Have Students Used Techniques to Stop the Bleed?

INTRODUCTION: The Stop the Bleed course was initiated in response to the Hartford Consensus and over 1 million people have been taught basic bleeding control techniques. Our study sought to determine the extent to which this training has been utilized. METHODS: Surveys were sent by email to students that had taken the Stop the Bleed course through our institution in 2017 or 2018. Data were collected utilizing the REDCap system and statistical calculations were performed. RESULTS: 2505 surveys were sent with 445 (18%) responses. The mean age of respondents was 48 years of age, 343 (77%) were female, and 230 (52%) were in the medical field. There were 17 respondents (3.8%) that stated they had utilized the techniques taught in the course; 16 out of 17 put pressure on a wound, 7 packed a wound, and 6 used a tourniquet. Patients had been injured by a variety of mechanisms including gunshot wound, stabbing, accidental laceration, and motor vehicle collision. Patients had good outcomes with 3 out of 17 surviving to emergency medical services arrival without known final outcome and the remaining 14 were known to do well. CONCLUSION: The Stop the Bleed course is important to enable bystanders to provide hemorrhage control. Our study shows that the techniques have been utilized with 17 treated patients having a good outcome and while a utilization rate of 3.8% may appear low, it is similar to the utilization rate of cardiopulmonary resuscitation instruction of 2%.

Defining a Research Agenda for Layperson Prehospital Hemorrhage Control: A Consensus Statement.

Importance: Trauma is the leading cause of death for US individuals younger than 45 years, and uncontrolled hemorrhage is a major cause of trauma mortality. The US military's medical advancements in the field of prehospital hemorrhage control have reduced battlefield mortality by 44%. However, despite support from many national health care organizations, no integrated approach to research has been made regarding implementation, epidemiology, education, and logistics of prehospital hemorrhage control by layperson immediate responders in the civilian sector. Objective: To create a national research agenda to help guide future work for prehospital hemorrhage control by laypersons. Evidence Review: The 2-day, in-person, National Stop the Bleed (STB) Research Consensus Conference was conducted on February 27 to 28, 2019, to identify and achieve consensus on research gaps. Participants included (1) subject matter experts, (2) professional society-designated leaders, (3) representatives from the federal government, and (4) representatives from private foundations. Before the conference, participants were provided a scoping review on layperson prehospital hemorrhage control. A 3-round modified Delphi consensus process was conducted to determine high-priority research questions. The top items, with median rating of 8 or more on a Likert scale of 1 to 9 points, were identified and became part of the national STB research agenda. Findings: Forty-five participants attended the conference. In round 1, participants submitted 487 research questions. After deduplication and sorting, 162 questions remained across 5 a priori-defined themes. Two subsequent rounds of rating generated consensus on 113 high-priority, 27 uncertain-priority, and 22 low-priority questions. The final prioritized research agenda included the top 24 questions, including 8 for epidemiology and effectiveness, 4 for materials, 9 for education, 2 for global health, and 1 for health policy. Conclusions and Relevance: The National STB Research Consensus Conference identified and prioritized a national research agenda to support laypersons in reducing preventable deaths due to life-threatening hemorrhage. Investigators and funding agencies can use this agenda to guide their future work and funding priorities.

Tourniquets USA: A Review of the Current Literature for Commercially Available Alternative Tourniquets for Use in the Prehospital Civilian Environment.

The American College of Surgeons' "Stop the Bleed" (STB) campaign emphasizes how to apply the Combat Application Tourniquet (CAT), a device adopted by the military to control extremity hemorrhage. However, multiple commercially available alternatives to the CAT exist, and it would be helpful for instructors to be knowledgeable about how these other models compare. A PubMed search from January 2012 to January 2020 cross-referenced with a Google search for "tourniquet" was performed for commercially available tourniquets that had been trialed against the CAT. Windlass-type models included the Special Operations Forces Tactical Tourniquet (SOFT-T), the SOFT-T Wide (SOFFT-W), the SAM-XT tourniquet, the Military Emergency Tourniquet (MET), and the Tactical Medical Tourniquet (TMT). Elastic-type tourniquets included were the Stretch, Wrap, And Tuck Tourniquet (SWAT-T), the Israeli Silicone Tourniquet (IST), and the Rapid Activation Tourniquet System (RATS). Ratchet-type tourniquets included were the Ratcheting Medical Tourniquet (RMT) and TX2/TX3 tourniquets, and pneumatic-type tourniquets were the Emergency and Military Tourniquet (EMT) and Tactical Pneumatic Tourniquet (TPT). This review aims to describe the literature surrounding these models so that instructors can help laypeople make more informed purchases, stop the bleed, and save a life.

Fatal Necrotizing Soft-Tissue Infection Caused by Clostridium tetani in an Injecting Drug User: A Case Report.

The aim of this brief report is to raise awareness of necrotizing soft-tissue infections caused by Clostridium tetani in intravenous drug users, highlight the potentially unique dangers of this infection in this specific patient population, and outline the course of treatment currently considered the standard of care.

A novel, minimally invasive approach to assure hemostasis for intercostal bleeding after trauma.

Intercostal artery injury can cause large hemothoraces. While many patients with intercostal artery injury present hemodynamically unstable and require emergent thoracotomy for hemostasis, some tamponade spontaneously. They may rebleed later, however, and cause recurrent hemothorax or retained hemothorax. Video-assisted thoracic surgery (VATS) is an effective way to evacuate retained hemothorax. However, assessing and ligating intercostal artery injury during VATS can be difficult, and often, open thoracotomy is pursued. Even with open surgery, ligation of the intercostal artery can be a challenge. We present a minimally invasive method of definitive intercostal artery ligation during VATS or open thoracotomy.

Definitive Wound Closure Techniques in Fournier's Gangrene.

Necrotizing soft tissue infection of the perineum, or Fournier's gangrene (FG), is a morbid and mortal diagnosis. Despite the severity of FG, the optimal definitive wound closure strategy is unknown, as are long-term wound outcomes. A retrospective review was performed over a 3-year period at a single trauma center. Patients were managed according to our institutional approach focusing on primary wound closure and secondary intention healing in residual wounds. Overall 168 patients were included. Complete primary wound closure was accomplished in 39.9 per cent of patients. Patients undergoing primary wound closure were primarily male (89.6 vs 64.4%, P < 0.001), had lower mean sequential organ failure assessment (SOFA) scores (1.70 ± 2.30 vs 2.98 ± 3.36, P = 0.004), more often had perineum-limited FG (67.2 vs 42.6%, P = 0.003), and required fewer debridements (2.40 vs 2.79, P = 0.02). On logistic regression, predictors of primary closure included gender (odds ratio 4.643, 95% confidence interval 1.885-11.437, P = 0.001) and SOFA score (odds ratio 0.834, 95% confidence interval 0.727-0.957, P = 0.01). Wound healing rates increased over time, to an 82.1 per cent wound healing rate without further intervention at greater than six months of follow-up. Wounds healed with secondary intention ranged from 70 to 9520 cm3 and primary closure ranged from 126 to 6912 cm3, whereas wounds requiring skin grafts ranged from 405 to 16,170 cm3. Complete primary wound closure is often achievable in FG patients. Using this standardized approach to FG wound management, even large wounds and wounds undergoing secondary intention healing will often close with long-term wound care and do not require flap creation or early skin grafting.

Preventing Distal Catheter Obstruction in Laparoscopic Ventriculoperitoneal Shunt Placement in Adults: The "Falciform Technique".

BACKGROUND: Distal obstruction of ventriculoperitoneal (VP) shunts is a major problem in the treatment of hydrocephalus. To avoid this complication, we describe a simple method using the falciform ligament to place and hold the distal catheter in the right subdiaphragmatic space, preventing catheter migration and distal obstruction. MATERIALS AND METHODS: We retrospectively collected data of all VP shunt insertion and revision for adults with idiopathic normal-pressure hydrocephalus between November 2011 and September 2013. All of these were done using the "falciform technique," with the distal catheter portion performed laparoscopically. No exclusion criteria were applied. A neurosurgeon and a laparoscopic surgeon were involved in each case. The falciform ligament was used to tether the distal catheter above the liver, with the distal tip of the catheter reaching the hepatic flexure to allow for drainage directly into the right paracolic gutter. Baseline, operative, and postoperative data were collected and analyzed. RESULTS: In total, 58 patients underwent a shunt procedure during the period of study. The majority (74%) underwent new VP shunt placement, and 26% underwent revision and replacement for catheter obstruction. The female to male ratio was 1.14:1. Mean age was 67.3±17.5 years. Revisions due to distal catheter obstruction were subsequent to previous surgery placement. Median follow-up was 329 days. Three patients (5%) had proximal catheter obstruction requiring shunt revision. None of the patients (0%) was found to have distal obstruction at the end of the study period at the most recent follow-up. CONCLUSIONS: The faparoscopic falciform technique significantly reduces the rate of distal VP shunt obstruction in adults with idiopathic normal-pressure hydrocephalus. Continued follow-up is needed to confirm long-term patency of the catheter.

Robotic single-site cholecystectomy in the obese: outcomes from a single institution.

BACKGROUND: Robotic single-site cholecystectomy (RSSC) has been shown to be a safe alternative to the laparoscopic approach in selected patients. Patient exclusion criteria have prevented RSSC as a surgical option in many obese patients. This study reports the feasibility of performing RSSC in obese patients (body mass index [BMI] ≥ 30). METHODS: Between November 2012 and February 2014, a total of 200 patients underwent RSSC at our institution. All patients were offered the robotic procedure regardless of their BMI, age, previous surgery, and acuity of their disease with no exclusion criteria. All patients with BMI ≥ 30 were included in the study and were compared to nonobese patients for demographic characteristics, co-morbidities, and postoperative outcomes. Data were compared to RSSC performed in nonobese patients by the same surgeon, as well to published data for standard laparoscopic cholecystectomy (LC). RESULTS: A total of 112 cholecystectomies were successfully performed with the robotic approach in patients with BMI ≥ 30 without conversion to open, laparoscopic, or multiport procedures. The mean BMI was 39.5 (range 30.1-62.3). Twenty-eight patients had a BMI ≥ 40 (25%), and 13 patients had a BMI ≥ 50 (11.6%). Fifty-two patients (46.4%) had a history of prior abdominal surgery. Most procedures were nonelective (78.6%) with patients presenting with acute symptoms. Pathology showed chronic cholecystitis and cholelithiasis in 79 patients (70.5%), acute cholecystitis in 26 patients (23.3%), cholelithiasis in 4 patients (3.5%), and gangrenous cholecystitis in 3 patients (2.7%). Total mean operative time was 69.8 (26) minutes for obese patients compared to 59.2 (19.7) minutes in the nonobese, which was statistically significant (P = .0012). After a mean follow-up of 6 months, there were no major complications recorded including bile leak, hematoma, or ductal injury. There was 1 umbilical (incisional) hernia (0.9%) reported, and zero wound infections. When comparing RSSC performed in obese patients, RSSC in nonobese patients, and published data for standard LC, we found no difference in operative time, with less conversion to open. CONCLUSIONS: Robotic single-site cholecystectomy is a feasible option in the obese patient population with excellent short-term outcomes. Patients should not be excluded based on their high BMI although further study is needed to determine long-term outcomes.

Percutaneous versus open tracheostomy: comparison of procedures and surgical site infections.

BACKGROUND: Tracheostomy is one of the most common procedures performed in trauma patients in the intensive care unit (ICU). Few studies have evaluated the incidence of surgical site infections (SSIs) specifically in a trauma population. Our objective was to compare the incidence of SSI after open versus percutaneous tracheostomy and to discern whether there were any differences in outcome. METHODS: A prospective single-institution study was conducted on 640 patients admitted to the ICU over eight years who underwent tracheostomy. Age, gender, race, admission Injury Severity Score (ISS) and Acute Physiology and Chronic Health Evaluation (APACHE) II score, and mechanism of injury were obtained. The majority of patients were male (56.1%) and white (62.5%) with a mean age of 43.2 ± 20.2 years, ISS of 30.7 ± 13.2 points, and APACHE score of 13.3 ± 6.3 points. The majority of patients were admitted for blunt trauma (85.1%). The outcome was measured by hospital (HLOS) and ICU (ILOS) lengths of stay, duration of mechanical ventilation, infection rate, and mortality rate. RESULTS: A total of 330 open and 310 percutaneous tracheostomies were performed. A total of 36 SSIs (5.3%) were found. Patients who underwent percutaneous tracheostomy had a statistically significantly lower rate of SSI (3.4%) than the open surgery group (7%) (p=0.04). There was no difference in HLOS, ILOS, ventilator days, or mortality rate. CONCLUSION: To our knowledge, this is the largest study of the benefit of percutaneous tracheostomy in a critically injured trauma population. The risk of SSI is significantly lower after percutaneous than open tracheostomy.

Complex wounds and their management.

Complex wounds present a challenge to both the surgeon and patient in operative management, long-term care, cosmetic outcome, and effects on lifestyle, self-image, and general health. Each patient with complex wounds usually manifests multiple risk factors for their development. This article focuses on complex wounds involved with traumatic and orthopedic blunt or penetrating injuries, particularly in the extremities, as well as massive soft tissue infections including necrotizing fasciitis, gas gangrene, and Fournier gangrene. The principles of management of complex wounds involve assessing the patient's clinical status and the wound itself, appropriate timing of intervention, providing antibiotic therapy when necessary, and planning and executing surgical therapy, including the establishment of a clean wound bed and closure/reconstructive strategies.

Methicillin resistant Staphylococcus aureus infection in descending necrotizing mediastinitis from retropharyngeal perforation: a rare event.

BACKGROUND: Descending necrotizing mediastinitis is a rare but serious infection of the interpleural spaces and mediastinal connective tissue from the cervical region to the diaphragm that spreads rapidly along fascial planes. CASE: This report describes an unusual presentation of descending necrotizing mediastinitis in an otherwise healthy 25-year-old woman infected with methicillin-resistant Staphylococcus aureus, whose management required open sternotomy with frequent debridement. CONCLUSION: The mainstays of descending necrotizing mediastinitis management are early diagnosis, aggressive surgical debridement and drainage, and appropriate antibiotic therapy.