Ex-vivo and live animal models are equally effective training for the management of a penetrating cardiac injury.

BACKGROUND: Live tissue models are considered the most useful simulation for training in the management for hemostasis of penetrating injuries. However, these models are expensive, with limited opportunities for repetitive training. Ex-vivo models using tissue and a fluid pump are less expensive, allow repetitive training and respect ethical principles in animal research. The purpose of this study is to objectively evaluate the effectiveness of ex-vivo training with a pump, compared to live animal model training. Staff surgeons and residents were divided into live tissue training and ex-vivo training groups. Training in the management of a penetrating cardiac injury was conducted for each group, separately. One week later, all participants were formally evaluated in the management of a penetrating cardiac injury in a live animal. RESULTS: There are no differences between the two groups regarding average years of experience or previous trauma surgery experience. All participants achieved hemostasis, with no difference between the two groups in the Global Rating Scale score (ex-vivo: 25.2 ± 6.3, live: 24.7 ± 6.3, p = 0.646), blood loss (1.6 ± 0.7, 2.0 ± 0.6, p = 0.051), checklist score (3.7 ± 0.6, 3.6 ± 0.9, p = 0.189), or time required for repair (101 s ± 31, 107 s ± 15, p = 0.163), except overall evaluation (3.8 ± 0.9, 3.4 ± 0.9, p = 0.037). The internal consistency reliability and inter-rater reliability in the Global Rating Scale were excellent (0.966 and 0.953 / 0.719 and 0.784, respectively), and for the checklist were moderate (0.570 and 0.636 / 0.651 and 0.607, respectively). The validity is rated good for both the Global Rating Scale (Residents: 21.7 ± 5.6, Staff: 28.9 ± 4.7, p = 0.000) and checklist (Residents: 3.4 ± 0.9, Staff Surgeons: 3.9 ± 0.3, p = 0.003). The results of self-assessment questionnaires were similarly high (4.2-4.9) with scores in self-efficacy increased after training (pre: 1.7 ± 0.8, post: 3.2 ± 1.0, p = 0.000 in ex-vivo, pre: 1.9 ± 1.0, post: 3.7 ± 0.7, p = 0.000 in live). Scores comparing pre-training and post-evaluation (pre: 1.7 ± 0.8, post: 3.7 ± 0.9, p = 0.000 in ex-vivo, pre: 1.9 ± 1.0, post: 3.8 ± 0.7, p = 0.000 in live) were increased. CONCLUSION: Training with an ex-vivo model and live tissue training are similar for the management of a penetrating cardiac injury, with increased self-efficacy of participants in both groups. The ex-vivo model is useful to learn hemostatic skills in trauma surgery.

Self-inflicted injuries are an important cause of penetrating traumatic injuries in Japan.

Aim: Japan has a low crime rate, but a high suicide rate. The aim of this study is to review the causes of penetrating traumatic injuries in a tertiary care emergency center in Japan. Methods: We retrospectively reviewed all admissions for traumatic injuries over a 3-year period, and calculated the proportion of patients with penetrating traumatic injuries. Weapon used, age, gender, Injury Severity Score, cause of injury, and site of injury in all patients with penetrating injuries were reviewed. The proportion of patients with penetrating injuries among patients with all types of traumatic injuries requiring surgical intervention was calculated. Results: Of 1,321 patients admitted over 3 years, 65 patients (5%) suffered from penetrating injuries. Most were stab wounds, with only one gunshot (2%). The most common site of injury was an extremity (48%). The most common cause of penetrating injury was self-inflicted (38%). The abdomen is the most common site injured among self-inflicted injuries. Of patients with all types of traumatic injuries requiring surgical intervention, penetrating injuries accounted for 23%. Conclusion: Penetrating injuries represent 23% of all patients with traumatic injuries who required surgical intervention. Self-inflicted penetrating injuries were most common, supporting the need for preventive services. Acute care surgeons must be familiar with the surgical management of penetrating traumatic injuries, even in a country with a low crime rate.

Predicting the need for massive transfusion in trauma patients: the Traumatic Bleeding Severity Score.

BACKGROUND: The ability to easily predict the need for massive transfusion may improve the process of care, allowing early mobilization of resources. There are currently no clear criteria to activate massive transfusion in severely injured trauma patients. The aims of this study were to create a scoring system to predict the need for massive transfusion and then to validate this scoring system. METHODS: We reviewed the records of 119 severely injured trauma patients and identified massive transfusion predictors using statistical methods. Each predictor was converted into a simple score based on the odds ratio in a multivariate logistic regression analysis. The Traumatic Bleeding Severity Score (TBSS) was defined as the sum of the component scores. The predictive value of the TBSS for massive transfusion was then validated, using data from 113 severely injured trauma patients. Receiver operating characteristic curve analysis was performed to compare the results of TBSS with the Trauma-Associated Severe Hemorrhage score and the Assessment of Blood Consumption score. RESULTS: In the development phase, five predictors of massive transfusion were identified, including age, systolic blood pressure, the Focused Assessment with Sonography for Trauma scan, severity of pelvic fracture, and lactate level. The maximum TBSS is 57 points. In the validation study, the average TBSS in patients who received massive transfusion was significantly greater (24.2 [6.7]) than the score of patients who did not (6.2 [4.7]) (p < 0.01). The area under the receiver operating characteristic curve, sensitivity, and specificity for a TBSS greater than 15 points was 0.985 (significantly higher than the other scoring systems evaluated at 0.892 and 0.813, respectively), 97.4%, and 96.2%, respectively. CONCLUSION: The TBSS is simple to calculate using an available iOS application and is accurate in predicting the need for massive transfusion. Additional multicenter studies are needed to further validate this scoring system and further assess its utility. LEVEL OF EVIDENCE: Prognostic study, level III.

Ex-vivo porcine organs with a circulation pump are effective for teaching hemostatic skills.

Surgical residents have insufficient opportunites to learn basic hemostatic skills from clinical experience alone. We designed an ex-vivo training system using porcine organs and a circulation pump to teach hemostatic skills. Residents were surveyed before and after the training and showed significant improvement in their self-confidence (1.83 ± 1.05 vs 3.33 ± 0.87, P < 0.01) on a 5 point Likert scale. This training may be effective to educate residents in basic hemostatic skills.

Sonographic diagnosis and successful nonoperative management of sealed perforated duodenal ulcer.

We encountered a case of sealed perforated duodenal ulcer in a 75-year-old woman with rheumatoid arthritis and chronic renal failure. Abdominal sonography showed a bright linear echo within the thickened anterior wall of the duodenal bulb and the presence of free air at the anterior surface of the liver. We found no signs of direct communication between the duodenal lumen and the peritoneal cavity or any free fluid. On follow-up sonography performed every 2 days during the first week of the patient's hospitalization, no free fluid was found in the abdomen. The use of sonography to diagnose this patient's sealed perforated duodenal ulcer and to monitor the ulcer for the appearance of free fluid allowed us to provide successful nonsurgical management to this patient. We believe that the use of abdominal sonography in all patients suspected of having a perforated duodenal ulcer may help increase the diagnostic accuracy of this modality and may reduce the need for surgery in such patients.