A randomized, controlled, blinded evaluation of augmenting point-of-care ultrasound and remote telementored ultrasound in inexperienced operators.

BACKGROUND: Handheld ultrasound devices present an opportunity for prehospital sonographic assessment of trauma, even in the hands of novice operators commonly found in military, maritime, or other austere environments. However, the reliability of such point-of-care ultrasound (POCUS) examinations by novices is rightly questioned. A common strategy being examined to mitigate this reliability gap is remote mentoring by an expert. OBJECTIVES: To assess the feasibility of utilizing POCUS in the hands of novice military or civilian emergency medicine service (EMS) providers, with and without the use of telementoring. To assess the mitigating or exacerbating effect telementoring may have on operator stress. METHODS: Thirty-seven inexperienced physicians and EMTs serving as first responders in military or civilian EMS were randomized to receive or not receive telementoring during three POCUS trials: live model, Simbionix trainer, and jugular phantom. Salivary cortisol was obtained before and after the trial. Heart rate variability monitoring was performed throughout the trial. RESULTS: There were no significant differences in clinical performance between the two groups. Iatrogenic complications of jugular venous catheterization were reduced by 26% in the telementored group (P < 0.001). Salivary cortisol levels dropped by 39% (P < 0.001) in the telementored group. Heart rate variability data also suggested mitigation of stress. CONCLUSIONS: Telementoring of POCUS tasks was not found to improve performance by novices, but findings suggest that it may mitigate caregiver stress.

A Prospective Evaluation of the Utility of a Hybrid Operating Suite for Severely Injured Patients: Overstated or Underutilized?

OBJECTIVE: The primary objective of this study was to evaluate the utility, clinical impact, and work flow of a new trauma hybrid operating theater. SUMMARY BACKGROUND DATA: The potential utility and clinical benefit of hybrid operating theaters are increasingly postulated. Unfortunately, the clinical outcomes and efficiencies of these environments remain unclear. METHODS: All severely injured patients who were transferred to the hybrid suite for emergent intervention between 2013 and 2017 were compared to consecutive prehybrid patients. Standard statistical methodology was employed (P < 0.05 = significant). RESULTS: One hundred sixty-nine patients with severe injuries (mean ISS = 23; hemodynamic instability = 70%; hospital/ICU stay = 12 d; mortality = 14%) were transferred urgently to the hybrid suite. Most were young (38 yrs) males (84%) with blunt injuries (51%). Combined hybrid trauma procedures occurred in 18% of cases (surgery (82%) and angiography (11%) alone). Procedures within the hybrid suite included: laparotomy (57%), extremity (14%), thoracotomy/sternotomy (12%), angioembolization of the spleen/pelvis/liver/other (9%), neck (9%), craniotomy (4%), and aortic endostenting (6%). Compared with historical controls, use of the hybrid suite resulted in shorter arrival to intervention and total procedure times (P < 0.05). A clear benefit for survival was evident (42% vs. 22%). CONCLUSIONS: Availability of a hybrid environment for severely injured patients reduces time to intervention, total procedural duration, blood product transfusion and salvages a small subset of patients who would not otherwise survive. The cost associated with a hybrid suite remains prohibitive for many centers.

Transoceanic Telementoring of Tube Thoracostomy Insertion: A Randomized Controlled Trial of Telementored Versus Unmentored Insertion of Tube Thoracostomy by Military Medical Technicians.

Background:Tension pneumothorax is a frequent cause of potentially preventable death. Tube thoracostomy (TT) can obviate death but is invasive and fraught with complications even in experienced hands. We assessed the utility of a remote international virtual network (RIVN) of specialized mentors to remotely guide military medical technicians (medics) using wireless informatics.Methods:Medics were randomized to insert TT in training mannequins (TraumaMan; Abacus ALS, Meadowbrook, Australia) supervised by RIVN or not. The RIVN consisted of trauma surgeons in Canada and Australia and a senior medic in Ohio. Medics wore a helmet-mounted wireless camera with laser pointer to confirm anatomy and two-way voice communication using commercial software (Skype®). Performance was measured through objective task completion (pass/fail) regarding safety during the procedure, proper location, and secure anchoring of the tube, in addition to remote mentor opinion and subjective debrief.Results:Fourteen medics attempted TT, seven mentored and seven not. The RIVN was functional and surgeons on either side of the globe had real-time communication with the mentees. TT placement was considered safe, successful, and secure in 100% of mentored (n = 7) procedures, although two (29%) received corrective remote guidance. All (100%) of the unmentored attempted and adequately secured the TT and were safe. However, only 71% (n = 5) completed the task successfully (p = 0.46). Participating medics subjectively felt remote telementoring (RTM) increased self-confidence (strong agreement mean 5/5 ± 0); confidence to perform field TT (agreement (4/5 ± 1); and decreased anxiety (strong agreement 5/5 ± 1). Subjectively, the remote mentors felt in 100% of the mentored procedures that "yes" they were able to assist the medics (1.86 ± 0.38), and in 71% (n = 5) felt "yes" they made TT safer (2.29 ± 0.49).Conclusions:RTM descriptively increased the success of TT placement and allowed for real-time troubleshooting from thousands of kilometers with a redundant capability. RTM was subjectively associated with high levels of satisfaction and self-reported self-confidence. Continued controlled and critical evaluation and refinement of telemedical techniques should continue. Trial Registration: ID ISRCTN/77929274.

Indications for Use of Damage Control Surgery in Civilian Trauma Patients: A Content Analysis and Expert Appropriateness Rating Study.

OBJECTIVES: To characterize and evaluate indications for use of damage control (DC) surgery in civilian trauma patients. BACKGROUND: Although DC surgery may improve survival in select, severely injured patients, the procedure is associated with significant morbidity, suggesting that it should be used only when appropriately indicated. METHODS: Two investigators used an abbreviated grounded theory method to synthesize indications for DC surgery reported in peer-reviewed articles between 1983 and 2014 into a reduced number of named, content-characteristic codes representing unique indications. An international panel of trauma surgery experts (n = 9) then rated the appropriateness (expected benefit-to-harm ratio) of the coded indications for use in surgical practice. RESULTS: The 1107 indications identified in the literature were synthesized into 123 unique pre- (n = 36) and intraoperative (n = 87) indications. The panel assessed 101 (82.1%) of these indications to be appropriate. The indications most commonly reported and assessed to be appropriate included pre- and intraoperative hypothermia (median temperature <34°C), acidosis (median pH <7.2), and/or coagulopathy. Others included 5 different injury patterns, inability to control bleeding by conventional methods, administration of a large volume of packed red blood cells (median >10 units), inability to close the abdominal wall without tension, development of abdominal compartment syndrome during attempted abdominal wall closure, and need to reassess extent of bowel viability. CONCLUSIONS: This study identified a comprehensive list of candidate indications for use of DC surgery. These indications provide a practical foundation to guide surgical practice while studies are conducted to evaluate their impact on patient care and outcomes.

Utility of simultaneous interventional radiology and operative surgery in a dedicated suite for seriously injured patients.

PURPOSE OF REVIEW: In recent years, combined interventional radiology and operative suites have been proposed and are now becoming operational in select trauma centres. Given the infancy of this technology, this review aims to review the rationale, benefits and challenges of hybrid suites in the management of seriously injured patients. RECENT FINDINGS: No specific studies exist that investigate outcomes within hybrid trauma suites. Endovascular and interventional radiology techniques have been successfully employed in thoracic, abdominal, pelvic and extremity trauma. Although the association between delayed haemorrhage control and poorer patient outcomes is intuitive, most supporting scientific data are outdated. The hybrid suite model offers the potential to expedite haemorrhage control through synergistic operative, interventional radiology and resuscitative platforms. Maximizing the utility of these suites requires trained multidisciplinary teams, ergonomic and workplace considerations, as well as a fundamental paradigm shift of trauma care. This often translates into a more damage-control orientated philosophy. SUMMARY: Hybrid suites offer tremendous potential to expedite haemorrhage control in trauma patients. Outcome evaluations from trauma units that currently have operational hybrid suites are required to establish clearer guidelines and criteria for patient management.

Timeliness in obtaining emergent percutaneous procedures in severely injured patients: how long is too long and should we create quality assurance guidelines?

BACKGROUND: Modern trauma care relies heavily on nonoperative, emergent percutaneous procedures, particularly in patients with splenic, pelvic and hepatic injuries. Unfortunately, specific quality measures (e.g., arrival to angiography times) have not been widely discussed. Our objective was to evaluate the time interval from arrival to initiation of emergent percutaneous procedures in severely injured patients. METHODS: All severely injured trauma patients (injury severity score [ISS] > 12) presenting to a level 1 trauma centre (2007-2010) were analyzed with standard statistical methodology. RESULTS: Among 60 severely injured patients (mean ISS 31, hypotension 18%, mortality 12%), the median time interval to the initiation of an angiographic procedure was 270 minutes. Of the procedures performed, 85% were therapeutic embolizations and 15% were diagnostic procedures. Splenic (median time 243 min, range 32-801 min) and pelvic (median time 278 min, range 153-466 min) embolizations accounted for 43% and 25% of procedures, respectively. The median embolization procedure duration for the spleen was 28 (range 15-153) minutes compared with 59 (range 34-171) minutes for the pelvis. Nearly 22% of patients required both an emergent percutaneous and subsequent operative procedure. Percutaneous therapy typically preceded open operative explorations. CONCLUSION: The time interval from arrival at the trauma centre to emergent percutaneous procedures varied widely. Improved processes emphasizing patient transition from the trauma bay to the angiography suite are essential. Discussion regarding the appropriate time to angiography is needed so this marker can be used as a quality outcome measure for all level 1 trauma centres.

CONTEXTE: De nos jours, en traumatologie, les soins reposent largement sur des interventions non chirurgicales percutanées d'extrême urgence, particulièrement chez les patients blessés à la rate, au bassin et au foie. Malheureusement, les indices de qualité spécifiques (p. ex., temps écoulé entre l'arrivée et l'angiographie) n'ont pas fait l'objet de discussions approfondies. Notre objectif était de mesurer le temps écoulé entre l'arrivée et l'instauration des interventions percutanées d'extrême urgence chez les grands blessés. MÉTHODES: Tous les grands polytraumatisés (indice de gravité des blessures [IGB] > 12) amenés dans un centre de traumatologie de niveau 1 (2007­2010) ont fait l'objet d'une analyse au moyen d'une méthodologie statistique standard. RÉSULTATS: Pour 60 patients gravement blessés (IGB moyen 31, hypotension 18 %, mortalité 12%), le temps écoulé avant l'instauration d'une intervention angio gra phique a été de 270 minutes. Parmi les interventions effectuées, 85% ont été des embolisations thérapeutiques et 15% des interventions diagnostiques. Les embolisations spléniques (temps écoulé médian 243 minutes, intervalle 32­801 minutes) et pelviennes (temps écoulé médian 278 minutes, intervalle 153­466 minutes) ont représenté 43% et 25% des interventions, respectivement. La durée médiane de l'intervention d'embolisation dans le cas de la rate a été de 28 (intervalle 15­153) minutes, contre 59 (intervalle 34­171) minutes pour les blessures touchant le bassin. Près de 22 % des patients ont eu besoin d'une intervention percutanée d'extrême urgence et d'une intervention chirurgicale par la suite. Les explorations chirurgicales ouvertes ont généralement été précédées d'un traitement percutané. CONCLUSION: Le temps écoulé entre l'arrivée au centre de traumatologie et les interventions percutanées d'extrême urgence varie beaucoup. Il faut, sans contredit, améliorer les processus en soulignant l'importance du transfert des patients de la salle de traumatologie à la salle d'angiographie et poursuivre la discussion sur le temps écoulé avant l'angiographie pour que ce marqueur puisse servir comme paramètre de mesure de la qualité dans tous les centres de traumatologie de niveau 1.

Injury trends and mortality in adult patients with major trauma in New South Wales.

OBJECTIVE: To examine trends in mechanism and outcome of major traumatic injury in adults since the implementation of the New South Wales trauma monitoring program, and to identify factors associated with mortality. DESIGN AND SETTING: Retrospective review of NSW Trauma Registry data from 1 January 2003 to 31 December 2007, including patient demographics, year of injury, and level of trauma centre where definitive treatment was provided. PARTICIPANTS: 9769 people aged ≥ 15 years hospitalised for trauma, with an injury severity score (ISS) > 15. MAIN OUTCOME MEASURES: The NSW Trauma Registry outcome measures included were overall hospital length of stay, length of stay in an intensive care unit and in ospital mortality. RESULTS: There was a decreasing trend in severe trauma presentations in the age group 16-34 years, and an increasing trend in presentations of older people, particularly those aged ≥ 75 years. Road trauma and falls were consistently the commonest injury mechanisms. There were 1328 inhospital deaths (13.6%). Year of injury, level of trauma centre, ISS, head/neck injury and age were all independent predictors of mortality. The odds of mortality was significantly higher among patients receiving definitive care at regional trauma centres compared with Level I centres (odds ratio, 1.34; 95% CI, 1.10-1.63). CONCLUSIONS: Deaths from major trauma in NSW trauma centres have declined since 2003, and definitive care at a Level 1 trauma centre was associated with a survival benefit. More comprehensive trauma data collection with timely analysis will improve injury surveillance and better inform health policy in NSW.

The Prevent Alcohol and Risk-Related Trauma in Youth (P.A.R.T.Y) program: An interactive injury prevention initiative in South-Western Sydney.

BACKGROUND: The Prevent Alcohol and Risk Related Trauma in Youth (P.A.R.T.Y) program is an interactive injury prevention intervention, specifically designed for "at risk" youths aged 15 to 19 years. Emerging evidence has highlighted its positive impact on altering student attitudes towards risk-taking behaviour across several Australian and international settings. This study aims to describe the risk-taking behaviours of youths in South-Western and Greater Western Sydney, and assess the effectiveness of the Liverpool P.A.R.T.Y program to alter attitudes towards risk-taking. METHODS: From 2015 to 2020, schools and youth organisations across South-Western and Greater Western Sydney were invited to participate in the Liverpool Hospital P.A.R.T.Y program. Youths aged 15 to 19 years were selected to attend by their respective teachers based on eligibility criteria. Knowledge and attitudes towards risk-taking behaviours were measured using surveys across three time points (pre-program, immediately post-program, 3-to-6 months post-program). RESULTS: A total of 2544 participants from 50 schools and youth organisations attended the Liverpool Hospital P.A.R.T.Y program. There were 130 participants who did not record a response to a single question across all three time points and were omitted from analysis. Of the remaining 2414 participants, 49% were male, and 41% had access to a provisional driver's license or learner's permit. There were significant changes in knowledge and attitudes to risk-taking behaviours from pre-to immediately-post-program. A separate analysis across all three time points was conducted in response to a poor 3-to-6-month follow-up rate (25%). There was decay in improvements across all six questions, with the largest change seen in perceived likelihood of injury when engaging in physically risk-taking activities (52.2% to 36.9%, OR 0.44, 95% CI 0.33 - 0.60, p < 0.001). CONCLUSION: This study demonstrated significant changes in participant attitudes towards risk-taking behaviours and their consequences, immediately after participating in the Liverpool Hospital P.A.R.T.Y program. However, the poor response rates at later follow-up highlight the need for ongoing engagement of the South-Western and Greater Western Sydney youths, to ensure these improvements are sustained.

Older trauma patients are at high risk of delirium, especially those with underlying dementia or baseline frailty.

BACKGROUND: Given the increasing numbers of older patients presenting with trauma, and the potential influence of delirium on outcomes, we sought to investigate the proportion of such patients who were diagnosed with delirium during their stay-and patient factors associated therewith-and the potential associations between delirium and hospital length of stay (LOS). We hypothesized that delirium would be common, associated with certain patient characteristics, and associated with long hospital LOS (highest quartile). METHODS: We conducted a retrospective observational cohort study of all trauma patients aged ≥65 years presenting in September to October 2019, interrogating medical records and the institutional trauma database. The primary outcome measure was occurrence of delirium. RESULTS: Among 99 eligible patients, delirium was common, documented in 23% (23 of 99). On multivariable analysis, adjusting for age, frailty and history of dementia, frailty (OR 4.09, 95% CI 1.08 to 15.53, p=0.04) and dementia (OR 5.23, 95% CI 1.38 to 19.90, p=0.02) were independently associated with likelihood of delirium. Standardized assessment tools were underused, with only 34% (34 of 99) screened within 4 hours of arrival. On univariate logistic regression analysis, having an episode of delirium was associated with long LOS (highest quartile), OR of 5.29 (95% CI 1.92 to 14.56, p<0.001). In the final multivariable model, adjusting for any (non-delirium) in-hospital complication, delirium was independently associated with long LOS (≥16 days; OR 4.81, p=0.005). DISCUSSION: In this study, delirium was common. History of dementia and baseline frailty were associated with increased risk. Delirium was independently associated with long LOS. However, many patients did not undergo standardized screening at admission. Early identification and targeted management of older patients at risk of delirium may reduce incidence and improve care of this vulnerable cohort. These data are hypothesis generating, but support the need for initiatives which improve delirium care, acknowledging the complex interplay between frailty and other geriatric syndromes in the older trauma patients. LEVEL OF EVIDENCE: III.

Variation in use of damage control laparotomy for trauma by trauma centers in the United States, Canada, and Australasia.

BACKGROUND: It is unknown how frequently damage control (DC) laparotomy is used across trauma centers in different countries. We conducted a cross-sectional survey of trauma centers in the United States, Canada, and Australasia to study variations in use of the procedure and predictors of more frequent use of DC laparotomy. METHODS: A self-administered, electronic, cross-sectional survey of trauma centers in the United States, Canada, and Australasia was conducted. The survey collected information about trauma center and program characteristics. It also asked how often the trauma program director estimated DC laparotomy was performed on injured patients at that center on average over the last year. Multivariable logistic regression was used to identify predictors of a higher reported frequency of use of DC laparotomy. RESULTS: Of the 366 potentially eligible trauma centers sent the survey, 199 (51.8%) trauma program directors or leaders responded [United States = 156 (78.4%), Canada = 26 (13.1%), and Australasia = 17 (8.5%)]. The reported frequency of use of DC laparotomy was highly variable across trauma centers. DC laparotomy was used more frequently in level-1 than level-2 or -3 trauma centers. Further, high-volume level-1 centers used DC laparotomy significantly more often than lower volume level-1 centers (p = 0.02). Nearly half (48.4%) of high-volume volume level-1 trauma centers reported using the procedure at least once weekly. Significant adjusted predictors of more frequent use of DC laparotomy included country of origin [odds ratio (OR) for the United States vs. Canada = 7.49; 95% confidence interval (CI) 1.39-40.27], level-1 verification status (OR = 6.02; 95% CI 2.01-18.06), and the assessment of a higher number of severely injured (Injury Severity Scale score > 15) patients (OR per-100 patients = 1.62; 95% CI 1.20-2.18) and patients with penetrating injuries (OR per-5% increase = 1.27; 95% CI 1.01-1.58) in the last year. CONCLUSIONS: The reported frequency of use of DC laparotomy was highly variable across trauma centers. Those centers that most need to evaluate the benefit-to-risk ratio of using DC laparotomy in different scenarios may include high-volume, level-1 trauma centers, particularly those that often manage penetrating injuries.

Intraabdominal hypertension and the abdominal compartment syndrome in burn patients.

Severe burns represent a devastating injury that induces profound systemic inflammation requiring large volumes of resuscitative fluids. The consequent massive swelling and peritoneal ascites raises intraabdominal pressures (IAP) to supraphysiologic levels commensurate with intraabdominal hypertension (IAH) and with the abdominal compartment syndrome (ACS) if consistently associated with IAP >20 mmHg and associated with new organ failure. Severe burn injuries are an example of the secondary ACS (secondary ACS), wherein there has been no primary inciting intraperitoneal injury, yet severe IAH/ACS develops, setting the stage for progressive multiorgan dysfunction. These definitions along with practice management guidelines have recently been promulgated by the World Society of the Abdominal Compartment Syndrome (WSACS) in an effort to standardize terminology and communication regarding IAH/ACS in critical care. It is currently unknown whether these syndromes are iatrogenic consequences of excessive or poorly managed fluid resuscitation or unavoidable sequelae of the primary injury. It occurs frequently with burns of >60% body surface area, especially with associated inhalational injury, delayed resuscitation, and abdominal wall injuries. IAH/ACS is often a hyperacute phenomenon that occurs within the first hours of admission and thereafter with any complication requiring aggressive fluid resuscitation. Despite a number of noninvasive management strategies, interventions such as percutaneous peritoneal drainage and, ultimately, decompressive laparotomy are often required once the ACS is established. Whether novel resuscitation strategies can avoid or minimize IAH/ACS is unproven at present and requires further study. Truly understanding postburn ACS may require further insights into the basic mechanisms of injury and resuscitation.

Ten-year evolution of a massive transfusion protocol in a level 1 trauma centre: have outcomes improved?

BACKGROUND: We aimed to evaluate the evolution and implementation of the massive transfusion protocol (MTP) in an urban level 1 trauma centre. Most data on this topic comes from trauma centres with high exposure to life-threatening haemorrhage. This study examines the effect of the introduction of an MTP in an Australian level 1 trauma centre. METHODS: A retrospective study of prospectively collected data was performed over a 14-year period. Three groups of trauma patients, who received more than 10 units of packed red blood cells (PRBC), were compared: a pre-MTP group (2002-2006), an MTP-I group (2006-2010) and an MTP-II group (2010-2016) when the protocol was updated. Key outcomes were mortality, complications and number of blood products transfused. RESULTS: A total of 168 patients were included: 54 pre-MTP patients were compared to 47 MTP-I and 67 MTP-II patients. In the MTP-II group, fewer units of PRBC and platelets were administered within the first 24 h: 17 versus 14 (P = 0.01) and 12 versus 8 (P < 0.001), respectively. Less infections were noted in the MTP-I group: 51.9% versus 31.9% (P = 0.04). No significant differences were found regarding mortality, ventilator days, intensive care unit and total hospital lengths of stay. CONCLUSION: Introduction of an MTP-II in our level 1 civilian trauma centre significantly reduced the amount of PRBC and platelets used during damage control resuscitation. Introduction of the MTP did not directly impact survival or the incidence of complications. Nevertheless, this study reflects the complexity of real-life medical care in a level 1 civilian trauma centre.

Acute resuscitation of the unstable adult trauma patient: bedside diagnosis and therapy.

Traumatic injury remains the leading cause of potentially preventable death in Canadians under age 40 years. Although only a minority of patients present with hemodynamic instability, these patients have a significant chance of dying. The causes of instability must be recognized and corrected quickly by using a systematic approach. To allow key supportive interventions to be undertaken swiftly, it is more important to identify and prioritize systemic compromise than to confirm specific diagnoses. Most potentially preventable trauma death relates to airway obstruction, hemopneumothorax, intracranial hemorrhage and intracavitary bleeding. Definitive airway control should be assured as a first priority. Hemopneumothoraces are typically addressed by chest tube insertion, although thoracic exploration will occasionally be urgently required. Hemorrhage control is much more important than fluid resuscitation and mandates the earliest possible definitive management. Unstable patients nearing physiological exhaustion require abbreviated or "damage-control" surgical tactics. This should be recognized early in the resuscitation rather than late in an operative procedure. The management of expanding intracranial hemorrhage requires optimization of oxygenation, ventilation and circulatory support while urgent CT and expert neurosurgical care are provided. Polytrauma presenting with head injury challenges the most developed of trauma systems, necessitating thoughtful prioritization of care and taking into consideration local capabilities. Bedside trauma sonography is an evolving tool that complements the physical examination during an initial survey. Future breakthroughs in trauma resuscitation may involve procoagulant medications, imaging technology, circulatory assist techniques and the use of inflammatory modulators. The greatest future challenge in trauma care, though, will be the provision of basic organized resuscitative care to the global community.

Results from the International Conference of Experts on Intra-abdominal Hypertension and Abdominal Compartment Syndrome. II. Recommendations.

OBJECTIVE: Intra-abdominal hypertension (IAH) and abdominal compartment syndrome (ACS) have been increasingly recognized in the critically ill over the past decade. In the absence of consensus definitions and treatment guidelines the diagnosis and management of IAH and ACS remains variable from institution to institution. DESIGN: An international consensus group of multidisciplinary critical care specialists convened at the second World Congress on Abdominal Compartment Syndrome to develop practice guidelines for the diagnosis, management, and prevention of IAH and ACS. METHODS: Prior to the conference the authors developed a blueprint for consensus definitions and treatment guidelines which were refined both during and after the conference. The present article is the second installment of the final report from the 2004 International ACS Consensus Definitions Conference and is endorsed by the World Society of the Abdominal Compartment Syndrome. RESULTS: The prevalence and etiological factors for IAH and ACS are reviewed. Evidence-based medicine treatment guidelines are presented to facilitate the diagnosis and management of IAH and ACS. Recommendations to guide future studies are proposed. CONCLUSIONS: These definitions, guidelines, and recommendations, based upon current best evidence and expert opinion are proposed to assist clinicians in the management of IAH and ACS as well as serve as a reference for future clinical and basic science research.

Blunt cerebrovascular injury: an evaluation from a major trauma centre.

BACKGROUND: Blunt cerebrovascular injury (BCVI), although uncommon, is associated with substantial morbidity and mortality and remains poorly understood. This study was conducted to determine the pattern and outcome of BCVI at a major trauma centre. METHODS: A retrospective review of all trauma admissions between 1996 and 2004 at Liverpool Hospital, the major trauma service for south-west Sydney, was undertaken using the hospital's computerized trauma registry. RESULTS: Fourteen of the 7788 (0.18%) admitted blunt trauma patients sustained BCVI. Blunt carotid injury occurred in 10 of 14 and blunt vertebral injury occurred in 4 of 14 patients. Road trauma accounted for 9 of 14 cases. The median time to diagnosis was 2 days (range 1-45 days). The stroke rate was 36%, and the overall mortality was 29%. CONCLUSION: This study identified BCVI as a relatively infrequent occurrence but with significant mortality and morbidity rates. Practice guidelines for both the screening and management of this patient group need to be developed and introduced in this major trauma centre.

Treatment response in liver metastases following 90Y SIR-spheres: an evaluation with PET.

Selective internal radiation therapy (SIRT) with radiolabeled Yttrium-90 (90Y) microspheres is a relatively new therapeutic option for patients with primary or secondary hepatic malignancy. However, the evaluation of the therapeutic efficacy on anatomic imaging alone is suboptimal. Functional imaging with F18-2-fluoro-2-deoxy-D-glucose (FDG) positron emission tomography (PET) is increasingly utilised in therapy monitoring in malignancy and provides an accurate assessment of metabolic response. We report a case of a 75-year-old gentleman with colorectal hepatic metastases who demonstrated a dramatic metabolic response on PET scan following SIRT. This case illustrates the utility of FDG PET in the assessment of the therapeutic efficacy of 90Y microspheres in colorectal hepatic metastases.

Results from the International Conference of Experts on Intra-abdominal Hypertension and Abdominal Compartment Syndrome. I. Definitions.

OBJECTIVE: Intra-abdominal hypertension (IAH) and abdominal compartment syndrome (ACS) have been increasingly recognized in the critically ill over the past decade. The variety of definitions proposed has led to confusion and difficulty in comparing one study to another. DESIGN: An international consensus group of critical care specialists convened at the second World Congress on Abdominal Compartment Syndrome to standardize definitions for IAH and ACS based upon the current understanding of the pathophysiology surrounding these two syndromes. METHODS: Prior to the conference the authors developed a blueprint for the various definitions, which was further refined both during and after the conference. The present article serves as the final report of the 2004 International ACS Consensus Definitions Conference and is endorsed by the World Society of Abdominal Compartment Syndrome (WSACS). RESULTS: IAH is redefined as an intra-abdominal pressure (IAP) at or above 12 mmHg. ACS is redefined as an IAP above 20 mmHg with evidence of organ dysfunction/failure. ACS is further classified as either primary, secondary, or recurrent based upon the duration and cause of the IAH-induced organ failure. Standards for IAP monitoring are set forth to facilitate accuracy of IAP measurements from patient to patient. CONCLUSIONS: State-of-the-art definitions for IAH and ACS are proposed based upon current medical evidence as well as expert opinion. The WSACS recommends that these definitions be used for future clinical and basic science research. Specific guidelines and recommendations for clinical management of patients with IAH/ACS are published in a separate review.