Tactics for hemorrhagic shock: A virtual course and visual aid for improved resuscitation.

BACKGROUND: Our trauma performance improvement initiative recognized missed treatment opportunities for patients undergoing massive transfusion. To improve patient care, we developed a novel cognitive aid in the form of a poster entitled "TACTICS for Hemorrhagic Shock." We hypothesized that this reference and corresponding course would improve the performance of trauma leaders caring for simulated patients requiring massive transfusion. METHODS: First, residents and physician assistants participated in a one-on-one, socially distanced, screen-based virtual patient simulation. Next, they watched a short presentation introducing the TACTICS visual aid. They then underwent a similar second virtual simulation during which they had access to the reference. In both simulations, the participants were assessed using a scoring system developed to measure their ability to provide appropriate predetermined interventions while leading a trauma resuscitation (score range, 0-100%). Preintervention and postintervention scores were compared using a one-group pre-post within-subject design. Participants' feedback was obtained anonymously. RESULTS: Thirty-two participants (21 residents and 11 physician assistants) completed the course. The median score for the first simulation without the use of the visual aid was 43.8% (interquartile range, 33.3.8-61.5%). Commonly missed treatments included giving tranexamic acid (success rate, 37.5%), treating hypothermia (31.3%), and reversing known anticoagulation (28.1%). All participants' performance improved using the visual aid, and the median score of the second simulation was 89.6% (interquartile range, 79.2-94.8%; p < 0.001). Ninety-two percent of survey respondents "strongly agreed" that the TACTICS visual aid would be a helpful reference during real-life trauma resuscitations. CONCLUSION: The TACTICS visual aid is a useful tool for improving the performance of the trauma leader and is now displayed in our emergency department resuscitation rooms. This performance improvement course, the associated simulations, and visual aid are easily and virtually accessible to interested trauma programs. LEVEL OF EVIDENCE: Therapeutic/Care Management; Level IV.

Functional Superior Mesenteric Artery Syndrome Induced by an Optional IVC Filter.

This patient suffered multiple injuries in a motor vehicle crash. She had an optional IVC filter placed in the usual fashion and location which resulted in a functional obstruction of the third part of the duodenum much as one would expect with a Superior Mesenteric Artery (SMA) syndrome. The symptoms persisted over the sixteen-day filter dwell time and resolved completely with the retrieval of the filter.

An Ounce of Prevention Saves Tons of Lives: Infection in Burns.

BACKGROUND: Modern day burn care continues to wage an uphill battle against an enemy that evolves faster than we can develop weapons. Bacteria (bioburden) are everywhere and can infiltrate anywhere within our susceptible population of burn patients. This is why prevention of infection is key to improving their survival and outcome. PURPOSE: To reduce the incidence of infection in the burn patient population. MATERIALS: Review of pertinent recent literature regarding infection prevention and control in the intensive care unit setting. RESULTS: We propose that bioburden is one of the central elements in the infectious cycle that is ever-present in burn units. The mechanism of bacterial entry into the unit and subsequent transmission and infection are delineated. Recommendations for mitigating this risk are provided to guide future clinicians in their care of burn patients. CONCLUSIONS: The treatment of infection and sepsis against highly adaptable bacteria is often insurmountable by ill patients. In this process, bioburden needs to be corralled to have any success. Thus, preventing organisms from entering the unit and transferring onto other patients, and eliminating the bacteria dwelling in the unit are all necessary actions in this battle. Ultimately, maintaining a culture that is constantly wary of this risk only can achieve this goal.

A comparison of Biobrane™ and cadaveric allograft for temporizing the acute burn wound: Cost and procedural time.

INTRODUCTION: In many circumstances early burn excision and autografting is unsafe or even impossible. In these situations, skin substitute dressings can be utilized for temporary wound coverage. Two commonly used dressings for this purpose are cadaveric allograft and Biobrane™. MATERIALS AND METHODS: Five year retrospective cohort study evaluating upper extremity burns treated with temporary wound coverage (Biobrane™ or allograft). The primary outcome was to determine the impact choice of wound coverage had on operative time and cost. The secondary outcome was the need for revision of upper extremity debridement prior to definitive autografting. RESULTS: 45 patients were included in this study: 15 treated with cadaveric allograft and 30 treated with Biobrane™ skin substitute. Biobrane™ had a significantly lower procedure time (21.12 vs. 54.78 min per %TBSA excised, p=0.02) and cost (1.30 vs. 2.35 dollars per minute per %TBSA excised, p=0.002). Both techniques resulted in 2 revisions due to complications. CONCLUSION: Biobrane™ is superior to cadaveric allograft as a temporizing skin substitute in the acute burn wound, both in terms of procedure time and associated cost. We believe that this is largely due to the relative ease of application of Biobrane™. Furthermore, given its unique characteristics, Biobrane™ may serve as a triage and transport option for severe burns in the military and mass casualty settings.

Management of adult patients with buttock and perineal burns: The Ross Tilley Burn Centre experience.

BACKGROUND: Perineal and buttock burns are challenging wounds to heal for several reasons because of the contamination risk and shear stress that is always present. Because of the nature of the wound bed, pathogens can have ready access to create systemic infections and complications. Prolonged healing times also delay the recovery for patients and add to their discomfort and psychological stress from the injury. The ideal treatment approach is not well defined, and the aims of this study were to conduct a literature review of current treatment suggestions and to look at our own patient population to determine how our center treated these challenging patients. METHODS: This is a retrospective review of all patients treated between 2010 and 2013 at our center. Patients that received care for burns to the perineum or buttocks were evaluated. Mortalities within 24 hours of admission and transfers before completion of their care were excluded. All patients older than 18 years were included in the study. The primary outcome studied was a cause for graft revision. Secondary outcomes included benefits and risks of fecal management devices, risk of infection, and mortality. RESULTS: The literature review did not show consensus on how to best manage this patient population. Our results however demonstrated that patients treated with the fecal management device Flexi-seal (Convatec, Skillman, NJ) were at increased risk of developing an infection involving an enteric pathogen and requiring revision procedures. The patient population that was treated with this device was also older and had larger burns. The patients within this group that were treated initially with allograft required fewer revisions when compared with patients that received autograft in this group (23% vs. 34%, p > 0.05). CONCLUSION: After our data and the literature had been reviewed, the lack of evidence-based treatment protocols led us to create recommendations for burn surgeons with regard to the initial management of this complicated area. Certain key features include avoiding autograft at the primary excision if they have an increased revised Baux score and minimizing the amount of liquid stool contaminating the wound bed to increase success. LEVEL OF EVIDENCE: Epidemiologic study, level IV. Therapeutic study, level V.

Can CT angiography replace conventional bi-planar angiography in the management of severe scapulothoracic dissociation injuries?

Severe scapulothoracic dissociation (SSTD) (Type III or IV; Zelle classification) is often life-threatening and is commonly associated with other devastating injuries. Rapid evaluation, including of the vascular system, is critical to limit the time to definitive therapy. CT angiography (CTA) has evolved as a diagnostic tool, replacing angiography (angio) as it can simultaneously evaluate bony, soft tissue, and vascular injuries. We hypothesized that CTA would be useful in evaluating patients with SSTD. We retrospectively reviewed the trauma registry between June 2002 and June 2010 to identify patients over 18 years of age who sustained SSTD. Patients that were transferred or died before diagnostic imaging were excluded. Comparisons were made between the group that underwent angio before surgery compared with CTA with regards to outcome and length of hospital and intensive care unit stay. Fourteen patients were identified with Type III or IV SSTD over the study period. In the CTA group, mean Injury Severity Score was higher, but time to definitive operative intervention was significantly shorter. There was no difference in amputation rates or mortality. Replacing arteriography with CTA in the preoperative workup of patients with SSTD reduces time to surgery. Despite a greater injury severity in the group in which CTA was used as the primary imaging modality, length of stay, amputation rates, and mortality were no different. CTA can be safely used to evaluate patients with suspected SSTD.

Cancer surgery in the elderly.

The proportions both of elderly patients in the world and of elderly patients with cancer are both increasing. In the evaluation of these patients, physiologic age, and not chronologic age, should be carefully considered in the decision-making process prior to both cancer screening and cancer treatment in an effort to avoid ageism. Many tools exist to help the practitioner determine the physiologic age of the patient, which allows for more appropriate and more individualized risk stratification, both in the pre- and postoperative periods as patients are evaluated for surgical treatments and monitored for surgical complications, respectively. During and after operations in the oncogeriatric populations, physiologic changes occuring that accompany aging include impaired stress response, increased senescence, and decreased immunity, all three of which impact the risk/benefit ratio associated with cancer surgery in the elderly.

Early Hepatocellular Carcinoma: Transplantation versus Resection: The Case for Liver Resection.

The optimal surgical treatment of hepatocellular carcinoma on well-compensated cirrhosis is controversial. Advocates of liver transplantation cite better long-term survival, lower risk of recurrence, and the ability of transplantation to treat both the HCC and the underlying liver cirrhosis. Transplantation, however, is not universally available to all appropriate-risk candidates because of a lack of sufficient organ donors and in addition suffers from the disadvantages of requiring a more complex pre- and postoperative management associated with risks of inaccessibility, noncompliance, and late complications. Resection, by contrast, is much more easily and widely available, avoids many of those risks, is by many accounts as effective at achieving similar long-term survival, and still allows for safe, subsequent liver transplantation in cases of recurrence. Here, arguments are made in favor of resection being easier, safer, simpler, and comparably effective in the treatment of HCC relative to transplantation, and therefore being the optimal initial treatment in cases of hepatocellular carcinoma on well-compensated cirrhosis.

Variation in diagnosis of compartment syndrome by surgeons treating tibial shaft fractures.

BACKGROUND: It is agreed that missed compartment syndrome is associated with significant morbidity, but controversy regarding its diagnosis remains. To our knowledge, no one has analyzed the effect of individual surgeon variation on the diagnosis of compartment syndrome. METHODS: We analyzed a consecutive cohort of patients with tibial shaft fractures at our level I trauma center (n = 386 fractures). We identified all patients who were diagnosed as having compartment syndrome and who therefore underwent fasciotomy. The surgeon of record for each patient was recorded. Surgeons took call on random nights. All the surgeons were full-time orthopedic trauma surgeons. Patients with "prophylactic" fasciotomies were not included. Results were analyzed by conducting analysis of variance and the Kruskal-Wallis H test. RESULTS: Even though all the surgeons practiced at the same hospital during the same time period, wide variation existed in the rate of diagnosis and treatment of compartment syndrome. The rate ranged from a maximum of 24% to a minimum of 2% of the tibial fractures being diagnosed with compartment syndrome, depending on the surgeon. The differences were highly statistically significant (p < 0.005, Kruskal-Wallis H test). The surgeons' use of compartment pressure checks also varied (p < 0.05, Kruskal-Wallis H test) and seemed to approximately parallel the rate of compartment syndrome diagnosis. CONCLUSIONS: The diagnosis of compartment syndrome is difficult, and the data reported herein show that significant practice variation is likely, even within a single institution. It is unknown what the "true" rate of compartment syndrome should be, considering that a rate that is too high indicates unnecessary surgery and a rate that is too low means missing a devastating injury. Our data indicate lack of consensus in practice regarding the diagnosis of compartment syndrome, even at a high-volume level I trauma center, and emphasize the possibility of false-positive results of compartment pressure checks in clinical practice.