Search

Background Traumatic injury to the pancreas is rare but is associated with significant morbidity and mortality, including fistula, sepsis, and death. There are currently no practice management guidelines for the medical and surgical management of traumatic pancreatic injuries. The overall objective of this article is to provide evidence-based recommendations for the physician who is presented with traumatic injury to the pancreas. Methods The MEDLINE database using PubMed was searched to identify English language articles published from January 1965 to December 2014 regarding adult patients with pancreatic injuries. A systematic review of the literature was performed, and the Grading of Recommendations Assessment, Development and Evaluation framework was used to formulate evidence-based recommendations. Results Three hundred nineteen articles were identified. Of these, 52 articles underwent full text review, and 37 were selected for guideline construction. Conclusion Patients with grade I/II injuries tend to have fewer complications; for these, we conditionally recommend nonoperative or nonresectional management. For grade III/IV injuries identified on computed tomography or at operation, we conditionally recommend pancreatic resection. We conditionally recommend against the routine use of octreotide for postoperative pancreatic fistula prophylaxis. No recommendations could be made regarding the following two topics: optimal surgical management of grade V injuries, and the need for routine splenectomy with distal pancreatectomy. Level of evidence Systematic review, level III.

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.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.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%.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.

An increasing number of patients are presenting to trauma units with head injuries on antiplatelet therapy (APT). The influence of APTon these patients is poorly defined. This study examines the outcomes of patients on APT presenting to the hospital with blunt head trauma (BHT). Registries of two Level I trauma centers were reviewed for patients older than 40 years of age from January 2008 to December 2011 with BHT. Patients on APT were compared with control subjects. Primary outcome measures were in-hospital mortality, intracranial hemorrhage (ICH), and need for neurosurgical intervention (NI). Hospital length of stay (LOS) was a secondary outcome measure. Multivariate analysis was used and adjusted models included antiplatelet status, age, Injury Severity Score (ISS), and Glasgow coma scale (GCS). Patients meeting inclusion criteria and having complete data (n = 1547) were included in the analysis; 422 (27%) patients were taking APT. Rates of ICH, NI, and in-hospital mortality of patients with BHT in our study were 45.4, 3.1, and 5.8 per cent, respectively. Controlling for age, ISS, and GCS, there was no significant difference in ICH (odds ratio [OR], 0.84; 95% confidence interval [CI], 0.61 to 1.16), NI (OR, 1.26; 95% CI, 0.60 to 2.67), or mortality (OR, 1.79; 95% CI, 0.89 to 3.59) associated with APT. Subgroup analysis revealed that patients with ISS 20 or greater on APT had increased in-hospital mortality (OR, 2.34; 95% CI, 1.03 to 5.31). LOS greater than 14 days was more likely in the APT group than those in the non-APT group (OR, 1.85; 95% CI, 1.09 to 3.12). The effects of antiplatelet therapy in patients with BHT aged 40 years and older showed no difference in ICH, NI, and in-hospital mortality.

Stab wound injury to the cervical spinal cord is a rare occurrence and usually presents with immediate, disastrous, and permanent neurological consequences. Rarer, and potentially as severe, is the complication of a delayed cerebrospinal fluid leak following a stab wound to the cervical spine. In this case, magnetic resonance imaging demonstrates a cerebrospinal fluid leak that extends to the skin with injury to the posterior dura at the C1/C2 level. Epidemiology and management of penetrating cervical spinal cord injury and delayed cerebrospinal fluid leaks are discussed.

Background Checklists have been advocated to improve quality outcomes/communication in the critical care setting, but results have been mixed. A new checklist process, “TRAUMA LIFE”, was implemented in our Trauma Intensive Care Unit (TICU) to replace prior checklists. The purpose of this study was to evaluate the impact of the “TRAUMA LIFE” process implementation on quality metrics and on patient/family communication in the TICU. Methods “TRAUMA LIFE” was considered maturely implemented by 2016. Multiple quality metrics, including restraint order compliance, were compared between 2013 and 2016 (pre- and post-implementation). Compliance with the “Family Message” (FM), a part of the “TRAUMA LIFE” communication process, was analyzed in 2016. Results Improvement was seen in CAUTI, VAE, and IUCU; CLABSI rates increased. Restraint order compliance increased significantly. FM delivery compliance was inconsistent; improvement was noted in concordance between update content and FM documented in Electronic Medical Record. Conclusion Implementation of “TRAUMA LIFE” was well integrated into the rounding process and was associated with some improvement in quality metrics and communication. Additional evaluation is required to assess sustainability.

BACKGROUND: Damage-control laparotomy (DCL) has revolutionized the surgery of injury. However, this has led to the dilemma of the nonclosable abdomen. Subsequently, there exists a subgroup of patients who after resuscitation and diuresis, remain nonclosable. Before the adoption of our open abdomen protocol (OAP) and use of transabdominal wall traction (TAWT), these patients required skin grafting and a planned ventral hernia. We hypothesize that our OAP and TAWT device, which use full abdominal wall thickness sutures to dynamically distribute midline traction, achieve an improved method of fascial reapproximation. METHODS: From 2008 to 2011, all DCL and decompressive laparotomy patients in our urban trauma center were managed by our OAP. Thirty two were noncloseable ‘‘domain loss abdomens’’ after achieving physiologic steady state and near dry weight. All patients received the TAWT device when near dry weight was achieved. Wound size, days to closure, days to TAWT, and TAWT to closure were tracked. RESULTS: During this 36-month period, OAP/TAWTwas applied to 32 patients. All patients demonstrated domain loss precluding fascial closure. Average wound size was 18.5-cm width by 30.5-cm length. Mean time DCL surgery to TAWTwas 9.5 days. At time of placement, TAWT decreased initial wound width by an average of 9.8 cm (51.4%). Patients returned to the operating room for tightening/washout an average of 2.2 times (excluding TAWT insertion and final closure operations). Mean time TAWT to closure was 8.7 days. Mean time from admission surgery to primary closure was 18.2 days. All patients achieved primary fascial closure using this method without components separation or biologic bridge operations. CONCLUSION: OAP/TAWT has revolutionized the way we manage ‘‘domain loss’’ open abdomen patients and has virtually eliminated the acceptance of planned ventral hernia. TAWT consistently recaptures lost domain, preserves the leading fascial edge, and eliminates the need for biologic bridges, components separation, or skin grafting. (J Trauma Acute Care Surg. 2013;74: 1486Y1492. Copyright * 2013 by Lippincott Williams & Wilkins)

An estimated 10,000 Americans suffer cervical spine injuries each year. More than 800,000 cervical spine radiographs (CSR) are ordered annually. The human and healthcare costs associated with these injuries are enormous especially when diagnosis is delayed. Controversy exists in the literature concerning the diagnostic accuracy of CSR, with reported sensitivity ranging from 32% to 89%. We sought to compare prospectively the sensitivity of cervical CT (CCT) to CSR in the initial diagnosis of blunt cervical spine injury for patients meeting one or more of the NEXUS criteria.The study prospectively compared the diagnostic accuracy of CSR to CCT in consecutive patients evaluated for blunt trauma during 23 months at an urban, public teaching hospital and Level I Trauma Center. Inclusion criteria were adult patient, evaluated for blunt cervical spine injury, meeting one or more of the NEXUS criteria. All patients received both three-view CSR and CCT as part of a standard diagnostic protocol. Each CSR and CCT study was interpreted independently by a different radiology attending who was blinded to the results of the other study. Clinically significant injuries were defined as those requiring one or more of the following interventions: operative procedure, halo application, and/or rigid cervical collar.Of 1,583 consecutive patients evaluated for blunt cervical spine trauma, 78 (4.9%) patients received only CCT or CSR and were excluded from the study. Of the remaining 1,505 patients, 78 (4.9%) had evidence of a radiographic injury by CSR or CCT. Of these 78 patients with radiographic injury, 50 (3.3%) patients had clinically significant injuries. CCT detected all patients with clinically significant injuries (100% sensitive), whereas CSR detected only 18 (36% sensitive). Of the 50 patients, 15 were at high risk, 19 at moderate risk, and 16 at low risk for cervical spine injury according to previously published risk stratification. CSR detected clinically significant injury in 7 high risk (46% sensitive), 7 moderate risk (37% sensitive), and 4 low risk patients (25% sensitive).Our results demonstrate the superiority of CCT compared with CSR for the detection of clinically significant cervical spine injury. The improved ability to exclude injury rapidly provides further evidence that CCT should replace CSR for the initial evaluation of blunt cervical spine injury in patients at any risk for injury.

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.

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

Background: A higher rate of pulmonary embolism has been associated with pulmonary artery (PA) catheters; however, no mechanism has been described. Conventional tests of coagulation reveal no changes related to PA catheterization. The purpose of this study was to determine whether PA catheterization resulted in a hypercoagulable state detectable by thrombelastography (TEG). Methods: Animal: Healthy, anesthetized, swine (n = 19) underwent PA catheterization. Samples were drawn from 7F femoral arterial catheters before and two hours after PA catheterization, at 5 mL/ min, and analyzed (native whole blood, n = 15, kaolin activated blood, n = 4) by TEG (Hemoscope, Niles, IL) at precisely two minutes. Human: An IRB-approved prospective, observational trial was conducted in critically ill patients (n = 19). Samples were drawn from 22-gauge radial artery catheters, before and three hours after PA catheterization. Kaolin-activated TEG samples were analyzed at precisely five minutes. Data are mean ± SE; Groups were compared with analysis of variance and significance was assessed at the 95% confidence interval. Results: In both animals and patients, PA catheterization truncated R times (time to initial fibrin formation). In swine, the R times were 17.6 ± 1.3 minutes (native) and 3.8 ± 0.4 (kaolin) before PA catheterization, and decreased to 6.3 ± 1.0 minutes (p = 0.002) and 1.9 ± 0.5 minutes (p = 0.010) afterward. There were no changes in pH or temperature during the experiment. In patients, 4 of 19 were excluded for protocol violations. The R time was 6.3 ± 1.0 minutes (kaolin) before and 3.0 ± 0.3 minutes after catheterization (p = 0.003). No changes were observed in conventional coagulation parameters, temperature or pH. Conclusion: In healthy swine, and critically ill patients, PA catheters may enhance thrombin formation and fibrin polymerization, indicating a systemic hypercoagulable state. This may explain why PA catheters are associated with an increased risk of pulmonary emboli.

Purpose: The surgical resident experience with trauma has changed. Many residents are exposed to predominantly nonoperative patient care experiences while on trauma rotations. Data from a large multicenter study were analyzed to estimate surgical resident exposure to trauma laparotomy, diagnostic peritoneal lavage (DPL), and focused abdominal sonography for trauma (U/S). Methods: Centers completed a self-report questionnaire on their institutional demographics, admissions, and procedure for a 2-year period (1998-1999). Results: A total of 82 trauma centers that provide resident teaching were included. The included centers represent over 247,000 trauma admissions. The majority of trauma centers (65.9%) had > 80% blunt injury. Although all centers performed laparotomies, other results were more variable. For U/S, 24.2% performed none at all and 47.0% performed fewer than two U/S examinations per month. For DPLs, 3.8% performed none and 66.7% performed fewer than two per month. Assuming 1 night of 4 on call, the average surgical resident training at a trauma center performing > 80% blunt trauma has the potential to participate in only 15 trauma laparotomies, 6 diagnostic peritoneal lavages, and 45 ultrasound examinations per year. In addition, the resident will care for an average of 500 blunt trauma patients before performing a splenectomy or liver repair. Conclusion: Surgical resident experience on most trauma services is heavily weighted to nonoperative management, with a relatively low number of procedures, little experience with DPL, and highly variable experience with ultrasound. These data have serious implications for resident training and recruitment into the specialty.

I. STATEMENT OF THE PROBLEM Evaluation of patients who have sustained blunt abdominal trauma (BAT) may pose a significant diagnostic challenge to the most seasoned trauma surgeon. Blunt trauma produces a spectrum of injury from minor, single-system injury to devastating, multisystem trauma. Trauma surgeons must have the ability to detect the presence of intra-abdominal injuries across this entire spectrum. Although a carefully performed physical examination remains the most important method to determine the need for exploratory laparotomy, there is little Level I evidence to support this tenet. In fact, several studies have highlighted the inaccuracies of the physical examination in BAT. The effect of altered level of consciousness as a result of neurologic injury, alcohol, or drugs is another major confounding factor in assessing BAT. Because of the recognized inadequacies of physical examination, trauma surgeons have come to rely on a number of diagnostic adjuncts. Commonly used modalities include diagnostic peritoneal lavage (DPL) and computed tomographic (CT) scanning. Although not available universally, focused abdominal sonography for trauma (FAST) has recently been included in the diagnostic armamentarium. Diagnostic algorithms outlining appropriate use of each of these modalities individually have been established. Several factors influence the selection of diagnostic testing: type of hospital (i.e., trauma center vs. “nontrauma” hospital); access to a particular technology at the surgeon’s institution; and the surgeon’s individual experience with a given diagnostic modality. As facilities evolve, technologies mature, and surgeons gain new experience, it is important that any diagnostic strategy constructed be dynamic. The primary purpose of this study was to develop an evidence-based, systematic diagnostic approach to BAT using the three major diagnostic modalities: DPL, CT scanning, and FAST. This diagnostic regimen would be designed such that it could be reasonably applied by all general surgeons performing an initial evaluation of BAT.

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.

I. STATEMENT OF THE PROBLEM Mild traumatic brain injury (MTBI), or concussion, is a common cause for admission at trauma centers, particularly those centers admitting primarily blunt trauma victims. Represented by ICD-9-CM codes 850.0–850.9, MTBI may be generally defined as an injury caused by blunt acceleration/ deceleration forces which produce a period of unconsciousness for 20 minutes or less and/or brief retrograde amnesia, a Glasgow Coma Scale (GCS) score of 13 to 15, no focal neurologic deficit, no intracranial complications (e.g., seizure activity), and normal computed tomography (CT) findings.1–3 This brief loss of consciousness and/or retrograde amnesia has to be referred to as a transient disturbance of neurologic function and is a sine qua non to the diagnosis of MTBI. Focal neurologic deficits as well as seizure activity fall outside the definition of MTBI in this guideline. Despite the frequency of MTBI, there is no uniform agreement regarding the nature of the illness, the role of a variety of diagnostic tests, or the necessity of acute hospitalization. Neurotrauma textbooks and a large number of review articles have addressed the definition, epidemiology, and clinical characteristics of MTBI.1–8 Similarly, a number of studies have examined the role of CT9–31 and neuropsychological testing32–46 in the diagnosis and management of MTBI. Several studies, mostly retrospective, suggest which patients might be best served by hospital admission versus evaluation and discharge to home.9,47–53 Additional studies exist regarding management strategies in MTBI from the neurosurgeon’s perspective.17,28,31,54–64 Finally, the complicated and poorly understood issues surrounding posttraumatic and emotional symptoms in patients with MTBI are discussed in several publications.65–69 From this core of knowledge, recommendations can be made to facilitate a safe, more uniform, and cost-effective approach to the understanding and management of MTBI.9,15,70–72

BackgroundThe management of colon injuries that require resection is an unresolved issue because the existing practices are derived mainly from class III evidence. Because of the inability of any single trauma center to accumulate enough cases for meaningful statistical analysis, a multicenter prosp

The objective of this study was to determine prospectively which risk factors require cardiac monitoring for blunt cardiac injury (BCI) following blunt chest trauma. All patients who sustained blunt chest trauma had an electrocardiogram (ECG) on admission to our urban level I trauma center. Those with ST segment changes, dysrhythmias, hemodynamic instability, history of cardiac disease, age > 55 years, or a need for general anesthesia within 24 hours (group 1) were admitted to the intensive care unit (ICU) for 24 hours where they were subjected to serial ECGs, creatinine phosphokinase (CPK) assays, and echocardiography (ECHO). Those with only mechanism for BCI, i.e., none of the above risk factors (group 2), were admitted to a nonmonitored bed and had a follow-up ECG 24 hours later. A series of 315 patients were admitted with blunt chest trauma during a 17-month period; 144 patients were in group 1 and 171 in group 2. Overall, 22 patients were diagnosed as BCI (+BCI), defined as evolving ST segment changes, dysrhythmias, a CPK-MB index of > 2.5, or hemodynamic instability. Of the 18 +BCI patients in group 1, all were symptomatic (i.e., none was included solely for a cardiac history, age, or need for general anesthesia). Six of these patients required treatment for dysrhythmias, hypotension, or pulmonary edema; one of whom died. Four patients with +BCI were in group 2 and had ECG changes at 24 hours; none of these four had any sequelae from their +BCI. None of the ECHOs demonstrated abnormal wall motion. Patients who sustain blunt chest trauma with a normal ECG, normal blood pressure, and no dysrhythmias on admission require no further intervention for BCI. Patients with ST segment changes, dysrhythmias, or hypotension following blunt chest trauma should be monitored for 24 hours, as this subgroup occasionally requires further treatment for complications of BCI. ECHO adds nothing as a screening test.

This study was undertaken to confirm the safety and efficacy of diagnostic peritoneal lavage (DPL) for trauma patients. A prospectively maintained database of all DPLs performed in the past 75 months was analyzed. A red blood cell count of 100,000/mm(3) was considered positive for injury in blunt trauma; 10,000/mm(3) was considered positive for peritoneal penetration in penetrating trauma. Information relative to type of injury, DPL result, laparotomy result and complications, was analysed to determine if DPL was more or less suited to any specific indication or type of patient. Over a 75 month period, 2501 DPLs were performed at our urban level I trauma center. The overall sensitivity, specificity and accuracy for the above thresholds were 95, 99 and 98%. The majority (2409, 96%) were performed using percutaneous or "closed" seldinger technique. Ninety-two (4%) were performed using open technique because of pelvic fractures, previous scars and pregnancy. Open DPL was less sensitive than closed DPL in patients who sustained blunt trauma (90 vs 95%) but slightly more sensitive in determining penetration (100 vs 96%). Overall, there were 21 complications (0.8%). There was no difference in complication rate between open and closed DPL. In conclusion, DPL remains a highly accurate, sensitive and specific test with an extremely low complication rate. It can be performed either open or closed with comparable results. We recommend its use in the evaluation of both blunt and penetrating trauma.

Federal regulations allow an exception to informed consent when it is not feasible to obtain informed consent in certain emergency research circumstances. A multicenter, randomized, single-blinded, normal saline procedure-controlled efficacy trial of diaspirin cross-linked hemoglobin (DCLHb) in acute traumatic hemorrhagic shock was conducted. The study intended to include 850 of the most severely injured trauma patients with hemorrhage and persistent hypoperfusion as demonstrated by vital signs suggestive of vascular collapse or a base deficit that signified prolonged hypoperfusion. It was anticipated that some patients would be unable to provide informed consent, and that identification and availability of some patients' legally authorized representatives (LARs) would be unlikely within the therapeutic window of the intervention. Each participating institution therefore developed a process to implement exception to informed consent. Each hospital's proposed process was reviewed by the institutional review board, the sponsor, the FDA, and the study's data monitoring committee chair. The goal was the development of local implementation processes by which the best interests of patients and their families could be fulfilled using prospective informed consent, the exception to informed consent, and consent to continue in emergency research, as appropriate for each individual patient. This paper describes the proposed implementation method developed for Cook County Hospital. It includes several important features, 1) prospective informed consent by the patient, when feasible; 2) the ability of the patient to decline participation, even when deemed incompetent to provide prospective informed consent; 3) prospective consent by the family/LAR, when feasible; 4) the use of a scripted abbreviated consent by the patient family/ LAR in life-threatening situations when it is possible only to briefly discuss the research being conducted; 5) independent approval for the use of the consent exception by a second physician immediately prior to patient enrollment; 6) the repeated use of consent to continue (both for the family/LAR and by the patient) when an exception to consent has been utilized; and 7) ongoing review of the informed consent process on a case-by-case basis by the institution's scientific review committee. The authors believe this proposed informed consent process maximizes the communication between investigators, patients and their proxies, and the institution's scientific review committee. Multiple mechanisms exist that allow for consent to be provided or declined, both prior to and after enrollment in the research protocol. The ongoing immediate review of the process allows for process enhancements to be made as needed.

Background: To determine which patients need a "one-shot" intravenous pyelogram (IVP) before laparotomy for penetrating abdominal trauma. Study Design: Over a 15-month period, 240 laparotomies were performed for penetrating trauma at our urban level I trauma center. Prospectively collected data included clinical suspicion of genitourinary injury, results of preoperative IVP, intraoperative findings, and operative decisions influenced by the IVP. Results: Preoperative IVP was performed in 175 patients (73%). Of these, 71 (41%) had suspicion of a renal injury based on the presence of a flank wound or gross hematuria. The IVP was believed to influence operative decisions in six patients, all in this group. Each of these six patients had either a shattered kidney or a renovascular injury and had a nephrectomy performed with the knowledge that a normal functioning kidney was present on the contralateral side. No patient without a flank wound or gross hematuria had an IVP that was judged to be helpful intraoperatively. Preoperative IVP was helpful only in patients with flank wounds or gross hematuria. Nephrectomy was performed in two additional patients who did not undergo IVP, both of whom presented in shock. Conclusions: Routine preoperative IVP is not necessary in all patients undergoing laparotomy for penetrating trauma. The number of IVPs can be safely reduced by 60% if the indications are narrowed to include only those stable patients with a flank wound or gross hematuria.

Background: It has previously been shown that 98% of gunshot wounds that penetrate the peritoneal cavity cause injuries that require surgical repair. Many gunshot wounds in the vicinity of the abdomen (GSWA) may actually be tangential and not penetrate the peritoneal cavity at all. Patients with such wounds may not require laparotomy. It is important to determine which patients with a potential tangential GSWA actually have penetration of the peritoneal cavity to minimize negative laparotomies. This study was undertaken to determine the sensitivity, specificity, and accuracy of diagnostic peritoneal lavage (DPL) in the determination of peritoneal penetration for patients who sustain GSWA. Methods: DPI, was performed for all patients who had sustained a GSWA in whom peritoneal penetration was unclear, i.e., patients whose GSWA appeared to be tangential, thoraco-abdominal, or transpelvic and for whom a clear indication for laparotomy (shock, peritonitis, etc.) did not exist. Our threshold for a positive DPL, was 10,000 red blood cells (RBC)/mm 3 . A prospective data base was kept with information on the location of the wound, DPI, result, findings at laparotomy, and outcome. Results: During a 4-year period, 429 consecutive DPLs were performed for GSWA at our urban Level I trauma center. One hundred fifty DPLs were positive, with more than 10,000 RBC/ mm 3 . Six of these patients were found to have no peritoneal penetration at laparotomy (false-positive). The remaining 144 patients with positive DPLs were found to have operative injuries (true-positive). Of the 279 patients with DPL counts less than 10,000 RBC/mm 3 , 2 developed indications for laparotomy and were found to have intraperitoneal injuries (false-negative). The remaining 277 patients had no peritoneal injuries (true-negative). This was demonstrated either by laparotomy done for another indication In = 7) or by uneventful inpatient observation for 24 hours In = 270). The sensitivity, specificity, and accuracy of DPL in determining peritoneal penetration in GSWA is therefore 99, 98, and 98%, respectively. Conclusion: For patients who sustain GSWA for whom peritoneal penetration is unclear, DPL is a sensitive, specific, and accurate test to determine the need for laparotomy. It remains our test of choice when confronted with these patients.

Objective : To determine the usefulness of early echocardiography in stable patients with penetrating wounds in proximity to the heart. Design : Retrospective chart review over a 1-year period. Setting : Urban level I trauma center. Patients : 121 clinically stable patients with penetrating wounds in proximity to the heart underwent immediate echocardiography (ECHO). Those with evidence of pericardial effusion then underwent subxiphoid pericardial window (SPW), followed by a median sternotomy if blood was found. Results : Thirty patients had an ECHO that was positive and underwent immediate SPW. One patient with an initially negative ECHO deteriorated 5 hours after admission ; a repeat ECHO was positive, and he also underwent SPW. In 16 of the 31 SPW performed, blood in the pericardial sac was confirmed. Of these 16, four had pericardial blood that cleared with irrigation and required no further intervention. The remaining 12 patients underwent exploration : 3 had injury to the pericardium only, 4 had injury to the right atrium, 3 had injury to the right ventricle, and 2 had injury to the left ventricle. All nine myocardial injuries required operative repair ; all survived. Conclusions : Using the protocol of early ECHO and selective pericardial window, no clinically significant injuries were missed. In all, 12 penetrating cardiac injuries were identified and repaired successfully. We have found early and aggressive work-up, as outlined herein, to be helpful in the successful treatment of occult cardiac injuries.

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 3 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.

OBJECTIVE: This study piloted the use of the Primary Care PTSD (PC-PTSD) screening tool in an outpatient setting to determine its utility for broader use and to gather data on traumatic stress symptoms among direct (patients) and indirect (families) survivors of traumatic injuries. METHODS: Using the PC-PTSD plus one question exploring openness to seeking help, participants were screened for PTSD in the outpatient clinic of an urban Level 1 trauma center. The survey was distributed during a 23-week period from April to September 2011. The screen was self-administered, a sample of convenience, and participation was voluntary and anonymous. RESULTS: With a response rate of 66%, 307 surveys were completed. Forty-two percent of participants had a positive screen. Patients greater than 30 and 90 days from injury had 1.5 and 1.7 times more positive screens than those less than 30 days. Patients with gunshot wounds were 13 times as likely as those with falls and twice as likely as those in a motor vehicle crash to have a positive screen. Sixty percent of patients with a positive screen noted it would be helpful to talk to someone. CONCLUSION: The PC-PTSD was an easy to administer screening tool. Patients reported PTSD symptoms at higher rates than previous studies. Patients with gunshot wounds and those injured greater than 30 days from the time of the screen were more likely to report PTSD symptoms. Although males represented 82% of positive screens, there was no statistical difference in PTSD symptoms between male and female participants because of the small number of females represented. Families also reported significant levels of PTSD. Both patients and families may benefit from additional screening and intervention in the early posttrauma period. LEVEL OF EVIDENCE: Epidemiologic study, level IV. Language: en

Objective: To determine if patients who present with a history of loss of consciousness who are neurologically intact (minimal head injury) should be managed with head computed tomography (CT), observation, or both. Methods: We prospectively studied patients who presented to our urban Level I trauma center with a history of loss of consciousness after blunt trauma and a Glasgow Coma Scale score of 15. All patients underwent CT of the head and were subsequently admitted for 24 hours of observation. Results: A total of 1,170 patients with minimal head injury were studied during a 35-month period. All patients had Glasgow Coma Scale scores of 15 on arrival and had a history of either loss of consciousness or amnesia to the event. Two hundred forty-seven patients (21.1%) were intoxicated with drugs or alcohol on admission; 39 patients (3.3%) had abnormalities detected by CT, including 18 intracranial bleeds; 21 patients (1.8%) had changes in therapy as a direct result of their CT results, including 4 operative procedures. No patient with negative CT results deteriorated during the subsequent observation period. Conclusion: CT is a useful test in patients with minimal head injury because it may lead to a change in therapy in a small but significant number of patients. Subsequent hospital observation adds nothing to the CT results and is not necessary in patients with isolated minimal head injury.

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.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-Values0.05 were considered significant.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.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.

Thrombosis of the aorta and inferior vena cava is a rare sequela of blunt abdominal trauma. Inferior vena caval thrombosis developed in a 55-year-old man after blunt abdominal trauma. It was detected 18 days after injury through the use of computed tomography. The patient was treated with a Greenfield filter and anticoagulation.

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

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 pCO 2 (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.

Objective: To determine whether presumptive antibiotics reduce the risk of empyema or pneumonia following tube thoracostomy for traumatic hemopneumothorax. Methods: A prospective, randomized, double-blind trial was performed comparing the use of cefazolin for duration of tube thoracostomy placement (Group A) versus 24 hours (Group B) versus placebo (Group C). Results: A total of 224 patients received 229 tube thoracostomies. Logistic regression analysis revealed that duration of tube placement and thoracic acute injury score were predictive of empyema (p < 0.05). Empyema tended to occur more frequently in patients with penetrating injuries (p = 0.09). X 2 analysis showed pneumonia occurred significantly more frequently in blunt than penetrating injuries (p < 0.05). Presumptive antibiotic use did not significantly effect the incidence of empyema or pneumonia, although no empyemas occurred in Group A. Conclusions: The incidence of empyema was low and the use of presumptive antibiotics did not appear to reduce the risk of empyema or pneumonia.

After some abdominal surgical procedures, the abdominal wall defect may be too large for closure by tension-free approximation of the wound margins because of tissue loss or swelling of the abdominal viscera. A variety of absorbable and nonabsorbable prosthetic materials have been used for emergency abdominal wall reconstruction. Of these materials, polytetrafluoroethylene (PTFE) sheets have proved to be the most efficacious.This study compared the efficacy of allogenic acellular dermal matrix (ADM) and PTFE as prosthetic materials for wound closure in rats with surgical, full-thickness, 2 x 3-cm abdominal wounds. Healing was studied among animals with and those without experimentally induced peritonitis for 21 days after surgery.Acellular dermal matrix became vascularized and incorporated into the wound bed and was partially or fully epithelialized without the need for skin grafting. As a result, little superficial bleeding was seen, and ADM effectively closed the wounds even in the presence of peritonitis. Wounds treated with ADM also showed a significant reduction in wound area (sterile:p0.001; contaminated:p0.05). In contrast, PTFE temporarily closed the wounds, but was not incorporated into them. It consequently evoked the formation of extensive underlying granulation tissue that showed significant superficial bleeding when the PTFE was removed. Very limited wound contraction occurred in PTFE-treated wounds, and some instances of evisceration and fistula formation were observed. Wounds treated with both types of material showed significant amounts of adhesion to visceral organs underlying the wound site.Acellular dermal matrix exhibits a number of favorable features relative to PTFE for closing sterile or contaminated full-thickness abdominal wall defects.

In summary, BAI is a lethal result of severe blunt trauma. It should be considered in all patients who sustained injury by a deceleration or acceleration mechanism, especially in the face of physical or radiographic findings suggestive of mediastinal injury. Angiography remains the "gold standard" for diagnosis, although CT scanning is taking more of a role, especially for screening. Diagnosis should be followed by prompt surgical repair using some method of distal perfusion to minimize renal and spinal cord ischemia. If prompt repair is not feasible because of other injuries or comorbidities, medical control of blood pressure is warranted in the interim.

To show that resuscitation from hypothermic, hemorrhagic shock using 65 degrees C intravenous fluid results in a more rapid return to euthermia compared with 40 degrees C intravenous fluid, without significant endothelial or hemolytic injury.Fourteen anesthetized beagles (10-12 kg) were cooled to a core temperature of 30 degrees C and hemorrhaged to a mean arterial pressure of 40 to 45 mm Hg for 30 minutes. The animals were randomized to receive either 65 degrees C or 40 degrees C intravenous fluid through a specially designed catheter at a rate of 80% of their blood volume per hour until euthermic (37 degrees C) or for 2 hours.Blood pressure, pulmonary artery pressure, heart rate, and core temperature were continuously monitored. Blood samples were collected at baseline, after hemorrhage, 2 hours of resuscitation, and at postmortem examination after 7 days of survival. Laboratory measurements included complete blood count, plasma-free hemoglobin, and osmotic fragility. Values were compared using the Student's paired or unpaired t test with p approximately 0.05 indicating significance. Postmortem examination included light microscopy of the proximal superior vena cava or right atrium.Animals receiving 65 degrees C intravenous fluid warmed 3.6 degrees C/hour, significantly faster than the 40 degrees C animals (1.9 degrees C/hour). There were no significant differences in plasma-free hemoglobin or osmotic fragility. Endothelial injuries were found in two animals in each group. These defects occurred along the path of catheter insertion and not at the infusion site.Central intravenous fluid at 65 degrees C is a more rapid means of treating hypothermia than standard 40 degrees C intravenous fluid. It is safe even in hypovolemic animals.

Objectives: To determine the incidence of intra-abdominal injury requiring laparotomy after an abdominal stab wound with evisceration. To identify clinical signs that increase the likelihood of an intra-abdominal injury in the presence of such a wound. Methods: Information was collected prospectively over an 8-year period on all patients who presented to our urban Level I trauma center with an abdominal stab wound and evisceration. This information included which organ eviscerated, presence of other indications for laparotomy, organs injured, and postoperative complications. All comparisons used the Fisher's exact X 2 . Results: A total of 81 patients were admitted with evisceration after an abdominal stab wound. Sixty-one patients (75%) had eviscerated omentum, 18 patients (22%) had eviscerated small bowel, and 2 patients (2%) had eviscerated colon. Sixty-two patients (76%) had evisceration as the sole indication for laparotomy, the remaining 19 patients (24%) had another indication such as hypotension or peritonitis. Overall, 63 patients (78%) had an intra-abdominal injury that required repair. This was true regardless of organ eviscerated (omentum = 77% vs. vis-cus = 80%, not significant) or clinical presentation (no other indication = 76% vs. another indication = 84%, not significant). Conclusion: The majority of patients who present with an evisceration after a stab wound to the abdomen require a laparotomy. This is true regardless of what has eviscerated or the presence of other clinical indications to operate. Evisceration should continue to prompt operative intervention.

Objective: To compare two prostheses for use in acute abdominal wall replacement in the presence and absence of peritonitis. Materials and Methods: Forty male Sprague-Dawley rats underwent full-thickness removal of a 2 × 3 cm portion of their anterior abdominal wall. Twenty rats had intraperitoneal contamination with stool slurry. Ten rats in each group (contaminated and noncontaminated) had a 2 × 3 cm piece of Gore-Tex dual-mesh expanded polytetrafluoroethylene (PTFE) sewn full-thickness to cover the abdominal wall defect. The remaining 10 rats in each group had replacement with a 2 × 3 cm piece of Dexon polyglycolic acid mesh (PGA). The rats were then awakened and returned to their cages. Rats were humanely killed at the end of a 3-week observation period or at the time of fistula formation or evisceration. At necropsy, the density of intra-abdominal adhesions was graded on a scale of 0 to 3, and the extent of reepithelialization was noted. Results were analyzed with the Student's t test or Fisher's exact method of X 2 test as indicated. Results: Nineteen PTFE rats and 10 PGA rats survived the observation period, The PTFE rats had significantly fewer adhesions (0.10 ± 0.30 vs. 1.27 ± 1.49, p < 0.005) and significantly more reepithelialization of their wounds (78.2 ± 23.4% vs. 43.6 ± 50.4%, p < 0.05) than the PGA rats. Evisceration and fistula formation occurred more frequently in the PGA group. The mortality in the PTFE rats was significantly less than the PGA rats (5% vs. 50%, p < 0.001.) Notably, the contaminated PGA rats had a significantly higher mortality (90%, p < 0.001) than any of the other subgroups. Conclusion: PTFE is superior to PGA as a replacement prosthesis for acute abdominal wall defects. There are significantly fewer adhesions, improved epithelialization of the wound, and less morbidity and mortality when PTFE is used. This finding is especially true in the presence of intraperitoneal fecal soilage.

Background: Blunt aortic injury is a major cause of death from blunt trauma. Evolution of diagnostic techniques and methods of operative repair have altered the management and posed new questions in recent years. Methods: This study was a prospectively conducted multicenter trial involving 50 trauma centers in North America under the direction of the Multi-institutional Trial Committee of the American Association for the Surgery of Trauma. Results: There were 274 blunt aortic injury cases studied over 2.5 years, of which 81% were caused by automobile crashes. Chest computed tomography and transesophageal echocardiography were applied in 88 and 30 cases, respectively, and were 75 and 80% diagnostic, respectively. Two hundred seven stable patients underwent planned thoracotomy and repair. Clamp and sew technique was used in 73 (35%) and bypass techniques in 134 (65%). Overall mortality was 31%, with 63% of deaths being attributable to aortic rupture; mortality was not affected by method of repair. Paraplegia occurred postoperatively in 8.7%. Logistic regression analysis demonstrated clamp and sew (p = 0.002) and aortic cross clamp time of 30 minutes (p = 0.01) to be associated with development of postoperative paraplegia. Conclusions: Rupture after hospital admission remains a major problem. Although newer diagnostic techniques are being applied, at this time aortography remains the diagnostic standard. Aortic cross clamp time beyond 30 minutes was associated with paraplegia; bypass techniques, which provide distal aortic perfusion, produced significantly lower paraplegia rates than the clamp and sew approach.

Objective: To determine the accuracy of CT of the chest in diagnosing the presence of cardiac injury in stable pitients with penetrating chest injuries. Methods: A retrospective chart review of a convenience sample of stable patients with penetrating thoracic wounds evaluated for hemopericardium using chest CT at an urban level I trauma center. Results: 60 stable patients with penetrating wounds in proximity to the heart underwent CT. Three patients had radiographic evidence of pericardial fluid, and 1 had an equivocal study. These 4 patients underwent subxiphoid pericardial window exploration: 2 had only clear fluid present, the other 2 had hemopericardium. The latter patients had a total of 3 cardiac and 1 diaphragmatic injuries, which were repaired at subsequent sternotomy. None of the 56 patients who had negative CTs had further clinical evidence of cardiac injury. The sensitivity, specificity, and accuracy of CT in this setting for hemopericardium are 100% (95% CI 18–100%). 96.6% (95% CI 88–100%). and 96.7% (95% CI 89–100%), respectively. Conclusion: Chest CT may be a useful test for diagnosing the presence of hemopericardium in the setting of penetrating thoracic injury. With the caveat that the patient must be removed from a closely monitored environment, the authors advocate the use of CT in stable patients with penetrating chest wounds whenever echocardiography is unavailable.