The worst-case scenario: Bridging repair with a biologic mesh in high-risk patients with very large abdominal wall hernias-a prospective multicenter study.

BACKGROUND: While modern techniques allow midline fascial closure for most abdominal hernias, a bridge repair with mesh may be the only alternative in very large defects. When the risk of infection is high, the use of prosthetic mesh is controversial. We aim to examine outcomes after bridge repair of very large abdominal hernias at high risk for postoperative infection with a second-generation biologic mesh. METHODS: Prospective, multicenter, single-arm study of patients with very large abdominal hernias who received bridge repair with a neonatal bovine dermis mesh. Primary outcome was hernia recurrence, as identified on computed tomography 1 year after the operation. Secondary outcomes included mesh laxity, surgical site occurrences, and any other mesh-related complications. Independent risk factors of the outcomes were determined by univariate and multivariable analyses. RESULTS: A total of 117 bridge repair patients were enrolled with a mean defect size of 442.5 ± 254.2 cm2. The patients were predominantly obese (mean body mass index 36.5 ± 10.5) and with multiple comorbidities (Charlson comorbidity index 3 ± 2.5). Hernia recurrence was identified in 24 (20.5%) patients. An infected mesh at the index operation was an independent predictor of hernia recurrence, whereas obesity was an independent predictor of the pooled endpoint of recurrence and mesh laxity. Surgical site occurrences were recorded in 36.8% of the patients, and no independent risk factors were identified. CONCLUSION: In patients with very large abdominal hernias and at high risk for postoperative infection, who cannot undergo midline fascial closure, a bridge repair with neonatal bovine dermis mesh offers an acceptable profile in terms of hernia recurrence and wound occurrences.

Continuous positive airway pressure with pressure support ventilation is effective in treating acute-onset bilateral recurrent laryngeal nerve palsy.

Acute bilateral recurrent laryngeal nerve injury leading to acute vocal cord paralysis (VCP) is a serious complication of head and neck surgery, often requiring emergent surgical intervention. Although well documented, its presentation may be sudden and unexpected, occurring despite lack of obvious intraoperative nerve injury. There is limited literature on airway management strategies for patients with acute bilateral VCP before attaining a secure airway. We report a case of acute VCP that was successfully treated with continuous positive airway pressure via facemask ventilation. This effective temporizing strategy allowed clinicians to plan and prepare for tracheostomy, minimizing potential complications.

Emergency cardiopulmonary bypass for massive pulmonary embolism occurring during nephrectomy.

We report a case of cardiac arrest secondary to pulmonary tumor embolization occurring in a patient undergoing nephrectomy for renal cell carcinoma with a tumor thrombus invading the inferior vena cava infrahepatically. Tumor embolization in such cases is very rare (1.5%), but if it occurs, mortality is 75%. In our case, resources were rapidly mobilized, and cardiopulmonary bypass was initiated for pulmonary embolectomy within 34 minutes of the cardiac arrest. The patient's trachea was extubated on postoperative day 1, and he was discharged home 9 days later neurologically intact. Excellent preoperative and intraoperative communication among all involved health care providers, as well as rapid mobilization of the available resources, played important roles in the patient's positive outcome.

MDCT quantification is the dominant parameter in decision-making regarding chest tube drainage for stable patients with traumatic pneumothorax.

It is commonly believed that the size of a pneumothorax is an important determinant of treatment decision, in particular regarding whether chest tube drainage (CTD) is required. However, the volumetric quantification of pneumothoraces has not routinely been performed in clinics. In this paper, we introduced an automated computer-aided volumetry (CAV) scheme for quantification of volume of pneumothoraces in chest multi-detect CT (MDCT) images. Moreover, we investigated the impact of accurate volume of pneumothoraces in the improvement of the performance in decision-making regarding CTD in the management of traumatic pneumothoraces. For this purpose, an occurrence frequency map was calculated for quantitative analysis of the importance of each clinical parameter in the decision-making regarding CTD by a computer simulation of decision-making using a genetic algorithm (GA) and a support vector machine (SVM). A total of 14 clinical parameters, including volume of pneumothorax calculated by our CAV scheme, was collected as parameters available for decision-making. The results showed that volume was the dominant parameter in decision-making regarding CTD, with an occurrence frequency value of 1.00. The results also indicated that the inclusion of volume provided the best performance that was statistically significant compared to the other tests in which volume was excluded from the clinical parameters. This study provides the scientific evidence for the application of CAV scheme in MDCT volumetric quantification of pneumothoraces in the management of clinically stable chest trauma patients with traumatic pneumothorax.

Emergent cricothyroidotomies for trauma: training considerations.

BACKGROUND: Emergent cricothyroidotomy remains an uncommon, but life-saving, core procedural training requirement for emergency medicine (EM) physician training. We hypothesized that although most cricothyroidotomies for trauma occur in the emergency department (ED), they are usually performed by surgeons. METHODS: We conducted a retrospective analysis of all emergent cricothyroidotomies for trauma presentations performed at 2 large level I trauma centers over 10 years. Operators and assistants for all procedures were identified, as well as mechanism of injury and patient demographics were examined. RESULTS: Fifty-four cricothyroidotomies were analyzed. Patients had a mean age of 50 years, 80% were male, and 90% presented as a result of blunt trauma. The most common primary operator was a surgeon (n = 47, 87%), followed by an emergency medical services (EMS) provider (n = 6, 11%) and an EM physician (n = 1, 2%). In all cases, except those performed by EMS, the operator or assistant was an attending surgeon. All EMS procedures resulted in serious complications compared with in-hospital procedures (P < .0001). CONCLUSIONS: (1) Prehospital cricothyroidotomy results in serious complications. (2) Despite the ubiquitous presence of EM physicians in the ED, all cricothyroidotomies were performed by a surgeon, which may present opportunities for training improvement.

Pain as an indication for rib fixation: a bi-institutional pilot study.

BACKGROUND: In trauma patients, open reduction and internal fixation of rib fractures remain controversial. We hypothesized that patients who have open reduction and internal fixation of rib fractures would experience less pain compared with controls and thus require fewer opiates. Further, we hypothesized that improved pain control would result in fewer pulmonary complications and decreased length of stay. METHODS: This is a retrospective bi-institutional matched case-control study. Cases were matched 1:2 by age, injury severity Score, chest abbreviated injury severity score, head abbreviated injury severity score, pulmonary contusion score, and number of fractured ribs. The daily total doses of analgesic drugs were converted to equianalgesic intravenous morphine doses, and the primary outcome was inpatient narcotic administration. RESULTS: Sixteen patients between July 2005 and June 2009 underwent rib fixation in 5 ± 3 days after injury using an average of 3 (1-5) metallic plates. Morphine requirements decreased from 110 mg ± 98 mg preoperatively to 63 ± 57 mg postoperatively (p = 0.01). There were no significant differences between cases and controls in the mean morphine dose (79 ± 63 vs. 76 ± 55 mg, p = 0.65), hospital stay (18 ± 12 vs. 16 ± 11 days, p = 0.67), intensive care unit stay (9 ± 8 vs. 7 ± 10 days, p = 0.75), ventilation days (7 ± 8 vs. 6 ± 10, p = 0.44), and pneumonia rates (31% vs. 38%, p = 0.76). CONCLUSION: The need for analgesia was significantly reduced after rib fixation in patients with multiple rib fractures. However, no difference in outcomes was observed when these patients were compared with matched controls in this pilot study. Further study is required to investigate these preliminary findings.

Hemostatic and pharmacologic resuscitation: results of a long-term survival study in a swine polytrauma model.

BACKGROUND: We have previously demonstrated that valproic acid (VPA), a histone deacetylase inhibitor, and spray-dried plasma (SDP) improve early survival after lethal hemorrhage and polytrauma, but their effect on long-term survival and organ function remains untested. METHODS: Yorkshire swine (n=27; 6-8/group) underwent a protocol simulating different phases of trauma care: (1) prehospital-rib fracture, soft-tissue injury, hemorrhage (50% blood volume), 30 minutes of shock, and infusion of 0.9% saline (3× shed blood); (2) early hospital/treatment-grade IV liver (partial amputation of the median lobe) and grade V splenic (transection of spleen into three pieces) injuries to simulate rupture of contained hematomas, followed by 30 minutes of uncontrolled hemorrhage. Animals were treated with (a) Hextend (6% hetastarch), (b) fresh whole blood (FWB), (c) SDP, and (d) VPA (300 mg/kg) plus Hextend. VPA was given during the prehospital phase, and the volumes of Hextend, FWB and SDP (reconstituted in water) matched shed blood; (3) repair/resuscitation-liver injury was controlled by suture control of the transected edge, and splenic injury was treated by partial splenectomy; 1 hour after repair of injuries, surviving animals were fully resuscitated with packed red blood cells; and (4) monitoring-survival was monitored for 7 days (primary endpoint), and blood samples were drawn serially to measure organ function. RESULTS: Only 25% of the Hextend-treated animals survived. Addition of VPA improved survival to only 50% (p=0.28), whereas treatment with SDP and FWB increased survival significantly to 83% and 100%, respectively (p<0.05). Surviving animals showed no long-term organ dysfunction, postoperative hemorrhage, and delayed complications. CONCLUSIONS: In a clinically relevant lethal polytrauma model, administration of SDP significantly improves survival without any long-term organ dysfunction or complications.

Development and testing of low-volume hyperoncotic, hyperosmotic spray-dried plasma for the treatment of trauma-associated coagulopathy.

BACKGROUND: Trauma-associated coagulopathy carries an extremely high mortality. Fresh-frozen plasma (FFP) is the mainstay of treatment; however, its availability in the battlefield is limited. We have already shown that lyophilized, freeze-dried plasma (FDP) reconstituted in its original volume can reverse trauma-associated coagulopathy. To enhance the logistical advantage (lower volume and weight), we developed and tested a hyperoncotic, hyperosmotic spray-dried plasma (SDP) product in a multiple injuries/hemorrhagic shock swine model. METHODS: Plasma separated from fresh porcine blood was stored as FFP or preserved as FDP and SDP. In in vitro testing, SDP was reconstituted in distilled water that was either equal (1 × SDP) or one-third (3 × SDP) the original volume of FFP. Analysis included measurements of prothrombin time (PT), partial thromboplastin time (PTT), fibrinogen levels, and activity of selected clotting factors. In in vivo testing, swine were subjected to multiple injuries (femur fracture and grade V liver injury) and hemorrhagic shock (60% arterial hemorrhage, with the "lethal triad" of acidosis, coagulopathy, and hypothermia) and were treated with FFP, FDP, or 3 × SDP (n=4-5/group). Coagulation profiles (PT, PTT, and thromboelastography) were measured at baseline, post-shock, post-crystalloid, treatment (M0), and during 4 hours of monitoring (M1-4). RESULTS: In vitro testing revealed that clotting factors were preserved after spray drying. The coagulation profiles of FFP and 1 × SDP were similar, with 3 × SDP showing a prolonged PT/PTT. Multiple injuries/hemorrhagic shock produced significant coagulopathy, and 3 × SDP infusion was as effective as FFP and FDP in reversing it. CONCLUSION: Plasma can be spray dried and reconstituted to one-third of its original volume without compromising the coagulation properties in vivo. This shelf-stable, low-volume, hyperoncotic, hyperosmotic plasma is a logistically attractive option for the treatment of trauma-associated coagulopathy in austere environments, such as a battlefield.

Successful selective nonoperative management of abdominal gunshot wounds despite low penetrating trauma volumes.

OBJECTIVE: To determine whether selective nonoperative management of abdominal gunshot wounds (AGSW) is safe in trauma centers with a low volume of penetrating trauma. DESIGN: Retrospective study. SETTING: Academic level 1 trauma center with approximately 10% penetrating trauma. PATIENTS: All patients with anterior and posterior AGSW (January 1, 1999, through December 31, 2009), excluding tangential injuries, transfers, and deaths in the emergency department. Patients with hemodynamic instability or peritonitis received an urgent laparotomy. The remaining patients had selective nonoperative management. A delayed laparotomy was offered for worsening symptoms or worrisome computed tomography findings. MAIN OUTCOME MEASURES: Hospital stay, complications, and mortality. RESULTS: Of 125 AGSW patients, 38 (30%) were initially managed by selective nonoperative management (25 of 99 anterior and 13 of 26 posterior AGSW patients). Seven selective nonoperative management patients received delayed laparotomy as late as 11 hours after admission. At the end, 30 of the 125 patients (24%) were successfully managed without an operation (20 of 99 anterior and 10 of 26 posterior AGSW patients). There were no predictors of delayed laparotomy and no complications or mortality attributed to it. Ten patients (8%) had a nontherapeutic laparotomy, and 3 of them developed complications. CONCLUSIONS: Selective nonoperative management of AGSW is feasible and safe in trauma centers with low penetrating trauma volumes. Nearly 1 in 4 AGSW patients does not need a laparotomy, and nontherapeutic laparotomies are associated with complications. The volume of AGSW per se should not be an excuse for routine laparotomies. These data become particularly important because penetrating trauma volumes are decreasing around the country.

Presenting blood pressure in traumatic brain injury: a bimodal distribution of death.

BACKGROUND: Recent research explores the relationship between vital signs on arrival to the emergency department and early outcomes. This work has not included traumatic brain injury (TBI). We aimed to evaluate the relationship of the initial emergency department systolic blood pressure (EDSBP) with outcome. METHODS: By using the National Trauma Data Bank (v7), we analyzed patients older than 16 years with isolated moderate to severe blunt TBI. TBI was defined by International Classification of Diseases--9th Rev diagnosis codes and Abbreviated Injury Scale scores. We determined mortality rates while controlling for age, gender, race, payment type, and injury severity using logistic regression. Survival analysis was performed to determine 3-day survival rates. Scores and rates were plotted against EDSBP. RESULTS: A total of 7,238 patients were included in the analysis. Plots of adverse outcomes versus EDSBP demonstrated bimodal distributions. The mortality curve had one inflection point at EDSBP 120 mm Hg, indicating higher mortality when blood pressures were lower than this threshold. Another inflection began at EDSBP 140 mm Hg. The mortality rate was 21% when EDSBP was <120 mm Hg, 9% when it was between 120 mm Hg and 140 mm Hg, and 19% when EDSBP was ≥140 mm Hg. Multivariate analysis demonstrated that patients presenting with an EDSBP of <120 mm Hg and ≥140 mm Hg were 2.7 (95% confidence interval =2.13,3.48) and 1.6 (95% confidence interval =1.32,1.96) times more likely to die, respectively, than those who presented with a EDSBP of 120 mm Hg to 140 mm Hg. CONCLUSIONS: Mortality in moderate to severe TBI has a bimodal distribution. Like hypotension, hypertension at hospital admission seems to be associated with increased mortality in TBI, even after controlling for other factors.

Predictors of bleeding from stable pelvic fractures.

HYPOTHESIS: Stable pelvic fractures (SPFs) that do not need operative fixation are only infrequently associated with significant bleeding (SigBleed). Our hypothesis is that simple indicators, easily detectable at the bedside, can alert the clinician about the likelihood of bleeding and the need for closer monitoring or early intervention in patients with SPFs. DESIGN: Retrospective review of medical records. SETTING: Academic level 1 trauma center. PATIENTS: The medical records of patients with SPFs admitted to our academic level 1 trauma center from January 1, 2002, to June 30, 2007, were reviewed. Stable pelvic fractures were defined as fractures not requiring external or internal fixation. SigBleed was defined as the need for blood transfusion and/or intervention for bleeding control within the first 24 hours after admission. The patients were divided into group A, which included patients without SigBleed; group B, which included patients with SigBleed of a nonpelvic cause; and group C, which included patients with SigBleed caused by the SPF. The 3 groups were compared by univariate and multivariate analysis. MAIN OUTCOME MEASURE: Significant bleeding from SPFs. RESULTS: Of 391 patients with SPFs, 280 (72%) were in group A, 90 (23%) were in group B, and 21 (5%) were in group C. Compared with group A patients, those in group C were older and had a lower hematocrit and systolic blood pressure on admission. They also had longer hospital stays and a higher mortality. The following independent predictors of SigBleed from SPF were identified: hematocrit of 30% or lower (odds ratio [OR], 43.93; 95% confidence interval [CI], 9.78-197.32; P < .001); presence of pelvic hematoma on computed tomographic scan (OR, 39.37; 95% CI, 4.58-338.41; P < .001); and systolic blood pressure of 90 mm Hg or lower (OR, 18.352; 95% CI, 1.98-169.87; P = .01). When all independent predictors were present, 100% of the patients had SigBleed; when all were absent, no one had SigBleed. CONCLUSIONS: The incidence of SigBleed due to SPFs is low (5% in this study) and independently predicted by an admission hematocrit of 30% or lower, the presence of a pelvic hematoma on computed tomographic scan, and systolic blood pressure of 90 mm Hg or lower.