dysfunction during resuscitation is a reversible response to severe injury and often resolves during the resuscitation period.

Diagnostic implications of C-reactive protein.

An elevated level of C-reactive protein (CRP), an acute phase protein, is one of many downstream indicators of inflammation. Physiologically, CRP enhances cell-mediated immunity by promoting phagocytosis, accelerating chemotaxis, and activating platelets. The purposes of this article are (1) to review the clinical data implicating serum CRP level as a systemic marker of focal inflammation and (2) to explore serum CRP level as a reflection of the inflammatory component of atherogenesis. Our findings indicate that CRP levels serve as an early marker of the magnitude of inflammation in events as dissimilar as appendicitis and myocardial infarction. The level of circulating CRP correlates with endovascular disease and may serve to identify otherwise asymptomatic patients at sufficient cardiovascular risk to warrant aggressive therapy. Determining whether CRP has a direct pathologic role in the vascular wall itself may have the most clinical relevance.

Lung-sparing techniques are associated with improved outcome compared with anatomic resection for severe lung injuries.

BACKGROUND: Pulmonary tractotomy was introduced in 1994 as a novel concept for lung salvage after penetrating wounds. Recently, tractotomy has been suggested to increase morbidity and, thus, its practice has been challenged. The purpose of this study was to compare the morbidity and mortality associated with nonanatomic and anatomic lung resection in the management of severe pulmonary injuries. METHODS: Using our trauma registry, patients admitted to an urban Level I trauma center during an 11-year period with thoracic injuries requiring thoracotomy and pulmonary operation were identified. A chart review was performed with attention to patient demographics, operative treatment, and outcome. Pulmonary operations performed were classified as either nonanatomic (wedge resection and tractotomy) or anatomic resection (lobectomy and pneumonectomy). Statistical analysis was performed using Student's test, Fisher's exact test, and logistic regression as appropriate. RESULTS: There were 34 men and 2 women, with a mean age of 29 +/- 2 years. Mechanism of injury was predominantly penetrating, with 26 (72%) gunshot wounds and 8 (22%) stab wounds. Intraoperative blood loss and early red blood cell transfusion requirement were lower in patients undergoing nonanatomic resection (3.85 L vs. 11.90 L and 17.4 U vs. 27.9 U, respectively; p < 0.05). Mortality was 4% in the nonanatomic resection group versus 77% in the anatomic resection group. CONCLUSION: Nonanatomic resection is associated with an improved morbidity and mortality compared with anatomic resection in the management of severe lung injuries. Although not a randomized study, these findings encourage the continued application of lung-sparing procedures when feasible.

Evaluation of a new technique for bedside percutaneous tracheostomy.

BACKGROUND: Percutaneous tracheostomy as described by Ciaglia is accepted as a safe technique with minimal associated morbidity. Recent modification of the technique to a single-step dilator prompted us to evaluate this in the critically injured patient. METHODS: A comparison of patients undergoing percutaneous tracheostomy was performed. From May 1998 to May 1999, patients underwent surgery using the sequential multidilator technique (MDT), and from July 1999 to July 2000, patients underwent surgery using the single dilation technique (SDT). RESULTS: Ninety-three tracheostomies were performed, 49 MDT and 44 SDT. Time to tracheostomy and total ventilator days was similar between the groups. Three complications occurred. In the MDT group, 1 patient experienced delayed tracheal hemorrhage not requiring transfusion. In the SDT group, 1 patient had transient right lower lobe collapse, and another patient had unexplained extubation requiring emergent cricothyroidotomy. CONCLUSIONS: Percutaneous tracheostomy using the single-step Rhino dilator technique is technically easier than the currently accepted multidilator technique with equivalent complications.

Urachal carcinoma: key points for the general surgeon.

Urachal carcinoma is a rare neoplasm with the majority of cases reported in the urologic literature. Because of its presentation as an intra-abdominal mass with involvement of adjacent structures the general surgeon may be consulted early in the diagnostic evaluation. One should be aware of this entity as early recognition and appropriate surgery provides the best opportunity for long-term survival. Herein we describe a typical case, appropriate evaluation, and review of the literature.