Hematomas in Tiger Territory: An Endovascular Alternative to Wading In.

A 26-year-old man presented with gunshot wound to the epigastrium. At surgery, he was hemodynamically stable and had a tense hematoma with thrill in zone 2 (right side) and porta triad. After liver injury was controlled, he underwent percutaneous stenting of a renal artery-vena cava fistula and the hepatic artery injury was followed. Historically, penetrating injury to zone 2 has mandated operative exploration. However, with the advent of endovascular options, in stable patients, catheter-based options offer a reasonable alternative with less risk of blood loss and possible nephrectomy. Renal artery stenting has been advocated for renal artery cava fistulas. The role of timing, hybrid operating suites, and traditional operative exposure will vary based on presentation and institutional capabilities.

Model for Team Training Using the Advanced Trauma Operative Management Course: Pilot Study Analysis.

BACKGROUND: Education and training of surgeons has traditionally focused on the development of individual knowledge, technical skills, and decision making. Team training with the surgeon's operating room staff has not been prioritized in existing educational paradigms, particularly in trauma surgery. We aimed to determine whether a pilot curriculum for surgical technicians and nurses, based on the American College of Surgeons' Advanced Trauma Operative Management (ATOM) course, would improve staff knowledge if conducted in a team-training environment. METHODS: Between December 2012 and December 2014, 22 surgical technicians and nurses participated in a curriculum complementary to the ATOM course, consisting of 8 individual 8-hour training sessions designed by and conducted at our institution. Didactic and practical sessions included educational content, hands-on instruction, and alternating role play during 5 system-specific injury scenarios in a simulated operating room environment. A pre- and postcourse examination was administered to participants to assess for improvements in team members' didactic knowledge. RESULTS: Course participants displayed a significant improvement in didactic knowledge after working in a team setting with trauma surgeons during the ATOM course, with a 9-point improvement on the postcourse examination (83%-92%, p = 0.0008). Most participants (90.5%) completing postcourse surveys reported being "highly satisfied" with course content and quality after working in our simulated team-training setting. CONCLUSIONS: Team training is critical to improving the knowledge base of surgical technicians and nurses in the trauma operative setting. Improved communication, efficiency, appropriate equipment use, and staff awareness are the desired outcomes when shifting the paradigm from individual to surgical team training so that improved patient outcomes, decreased risk, and cost savings can be achieved. OBJECTIVE: Determine whether a pilot curriculum for surgical technicians and nurses, based on the American College of Surgeons' ATOM course, improves staff knowledge if conducted in a team-training environment. DESIGN: Surgical technicians and nurses participated in a curriculum complementary to the ATOM course. In all, 8 individual 8-hour training sessions were conducted at our institution and contained both didactic and practical content, as well as alternating role play during 5 system-specific injury scenarios. A pre- and postcourse examination was administered to assess for improvements in didactic knowledge. SETTING: The course was conducted in a simulated team-training setting at the Legacy Institute for Surgical Education and Innovation (Portland, OR), an American College of Surgeons Accredited Educational Institute. PARTICIPANTS: In all, 22 surgical technicians and operating room nurses participated in 8 separate ATOM(s) courses and had at least 1 year of surgical scrubbing experience in general surgery with little or no exposure to Level I trauma surgical care. Of these participants, 16 completed the postcourse examination. RESULTS: Participants displayed a significant improvement in didactic knowledge (83%-92%, p = 0.0008) after the ATOM(s) course. Of the 14 participants who completed postcourse surveys, 90.5% were "highly satisfied" with the course content and quality. CONCLUSIONS: Team training is critical to improving the knowledge base of surgical technicians and nurses in the trauma operative setting and may contribute to improved patient outcomes, decreased risk, and hospital cost savings.

Management of pediatric occult pneumothorax in blunt trauma: a subgroup analysis of the American Association for the Surgery of Trauma multicenter prospective observational study.

BACKGROUND: Occult pneumothorax (OPTX) represents air within the pleural space not visible on conventional chest radiographs. Increased use of computed tomography has led to a rise in the detection of OPTX. Optimal management remains undefined. METHODS: A pediatric subgroup analysis (age <18 years) from a multicenter, observational study evaluating OPTX management. Data analyzed were pneumothorax size, management outcome, and associated risk factors to characterize those that may be safely observed. RESULTS: Fifty-two OPTX (7.3 ± 6.2 mm) in 51 patients were identified. None were greater than 27 mm; all those under 16.5 mm (n = 48) were successfully managed without intervention. Two patients underwent initial tube thoracostomy (one [21 mm] and the other with bilateral OPTX [24 mm, 27 mm]). Among patients under observation (n = 49), OPTX size progressed in 2; one (6.4mm) required no treatment, while one (16.5 mm) received elective intervention. Respiratory distress occurred in one patient (10.7 mm) who did not require tube thoracostomy. Nine received positive pressure ventilation; 8 did not have a tube thoracostomy. Twenty-four patients (51%) had one or more rib fractures; 3 required tube thoracostomy. CONCLUSION: No pediatric OPTX initially observed developed a tension pneumothorax or adverse event related to observation. Pediatric patients with OPTX less than 16 mm may be safely observed. Neither the presence of rib fractures nor need for PPV alone necessitates intervention.

Blunt traumatic occult pneumothorax: is observation safe?--results of a prospective, AAST multicenter study.

BACKGROUND: An occult pneumothorax (OPTX) is found incidentally in 2% to 10% of all blunt trauma patients. Indications for intervention remain controversial. We sought to determine which factors predicted failed observation in blunt trauma patients. METHODS: A prospective, observational, multicenter study was undertaken to identify patients with OPTX. Successfully observed patients and patients who failed observation were compared. Multivariate logistic regression was used to identify predictors of failure of observation. OPTX size was calculated by measuring the largest air collection along a line perpendicular from the chest wall to the lung or mediastinum. RESULTS: Sixteen trauma centers identified 588 OPTXs in 569 blunt trauma patients. One hundred twenty-one patients (21%) underwent immediate tube thoracostomy and 448 (79%) were observed. Twenty-seven patients (6%) failed observation and required tube thoracostomy for OPTX progression, respiratory distress, or subsequent hemothorax. Fourteen percent (10 of 73) failed observation during positive pressure ventilation. Hospital and intensive care unit lengths of stay, and ventilator days were longer in the failed observation group. OPTX progression and respiratory distress were significant predictors of failed observation. Most patient deaths were from traumatic brain injury. Fifteen percentage of patients in the failed observation group developed complications. No patient who failed observation developed a tension PTX, or experienced adverse events by delaying tube thoracostomy. CONCLUSION: Most blunt trauma patients with OPTX can be carefully monitored without tube thoracostomy; however, OPTX progression and respiratory distress are independently associated with observation failure.

Natural history of traumatic rupture of the thoracic aorta managed nonoperatively: a longitudinal analysis.

BACKGROUND: Although traumatic rupture of the thoracic aorta (TRA) has traditionally been considered a surgical emergency, there exists a small patient population for whom nonoperative management may be appropriate. The short- and long-term consequences of patients managed in a nonoperative fashion remain unclear. METHODS: A review of patients admitted with TRA over a period of 16 years was performed. Patients who did not undergo operative repair within 24 hours of injury and diagnosis comprised the study group. RESULTS: One hundred forty-five patients were admitted with TRA. Of these, 30 underwent a period of nonoperative management. The mean age of the study patients was 44 +/- 21 years, 80% were male, and the mean Injury Severity Score (ISS) was 34 +/- 9. Fifteen patients underwent delayed operation (DELAY group) at more than 24 hours after injury and diagnosis and 15 patients never underwent repair (NON-OP group). The median time to operation in the DELAY group was 3 days (range 2 to 90). Three patients exhibited progression of TRA within 5 days of injury and of these, 2 died. A total of 3 deaths occurred in the DELAY group (1 rupture and 2 intraoperative arrests). The fifteen NON-OP patients were significantly older (mean age 52 +/- 22 versus 36 +/- 18 years; p = 0.03), tended to be more severely injured (mean ISS 36 +/- 9 versus 32 +/- 8; p = 0.2), and had more premorbid risk factors than the DELAY patients. Five NON-OP patients died, all because of severe head injuries. On long-term follow-up of NON-OP patients, all 10 survivors are alive at a median of 2.5 years (range 6 months to 5 years) without progression of injury or the need for operation. Five of the 10 had complete radiographic resolution of their injuries and 5 have asymptomatic and radiographically stable pseudoaneurysms. CONCLUSIONS: Selected patients with multiple severe associated injuries or high-risk premorbid conditions may have their operations for TRA delayed temporarily or even indefinitely with acceptable survival rates. The potential for rapid progression of TRA in the same patients, however, mandates serial radiographic examinations during the first week of hospitalization after injury and diagnosis.

Is delayed laparotomy for blunt abdominal trauma a valid quality improvement measure in the era of nonoperative management of abdominal injuries?

BACKGROUND: Review of hemodynamically stable patients who undergo laparotomy for trauma greater than 4 hours after admission is an American College of Surgeons quality improvement filter. We reviewed our recent experience with patients who underwent laparotomy for trauma greater than 4 hours after admission to evaluate the reasons for delay, and to determine whether they were because of failure of nonoperative management or other causes. METHODS: The registry at our Level I trauma center was searched from January 1998 through December 2000 for patients who required a laparotomy for trauma greater than 4 hours after admission. Of 3,369 admitted blunt trauma patients, 90 (2.7%) underwent laparotomy for trauma, of which 26 (29%) were identified as delayed laparotomies greater than 4 hours after admission. RESULTS: The most common mechanism of injury was motor vehicle crash, the mean Injury Severity Score was 18, and 65% of the patients had significant distracting injuries. Five patients had laparotomy greater than 24 hours after admission. The average time to the operating room in the remaining patients was 8.6 hours. Clinical examination (61%) findings were the most common indication for operation. Gastrointestinal (GI) tract injury was the most common injury associated with delay in laparotomy (58%). CONCLUSION: GI tract injuries are the predominant injury leading to delayed laparotomy for blunt trauma (58%). Failed nonoperative management of solid organ injuries occurred less frequently (15%). Future efforts should concentrate on earlier identification of GI tract injury. Delayed laparotomy for blunt abdominal trauma is a valid quality improvement measure.