"We Can Make Ownership Safer" - A Conversation with ECU Trauma Surgeon Eric Toschlog About Preventing Firearm Injury and Death.

ECU trauma surgeon Dr. Eric A. Toschlog speaks with injury prevention epidemiologist Stephen W. Marshall about the role of clinicians and policymakers in deterring firearm injury and death in North Carolina and nationwide.

Direct Peritoneal Resuscitation in Trauma Patients Results in Similar Rates of Intra-Abdominal Complications.

Background: Trauma patients undergoing damage control surgery (DCS) have a propensity for complicated abdominal closures and intra-abdominal complications. Studies show that management of open abdomens with direct peritoneal resuscitation (DPR) reduces intra-abdominal complications and accelerates abdominal closure. This novel study compares intra-abdominal complication rates and the effect of DPR initiation in patients who received DPR and those who did not. Patients and Methods: A retrospective chart review was performed on 120 patients who underwent DCS. Fifty patients were identified as DCS with DPR, and matched to 70 controls by gender, race, age, body mass index (BMI), past medical history, mechanism of trauma, and injury severity score. Results: The two groups of patients, those without DPR (-DPR) and those with DPR (+DPR), were similar in their characteristics. The +DPR group was more likely to have a mesh closure than the -DPR (14% and 3%; p = 0.022). The +DPR group took longer to have a final closure (3.5 ± 2.6 days vs. 2.5 ± 1.8; p = 0.020). Infection complications and mechanical failure of the closure technique were similar among the two groups. Timing of DPR initiation had no effect on closure type but did statistically increase the number of days to closure (initiation at first operation 2.8 ± 1.8 days vs. initiation at subsequent operations 6.0 ± 3.3 days; p ≤ 0.001). Conclusions: The use of DPR did not result in different outcomes in trauma patients. Therefore, traditional resuscitative measures for DCS may not be inferior to DCS with DPR. When choosing to use DPR, initiating it at the first operation could reduce the number of days to closure.

An in-situ simulation-based educational outreach project for pediatric trauma care in a rural trauma system.

BACKGROUND: Outcome disparities between urban and rural pediatric trauma patients persist, despite regionalization of trauma systems. Rural patients are initially transported to the nearest emergency department (ED), where pediatric care is infrequent. We aim to identify educational intervention targets and increase provider experience via pediatric trauma simulation. METHODS: Prospective study of simulation-based pediatric trauma resuscitation was performed at three community EDs. Level one trauma center providers facilitated simulations, providing educational feedback. Provider performance comfort and skill with tasks essential to initial trauma care were assessed, comparing pre-/postsimulations. Primary outcomes were: 1) improved comfort performing skills, and 2) team performance during resuscitation. RESULTS: Provider comfort with the following improved (p-values <0.05): infant airway, infant IV access, blood administration, infant C-spine immobilization, chest tube placement, obtaining radiographic images, initiating transport, and Broselow tape use. The proportion of tasks needing improvement decreased: 42% to 27% (p-value=0.001). Most common deficiencies were: failure to obtain additional history (75%), beginning secondary survey (58.33%), log rolling/examining the back (66.67%), calling for transport (50%), calculating medication dosages (50%). CONCLUSIONS: Simulation-based education improves provider comfort and performance. Comparison of patient outcomes to evaluate improvement in pediatric trauma care is warranted. LEVEL OF EVIDENCE RATING: IV.

The American Association for the Surgery of Trauma Severity Grade is valid and generalizable in adhesive small bowel obstruction.

BACKGROUND: The American Association for the Surgery of Trauma (AAST) anatomic severity grading system for adhesive small bowel obstruction (ASBO) was validated at a single institution. We aimed to externally validate the AAST ASBO grading system using the Eastern Association for the Surgery of Trauma multi-institutional small bowel obstruction prospective observational study. METHODS: Adults (age ≥ 18) with (ASBO) were included. Baseline demographics, physiologic parameters (heart rate, blood pressure, respiratory rate), laboratory tests (lactate, hemoglobin, creatinine, leukocytosis), imaging findings, operative details, length of stay, and Clavien-Dindo complications were collected. The AAST ASBO grades were assigned by two independent reviewers based on imaging findings. Kappa statistic, univariate, and multivariable analyses were performed. RESULTS: There were 635 patients with a mean (±SD) age of 61 ± 17.8 years, 51% female, and mean body mass index was 27.5 ± 8.1. The AAST ASBO grades were: grade I (n = 386, 60.5%), grade II (n = 135, 21.2%), grade III (n = 59, 9.2%), grade IV (n = 55, 8.6%). Initial management included: nonoperative (n = 385; 61%), laparotomy (n = 200, 31.3%), laparoscopy (n = 13, 2.0%), and laparoscopy converted to laparotomy (n = 37, 5.8%). An increased median [IQR] AAST ASBO grade was associated with need for conversion to an open procedure (2 [1-3] vs. 3 [2-4], p = 0.008), small bowel resection (2 [2-2] vs. 3 [2-4], p < 0.0001), postoperative temporary abdominal closure (2 [2-3] vs. 3 [3-4], p < 0.0001), and stoma creation (2 [2-3] vs. 3 [2-4], p < 0.0001). Increasing AAST grade was associated with increased anatomic severity noted on imaging findings, longer duration of stay, need for intensive care, increased rate of complication, and higher Clavien-Dindo complication grade. CONCLUSION: The AAST ASBO severity grading system has predictive validity for important clinical outcomes and allows for standardization across institutions, providers, and future research focused on optimizing preoperative diagnosis and management algorithms. LEVEL OF EVIDENCE: Prognostic, level III.

REBOA for the IVC? Resuscitative balloon occlusion of the inferior vena cava (REBOVC) to abate massive hemorrhage in retrohepatic vena cava injuries.

BACKGROUND: The use of resuscitative endovascular balloon occlusion as a maneuver for occlusion of the aorta is well described. This technique has life-saving potential in other cases of traumatic hemorrhage. Retrohepatic inferior vena cava (IVC) injuries have a high rate of mortality, in part, due to the difficulty in achieving total vascular isolation. The purpose of this study was to investigate the ability of resuscitative balloon occlusion of the IVC to control suprahepatic IVC hemorrhage in a swine model of trauma. METHODS: Thirteen swine were randomly assigned to control (seven animals) versus intervention (six animals). In both groups, an injury was created to the IVC. Hepatic inflow control was obtained via clamping of the hepatoduodenal ligament and infrahepatic IVC. In the intervention group, suprahepatic IVC control was obtained via a resuscitative balloon occlusion of the IVC placed through the femoral vein. In the control group, no suprahepatic IVC control was established. Vital signs, arterial blood gases, and lactate were monitored until death. Primary end points were blood loss and time to death. Lactate, pH, and vital signs were secondary end points. Groups were compared using the χ and the Student t test with significance at p < 0.05. RESULTS: Intervention group's time to death was significantly prolonged: 59.3 ± 1.6 versus 33.4 ± 12.0 minutes (p = 0.001); and total blood loss was significantly reduced: 333 ± 122 vs 1,701 ± 358 mL (p = 0.001). In the intervention group, five of the six swine (83.3%) were alive at 1 hour compared to zero of seven (0%) in the control group (p = 0.002). There was a trend toward worsening acidosis, hypothermia, elevated lactate, and hemodynamic instability in the control group. CONCLUSIONS: Resuscitative balloon occlusion of the IVC demonstrates superior hemorrhage control and prolonged time to death in a swine model of liver hemorrhage. This technique may be considered as an adjunct to total hepatic vascular isolation in severe liver hemorrhage and could provide additional time needed for definitive repair. LEVEL OF EVIDENCE: Therapeutic study, level II.

Multi-institutional, prospective, observational study comparing the Gastrografin challenge versus standard treatment in adhesive small bowel obstruction.

INTRODUCTION: Existing trials studying the use of Gastrografin for management of adhesive small bowel obstruction (SBO) are limited by methodological flaws and small sample sizes. We compared institutional protocols with and without Gastrografin (GG), hypothesizing that a SBO management protocol utilizing GG is associated with lesser rates of exploration, shorter length of stay, and fewer complications. METHODS: A multi-institutional, prospective, observational study was performed on patients appropriate for GG with adhesive SBO. Exclusion criteria were internal/external hernia, signs of strangulation, history of abdominal/pelvic malignancy, or exploration within the past 6 weeks. Patients receiving GG were compared to patients receiving standard care without GG. RESULTS: Overall, 316 patients were included (58 ± 18 years; 53% male). There were 173 (55%) patients in the GG group (of whom 118 [75%] successfully passed) and 143 patients in the non-GG group. There were no differences in duration of obstipation (1.6 vs. 1.9 days, p = 0.77) or small bowel feces sign (32.9% vs. 25.0%, p = 0.14). Fewer patients in the GG protocol cohort had mesenteric edema on CT (16.3% vs. 29.9%; p = 0.009). There was a lower rate of bowel resection (6.9% vs. 21.0%, p < 0.001) and exploration rate in the GG group (20.8% vs. 44.1%, p < 0.0001). GG patients had a shorter duration of hospital stay (4 IQR 2-7 vs. 5 days IQR 2-12; p = 0.036) and a similar rate of complications (12.5% vs. 17.9%; p = 0.20). Multivariable analysis revealed that GG was independently associated with successful nonoperative management. CONCLUSION: Patients receiving Gastrografin for adhesive SBO had lower rates of exploration and shorter hospital length of stay compared to patients who did not receive GG. Adequately powered and well-designed randomized trials are required to confirm these findings and establish causality. LEVEL OF EVIDENCE: Therapeutic, level III.

Lung protective ventilation (ARDSNet) versus airway pressure release ventilation: ventilatory management in a combined model of acute lung and brain injury.

BACKGROUND: Concomitant lung/brain traumatic injury results in significant morbidity and mortality. Lung protective ventilation (Acute Respiratory Distress Syndrome Network [ARDSNet]) has become the standard for managing adult respiratory distress syndrome; however, the resulting permissive hypercapnea may compound traumatic brain injury. Airway pressure release ventilation (APRV) offers an alternative strategy for the management of this patient population. APRV was hypothesized to retard the progression of acute lung/brain injury to a degree greater than ARDSNet in a swine model. METHODS: Yorkshire swine were randomized to ARDSNet, APRV, or sham. Ventilatory settings and pulmonary parameters, vitals, blood gases, quantitative histopathology, and cerebral microdialysis were compared between groups using χ2, Fisher's exact, Student's t test, Wilcoxon rank-sum, and mixed-effects repeated-measures modeling. RESULTS: Twenty-two swine (17 male, 5 female), weighing a mean (SD) of 25 (6.0) kg, were randomized to APRV (n = 9), ARDSNet (n = 12), or sham (n = 1). PaO2/FIO2 ratio dropped significantly, while intracranial pressure increased significantly for all three groups immediately following lung and brain injury. Over time, peak inspiratory pressure, mean airway pressure, and PaO2/FIO2 ratio significantly increased, while total respiratory rate significantly decreased within the APRV group compared with the ARDSNet group. Histopathology did not show significant differences between groups in overall brain or lung tissue injury; however, cerebral microdialysis trends suggested increased ischemia within the APRV group compared with ARDSNet over time. CONCLUSION: Previous studies have not evaluated the effects of APRV in this population. While our macroscopic parameters and histopathology did not observe a significant difference between groups, microdialysis data suggest a trend toward increased cerebral ischemia associated with APRV over time. Additional and future studies should focus on extending the time interval for observation to further delineate differences between groups.

When birds can't fly: an analysis of interfacility ground transport using advanced life support when helicopter emergency medical service is unavailable.

BACKGROUND: Helicopter emergency medical service (HEMS) transport of trauma patients is costly and of unproven benefit. Recent retrospective studies fail to control for crew expertise and therefore compare highly trained advance life support with less-trained basic life support crews. The purpose of our study was to compare HEMS with ground, interfacility transport while controlling for crew training. We hypothesized that patients transported by HEMS would experience shorter interhospital transport time and reduced mortality. METHODS: Our National Trauma Registry of the American College of Surgeons database was retrospectively queried to identify consecutive interfacility, hospital transfers (January 1, 2008, to November 1, 2012) to our Level I trauma center. Transfers were stratified by transportation vehicle (i.e., HEMS vs. ground transport). Cohorts were compared across standard demographic and clinical variables using univariate analysis. Multivariate logistic regression was performed to determine the association of these variables with mortality. RESULTS: The HEMS (n = 2,190) and ground (n = 223) cohorts were well matched overall, with no significant differences for demographics, injury severity, physiology, hospital length of stay, or complications. Median (interquartile range) time to definitive care was significantly lower for HEMS (150 [114] minutes vs. 255 [157] minutes, p < 0.001), without change in mortality (9.0% vs. 8.1%, p = 0.71). Multivariate logistic regression did not identify an association between transport mode and mortality. CONCLUSION: Despite faster interfacility transport times, HEMS offered no mortality benefit compared with ground when crew expertise was controlled for, contradicting recent large, retrospective National Trauma Data Bank studies. Our study may represent the best approximation of a prospective study by focusing on patients deemed worthy of HEMS by referring providers. Although HEMS may seem intuitively beneficial for time-dependent injuries, larger studies with a similar methodology are warranted to justify the cost and risk of HEMS and identify subsets of patients who may benefit. LEVEL OF EVIDENCE: Prognostic/epidemiologic study, level III.

Rural trauma recidivism: a different disease.

HYPOTHESIS: Unlike the well-characterized urban trauma recidivist (RC), factors associated with the rural RC remain undefined. In an attempt to devise preventative strategies, we theorized that the rural RC profile would be similar to that of urban counterparts. DESIGN: Retrospective review. SETTING: Rural, university-affiliated, level I trauma center. PATIENTS: All trauma patients admitted between January 1, 1994, and December 30, 2002. INTERVENTIONS: Identification and characterization of rural trauma RCs. MAIN OUTCOME MEASURES: Trauma recidivism incidence, risk factors, and cost. RESULTS: Of 15 370 consecutive admissions, 528 (3.4%) were RCs. Demographic comparisons to a non-RC cohort demonstrated rural RCs to be significantly older (mean +/- SD age, 55.9 +/- 24.8 vs 39.7 +/- 24.1 years), disproportionately white (65.2% [344/528] vs 56.5% [8386/14 842]), and more likely female (49.1% [259/528] vs 37.3% [5537/14 842]) (P<.001 for all). Clinical comparisons revealed significant associations between recidivism and substance abuse. The percentage of positive blood ethanol screen results (58.7% [310/528] vs 39.9% [5923/14 842]) and the mean +/- SD blood ethanol content (132.1 +/- 139.9 mg/dL [28.7 +/- 30.4 mmol/L] vs 69.5 +/- 114.4 mg/dL [15.1 +/- 24.8 mmol/L]) were higher for RCs (P<.001 for both). In addition, cocaine use was significantly higher in the RC cohort (6.4% [34/528] vs 4.1% [607/14 842]; P=.02). The total cost for all RC admissions exceeded $7 million. CONCLUSIONS: The rural RC profile is strikingly different from urban counterparts. The common feature seems to be substance abuse. Correspondingly, prevention strategies for recidivism must be considerably different among rural and urban populations.

Low-dose dopamine: a physiologically based review.

BACKGROUND: In an attempt to prevent or alter the course of acute renal failure, many surgeons continue to use low-dose dopamine. This article critically reviews the physiologic reasons why low-dose dopamine is not clinically efficacious. METHODS: A critical review of English language literature. RESULTS: The effect of dopamine on renal blood flow remains controversial. If dopamine does increase renal blood flow, the vascular anatomy of the kidney would limit its effectiveness. Rather than improving renal function, dopamine has been shown to impair renal oxygen kinetics, inhibit feedback systems that protect the kidney from ischemia, and may worsen tubular injury. Dopamine has not been proven useful in the prevention or alteration of the course of acute renal failure as a result of heart failure, cardiac surgery, abdominal aortic surgery, sepsis, and transplantation. Dopamine has been associated with multiple complications involving the cardiovascular, pulmonary, gastrointestinal, endocrine, and immune systems. CONCLUSIONS: Based on the anatomy and physiology of the kidney, low-dose dopamine would not be expected to improve renal failure and this has been demonstrated by the lack of efficacy in clinical trials.

Predicting the need for early tracheostomy: a multifactorial analysis of 992 intubated trauma patients.

BACKGROUND: Tracheostomy has few, severe risks, while prolonged endotracheal intubation causes morbidity. The need for tracheostomy was assessed, based on early clinical parameters. METHODS: Adult trauma patients (January 1994-August 2004), intubated for resuscitation, ventilated >24 hours, were retrospectively evaluated for demographics, physiology, brain, and pulmonary injury. Tracheostomy patients were compared with those without. Chi-square, Mann-Whitney, and multivariate logistic regression were used with statistical significance at p < 0.05.* RESULTS: Of 992 patients, 430 (43%) underwent tracheostomy at 9.22 +/- 5.7 days. Risk factors were age (45.6* +/- 18.8 vs. 36.7 +/- 15.9, OR: 2.1 (18 years increments), ISS (30.3* +/- 12.5 vs. 22.0 +/- 10.3, OR: 2.1 (12u increments), damage control (DC) [68%*(n = 51) vs. 32%*(n = 51), OR: 3.8], craniotomy [70%*(n = 21) versus 30%(n = 9), OR: 2.6], and intracranial pressure monitor (ICP) [65.4%*(n = 87) vs. 34.6%(n = 46), OR: 2.1]. A 100% tracheostomy rate (n = 30, 3.0%) occurred with ISS (injury severity score) = 75, ISS >or=50, and age >or=55, admit/24 hour GCS (Glasgow Coma Scale) = 3 and age >or=70, AIS abdomen, chest or extremities >or=5 and age >or=60, bilateral pulmonary contusions (BPC) and >or=8 rib fractures, craniotomy and age >or=50, craniotomy with intracranial pressure (ICP) and age >or=40, or craniotomy and GCS or=90% (n = 105, 10.6%) was found with ISS >or=54, ISS >or=40, and age >or=40, admit/24 hour GCS = 3 and age >or=55, paralysis and age >or=40, BPC and age >or=55.A tracheostomy rate >or=80% (n = 248, 25.0%) occurred with ISS >or=38, age >or=80, admit/24 hour GCS = 3 and age >or=45, DC and age >or=50, BPC and age >or=50, aspiration and age >or=55, craniotomy with ICP, craniotomy with GCS or=90% risk undergo early tracheostomy and that it is considered in the >or=80% risk group to potentially decreased morbidity, increased patient comfort, and optimize resource utilization.

Damage control surgery--the intensivist's role.

"Damage control" surgery has evolved during the past 20 years from an accepted surgical technique in the traumatized, moribund patient to an expanded role in critically ill, nontraumatized patients. Physicians caring for these patients in extremis have begun to recognize a pattern of severe physiologic derangement that prompts an abbreviated laparotomy after hemorrhage and contamination control. Emphasis then shifts from the operating theater to the intensive care unit, where the patient's physiologic deficits are corrected. Once these derangements have been resolved, the patient is taken back to the operating room for definitive, reconstructive surgical care. The purpose of this article is to review the concept of "damage control" in reference to the patient whose pathophysiologic depletion prompts the need for it. Resuscitation in the intensive care unit will be summarized, pitfalls will be identified, and treatment plans will be delineated. Complications such as abdominal compartment syndrome and difficult abdominal wall closures will also be discussed.

Popliteal artery trauma in a rural level I trauma center.

Popliteal vascular trauma has historically been an urban phenomenon. We hypothesized that rural popliteal artery injury would result more often from blunt mechanisms of injury (MOI), have a longer time to operation, and result in a higher amputation rate. We retrospectively reviewed all cases of popliteal artery injury from December 1994 to May 2001 at our rural trauma center. Age, gender, Injury Severity Score (ISS), MOI, scene transport versus transfer from a referring hospital, time to operation, and operative times were studied. Significance was determined by Student's t test with a P value < or = 0.05. Thirty-two popliteal artery injuries were found. Blunt trauma accounted for 50 per cent of the injuries. Eighty-eight per cent of the patients were transferred from a referring hospital. Patients transported directly from the scene had a higher ISS. Longer operative times translated into an increased need for fasciotomy. The amputation rate was 19 per cent. This is the first attempt to delineate the specific nature of rural popliteal artery trauma. The amputation rate was not different between the two different MOI and was independent of the time to operation. Of those patients receiving an amputation 83 per cent were transferred from another hospital and despite a statistically lower ISS still required an amputation.