Penetrating aerodigestive injuries in the neck: a proposed CT-aided modified selective management algorithm.

OBJECTIVES: To determine the specific CT findings of penetrating neck wound profile predicting aerodigestive injuries, diagnostic performance of CTA and to propose a modified selective management algorithm to reduce nontherapeutic invasive procedures. METHODS: We retrospectively evaluated CTAs of 102 patients to determine the presence of various CT signs. "Trajectory"-based signs included trajectory of the wound extending into the aerodigestive tract and trajectory violating the deep neck spaces. "Conventional" signs included transcervical injury; wall defect; air or blood in the deep neck spaces; irregular or thickened aerodigestive tract; and active mucosal bleeding. RESULTS: Trajectory of the wound extending into the aerodigestive tract (sensitivity 76 %, specificity 97 %) and trajectory of the wound violating the suprahyoid deep neck spaces or the infrahyoid visceral space (sensitivity 97 %, specificity 55 %) were the best predictors of injury on regression analysis. The most specific "conventional" CT signs were "wall defect" and "active mucosal bleed", but had very low sensitivity. The sensitivity of CTA for detecting an injury ranged from 89.5 % to 92 %, specificity ranged from 62.5 % to 89 %. CONCLUSION: CTA can be a useful technique in detecting aerodigestive injury. Our proposed management algorithm can exclude an injury with high degree of confidence (sensitivity 97 %). KEY POINTS: • Trajectory-based CT signs predict aerodigestive injury after penetrating neck trauma. • Surgery should be considered when trajectory extends into the infra-arytenoid aerodigestive tract. • Endoscopy or exploration should be considered when trajectory violates deep neck spaces. • This modified approach can decrease negative explorations and invasive diagnostic procedures.

Surgical Infection Society-Chest Wall Injury Society Recommendations for Management of Surgical Site or Implant-Related Infections After Surgical Stabilization of Traumatic Rib or Sternal Fractures.

Background: Surgical stabilization of rib fractures (SSRF) and surgical stabilization of sternal fractures (SSSF) involves open reduction and internal fixation of fractures with an implantable titanium plate to restore and maintain anatomic alignment. The presence of this foreign, non-absorbable material presents an opportunity for infection. Although surgical site infection (SSI) and implant infection rates after SSRF and SSSF are low, they present a challenging clinical entity. Methods: The Surgical Infection Society's Therapeutics and Guidelines Committee and Chest Wall Injury Society's Publication Committee convened to develop recommendations for management of SSIs or implant-related infections after SSRF or SSSF. PubMed, Embase, Web of Science and the Cochrane database were searched for pertinent studies. Using a process of iterative consensus, all committee members voted to accept or reject each recommendation. Results: For patients undergoing SSRF or SSSF who develop an SSI or an implant-related infection, there is insufficient evidence to suggest a single optimal management strategy. For patients with an SSI, systemic antibiotic therapy, local wound debridement, and vacuum-assisted closure have been used in isolation or combination. For patients with an implant-related infection, initial implant removal with or without systemic antibiotic therapy, systemic antibiotic therapy with local wound drainage, and systemic antibiotic therapy with local antibiotic therapy have been documented. For patients who do not undergo initial implant removal, 68% ultimately require implant removal to achieve source control. Conclusions: Insufficient evidence precludes the ability to recommend guidelines for the treatment of SSI or implant-related infection following SSRF or SSSF. Further studies should be performed to identify the optimal management strategy in this population.

Improved Outcomes for Trauma Patients in a Military Treatment Facility After Initiation of an American College of Surgeons-Verified Trauma Program.

INTRODUCTION: The National Defense Authorization Act of 2017 indicated the need for a national strategy to improve trauma care among military treatment facilities (MTFs). Part of the proposed strategy to improve trauma outcomes was to convert identified MTFs into verified trauma centers. The American College of Surgeons (ACS) verifies trauma centers through an evaluation process based on available resources at a facility. It has been proven that trauma centers, specifically those verified by the ACS, have improved trauma outcomes. In 2017, we implemented steps to become a level III trauma program, according to the standards for designation by the state and verification through the ACS. The goal of this retrospective review is to evaluate the impact of this implementation with regard to both patient care and the MTF. MATERIALS AND METHODS: Data from a single-MTF trauma registry from 2018, at the initiation of the trauma program, to present were reviewed. Outcomes were selected based upon the ACS verification criteria. Specifically, emergency department length of stay (ED LOS), nonsurgical admissions, injury severity score, diversion rates, and time to operating room were reviewed. Statistical analyses were performed using Student's t-tests. Institutional review board (IRB) approval was not required for this study as it was performed as a quality improvement project using deidentified data. RESULTS: ED LOS decreased significantly after implementation of the trauma program from an average of 6.43 h in 2018 to 4.73 h in 2019 and 4.6 h in 2020 (P < .04). Nonsurgical admissions decreased significantly from 57.8% in 2018, with rates of <20% in all subsequent years (P < .01). The average injury severity score increased from 5.61 in 2018 to 7.52 in 2020 (P < .01) and 7.27 in 2021 (P < .01). Diversion rates also decreased from >5% in 2018 to 0% in 2021. CONCLUSIONS: The establishment of a trauma program in accordance with the standards of the ACS for verification improved metrics of care for trauma patients at our MTF. This implementation as part of the local trauma system also led to increased injury severity seen by the MTF, which enhances readiness for its providers.

Graduating Surgical Residents Lack Competence in Critical Care Ultrasound.

OBJECTIVE: Ultrasound provides accessible imaging for bedside diagnostics and procedural guidance, but may lead to misdiagnosis in untrained users. The main objective of this study was to determine observed and self-perceived competence with critical care ultrasound in graduated general surgery residents. DESIGN: The design of this study was a retrospective review. Ultrasound training program records were reviewed for number of prior ultrasound examinations performed, self-perceived competence, observed competence on faculty examinations, and intended future use of individual critical care ultrasound examinations. SETTING: This study was undertaken at the R Adams Cowley Shock Trauma Center, which is a tertiary care center in Baltimore, MD. PARTICIPANTS: Graduated general surgery residents were identified at the beginning of their surgical critical care fellowship at our institution, and were included if they participated in our critical care ultrasound education program. Fifteen graduated general surgery residents were included. RESULTS: Prior ultrasound experience ranged from 100% for focused assessment of sonography for trauma (FAST) to 13.3% for advanced cardiac assessment. Self-perceived competence ranged from 46.7% with FAST to 0% for advanced cardiac assessment. Observed competence ranged from 20.0% for FAST examinations to 0% for basic cardiac assessment, advanced cardiac assessment, and inferior vena cava (IVC) assessment. All participants intended to use ultrasound in the future for FAST, pneumothorax detection and basic cardiac assessment, and 86.7% for IVC assessment and advanced cardiac assessment. Of participants with self-perceived competence, 28.6% had observed competence with FAST, 0% with IVC assessment, and 100% with pneumothorax detection. CONCLUSIONS: Graduated general surgery residents are not competent in multiple critical care ultrasound examinations despite universally planning to use critical care ultrasound in future practice. Current exposure to ultrasound in residency may give a false sense of competency with ultrasound use. A standardized ultrasound curriculum is an urgent need for general surgery training.

The ABC's of Pancreatic Trauma: Airway, Breathing, and Computerized Tomography Scan?

OBJECTIVES: Missed pancreatic injury carries significant morbidity. Computerized tomography (CT) imaging is useful, but may lack sensitivity to identify pancreatic injury. New-generation CT scanners should improve sensitivity, but this has not been studied. A previous study published in 2002 evaluating the sensitivity for identifying pancreatic injury with single-slice CT scanners yielded a 68% correlation between operative and CT findings. We aim to study the accuracy of modern CT for diagnosis and grading of pancreatic injury. METHODS: All trauma admissions from 2008 and 2012 were retrospectively reviewed. Patients with a pancreatic injury, either on CT or intraoperatively, were included (n = 96). Sensitivity and specificity were calculated using Student's t test. RESULTS: 48 patients had injuries noted on CT and in the operating room. In this group, 68.8% had CT findings discordant with operative findings. Of these, 78.8% had no injury noted on CT, of which 26.9% required surgical intervention. Seven patients with injury on CT had none identified in the operating room. Based on these results, the sensitivity for CT imaging to identify an injury is 36.4% with a positive predictive value of 68.2%. CONCLUSIONS: Our results indicate that despite advances in CT technology, the sensitivity and specificity for identifying pancreatic injury remains low. Although CT scans remain critical in trauma evaluation, awareness of this diagnostic gap is important. Further analysis is required to determine any impact on patient outcomes.

Exploratory Laparotomy for Proximal Vascular Control in Combat-Related Injuries.

BACKGROUND: Combat casualties have endured an increase in traumatic lower extremity amputations secondary to improvised explosive devices. Often surgical control of the proximal vasculature is required. We evaluate the safety profile of exploratory laparotomy (EXLAP) for proximal control (PC) in combat-injured patients. METHODS: Records of 845 combat casualties from June 2009 to December 2011 were reviewed. Patients undergoing EXLAP were divided by indication into PC and non-PC groups. Demographics, Injury Severity Score, mechanism of injury, transfusion requirements, EXLAP findings, reoperation rates, and abdominal-related complications were recorded. RESULTS: 44 patients were identified as PC and 91 as non-PC. Age was similar (23.7 ± 4.1 vs. 24.0 ± 4.6, p = 0.7138), and all were male. Improvised explosive devices blast was the most common mechanism of injury. Injury Severity Score (25.8 ± 8.2 vs. 21.4 ± 9.1, p = 0.0075), lower extremity amputation (93.1% vs. 28.6%, p = 0.0001), and transfusion requirements were different. Days to fascial closure (1.8 ± 1.9 vs. 1.7 ± 2.8, p = 0.8308) and number of EXLAPs were similar (2.4 ± 1.3 vs. 2.1 ± 1.5, p = 0.2581). PC had higher complications (43.1% vs. 24.2%, p = 0.0292). CONCLUSION: PC demonstrated an increase in abdominal complications. The reason for this remains unclear. Alternative approaches of achieving proximal vascular control may avoid the morbidity associated with laparotomy, and predeployment training of such procedures should be considered for the general surgeon. Further studies are warranted to determine best practices for these patients.

Through the looking glass: early non-invasive imaging in TBI predicts the need for interventions.

BACKGROUND: Early diagnosis and treatment of traumatic brain injury (TBI) lead to better outcomes. It is difficult to predict which patients benefit from specialised centres, leading to over triage or delay in definitive care. We propose that a non-invasive test comprising optic nerve sheath ultrasound, transcranial Doppler and quantitative papillary reactivity is feasible, correlates with CT findings and may allow for accurate early identification of TBI. METHODS: A 1-year, prospective observation study evaluated a low-risk, non-invasive method of assessing brain injury. Patients underwent a non-invasive neurological examination for trauma, including the above assessments. Data from the three examinations were collected within 6 hours of injury and at 24 hours, and were analysed. Demographics, haemodynamic data, imaging results and short-term outcomes/interventions were recorded. RESULTS: Trauma patients over the age of 18 years, with a Glascow coma scale (GCS) of <12 or CT evidence of TBI, and intubated were included (N=100). These were divided into +CT (n=49) and -CT groups (n=51) according to the Marshall CT classification of TBI. The +CT group was older, with worse GCS and higher lactate (p=0.008, p=0.001 and p=0.01) but were otherwise well matched. The +CT group included all TBI types, with 96% of the patients having more than one type of TBI. Pulsatility index and neurologic pupillary index were predictive of a +CT (p=0.04, p=0.02). Area under the receiver-operating curve for the logistic regression model for the prediction of positive radiographic findings was r=0.718. Finally, we suggest a preliminary scoring heuristic for predicting a positive radiological finding in a patient with TBI. CONCLUSIONS: The proposed examination is a feasible, non-invasive tool that may have clinical utility in the early prediction of TBI. If validated, it may improve trauma triage for the brain-injured patient. Further studies are warranted to validate this model.

Bridging the gap: Hybrid cardiac echo in the critically ill.

BACKGROUND: Point-of-care ultrasound often includes cardiac ultrasound. It is commonly used to evaluate cardiac function in critically ill patients but lacks the specific quantitative anatomic assessment afforded by standard transthoracic echocardiography (TTE). We developed the Focused Rapid Echocardiographic Examination (FREE), a hybrid between a cardiac ultrasound and TTE that places an emphasis on cardiac function rather than anatomy. We hypothesized that data obtained from FREE correlate well with TTE while providing actionable information for clinical decision making. METHODS: FREE examinations evaluating cardiac function (left ventricular ejection fraction), diastolic dysfunction (including early mitral Doppler flow [E] and early mitral tissue Doppler [E']), right ventricular function, cardiac output, preload (left ventricular internal dimension end diastole), stroke volume, stroke volume variation, inferior vena cava diameter, and inferior vena cava collapse were performed. Patients who underwent both a TTE and FREE on the same day were identified as the cohort, and quantitative measurements were compared. Correlation analyses were performed to assess levels of agreement. RESULTS: A total of 462 FREE examinations were performed, in which 69 patients had both a FREE and TTE. FREE ejection fraction was strongly correlated with TTE (r = 0.89, 95% confidence interval). Left ventricular outflow tract, left ventricular internal dimension end diastole, E, and lateral E' derived from FREE were also strongly correlated with TTE measurements (r = 0.83, r = 0.94, r = 0.77, and r = 0.88, respectively). In 82% of the patients, right ventricular function for FREE was the same as that reported for TTE; pericardial effusion was detected on both examinations in 94% of the cases. No significant valvular anatomy was missed with the FREE examination. CONCLUSION: Functionally rather than anatomically based hybrid ultrasound examinations, like the FREE, facilitate decision making for critically ill patients. The FREE's functional assessment correlates well with TTE measurements and may be of significant clinical value in critically ill patients, especially when used in remote operating environments where resources are limited. LEVEL OF EVIDENCE: Diagnostic test, level III.

Ratio-driven resuscitation predicts early fascial closure in the combat wounded.

BACKGROUND: Operation Iraqi Freedom and Operation Enduring Freedom have seen the highest rates of combat casualties since Vietnam. These casualties often require massive transfusion (MT) and immediate surgical attention to control hemorrhage. Clinical practice guidelines dictate ratio-driven resuscitation (RDR) for patients requiring MT. With the transition from crystalloid to blood product resuscitation, we have seen fewer open abdomens in combat casualties. We sought to determine the effect RDR has on achieving early definitive abdominal fascial closure in combat casualties undergoing exploratory laparotomy. METHODS: Records of 1,977 combat casualties admitted to a single US military hospital from April 2003 to December 2011 were reviewed. Patients receiving an MT and laparotomy in theater constituted the study cohort. The cohort was divided into RDR, defined as a ratio of 0.8-U to 1.2-U packed red blood cells to 1-U fresh frozen plasma, and No-RDR groups. Age, injury patterns, mechanism of injury, injury severity, blood products, number of laparotomies, and days to fascial closure were collected. Assessed outcomes were number of days (early ≤ 2 days) and number of laparotomies to achieve fascial closure. RESULTS: The mean age of the study cohort (n = 172) was 24.0 years, and mean Injury Severity Score (ISS) was 24.8. Improvised explosive device blast was the most common mechanism of injury (74.4%). The cohort was divided into RDR patients (n = 73) and no RDR (n = 99). There was no difference in mean age, mean ISS, or rate of nontherapeutic exploratory laparotomies between the groups. RDR patients had a significantly lower abdominal injury rate (34.2% vs. 72.7%, p < 0.01), had fewer laparotomies (2.7 vs. 4.3, p = 0.003), and achieved primary fascial closure faster (2.4 days vs. 7.2 days, p = 0.004). On multivariate analysis, RDR (2.74; 95% confidence interval, 1.44-5.2) was an independent predictor for early fascial closure. CONCLUSION: Adherence to RDR guidelines resulted in significantly decreased number of abdominal operations and was identified as an independent predictor for early fascial closure. Further investigation is warranted to validate these findings. LEVEL OF EVIDENCE: Therapeutic study, level III.