The Pathophysiology and Management of Hemorrhagic Shock in the Polytrauma Patient.

The recognition and management of life-threatening hemorrhage in the polytrauma patient poses several challenges to prehospital rescue personnel and hospital providers. First, identification of acute blood loss and the magnitude of lost volume after torso injury may not be readily apparent in the field. Because of the expression of highly effective physiological mechanisms that compensate for a sudden decrease in circulatory volume, a polytrauma patient with a significant blood loss may appear normal during examination by first responders. Consequently, for every polytrauma victim with a significant mechanism of injury we assume substantial blood loss has occurred and life-threatening hemorrhage is progressing until we can prove the contrary. Second, a decision to begin damage control resuscitation (DCR), a costly, highly complex, and potentially dangerous intervention must often be reached with little time and without sufficient clinical information about the intended recipient. Whether to begin DCR in the prehospital phase remains controversial. Furthermore, DCR executed imperfectly has the potential to worsen serious derangements including acidosis, coagulopathy, and profound homeostatic imbalances that DCR is designed to correct. Additionally, transfusion of large amounts of homologous blood during DCR potentially disrupts immune and inflammatory systems, which may induce severe systemic autoinflammatory disease in the aftermath of DCR. Third, controversy remains over the composition of components that are transfused during DCR. For practical reasons, unmatched liquid plasma or freeze-dried plasma is transfused now more commonly than ABO-matched fresh frozen plasma. Low-titer type O whole blood may prove safer than red cell components, although maintaining an inventory of whole blood for possible massive transfusion during DCR creates significant challenges for blood banks. Lastly, as the primary principle of management of life-threatening hemorrhage is surgical or angiographic control of bleeding, DCR must not eclipse these definitive interventions.

Optimizing transfusion strategies in damage control resuscitation: current insights.

From clinical and laboratory studies of specific coagulation defects induced by injury, damage control resuscitation (DCR) emerged as the most effective management strategy for hemorrhagic shock. DCR of the trauma patient who has sustained massive blood loss consists of 1) hemorrhage control; 2) permissive hypotension; and 3) the prevention and correction of trauma-induced coagulopathies, referred to collectively here as acute coagulopathy of trauma (ACOT). Trauma patients with ACOT have higher transfusion requirements, may eventually require massive transfusion, and are at higher risk of exsanguinating. Distinct impairments in the hemostatic system associated with trauma include acquired quantitative and qualitative platelet defects, hypocoagulable and hypercoagulable states, and dysregulation of the fibrinolytic system giving rise to hyperfibrinolysis or a phenomenon referred to as fibrinolytic shutdown. Furthermore, ACOT is a component of a systemic host defense dysregulation syndrome that bears several phenotypic features comparable with other acute systemic physiological insults such as sepsis, myocardial infarction, and postcardiac arrest syndrome. Progress in the science of resuscitation has been continuing at an accelerated rate, and clinicians who manage catastrophic blood loss may be incompletely informed of important advances that pertain to DCR. Therefore, we review recent findings that further characterize the pathophysiology of ACOT and describe the application of this new information to optimization of resuscitation strategies for the patient in hemorrhagic shock.

Gender differences in academic surgery, work-life balance, and satisfaction.

BACKGROUND: An increasing number of women are pursuing a career in surgery. Concurrently, the percentage of surgeons in dual-profession partnerships is increasing. We sought to evaluate the gender differences in professional advancement, work-life balance, and satisfaction at a large academic center. MATERIALS AND METHODS: All surgical trainees and faculty at a single academic medical center were surveyed. Collected variables included gender, academic rank, marital status, family size, division of household responsibilities, and career satisfaction. Student t-test, Fisher's exact test, and chi-square test were used to compare results. RESULTS: There were 127 faculty and 116 trainee respondents (>80% response rate). Respondents were mostly male (77% of faculty, 58% of trainees). Women were more likely than men to be married to a professional (90% versus 37%, for faculty; 82% versus 41% for trainees, P < 0.001 for both) who was working full time (P < 0.001) and were less likely to be on tenure track (P = 0.002). Women faculty were more likely to be primarily responsible for childcare planning (P < 0.001), meal planning (P < 0.001), grocery shopping (P < 0.001), and vacation planning (P = 0.003). Gender-neutral responsibilities included financial planning (P = 0.04) and monthly bill payment (P = 0.03). Gender differences in division of household responsibilities were similar in surgical trainees except for childcare planning, which was a shared responsibility. CONCLUSIONS: Women surgeons are more likely to be partnered with a full-time working spouse and to be primarily responsible for managing their households. Additional consideration for improvement in recruitment and retention strategies for surgeons might address barriers to equalizing these gender disparities.

Prevalence of cardiovascular and respiratory complications following trauma in patients with obesity.

BACKGROUND: It is generally accepted that obesity puts patients at an increased risk for cardiovascular and respiratory complications after surgical procedures. However, in the setting of trauma, there have been mixed findings in regards to whether obesity increases the risk for additional complications. OBJECTIVE: The aim of this study was to identify whether obese patients suffer an increased risk of cardiac and respiratory complications following traumatic injury. METHODS: A retrospective analysis of 275,393 patients was conducted using the 2012 National Trauma Data Bank. Hierarchical regression modeling was performed to determine the probability of experiencing a cardiac or respiratory complication. RESULTS: Patients with obesity were at a significantly higher risk of cardiac and respiratory complications compared to patients without obesity [OR: 1.81; CI: 1.72-1.91]. Prevalence of cardiovascular and respiratory complications for patients with obesity was 12.6% compared to 5.2% for non-obese patients. CONCLUSIONS: Obesity is predictive of an increased risk for cardiovascular and respiratory complications following trauma.

Infectious complications in obese patients after trauma.

BACKGROUND: Obesity is a public health concern in the United States due to its increasing prevalence, especially in younger age groups. Trauma is the most common cause of death for people under aged 40 y. The purpose of this study is to determine the association between obesity and specific infectious complications after traumatic injury. MATERIALS AND METHODS: A retrospective analysis was conducted using data from the 2012 National Trauma Data Bank. The National Trauma Data Bank defined obesity as having a body mass index of 30 or greater. Descriptive statistics were calculated and stratified by obesity status. A hierarchical regression model was used to determine the odds of experiencing an infectious complication in patients with obesity while controlling for age, gender, diabetes, number of comorbidities, injury severity, injury mechanism, head injury, and surgical procedure. RESULTS: Patients with a body mass index of 30 or greater compared with nonobese patients had increased odds of having an infectious complication (Odds Ratio, 1.59; 1.49-1.69). In addition to obesity, injury severity score greater than 29, age 40 y or older, diabetes, comorbid conditions, and having a surgical procedure were also predictive of an infectious complication. CONCLUSIONS: Our results indicate that trauma patients with obesity are nearly 60% more likely to develop an infectious complication in the hospital. Infection prevention and control measures should be implemented soon after hospital arrival for patients with obesity, particularly those with operative trauma.

Understanding the Barriers to Hiring and Promoting Women in Surgical Subspecialties.

BACKGROUND: The objective of this study was to characterize potential disparities in academic output, NIH-funding, and academic rank between male and female surgical faculty and identify subspecialties in which these differences may be more pronounced. STUDY DESIGN: Eighty metrics for 4,015 faculty members at the top-55 NIH-funded departments of surgery were collected. Demographic characteristics, NIH funding details, and scholarly output were analyzed. A new metric, academic velocity (V), reflecting recent citations is defined. RESULTS: Overall, 21.5% of surgical faculty are women. The percentage of female faculty is highest in science/research (41%) and surgical oncology (34%), and lowest in cardiothoracic surgery (9%). Female faculty are less likely to be full professors (22.7% vs 41.2%) and division chiefs (6.2% vs 13.6%). The fraction of women who are full professors is lowest in cardiothoracic surgery. Overall median numbers of publications/citations are lower for female faculty compared with male surgical faculty (21 of 364 vs 43 of 723, p < 0.001), and these differences are more pronounced for assistant professors. Current/previous NIH funding (21.3% vs 24%, p = NS) rates are similar between women and men, and surgical departments with more female full professors have higher NIH funding ranking (R(2) = 0.14, p < 0.05). In certain subspecialties, female associate and full professors outperform male counterparts. Overall, female authors have higher numbers of more recent citations. CONCLUSIONS: Subspecialty involvement and academic performance differences by sex vary greatly by subspecialty type and are most pronounced at the assistant professor level. Identification of potential barriers for entry of women into certain subspecialties, causes for the observed lower number of publications/citations among female assistant professors, and obstacles for attaining leadership roles need to be determined. We propose a new metric for assessment of publications/citations that can offset the effects of seniority differences between male and female faculty members.

Trends in Emergency Department Visits for Nonfatal Violence-Related Injuries Among Adolescents in the United States, 2009-2013.

PURPOSE: Violence-related injuries are a major cause of death and disability among adolescents in the United States. The objective of this study was to examine trends in adolescent violence-related injuries between 2009 and 2013. METHODS: This study examined data from the National Electronic Injury Surveillance System-All Injury Program for years 2009-2013. Linear regression was used to assess trends in rates of violence-related injuries among adolescents aged between 10 and 19 years. RESULTS: We found overall rates of nonfatal violence-related injuries among all adolescents did not change significantly across the study years (p = .502). However, self-harm injury rates have significantly increased among female and younger adolescents during the period (p = .001 and .011, respectively). CONCLUSIONS: Our results indicate that the overall intentional injury rates in adolescents have been stable; however, rates of self-injury have significantly increased in younger adolescents and females. Future research should focus on exploring causes of increases in self-harm injuries in these subpopulations.

Factors associated with pulmonary embolism within 72 hours of admission after trauma: a multicenter study.

BACKGROUND: Recent studies using thromboelastography indicate that patients are at risk for hypercoagulability early after injury. Pulmonary embolism (PE) is also well known to cause significant morbidity and mortality after injury and can occur within 72 hours of admission (early PE). Despite this risk, prophylactic anticoagulation is often delayed in patients with certain injuries due to concerns about bleeding. STUDY DESIGN: This was a retrospective study of injured patients with a PE from 2007 to 2013 at 3 level I trauma centers. Data collected included patient demographics, injury patterns, length of stay, timing of prophylaxis for deep vein thrombosis (DVT), and diagnosis of PE. Patients with early PE (≤ 3 days) were compared with those with late PE (>3 days) using bivariate and multivariable analysis. RESULTS: A total of 54,964 patients were admitted to the 3 centers during the study period, and 144 (0.26%) were diagnosed with a PE. Eleven were excluded from the study due to a lack of critical data, leaving 133 patients (43% early PE). Factors associated with early PE included long bone fractures in the lower extremity and an Abbreviated Injury Score (AIS) Extremity ≥ 3. Higher Injury Severity Score, severe chest and head trauma (AIS ≥ 3), and not receiving DVT prophylaxis within 48 hours of hospital admission were not associated with early PE. CONCLUSIONS: Early PE is a significant clinical entity occurring in nearly half the patients who suffered a PE. Early PE is associated with long bone fractures and severe extremity trauma, but not severe thoracic injury. Timing of prophylactic anticoagulation had no impact on early PE. If further studies confirm this incidence of unsuspected early PE, all admitted trauma patients should be assessed for a hypercoagulable state after injury.

Unplanned intubation: when and why does this deadly complication occur?

BACKGROUND: Risk factors for unplanned intubation have been delineated, but details regarding when and why reintubations occur as well as strategies for prevention have not been defined. METHODS: Over a 2-year period, 104 of 3,141 patients (3.3%) monitored via the American College of Surgeons-National Surgical Quality Improvement Program required unplanned intubation. These patients were compared to those who remained extubated and were characterized by (1) the operation performed; (2) the postoperative day when reintubation occurred; and (3) the underlying causes. RESULTS: Patients who required reintubation were significantly older (65.8 years) and were more likely to be male (55%) and to have several comorbidities, weight loss (16%), dependency (14%), or sepsis (9%). The operations complicated most commonly by unplanned intubation were gastrectomy (13%), nephrectomy (10%), colectomy (9%), pancreatectomy (8%), hepatectomy (7%), and enterectomy (6%). The most common causes and median postoperative days were sepsis (33%, day 8) and aspiration/pneumonia (31%, day 4). Sepsis was due most commonly to an abdominal or pelvic abscess (74%), which was frequently not recognized despite an inflammatory response. Aspiration occurred most commonly after upper abdominal operations (78%) despite signs of diminished bowel function. CONCLUSION: Postoperative sepsis and aspiration/pneumonia account for two thirds of unplanned intubations. Opportunities for management of patients exist for the prevention of this deadly complication.

Hemodynamic monitoring in the intensive care unit.

Patients in the intensive care unit are often critically ill with inadequate tissue perfusion and oxygenation. This inadequate delivery of substrates at the cellular level is a common definition of shock. Hemodynamic monitoring is the observation of cardiovascular physiology. The purpose of hemodynamic monitoring is to identify abnormal physiology and intervene before complications, including organ failure and death, occur. The most common types of invasive hemodynamic monitors are central venous catheters, pulmonary artery catheters, and arterial pulse-wave analysis. Ultrasonography is a noninvasive alternative being used in intensive care units for hemodynamic measurements and assessments.

Optimizing outcomes in emergency room thoracotomy: a 20-year experience in an urban Level I trauma center.

Emergency room thoracotomy (ERT) has remained a last resort tool of resuscitation in the management of patients with major trauma. The medical records of all patients undergoing ERT for penetrating chest trauma from January 1, 2000 through April 30, 2008 were retrospectively reviewed. The data from this study were added to data collected in two previous studies conducted at our institution for meta-analysis. A total of 102 ERTs were performed. There were 28 Class I patients (27.4%), 58 Class II (56.8%), six Class III (5.8%), and 11 Class IV (10.7%). The number of ERTs performed on Class I patients has decreased from 58.3 per cent in the 1995 group to 35.4 per cent in the 1999 group. There was an overall survival of 7.8 per cent in the current period of review. Overall survival in the 1995 group was 2.5 per cent, 1999 was 2.7 per cent, and 2008 was 7.8 per cent. The majority of the survival benefit occurs in patients who have electrical activity and a blood pressure when examined in the emergency department (Class III and IV). We intend to do future prospective research to further clarify the Class II patients when evaluating the type of rhythm shown on electrocardiogram tracing to move away from the generic pulseless electrical activity category.

Attacking the problem of hospital diversion: a report of success.

Hospital diversion is a critical issue for hospitals that affects safety and overall patient care. At Wishard Hospital, a public hospital with a level 1 trauma center, we critically reviewed our diversion policies and implemented a series of changes. This hospital-wide process significantly decreased our diversion rates, thereby providing consistent and safe care to our community.

Mediastinal bronchogenic cyst.

A 29 year old woman was found to have a chest mass as part of routine screening with a chest x-ray for an unrelated neurosurgical procedure. Further investigation with a chest CT raised the suspicion of a paravertebral neurogenic tumor. The patient underwent bronchoscopy and resection of the lesion by Video Assisted Thoracic Surgery (VATS). The diagnosis of Bronchogenic Cyst was established after histopathologic examination of the resected tumor. Bronchogenic Cysts are relatively rare primary mediastinal tumors. The paravertebral site is an unusual presentation for these tumors.

Cardiac operations in patients with hematologic malignancies.

OBJECTIVES: Patients with hematologic malignancies are frequently in need of major cardiac operations. Previous reports suggest an increased risk for perioperative complications in these immunodeficient patients. METHODS: Patients diagnosed with any type of hematologic malignancy who underwent open-heart surgery at our institution between 7/1996 and 6/2002 were identified. Their hospital charts were reviewed; demographics, perioperative data and outcomes were recorded. RESULTS: There were 24 patients (20 men, 4 women); mean age was 68+/-13 years (range 31-84 years). Ten patients had chronic lymphocytic leukemia, seven non-Hodgkin lymphomas, three multiple myeloma and one Hodgkin's disease, chronic myelocytic leukemia, hairy cell leukemia and cutaneous T-cell lymphoma each. The mean pre-operative duration of the hematologic disease was 6.6 years. Twenty-two patients underwent coronary artery bypass grafting (with valve replacement in three patients) and two patients had isolated valve replacement. There was one in-hospital death (4.1%). Twelve patients (50%) had a minor or major complication. Seven reoperations were required-five during the same admission (one for mediastinal bleeding, one for an expanding femoral pseudoaneurysm, one for acute cholecystitis and two for IACD/pacer insertion) and two within 30 days (one for deep sternal wound infection and one for leg wound infection). Mean post-operative stay was 8.2+/-5.8 days and mean ICU stay was 1.6+/-1.1 days. There were three late deaths-two were due to progression of the hematologic disease. The 3-year actuarial survival was 83%. CONCLUSIONS: Cardiac operations can be performed with acceptable mortality but significant morbidity rates in patients with hematologic malignancies. Bleeding and infectious complications are most frequently seen and usually lead to reoperations. These findings warrant caution during patient selection.