American Association for the Surgery of Trauma Prevention Committee topical update: Impact of community violence exposure, intimate partner violence, hospital-based violence intervention, building community coalitions and injury prevention program evaluation.

An effective injury prevention program is an important component of a successful trauma system. Maintaining support for a hospital-based injury prevention program is challenging, given competing institutional and trauma program priorities and limited resources. In light of those pressures, the American College of Surgeons Committee on Trauma mandates that trauma centers demonstrate financial support for an injury prevention program as part of the verification process, recognizing that hospital administrators might see such support as discretionary and ripe as a target for expense reduction efforts. This Topical Update from the American Association for the Surgery of Trauma Injury Prevention Committee focuses on strategies to be more effective with the limited resources that are allocated to hospital-based injury prevention programs. First, this review tackles two of the many social determinates of violence, including activities aimed at mitigating the impact of both community violence exposure and intimate partner/domestic violence. Developing or participating in coalitions for injury prevention, both in general with any injury prevention initiative, and specifically while developing a hospital-based violence intervention program, efficiently extends the hospital's efforts by gaining access to expertise, resources, and influence over the target population that the hospital might otherwise have difficulty impacting. Finally, the importance of systematic program evaluation is explored. In an era of dwindling resources for injury prevention, both at the national level and the institutional level, it is important to measure the effectiveness of injury prevention efforts on the target population, and when necessary, make changes to programs to both improve their effectiveness and to assist organizations in making wise choices in the use of their limited resources.

Does Pain Have a Role When It Comes to Tourniquet Training?

BACKGROUND: One of the greatest conundrums with tourniquet (TQ) education is the use of an appropriate surrogate of hemorrhage in the training setting to determine whether a TQ has been successfully used. At our facility, we currently use loss of audible Doppler signal or loss of palpable pulse to represent adequate occlusion of vasculature and thus successful TQ application. We set out to determine whether pain can be used to indicate successful TQ application in the training setting. METHODS: Three tourniquet systems (a pneumatic tourniquet, Combat Application Tourniquet® [C-A-T], and Stretch Wrap and Tuck Tourniquet™ [SWAT-T]) were used to occlude the arterial vasculature of the left upper arm (LUA), right upper arm (RUA), left forearm (LFA), right forearm (RFA), right thigh (RTH), and right calf (RCA) of 41 volunteers. A 4MHz, handheld Doppler ultrasound was used to confirm loss of Doppler signal (LOS) at the radial or posterior tibial artery to denote successful TQ application. Once successful placement of the TQ was noted, subjects rated their pain from 0 to 10 on the visual analog scale. In addition, the circumference of each limb, the pressure with the pneumatic TQ, number of twists with the C-A-T, and length of TQ used for the SWAT-T to obtain LOS was recorded. RESULTS: All 41 subjects had measurements at all anatomic sites with the pneumatic TQ, except one participant who was unable to complete the LUA. In total, pain was rated as 1 or less by 61% of subjects for LUA, 50% for LFA, 57.5% for RUA, 52.5% RFA, 15% for RTH, and 25% for RCA. Pain was rated 3 or 4 by 45% of subjects for RTH. For the C-A-T, data were collected from 40 participants. In total, pain was rated as 1 or less by 57.5% for the LUA, 70% for the LFA, 62.5% for the RUA, 75% for the RFA, 15% for the RTH, and 40% for the RCA. Pain was rated 3 or 4 by 42.5%. The SWAT-T group consisted of 37 participants for all anatomic locations. In total, pain was rated as 1 or less by 27% for LUA, 40.5% for the LFA, 27.0% for the RUA, 43.2 for the RFA, 18.9% for the RTH, and 16.2% for the RCA. Pain was rated 5 by 21.6% for RTH application, and 3 or 4 by 35%. CONCLUSION: The unexpected low pain values recorded when loss of signal was reached make the use of pain too sensitive as an indicator to confirm adequate occlusion of vasculature and, thus, successful TQ application.

Taser X26 discharges in swine: ventricular rhythm capture is dependent on discharge vector.

BACKGROUND: Data from our previous studies indicate that Taser X26 stun devices can acutely alter cardiac function in swine. We hypothesized that most transcardiac discharge vectors would capture ventricular rhythm, but that other vectors, not traversing the heart, would fail to capture the ventricular rhythm. METHODS: Using an Institutional Animal Care and Use Committee (IACUC) approved protocol, four Yorkshire pigs (25-36 kg) were anesthetized, paralyzed with succinylcholine (2 mg/kg), and then exposed to 10 second discharges from a police-issue Taser X26. For most discharges, the barbed darts were pushed manually into the skin to their full depth (12 mm) and were arranged in either transcardiac (such that a straight line connecting the darts would cross the region of the heart) or non-transcardiac vectors. A total of 11 different vectors and 22 discharge conditions were studied. For each vector, by simply rotating the cartridge 180-degrees in the gun, the primary current-emitting dart was changed and the direction of current flow during the discharge was reversed without physically moving the darts. Echocardiography and electrocardiograms (ECGs) were performed before, during, and after all discharges. p values < 0.05 were considered significant. RESULTS: ECGs were unreadable during the discharges because of electrical interference, but echocardiography images clearly demonstrated that ventricular rhythm was captured immediately in 52.5% (31 of 59) of the discharges on the ventral surface of the animal. In each of these cases, capture of the ventricular rhythm with rapid ventricular contractions consistent with ventricular tachycardia (VT) or flutter was seen throughout the discharge. A total of 27 discharges were administered with transcardiac vectors and ventricular capture occurred in 23 of these discharges (85.2% capture rate). A total of 32 non-transcardiac discharges were administered ventrally and capture was seen in only eight of these (25% capture rate). Ventricular fibrillation (VF) was seen with two vectors, both of which were transcardiac. In the remaining animals, VT occurred postdischarge until sinus rhythm was regained spontaneously. CONCLUSIONS: For most transcardiac vectors, Taser X26 caused immediate ventricular rhythm capture. This usually reverted spontaneously to sinus rhythm but potentially fatal VF was seen with two vectors. For some non-transcardiac vectors, capture was also seen but with a significantly (p < 0.0001) decreased incidence.

TASER X26 discharges in swine produce potentially fatal ventricular arrhythmias.

OBJECTIVES: Data from the authors and others suggest that TASER X26 stun devices can acutely alter cardiac function in swine. The authors hypothesized that TASER discharges degrade cardiac performance through a mechanism not involving concurrent acidosis. METHODS: Using an Institutional Animal Care and Use Committee (IACUC)-approved protocol, Yorkshire pigs (25-71 kg) were anesthetized, paralyzed with succinylcholine (SCh; 2 mg/kg), and then exposed to two 40-second discharges from a TASER X26 with a transcardiac vector. Vital signs, blood chemistry, and electrolyte levels were obtained before exposure and periodically for 48 hours postdischarge. Electrocardiograms and echocardiography (echo) were performed before, during, and after the discharges. p-Values < 0.05 were considered significant. RESULTS: Electrocardiograms were unreadable during the discharges due to electrical interference, but echo images showed unmistakably that cardiac rhythm was captured immediately at a rate of 301 +/- 18 beats/min (n = 8) in all animals tested. Capture continued for the duration of the discharge and in one animal degenerated into fatal ventricular fibrillation (VF). In the remaining animals, ventricular tachycardia (VT) occurred postdischarge for 1-17 seconds, whereupon sinus rhythm was regained spontaneously. Blood chemistry values and vital signs were minimally altered postdischarge and no significant acidosis was seen. CONCLUSIONS: Extreme acid-base disturbances usually seen after lengthy TASER discharges were absent with SCh, but TASER X26 discharges immediately and invariably produced myocardial capture. This usually reverted spontaneously to sinus rhythm postdischarge, but fatal VF was seen in one animal. Thus, in the absence of systemic acidosis, lengthy transcardiac TASER X26 discharges (2 x 40 seconds) captured myocardial rhythm, potentially resulting in VT or VF in swine.

Acute effects of TASER X26 discharges in a swine model.

BACKGROUND: Very little objective laboratory data are available describing the physiologic effects of stun guns or electromuscular incapacitation devices (EIDs). Unfortunately, there have been several hundred in-custody deaths, which have been temporally associated with the deployment of these devices. Most of the deaths have been attributed to specific cardiac and metabolic effects. We hypothesized that prolonged EID exposure in a model animal system would induce clinically significant metabolic acidosis and cardiovascular disturbances. METHODS: Using an Institutional Animal Care and Use Committee-approved protocol, 11 standard pigs (6 experimentals and 5 sham controls) were anesthetized with ketamine and xylazine. The experimentals were exposed to two 40-second discharges from an EID (TASER X26, TASER Intl., Scottsdale, AZ) across the torso. Electrocardiograms, blood pressure, troponin I, blood gases, and electrolyte levels were obtained pre-exposure and at 5, 15, 30, and 60 minutes and 24, 48, and 72 hours postdischarge. p values <0.05 were considered significant. RESULTS: Two deaths were observed immediately after TASER exposure from acute onset ventricular fibrillation (VF). In surviving animals, heart rate was significantly increased and significant hypotension was noted. Acid-base status was dramatically affected by the TASER discharge at the 5-minute time point and throughout the 60-minute monitoring period. Five minutes postdischarge, central venous blood pH (6.86 +/- 0.07) decreased from baseline (7.45 +/- 0.02; p = 0.0004). Pco2 (94.5 mm Hg +/- 14.8 mm Hg) was significantly increased from baseline (45.3 mm Hg +/- 2.6 mm Hg) and bicarbonate levels significantly decreased (15.7 mmol/L +/- 1.04 mmol/L) from baseline (30.4 mmol/L +/- 0.7 mmol/L). A large, significant increase in lactate occurred postdischarge (22.1 mmol/L +/- 1.5 mmol/L) from baseline (1.5 mmol/L +/- 0.3 mmol/L). All values returned to normal by 24 hours postdischarge in surviving animals. A minor, nonsignificant increase in troponin I was seen at 24 hours postdischarge (0.052 ng/mL +/- 0.030 ng/mL, mean +/- SEM). CONCLUSIONS: Immediately after the discharge, two deaths occurred because of ventricular fibrillation. In this model of prolonged EID exposure, clinically significant acid-base and cardiovascular disturbances were clearly seen. The severe metabolic and respiratory acidosis seen here suggests the involvement of a primary cardiovascular mechanism.

Repeated thoracic discharges from a stun device.

BACKGROUND: Little objective laboratory data are available describing the physiologic effects of stun guns or electromuscular incapacitation (EMI) devices, but increasing morbidity and even deaths are associated with their use. We hypothesized that exposure to EMI discharges in a model animal system would induce clinically significant acidosis and cardiac arrhythmia. METHODS: Ten Yucatan mini-pigs, six experimental and four sham controls, were anesthetized with ketamine, xylazine, and glycopyrrolate. Experimental pigs were exposed to two 40-second discharges from an EMI device over the left thorax. Electrocardiograms, troponin I, blood gases, and lactate levels were obtained pre-exposure, at 5, 15, 30, 60 minutes, and at 24, 48, and 72 hours postdischarge. RESULTS: No acute or delayed cardiac arrhythmias were seen. Heart rate was not affected significantly (p>0.05). A subclinical increase in troponin I was seen at 24 hours postdischarge (0.040+/-0.030 ng/mL, p>0.05). Central venous blood pH (7.432+/-0.014) and pCO2 (36.1+/-0.9 mm Hg) were not changed significantly (p>0.05) during the 60-minute postdischarge period. A moderate significant increase in lactate occurred in the 5-minute postdischarge group (4.9+/-0.3 mmol/L, p=0.0179). All blood chemistry and vital signs were normal at 24, 48, and 72 hours postdischarge. CONCLUSIONS: Although significant changes in some parameters were seen, these changes were small and of little clinical significance. Lengthy EMI exposures did not cause extreme acidosis or cardiac arrhythmias. These findings may differ from those seen with other EMI devices because of the unique MK63 waveform characteristics or to specific characteristics of the model systems.

Detection of intra-abdominal injury using diagnostic peritoneal lavage after shotgun wound to the abdomen.

BACKGROUND: The utility of diagnostic peritoneal lavage (DPL) as a diagnostic tool specifically for shotgun wound to the abdomen (SGWA) is unknown. This prospective study was undertaken to determine the sensitivity, specificity, and accuracy of DPL for the detection of intra-abdominal injuries following SGWA. METHODS: DPL was performed on all patients sustaining SGWA who lacked a clear indication for laparotomy. Patients exceeding 10,000 red blood cells (RBC)/mm were taken for exploratory laparotomy. A prospective database was kept with information on wound location, DPL result, findings upon laparotomy and outcome. RESULTS: Thirty-two DPLs were performed at our urban Level I trauma center for SGWA. Of these, 8 patients had a positive DPL. Upon laparotomy, 7 patients were found to have intra-abdominal injuries, 6 of which required surgical intervention. One patient had no peritoneal penetration or intra-abdominal injury. Of the 24 patients that had a negative DPL, 1 subsequently developed indications for laparotomy and was found to have operative injuries. For predicting intra-abdominal injuries DPL has a sensitivity, specificity and accuracy of 87.5%, 95.8% and 93.8%, respectively. CONCLUSION: For patients presenting with SGWA who do not present with indications for immediate laparotomy, DPL is a reliable indicator of intra-abdominal injury and need for operative intervention.

Trans-mediastinal gunshot wounds: are "stable" patients really stable?

Gunshot wounds that traverse the mediastinum frequently cause serious injury to the cardiac, vascular, pulmonary, and digestive structures contained within. Most patients present with unstable vital signs signifying the need for emergency operation. An occasional patient will present with stable vital signs. Work-ups for such a patient may range from surgical exploration to radiographic and endoscopic testing to mere observation. We report our experience with diagnostic work-up of the stable patient with a transmediastinal gunshot wound. All stable patients who present to our urban level I trauma center following a transmediastinal gunshot wound undergo diagnostic work-up consisting of chest radiograph, cardiac ultrasound, angiography, esophagoscopy, barium swallow, and bronchoscopy. The work-up is dependent on the trajectory of the missile. Information on these patients is kept in a prospective database maintained by the trauma attending physicians. This database was analyzed and comparisons were made using Student's t-test and the Fisher exact c2 as appropriate. Over a 68-month period, 50 stable patients were admitted following a transmediastinal gunshot wound. All of these patients had a chest radiograph followed by one or more of the above tests. 8 patients (16%) were found to have a mediastinal injury (4 cardiac, 3 vascular, and 1 tracheo-esophageal) requiring urgent operation (group 1). The remaining 42 patients (84%) did not have a mediastinal injury (group 2). There was no difference between groups with respect to blood pressure, pulse, respiratory rate, pH, base deficit, or initial chest tube output. There was one death in each group, and three complications in group 2. Patients may appear stable following a transmediastinal gunshot wound, even when they have life-threatening injuries. There is no difference in vital signs, blood gas, or hemothorax to indicate which patients have serious injuries. We advocate continued aggressive work-up of these patients to avoid missing an injury with disastrous consequences.