Management of lower extremity vascular injuries in pediatric trauma patients: 20-year experience at a level 1 trauma center.

Introduction: Pediatric lower extremity vascular injuries (LEVI) are rare but can result in significant morbidity. We aimed to describe our experience with these injuries, including associated injury patterns, diagnostic and therapeutic challenges, and outcomes. Methods: This was a retrospective review at a single level 1 trauma center from January 2000 to December 2019. Patients less than 18 years of age with LEVI were included. Demographics, injury patterns, clinical status at presentation, and intensive care unit (ICU) and hospital length of stay (LOS) were collected. Surgical data were extracted from patient charts. Results: 4,929 pediatric trauma patients presented during the 20-year period, of which 53 patients (1.1%) sustained LEVI. The mean age of patients was 15 years (range 1-17 years), the majority were Black (68%), male (96%), and most injuries were from a gunshot wound (62%). The median Glasgow Coma Scale score was 15, and the median Injury Severity Score was 12. The most commonly injured arteries were the superficial femoral artery (28%) and popliteal artery (28%). Hard signs of vascular injury were observed in 72% of patients and 87% required operative exploration. There were 36 arterial injuries, 36% of which were repaired with a reverse saphenous vein graft and 36% were repaired with polytetrafluoroethylene graft. One patient required amputation. Median ICU LOS was three days and median hospital LOS was 15 days. There were four mortalities. Conclusion: Pediatric LEVIs are rare and can result in significant morbidity. Surgical principles for pediatric vascular injuries are similar to those applied to adults, and this subset of patients can be safely managed in a tertiary specialized center. Level of evidence: Level IV, retrospective study.

Declaration on infection prevention and management in global surgery.

Surgeons in their daily practice are at the forefront in preventing and managing infections. However, among surgeons, appropriate measures of infection prevention and management are often disregarded. The lack of awareness of infection and prevention measures has marginalized surgeons from this battle. Together, the Global Alliance for Infections in Surgery (GAIS), the World Society of Emergency Surgery (WSES), the Surgical Infection Society (SIS), the Surgical Infection Society-Europe (SIS-E), the World Surgical Infection Society (WSIS), the American Association for the Surgery of Trauma (AAST), and the Panamerican Trauma Society (PTS) have jointly completed an international declaration, highlighting the threat posed by antimicrobial resistance globally and the need for preventing and managing infections appropriately across the surgical pathway. The authors representing these surgical societies call all surgeons around the world to participate in this global cause by pledging support for this declaration for maintaining the effectiveness of current and future antibiotics.

Umbilical cord mesenchymal stem cells for COVID-19 acute respiratory distress syndrome: A double-blind, phase 1/2a, randomized controlled trial.

Acute respiratory distress syndrome (ARDS) in COVID-19 is associated with high mortality. Mesenchymal stem cells are known to exert immunomodulatory and anti-inflammatory effects and could yield beneficial effects in COVID-19 ARDS. The objective of this study was to determine safety and explore efficacy of umbilical cord mesenchymal stem cell (UC-MSC) infusions in subjects with COVID-19 ARDS. A double-blind, phase 1/2a, randomized, controlled trial was performed. Randomization and stratification by ARDS severity was used to foster balance among groups. All subjects were analyzed under intention to treat design. Twenty-four subjects were randomized 1:1 to either UC-MSC treatment (n = 12) or the control group (n = 12). Subjects in the UC-MSC treatment group received two intravenous infusions (at day 0 and 3) of 100 ± 20 × 106 UC-MSCs; controls received two infusions of vehicle solution. Both groups received best standard of care. Primary endpoint was safety (adverse events [AEs]) within 6 hours; cardiac arrest or death within 24 hours postinfusion). Secondary endpoints included patient survival at 31 days after the first infusion and time to recovery. No difference was observed between groups in infusion-associated AEs. No serious adverse events (SAEs) were observed related to UC-MSC infusions. UC-MSC infusions in COVID-19 ARDS were found to be safe. Inflammatory cytokines were significantly decreased in UC-MSC-treated subjects at day 6. Treatment was associated with significantly improved patient survival (91% vs 42%, P = .015), SAE-free survival (P = .008), and time to recovery (P = .03). UC-MSC infusions are safe and could be beneficial in treating subjects with COVID-19 ARDS.

Using Telemedicine in Mass Casualty Disasters.

OBJECTIVES: The goal of this study is to test an implementation and examine users' perceptions about the usefulness of telemedicine in mass casualty and disaster settings and to provide recommendations for using telemedicine in these settings. METHODS: Ninety-two US Army Forward Surgical Team (FST) members participated in a high-fidelity mass casualty simulation at the Army Trauma Training Center (ATTC). Telemedicine was implemented into this simulation. RESULTS: Only 10.9% of participants chose to use telemedicine. The most common users were surgeons and nurses. Participants believed it somewhat improved patient care, attainment of expert resources, decision-making, and adaptation, but not the timeliness of patient care. Participants reported several barriers to using telemedicine in the mass casualty setting, including (1) confusion around team roles, (2) time constraints, and (3) difficultly using in the mass casualty setting (eg, due to noise and other conditions). CONCLUSIONS: There appear to be barriers to the use and usefulness of telemedicine in mass casualty and disaster contexts. Recommendations include designating a member to lead the use of telemedicine, providing telemedical resources whose benefits outweigh the perceived cost in lost time, and ensuring telemedicine systems are designed for the conditions inherent to mass casualty and disaster settings.

Trauma, Teams, and Telemedicine: Evaluating Telemedicine and Teamwork in a Mass Casualty Simulation.

INTRODUCTION: Mass casualty events (MASCAL) are on the rise globally. Although natural disasters are often unavoidable, the preparation to respond to unique patient demands in MASCAL can be improved. Utilizing telemedicine can allow for a better response to such disasters by providing access to a virtual team member with necessary specialized expertise. The purpose of this study was to examine the positive and/or negative impacts of telemedicine on teamwork in teams responding to MASCAL events. METHODS: We introduced a telemedical device (DiMobile Care) to Forward Surgical Teams during a MASCAL simulated training event. We assessed teamwork-related attitudes, behaviors, and cognitions during the MASCAL scenario through pre-post surveys and observations of use. Analyses compare users and nonusers of telemedicine and pre-post training differences in teamwork. RESULTS: We received 50 complete responses to our surveys. Overall, clinicians have positive reactions toward the potential benefits of telemedicine; further, participants report a significant decrease in psychological safety after training, with users rating psychological safety as significantly higher than non-telemedicine users. Neither training nor telemedicine use produced significant changes in cognitive and behavioral-based teamwork. Nonetheless, participants reported perceiving that telemedicine improved leadership and adaptive care plans. CONCLUSIONS: Telemedicine shows promise in connecting Forward Surgical Teams with nuanced surgical expertise without harming quality of care metrics (i.e., teamwork). However, we advise future iterations of DiMobile Care and other telemedical devices to consider contextual features of information flow to ensure favorable use by teams in time-intensive, high-stakes environments, such as MASCAL.

Kidney Salvage with Renal Artery Reconstruction after Blunt Traumatic Injury.

Renal artery injury from blunt abdominal trauma is a rare condition that is typically managed nonoperatively in hemodynamically stable patients. Revascularization can be achieved by stenting or surgical reconstruction of the renal artery. All attempts at revascularization should minimize warm ischemic time. Here, we discuss a patient postmotor vehicle accident who presented to Ryder Trauma Center with intra-abdominal bleeding. He underwent emergency exploratory laparotomy with splenectomy and abdominal packing. Postoperative CT scan revealed a contrast nonenhancing left kidney. The patient then returned to the operating room and underwent in situ renal artery reconstruction after >4 hours of warm ischemia. The patient survived a 2-month hospital course and was discharged home after prolonged in-hospital stay and intensive care treatment. Nuclear medicine scan showed scarring and atrophy of the reattached kidney with 16.3% of overall function attributed to the affected kidney. This case shows that patients with renal artery injury can be managed operatively with arterial reconstruction. Reducing warm ischemic time is critical in preserving kidney function.

Infrared thermography study as a complementary method of screening and prevention of muscle injuries: pilot study.

OBJECTIVE: To evaluate thermography application as a complementary method in preventing muscle injury in professional soccer players. METHODS: A longitudinal prospective study with 28 professional soccer players that composed a first division of Brazilian's soccer team between 2015 and 2016. In both seasons (2015 and 2016), muscle injuries were documented and classified in grade of severity, by ultrasound. During the following season (2016), infrared medical thermography was applied twice a week (48 hours after game) and if a difference of temperature was detected higher than 0.4°C, a prevention protocol was initiated. Muscle injuries in 2016 were documented. RESULTS: In 2015, the total number of muscle injuries was 11. In 2016, the total number of muscle injuries was 4 (p=0.04). It represents an incidence/player of 78% in 2015 and 28% in 2016, corresponding to a decrease of 64% in 2016. Seven players played in the first team in both seasons. Among these seven players, muscle injuries were reduced from 8 (in 2015) to 3 (in 2016)-a decrease of 63% in the season we used thermographic monitoring (p=0.06). CONCLUSION: The pilot data provide a promising catalyst for a rigorous RCT that could examine whether thermography can contribute to a muscle injury prevention programme.

Clinical and Neurophysiological Changes after Targeted Intrathecal Injections of Bone Marrow Stem Cells in a C3 Tetraplegic Subject.

High-level quadriplegia is a devastating condition with limited treatment options. Bone marrow derived stem cells (BMSCs) are reported to have immunomodulatory and neurotrophic effects in spinal cord injury (SCI). We report a subject with complete C2 SCI who received three anatomically targeted intrathecal infusions of BMSCs under a single-patient expanded access investigational new drug (IND). She underwent intensive physical therapy and was followed for >2 years. At end-point, her American Spinal Injury Association Impairment Scale (AIS) grade improved from A to B, and she recovered focal pressure touch sensation over several body areas. We conducted serial neurophysiological testing to monitor changes in residual connectivity. Motor, sensory, and autonomic system testing included motor evoked potentials (MEPs), somatosensory evoked potentials (SSEPs), electromyography (EMG) recordings, F waves, galvanic skin responses, and tilt-table responses. The quality and magnitude of voluntary EMG activations increased over time, but remained below the threshold of clinically obvious movement. Unexpectedly, at 14 months post-injury, deep inspiratory maneuvers triggered respiratory-like EMG bursting in the biceps and several other muscles. This finding means that connections between respiratory neurons and motor neurons were newly established, or unmasked. We also report serial analysis of MRI, International Standards for Neurological Classification of SCI (ISNCSCI), pulmonary function, pain scores, cerebrospinal fluid (CSF) cytokines, and bladder assessment. As a single case, the linkage of the clinical and neurophysiological changes to either natural history or to the BMSC infusions cannot be resolved. Nevertheless, such detailed neurophysiological assessment of high cervical SCI patients is rarely performed. Our findings indicate that electrophysiology studies are sensitive to define both residual connectivity and new plasticity.

Use of Telemedicine in Surgical Education: A Seven-Year Experience.

Uniformity in surgical education is challenging because surgical experience is based on rotation assignments. With work hour restrictions, the likelihood of residents being exposed to rare or unusual cases is diminished. Telemedicine may create a new learning paradigm for surgical education and supplement exposure for rare or unusual cases. A retrospective review (2010-2016) of teleconferences involving trauma centers worldwide was conducted. Participating hospitals included centers from underdeveloped countries to first world nations. Trauma cases were discussed among surgeons with different levels of experience and resource availability. Data collected included types of cases, anatomic injury patterns, hospital location, and the number of telemedicine centers and viewers participating. Seventy-three hospitals in 64 cities, spanning 27 countries, participated in 276 telemedicine grand round conferences. Cases discussed included penetrating trauma (47%), blunt trauma (42%), and blast injury (4%). The anatomic regions included were the thorax (28%), abdomen (26%), thoracoabdominal region (13%), neck (7%), and pelvis (6%). The most common injury discussed was vascular in nature (18%), followed by the lung, liver, diaphragm, and heart. The most common vascular lesion was in the aorta (18%), followed by the iliac vessels (8%) and the vena cava (7%). Telemedicine is a valuable tool, allowing the dissemination of diverse experiences. Most cases presented evaluated rare injuries or complex surgical approaches, which are not commonly seen on trauma sites. Learning different approaches in the management of complex trauma will make surgeons more prepared to deal with challenging cases.

Utilizing Telemedicine in the Trauma Intensive Care Unit: Does It Impact Teamwork?

BACKGROUND: The aim of this study was to examine the impact of a telemedical robot on trauma intensive care unit (TICU) clinician teamwork (i.e., team attitudes, behaviors, and cognitions) during patient rounds. MATERIALS AND METHODS: Thirty-two healthcare providers who conduct rounds volunteered to take surveys assessing teamwork attitudes and cognitions at three time periods: (1) the onset of the study, (2) the end of the 30-day control period, and (3) the end of the 30-day experimental period, which immediately followed the control period. Rounds were recorded throughout the 30-day control period and 30-day experimental period to observe provider behaviors. For the initial 30 days, there was no access to telemedicine. For the final 30 days, the rounding healthcare providers had access to the RP-7 robot (Intouch Health Inc., Santa Barbara, CA), a telemedical tool that can facilitate patient rounds conducted away from bedside. RESULTS: Using a one-tailed, one-way repeated-measures analysis of variance (ANOVA) to compare trust at Times 1, 2, and 3, there was no significant effect on trust: F(2, 14)=1.20, p=0.16. When a one-tailed, one-way repeated-measures ANOVA to compare transactive memory systems (TMS) at Times 1, 2, and 3 was conducted, there was no significant effect on TMS: F(2, 15)=1.33, p=0.15. We conducted a one-tailed, one-way repeated-measures ANOVA to compare team psychological safety at Times 1, 2, and 3, and there was no significant effect on team psychological safety: F(2,15)=1.53, p=0.12. There was a significant difference in communication between rounds with and without telemedicine [t(25)=-1.76, p<0.05], such that there was more task-based communication during telerounds. Telemedicine increased task-based communication and did not negatively impact team trust, psychological safety, or TMS during rounds. CONCLUSIONS: Telemedicine may offer advantages for some teamwork competencies without sacrificing the efficacy of others and may be adopted by intact rounding teams without hindering teamwork.

Usability of telepresence in a level 1 trauma center.

OBJECTIVES: Limited resources and the diminishing physician workforce in trauma require unique and innovative solutions. Our hypothesis is that telepresence by a remote physician is an appropriate application in an urban trauma setting. The purpose of this study is to assess user satisfaction and usability of a mobile telemedicine robot in trauma care. MATERIALS AND METHODS: A usability study of trauma patient assessments utilizing the Remote Presence-7 (RP-7) robot (InTouch Health, Santa Barbara, CA) with real-time, two-way communication between remote and local physicians was conducted at a Level 1 trauma center. Usability and acceptability was measured using survey questionnaires, open-ended feedback, and general observations. Comparisons were made between remote and local physician responses. RESULTS: One hundred fourteen patient encounters utilizing telepresence were performed. Remote and local physicians expressed a high level of satisfaction with the mobility (92% and 79%, respectively), communication (97% and 90%, respectively), and visual abilities (91% and 97%, respectively) of the RP-7 robot for remote consultation purposes. On average, 89% of remote and local physician participants rated their overall telemedicine experience as "excellent" or "above average." CONCLUSIONS: This study suggests that telepresence of a remote trauma surgeon may be a useful and functional adjunct in the trauma setting. Further development of these technologies could mitigate current and future concerns about gaps in rural and urban trauma care and critical care staffing shortages and during mass casualty or disaster scenarios.

Initial experience at a university teaching hospital from using telemedicine to promote education through video conferencing.

CONTEXT AND OBJECTIVE: Telehealth and telemedicine services are advancing rapidly, with an increasing spectrum of information and communication technologies that can be applied broadly to the population's health, and to medical education. The aim here was to report our institution's experience from 100 videoconferencing meetings between five different countries in the Americas over a one-year period. DESIGN AND SETTING: Retrospective study at Universidade Estadual de Campinas. METHODS: Through a Microsoft Excel database, all conferences in all specialties held at our institution from September 2009 to August 2010 were analyzed retrospectively. RESULTS: A total of 647 students, physicians and professors participated in telemedicine meetings. A monthly mean of 8.3 (± 4.3) teleconferences were held over the analysis period. Excluding holidays and the month of inaugurating the telemedicine theatre, our teleconference rate reached a mean of 10.3 (± 2.7), or two teleconferences a week, on average. Trauma surgery and meetings on patient safety were by far the most common subjects discussed in our teleconference meetings, accounting for 22% and 21% of the total calls. CONCLUSION: Our experience with telemedicine meetings has increased students' interest; helped our institution to follow and discuss protocols that are already accepted worldwide; and stimulated professors to promote telemedicine-related research in their own specialties and keep up-to-date. These high-technology meetings have shortened distances in our vast country, and to other reference centers abroad. This virtual proximity has enabled discussion of international training with students and residents, to increase their overall knowledge and improve their education within this institution.

Venous thromboembolism prophylaxis in patients with traumatic brain injury.

Traumatic brain injury (TBI) with associated intracranial hemorrhage (ICH) occurs frequently in trauma. Trauma patients are also at high risk of developing venous thromboembolic (VTE) complications. Low Molecular Weight Heparin (LMWH) is used in trauma patients as prophylaxis to reduce the risk of VTE events. It remains unclear, however, if LMWH is safe to use in trauma patients with ICH for fear of hematoma progression. The "Evidence-based telemedicine: trauma & acute care surgery (EBT-TACS)" Journal Club performed a critical appraisal of 3 recent and most relevant studies on timing to initiate, safety and use of LMWH in trauma patients with ICH. Specifically, we appraised a i) critical literature review on the topic, ii) a multicenter, retrospective cohort study assessing the safety of LMWH in trauma patients with ICH and iii) a randomized, pilot study assessing the feasibility and event rates of ICH progression, laying the groundwork for future randomized controlled trials (RCT) on the topic. Some results are conflicting, with the highest level of evidence being the pilot RCT demonstrating the safety for early use of LMWH in TBI with ICH. Much of this research, however, was generated by a single center and consequently lacks external validity. Furthermore, clinical recommendations cannot be generated based on pilot studies. Evidence-based guidelines and recommendations could not be made at this time, until the completion of further studies on this challenging topic.

Enhancing trauma education worldwide through telemedicine.

Advances in information and communication technologies are changing the delivery of trauma care and education. Telemedicine is a tool that can be used to deliver expert trauma care and education anywhere in the world. Trauma is a rapidly-evolving field requiring access to readily available sources of information. Through videoconferencing, physicians can participate in continuing education activities such as Grand Rounds, seminars, conferences and journal clubs. Exemplary programs have shown promising outcomes of teleconferences such as enhanced learning, professional collaborations, and networking. This review introduces the concept of telemedicine for trauma education, and highlights efforts of programs that are utilizing telemedicine to unite institutions across the world.

Surgical telepresence: the usability of a robotic communication platform.

INTRODUCTION: The benefits of telepresence in trauma and acute surgical care exist, yet its use in a live, operating room (OR) setting with real surgical cases remains limited. METHODS: We tested the use of a robotic telepresence system in the OR of a busy, level 1 trauma center. After each case, both the local and remote physicians completed questionnaires regarding the use of the system using a five point Likert scale. For trauma cases, physicians were asked to grade injury severity according to the American Association for the Surgery of Trauma (AAST) Scaling System. RESULTS: We collected prospective, observational data on 50 emergent and elective cases. 64% of cases were emergency surgery on trauma patients, almost evenly distributed between penetrating (49%) and blunt injuries (51%). 40% of non-trauma cases were hernia-related. A varied distribution of injuries was observed to the abdomen, chest, extremities, small bowel, kidneys, spleen, and colon. Physicians gave the system high ratings for its audio and visual capabilities, but identified internet connectivity and crowding in the operating room as potential challenges. The loccal clinician classified injuries according to the AAST injury grading system in 63% (n=22) of trauma cases, compared to 54% (n=19) of cases by the remote physicians. The remote physician cited obstruction of view as the main reason for the discrepancy. 94% of remote physicians and 74% of local physicians felt comfortable communicating via the telepresence system. For 90% of cases, both the remote and local physicians strongly agreed that a telepresence system for consultations in the OR is more effective than a telephone conversation. CONCLUSIONS: A telepresence system was tested on a variety of surgical cases and demonstrated that it can be an appropriate solution for use in the operating room. Future research should determine its impact on processes of care and surgical outcomes.

Interruptions and distractions in the trauma operating room: understanding the threat of human error.

OBJECTIVE: To understand the human factor as a threat to the security of trauma patients in the operating room, bringing to the operating room some important rules already applied in the field of aviation. METHODS: The sample included 50 cases of surgical trauma patients prospectively collected by observers in shifts of 12 hours, for six months in a Level I trauma center in the United States of America. Information regarding the type of trauma, severity score and mortality were collected, as well as determinants of distractions / interruptions and the volume of noise in the operating room during surgery. RESULTS: There was an average of 60 interruptions or distractions during surgery, most often triggered by the movement of people in the room. In more severe patients (ISS> 45), subjected to damage control, the incidence of distractions was even greater. The average noise in the trauma surgery room was very high, close to the noise of a hair dryer. CONCLUSION: Interruptions and distractions are frequent and should be studied by the trauma surgeon to develop prevention strategies and lines of defense to minimize them and reduce their effects.

A review of ureteral injuries after external trauma.

INTRODUCTION: Ureteral trauma is rare, accounting for less than 1% of all urologic traumas. However, a missed ureteral injury can result in significant morbidity and mortality. The purpose of this article is to review the literature since 1961 with the primary objective to present the largest medical literature review, to date, regarding ureteral trauma. Several anatomic and physiologic considerations are paramount regarding ureteral injuries management. LITERATURE REVIEW: Eighty-one articles pertaining to traumatic ureteral injuries were reviewed. Data from these studies were compiled and analyzed. The majority of the study population was young males. The proximal ureter was the most frequently injured portion. Associated injuries were present in 90.4% of patients. Admission urinalysis demonstrated hematuria in only 44.4% patients. Intravenous ureterogram (IVU) failed to diagnose ureteral injuries either upon admission or in the operating room in 42.8% of cases. Ureteroureterostomy, with or without indwelling stent, was the surgical procedure of choice for both trauma surgeons and urologists (59%). Complications occurred in 36.2% of cases. The mortality rate was 17%. CONCLUSION: The mechanism for ureteral injuries in adults is more commonly penetrating than blunt. The upper third of the ureter is more often injured than the middle and lower thirds. Associated injuries are frequently present. CT scan and retrograde pyelography accurately identify ureteral injuries when performed together. Ureteroureterostomy, with or without indwelling stent, is the surgical procedure of choice of both trauma surgeons and urologists alike. Delay in diagnosis is correlated with a poor prognosis.

Is the FAST exam reliable in severely injured patients?

INTRODUCTION: Highly sensitive and accurate for the detection of injuries requiring intervention in haemodynamically unstable patients, FAST may underestimate intra-abdominal injuries in stable patients with blunt abdominal trauma. Diminished accuracy of ultrasound has been reported in different cohorts of multiple injured patients. We hypothesised that multiple injured patients with a high Injury Severity Score (ISS) will have a decreased accuracy of FAST for the assessment of blunt abdominal trauma. METHODS: Data from the trauma registry of a Level 1 trauma centre were retrospectively reviewed. All haemodynamically stable blunt trauma patients who underwent both FAST and CT scan of abdomen from January 1, 2000 to January 1, 2005 were included in the cohort. All patients were divided into three groups according to their ISS: Group 1 included patients with an ISS from 1 to 14, Group 2 included patients with an ISS from 16 to 24, and Group 3 consisted of patients with ISS>or=25. RESULTS: 3181 patients with blunt abdominal trauma included into the study were divided into the three groups according to the ISS. The mean ISS was 7.9+/-3.97, 19.6+/-2.48 and 41.3+/-11.95 in Groups 1, 2 and 3, respectively. The accuracy of ultrasound was 90.6% in the group of patients with the highest ISS (>or=25) compared with 97.5 and 97.1 for Groups 1 and 2 (p<0.001). Similarly, ultrasound had a significantly lower sensitivity, specificity, PPV and NPV for patients in Group 3 compared with the first two groups (p<0.001). There was a significantly lower sensitivity in Group 2 compared with Group 1 (p<0.001), but no differences in specificity, accuracy, PPV or NPV were demonstrated. CONCLUSION: Patients with high ISS are at increased risk of having ultrasound-occult injuries and have a lower accuracy of their ultrasound examination than patients with low and moderate ISS.