Homemade Dart Attacks in Hawai'i.

Over a 4.5-year period (September 2014 to March 2019), 7 patients presented to the State's only Level I Trauma Center with penetrating injuries inflicted by homemade metallic darts. Previously described in Micronesia, these are the first domestic cases of assaults utilizing this type of weaponry. Retrospective chart review was conducted for all patients who presented to our institution with a dart injury within the study period. Details regarding demographics, imaging, and patient management were collected and described herein. All 7 patients were male with a median age of 24.6 years impaled with darts that penetrated through the deep muscle and tissue layers of the neck, torso, or extremity. Three patients required operative intervention and no mortalities were observed. The depth of penetration and proximity to vital structures highlight the potential for life-threatening injuries from these homemade darts.

Cookiecutter Shark-Related Injuries: A New Threat to Swimming Across the Ka'iwi Channel.

In a 5-month period in 2019, 3 long-distance swimmers sustained cookiecutter shark-related injuries while attempting to cross the Ka'iwi Channel between the Hawaiian Islands of O'ahu and Moloka'i. This report is the first case series of cookiecutter shark bites on live humans. A retrospective review of the State of Hawai'i Division of Aquatic Resources Shark Incidents List was conducted between March 1, 2019, and July 31, 2019. Trauma registry data and medical records were reviewed in patients treated for cookiecutter shark bites at The Queen's Medical Center in Honolulu, Hawai'i. All 3 patients sustained nonfatal cookiecutter shark bite circular wounds measuring between 8-13 cm in diameter. They were injured swimming over waters with depths of greater than 2000 feet at night. Patients had prolonged transport times to the emergency department (ED), averaging 73 minutes, due to their injuries occurring on the open water. All were hemodynamically stable upon ED arrival and did not require blood products. Tetanus toxoid was updated, and prophylactic antibiotic coverage, including doxycycline for Vibrio spp., was administered. Two of 3 patients were treated with operative management. Open water swimmers crossing the deep waters between the Hawaiian Islands at night are most at risk for cookiecutter shark bites. Wounds may penetrate down to and through the fascial level. Immediate life-saving hemorrhage control administered by personnel accompanying the swimmers on the open water is important for preventing morbidity and mortality. Antibiotic prophylaxis for marine bacteria is recommended.

Comparison of Shock Index With the Assessment of Blood Consumption Score for Association With Massive Transfusion During Hemorrhage Control for Trauma.

BACKGROUND: Hemorrhage is a leading cause of early mortality following trauma. A massive transfusion protocol (MTP) to guide resuscitation while bleeding is definitively controlled may improve outcomes. Prompts to initiate massive transfusion (MT) include shock index (SI) and the Assessment of Blood Consumption (ABC) score. OBJECTIVE: To compare SI with the ABC score for association with transfusion requirement, need for emergency hemorrhage interventions, and early mortality. METHODS: A retrospective cohort analysis of trauma MTP activations at our Level I trauma center was conducted from January 1, 2012, to December 31, 2016. The study data were obtained from the Trauma Registry and the blood bank. An SI cutoff of 1.0 was chosen for comparison with the positive ABC score. RESULTS: The study cohort included 146 patients. Shock index ≥ 1 had significant association with MT requirement (p = .002) whereas a positive ABC score did not (p = .65). More patients with SI ≥ 1 required bleeding control interventions (67% surgery, 47% interventional radiology) than patients having a positive ABC score (49% surgery, 29% interventional radiology). For geriatric patients who received MT, 65% had SI ≥ 1 but only 30% had a positive ABC score. Three-hour mortality following emergency department arrival was similar (60% SI ≥ 1, 62% positive ABC score). CONCLUSION: Shock index ≥ 1 outperformed a positive ABC score for association with MT requirement. Shock index is a simple tool registered nurses can independently utilize to anticipate MT.

Delayed Respiratory Failure After Blunt Chest Trauma.

BACKGROUND: Patient factors associated with delayed respiratory failure (DRF) after blunt chest trauma are not well documented. Earlier identification and closer monitoring may improve outcomes for these patients. The purpose of this study was to identify the prevalence and clinical predictors of DRF in patients after blunt chest trauma. MATERIALS AND METHODS: A retrospective review of adult patients admitted to a Level 1 trauma center after blunt chest trauma between January 1, 2009 and December 31, 2013, was conducted. Patients with early respiratory failure were compared to patients with DRF using Fisher's exact tests, chi square, and Student's t-tests. A P-value of <.05 was considered significant. RESULTS: 1299 patients had blunt chest trauma and at least 1 rib fracture, of which 830 met inclusion criteria. 5.8% of patients progressed to respiratory failure. Respiratory failure was delayed in 25% of these patients. DRF patients had significantly lower ISS (16.5 vs. 22.7, P = .04), more bilateral rib fractures (66.7% vs. 28.7%, P = .02) and fewer pulmonary contusions (16.7% vs. 50.0%, P = .04). DISCUSSION: Injury patterns, including bilateral rib fractures without pulmonary contusions and low but severe Injury Severity Score burden, may help identify high-risk patients who may benefit from closer monitoring and more aggressive therapy.

Shark-related injuries in Hawai'i treated at a level 1 trauma center.

BACKGROUND: Although rare, human-shark interactions can result in a wide spectrum of injuries. This is the first study to characterize shark-related injuries (SRIs) in Hawai'i. METHODS: This is a retrospective review of the State of Hawai'i Division of Aquatic Resources Shark Incidents List between January 1, 2009 and December 31, 2019. Trauma registry data and medical records of patients treated for SRIs at the only level 1 trauma center in Hawai'i were reviewed. RESULTS: Sixty-one patients sustained SRIs in the Hawaiian Islands: 25 in Maui, 16 in O'ahu, 12 in Hawai'i, and 8 in Kaua'i. In cases where the shark species could be identified, tiger sharks were the most frequent (25, 41%). Four cases were fatal-all died on scene in Maui with the shark species unknown. Forty-five survivors (79%) received definitive care at regional facilities. Twelve (21%) were treated at the level 1 trauma center, of which two were transferred in for higher level of care. Of the 12 patients, 11 (92%) had extremity injuries, with 3 lower extremity amputations (25%), 2 with vascular injuries (17%), and 5 with nerve injuries (42%). One had an injury to the abdomen. All patients had local bleeding control in the prehospital setting, with 9 (75%) tourniquets and 3 (25%) hemostatic/pressure dressings applied for truncal or proximal extremity injuries. The mean time from injury to emergency department arrival was 63 minutes. DISCUSSION: Most SRIs are managed at regional facilities, rather than at a level 1 trauma center. Prehospital hemorrhage control is an important survival skill as time to definitive care may be prolonged. For cases treated at the level 1 trauma center, nerve injuries were common and should be suspected even in the absence of major vascular injury. Correlating shark behavior with observed injury patterns may help improve public awareness and ocean safety. LEVEL OF EVIDENCE: Level V, epidemiological.

The why and how our trauma patients die: A prospective Multicenter Western Trauma Association study.

BACKGROUND: Historically, hemorrhage has been attributed as the leading cause (40%) of early death. However, a rigorous, real-time classification of the cause of death (COD) has not been performed. This study sought to prospectively adjudicate and classify COD to determine the epidemiology of trauma mortality. METHODS: Eighteen trauma centers prospectively enrolled all adult trauma patients at the time of death during December 2015 to August 2017. Immediately following death, attending providers adjudicated the primary and contributing secondary COD using standardized definitions. Data were confirmed by autopsies, if performed. RESULTS: One thousand five hundred thirty-six patients were enrolled with a median age of 55 years (interquartile range, 32-75 years), 74.5% were male. Penetrating mechanism (n = 412) patients were younger (32 vs. 64, p < 0.0001) and more likely to be male (86.7% vs. 69.9%, p < 0.0001). Falls were the most common mechanism of injury (26.6%), with gunshot wounds second (24.3%). The most common overall primary COD was traumatic brain injury (TBI) (45%), followed by exsanguination (23%). Traumatic brain injury was nonsurvivable in 82.2% of cases. Blunt patients were more likely to have TBI (47.8% vs. 37.4%, p < 0.0001) and penetrating patients exsanguination (51.7% vs. 12.5%, p < 0.0001) as the primary COD. Exsanguination was the predominant prehospital (44.7%) and early COD (39.1%) with TBI as the most common later. Penetrating mechanism patients died earlier with 80.1% on day 0 (vs. 38.5%, p < 0.0001). Most deaths were deemed disease-related (69.3%), rather than by limitation of further aggressive care (30.7%). Hemorrhage was a contributing cause to 38.8% of deaths that occurred due to withdrawal of care. CONCLUSION: Exsanguination remains the predominant early primary COD with TBI accounting for most deaths at later time points. Timing and primary COD vary significantly by mechanism. Contemporaneous adjudication of COD is essential to elucidate the true understanding of patient outcome, center performance, and future research. LEVEL OF EVIDENCE: Epidemiologic, level II.

Blood volume measured by ultrasound and radioisotope dilution in critically ill subjects.

BACKGROUND: Accurate bedside assessment of circulating blood volume (BV) continues to challenge clinicians in their attempt to implement goal-directed therapy in the critically ill subject. The aim of this investigation was to comparatively evaluate BV measurements obtained by ultrasound and radioisotope dilution methodologies in adult subjects admitted to a surgical intensive care unit. MATERIALS AND METHODS: Fifty subjects with concurrent central venous catheters and peripheral arterial lines underwent measurement of BV using both ultrasound and radioisotope dilution (BV-RD) methods. The ultrasound dilution method was performed using a 30-mL injectate (BV-UD30) and a 60-mL injectate (BV-UD60) of isotonic saline. RESULTS: There were 24 paired data points for the BV-UD30 and 40 paired data points for the BV-UD60 measurements. Spearman's rank-order correlation demonstrated a positive relationship comparing both the BV-UD30 (r = 0.46, P = 0.0249) and the BV-UD60 (r = 0.80, P < 0.0001) to values obtained by radioisotope measurements. Bland-Altman analysis showed a mean bias of 1329 mL with limits of agreement (LOA) ± 2559 mL comparing BV-RD and BV-UD30, and a mean bias of 62 mL with LOA ±1353 mL for BV-RD and BV-UD60. CONCLUSIONS: This preliminary investigation shows that the BV-UD60 had better agreement with BV-RD, compared with the BV-UD30, but its utility appears limited by a large LOA. As this technology continues to evolve, the ultrasound dilution approach may potentially become a feasible means to calculate BV in critically ill surgical subjects.

Brain-type natriuretic peptide and right ventricular end-diastolic volume index measurements are imprecise estimates of circulating blood volume in critically ill subjects.

BACKGROUND: Surrogate indicators have often been used to estimate intravascular volume to guide fluid management. Brain-type natriuretic peptide (BNP) has been used as a noninvasive adjunct in the diagnosis of fluid overload and as a marker of response to therapy, especially in individuals with congestive heart failure. Similarly, right ventricular end-diastolic volume index (RVEDVI) measurements represent another parameter used to guide fluid resuscitation. The aim of this study was to evaluate whether BNP and RVEDVI are clinically valuable parameters that can distinguish among hypovolemia, euvolemia, and hypervolemia, as measured by blood volume (BV) analysis in critically ill surgical subjects. METHODS: This observational study was part of a prospective, randomized controlled trial. Subjects with pulmonary artery catheters for the treatment of traumatic injuries, severe sepsis/septic shock, cardiovascular collapse, adult respiratory distress syndrome, and postsurgical care were studied. Circulating BV was measured by a radioisotope dilution technique using the BVA-100 Analyzer (Daxor Corporation, New York, NY) within the first 24 hours of acute resuscitation. BV results were reported as percent deviation from the patient's ideal BV based on height and percent deviation from optimum weight. Hypovolemia was defined as less than 0%, euvolemia was defined as 0% to +16%, and hypervolemia was defined as greater than +16% deviation from ideal BV. RVEDVI was measured by continuous cardiac output pulmonary artery catheters (Edwards Lifesciences, Irvine, CA). BNP and RVEDVI measurements obtained with BV analysis were evaluated with Fisher's exact test and regression analysis. RESULTS: In 81 subjects, there was no difference in BV status between those with BNP of 500 pg/mL or greater and BNP of less than 500 pg/mL (p = 0.82) or in those with RVEDVI of 140 mL/m or greater and RVEDVI of less than 140 mL/m (p = 0.43). No linear relationship existed between BV and these parameters. CONCLUSION: In critically ill surgical patients, BNP and RVEDVI were not associated with intravascular volume status, although they may be useful as indices that reflect increased cardiac preload. LEVEL OF EVIDENCE: Diagnostic study, level III.

Use of Seamguard to prevent pancreatic leak following distal pancreatectomy.

OBJECTIVE: To investigate the use of Seamguard, a bioabsorbable staple line-reinforcement product, to prevent pancreatic leak after distal pancreatectomy. DESIGN, SETTING, AND PARTICIPANTS: A retrospective study examined 85 consecutive patients undergoing distal pancreatectomy at an academic institution from September 5, 1997, to September 30, 2007. MAIN OUTCOME MEASURES: Pancreatic fistula and overall mortality and morbidity. RESULTS: In February 2004, the use of Seamguard in distal pancreas resections was introduced at our institution. Indications for resection included trauma (11 patients), neoplasms (62 patients), and chronic pancreatitis (12 patients). Pancreatic leak was defined as drain output of 25 mL/d or more 7 days postoperatively with a drain amylase level of 1000 U/L or more. Pancreatic leak occurred in 10 of 38 patients (26%) undergoing conventional resection with suture ligation of the pancreatic duct or nonreinforced stapled resection vs 2 of 47 patients (4%) undergoing staple resection using Seamguard reinforcement. Multivariate analysis showed that use of Seamguard with the stapler independently decreased the risk for pancreatic fistula after distal pancreatectomy (odds ratio, 0.07; 95% confidence interval, 0.01-0.43; P = .01). CONCLUSIONS: The use of Seamguard is quickly becoming a common adjunct in distal pancreas resections. Our study shows a lower incidence of pancreatic leak after distal pancreatectomy with the use of this staple line-reinforcing product.

Is there a current role for preoperative non-absorbable oral antimicrobial agents for prophylaxis of infection after colorectal surgery?

BACKGROUND: In numerous scientific studies, oral antibiotic bowel preparation has reduced surgical site infections in patients undergoing colorectal surgery. The historical evolution of antibiotic bowel preparation is presented with a review of the scientific basis of its effectiveness. METHODS: Review of the pertinent English language literature. RESULTS: Successful oral antibiotic bowel preparation requires effective mechanical preparation. The progressive shift of preoperative preparation to the outpatient setting has led to a reduction in the use of oral antibiotics. Such preparation, however, continues to be effective although in current surgical practice is often augmented with perioperative, parenteral antimicrobials. CONCLUSION: Oral antibiotic bowel preparation has a role in the prevention of surgical site infection in the patient undergoing colorectal surgery.