Recent advances in austere combat surgery: Use of aortic balloon occlusion as well as blood challenges by special operations medical forces in recent combat operations.

BACKGROUND: Resuscitative endovascular balloon occlusion of the aorta (REBOA) for control of noncompressible torso hemorrhage is a technology that is increasingly being utilized in the combat casualty setting. Its use in the resource restricted environment holds potential to improve hemorrhage control, decrease blood product utilization, decrease morbidity, and improve combat mortality. The objective of this report is to present the single largest series of REBOA use on severely injured combat casualties. METHODS: Over an 18-month period, austere surgical teams comprised of coalition partners provided initial damage control resuscitation (DCR) and surgical stabilization for over 2,300 combat casualties prior to transferring patients to the next level of trauma care. RESULTS: Twenty patients presented with injuries from explosion and gunshot wounds with mean initial heart rate of 129 bpm and mean initial systolic blood pressure of 71 mm Hg. Femoral cutdowns were used in six patients. Aortic occlusion was achieved with REBOA catheter placement in Zone 1 (n = 17) and Zone 3 (n = 2). Systolic blood pressure increased an average of 56 mm Hg with aortic occlusion. There were no access related site complications. All patients survived transport to the next level of care. The majority of blood products transfused in this cohort were whole blood, largely supported by emergent blood drives. CONCLUSION: This series demonstrates the potential for REBOA as a lifesaving technique for the patient who presents with hemodynamic instability and noncompressible torso hemorrhage. Resuscitative endovascular balloon occlusion of the aorta allows austere surgical teams to rapidly stabilize severely injured combat casualties, expand capability, and provide enhanced DCR while minimizing personnel, resources, and blood product utilization. The use of "whole blood only" strategy for DCR shows potential to be superior to traditional component therapy, and when combined with "proactive" REBOA utilization, provides significant improvements in hemodynamics and hemorrhage control. LEVEL OF EVIDENCE: Case series, level V.

Surgical Management of Vascular Trauma.

Vascular injuries remain among the most challenging entities encountered in trauma care. Improvements in diagnostic capabilities, resuscitation approaches, vascular techniques, and prosthetic device options have afforded considerable advancement in the care of these patients. This evolution in care capabilities continues. Despite advances, uncontrolled hemorrhage due to major vascular injury remains one of the most common causes of death after trauma. Successful management of vascular injury requires the timely diagnosis and control of bleeding sources; to facilitate this task, trauma providers must appreciate the capabilities and limitations of diagnostic imaging modalities. Trauma providers must understand when and how to effectively apply these strategies.

Parameters for successful nonoperative management of traumatic aortic injury.

OBJECTIVE: Blunt traumatic aortic injury is associated with significant mortality, and increased computed tomography use identifies injuries not previously detected. This study sought to define parameters identifying patients who can benefit from medical management. METHODS: We reviewed 4.5 years of blunt traumatic aortic injuries. Injury was classified as grade I (intimal flap or intramural hematoma), II (small pseudoaneurysm <50% circumference), III (large pseudoaneurysm >50% circumference), and IV (rupture/transection). Secondary signs of injury included pseudocoarctation, extensive mediastinal hematoma, and large left hemothorax. Follow-up, including computed tomography, was reviewed. RESULTS: We identified 97 patients: 31 grade I, 35 grade II, 24 grade III, and 7 grade IV; 67(69%) male; mean age 47 ± 18.8 years, mean Injury Severity Score 38.8 ± 14.6; overall survival 76 (78.4%). Secondary signs of injury were found in 30 patients. Overall, 52 (53.6%) underwent repair, 45 undergoing thoracic endovascular aortic repair, with 2 (2.22%) procedure-related deaths, and 7 undergoing open repair. Five patients undergoing thoracic endovascular aortic repair required 7 additional procedures. In 45 medically managed patients, there were 14 deaths (31%), all secondary to associated injuries. Injury Severity Scores of survivors and nonsurvivors were 33 ± 10.8 and 48.6 ± 12.8, respectively (P < .001). Follow-up showed resolution or no change in 21 (91%) and a small increase in 2 grade I injuries. CONCLUSIONS: All blunt traumatic aortic injury does not necessitate repair. Stratification by injury grade and secondary signs of injury identifies patients appropriate for medical management. Grade IV injury necessitates emergency procedures and carries high mortality. Grade III injury with secondary signs of injury should be urgently repaired; patients without secondary signs of injury may undergo delayed repair. Grade I and II injuries are amenable to medical management.

Post-traumatic empyema: aetiology, surgery and outcome in 125 consecutive patients.

INTRODUCTION: Empyema remains a potentially serious condition with multiple etiologies including post-pneumonic, post-resection, and post-traumatic. There are few studies describing the latter. We reviewed our experience at a high volume trauma centre in injured patients with empyema, examining pre-operative status, surgical procedures, pathogens and outcome. METHODS: Retrospective trauma registry review, from 9/01 to 4/10. Empyema was defined as culture positive pleural fluid or purulence at operation. Data collected included demographics, injury mechanism, thoracic injuries, organ dysfunction, pathogens isolated, surgical procedures, outcomes and follow up. RESULTS: One hundred twenty-five consecutive patients with empyema were identified. Average injury severity score and age were 27.3 and 37.2 years respectively; 89.6% were male, 63.2% sustained blunt chest trauma. Time from injury to diagnosis averaged 12.1 days. All underwent decortication; 80% by thoracotomy, the remainder thoracoscopically. At operation over half were mechanically ventilated and 13.6% required vasoactive infusions. Monomicrobial cultures with Gram positive cocci predominating were obtained in 44%, 48% had polymicrobial cultures and 18.4% had a ruptured lung abscess. There were five deaths (4%); two occurring after a ruptured lung abscess. Recurrent empyema occurred in 6.4%, all successfully treated by re-operation or catheter drainage. Intensive care and hospital stays were 18.1 and 30.6 days respectively. All survivors achieved resolution of empyema. CONCLUSIONS: Trauma patients with empyema represent a subset of severely injured critically ill patients with diverse pathogens and polymicrobial flora. Appropriate surgical management and specific antibiotic therapy yields excellent results with acceptable risk. A ruptured lung abscess may be the aetiology of the post-traumatic empyema in a subset of patients and may represent an increased operative risk.

The impact of nontherapeutic hypothermia on outcomes after severe traumatic brain injury.

INTRODUCTION: In patients with isolated severe traumatic brain injury (TBI), the effect of controlled, therapeutic hypothermia on outcomes has been studied extensively. What is not well understood, however, and the purpose of this study, was to examine the impact of noninduced, nontherapeutic hypothermia on outcomes in these patients. METHODS: A retrospective review of the institutional trauma registry at the Los Angeles County + University of Southern California Medical Center was performed to identify all trauma patients admitted to the surgical intensive care unit (SICU) with isolated severe TBI from January 2000 to December 2008. Patients were classified as hypothermic (core temperature [Tc] ≤35°C) or normothermic (Tc >35°C) based on their first Tc recorded on SICU admission. The primary outcome measure was in-hospital mortality, and secondary outcomes included SICU and hospital length of stay. RESULTS: During the study period, 1,403 patients sustaining an isolated severe TBI were admitted to the SICU. After excluding 122 patients with missing temperature data, 1,281 patients were analyzed. Hypothermia (Tc ≤35°C) on SICU admission was identified in 10.9% (n = 140) of the study population, with the remaining 89.1% (n = 1,141) being normothermic (Tc >35°C). After adjusting for differences in baseline characteristics between the two groups, patients who were hypothermic on SICU admission were found to be significantly less likely to survive (odds ratio, 2.9; 95% confidence interval, 1.3, 6.7; p < 0.013). A penetrating mechanism of injury, Injury Severity Score ≥25, and undergoing an exploratory laparotomy before admission were found to be independent risk factors for the development of hypothermia on SICU admission. CONCLUSION: For patients who have sustained isolated severe TBI, the presence of noninduced, nontherapeutic hypothermia on SICU admission is associated with a significant increase in mortality. The impact of preventative measures used to avoid the development of hypothermia and the effectiveness of measures for restoring normothermia warrant further investigation.

Vascular trauma in geriatric patients: a national trauma databank review.

BACKGROUND: The epidemiology of vascular injuries in the geriatric patient population has not been described. The purpose of this study was to examine nationwide data on vascular injuries in the geriatric patients and to compare this with the nongeriatric adult patients with respect to the incidence, injury mechanisms, and outcomes. METHODS: Geriatric patients aged 65 or older with at least one traumatic vascular injury were compared with an adult cohort aged 16 years to 64 years with a vascular injury using the National Trauma Databank version 7.0. RESULTS: During the study period, 29,736 (1.6%) patients with a vascular injury were identified. Of those, geriatric patients accounted for 7.6% (2,268) and the nongeriatric adult patients accounted for 83.1% (n=24,703). Compared with the nongeriatric adult patients, the geriatric vascular patients had a significantly higher Injury Severity Score (26.6±17.0 vs. 21.3±16.7; p<0.001) and less frequently sustained penetrating injuries (16.1% vs. 54.1%; p<0.001). The most commonly injured vessels in the elderly were vessels of the chest (n=637, 40.2%), including the thoracic aorta and innominate and subclavian vessels. The overall incidence of thoracic aorta injuries was significantly higher in geriatric patients (33.0% vs. 13.9%; p<0.001) and increased linearly with progressing age. After adjusting for confounding factors, geriatric patients demonstrated a fourfold increase in mortality following vascular injuries (adjusted odds ratio, 3.9; 95% confidence interval, 3.32-4.58; p<0.001). CONCLUSION: Vascular trauma is rare in the geriatric patient population. These injuries are predominantly blunt, with the thoracic aorta being the most commonly injured vessel. Although vascular injuries occur less frequently than in the nongeriatric cohort, in the geriatric patient, vascular injury is associated with a fourfold increase in adjusted mortality.

Pacifying the open abdomen with concomitant intestinal fistula: a novel approach.

The management of the open abdomen, particularly when complicated by the presence of intestinal fistula, remains a significant challenge of modern trauma care. Although several approaches have been proposed, these varied and complex cases defy the application of a universal approach to local therapy. Ultimately, abdominal closure is desired but is not always possible. Accordingly, surgeons must be well versed in the application of a number of useful approaches that may serve to facilitate control of fistula drainage while permitting management of the surrounding open wound. We contribute a management approach that is simplistic in design, provides for effective fistula control, and permits the subsequent unhindered granulation of the surrounding wound in abdomens not amenable to delayed closure techniques.

Colonic trauma: indications for diversion vs. repair.

INTRODUCTION: The management of colonic trauma has evolved considerably over the past several decades. An appreciation of best-evidence practices is paramount to the optimal management of these injuries. MATERIALS AND METHODS: Literature review of pertinent clinical literature regarding the management of colonic trauma was performed. RESULTS: Based on available level I evidence, primary repair of all colorectal injuries should be attempted, irrespective of associated risk factors. Diversion should only be considered if the colonic tissue itself is deemed inappropriate for repair, as in the setting of prohibitive edema or questionable perfusion of the tissues. Diversion does remain the standard of care for the management of extra-peritoneal rectal injuries, although this practice is under active investigation. CONCLUSION: Level 1 evidence has failed to demonstrate that routine proximal diversion, once considered the standard of care for the treatment of all colorectal trauma, affords benefit for victims of the injuries. While utilization of these practices may prove beneficial in select circumstances, the routine utilization of proximal diversion for the treatment of colorectal injuries is unwarranted.

The establishment of a surgical interest society for medical students.

With the advent of initiatives by many medical schools to attract students to generalist fields, the curriculum at these institutions has undergone substantial change. In many instances these changes include the abbreviation of exposure to specialty fields such as surgery. Consequently, the exposure of medical students to the surgical discipline and surgeons may be decreased at these institutions. These changes are particularly concerning in light of studies that suggest that these important interactions are the primary influences that lead students to pursue a career in specific fields. It is also interesting to note that these trends in decreasing exposure to surgical fields seem to correlate with recent increases in the number of unfilled categorical residency positions in general surgery. This article focuses on the experiences of a group of students and faculty mentors at the University of Virginia School of Medicine as they set about creating an extracurricular opportunity for students to explore interests in surgical fields. We shall present the thoughts and rationale we used in planning the establishment of our own student surgical interest society, as well as the manner in which we ultimately went about constructing this organization. It is our hope that this information will provide some ideas for the creation of similar societies at other institutions.