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Background: Discontinuity of the bowel following intestinal injury and resection is a common practice in damage control procedures for severe abdominal trauma. However, there are concerns that complete occlusion of the bowel, especially in the presence of hypotension or edema that may result in ischemic bowel changes or increase bacterial or toxin translocation. Methods: This was a retrospective study from three Level-1 trauma centers. Included were trauma patients who required bowel resection and damage control. The study population was stratified into two groups based on the management for bowel injury: bowel discontinuity versus primary anastomosis. Outcomes included anastomotic leak, organ space infection, bowel ischemia, and mortality. Results: A total of 167 cases were included. In 84 cases, continuity of the bowel was established, and in 83, the bowel was left in discontinuity. The epidemiological, admission, and intraoperative physiological characteristics, the abdominal Abbreviated Injury Scale, type of intra-abdominal injury, and transfusion requirements were similar in the two study groups. The mortality was 8.3 % in the continuity group and 16.9 % for the discontinuity group ( p = 0.096). On the crude bivariate and adjusted regression analyses, there was a higher rate of bowel ischemia at the take-back operation in the discontinuity group ( p = 0.003 for the crude and p = 0.034 for the adjusted). The organ space infection and anastomotic leak rate were not significantly different between the study groups. Conclusions: Discontinuity of the bowel following damage control operation is associated with a higher risk of bowel ischemia than in patients with anastomosis. Further prospective observational and randomized studies are warranted. Level of evidence: III. [ABSTRACT FROM AUTHOR]

Objective:Test computer-assisted modeling techniques using prehospital vital signs of injured patients to predict emergency transfusion requirements, number of intensive care days, and mortality, compared to vital signs alone.Methods:This single-center retrospective analysis of 17,988 trauma patients used vital signs data collected between 2006 and 2012 to predict which patients would receive transfusion, require 3 or more days of intensive care, or die. Standard transmitted prehospital vital signs (heart rate, blood pressure, shock index, and respiratory rate) were used to create a regression model (PH-VS) that was internally validated and evaluated using area under the receiver operating curve (AUROC). Transfusion records were matched with blood bank records. Documentation of death and duration of intensive care were obtained from the trauma registry.Results:During the course of their hospital stay, 720 of the 17,988 patients in the study population died (4%), 2,266 (12.6%) required at least a 3-day stay in the intensive care unit (ICU), 1,171 (6.5%) required transfusions, and 210 (1.2%) received massive transfusions. The PH-VS model significantly outperformed any individual vital sign across all outcomes (average AUROC = 0.82), The PH-VS model correctly predicted that 512 of 777 (65.9%) and 580 of 931 (62.3%) patients in the study population would receive transfusions within the first 2 and 6 hours of admission, respectively.Conclusions:The predictive ability of individual vital signs to predict outcomes is significantly enhanced with the model. This could support prehospital triage by enhancing decision makers’ ability to match critically injured patients with appropriate resources with minimal delays. [ABSTRACT FROM PUBLISHER]

Purpose: Though primary repair of colon injuries is preferred, certain injury patterns require colostomy creation. Colostomy reversal is associated with significant morbidity and healthcare cost. Complication rates may be influenced by technique of diversion (loop vs. end colostomy), though this remains ill-defined. We hypothesized that reversal of loop colostomies is associated with fewer complications than end colostomies. Methods: This is a retrospective, multi-institutional study (four, level-1 trauma centers) of patients undergoing colostomy takedown for trauma during the time period 1/2006-12/2012. Data were collected from index trauma admission and subsequent admission for reversal and included demographics and complications of reversal. Student's t test was used to compare continuous variables against loop versus end colostomy. Discrete variables were compared against both groups using Chi-squared tests. Results: Over the 6-year study period, 218 patients underwent colostomy takedown after trauma with a mean age of 30; 190 (87 %) were male, 162 (74 %) had penetrating injury as their indication for colostomy, and 98 (45 %) experienced at least one complication. Patients in the end colostomy group ( n = 160) were more likely to require midline laparotomy (145 vs. 18, p < 0.001), had greater intra-operative blood loss (260.7 vs. 99.4 mL, p < 0.001), had greater hospital length of stay (8.4 vs. 5.5 days, p < 0.001), and had more overall complications (81 vs. 17, p = 0.005) than patients managed with loop colostomy ( n = 58). Conclusions: Local takedown of a loop colostomy is safe and leads to shorter hospital stays, less intra-operative blood loss, and fewer complications when compared to end colostomy. [ABSTRACT FROM AUTHOR]

Introduction: Trauma patients with sudden loss of distal perfusion due to tibial injuries are frequently not offered vascular interventions if a single vessel retains patency. We hypothesized that sudden loss of either all or some tibial vasculature would result in increased non-operative failure and higher amputation rates.Methods: In this retrospective observational study, all traumatically injured patients from 2009 to 2012 with CT-angiogram-confirmed anterior tibial, posterior tibial, or peroneal artery injuries were included.Results: From 2009 to 2012, 437 patients were admitted with arterial extremity injury of which 234 (53%) were lower extremity. From this group, 84 (36%) patients were identified with CT-angiogram-confirmed limited or no flow in the tibial arteries. A total of 44% (4/9) with 0 or 1 tibial vessel failed observation while only 8% (2/27) failed if they had 2 or 3 patent vessels (p < 0.05). Amputation rate was inversely related the number of open tibial vessels. There were 2.7 open tibial vessels in the limb salvage group compared to 1.1 in the amputation group (p < 0.05).Conclusion: Patients who failed an initial trial of observation were significantly more likely to have 0 or 1 tibial vessels patent. The number of open tibial vessels is significantly associated with limb salvage. [ABSTRACT FROM AUTHOR]

The article presents abstracts of studies to be presented at the 2015 Scientific Session of the Society of American Gastrointestinal and Endoscopic Surgeons (SAGES) in Nashville, Tennessee in April 2015 on topics including aspirin-mediated colorectal cancer prevention, effect of yoga practice on laparoscopic surgery outcomes, and pyloric sphincter activity.

Introduction. This study aimed to compare management patterns of patients with superficial venous thrombophlebitis (SVT) among phlebologists and vascular surgeons. Methods. A survey was provided to practitioners who attended the American Venous Forum meeting in 2011. Statistical analysis included descriptive statistics, unpaired t tests, and Friedman’s test for correlation. Results. There were 354 US or Canadian health care providers of whom 169 were phlebologists and 185 were vascular surgeons. There was a significant different in anticoagulation administration and duration (P = .034, P = .032, respectively). Friedman’s test for correlation between multiple surgical treatments showed no correlation between surgical treatments tested with all treatments having an equal distribution in our data. Follow-up differed between groups with vascular surgeons following up with imaging more than phlebologists (P = .03). Conclusion. Our data indicate that there is no consensus between or among phlebologists or vascular surgeons as to the surgical management of superficial venous thrombophlebitis, duration of follow-up, and anticoagulation parameters. [ABSTRACT FROM PUBLISHER]

The article presents abstracts of oral presentations at the American Telemedicine Association's 17th Annual International Meeting and Exposition on topics including the use of telemedicine to address children's health, the telemental health, and mobile health innovations for disease management.

The article presents abstracts of research papers presented at 11th European Congress of Trauma and Emergency Surgery which include a comparison between plate fixation and nonoperative treatment for displaced midshaft clavicular fractures, minimal invasive plate osteosynthesis of clavicle fracture with locking plate (LCP), and clinical relevance of high resolution magnetic resonance imaging (MRI) for acromioclavicular joint instability.

Objectives: To review the literature to determine the rates of airway stenosis after cricothyrotomy, particularly as they compare with previously documented rates of this complication after tracheotomy, and to examine the complications associated with conversion. Data Sources: We conducted a review of the medical literature by the use of PubMed and OVID MEDLINE databases. Study Selection: We identified all published series that describe the use of cricothyrotomy, with the inclusion of the subset of patients who require an emergency airway after trauma, from January 1, 1978, to January 1, 2008. Data Extraction: Only 20 published series of cricothyrotomy were identified: 17 retrospective reports and 3 prospective, observational series. Data Synthesis: Considerable variance in methods and follow-up periods were noted between examinations. Published experiences documented the results of 1134 total patients for whom cricothyrotomy was performed, including 368 trauma patients who underwent emergent cricothyrotomy. The rate of chronic subglottic stenosis among survivors after cricothyrotomy was 2.2% (11/ 511) overall and 1.1% (4/368) among trauma patients for follow-up periods with a range from 2 to 60 months. Only 1 (0.27%) of the 368 trauma patients in whom an emergent cricothyrotomy was performed required surgical treatment for chronic subglottic stenosis. Although the literature that documents complications of surgical airway conversion is scarce, rates of severe complications of up to 43% were reported. Conclusions: Cricothyrotomy after trauma is safe for initial airway access among patients who require the establishment of an emergent airway. The prolonged use of a cricothyrotomy tube, however, remains controversial. Although no study to date has demonstrated any benefit of routine conversion to tracheostomy, considerable deficiencies in existing studies highlight the need for further investigations of this practice. [ABSTRACT FROM AUTHOR]

The purpose of this study was to investigate the relationship between the method of transport after injury and survival among trauma patients admitted to a Level 1 trauma facility in Los Angeles, California. The trauma registry of LAC+USC Medical Center was reviewed to identify all injured patients evacuated by emergency medical service (EMS) from the injury scene from 1998 to 2007. The study population was divided into those who were airlifted (HEMS) and those who were transported by ground emergency medical service (GEMS) with transportation time that exceeded 30 minutes (GEMS > 30 minutes). During the 10-year study period, 1,836 patients were airlifted (helicopters for emergency medical service (HEMS)) and 1,537 patients were ground transported (GEMS > 30 minutes). HEMS patients suffered more frequently a penetrating injury (19% vs. 11%, p < 0.001), presented more often hypotensive to the emergency department (4% vs. 1%, p < 0.001), had more frequently a Glasgow Coma Scale (GCS) ≤ 8 (9% vs. 3%, p < 0.001) and required more often an intubation at the injury scene (1.6% vs. 0.4%, p < 0.001). However, the transportation time and the total prehospital time were significantly shorter for airlifted patients. After multivariable analysis, the difference in mortality between the two transport modalities was not significant (adjusted odds ratio (95% confidence interval, 0.72 (0.22, 2.35); p = 0.596). In a metropolitan Los Angeles trauma system, EMS helicopter transportation of injured patients does not appear to improve overall adjusted survival after injury. There is however a potential benefit for severely injured subgroups of patients due to the shorter prehospital times. [ABSTRACT FROM AUTHOR]

The objective of this study was to describe the management of the Jehovah's Witness (JW) in an intensely active level I trauma center and review the modern therapeutic options available for the trauma care of these patients. A retrospective review of injured JWs admitted to a busy trauma center over a 13-year period was conducted. Over the study period, 143 JWs were identified. Among these, 15.4% (22/143) overall and 32.3% (10/31) requiring surgical intensive care unit (SICU) admission accepted transfusion. Overall, 56.6% of JWs (81/143) required operation and 21.7% (31/143) were admitted to the SICU with a complication rate of 4.2% (6/143) and a mortality of 1.4% (2/143). One patient of the 31 patients that were admitted to the SICU received 10 ml of blood with subsequent discontinuation of the transfusion and was excluded from analysis. Of the 30 JWs admitted to the SICU, 20 (66.7%) did not receive transfusion and demonstrated mean admission and nadir hemoglobin (Hb) levels of 12.7 (±2.5) and 9.1 (±3.0) mg/dl, respectively. Ten patients accepted transfusion. This group had longer mean SICU stays (23.3 vs. 5.5 days) but similar mortality (10%, 1/10 vs. 5%, 1/20) compared to non-transfused counterparts. Only one complication (1/20, 5%) was observed in the JWs who were not transfused, compared to a 40% (4/10) complication rate in those accepting transfusion. Although our experience was limited, we found no significant difference in the mortality or morbidity between JW patients who received or abstained from transfusion following major trauma. We should keep in mind that the population was small, in order to extract safe conclusions regarding whether we should transfuse or not transfuse trauma patients. We can, however, see interesting insights on the value of trauma resuscitation. [ABSTRACT FROM AUTHOR]

Terrorist violence has emerged as an increasingly common cause of mass casualty incidents (MCI) due to the sequelae of explosive devices and shooting massacres. A proper emergency medical system disaster plan for dealing with an MCI is of paramount importance to salvage lives. Because the number of casualties following a MCI is likely to exceed the medical resources of the receiving health care facilities, patients must be appropriately sorted to establish treatment priorities. By necessity, clinical signs are likely to prove cornerstones of triage during MCI. An appropriate and effective application of experiences learned from the use of selective nonoperative management (SNOM) techniques may prove essential in this triage process. The present appraisal of the available literature strongly supports that the appropriate utilization of these clinical indicators to identify patients appropriate for SNOM is essential, critical, and readily applicable. We also review the initial emergent triage priorities for penetrating injuries to the head, neck, torso, and extremities in a mass casualty setting. [ABSTRACT FROM AUTHOR]

Objective: To analyze the preventable and potentially preventable complications occurring at a mature level I trauma center. Design: Retrospective review. Setting: Academic level I trauma center. Patients: The study included 35 311 trauma registry patients. Main Outcome Measures: The cause, effect on outcome, preventability (preventable, potentially preventable, or nonpreventable), and loop closure recommendations for all preventable and potentially preventable complications, and clinical data related to each complication retrieved from the trauma registry and individual medical records. Results: Over the 8-year study, 35 311 trauma registry patients experienced 2560 complications. Three hundred fifty-one patients (0.99% of all patients) had 403 preventable or potentially preventable complications. The most common preventable or potentially preventable complications were unintended extubation (63 patients [17% of complications]), surgical technical failures (61 patients [15% of complications]), missed injuries (58 patients [14% of complications]), and intravascular catheter-related complications (48 patients [12% of complications]). These complications were clinically relevant; 258 (64% of complications) resulted in a change in management, including 61 laparotomies, 52 reintubations, 41 chest tube insertions, and 19 vascular interventions. Conclusions: The incidence of preventable or potentially preventable complications at an academic level I trauma center is low. These complications often require a change in management and cluster in 4 major categories (ie, unintended extubation, surgical technical failures, missed injuries, and intravascular catheter-related complications) that must be recognized as critical areas for quality improvement initiatives. [ABSTRACT FROM AUTHOR]

Background Admission hypothermia (core temperature ≤ 35°C) is an independent risk factor for mortality after trauma. The predictive value of perioperative core temperatures during acute trauma surgery, however, although widely employed as a criterion for initiating damage control, is unknown. We hypothesized that for trauma patients undergoing laparotomy or thoracotomy, early postoperative hypothermia is a predictor of mortality.Methods After institutional review board (IRB) approval, all critically ill trauma patients undergoing cavitary surgery (laparotomy or thoracotomy) at a level 1 trauma center from 01/1998 to 07/2006 were identified from the trauma registry. Immediate postoperative core temperature (Tc) was used to classify patients as hypothermic (Tc ≤ 35°C) or normothermic (Tc > 35°C). The profoundly hypothermic subgroup of patients with a Tc < 33°C was also analyzed.Results During the study period, 2,489 patients required cavitary surgery, 1,252 of whom (50%) were admitted to the intensive care unit (ICU). On arrival in the ICU 15% of the patients had a Tc ≤ 35°C and were more likely to be ≥ 55 years old (12% versus 7%; p = 0.04); in addition, they were hypotensive on admission (25% versus 13%; p < 0.001), had a lower admission Glasgow Coma Score (GCS; 11 ± 5 versus 14 ± 3; p < 0.001), a higher Injury Severity Score (ISS; 29 ± 15 versus 22 ± 12; p < 0.001), higher head and chest Abbreviated Injury Scale (AIS), and greater intraoperative blood loss (2.6 ± 2.4 l versus 1.7 ± 1.8 l; p < 0.001). When compared to patients who were normothermic at the end of their operation, hypothermic patients had a significantly higher mortality (35% versus 8%; p < 0.001). With decreasing Tc, there was a stepwise increase in mortality. Compared to patients with a Tc > 35°C, the relative risk of death for patients with a Tc between 35°C and 33°C was 4.0, and that for patients with a Tc ≤ 33°C it was 7.1. After adjusting for multiple differences between groups, postoperative hypothermia remained an independent predictor of mortality (adjusted odds ratio [OR] 3.2; 95% confidence interval [CI] 1.9–5.3; p < 0.001).Conclusions Postoperative hypothermia is common in critically injured patients requiring cavitary surgery and is an independent predictor of mortality. The impact of measures to maintain or restore normothermia in the operating room warrants further investigation. [ABSTRACT FROM AUTHOR]

As of August 2007, 96 900 people are awaiting organ transplantation in the United States, while only 28 930 transplants were performed in 2006. With such a large gap between organ need and organ availability, it is inevitable that many will die while awaiting transplantation. This organ shortage has become a national public health crisis, and as a response, the United States Department of Health and Human Services launched the Organ Donation Breakthrough Collaborative, an ambitious campaign to dramatically increase the number of transplantable organs. One of the suggested strategies involves maximizing the number of organs obtained from the available cadaveric ''brain dead'' donor pool by using donor management protocols that optimize and treat the profound physiological disturbances that are associated with brain death. The use of these standardized and aggressive donor management protocols has been shown to increase the number of transplanted organs and prevent the number of donors lost due to medical failures. A protocol-driven approach by a dedicated organ donor management team should be considered a key component of any program designed to bridge the gap between organ supply and demand. [ABSTRACT FROM AUTHOR]

Post-Traumatic Acute Respiratory Distress Syndrome (ARDS) is a major cause of morbidity and mortality in the acutely injured patient. The American-European Consensus Conference Report established the most widely accepted definition of ARDS in 1994. In recent years it appears the incidence and impact of the disease are on the decline. This article reviews strategies to prevent and treat post-traumatic ARDS. Well-accepted, proven strategies include lung protective ventilation strategies, as well as conservative transfusion and crystalloid resuscitation policies and the adoption of leukoreduction techniques. Other modalities including hypertonic saline resuscitation, use of albumin and diuretics, positive end expiratory pressure, high-frequency ventilation, prone positioning, recruitment maneuvers, extracorporeal membrane oxygenation, corticosteroids, exogenous surfactant, and inhaled nitric oxide are also reviewed. [ABSTRACT FROM AUTHOR]

Background: Resuscitative endovascular balloon occlusion of the aorta (REBOA) could provide a survival benefit to severely injured patients as it may improve their initial ability to survive the hemorrhagic shock. Although the evidence supporting the use of REBOA is not conclusive, its use has expanded worldwide. We aim to compare the management approaches and clinical outcomes of trauma patients treated with REBOA according to the countries' income based on the World Bank Country and Lending Groups. Methods: We used data from the AORTA (USA) and the ABOTrauma (multinational) registries. Patients were stratified into two groups: (1) high-income countries (HICs) and (2) low-to-middle income countries (LMICs). Propensity score matching extracted 1:1 matched pairs of subjects who were from an LMIC or a HIC based on age, gender, the presence of pupillary response on admission, impeding hypotension (SBP ≤ 80), trauma mechanism, ISS, the necessity of CPR on arrival, the location of REBOA insertion (emergency room or operating room) and the amount of PRBCs transfused in the first 24 h. Logistic regression (LR) was used to examine the association of LMICs and mortality. Results: A total of 817 trauma patients from 14 countries were included. Blind percutaneous approach and surgical cutdown were the preferred means of femoral cannulation in HICs and LIMCs, respectively. Patients from LMICs had a significantly higher occurrence of MODS and respiratory failure. LR showed no differences in mortality for LMICs when compared to HICs; neither in the non-matched cohort (OR = 0.63; 95% CI: 0.36‑1.09; p = 0.1) nor in the matched cohort (OR = 1.45; 95% CI: 0.63‑3,33; p = 0.3). Conclusion: There is considerable variation in the management practices of REBOA and the outcomes associated with this intervention between HICs and LMICs. Although we found significant differences in multiorgan and respiratory failure rates, there were no differences in the risk-adjusted odds of mortality between the groups analyzed. Trauma surgeons practicing REBOA around the world should joint efforts to standardize the practice of this endovascular technology worldwide. [ABSTRACT FROM AUTHOR]

Background: The traditional sequence of trauma care: Airway, Breathing, Circulation (ABC) has been practiced for many years. It became the standard of care despite the lack of scientific evidence. We hypothesized that patients in hypovolemic shock would have comparable outcomes with initiation of bleeding treatment (transfusion) prior to intubation (CAB), compared to those patients treated with the traditional ABC sequence. Methods: This study was sponsored by the American Association for the Surgery of Trauma multicenter trials committee. We performed a retrospective analysis of all patients that presented to trauma centers with presumptive hypovolemic shock indicated by pre-hospital or emergency department hypotension and need for intubation from January 1, 2014 to July 1, 2016. Data collected included demographics, timing of intubation, vital signs before and after intubation, timing of the blood transfusion initiation related to intubation, and outcomes. Results: From 440 patients that met inclusion criteria, 245 (55.7%) received intravenous blood product resuscitation first (CAB), and 195 (44.3%) were intubated before any resuscitation was started (ABC). There was no difference in ISS, mechanism, or comorbidities. Those intubated prior to receiving transfusion had a lower GCS than those with transfusion initiation prior to intubation (ABC: 4, CAB:9, p = 0.005). Although mortality was high in both groups, there was no statistically significant difference (CAB 47% and ABC 50%). In multivariate analysis, initial SBP and initial GCS were the only independent predictors of death. Conclusion: The current study highlights that many trauma centers are already initiating circulation first prior to intubation when treating hypovolemic shock (CAB), even in patients with a low GCS. This practice was not associated with an increased mortality. Further prospective investigation is warranted. Trial registration: IRB approval number: HM20006627. Retrospective trial not registered. [ABSTRACT FROM AUTHOR]