Search

This article outlines the position of The Eastern Association of the Surgery of Trauma (EAST) in defining the role of surgeons, and specifically trauma/critical care surgeons, in the development of public health initiatives that are designed to react to and deal effectively with acts of terrorism. All aspects of the surgeon's role in response to mass casualty incidents are considered, from prehospital response teams to the postevent debriefing. The role of the surgeon in response to mass casualty incidents (MCIs) is substantial in response to threats and injury from natural, unintentional, and intentional disasters. The surgeon must take an active role in pre-event community preparation in training, planning, and executing the response to MCI. The marriage of initiatives among Departments of Public Health, the Department of Homeland Security, and existing trauma systems will provide a template for successful responses to terrorist acts.

Spine injuries after gunshot wounds are thought to be rare among asymptomatic patients. The occurrence of spine injuries among asymptomatic patients with gunshot wounds was studied to determine the necessity for mandatory spine immobilization and radiographic imaging.In this retrospective cohort study, initial physical examination, radiographic findings, and final diagnosis and treatment were reviewed. Patients were included if they were admitted to the authors' level 1 trauma center with gunshot wounds to the head, neck, or trunk during a 10-year period. Spine injuries were considered "significant" if the injury was associated with spinal cord injury or required spine-related surgical procedures or prolonged spine immobilization. Spine injuries were defined as "unsuspected" if there were no neurologic findings at admission.During the study period, 2,450 patients who survived more than 24 hours were admitted with gunshot wounds to the trunk, neck, or head. Of these patients, 244 (approximately 10%) had spine injuries, and 228 of them had complete records. Two thirds of the spine injuries were found to be significant, requiring surgery or prolonged immobilization, and 13% were unsuspected.Spine injuries without neurologic signs are not uncommon among patients with gunshot wounds. Complete radiographic spine imaging is therefore recommended to ensure that spine injuries are not missed in this population.

Approximately one third of stable patients with significant intra-abdominal injury do not have significant intraperitoneal blood evident on admission. We hypothesized that a delayed, repeat ultrasound study (Secondary Ultrasound--SUS) will reveal additional intra-abdominal injuries and hemoperitoneum.We performed a prospective observational study of trauma patients at our Level I trauma center from April 2003 to December 2003. Patients underwent an initial ultrasound (US), followed by a SUS examination within 24 hours of admission. Patients not eligible for a SUS because of early discharge, operative intervention or death were excluded. All US and SUS exams were performed and evaluated by surgical/emergency medicine house staff or surgical attendings.Five hundred forty-seven patients had both an initial US and a SUS examination. The sensitivity of the initial US in this patient population was 31.1% and increased to 72.1% on SUS (p0.001) for intra-abdominal injury or intra-abdominal fluid. The specificity for the initial US was 99.8% and 99.8% for SUS. The negative predictive value was 92.0% for the initial US and increased to 96.6% for SUS (p = 0.002). The accuracy of the initial ultrasound was 92.1% and increased to 96.7% on the SUS (p0.002). No patient with a negative SUS after 4 hours developed clinically significant hemoperitoneum.A secondary ultrasound of the abdomen significantly increases the sensitivity of ultrasound to detect intra-abdominal injury.

Background We recently reported that a new dressing, the Modified Rapid Deployment Hemostat (MRDH) controlled bleeding in hypothermic coagulopathic swine after traumatic liver avulsion. The purpose of this study was to evaluate the MRDH in coagulopathic trauma patients undergoing abbreviated laparotomy. Methods A prospective, observational clinical trial of the MRDH dressing was performed at our Level One Trauma Center in patients with high-grade visceral injuries with coagulopathy who failed conventional therapy and required packing. Attending surgeons graded the injury and the adequacy of hemostasis following application of the dressing. Patients were followed until discharge or death. Results Ten patients were enrolled: nine severe hepatic injuries, and one major abdominal vascular injury. All patients were hypothermic, acidotic, and clinically coagulopathic. Intraoperative hemostasis was immediately obtained after MRDH placement in all cases except one. There was one death. Conclusion The Modified Rapid Deployment Hemostat terminates bleeding from severe visceral injuries in coagulopathic patients undergoing abbreviated laparotomy.

Coagulopathy and hemorrhage are known contributors to trauma mortality; however, the actual relationship of prothrombin time (PT) and partial thromboplastin time (PTT) to mortality is unknown. Our objective was to measure the predictive value of the initial coagulopathy profile for trauma-related mortality.We reviewed prospectively collected data on trauma patients presenting to a Level I trauma center. A logistic regression analysis was performed of PT, PTT, platelet count, and confounders to determine whether coagulopathy is a predictor of all-cause mortality.From a trauma registry cohort of 20103 patients, 14397 had complete disposition data for initial analysis and 7638 had complete data for all variables in the final analysis. The total cohort was 76.2% male, the mean age was 38 years (range, 1-108 years), and the median Injury Severity Score was 9. There were 1276 deaths (all-cause mortality, 8.9%). The prevalence of coagulopathy early in the postinjury period was substantial, with 28% of patients having an abnormal PT (2994 of 10790) and 8% of patients having an abnormal PTT (826 of 10453) on arrival at the trauma bay. In patients with disposition data and a normal PT, 489 of 7796 died, as compared with 579 of 2994 with an abnormal PT (6.3% vs. 19.3%; chi2 = 414.1, p0.001). Univariate analysis generated an odds ratio of 3.6 (95% confidence interval [CI], 3.15-4.08; p0.0001) for death with abnormal PT and 7.81 (95% CI, 6.65-9.17; p0.001) for deaths with an abnormal PTT. The PT and PTT remained independent predictors of mortality in a multiple regression model, whereas platelet count did not. The model also included the independent risk factors age, Injury Severity Score, scene and trauma-bay blood pressure, hematocrit, base deficit, and head injury. The model generated an adjusted odds ratio of 1.35 for PT (95% CI, 1.11-1.68; p0.001) and 4.26 for PTT (95% CI, 3.23-5.63; p0.001).The incidence of coagulation abnormalities, early after trauma, is high and they are independent predictors of mortality even in the presence of other risk factors. An initial abnormal PT increases the adjusted odds of dying by 35% and an initial abnormal PTT increases the adjusted odds of dying by 326%.

Background: Tourniquet application is a known means for bleeding prevention in the military prehospital setting. Methods: This study was a 4-year retrospective analysis of silicone and improvised tourniquet applications by Israeli Defense Force soldiers. Results: Of 550 soldiers who were treated in the prehospital setting, tourniquets were applied to 91 (16%) patients and in less than 15 minutes in 88% of the cases with almost no complications. Penetrating trauma was the main mechanism of injury. The indication was situational and nonmedical in 58 (53%) of the cases. The patients' ischemic time was 83 ± 52 minutes (range, 1-305 minutes). A total of 78% of applications were effective, with higher success rates for medical staff compared with fellow soldiers and for upper limbs (94%) compared with lower limbs (71%,p < 0.01). Conclusion: Tourniquet application is an effective and easily applied (by medical and nonmedical personnel) method for prevention of exsanguination in the military prehospital setting.

Background: Recombinant factor VIIa (rFVIIa) is used for treatment of bleeding episodes in hemophilia patients who develop inhibitors to factors VIII and IX. We tested the hypothesis that administration of rFVIIa early after injury would decrease bleeding and prolong the time from injury to death after experimental hepatic trauma. Methods: Anesthetized swine were cannulated for blood sampling and hemodynamic monitoring. Avulsion of the left median lobe of the liver induced uncontrolled hemorrhage. After a 10% reduction in mean arterial pressure, animals (n = 8 per group) were blindly randomized to receive intravenous rFVIIa 180 μg/kg, rFVIIa 720 μg/kg, or placebo. Pathologic examination of brain, lung, kidney, heart, and small bowel was performed to assess intravascular thrombosis. Results: Mortality during the first hour was 50% (four of eight) in controls versus 0% with rFVIIa 720 μg/kg (p = 0.02, X 2 ). Blood loss was decreased in the rFVIIa 720 μg/kg group versus the placebo group (13.2 ± 5.5 mL/kg vs. 21.9 ± 7.7 mL/kg; p = 0.0223). Time from injury to death was significantly prolonged in the rFVIIa 720 μg/kg group compared with placebo (116 minutes vs. 8.5 ± 3.5 minutes; p = 0.02). No macro- or microthrombi in vital organs were identified on pathologic examination. Conclusion: Intravenous administration of high-dose rFVIIa early after induction of hemorrhage decreased bleeding and prolonged survival. No evidence of thrombosis in vital organs was observed.

Background: Recombinant factor VIIa (rFVIIa) is used for treatment of bleeding episodes in hemophilia patients who develop inhibitors to factors VIII and IX. We tested the hypothesis that administration of rFVIIa early after injury would decrease bleeding and improve survival after experimental hepatic trauma. Methods: Anesthetized swine were cannulated for blood sampling and hemodynamic monitoring. Avulsion of left median lobe of the liver induced uncontrolled hemorrhage. After a 10% reduction of mean arterial pressure, animals were blindly randomized to receive intravenous rFVIIa (180 μg/kg) (n = 6) or placebo (n = 7). Results: Mortality was 43% (three of seven) in controls versus 0% with rFVIIa (p = 0.08, X 2 ). Significantly shorter prothrombin time and higher mean arterial pressures were observed in the rFVIIa group. Conclusion: Intravenous administration of rFVIIa early after induction of hemorrhage shortens prothrombin time and improves mean arterial pressure. A trend toward improved survival was observed.

BACKGROUND: Postmortem examination serves as a tool for confirmation of clinical diagnosis, "quality" assurance, and education. In Israel, mostly because of religious reasons, most families withhold their permission to perform autopsies. To obtain objective information regarding the death of soldiers, the Israel Defense Forces Medical Corps started in September of 1997 to perform postmortem computed tomographic (PMCT) scans. The purpose of our study is to determine what information can be obtained from the PMCT scans. METHODS: In a period of 16 months, 27 soldiers were killed in low-intensity conflicts and PMCT was obtained in 22 cases. Medical data obtained from the field medical care providers were collected and compared with PMCT results. RESULTS: Several examples of patients whose death was determined at the scene either before any medical intervention or after initiation of resuscitative treatment are shown in our study and compared with the clinical impression of the treating physician. Two examples of autopsy results are compared with PMCT results. Gas was detected in various parts of the circulatory system in many cases. The significance of this finding, described in our study for the first time, needs further investigation. CONCLUSION: PMCT scanning has limits in detecting superficial injuries and injuries of the extremities and determining the exact route of fragments through body tissues in penetrating military trauma. It also cannot serve as a tool for examining ammunition or the protection provided by various armors. However, it can provide a substantial amount of evidence that, when reviewed with the clinical information obtained from the physician at the scene, can help in assessing the treatment given at the field and point toward the probable cause of death. Language: en

Objective: To determine whether surgeons and residents with minimal training can evaluate accurately emergency ultrasound (US) examinations compared with radiologists for blunt abdominal trauma. Methods: Over 7 months, we conducted a prospective study comparing the evaluation of emergency US for blunt abdominal trauma by surgeons and attending radiologists. US readings from the surgical team and the radiologists were correlated with outcome. Results: One hundred-twelve patients were included in the study. Ninety-two patients had an US read as negative by the surgical and radiology services with no subsequent injuries identified. Eighteen patients had an US deemed positive by the surgical service and radiologists. Injuries were confirmed in this group by operation or computed tomography. One patient had an US deemed positive by the surgical team and subsequently negative by the radiologist. A diagnostic peritoneal lavage was performed which was negative. Another patient had an US interpreted as negative by the surgical evaluator and positive by the radiologist. Exploratory laparotomy was negative for intraabdominal hemorrhage or organ injury. Overall results reveal an accuracy on US reading of 99% for the surgical team and 99% for the attending radiologists. Conclusion: Surgeons and surgical residents at different levels of training can accurately interpret emergency ultrasound examinations for blunt trauma from the real-time images, at a level comparable to attending radiologists.