Search

Background: Despite advances and improvements in the management of surgical patients, emergency and trauma surgery is associated with high morbidity and mortality. This may be due in part to delays in definitive surgical management in the operating room (OR). There is a lack of studies focused on OR prioritization and resource allocation in emergency surgery. The Operating Room management for emergency Surgical Activity (ORSA) study was conceived to assess the management of operating theatres and resources from a global perspective among expert international acute care surgeons. Method: The ORSA study was conceived as an international web survey. The questionnaire was composed of 23 multiple-choice and open questions. Data were collected over 3 months. Participation in the survey was voluntary and anonymous. Results: One hundred forty-seven emergency and acute care surgeons answered the questionnaire; the response rate was 58.8%. The majority of the participants come from Europe. One hundred nineteen surgeons (81%; 119/147) declared to have at least one emergency OR in their hospital; for the other 20/147 surgeons (13.6%), there is not a dedicated emergency operating room. Forty-six (68/147)% of the surgeons use the elective OR to perform emergency procedures during the day. The planning of an emergency surgical procedure is done by phone by 70% (104/147) of the surgeons. Conclusions: There is no dedicated emergency OR in the majority of hospitals internationally. Elective surgical procedures are usually postponed or even cancelled to perform emergency surgery. It is a priority to validate an effective universal triaging and scheduling system to allocate emergency surgical procedures. The new Timing in Acute Care Surgery (TACS) was recently proposed and validated by a Delphi consensus as a clear and reproducible triage tool to timely perform an emergency surgical procedure according to the clinical severity of the surgical disease. The new TACS needs to be prospectively validated in clinical practice. Logistics have to be assessed using a multi-disciplinary approach to improve patients' safety, optimise the use of resources, and decrease costs.

Following the innovations and new discoveries of the last 10 years in the field of lung ultrasound (LUS), a multidisciplinary panel of international LUS experts from six countries and from different fields (clinical and technical) reviewed and updated the original international consensus for point‐of‐care LUS, dated 2012. As a result, a total of 20 statements have been produced. Each statement is complemented by guidelines and future developments proposals. The statements are furthermore classified based on their nature as technical (5), clinical (11), educational (3), and safety (1) statements.

Shorter time to emergency department aortic occlusion did not improve survival in noncompressible torso hemorrhage. “Scoop and control” with hemostatic resuscitation closer to the point of injury needs special consideration.Introduction:Time is an essential element in outcomes of trauma patients. The relationship of time to treatment in management of noncompressible torso hemorrhage (NCTH) with resuscitative endovascular balloon occlusion of the aorta (REBOA) or resuscitative thoracotomy (RT) has not been previously described. We hypothesized that shorter times to intervention would reduce mortality. Methods:A review of the Aortic Occlusion for Resuscitation in Trauma and Acute Care Surgery registry from 2013 to 2022 was performed to identify patients who underwent emergency department aortic occlusion (AO). Multivariate logistic regression was used to examine the impact of time to treatment on mortality. Results:A total of 1,853 patients (1,245 [67%] RT, 608 [33%] REBOA) were included. Most patients were male (82%) with a median age of 34 years (interquartile range, 30). Median time from injury to admission and admission to successful AO were 31 versus 11 minutes, respectively. Patients who died had shorter median times from injury to successful AO (44 vs. 72 minutes, P< 0.001) and admission to successful AO (10 vs. 22 minutes, P< 0.001). Multivariate logistic regression demonstrated that receiving RT was the strongest predictor of mortality (odds ratio [OR], 6.6; 95% confidence interval [CI], 4.4–9.9; P< 0.001). Time from injury to admission and admission to successful AO were not significant. This finding was consistent in subgroup analysis of RT-only and REBOA-only populations. Conclusions:Despite expedited interventions, time to aortic occlusion did not significantly impact mortality. This may suggest that rapid in-hospital intervention was often insufficient to compensate for severe exsanguination and hypovolemia that had already occurred before emergency department presentation. Selective prehospital advanced resuscitative care closer to the point of injury with “scoop and control” efforts including hemostatic resuscitation warrants special consideration.

To link to full-text access for this article, visit this link: http://dx.doi.org/10.1016/j.amjsurg.2008.12.016 Byline: Paul B. McBeth (a), Chad G. Ball (b)(c)(d), Robert H. Mulloy (a), Andrew W. Kirkpatrick (a)(e)(f) Keywords: Trauma; Skiing; Snowboarding; Injury patterns Abstract: Alpine skiing and snowboarding are popular winter sports in Canada. Every year participation in these activities results in traumatic injury. The purpose of this study was to identify the incidence and injury patterns, as well as risk factors associated with ski and snowboarding injuries. Author Affiliation: (a) Department of Surgery, Foothills Medical Centre, University of Calgary, 1403-29th St. N.W., Calgary, Alberta T2N 2T9, Canada (e) Department of Critical Care Medicine, Foothills Medical Centre, University of Calgary, Calgary, Alberta, Canada (f) Regional Trauma Program, Foothills Medical Centre, University of Calgary, Calgary, Alberta, Canada (b) Department of Trauma, Grady Memorial Hospital, Emory University, Atlanta, GA, USA (c) Department of Surgery, Grady Memorial Hospital, Emory University, Atlanta, GA, USA (d) Department of Critical Care, Grady Memorial Hospital, Emory University, Atlanta, GA, USA Article History: Received 8 November 2008; Revised 29 December 2008

To link to full-text access for this article, visit this link: http://dx.doi.org/10.1016/j.amjsurg.2007.01.016 Byline: Chad G. Ball (a), Jill E. Ball (b), Andrew W. Kirkpatrick (a)(c)(d), Robert H. Mulloy (a)(d) Keywords: Equestrian; Injury; Trauma; Risk factors Abstract: Horseback riding is more dangerous than motorcycle riding, skiing, football, and rugby. The purpose of this study was to identify the incidence and injury patterns, as well as risk factors associated with severe equestrian trauma. Author Affiliation: (a) Department of Surgery, Foothills Medical Centre, 10th Floor, North Tower, 403 29th St. NW, Calgary, Alberta, Canada T2N 2T9 (b) Department of Occupational Therapy, Foothills Medical Centre, 3rd Floor, Special Services Bld, 403 29th Street, NW, Calgary, Alberta, Canada T2N 2T9 (c) Department of Critical Care Medicine, EG23, Foothills Medical Centre, 403 29th Street, NW, Calgary, Alberta, Canada T2N 2T9 (d) Trauma Program, Foothills Medical Centre, G780, 403 29th Street, NW, Calgary, Alberta, Canada T2N 2T9 Article History: Received 6 December 2006; Revised 21 January 2007

To link to full-text access for this article, visit this link: http://dx.doi.org/10.1016/j.amjsurg.2007.01.013 Byline: Paul B. McBeth (a), David A. Zygun (b), Sandy Widder (b)(c), Michael Cheatham (d), Imme Zengerink (e), Judy Glowa (b), Andrew W. Kirkpatrick (b)(c)(f) Keywords: Intra-abdominal pressure; Intra-abdominal pressure monitoring; Patient positioning; Ventilator-associated pneumonia Abstract: Intra-abdominal hypertension affects multiple organ systems. Current measurement standard requires supine positioning, which jeopardizes patient safety by increasing the risk for ventilator-associated pneumonia. This study evaluated the relationship between intra-abdominal pressure (IAP) and head-of-bed (HOB) positioning in critically ill intubated patients. Author Affiliation: (a) Faculty of Medicine, Foothills Medical Center, Foothills Hospital, University of Calgary, 1403-29th Street N.W., Calgary, Alberta, Canada, T2N 2T9 (b) Department of Critical Care Medicine, Foothills Medical Center, Foothills Hospital, University of Calgary, 1403-29th Street N.W., Calgary, Alberta, Canada, T2N 2T9 (c) Department of Surgery, Foothills Medical Center, Foothills Hospital, University of Calgary, 1403-29th Street N.W., Calgary, Alberta, Canada, T2N 2T9 (d) Department of Surgical Education, Orlando Regional Medical Center, 86 W. Underwood St., Orlando, FL 32806, USA (e) Faculty of Medicine, Maastricht University, Universiteitssingel 60, 6229 MD Maastricht, Limburg, The Netherlands (f) Regional Trauma Services, Foothills Medical Center, Foothills Hospital, University of Calgary, 1403-29th Street N.W., Calgary, Alberta, Canada, T2N 2T9 Article History: Received 6 December 2006; Revised 29 January 2007

To link to full-text access for this article, visit this link: http://dx.doi.org/10.1016/j.amjsurg.2006.02.013 Byline: Chad G. Ball (a), Andrew W. Kirkpatrick (a)(b), Serdar Yilmaz (a)(c), Mauricio Monroy (a)(c), Savvas Nicolaou (d), Anastasio Salazar (a)(c) Keywords: Renal allograft compartment syndrome; Renal transplantation Abstract: Renal allograft compartment syndrome (RACS) is early graft dysfunction secondary to retroperitoneal hypertension and resultant ischemia. Our purpose was to identify the incidence, therapies and outcomes of patients with RACS. Author Affiliation: (a) Department of Surgery, Foothills Medical Centre, 1403 29 St. N.W., Calgary, Alberta, Canada T2N 2T9 (b) Critical Care Medicine, Foothills Medical Centre, Calgary, Alberta, Canada (c) Transplantation, Foothills Medical Centre, Calgary, Alberta, Canada (d) Department of Radiology, Vancouver Hospital and Health Sciences Centre, Vancouver, British Columbia, Canada Article History: Received 24 November 2005; Revised 17 January 2006

Study objectives: Patients requiring prolonged admission to the ICU consume significant health-care resources and have a high rate of in-hospital death. The long-term mortality outcome of these patients has not [...]

Abstract Background: Aboriginal Canadians are considered to be at increased risk of major trauma. However, population-based studies characterizing the distribution, determinants and outcomes of major trauma in this group are [...]

AbstractBackground:New care paradigms are required to enable remote life-saving interventions (RLSIs) in extreme environments such as disaster settings. Informatics may assist through just-in-time expert remote-telementoring (RTM) or video-modelling (VM). Currently, RTM relies on real-time communication that may not be reliable in some locations, especially if communications fail. Neither technique has been extensively developed however, and both may be required to be performed by inexperienced providers to save lives. A pilot comparison was thus conducted.Methods:Procedure-naïve Search-and-Rescue Technicians (SAR-Techs) performed a tube-thoracostomy (TT) on a surgical simulator, randomly allocated to RTM or VM. The VM group watched a pre-prepared video illustrating TT immediately prior, while the RTM group were remotely guided by an expert in real-time. Standard outcomes included success, safety, and tube-security for the TT procedure.Results:There were no differences in experience between the groups. Of the 13 SAR-Techs randomized to VM, 12/13 (92%) placed the TT successfully, safely, and secured it properly, while 100% (11/11) of the TT placed by the RTM group were successful, safe, and secure. Statistically, there was no difference (P = 1.000) between RTM or VM in safety, success, or tube security. However, with VM, one subject cut himself, one did not puncture the pleura, and one had barely adequate placement. There were no such issues in the mentored group. Total time was significantly faster using RTM (P = .02). However, if time-to-watch was discounted, VM was quicker (P = .000).Conclusions:Random evaluation revealed both paradigms have attributes. If VM can be utilized during “travel-time,” it is quicker but without facilitating “trouble shooting.” On the other hand, RTM had no errors in TT placement and facilitated guidance and remediation by the mentor, presumably avoiding failure, increasing safety, and potentially providing psychological support. Ultimately, both techniques appear to have merit and may be complementary, justifying continued research into the human-factors of performing RLSIs in extreme environments that are likely needed in natural and man-made disasters.

The Gurd Family surgical legacy was deeply intertwined with National service in both World Wars. My own personal research mission has attempted to emulate such service, by enhancing the tools and techniques available to facilitate point-of-care diagnosis and resuscitation in extreme and adverse environments. Our efforts involving point-of-care diagnosis/resuscitation and the telementored guidance of those remotely responding to catastrophic injury have included collaborations with National Aeronautics and Space Administration (NASA) the Canadian Space Agency, the Canadian Forces, its democratic allies, and non-governmental surgical organizations. Research has been conducted in resuscitative suites and operating theaters, research laboratories, parabolic flight aircraft, on humanitarian surgical missions, and from ski-hills and firehalls. The initial phases of these efforts involved inaugural studies in resuscitative sonography including defining the Extended Focused Assessment with Sonography for Trauma (EFAST) examination. Although the original work was commissioned for Space Medicine, generalization to mainstream practice further justifies space medicine research. Iterative steps in advancing telementored resuscitation have subsequently involved the maturation of space-mandated telementored ultrasound support (TMUS), exploration of TMUS in terrestrial clinical practice, and the creation of increasingly mobile (hand-held) TMUS solutions. Subsequently it was recognized that teleultrasound is simply one informatic dimension of remote telemedicine, and current efforts are focused in a Program known as TeleMentored Ultrasound Supported Medical Interactions (TMUSMI) of remote responders required to intervene with catastrophic trauma. While this research program has yielded many techniques and findings that have benefited mainstream terrestrial practice, these investigations are currently ongoing, and we hope to demonstrate that TMUSMI may benefit all Canadians especially those in remote areas, as well as potentially every global inhabitant without immediate access to care. Further, we propose that to fully utilize these techniques, a new specialty, that of the remote medical mentor will be required, a new specialty that will require the creation and scientific validation of its principles and techniques.

Innovation can be variably defined, but when applied to healthcare is often considered to be the introduction of something new, whether an idea, method or device, into an unfilled void or needy environment. Despite the introduction of many positive surgical subspecialty altering concepts/devices however, epic failures are not uncommon. These failures can be dramatic in regards to both their human and economic costs. They can also be very public or more quiet in nature. As surgical leaders in our communities and advocates for patient safety and outcomes, it remains crucial that we meet new introductions in technology and patient care with a measured level of curiosity, skepticism and science-based conclusions. The aim of an expert committee was to identify the most dominant failures in technological innovation and/or dogmatic clinical beliefs within each major surgical subspecialty. In summary, this effort was pursued to highlight the past failures and remind surgeons to remain vigilant and appropriately skeptical with regard to the introduction of new innovations and clinical beliefs within our craft.

Tube thoracostomy (TT) is a common yet potentially life-saving trauma procedure. After successful placement however, securing a TT through suturing is a skillset that requires practice, risking that the TT may become dislodged during prehospital transport. The purpose of this study was to examine if the iTClamp was a simpler technique with equivalent effectiveness for securing TTs.

AbstractBackgroundControlling bleeding early in the prehospital and military setting is an extremely important and life-saving skill. Wound clamping is a newly introduced technique that may augment both the effectiveness and logistics of wound packing with any gauze product. As these devices may be inadvertently removed, the potential consequences of such were examined in a simulated, extreme, inadvertent disengagement.MethodsThe wound clamp used was an iTClamp (Innovative Trauma Care; Edmonton, Alberta, Canada) that was applied and forcefully removed (skin-pull) from the skin of both a human cadaver and swine. Sixty skin-pull tests were sequentially performed to measure the pull weight required to remove the device, any potential skin and device damage, how the device failed, and if the device could be re-applied.ResultsObservations of the skin revealed that other than the expected eight small needle holes from device application, no other damage to the skin was sustained in 98.3% of cases. Conversely, of the 60 devices pulled, 93.3% of the devices sustained no damage and all could be re-applied. Four (6.7%) of the devices remained in place despite a maximum pull weight >22lbF(pound-force). The mean pull weights for pin bar pull were (lbF): vertical 9.2 (SD=5.0); perpendicular 2.5 (SD=1.7); and parallel 5.3 (SD=3.1). For the encompassed pull position group, mean pull weights were (lbF): vertical 5.7 (SD=2.3); perpendicular 3.0 (SD=2.5); and parallel 14.5 (SD=3.5). The overall mean for all groups was 6.7 (SD=5.2). The two main reasons that the iTClamp was pulled off were because the friction lock let go or the needles slipped out of one side of the skin due to the angle of the pull.ConclusionInadvertent, forcible removal of the iTClamp created essentially no skin damage seen when the wound clamp was forcibly removed from either cadaver or swine models in a variety of positions and directions. Thus, the risks of deployment in operational environments do not seem to be increased.MckeeJL, LakshminarasimhanP, AtkinsonI, LaPortaAJ, KirkpatrickAW. Evaluation of skin damage from accidental removal of a hemostatic wound clamp (the iTClamp). Prehosp Disaster Med. 2017;32(6):651–656.

“Although we generally agree with the conclusions of the Western Trauma Association guidelines for the Evaluation and Management of Traumatic Pneumothorax, we believe further discussion of several critical points raised by these guidelines is necessary.”

Hemorrhage is the most preventable cause of posttraumatic death. Many cases are potentially anatomically salvageable, yet remain lethal without logistics or trained personnel to deliver diagnosis or resuscitative surgery in austere environments. Revolutions in technology for remote mentoring of ultrasound and surgery may enhance capabilities to utilize the skill sets of non-physicians. Thus, our research collaborative explored remote mentoring to empower non-physicians to address junctional and torso hemorrhage control in austere environments. Major studies involved using remote-telementored ultrasound (RTMUS) to identify torso and junctional exsanguination, remotely mentoring resuscitative surgery for torso hemorrhage control, understanding and mitigating physiological stress during such tasks, and the technical practicalities of conducting damage control surgery (DCS) in austere environments. Iterative projects involved randomized guiding of firefighters to identify torso (RCT) and junctional (pilot) hemorrhage using RTMUS, randomized remote mentoring of MedTechs conducting resuscitative surgery for torso exsanguination in an anatomically realistic surgical trainer (“Cut Suit”) including physiological monitoring, and trained surgeons conducting a comparative randomized study for torso hemorrhage control in normal (1g) versus weightlessness (0g). This work demonstrated that firefighters could be remotely mentored to perform just-in-time torso RTMUS on a simulator. Both firefighters and mentors were confident in their abilities, the ultrasounds being 97% accurate. An ultrasound-naive firefighter in Memphis could also be remotely mentored from Hawaii to identify and subsequently tamponade an arterial junctional hemorrhage using RTMUS in a live tissue model. Thereafter, both mentored and unmentored MedTechs and trained surgeons completed resuscitative surgery for hemorrhage control on the Cut-Suit, demonstrating practicality for all involved. While remote mentoring did not decrease blood loss among MedTechs, it increased procedural confidence and decreased physiologic stress. Therefore, remote mentoring may increase the feasibility of non-physicians conducting a psychologically daunting task. Finally, DCS in weightlessness was feasible without fundamental differences from 1g. Overall, the collective evidence suggests that remote mentoring supports diagnosis, noninvasive therapy, and ultimately resuscitative surgery to potentially rescue those exsanguinating in austere environments and should be more rigorously studied.

Supplemental Digital Content is available in the text

Supplemental digital content is available in the text.

Supplemental Digital Content is available in the text

Supplemental digital content is available in the text.

Supplemental Digital Content is Available in the Text.This randomized trial observed a survival difference between patients randomized to the ABThera versus Barker's vacuum pack after abbreviated laparotomy. As this difference did not seem to be mediated by improved peritoneal fluid drainage, fascial closure rates, or markers of systemic inflammation, it should be confirmed by a multicenter trial.

To determine whether the reported clinical presentation of tension pneumothorax differs between patients who are breathing unassisted versus receiving assisted ventilation.

Variation in the use of damage control (DC) surgery across trauma centers may partially be driven by uncertainty as to when the procedure is indicated. We sought to scope the literature on DC surgery and DC interventions, identify their reported indications, and examine the content and evidence upon which they are based.

The Focused Assessment with Sonography for Trauma (FAST) examination has become a valuable tool in trauma resuscitation. Despite the widespread use of FAST training among traumatologists, no evidence-based guidelines exist to support optimal training requirements or to provide quantitative objective assessments of imaging capabilities. Both Task-Specific Checklist (TSC) and Global Rating Scale (GRS) have been validated as objective skill assessment tools; we developed both types of scoring checklist and assessed them for construct validity with the FAST examination.

This review will describe the definitions on intra-abdominal hypertension (IAH) and abdominal compartment syndrome (ACS). In order to understand these definitions the reader must be aware of the interactions between intra-abdominal pressure (IAP) and intra-abdominal volume (IAV), explaining why dramatic IAP increases can be observed in some patients related to anthropomorphic measurements, body positioning, use of positive pressure ventilation, or relatively small accumulations of fluid or blood. The adverse effects related to increased IAP have been named IAH for moderate cases and ACS for advanced cases. In order to improve clinical communication as well as evaluation of the scientific literature, the World Society for the Abdominal Compartment Syndrome (WSACS) has published its first guidelines and definitions in 2006. The definitions and guidelines have recently been revised according to evidence based medicine and the Grading of Recommendations Assessment, Development and Evaluation (GRADE) methodology. This review will be based on the revised guidelines. The standard method to measure IAP is via the bladder and as experience with IAP measurement has evolved considerably, a number of tips and potential pitfalls are listed.

Patients with an occult pneumothoraces (OPTXs) may be at risk of tension pneumothoraces (TPTXs) without drainage or pleural drainage complications if treated.

Open abdominal management with negative-pressure wound therapy (NPWT) is increasingly used for critically ill trauma and surgery patients. We sought to determine the comparative efficacy and safety of NPWT versus alternate temporary abdominal closure (TAC) techniques in critically ill adults with open abdominal wounds.

Elevated base deficit (BD) and lactate levels at admission in patients with injury have been shown to be associated with increased mortality. This relationship is undefined in the Canadian experience. The goal of this study was to define the association between arterial blood gas (ABG) values at admission and mortality for Canadians with severe blunt injury.

Growing evidence suggests that for many treatments, a relationship exists between provider volume and patient outcomes. This relationship is less clear in injury management. We sought to evaluate whether a relationship exists between trauma center volume and the nature of quality improvement (QI) programs.

Apnea (APN) and pneumothorax (PTX) are common immediately life-threatening conditions. Ultrasound is a portable tool that captures anatomy and physiology as digital information allowing it to be readily transferred by electronic means. Both APN and PTX are simply ruled out by visualizing respiratory motion at the visceral-parietal pleural interface known as lung sliding (LS), corroborated by either the M-mode or color-power Doppler depiction of LS. We thus assessed how economically and practically this information could be obtained remotely over a cellular network.

The Trauma Association of Canada is now 27 years old, having been officially founded in 1983, at the meetings of the Royal College as a maturation of the trauma committee of the Canadian Association of General Surgeons. The first page of the official minutes also stressed the need to welcome other disciplines into the fold. Personally, it has taken me years of involvement, as well as the Presidency, to truly appreciate the depth of our Founding Members commitment. These individuals set lofty mission goals for the organization, namely: to strive to improve the quality of care provided to the injured patient, including prehospital management and transport, acute care hospitalization, and reintegration into society; to support, conduct, and apply basic science and clinical and outcome research related to trauma; to encourage effective and efficient use of healthcare resources in the delivery of trauma care; and to foster professional and community education in the field of injury prevention and in the care of the injured patient. As daunting as these responsibilities are, I am suggesting one more: to overcome the great penalty of geography that challenges our nation and penalizes many of our citizens by aspiring to optimize these four goals, for all Canadians, irrespective of where they live—our potential fifth mission. Furthermore, I believe that lessons from space medicine may offer some strategies to accomplish this goal.

Trauma is a leading cause of morbidity, potential years of life lost and health care expenditure in Canada and around the world. Trauma systems have been established across North America to provide comprehensive injury care and to lead injury control efforts. We sought to describe the current status of trauma systems in Canada and Canadians' access to acute, multidisciplinary trauma care.

Up to 20% of all trauma patients admitted to an intensive care unit die from their injuries. End-of-life decision making is a variable process that involves prognosis, predicted functional outcomes, personal beliefs, institutional resources, societal norms, and clinician experience. The goal of this study was to better understand end-of-life processes after major injury by comparing clinician viewpoints from various countries and cultures.

Swelling is inexorably linked to shock and resuscitation in trauma. In many forms, swelling complicates and interacts with traumatic injury to raise pressures in the abdomen, resulting in intraabdominal hypertension, which may overtly manifest as abdominal compartment syndrome (ACS) driving multiple organ failure. Despite renewed clinical interest in posttraumatic intraabdominal pressure, there remains a chiasm between knowledge of the risks and clinical interventions to mitigate them. This review provides a concise overview of definitions, risk factors, diagnosis and management using an illustrative trauma case.