Timing of intervention may influence outcomes in blunt injury to the carotid artery.

OBJECTIVE: Blunt carotid artery injury (BCI) is present in approximately 1.0% to 2.7% of all blunt trauma admissions and can result in significant morbidity and mortality. Management ranges from antithrombotic therapy alone to surgery, where potential indications include pseudoaneurysm, failed or contraindication to medical therapy, and progression of neurologic symptoms. Still, optimal management, including approach and timing, continues to be an active area for debate. The goal of this study was to assess the epidemiologic characteristics of BCI, and, after controlling for presenting features intrinsic to the data, compare outcomes based on management, operative approach, and timing of intervention. METHODS: A retrospective review was conducted of adult BCI patients identified within the National Trauma Data Bank from 2002 to 2016. The National Trauma Data Bank is the largest trauma database in the United States, collating data from each trauma admission for more than 900 trauma centers. Independent variables of interest included nonoperative versus operative management (OM); endovascular versus open intervention, and early (within 24 hours) versus delayed (after 24 hours) intervention. For each independent variable, groups were compared after propensity score matching to control for presenting factors and patterns of injury. RESULTS: There were 9190 patients who met the inclusion criteria, 812 of whom underwent operative intervention (open, n = 288; endovascular, n = 481, both: n = 43). During the review, there was no difference in proportion of OM over time, although there was a statistically significant decrease in the proportion of open intervention (0.48% per year; P < .05). For outcomes, operative versus nonoperative management (nOM) resulted in no difference in mortality, but the operative group demonstrated an increased risk of stroke (11.8% vs 6.5%), longer hospital and intensive care length of stay, and more days on mechanical ventilation (P < .001 for each). With regard to timing: mortality was increased for early intervention (early, 16% vs delayed, 6.3%; P < .001), which was predominantly driven by the endovascular cohort (early, 19.2% vs delayed, 2.5%; P < .001). CONCLUSIONS: In this study, there was no significant trend in the overall volume of operative or nOM; however, when considering approach to OM, there was a significant decrease in open procedures. Consistent with previous literature, injury to the neck, head, and chest was significant associated with BCI. Also outcomes demonstrated an increased prevalence of stroke after operative relative to nOM. Importantly, after critically assessing the timing to intervention, results strongly suggested that, if possible, intervention should be delayed for at least 24 hours.

Veno-Venous Extracorporeal Membrane Oxygenation (VV ECMO) for Acute Respiratory Failure Following Injury: Outcomes in a High-Volume Adult Trauma Center with a Dedicated Unit for VV ECMO.

INTRODUCTION: The use of veno-venous extracorporeal membrane oxygenation (VV ECMO) has increased over the past decade. The purpose of this study was to evaluate outcomes in adult trauma patients requiring VV ECMO. METHODS: Data were collected on adult trauma patients admitted between January 1, 2015, and November 1, 2016. Demographics, injury-specific data, ECMO data, and survival to discharge were recorded. Medians [interquartile range (IQR)] were reported. A p value ≤0.05 was considered statistically significant. RESULTS: Eighteen patients required VV ECMO during the study period. Median age was 28.5 years (IQR 24-43). Median injury severity score (ISS) was 27 (IQR 21-41); median PaO2/FiO2 (P/F) prior to ECMO cannulation was 61 (IQR 50-70). Median time from injury to cannulation was 3 (IQR 0-6) days. Median duration of ECMO was 266 (IQR 177-379) hours. Survival to discharge was 78%. Survivors had a significantly higher ISS (p = 0.03), longer intensive care unit length of stay (ICU LOS) (p < 0.0004), hospital LOS (p < 0.000004), and time on the ventilator (p < 0.0003). Median time of injury to cannulation was significantly longer in patients who survived to discharge (p = 0.01). There was no difference in P/F ratio prior to cannulation (p = ns). CONCLUSION: We have demonstrated improved outcome of patients requiring VV ECMO following injury compared to historical data. Although shorter time from injury to cannulation for VV ECMO was associated with death, select patients who meet criteria for VV ECMO early following injury should be referred/transferred to a tertiary care facility that specializes in trauma and ECMO care.

A new aortic injury score predicts early rupture more accurately than clinical assessment.

OBJECTIVE: The optimal timing for repair of a high-grade blunt thoracic aortic injury (BTAI) is uncertain. Delayed repair is common and associated with improved outcomes, but some lesions may rupture during observation. To determine optimal patient selection for appropriate management, we developed a pilot clinical risk score to evaluate aortic stability and predict rupture. METHODS: Patients presenting in stable condition with Society for Vascular Surgery grade III or IV BTAI diagnosed on computed tomography (CT) were retrospectively reviewed. To determine clinical and radiographic factors associated with aortic rupture, patients progressing to aortic rupture (defined by contrast extravasation on CT or on operative or autopsy findings) were compared with those who had no intervention ≤48 hours of admission. A model targeting 100% sensitivity for rupture was generated and internally validated by bootstrap analysis. Clinical utility was tested by comparison with clinical assessment by surgeons experienced in BTAI management who were provided with CT images and clinical data but were blinded to outcome. RESULTS: The derivation cohort included 18 patients whose aorta ruptured and 31 with stable BTAI. There was no difference in age, gender, injury mechanism, nonchest injury severity, blood pressure, or Glasgow Coma Scale on admission between patient groups. As dichotomous factors, admission lactate >4 mM, posterior mediastinal hematoma >10 mm, and lesion/normal aortic diameter ratio >1.4 on the admission CT were independently associated with aortic rupture. The model had an area under the receiver operator curve of .97, and in the presence of any two factors, was 100% sensitive and 84% specific for predicting aortic rupture. No aortic lesions ruptured in patients with fewer than two factors. In contrast, clinical assessment had lower accuracy (65% vs 90% total accuracy, P < .01). CONCLUSIONS: This novel risk score can be applied on admission using clinically relevant factors that incorporate patient physiology, size of the aortic lesion, and extent of the mediastinal hematoma. The model reliably identifies and distinguishes patients with high-grade BTAI who are at risk for early rupture from those with stable lesions. Although preliminary, because it is more accurate than clinical assessment alone, the score may improve patient selection for emergency or delayed intervention.

Operative Management of Aerodigestive Injuries: Improved Survival Over two Decades.

INTRODUCTION: Non-iatrogenic aerodigestive injuries are infrequent but potentially fatal. We hypothesize that advances in management and adoption of innovative therapies resulted in improved survival. METHODS: Trauma registry review at a university Level 1 center from 2000 to 2020 that identified adults with aerodigestive injuries requiring operative or endoluminal intervention. Demographics, injuries, operations, and outcomes were abstracted. Univariate analysis was performed, P < .05 was statistically significant. RESULTS: 95 patients had 105 injuries: 68 tracheal and 37 esophageal (including 10 combined). Mean age 30.9 (± 14), 87.4% male, 82.1% penetrating, and 28.4% with vascular injuries. Median ISS, chest AIS, admission BP, Shock Index, and lactate were 26 (16-34), 4 (3-4), 132 (113-149) mmHg, .8 (.7-1.1), and 3.1 (2.4-5.6) mmol/L, respectively. There were 46 cervical and 22 thoracic airway injuries; 5 patients in extremis required preoperative ECMO. 66 airway injuries were surgically repaired and 2 definitively managed with endobronchial stents. There were 24 cervical, 11 thoracic, 2 abdominal esophageal injuries-all repaired surgically. Combined tracheoesophageal injuries were individually managed and buttressed. 4 airway complications were successfully managed, and 11 esophageal complications managed conservatively, stented, or resected. Mortality was 9.6%, half from intraoperative hemorrhage. Specific mortality: tracheobronchial 8.8%, esophageal 10.8%, and combined 20%. Mortality was significantly associated with higher ISS (P = .01), vascular injury (P = .007), blunt mechanism (P = .01), bronchial injury (P = .01), and years 2000-2010 (P = .03), but not combined tracheobronchial injury. CONCLUSION: Mortality is associated with several variables, including vascular trauma and years 2000-2010. The use of ECMO and endoluminal stents in highly selected patients and institutional experience may account for 97.8% survival over the past decade.

Early veno-venous extracorporeal membrane oxygenation is an effective strategy for traumatically injured patients presenting with refractory respiratory failure.

BACKGROUND: Venovenous extracorporeal membrane oxygenation (VV ECMO) is used for respiratory failure when standard therapy fails. Optimal trauma care requires patients be stable enough to undergo procedures. Early VV ECMO (EVV) to stabilize trauma patients with respiratory failure as part of resuscitation could facilitate additional care. As VV ECMO technology is portable and prehospital cannulation possible, it could also be used in austere environments. We hypothesize that EVV facilitates injury care without worsening survival. METHODS: Our single center, retrospective cohort study included all trauma patients between January 1, 2014, and August 1, 2022, who were placed on VV ECMO. Early VV was defined as cannulation ≤48 hours from arrival with subsequent operation for injuries. Data were analyzed with descriptive statistics. Parametric or nonparametric statistics were used based on the nature of the data. After testing for normality, significance was defined as a p < 0.05. Logistic regression diagnostics were performed. RESULTS: Seventy-five patients were identified and 57 (76%) underwent EVV. There was no difference in survival between the EVV and non-EVV groups (70% vs. 61%, p = 0.47). Age, race, and gender did not differ between EVV survivors and nonsurvivors. Time to cannulation (4.5 hours vs. 8 hours, p = 0.39) and injury severity scores (34 vs. 29, p = 0.74) were similar. Early VV survivors had lower lactic acid levels precannulation (3.9 mmol/L vs. 11.9 mmol/L, p < 0.001). A multivariable logistic regression analysis examining admission and precannulation laboratory and hemodynamic values demonstrated that lower precannulation lactic acid levels predicted survival (odds ratio, 1.2; 95% confidence interval, 1.02-1.5; p = 0.03), with a significant inflection point of 7.4 mmol/L corresponding to decreased survival at hospital discharge. CONCLUSION: Patients undergoing EVV did not have increased mortality compared with the overall trauma VV ECMO population. Early VV resulted in ventilatory stabilization that allowed subsequent procedural treatment of injuries. LEVEL OF EVIDENCE: Therapeutic Care/Management; Level III.

Contemporary Management and Outcomes of Injuries to the Inferior Vena Cava: A Prospective Multicenter Trial From PROspective Observational Vascular Injury Treatment.

INTRODUCTION: Injuries to the inferior vena cava (IVC), while uncommon, have a high mortality despite modern advances. The goal of this study is to describe the diagnosis and management in the largest available prospective data set of vascular injuries across anatomic levels of IVC injury. METHODS: The American Association for the Surgery of Trauma PROspective Observational Vascular Injury Treatment (PROOVIT) registry was queried from November 2013 to January 2019. Demographics, diagnostic modalities, injury patterns, and management strategies were recorded and analyzed. Comparisons between anatomic levels were made using non-parametric Wilcoxon rank-sum statistics. RESULTS: 140 patients from 19 institutions were identified; median age was 30 years old (IQR 23-41), 75% were male, and 62% had penetrating mechanism. The suprarenal IVC group was associated with blunt mechanism (53% vs 32%, P = .02), had lower admission systolic blood pressure, pH, Glasgow Coma Scale (GCS), and higher ISS and thorax and abdomen AIS than the infrarenal injury group. Injuries were managed with open repair (70%) and ligation (30% overall; infrarenal 37% vs suprarenal 13%, P = .01). Endovascular therapy was used in 2% of cases. Overall mortality was 42% (infrarenal 33% vs suprarenal 66%, P<.001). Among survivors, there was no difference in first 24-hour PRBC transfusion requirement, or hospital or ICU length of stay. CONCLUSIONS: Current PROOVIT registry data demonstrate continued use of ligation extending to the suprarenal IVC, limited adoption of endovascular management, and no dramatic increase in overall survival compared to previously published studies. Survival is likely related to IVC injury location and total injury burden.

Extracorporeal Membrane Oxygenation Support During Repair of a Noniatrogenic Tracheal Injury.

Tracheal trauma is uncommon but carries major morbidity and mortality. A 26-year-old man sustained a near-transection of the cervical trachea due to penetrating trauma. Venovenous extracorporeal membrane oxygenation support allowed a controlled primary repair with muscular buttress and facilitated airway management. Facial injuries prevented oral intubation, and retrograde intubation through the transection established an airway. On the 10th postoperative day a percutaneous tracheostomy was performed through the surgical site. This case discusses the management, technical details, and adjuncts to successfully repair complex tracheal injuries.

Treatment of penetrating cardiac wounds for the general surgeon on call.

ABSTRACT: "Scoop and run" approaches for severely injured patients have been adopted by emergency medical services over the past 40 years. This has resulted in more patients with severe injuries including penetrating cardiac wounds arriving at trauma centers and other acute care hospitals. General surgery trauma teams and general surgeons taking trauma call are the first responders for diagnosis, resuscitation, and operative management of injured patients. By natural selection, 96% to 98% of patients with signs of life on arrival to the trauma center after sustaining a penetrating cardiac wound have injuries that are amenable to repair by a general surgeon, fellow, or senior surgical resident without the need for a cardiothoracic surgeon or cardiopulmonary bypass.This literature and experience-based review summarizes the diagnostic and operative approaches that should be known by all trauma teams and general surgeons taking trauma call. In addition, it describes when a cardiothoracic surgeon should be consulted and briefly reviews how complex penetrating cardiac injuries are repaired.

Association of Volume Status During Veno-Venous Extracorporeal Membrane Oxygenation with Outcome.

Fluid overload in acute respiratory distress syndrome is associated with increased mortality. The purpose of this study was to investigate the association of cumulative fluid balance (CFB) during the first 7 days of veno-venous extracorporeal membrane oxygenation (VV ECMO) and mortality. Adult patients on VV ECMO for greater than 168 hours, between November 2015 and October 2019, were included. CFB during the first 7 ECMO days was compared between survivors and nonsurvivors, and survival was analyzed using Kaplan-Meier analysis and cox proportional hazards modeling. One hundred forty-six patients were included. Median age was 45 years [32, 55], respiratory ECMO survival prediction score was 3 [0, 5], and P/F ratio was 70 [55, 85]. CFB for ECMO days 1-3 was +2,350 cc [-540, 5,941], days 4-7 -3,070 cc [-6,545, 437], and days 1-7 -341 cc [-4,579, 5,290]. One hundred seventeen patients (80%) survived to hospital discharge. Survivors were younger (41 years [31, 53] vs. 53 years [45, 60], p < 0.001) and had a higher respiratory ECMO survival prediction score, (3 [1, 5] vs. 1.5 [-1, 3], p = 0.002). VV ECMO survivors had a significantly more negative CFB during the first 7 days of VV ECMO (-1,311 cc [-4,755, 4,217] vs. 3,617 cc [-2,764, 9,413], p = 0.02), and CFB was an independent predictor of 90 day mortality (HR = 1.07 [1.01, 1.14], p = 0.02). Further studies are needed to determine the causal relationship between fluid balance and survival during VV ECMO.

Occupant and crash characteristics for case occupants with cervical spine injuries sustained in motor vehicle collisions.

BACKGROUND: Motor vehicle collisions (MVCs) are the leading cause of spine and spinal cord injuries in the United States. Traumatic cervical spine injuries (CSIs) result in significant morbidity and mortality. This study was designed to evaluate both the epidemiologic and biomechanical risk factors associated with CSI in MVCs by using a population-based database and to describe occupant and crashes characteristics for a subset of severe crashes in which a CSI was sustained as represented by the Crash Injury Research Engineering Network (CIREN) database. METHODS: Prospectively collected CIREN data from the eight centers were used to identify all case occupants between 1996 and November 2009. Case occupants older than 14 years and case vehicles of the four most common vehicle types were included. The National Automotive Sampling System's Crashworthiness Data System, a probability sample of all police-reported MVCs in the United States, was queried using the same inclusion criteria between 1997 and 2008. Cervical spinal cord and spinal column injuries were identified using Abbreviated Injury Scale (AIS) score codes. Data were abstracted on all case occupants, biomechanical crash characteristics, and injuries sustained. Univariate analysis was performed using a χ analysis. Logistic regression was used to identify significant risk factors in a multivariate analysis to control for confounding associations. RESULTS: CSIs were identified in 11.5% of CIREN case occupants. Case occupants aged 65 years or older and those occupants involved in rollover crashes were more likely to sustain a CSI. In univariate analysis of the subset of severe crashes represented by CIREN, the use of airbag and seat belt together (reference) were more protective than seat belt alone (odds ratio [OR]=1.73, 95% confidence interval [CI]=1.32-2.27) or the use of neither restraint system (OR=1.45, 95% CI=1.02-2.07). The most frequent injury sources in CIREN crashes were roof and its components (24.8%) and noncontact sources (15.5%). In multivariate analysis, age, rollover impact, and airbag-only restraint systems were associated with an increased odds of CSI. Using the population-based National Automotive Sampling System's Crashworthiness Data System data, 0.35% of occupants sustained a CSI. In univariate analysis, older age was noted to be a significant risk factor for CSI. Airbag-only restraint systems and both rollover and lateral crashes were also identified as risk factors for CSI. In addition, increasing delta v was highly associated with CSIs. In multivariate analysis, similar risk factors were noted. Of all the restraint systems, seat belt use without airbag deployment was found to be the most protective restraint system (OR=0.29, 95% CI=0.16-0.50), whereas airbag-only restraint was associated with the highest risk of CSI (OR=3.54, 95% CI=2.29-5.46). CONCLUSIONS: Despite advances in automotive safety, CSIs sustained in MVC continue to occur too often. Older case occupants are at an increased risk of CSI. Rollover crashes and severe crashes led to a much higher risk of CSI than other types and severity of MVCs. Seat belt use is very effective in preventing CSI, whereas airbag deployment may increase the risk of occupants sustaining a CSI. More protection for older occupants is needed and protection in both rollover and lateral crashes should remain a focus of the automotive industry. The design of airbag restraint systems should be evaluated so that they are not causative of serious injury. In addition, engineers should continue to focus on improving automotive design to minimize the risk of spinal injury to occupants in high severity crashes.

Extracorporeal Life Support (ECLS): A Review and Focus on Considerations for COVID-19.

ABSTRACT: Extracorporeal life support (ECLS) is a support modality for patients with severe acute respiratory distress syndrome (ARDS) who have failed conventional treatments including low tidal volume ventilation, prone positioning, and neuromuscular blockade. In addition, ECLS can be used for hemodynamic support for patients with cardiogenic shock or following cardiac arrest. Injured patients may also require ECLS support for ARDS and other indications. We review the use of ECLS for ARDS patients, trauma patients, cardiogenic shock patients, and post-cardiac arrest patients. We then describe how these principles are applied in the management of the novel coronavirus disease 2019 pandemic. Indications, predictors, procedural considerations, and post-cannulation management strategies are discussed.

Single Center Experience With Veno-Venous Extracorporeal Membrane Oxygenation in Patients With Traumatic Brain Injury.

METHODS: We retrospectively reviewed TBI patients ≥ 18 years of age treated with VV-ECMO. The primary outcome was survival to discharge. Secondary outcomes included progression of intracranial hemorrhage, bleeding complications, and episodes of oxygenator thrombosis requiring exchange. Medians and interquartile ranges were reported where appropriate. RESULTS: 13 TBI patients received VV-ECMO support during the study period. The median age was 28 years (Interquartile range (IQR) 25-37.5) and 85% were men. Median admission Glasgow coma scale was 5 (IQR 3-13.5). Median injury severity score (ISS) was 48 (IQR 33.5-66). Median pre-ECMO PaO2:FiO2 ratio was 58 (IQR 47-74.5). Five (38.4%) patients survived to discharge. Six patients (46%) received systemic A/C while on ECMO. No patient had worsening of intracranial hemorrhage on computed tomography imaging. There were two bleeding complications in patients on A/C, neither was related to TBI. Four patients required an oxygenator change; 2 in patients on A/C. CONCLUSION: VV-ECMO appears safe with TBI. We have demonstrated that A/C can be withheld without increased complications. Traumatic brain injury should not be considered an absolute contraindication to the use of VV-ECMO for severe respiratory failure and should be decided on a case by case basis. Additional research is needed to confirm these preliminary findings.

Mortality Risk Assessment in COVID-19 Venovenous Extracorporeal Membrane Oxygenation.

BACKGROUND: A life-threatening complication of coronavirus disease 2019 (COVID-19) is acute respiratory distress syndrome (ARDS) refractory to conventional management. Venovenous (VV) extracorporeal membrane oxygenation (ECMO) (VV-ECMO) is used to support patients with ARDS in whom conventional management fails. Scoring systems to predict mortality in VV-ECMO remain unvalidated in COVID-19 ARDS. This report describes a large single-center experience with VV-ECMO in COVID-19 and assesses the utility of standard risk calculators. METHODS: A retrospective review of a prospective database of all patients with COVID-19 who underwent VV-ECMO cannulation between March 15 and June 27, 2020 at a single academic center was performed. Demographic, clinical, and ECMO characteristics were collected. The primary outcome was in-hospital mortality; survivor and nonsurvivor cohorts were compared by using univariate and bivariate analyses. RESULTS: Forty patients who had COVID-19 and underwent ECMO were identified. Of the 33 patients (82.5%) in whom ECMO had been discontinued at the time of analysis, 18 patients (54.5%) survived to hospital discharge, and 15 (45.5%) died during ECMO. Nonsurvivors presented with a statistically significant higher Prediction of Survival on ECMO Therapy (PRESET)-Score (mean ± SD, 8.33 ± 0.8 vs 6.17 ± 1.8; P = .001). The PRESET score demonstrated accurate mortality prediction. All patients with a PRESET-Score of 6 or lowers survived, and a score of 7 or higher was associated with a dramatic increase in mortality. CONCLUSIONS: These results suggest that favorable outcomes are possible in patients with COVID-19 who undergo ECMO at high-volume centers. This study demonstrated an association between the PRESET-Score and survival in patients with COVID-19 who underwent VV-ECMO. Standard risk calculators may aid in appropriate selection of patients with COVID-19 ARDS for ECMO.

Penetrating thoracic great vessel injury: impact of admission hemodynamics and preoperative imaging.

BACKGROUND: The management of penetrating great vessel (PGV) injury is challenging. Patients in shock require rapid evaluation, whereas in stable patients, imaging studies may optimize the surgical approach. We reviewed our experience with PGV injury to determine the impact of admission blood pressure and accuracy of imaging studies, both angiography and computed tomographic angiography (CTA). METHODS: Retrospective review of the trauma registry from 2001 to 2007 identifying patients with PGV injury. Demographics, admission systolic blood pressure, imaging studies, specific injuries, incision, methods of repair, hospital and intensive care length of stay, complications, and mortality were recorded. Shock was defined as systolic blood pressure <90 mm Hg. RESULTS: Thirty-six consecutive patients were identified, average age was 28 (+/-10) years, of whom 20 (56%) presented in shock. Those in shock had more combined arterial-venous injuries (60% vs. 25%), concomitant thoracic injuries requiring resection (45% vs. 19%), and units of packed red blood cells (5.8 +/- 2 vs. 2.7 +/- 1.5), p < 0.01. For those in shock, the mean time to the operating room was 27 minutes +/- 9 minutes and 75% had sternotomy. Among stable patients, 56% had a periclavicular approach and 31% partial sternotomy. All 16 stable patients had imaging; angiography in 3 patients and CTA in 7 patients. In six patients who had both angiography and CTA, the results were concordant; therefore, CTA accurately diagnosed arterial injury in all 13 patients. Imaging changed the choice of incision in 4 (25%). Intensive care length of stay was significantly longer in the shock group 3.1 (+/-2.1) days versus 1.4 (+/-1.6) days (p = 0.01). There were 5 (14%) complications and no deaths. CONCLUSION: Patients in shock require rapid evaluation. Sternotomy affords excellent exposure to all PGV injuries, and partial sternotomy is useful in stable patients. In stable patients, CTA can be valuable in defining the injury and may influence the surgical approach. Surgical results are surprisingly good, even in unstable patients and may be related to rapid transport and operation.

Admission Physiology vs Blood Pressure: Predicting the Need for Operating Room Thoracotomy after Penetrating Thoracic Trauma.

BACKGROUND: Approximately 15% of patients with penetrating thoracic trauma require an emergency center or operating room thoracotomy, usually for hemodynamic instability or persistent hemorrhage. The hypothesis in this study was that admission physiology, not vital signs, predicts the need for operating room thoracotomy. STUDY DESIGN: We conducted a trauma registry review, 2002 to 2017, of adult patients undergoing operating room thoracotomy within 6 hours of admission (emergency department thoracotomies excluded). Demographics, injuries, admission physiology, time to operating room (OR), operations, and outcomes were reviewed. Data are reported as mean (SD) or median (IQR). RESULTS: Of the 301 consecutive patients in this 15-year review, 75.6% were male, mean age was 31.1 years (11.5), and 41.5% had gunshot wounds. The median Injury Severity Score was 25 (range 16 to 29), time to operating room was 38 minutes (interquartile range [IQR] 19 to 105 minutes), and 21.9% had a thoracic damage control operation. Mean admission systolic blood pressure was 115 mmHg (SD 37 mmHg), with only 23.9% <90 mmHg; however, admission pH 7.22 (SD 0.14), base deficit 7.6 (SD 6.1), and lactate 7.2 (SD 4.5) were markedly abnormal. Overall, there were 136 (45.2%) patients with significant pulmonary injuries treated with 112 major nonanatomic resections, 17 lobectomies, and 7 pneumonectomies; respective mortalities were 2.7%, 11.8%, and 42.9%. There were 100 (33.2%) cardiac, 30 (9.9%) great vessel, 14 (4.7%) aerodigestive, and 58 (19%) combined thoracic injuries. Mortalities for cardiac, great vessel, and aerodigestive injuries were 7%, 0%, and 14.3%, respectively. Overall mortality was 6.6%, 15.2% after damage control, and 4.3% for all others. CONCLUSIONS: Shock characterized by acidosis, but not hypotension, is the most common presentation in patients who will need operating room thoracotomy after penetrating thoracic trauma. Survival rates are excellent unless a pneumonectomy or damage control thoracotomy is required.

Shock, Not Blood Pressure or Shock Index, Determines the Need for Thoracic Damage Control Following Penetrating Trauma.

BACKGROUND: Damage control laparotomy has increased survival for critically injured patient with penetrating abdominal trauma. There has been a slower adoption of a damage control strategy for thoracic trauma despite the considerable mortality associated with emergent thoracotomy for patients in profound shock. We postulated admission physiology, not blood pressure or shock index, would identify patients who would benefit from thoracic damage control. STUDY DESIGN: Retrospective trauma registry review from 2002 to 2017 at a busy, urban trauma center. Three hundred one patients with penetrating thoracic trauma operated on within 6 h of admission were identified. Of those 66 (21.9%) required thoracic damage control and comprise the study population. RESULTS: Compared with the non-damage control group, the 66 damage control patients had significantly higher Injury Severity Score, chest Abbreviated Injury Scale, lactate and base deficit, and lower pH and temperature. In addition, the damage control thoracic surgery group had significantly more gunshot wounds, transfusions, concomitant laparotomies, vasoactive infusions, and shorter time to the operating room. Notably, however, there were no significant differences in admission systolic blood pressure or shock index between the groups. Once normal physiology was restored, chest closure was performed 1.7 (0.7) days after the index operation. Mortality for thoracic damage was 15.2%, significantly higher than the 4.3% in the non-damage control group. Over two-thirds of damage control deaths occurred prior to chest closure. CONCLUSIONS: Mortality in this series of severely injured, profoundly physiologically altered patients undergoing thoracic damage control is substantially lower than previously reported. Rather than relying on blood pressure and shock index, early recognition of shock identifies patients in whom thoracic damage control is beneficial.

Prehospital Point of Care Testing for the Early Detection of Shock and Prediction of Lifesaving Interventions.

INTRODUCTION: Early diagnosis and treatment are essential for enhancing outcomes for the traumatically injured. In this prospective prehospital observational study, we hypothesized that a variety of laboratory results measured in the prehospital environment would predict both the presence of early shock and the need for lifesaving interventions (LSIs) for adult patients with traumatic injuries. METHODS: Adult trauma patients flown by a helicopter emergency medical service were prospectively enrolled. Using an i-STAT portable analyzer, data from 16 laboratory tests were collected. Vital signs data were also collected. Outcomes of interest included detection of shock, mortality, and requirement for LSIs. Logistic regression, including a Bayesian analysis, was performed. RESULTS: Among 300 patients screened for enrollment, 261 had complete laboratory data for analysis. The majority of patients were male (75%) with blunt trauma (91.2%). The median injury severity score was 29 (IQR, 25-75) and overall mortality was 4.6%. A total of 170 LSIs were performed. The median lactate for patients who required an LSI was 4.1 (IQR, 3-5.4). The odds of requiring an LSI within the first hour of admission to the trauma center was highly associated with increases in lactate and glucose. A lactate level > 4 mmol/L was statistically associated with greater sensitivity and specificity for predicting the need for a LSI compared with shock index. CONCLUSIONS: In this prospective observational trial, lactate outperformed static vital signs, including shock index, for detecting shock and predicting the need for LSIs. A lactate level > 4 mmol/L was found to be highly associated with the need for LSIs.

Crash and occupant predictors of pulmonary contusion.

OBJECTIVES: Pulmonary contusions (PCs) are a common injury sustained in motor vehicle collisions. The crash and occupant characteristics of PC in motor vehicle collisions are currently unknown. Additionally, the clinical significance and the impact on mortality have not been determined. METHODS: A retrospective review of the Crash Injury Research and Engineering Network database with inclusion criteria of frontal (F) and near-side lateral (L) crashes involving occupants older than 15 years, yielded 2,184 case occupants. Pearson's chi and multivariate logistic regression were used with a p < 0.05 conferring statistical significance. RESULTS: Median age was 38 years, 80% were drivers and mortality was 16%. Forty-nine percent of case occupants were not wearing lap-shoulder belts. Chest trauma was sustained by 1,131 (52%), of whom 379 had PC. Crash characteristics included: 38 kph median change in velocity (delta V), 72% frontal deformation, and 35% struck a fixed object. Injury characteristics included median Injury Severity Score 17 with the following Abbreviated Injury Score (AIS) >2 injuries: thoracic 40%, abdominal 19%, and head 24%. Univariate predictors of PC included: age <25, male, higher Injury Severity Score, fatality, delta V >45 kph, L impacts, and collision with fixed object. PC was significantly associated with occupant compartment intrusion in F but not L crashes. In multivariate analysis, significant predictors of PC included: age <25 (odds ratios [OR] = 1.5), delta V >45 kph (OR = 1.9), and fixed object (frontal crash only) (OR = 1.8). Controlling for head, spine, abdominal, and extremity injuries AIS >2, PC was not a statistically significant risk factor for mortality. This was consistent whether or not another AIS >2 thoracic injury was present. The effectiveness of side-impact airbags was not evaluated due to the small sample size. CONCLUSIONS: Crash severity as demonstrated by higher delta V was strongly associated with PC in all crashes. Frontal crashes with a fixed object or intrusion are more likely to result in a PC. The risk of PC is greatly increased in near-side lateral impacts regardless of intrusion or object struck; suggesting occupant proximity may be the most important factor. Further investigations of the efficacy of side airbags as a counter measure should be considered and continued public education of the efficacy of lap-shoulder restrains should continue. Unexpectedly, although a marker for crash severity, PC is not an independent marker of mortality.

Blunt traumatic thoracic aortic injuries: early or delayed repair--results of an American Association for the Surgery of Trauma prospective study.

BACKGROUND: The traditional approach to stable blunt thoracic aortic injuries (TAI) is immediate repair, with delayed repair reserved for patients with major associated injuries. In recent years, there has been a trend toward delayed repair, even in low-risk patients. This study evaluates the current practices in the surgical community regarding the timing of aortic repair and its effects on outcomes. METHODS: This was a prospective, observational multicenter study sponsored by the American Association for the Surgery of Trauma. The study included patients with blunt TAI scheduled for aortic repair by open or endovascular procedure. Patients in extremis and those managed without aortic repair were excluded. The data collection included demographics, initial clinical presentation, Injury Severity Scores, type and site of aortic injury, type of aortic repair (open or endovascular repair), and time from injury to aortic repair. The study patients were divided into an early repair (< or = 24 hours) and delayed repair groups (> 24 hours). The outcome variables included survival, ventilator days, intensive care unit (ICU) and hospital lengths of stay, blood transfusions, and complications. The outcomes in the two groups were compared with multivariate analysis after adjusting for age, Glasgow Coma Scale, hypotension, major associated injuries, and type of aortic repair. A second multivariate analysis compared outcomes between early and delayed repair, in patients with and patients without major associated injuries. RESULTS: There were 178 patients with TAI eligible for inclusion and analysis, 109 (61.2%) of which underwent early repair and 69 (38.8%) delayed repair. The two groups had similar epidemiologic, injury severity, and type of repair characteristics. The adjusted mortality was significantly higher in the early repair group (adjusted OR [95% CI] 7.78 [1.69-35.70], adjusted p value = 0.008). The adjusted complication rate was similar in the two groups. However, delayed repair was associated with significantly longer ICU and hospital lengths of stay. Analysis of the 108 patients without major associated injuries, adjusting for age, Glasgow Coma Scale, hypotension, and type of aortic repair, showed that in early repair there was a trend toward higher mortality rate (adjusted OR 9.08 [0.88-93.78], adjusted p value = 0.064) but a significantly lower complication rate (adjusted OR 0.4 [0.18-0.96], adjusted p value 0.040) and shorter ICU stay (adjusted p value = 0.021) than the delayed repair group. A similar analysis of the 68 patients with major associated injuries, showed a strong trend toward higher mortality in the early repair group (adjusted OR 9.39 [0.93-95.18], adjusted p value = 0.058). The complication rate was similar in both groups (adjusted p value = 0.239). CONCLUSIONS: Delayed repair of stable blunt TAI is associated with improved survival, irrespective of the presence or not of major associated injuries. However, delayed repair is associated with a longer length of ICU stay and in the group of patients with no major associated injuries a significantly higher complication rate.

Blunt Thoracic Aortic Injury: Endovascular Repair Is Now the Standard.

BACKGROUND: Incidence and treatment of blunt thoracic aortic injury (BTAI) has evolved, likely from improved imaging and emergence of endovascular techniques; however, multicenter data demonstrating this are lacking. We examined trends in incidence, management, and outcomes in BTAI. STUDY DESIGN: The American College of Surgeons National Trauma Databank (2003 to 2013) was used to identify adults with BTAI. Management was categorized as nonoperative repair, open aortic repair (OAR), or thoracic endovascular repair (TEVAR). Outcomes included demographics, management, and outcomes. RESULTS: There were 3,774 patients. Median age was 46.0 years (interquartile range [IQR] 29.3, 62.0 years), with 70.8% males, and median Injury Severity Score (ISS) of 34.0 (IQR 26.0, 45.0). The number of BTAIs diagnosed over the decade increased 196.8% (p < 0.001), median ISS decreased from 38 to 33 (p < 0.001), and significantly more patients were treated at a level I trauma center (p < 0.001). After FDA approval of TEVAR devices, there was a significant increase in endovascular repair overall (1.0% to 30.6%, p < 0.001) and in those treated operatively (0.0% to 94.9%, p < 0.001), with a marked decrease in OAR. Use of TEVAR was associated with significantly reduced median ICU LOS (9.0 vs 12.0 days, p = 0.048) and mortality (9.3% vs 16.6%; p = 0.015) compared with OAR. In modern BTAI care, TEVAR has nearly completely replaced OAR. CONCLUSIONS: The diagnosis of BTAI has increased, likely due to more sensitive imaging. Nearly 70% of patients get nonoperative care. Treatment with TEVAR improves outcomes relative to OAR. Part of the proportional increase in TEVAR use may represent overtreatment of lower grade BTAI amenable to medical management, and warrants further investigation.