Emergency Department Resuscitative Endovascular Balloon Occlusion of the Aorta in Trauma Patients With Exsanguinating Hemorrhage: The UK-REBOA Randomized Clinical Trial.

Importance: Bleeding is the most common cause of preventable death after trauma. Objective: To determine the effectiveness of resuscitative endovascular balloon occlusion of the aorta (REBOA) when used in the emergency department along with standard care vs standard care alone on mortality in trauma patients with exsanguinating hemorrhage. Design, Setting, and Participants: Pragmatic, bayesian, randomized clinical trial conducted at 16 major trauma centers in the UK. Patients aged 16 years or older with exsanguinating hemorrhage were enrolled between October 2017 and March 2022 and followed up for 90 days. Intervention: Patients were randomly assigned (1:1 allocation) to a strategy that included REBOA and standard care (n = 46) or standard care alone (n = 44). Main Outcomes and Measures: The primary outcome was all-cause mortality at 90 days. Ten secondary outcomes included mortality at 6 months, while in the hospital, and within 24 hours, 6 hours, or 3 hours; the need for definitive hemorrhage control procedures; time to commencement of definitive hemorrhage control procedures; complications; length of stay; blood product use; and cause of death. Results: Of the 90 patients (median age, 41 years [IQR, 31-59 years]; 62 [69%] were male; and the median Injury Severity Score was 41 [IQR, 29-50]) randomized, 89 were included in the primary outcome analysis because 1 patient in the standard care alone group declined to provide consent for continued participation and data collection 4 days after enrollment. At 90 days, 25 of 46 patients (54%) had experienced all-cause mortality in the REBOA and standard care group vs 18 of 43 patients (42%) in the standard care alone group (odds ratio [OR], 1.58 [95% credible interval, 0.72-3.52]; posterior probability of an OR >1 [indicating increased odds of death with REBOA], 86.9%). Among the 10 secondary outcomes, the ORs for mortality and the posterior probabilities of an OR greater than 1 for 6-month, in-hospital, and 24-, 6-, or 3-hour mortality were all increased in the REBOA and standard care group, and the ORs were increased with earlier mortality end points. There were more deaths due to bleeding in the REBOA and standard care group (8 of 25 patients [32%]) than in standard care alone group (3 of 18 patients [17%]), and most occurred within 24 hours. Conclusions and Relevance: In trauma patients with exsanguinating hemorrhage, a strategy of REBOA and standard care in the emergency department does not reduce, and may increase, mortality compared with standard care alone. Trial Registration: isrctn.org Identifier: ISRCTN16184981.

The impact of the COVID-19 pandemic on the number of presentations of penetrating injuries to a UK major trauma centre.

BACKGROUND: Knife-related violence is of growing concern in the UK. This study aims to investigate the impact of the COVID-19 pandemic on the frequency of penetrating injuries at a UK major trauma centre. METHODS: This was a retrospective study comparing the number of patients attending the emergency department of King's College Hospital (KCH) with a penetrating injury (gunshot or stab wound) during the 'pandemic year' (1 March 2020-28 February 2021) compared with the equivalent time period in the previous year. Penetrating injuries as a result of self-harm were excluded. The primary outcome was to assess whether there were any changes to the frequency of presentations during three periods of national lockdowns. RESULTS: Lockdown 1 showed a 48.45% reduction in presentations in the 'pandemic year' compared to the previous year, lockdown 2 showed a 31.25% reduction; however, lockdown 3 showed an 8.89% increase in the number of presentations. CONCLUSION: Our findings suggest that despite the initial reduction in the number of presentations of penetrating injury during lockdown 1, this returned to normal levels by lockdown 3. Further research is required to understand the effects of government-imposed restrictions on interpersonal violence and identify appropriate methods of outreach prevention during a pandemic.

Medical and surgical devices in the emergency and trauma patient: what the radiologist should know, and how they can add value.

A variety of different external and internal medical devices are used in the acute setting to maintain life support and manage severely injured and unstable trauma or emergency patients. These devices are inserted into the acutely ill patient with the specific purpose of improving outcome, but misplacement can cause additional morbidity and mortality. Consequently, meaningful interpretation of the position of devices can affect acute management. Some devices such as nasopharyngeal, nasogastric and endotracheal tubes and chest and surgical drains are well known to most clinicians, however, little formal training exists for radiologists in composing their report on the imaging of these devices. The novice radiologist often relies on tips and phrases handed down in an aural tradition or resorts to phrases such as: "position as shown". Furthermore, radiologists with limited experience in trauma might not be familiar with the radiological appearance of other more specific devices. This review will focus on the most common medical devices used in acute trauma patients, indications, radiological appearance and their correct and suboptimal positioning.

Penetrating head & neck trauma - Epidemiology and injury characteristics in terror-related violence, interpersonal violence and deliberate self-harm at a level 1 trauma centre.

INTRODUCTION: Penetrating trauma to the head and neck presents specific clinical challenges. Aetiologies include interpersonal violence, deliberate self-harm and terror-related violence. King's College Hospital is a Major Trauma Centre serving inner-city London boroughs with a high incidence of knife and gun crime. It also received victims of the terrorist attack at London Bridge in June 2017. METHODS: Data was collected prospectively on all patients presenting with penetrating trauma to the head and neck over a one-year period (August 2016-July 2017). RESULTS: Overall figures for penetrating trauma are the highest since comparable records began with 478 cases (2016/17) compared with 172 (2010/11). Most patients had injuries resulting from interpersonal violence (83%); a group consisting mostly in males (88%) under the age of 30 (69%). The sole fatality among all patients was a result of repeat deliberate self-harm. Terror-related violence victims were equally gender split and older; all patients in this group required surgical intervention and had longer lengths of stay (16.3 days) compared with interpersonal violence (6.3 days) and deliberate self-harm (3 days). CONCLUSION: Violent crime is increasing. Overall penetrating injury has more than doubled in 6 years. The injury characteristics observed are distinct depending on the assailants and motives. Head and neck trauma requires a multidisciplinary approach, with an understanding of the care needs of patients. Interpersonal violence is the most common aetiology and as such efforts to tackle rising violent crime must involve police and the community. In addition, terror-related violence is evolving in the United Kingdom and globally, and as such healthcare professionals must understand differences in aetiologies to promote optimal patient care.

Acute Porphyria Presenting as Major Trauma: Case Report and Literature Review.

BACKGROUND: Acute porphyria is historically known as "the little imitator" in reference to its reputation as a notoriously difficult diagnosis. Variegate porphyria is one of the four acute porphyrias, and can present with both blistering cutaneous lesions and acute neurovisceral attacks involving abdominal pain, neuropsychiatric features, neuropathy, hyponatremia, and a vast array of other nonspecific clinical features. CASE REPORT: A 40-year-old man presented to the Emergency Department (ED) as a major trauma call, having been found in an "acutely confused state" surrounded by broken glass. Primary survey revealed: hypertension, tachycardia, abdominal pain, severe agitation, and confusion with an encephalopathy consistent with acute delirium, a Glasgow Coma Scale score of 13, and head-to-toe "burn-like" abrasions. Computed tomography was unremarkable, and blood tests demonstrated hyponatremia, acute kidney injury, and a neutrophilic leukocytosis. The next of kin eventually revealed a past medical history of variegate porphyria. The patient was experiencing an acute attack and received supportive management prior to transfer to intensive care, subsequently making a full recovery. WHY SHOULD AN EMERGENCY PHYSICIAN BE AWARE OF THIS?: This case highlights the importance of recognizing acute medical conditions in patients thought to be suffering from major trauma. Acute porphyria should be considered in any patient with abdominal pain in combination with neuropsychiatric features, motor neuropathy, or hyponatremia. Patients often present to the ED without any medical history, and accurate diagnosis can be essential in the acute setting to minimize morbidity and mortality. The label of the major trauma call must be taken with great caution, and a broad differential diagnosis must be maintained throughout a diligent and thorough primary survey.

Can contrast-enhanced ultrasonography improve Zone III REBOA placement for prehospital care?

BACKGROUND: Torso hemorrhage is the primary cause of potentially preventable mortality in trauma. Resuscitative endovascular balloon occlusion of the aorta (REBOA) has been advocated as an adjunct to bridge patients to definitive hemorrhage control. The primary aim of this study was to assess whether contrast-enhanced ultrasonography can improve the accuracy of REBOA placement in the infrarenal aorta (Zone III). METHODS: A fluoroscopy-free "enhanced" Zone III REBOA technique was developed using a porcine cadaver model. A "standard" over-the-wire Seldinger technique was used, which was enhanced with the addition of a microbubble contrast medium to inflate the balloon, observed with ultrasonography. Following this, attending- and resident-level physicians were randomized into two groups. They were taught either the enhanced with ultrasonography guidance (Group A) or the standard measuring length of catheter insertion (Group B) technique as part of a human cadaver trauma skills course. Outcomes assessed included time (seconds) from insertion to inflation, accuracy, and missed targets. All results were benchmarked against three endovascular experts. RESULTS: There were 20 participants who performed REBOA with Group A (51 [31]) being significantly faster than Group B (90 [63]) (p = 0.003) and more accurate (p = 0.023) with no missed targets. Group B had five missed targets, the most common error being inflation within Zone II. CONCLUSION: For Zone III REBOA, contrast-enhanced ultrasonography technique is faster and more accurate than the standard technique. This may have value in time-critical and austere environments. Clinical studies are now required to evaluate this approach further.

The Face, Content, and Construct Validity Assessment of a Focused Assessment in Sonography for Trauma Simulator.

OBJECTIVE: Hemorrhage identification in trauma care is a major priority. Focused assessment in sonography for trauma (FAST) offers a rapid, reliable means of detecting torso bleeding. The aims of this study were to conduct a face, content, and construct validity assessment of a FAST simulator and establish a rigorous assessment tool. DESIGN: Participants were requested to perform a FAST scan and state if any abnormality was found in each region. Metrics evaluated included time, errors, and missed targets. Accuracy of images obtained was assessed by 2 independent radiologists. Experts completed a face and content validity questionnaire at the end of the study. SETTING: The study took place in the simulation suite within the Academic Surgical Unit of the Department of Surgery and Cancer. PARTICIPANTS: Novices had no prior experience with ultrasound, intermediates had less than 6 months experience with fewer than 50 FAST scans performed, and experts had more than 1 year of experience with greater than 100 FAST scans performed. There were 31 participants: 11 experts, 10 intermediates, and 10 novices. RESULTS: The face and content validity questionnaire scored high marks across all categories and achieved an overall median realism score of 8 ± 1.5 on a Likert scale. Experts performed the FAST scan faster with more accuracy and fewer errors than other cohorts (p < 0.001). Both the novices and intermediates were the slowest, least accurate, and either missed or made the most errors when scanning the lung bases and spleen. CONCLUSIONS: This study has established the face, content, and construct validities of a FAST simulator, which could be used to accelerate training for novices. Additionally, it has demonstrated a rigorous method for FAST assessment, which has proven to be effective and in doing so addressed some of the criticisms leveled against it.

Traumatic intra-abdominal hemorrhage control: has current technology tipped the balance toward a role for prehospital intervention?

BACKGROUND: The identification and control of traumatic hemorrhage from the torso remains a major challenge and carries a significant mortality despite the reduction of transfer times. This review examines the current technologies that are available for abdominal hemorrhage control within the prehospital setting and evaluates their effectiveness. METHODS: A systematic search of online databases was undertaken. Where appropriate, evidence was highlighted using the Oxford levels of clinical evidence. The primary outcome assessed was mortality, and secondary outcomes included blood loss and complications associated with each technique. RESULTS: Of 89 studies, 34 met the inclusion criteria, of which 29 were preclinical in vivo trials and 5 were clinical. Techniques were subdivided into mechanical compression, endovascular control, and energy-based hemostatic devices. Gas insufflation and manual pressure techniques had no associated mortalities. There was one mortality with high intensity focused ultrasound. The intra-abdominal infiltration of foam treatment had 64% and the resuscitative endovascular balloon occlusion of the aorta had 74% mortality risk reduction. In the majority of cases, morbidity and blood loss associated with each interventional procedure were less than their respective controls. CONCLUSION: Mortality from traumatic intra-abdominal hemorrhage could be reduced through early intervention at the scene by emerging technology. Manual pressure or the resuscitative endovascular balloon occlusion of the aorta techniques have demonstrated clinical effectiveness for the control of major vessel bleeding, although complications need to be carefully considered before advocating clinical use. At present, fast transfer to the trauma center remains paramount. LEVEL OF EVIDENCE: Systematic review, level IV.

Diagnostic peritoneal lavage and ultrasonography for blunt abdominal trauma: attitudes and training of current general surgical trainees.

OBJECTIVE: It has been suggested that diagnostic peritoneal lavage is now obsolete in UK hospitals with access to either skilled ultrasonography or emergency physician or surgeon-performed focused abdominal sonography in trauma. Diagnostic peritoneal lavage continues to be advocated and taught on Advanced Trauma Life Support courses. The aim of this study was to evaluate the experiences and attitudes of general-surgery trainees in one UK training region towards diagnostic peritoneal lavage and focused abdominal sonography in trauma in managing blunt abdominal trauma. METHODS: An anonymous postal piloted questionnaire was sent to all 66 general surgery specialist trainees in one UK training region between January and March 2005. RESULTS: Out of 40 replies to the questionnaire (response rate 61%), 53% and 38% of surgical trainees had either never performed or never observed a diagnostic peritoneal lavage during their training. Thirteen trainees (33%) felt diagnostic peritoneal lavage to be obsolete and would never contemplate using it; 15 trainees (37%) might consider using diagnostic peritoneal lavage if computed tomography or ultrasonography were unavailable. Ten trainees (25%) felt that diagnostic peritoneal lavage had been superseded by computed tomography. Only 12 trainees (30%) had worked in a UK hospital with access to facilities for focused abdominal sonography in trauma and only seven trainees (18%) had received any training or experience in focused abdominal sonography in trauma. CONCLUSIONS: Surgical trainees in one UK training region lack skills in both diagnostic peritoneal lavage and focused abdominal sonography in trauma for managing blunt abdominal trauma and are therefore reliant upon the availability of prompt, skilled radiological assistance or emergency physician-provided focused abdominal sonography in trauma.

Castleman's disease associated with myasthenia gravis.

Castleman's disease presents as a peculiar type of lymph node hyperplasia. Traditionally, the disease has been classified on clinical grounds (solitary or multicentric) and by histologic appearance (hyaline vascular pattern, plasma cell predominance, or mixed lesions). It is now increasingly clear that there are different etiologies for each of these different subtypes. Reported associations include POEMS syndrome (polyneuropathy, organomegally, endocrinopathy, monoclonal gammopathy, and skin changes), paraneoplastic pemphigus, Hodgkin's disease, and follicular dendritic cell sarcoma. We present a case of Castleman's disease associated with myasthenia gravis, the third reported case in the literature. We discuss Castleman's disease and review the literature.