The Role of Emergency Department Thoracotomy in Patients with Cranial Gunshot Wounds.

BACKGROUND: Although several society guidelines exist regarding emergency department thoracotomy (EDT), there is a lack of data upon which to base guidance for multiple gunshot wound (GSW) patients whose injuries include a cranial GSW. We hypothesized that survival in these patients would be exceedingly low. METHODS: We used Pennsylvania Trauma Outcomes Study (PTOS) data, 2002-2021, and included EDTs for GSWs. We defined EDT by ICD codes for thoracotomy or procedures requiring one, with a location flagged as ED. We defined head injuries as any head abbreviated injury scale (AIS) ≥1 and severe head injuries as head AIS ≥ 4. Head injuries were "isolated" if all other body regions AIS < 2. Descriptive statistics were performed. Discharge functional status was measured in 5 domains. RESULTS: Over 20 years in Pennsylvania, 3,546 EDTs were performed, 2,771 (78.1%) for penetrating injuries. Most penetrating EDTs (2,003, 72.3%) had suffered GSWs. Survival among patients with isolated head wounds (n = 25) was 0%. Survival was 5.3% for the non-head-injured (n = 94/1,787). In patients with combined head and other injuries, survival was driven by the severity of the head wound - 0% (0/81) with a severe head injury (p = 0.035 vs no severe head injury), and 4.5% (5/110) with a non-severe head injury. Of the 5 head-injured survivors, 2 were fully dependent for transfer mobility, and 3 were partially or fully dependent for locomotion. Of 211 patients with a cranial injury who expired, 2 (0.9%) went on to organ donation. CONCLUSIONS: Though there is clearly no role for EDT in patients with isolated head GSWs, EDT may be considered in patients with combined injuries, as most of these patients have minor head injuries and survival is not different from the non-head-injured. However, if a severe head injury is clinically apparent, even in the presence of other body cavity injuries, EDT should not be pursued. LEVEL OF EVIDENCE: Level II, retrospective observational cohort study.

Effectiveness of Sternal Intraosseous Device in Patients Presenting with Circulatory Shock: A Retrospective Observational Study.

BACKGROUND: Hemorrhagic shock requires timely administration of blood products and resuscitative adjuncts through multiple access sites. Intraosseous (IO) devices offer an alternative to intravenous (IV) access as recommended by the massive hemorrhage, A-airway, R-respiratory, C-circulation, and H-hypothermia (MARCH) algorithm of Tactical Combat Casualty Care (TCCC). However, venous injuries proximal to the site of IO access may complicate resuscitative attempts. Sternal IO access represents an alternative pioneered by military personnel. However, its effectiveness in patients with shock is supported by limited evidence. We conducted a pilot study of two sternal-IO devices to investigate the efficacy of sternal-IO access in civilian trauma care. METHODS: A retrospective review (October 2020 to June 2021) involving injured patients receiving either a TALON® or a FAST1® sternal-IO device was performed at a large urban quaternary academic medical center. Baseline demographics, injury characteristics, vascular access sites, blood products and medications administered, and outcomes were analyzed. The primary outcome was a successful sternal-IO attempt. RESULTS: Nine males with gunshot wounds transported to the hospital by police were included in this study. Eight patients were pulseless on arrival, and one became pulseless shortly thereafter. Seven (78%) sternal-IO placements were successful, including six TALON devices and one of the three FAST1 devices, as FAST1 placement required attention to Operator positioning following resuscitative thoracotomy. Three patients achieved return of spontaneous circulation, two proceeded to the operating room, but none survived to discharge. CONCLUSIONS: Sternal-IO access was successful in nearly 80% of attempts. The indications for sternal-IO placement among civilians require further evaluation compared with IV and extremity IO access.

An Intensive Multidisciplinary Approach in Management of Extensive Nonuremic Calciphylaxis of the Bilateral Lower Extremities with Angioinvasive Fungus and Mold.

Management of infected wounds related to calciphylaxis poses a significant clinical challenge with high morbidity and mortality. Given no definitive management guidelines exist specific to nonuremic calciphylaxis, multiple modalities including sodium thiosulfate, antibiotics, hyperbaric oxygen therapy, and surgical debridement with wound care must be considered. When occurring over a large surface area, standard daily dressing changes are especially labor intensive, inefficient, and ineffective. Negative pressure wound therapy with instillation and dwell time offers broad wound coverage with ongoing therapeutic benefit. We present the case of a previously healthy 19-year-old woman who was transferred for tertiary level care of extensive nonuremic calciphylaxis wounds of the bilateral lower extremities complicated by angioinvasive coinfection with fungus and mold that was managed with a multidisciplinary approach of intensive medical management, aggressive surgical debridement, and negative pressure wound therapy with instillation of hypochlorous acid solution. Ultimately, she achieved full granulation and wound coverage with skin grafting. Large area, infected wounds related to nonuremic calciphylaxis can be successfully managed with multidisciplinary medical management, aggressive surgical debridement, and negative pressure wound therapy that can instill and dwell hypochlorous acid solution.

Change in outcomes for trauma patients over time: Two decades of a state trauma system.

BACKGROUND: Trauma center mortality rates are benchmarked to expected rates of death based on patient and injury characteristics. The expected mortality rate is recalculated from pooled outcomes across a trauma system each year, obscuring system-level change across years. We hypothesized that risk-adjusted mortality would decrease over time within a state-wide trauma system. METHODS: We identified adult trauma patients presenting to Level I and II Pennsylvania trauma centers, 1999-2018, using the Pennsylvania Trauma Outcomes Study. Multivariable logistic regression generated risk-adjusted models for mortality in all patients, and in key subgroups: penetrating torso injury, blunt multisystem trauma, and patients presenting in shock. RESULTS: Of 162,646 included patients, 123,518 (76.1%) were white and 108,936 (67.0%) were male. The median age was 49 (interquartile range [IQR] 29-70), median injury severity score was 16 (IQR 10-24), and 87.5% of injuries were blunt. Overall, 9.9% of patients died, and compared to 1999, no year had significantly higher adjusted odds of mortality. Overall mortality was significantly lower in 2007-2009 and 2011-2018. Of patients with blunt, multisystem injuries, 17.7% died, and adjusted mortality improved over time. Mortality rates were 24.9% for penetrating torso injury, and 56.9% for shock, with no significant change. Mortality improved for patients with ISS < 25, but not for the most severely injured. CONCLUSIONS: Over 20 years, Pennsylvania trauma centers demonstrated improved risk-adjusted mortality rates overall, but improvement remains lacking in high-risk groups despite numerous innovations and practice changes in this time period. Identifying change over time can help guide focus to these critical gaps.

Perspectives on competencies for care in austere settings.

ABSTRACT: Austerity in surgical care may manifest by limited equipment/supplies, deficient infrastructure (power, water), rationing/triage requirements, or the unavailability of specialty surgical or medical expertise. Some settings in which surgeons may experience austerity include the following: military deployed operations (domestic and foreign), humanitarian surgical missions, care in rural or remote settings, mass-casualty events, natural disasters, and/or care in low- and some middle-income countries. Expanded competencies beyond those required in routine surgical practice can optimize the quality of surgical care in such settings. The purpose of this expert panel review is to introduce those competencies.

A Technique to Minimize Aerosolization During Percutaneous Tracheostomy in COVID-19 Patients.

BACKGROUND: The SARS-CoV-2 pandemic has caused respiratory failure in many patients. With no effective treatment or vaccine, prolonged mechanical ventilation is common in survivors. Timing and performance of tracheostomy, for both patient and surgical team safety, remains a question. Here within, we report our experience with percutaneous dilatational tracheostomy with modification to minimize aerosolization. METHODS: A modified percutaneous dilatational tracheostomy technique is described. The technique was performed on 10 patients in the surgical intensive care unit. RESULTS: Ten patients underwent percutaneous dilatational tracheostomy. There were 7 males, and the average age for the group was 60.8 years. The average number of ventilator days before the operation was 26.3. All procedures were successful, and no patient had any procedure-related complications. CONCLUSIONS: The procedure described was successful in our patient population. We believe that this approach is safe for patients with coronavirus disease 2019 and limits aerosolization during the operation. LEVEL OF EVIDENCE: Level IV, case series.

Nonsurgical Admissions With Traumatic Injury: Medical Patients Are Trauma Patients Too.

Nontrauma service (NTS) admissions are an increasing problem as ground-level falls in elderly patients become more common. The admission and evaluation of trauma patients to nontrauma services in trauma centers seeking American College of Surgeons (ACS) verification, must follow the ACS mandates for performance improvement requiring some method of evaluating this population when admitted to services other than trauma, orthopedics, and neurosurgery. The purpose of this study and performance improvement project was to improve our process for the definition and evaluation of trauma patients who were being admitted to nontrauma services. We designed an algorithm to evaluate appropriateness of NTS admission and evaluated outcomes for NTS admissions utilizing that algorithm.We created a scoring algorithm and evaluated appropriateness of NTS admission over 2 years in a community-teaching ACS Level II trauma center. We reviewed trauma registry data using χ and Fisher exact tests to determine differences in outcome for NTS versus trauma service (TS) admissions.From December 2014 to December 2016, NTS admission rate fell from maximum of 28% to 4% stabilizing between 8% and 10%. Mortality and overall complication rate between NTS and TS were similar (p = .40 and .66, respectively), but length of stay was lower for TS admissions (p < .0001).A scoring system of algorithm can be used to determine appropriateness of NTS admissions, and validity of the tool can be confirmed using registry-based outcome data for TS versus NTS admissions.

Effect of American College of Surgeons Trauma Center Designation on Outcomes: Measurable Benefit at the Extremes of Age and Injury.

BACKGROUND: American College of Surgeons (ACS) verification is believed to provide benefits for trauma patients, but is associated with direct costs. STUDY DESIGN: We performed a 1-year retrospective review of the National Trauma Data Bank (NTDB) for 2012. Patients were separated into 3 age groups; Pediatric (PEDS), 0 to 14 years; adult, 15 to 65 years; and elderly (ELD), older than 65 years. We analyzed 2 injury severity cohorts, Injury Severity Score (ISS) 9 to 74 (ALL) and ISS 25 to 74 (MAJ). Multiple logistic regression to determine significance of ACS verification on mortality and major complications, controlling for age, ISS, shock, Glasgow Coma Scale, sex, age, comorbidities, and mechanism. Patients were excluded with an ISS <8 or equal to 75, dead on arrival, emergency department transfers, and burns. RESULTS: There were 392,997 patients: 262,644 in ACS centers and 130,353 in non-ACS centers. Distribution was: PEDS 3.8%, adults 64.5%, ELD 31.7%. For ALL adults, no differences were observed for primary outcome in ACS vs non-ACS centers (p = 0.128 and 0.061, for mortality and complications, respectively). For ALL PEDS and ELD, complications were more likely in non-ACS centers: (p = 0.003, odds ratio [OR] 2.61 [95% CI 1.36 to 5.0], and p < 0.0001, OR 3.17 [95% CI 2.21 to 4.56]). For MAJ trauma, death was more likely in adults in ACS vs non-ACS centers (p = 0.013, OR 0.82 [95% CI 0.71 to 0.96]). Complications for MAJ trauma were more likely in all age groups in non-ACS centers (adult: p = 0.028, OR 1.48 [95% CI 1.04 to 2.1]; ELD: p < 0.0001, OR 2.49 [95% CI 1.7 to 3.7]; PEDS: p < 0.0001, OR 4.29 [95% CI 2.13 to 8.69]). Length of stay was increased for all patients with complications (p < 0.0001). CONCLUSIONS: Measurable benefits in complications were observed in all age groups with MAJ trauma and in PEDS and ELD for ALL injury severity in ACS vs non-ACS trauma centers.

Babesiosis as a cause of fever in patients undergoing a splenectomy.

Babesiosis is an emerging infection most commonly acquired from a tick bite. We describe three hospitalized patients with fever attributable to babesiosis after a splenectomy. Splenectomy was done because of splenic enlargement due to unsuspected babesia infection in one patient and because of splenic perforation due to babesiosis in a second patient. The third patient underwent splenectomy for trauma and acquired babesiosis postoperatively from a blood transfusion. Our cases demonstrate the need to be vigilant for babesiosis in patients undergoing splenectomy.

Geriatric motor vehicle collision survival: the role of institutional trauma volume.

BACKGROUND: Links between trauma center volumes and outcomes have been inconsistent in previous studies. This study examines the role of institutional trauma volume parameters in geriatric motor vehicle collision (MVC) survival. METHODS: The New York Statewide Planning and Research Cooperative Systems database was analyzed for all trauma admissions to state-designated Level I and II trauma centers from 1996 to 2003. For each center, the volume of patients was calculated in each of the following four categories: Young adult (age, 17-64 years) MVC and non-MVC, and geriatric (65 years and older) MVC and non-MVC. Logistic regression analysis was used to predict patient survival to hospital discharge based on the four volume parameters of the center at which they were treated, age, gender, ICISS, year of admission, and type of center. RESULTS: Five thousand three hundred sixty-five geriatric MVC victims were admitted to Level I (n = 3,541) or II (n = 1,824) centers in New York State excluding New York City. Four thousand eight hundred ninety-eight (91%) patients were discharged alive. Volume of geriatric MVC at the center at which the patient was treated was an independent significant predictor of survival (odds ratio, 32.6; 95% confidence interval, 2.8-377.0; p = 0.005) as were younger age, female gender, increased ICISS, and later year of discharge. Young adult non-MVC volume was an independent significant predictor of nonsurvival of geriatric patients (odds ratio, 0.8; 95% confidence interval, 0.64-0.99; p = 0.042). Type of center was unrelated to outcome. CONCLUSIONS: There may be a risk-adjusted survival advantage for geriatric MVC patients treated at trauma centers with relatively higher volumes of geriatric MVC trauma and lower volumes of young adult non-MVC trauma. These results support consideration of age in trauma center transfer criteria.

Clinical practice guideline: red blood cell transfusion in adult trauma and critical care.

OBJECTIVE: To develop a clinical practice guideline for red blood cell transfusion in adult trauma and critical care. DESIGN: Meetings, teleconferences and electronic-based communication to achieve grading of the published evidence, discussion and consensus among the entire committee members. METHODS: This practice management guideline was developed by a joint taskforce of EAST (Eastern Association for Surgery of Trauma) and the American College of Critical Care Medicine (ACCM) of the Society of Critical Care Medicine (SCCM). We performed a comprehensive literature review of the topic and graded the evidence using scientific assessment methods employed by the Canadian and U.S. Preventive Task Force (Grading of Evidence, Class I, II, III; Grading of Recommendations, Level I, II, III). A list of guideline recommendations was compiled by the members of the guidelines committees for the two societies. Following an extensive review process by external reviewers, the final guideline manuscript was reviewed and approved by the EAST Board of Directors, the Board of Regents of the ACCM and the Council of SCCM. RESULTS: Key recommendations are listed by category, including (A) Indications for RBC transfusion in the general critically ill patient; (B) RBC transfusion in sepsis; (C) RBC transfusion in patients at risk for or with acute lung injury and acute respiratory distress syndrome; (D) RBC transfusion in patients with neurologic injury and diseases; (E) RBC transfusion risks; (F) Alternatives to RBC transfusion; and (G) Strategies to reduce RBC transfusion. CONCLUSIONS: Evidence-based recommendations regarding the use of RBC transfusion in adult trauma and critical care will provide important information to critical care practitioners.

The "Fistula VAC," a technique for management of enterocutaneous fistulae arising within the open abdomen: report of 5 cases.

BACKGROUND: Management of intestinal fistulae in open abdominal wounds remains a significant clinical challenge for those caring for patients surviving damage control abdominal operations. Breaking the cycle of tissue inflammation, infection, and sepsis, resulting from leakage of enteric contents, should be a major goal in the approach to these complex patients. We describe a technique utilizing vacuum assisted closure (VAC) which achieves control of enteric flow from fistulae in open abdominal wounds. METHODS: The fistula-VAC is fashioned from standard sponge supplies, negative pressure pumps, and ostomy appliances. The fistula-VAC was changed every three days prior to split thickness skin grafting, and every five days following grafting. RESULTS: Five patients underwent application of the fistula-VAC. All patients had complete diversion of enteric contents. This enteric diversion allowed for successful skin grafting in all patients. CONCLUSION: Application of the fistula-VAC should be considered a useful option in treating patients with intestinal fistulae in open abdominal wounds.

Central nervous system involvement from malignant mixed Müllerian tumor (MMMT) of the uterus.

The central nervous system is traditionally considered as an uncommon site for metastatic disease from the female genital tract, and cerebral metastasis as the primary manifestation of an occult gynecological malignancy is even more rare. Here, we report the case of a 61-year-old female who presented with neurological symptoms of confusion, headache, cerebellar ataxia and right-sided weakness. Magnetic resonance imaging of the brain revealed two solid lesions in the frontal lobe and the left cerebellar hemisphere. Endometrial biopsy of a uterine mass detected during search for the primary lesion showed malignant mixed Müllerian tumor (MMMT). The patient refused surgery. Cranial radiotherapy for progressive cerebral disease led to resolution of her neurological symptoms. Two months after the diagnosis of MMMT the patient died from local complications of advanced pelvic disease. At autopsy, only the epithelial component of the tumor had metastasized to the brain. Attention should be paid to possibility of unusual distant metastases associated to MMMT in order to avoid delay in diagnosis and treatment of these patients.

Multiplicity of solid organ injury: influence on management and outcomes after blunt abdominal trauma.

OBJECTIVE: The current study was undertaken to examine how concomitant injury to liver and spleen after blunt abdominal trauma affects management and outcomes. METHODS: This study was a retrospective chart review of all blunt abdominal trauma patients admitted with a diagnosis of liver or spleen injury at two Level I trauma centers over a 4-year period. Presentation, injury grade, management, and outcomes were analyzed. Patients with single-organ injury (liver or spleen) were compared with patients having injury to both organs (liver and spleen). Significance was set at 95% confidence intervals. RESULTS: Of 1,288 patients who met entry criteria, 1,125 had single (spleen, 573; liver, 552) organ injury (group S) and 163 had injury to both organs (group B). Group B patients had significantly higher Injury Severity Score, higher admission lactate, and lower admission systolic blood pressure and base excess. Eighty-one percent (915 of 1,125) of group S and 69% (112 of 163) of group B patients were managed nonoperatively (p < 0.05). Of the nonoperatively managed patients, 5.8% (53 of 915) in group S and 11.6% (13 of 112) in group B failed this form of therapy (p < 0.05). Higher failure rate in group B was because of bleeding from injured solid organ(s), and not non-solid organ related failures. Mortality, intensive care unit and hospital lengths of stay, and transfusion requirements were all significantly higher in group B. CONCLUSION: Blunt trauma patients with concomitant injury to liver and spleen have higher Injury Severity Score, mortality, lengths of stay, and transfusion requirements. There is a higher failure rate with nonoperative management, and therefore extra vigilance is warranted when choosing this form of therapy in the presence of injury to both organs.

The effects of hemodynamic shock and increased intra-abdominal pressure on bacterial translocation.

BACKGROUND: We hypothesized that hemorrhagic shock followed by the abdominal compartment syndrome (ACS) resulted in bacterial translocation (BT) from the gastrointestinal (GI) tract. METHODS: Nineteen Yorkshire swine (20-30 kg) were divided into two groups. In the experimental group, group 1 (n = 10), animals were hemorrhaged to a mean arterial pressure (MAP) of 25-30 mm Hg for a period of 30 minutes and resuscitated to baseline MAP. Subsequently, intra-abdominal pressure (IAP) was increased to 30 mm Hg above baseline by instilling sterile normal saline into the peritoneal cavity. The IAP was maintained at this level for 60 minutes. Acid/base status, gastric mucosal ph (pHi), superior mesenteric artery (SMA) blood flow, and hemodynamic parameters were measured and recorded. Blood samples were analyzed by polymerase chain reaction (PCR) for the presence of bacteria. Spleen, lymph node, and portal venous blood cultures were obtained at 24 hours. Results were analyzed by ANOVA and are reported as mean +/- SEM. The second group was the control. These animals did not have the hemorrhage, resuscitation, or intra-abdominal hypertension (IAH) but were otherwise similar to the experimental group in terms of laparotomy and measured parameters. RESULTS: SMA blood flow in group 1 (baseline of 0.87 +/- 0.10 l/min) decreased in response to hemorrhage (0.53 +/- 0.10 l/min, p = 0.0001) and remained decreased with IAH (0.63 l/min +/- 0.10, p = 0.0006) as compared to control and returned towards baseline (1.01 +/- 0.5 l/min) on relief of IAH. pHi (baseline of 7.21 +/- 0.03) was significantly decreased with hemorrhage (7.04 +/- 0.03, p = 0.0003) and decreased further after IAH (6.99 +/- 0.03, p = 0.0001) in group 1 compared to control, but returned toward baseline at 24 hours (7.28 +/- 0.04). The mean arterial pH decreased significantly from 7.43 +/- 0.01 at baseline to 7.27 +/- 0.01 at its nadir within group 1 (p = 0.0001) as well as when compared to control (p = 0.0001). Base excess was also significantly decreased between groups 1 and 2 during hemorrhage (3.30 +/- 0.71 vs. 0.06 +/- 0.60, p = 0.001) and IAH (3.08 +/- 0.71 vs. -1.17 +/- 0.60, p = 0.0001). In group 1, 8 of the 10 animals had positive lymph node cultures, 2 of the 10 had positive spleen cultures, and 2 of the 10 had positive portal venous blood cultures for gram-negative enteric bacteria. Only 2 of the 10 animals had a positive PCR. In group 2, five of the nine animals had positive lymph node cultures, zero of the nine had positive spleen cultures, and one of the nine had positive portal venous blood cultures. Two of the nine animals had positive PCRs. There was no significant difference in cultures or PCR results between the two groups (Fisher's exact test, p = 0.3). CONCLUSION: In this study, hemorrhage followed by reperfusion and a subsequent insult of IAH caused significant GI mucosal acidosis, hypoperfusion, as well as systemic acidosis. These changes did not appear to be associated with a significant bacterial translocation as judged by PCR measurements, tissue, or blood cultures.