Robotic repair of traumatic bronchial disruption: A minimally invasive and multi-disciplinary approach to a complex constellation of injuries.

Bronchial disruption is a catastrophic consequence of blunt thoracic trauma with high pre-hospital lethality. This injury is classically managed through a large thoracotomy incision to facilitate adequate exposure for open repair. Here, we describe a case of complete bronchus intermedius disruption following a motor vehicle accident that was repaired via robotic thoracoscopy. The patient sustained multi-system trauma, including a grade III liver laceration, an innominate artery pseudoaneurysm, and femoral condyle fracture, all of which required systematic intervention and multi-disciplinary coordination to best facilitate this patient's care. This patient recovered well from his multiple injuries and was discharged after an uneventful post-operative course.

The Unrecognized Epidemic of Electronic Cigarette Burns.

Electronic cigarettes (e-cigarettes) are novel battery-operated devices that deliver nicotine as an inhaled aerosol. They originated from China in 2007 and their use has rapidly increased worldwide in the past decade, yet they remain largely unregulated. Reports of injuries associated with their use have appeared as unusual events in the news media and as case reports in the medical literature. This study was undertaken to explore e-cigarettes as a mechanism of burn injury. Referral records to three burn centers from January 2007 to July 2016 were searched to identify patients with injuries caused by e-cigarettes. Data were gathered from the electronic medical records (EMRs) of patients referred within the most recent 18 months. Thirty patients with burns resulting from e-cigarettes were identified. Twenty-nine were referred within the most recent 18 months. Only one was referred in the preceding 8 years. An explosion was identified by the patient as the inciting event in 26 of the 30 injuries (87%). Explosion of an isolated battery while it was carried on personal attire was reported in 10 cases. Explosion of a fully assembled e-cigarette was described in 16 cases. In seven of these 16 cases, the explosion occurred while the device was idle and carried on personal attire. In the other nine cases, the explosion occurred while the device was being operated. No injury occurred while batteries were charging. The mean age of injured patients was 30 years. The mean size of burn was 4% TBSA. The thighs, hands, and genitalia were the most common sites of injury. Twenty-six patients required hospital admission and nine required surgery. Serious burn injuries from e-cigarettes have recently occurred with greatly increased frequency. The increase in injuries appears out of proportion to the increased popularity of e-cigarettes. The most common pattern of injury is explosion when either the idle device or its batteries are carried on personal attire.

Combat versus civilian open tibia fractures: the effect of blast mechanism on limb salvage.

BACKGROUND: This study compares open tibia fractures in US Navy and US Marine Corps casualties from the current conflicts with those from a civilian Level I trauma center to analyze the effect of blast mechanism on limb-salvage rates. METHODS: Data from the 28,646 records in the University of California San Diego Trauma Registry from 1985 to 2006 was compared with 2,282 records from the US Navy and US Marine Corps Combat Trauma Registry Expeditionary Medical Encounter Database for the period of March 2004 to August 2007. Injuries were categorized by Gustilo-Anderson (G-A) open fracture classification. Independent variables included age, gender, mechanism of injury including blast mechanisms, shock, blood loss, prehospital time, procedures, Injury Severity Score, length of stay, and Mangled Extremity Severity Score (MESS). Dependent variables included early or late amputation and mortality. RESULTS: The civilian group had 850 open tibia fractures with 45 amputations; the military group had 21 amputation patients (3 bilateral) in 115 open tibia fractures. Military group patients were more severely injured, more likely have hypotension, and had a higher amputation rate for G-A IIIB and IIIC fractures then civilian group patients. Blast mechanism was seen in the majority of military group patients and was rare in the civilian group. MESS scores had poor sensitivity (0.46, 95% confidence interval: 0.29-0.64) in predicting the need for amputation in the civilian group; in the military group sensitivity was better (0.67, 95% confidence interval: 0.43-0.85), but successful limb salvage was still possible in most cases with an MESS score of ≥7 when attempted. CONCLUSION: Despite current therapy, limb salvage for G-A IIIB and IIIC grades are significantly worse for open tibia fractures as a result of blast injury when compared with typical civilian mechanisms. MESS scores do not adequately predict likelihood of limb salvage in combat or civilian open tibia fractures.

A phage-targeting strategy for the design of spatiotemporal drug delivery from grafted matrices.

BACKGROUND: The natural response to injury is dynamic and normally consists of complex temporal and spatial cellular changes in gene expression, which, when acting in synchrony, result in patent tissue repair and, in some instances, regeneration. However, current therapeutic regiments are static and most rely on matrices, gels and engineered skin tissue. Accordingly, there is a need to design next-generation grafting materials to enable biotherapeutic spatiotemporal targeting from clinically approved matrices. To this end, rather then focus on developing completely new grafting materials, we investigated whether phage display could be deployed onto clinically approved synthetic grafts to identify peptide motifs capable of linking pharmaceutical drugs with differential affinities and eventually, control drug delivery from matrices over both space and time. METHODS: To test this hypothesis, we biopanned combinatorial peptide libraries onto different formulations of a wound-healing matrix (Integra®) and eluted the bound peptides with 1) high salt, 2) collagen and glycosaminoglycan or 3) low pH. After three to six rounds of biopanning, phage recovery and phage amplification of the bound particles, any phage that had acquired a capacity to bind the matrix was sequenced. RESULTS: In this first report, we identify distinct classes of matrix-binding peptides which elute differently from the screened matrix and demonstrate that they can be applied in a spatially relevant manner. CONCLUSIONS: We suggest that further applications of these combinatorial techniques to wound-healing matrices may offer a new way to improve the performance of clinically approved matrices so as to introduce temporal and spatial control over drug delivery.

Beach and campfire burns: a site of pleasure and tragedy.

Seasonal use of campground bonfires and beach fire pits is a common practice. A sense of fellowship is derived from this experience. Unfortunately, many people are injured by these fires. It was the objective of this study to quantify and better identify those factors that lead to these injuries. A retrospective review of patients injured from a beach or campground, fire pits, or bonfires was conducted using data from a regional burn registry (1999-2007). Patients sustaining burns serious enough to merit admission were included in this study. Demographic information, circumstances surrounding the injury events, size and location of burn, operative procedures, length of stay, and outcomes were analyzed. There were 3083 patients admitted to the burn center of which 241 met criteria for inclusion in this study. Each year, between 12 and 39 patients were injured by this mechanism; 84% were men. Ages fell into two discrete groups; young age (2-9 years) and adults (18-64 years). Alcohol was a contributing factor in 60.6% of adult burns. The areas of burn, by location and rank order include upper extremities (35.3% of patients), thorax/abdomen/buttocks (32.8%), lower extremities (30.7%), and hands (29.5%). The mean TBSA was 6.1% (1-100%). Approximately 80.7% of the patients sustained combination partial- and full-thickness burns whereas, 4.2% were only partial and 5.1% only full-thickness burns; 36.6% of the patients required skin grafting. The mean length of stay was 8.6 days. There were four fatalities including one suicide. Burn injuries from recreational bonfires remain a problem in our community. Beaches were the most common location for these injuries. Universal safeguards to prevent burn injury should be implemented, including designated areas for fires, protective mechanical barriers to keep children and adults from inadvertently walking or falling into the fire pit. Disposal areas for hot coals from fires or charcoal grills must be furnished and usage strictly enforced. Consideration of the elimination of free-standing beach bonfires should be considered.

The noninvasive, quantitative, in vivo assessment of adenoviral-mediated gene delivery in skin wound biomaterials.

Because there are few reports using gene delivery in clinically-approved synthetic matrices, we examined the feasibility of using a noninvasive imaging system to study the kinetics of luciferase gene expression when delivered in an adenoviral vector. Using a mouse model of full thickness injury, we quantified the kinetics of gene expression, determined the optimal dose of particle delivery, and established the temporal importance of drug delivery in obtaining optimal gene expression. Specifically, we found that the ideal time to deliver adenovirus to a graft is during the early phase of graft wound closure (days 0-3 post-operatively) for a peak of gene expression to occur 7 days after delivery. Under these conditions, there is a saturating dose of 6 x 10(8) adenoviral particles per graft. In light of these findings, we examined whether the efficacy of delivery could be increased by modulating the composition of the grafts. When a collagen gene-activated matrix (GAM) containing basic fibroblast growth factor (FGF2) was compared to matrix alone, a significant increase in gene expression is observed when identical amounts of vector are delivered (p<0.05). Taken together, these results show how a noninvasive and quantitative assessment of gene expression can be used to optimize gene delivery and that the composition of matrices can dramatically influence gene expression in the wound bed.

Reversal of anticoagulation in trauma: a North-American survey on clinical practices among trauma surgeons.

BACKGROUND: Recent studies addressing reversal of anticoagulation in trauma have reported conflicting results. We hypothesized that current clinical practice is variable throughout North America. METHODS: We surveyed 100 trauma surgeons to obtain information regarding variability in current clinical practice. RESULTS: Seventy-five of 100 trauma surgeons surveyed responded, and the majority (98.7%) agreed that preinjury anticoagulation poses problems in trauma management that include bleeding, increased complications, and mortality. Nine participants (12.2%) had a protocol addressing reversal of anticoagulation in their institution. Most use fresh frozen plasma based on the type and location of injury, initial international normalized ratio (INR), and targeted INR value. Fresh frozen plasma was consistently used in patients with positive head computed tomographic scans, hemothorax, nonoperative solid organ injury management, pelvic and long bone fractures, and any operative intervention. Practice inconsistencies were found in patients with loss of consciousness and normal head computed tomographic scan, facial and rib fractures, and pulmonary contusion. Significant variability was found in the reversal INR target. One third of participants agreed that anticoagulation could be restarted 5 to 7 days after craniotomy; one sixth would do so within 72 hours and one third would wait 10 or more days. Most agreed that anticoagulation could be restarted 3 days after chest, abdominal, and orthopedic operations. Significant inconsistencies were also observed regarding when to restart anticoagulation in closed head injury patients treated nonoperatively. CONCLUSION: On the basis of the discrepancies observed in this survey, a clinical trial addressing specific injury location and patterns, INR thresholds, and type of strategy to achieve reversal is warranted, and most would agree to participate.

The use of recombinant factor VIIa for severe intractable bleeding during spine surgery.

STUDY DESIGN: A report on the use of recombinant activated factor VII in 4 patients who developed severe intractable bleeding and coagulopathy during spine surgery. OBJECTIVE: To describe the role of recombinant activated factor VII for hemostasis during spine surgery. SUMMARY OF BACKGROUND DATA: Recombinant activated factor VII is indicated for the treatment of bleeding episodes and the prevention of bleeding during surgery in patients with hemophilia with inhibitors. However, its use in adults undergoing spine surgery has not yet been reported. METHODS: Four patients who underwent multilevel spine surgery through an anterior approach incurred massive bleeding and subsequently became coagulopathic. Standard hemostatic techniques were performed and blood products were transfused. Persistence of the bleeding prompted the use of recombinant activated factor VII. RESULTS: Treatment with recombinant activated factor VII led to an improvement in prothrombin time and partial thromboplastin time and brought about cessation in gross, nonsurgical bleeding intraoperatively. No clinically relevant thrombotic complications related to the drug were noted. CONCLUSIONS: Recombinant activated factor VII is promising as an adjunctive hemostatic agent for patients with perioperative bleeding problems during spine surgery. Efficacy is seen even at low doses.

The epidemiology of serious and fatal injury in San Diego County over an 11-year period.

BACKGROUND: Analysis of the mechanism and severity of injury over time may permit a more focused planning of acute care and trauma prevention programs. METHODS: A retrospective, population-based study examining severe traumatic injury in a single county was undertaken. Three overlapping data sets were used to form a composite injury data set. RESULTS: There were 55,664 patients included in the study. A total of 40,897 (73.5%) patients survived and 14,767 (26.5%) died. Of those patients who died, 8,910 (60.3%) died in the field and were not transported to a trauma center. There was an increase in the mean age of all trauma victims (3 years) and an increase of 5 years in fatally injured patients. The mean Injury Severity Score decreased from 14.7 to 11.6 (p < 0.01); however, Injury Severity Score for fatal patients remained constant (39.7). The overall injury rate remained unchanged (195 per 10(5)), whereas the fatal injury rate decreased by 22% (45.9 per 10(5)) over the 11-year study period. The leading cause of injury was motor vehicle crash, followed by assault. The leading cause of fatal injury was suicide, followed by homicide. CONCLUSION: A combination of three independent injury data sources generated a composite data set of serious and fatal injury. This regional injury analysis was the most comprehensive overview of injury in our region. Important observations included the following: there has been no change in the overall incidence of severe injury within our county; the incidence of fatal traumatic injury has significantly decreased; the leading causes of nonfatal injury do not correlate with the rank order of fatal injury; intentional injury was the leading cause of injury deaths; and scene fatalities represent a poorly studied group of patients who may benefit from primary prevention and injury control research.

Does sexual dimorphism influence outcome of traumatic brain injury patients? The answer is no!

BACKGROUND: The protective effect of female gender on posttraumatic mortality or acute complications after traumatic brain injury (TBI) has been postulated. This effect might be seen if TBIs were analyzed by severity. To assess potential gender effects, we performed a retrospective case-controlled study matching female patients to male counterparts for overall injury severity; hemodynamic status at admission; and head, chest, and abdomen Abbreviated Injury Scale score. METHODS: All female patients sustaining TBI admitted over 6.5 years were reviewed. An overall comparison between women (n = 914) and their male matched counterparts (n = 916) was performed. Patients were then stratified according to the severity of head injury on the basis of admission Glasgow Coma Scale (GCS) score into three groups: group 1, GCS score of 13 to 15 (788 female patients, 769 male patients); group 2, GCS score of 9 to 12 (40 female patients, 42 male patients); and group 3, GCS score < 9 (63 female patients, 87 male patients). Cohorts were compared for mortality or the development of acute respiratory distress syndrome, pneumonia, and systemic sepsis using standard definitions. A subset analysis was performed excluding patients with age above 50 years (789 women, 811 men) to exclude the effects of menopause on the results. RESULTS: There was no statistically significant difference in outcome overall or in subset analysis of mild (group 1), moderate (group 2), or severe (group 3) TBI. The exclusion of patients older than 50 years showed no protective effect of female gender on outcome. CONCLUSION: Gender does not play a role in posttraumatic mortality or in the incidence of acute complications after any degree of TBI.

Female gender does not protect blunt trauma patients from complications and mortality.

BACKGROUND: The protective effect of gender on posttraumatic mortality or acute complications (acute respiratory distress syndrome [ARDS], pneumonia, and sepsis) is unclear. To assess potential effects, we performed a retrospective case-controlled study, matching patients for injury factors including overall severity (Injury Severity Sscore), the presence of shock (systolic blood pressure [SBP] < 90 mm Hg) at admission, and the presence of closed head injury (CHI). METHODS: All female patients admitted over a 61/2-year period were reviewed and divided into four groups: group 1, SBP > 90, no CHI; group 2, SBP < 90, no CHI; group 3, SBP > 90, with CHI; and group 4, SBP < 90, with CHI. Each cohort was matched one to one with an equivalent male counterpart. Cohorts were compared for mortality or the development of ARDS, pneumonia, and systemic sepsis using standard definitions. RESULTS: Overall, 1,229 female patients were identified for study. The average Injury Severity Score was 16.3 and overall mortality was 2.7%. Analysis of the groups described previously demonstrated no statistically significant difference in the development of ARDS, pneumonia, systemic sepsis, or overall mortality between male and female patients including patients presenting with shock, CHI, or both. CONCLUSION: We conclude that female gender offers no protection from the development of ARDS, pneumonia, sepsis, or decreased mortality after blunt trauma.