Mass casualty incident training in a resource-limited environment.

BACKGROUND: A mass casualty incident (MCI) occurs when a disaster involves a large number of injured people, overwhelming the capacity of local emergency medical services. This article describes the planning and execution of a MCI workshop created for use in Sierra Leone, a low-income country. METHODS: Surgeons OverSeas (SOS), an international non-governmental organization, partnered with the Sierra Leone Office of National Security and Connaught Hospital to develop a 2-day MCI workshop designed to meet needs specific to their resource-limited environment. Pre- and post-course questionnaires were completed. Day 1 consisted of didactic teaching focused on triage principles, resource deployment, communication/operations and tabletop drills. On day 2 a mock MCI with performance assessments by independent observers was staged, followed by post-event debriefing. RESULTS: Pre-course questionnaires identified the following deficits: lack of triage training (29 per cent), and transportation (19 per cent) and communication (17 per cent) shortfalls. Only 11 per cent could define MCI. During the drill, on-scene and hospital triage was accurate in 28 (93 per cent) and 23 (77 per cent) of 30 casualties respectively. Systematic deficiencies identified included: transport issues, no accurate system for tracking victims, and undersized triage areas. Participants identified interagency coordination (63 of 136 responses; 46·3 per cent) and triage (32 of 136; 23·5 per cent) as the most valuable lessons learned. CONCLUSION: Pre-existing MCI programmes based on first-world logistics do not account for challenges encountered when caring for casualties in resource-constrained settings. Logistical training, rather than medical skills or knowledge, was identified as the educational priority.

Increased platelet:RBC ratios are associated with improved survival after massive transfusion.

BACKGROUND: Several recent military and civilian trauma studies demonstrate that improved outcomes are associated with early and increased use of plasma-based resuscitation strategies. However, outcomes associated with platelet transfusions are poorly characterized. We hypothesized that increased platelet:red blood cells (RBC) ratios would decrease hemorrhagic death and improve survival after massive transfusion (MT). METHODS: A transfusion database of patients transported from the scene to 22 Level I Trauma Centers over 12 months in 2005 to 2006 was reviewed. MT was defined as receiving ≥ 10 RBC units within 24 hours of admission. To mitigate survival bias, 25 patients who died within 60 minutes of arrival were excluded from analysis. Six random donor platelet units were considered equal to a single apheresis platelet unit. Admission and outcome data associated with the low (>1:20), medium (1:2), and high (1:1) platelet:RBC ratios were examined. These groups were based on the median value of the tertiles for the ratio of platelets:RBC units. RESULTS: Two thousand three hundred twelve patients received at least one unit of blood and 643 received an MT. Admission vital signs, INR, temperature, pH, Glasgow Coma Scale, Injury Severity Score, and age were similar between platelet ratio groups. The average admission platelet counts were lower in the patients who received the high platelet:RBC ratio versus the low ratio (192 vs. 216, p = 0.03). Patients who received MT were severely injured, with a mean (± standard deviation) Injury Severity Score of 33 ± 16 and received 22 ± 15 RBCs and 11 ± 14 platelets within 24 hours of injury. Increased platelet ratios were associated with improved survival at 24 hours and 30 days (p < 0.001 for both). Truncal hemorrhage as a cause of death was decreased (low: 67%, medium: 60%, high: 47%, p = 0.04). Multiple organ failure mortality was increased (low: 7%, medium: 16%, high: 27%, p = 0.003), but overall 30-day survival was improved (low: 52%, medium: 57%, high: 70%) in the high ratio group (medium vs. high: p = 0.008; low vs. high: p = 0.007). CONCLUSION: Similar to recently published military data, transfusion of platelet:RBC ratios of 1:1 was associated with improved early and late survival, decreased hemorrhagic death and a concomitant increase in multiple organ failure-related mortality. Based on this large retrospective study, increased and early use of platelets may be justified, pending the results of prospective randomized transfusion data.

Are temporary inferior vena cava filters really temporary?

BACKGROUND: Despite significant risk for venous thromboembolism, severely injured trauma patients often are not candidates for prophylaxis or treatment with anticoagulation. Long-term inferior vena cava (IVC) filters are associated with increased risk of postphlebitic syndrome. Retrievable IVC filters potentially offer a better solution, but only if the filter is removed; our hypothesis is that the most of them are not. METHODS: This retrospective study queried a level I trauma registry for IVC filter insertion from September 1997 through June 2004. RESULTS: One IVC filter was placed before the availability of retrievable filters in 2001. Since 2001, 27 filters have been placed, indicating a change in practice patterns. Filters were placed for prophylaxis (n = 11) or for therapy in patients with pulmonary embolism or deep vein thrombosis (n = 17). Of 23 temporary filters, only 8 (35%) were removed. CONCLUSIONS: Surgeons must critically evaluate indications for IVC filter insertion, develop standard criteria for placement, and implement protocols to ensure timely removal of temporary IVC filters.

Stapled versus sutured gastrointestinal anastomoses in the trauma patient: a multicenter trial.

BACKGROUND: Construction of gastrointestinal anastomoses utilizing stapling devices has become a familiar procedure. In elective surgery, studies have shown no significant differences in complications between stapled and sutured anastomoses. Controversy has recently arisen regarding the accurate incidence of complications associated with anastomoses in the trauma patient. The objective of this multi-institutional study was to determine whether the incidence of postoperative complications differs between stapled and sutured anastomoses following the emergent repair of traumatic bowel injuries. METHODS: Using a retrospective cohort design, all trauma registry records from five Level I trauma centers over a period of 4 years were reviewed. RESULTS: A total of 199 patients with 289 anastomoses were identified. A surgical stapling device was used to create 175 separate anastomoses, while a hand-sutured method was employed in 114 anastomoses. A complication was defined as an anastomotic leak verified at reoperation, an intra-abdominal abscess, or an enterocutaneous fistula. The mean abdominal Abbreviated Injury Scale score and Injury Severity Score were similar in the two cohort groups. Stapling and suturing techniques were evenly distributed in both small and large bowel repairs. Seven of the total 175 stapled anastomoses and none of the 114 hand-sewn anastomoses resulted in a clinically significant leak requiring reoperation (RR = undefined, 95% CI 1.08-infinity, p = 0.04). Each anastomotic leak occurred in a separate individual. Nineteen stapled anastomoses and four sutured anastomoses were associated with an intra-abdominal abscess (RR = 2.7, 95% CI 0.96-7.57, p = 0.04). Enterocutaneous fistula formation was not statistically associated with either type of anastomoses (stapled cohort = 3 of 175 and sutured cohort = 2 of 114). Overall, 22 (13%) stapled anastomoses and 6 (5%) sutured anastomoses were associated with an intra-abdominal complication (RR = 2.08, 95% CI 0.89-4.86, p = 0.076). CONCLUSION: Anastomotic leaks and intra-abdominal abscesses appear to be more likely with stapled bowel repairs compared with sutured anastomoses in the injured patient. Caution should be exercised in deciding to staple a bowel anastomosis in the trauma patient.

Complications of surgical feeding jejunostomy in trauma patients.

OBJECTIVE: To determine the complication rate of feeding jejunostomy (FJ) performed as an adjunct to trauma celiotomy. METHODS: Retrospective analysis of 222 patients from January of 1988 to May of 1998. RESULTS: Thirty-seven total FJ-related complications occurred in 22 patients (10%). Major FJ-related complications occurred in nine patients (4%): two small bowel perforations, two small bowel volvuli with infarction, two intraperitoneal leaks, and three small bowel necroses. Patients suffering major FJ-related complications were similar to those without complications, except for the FJ type. Patients with major FJ-related complications were more likely to have had a Witzel tube jejunostomy than a needle catheter jejunostomy (p = 0.03). Three deaths were related to major FJ complications, for a FJ-related mortality rate of 1.4%. CONCLUSIONS: FJ has a major complication rate of 4% in severely injured patients. Major complications occur more frequently with larger, Witzel-type tubes. Needle catheter jejunostomy appears to be a safer method of surgical jejunal access in trauma patients.

Near-infrared spectroscopy: a potential method for continuous, transcutaneous monitoring for compartmental syndrome in critically injured patients.

BACKGROUND: Near-infrared spectroscopy (NIRS) noninvasively measures tissue O2 saturation (StO2), and has been proposed as a means of monitoring for compartmental syndrome (CS). However, its specificity in hypoxemic, hypotensive patients with severely reduced systemic oxygen delivery has not been tested. We hypothesized that NIRS can differentiate muscle ischemia caused by shock from ischemia caused by CS. METHODS: Nine swine were anesthetized and an NIRS probe placed over the anterolateral compartment of the hind leg. Compartment pressure was also measured. A nerve stimulator was placed over the peroneal nerve, and CS was defined as loss of dorsiflexion twitch. At 30-minute sequential intervals, mean arterial blood pressure was reduced to 60% of baseline (phlebotomy), fraction of inspired oxygen was reduced to 0.15, and compartment pressure was increased in one limb by interstitial albumin infusion until CS occurred. RESULTS: Hypotension combined with hypoxemia reduced StO2 from 82+/-4% to 66+/-10%. CS further reduced StO2 to 16+/-12% (p<0.0001). During hypotension + hypoxemia + CS, control limb StO2 was 70+/-15% (p = 0.0002 vs. experimental limb). CONCLUSION: NIRS detects muscle ischemia caused by CS despite severe hypotension and hypoxemia, making it potentially useful in critically injured, unstable patients.

Stapled versus sutured gastrointestinal anastomoses in the trauma patient.

BACKGROUND: Construction of gastrointestinal anastomoses by using stapling devices has become a familiar procedure. Most studies have shown no significant differences in complication rates between stapled and sutured anastomoses performed during elective surgery. To date, no study has evaluated the incidence of complications of stapled anastomoses in the trauma patient. The purpose of our study was to determine whether the incidence of postoperative complications differs between stapled and sutured anastomoses after the emergent repair of traumatic bowel injuries. METHODS: A retrospective analysis of the medical and institutional trauma registry records of patients identified to have undergone a gastrointestinal anastomosis in a regional Level I trauma center over a 4-year period. RESULTS: A total of 84 patients with 118 gastrointestinal anastomoses were identified. A surgical stapling device was used to create 58 separate anastomoses, whereas a hand-sutured method was used in 60 anastomoses. A complication was defined as an anastomotic leak verified at reoperation. The ratio of blunt versus penetrating injuries, mean abdominal Abbreviated Injury Scale score, and Injury Severity Score were similar in the two groups. Stapling and suturing techniques were evenly distributed between small and large bowel repairs. Mean intensive care unit length of stay was comparable in both cohorts. However, inpatient length of stay was longer in patients with solely a stapled anastomosis compared with sutured anastomoses. Four of the 58 stapled anastomoses and none of the 60 hand-sewn anastomoses resulted in a clinically significant leak requiring reoperation (relative risk = undefined; 95% confidence interval, 1.14-infinity; p = 0.037). Each anastomotic leak occurred in a separate individual. The only death occurred in the stapled cohort secondary to peritonitis and subsequent sepsis. CONCLUSION: Anastomotic leaks seem to be associated with stapled bowel repairs compared with sutured anastomoses in the traumatically injured patient.

Does the face protect the brain? A case-control study of traumatic brain injury and facial fractures.

BACKGROUND: The relationship between facial fractures and traumatic brain injury is controversial. Some studies show an increased risk of brain injury with the presence of facial fractures while others claim that facial fractures protect against brain injury. OBJECTIVE: To examine the association between facial fractures and traumatic brain injuries. DESIGN: Case-control study. SETTING: Subjects were recruited from the emergency departments of 7 hospitals in the Seattle, Wash, area. PATIENTS: Three thousand eight hundred forty-nine injured bicyclists and 5 scene deaths were identified from March 1, 1992, to August 31, 1994, with complete data available on 3388 bicyclists. INTERVENTIONS: None. RESULTS: The study group was composed of 1602 cases with injuries to the head, face, or brain and 1540 control subjects. There were 203 bicyclists with traumatic brain injuries, of whom 62 had an identifiable intracranial injury and 141 suffered a concussion. A total of 81 patients sustained facial fractures. The odds ratio for the risk of intracranial injury associated with facial fractures after adjustment for significant confounders was 9.9 (95% confidence interval, 5.1-19.3). The effect was less strong but still present when all traumatic brain injuries including concussions were considered (odds ratio, 2; 95% confidence interval, 1.1-3.7). No association was found for concussion only. CONCLUSIONS: This study demonstrates no evidence that facial fractures help prevent traumatic brain injury. Data indicate that facial fractures are markers for increased risk of brain injury.

The epidemiology of thoracic aortic injuries in pedestrians.

BACKGROUND: Traumatic rupture of the thoracic aorta is recognized as a common cause of occupant death after rapid deceleration in motor vehicle collisions. The incidence of thoracic aorta rupture in pedestrian victims of vehicular collisions, however, is unknown. This study focuses on the epidemiology of injury to the thoracic aorta in pedestrian vehicular collisions. METHODS: We performed a retrospective analysis of all pedestrian fatalities and survivors of rupture of the thoracic aorta during a 6-year period at a regional Level I trauma center and medical examiner's office. RESULTS: There were 220 pedestrian fatalities during the study period. Laceration of the thoracic aorta was noted in 28 of the 220 pedestrian victims (12.7%). Two additional pedestrians survived laceration of the thoracic aorta, for a mortality of 94%. Hospital mortality was 66% (4 of 6). The comparative hospital mortality for patients with rupture of the thoracic aorta secondary to motor vehicle collision was 42%. CONCLUSION: The incidence of thoracic aortic injury in pedestrian fatalities of 12.7% is comparable with previous reports of motor vehicle collision fatalities. Because of the presence of increased associated injuries, pedestrians have a significantly higher mortality. Severely injured pedestrians are at a similar risk to motor vehicle occupants for a life-threatening injury of the thoracic aorta.