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Surgery has traditionally been the definitive form of invasive management for renal vascular injuries. There is a growing trend in the use of endovascular techniques as an alternative to surgery in the trauma setting. We present the case of a 24-year-old woman with an acute renal arteriovenous fistula caused by a stab wound in the left flank, which was successfully managed with selective arterial embolization. This represents only the second reported case of such an approach in the acute setting. [ABSTRACT FROM AUTHOR]

Despite its near-universal use, few data exist to support the efficacy of prehospital supplemental oxygen (PH O2) in trauma patients. Data were reviewed from 5,090 patients not requiring assisted ventilation who were transported to our level I trauma center. Of these, 2,203 (43.3%) received PH O2 and 2,887 (56.7%) did not. Patients who received PH O2 had higher mortality than those without PH O2 (2.3% vs. 1.1%, p = 0.011). When corrected for Injury Severity Score, mechanism of injury, and age, those receiving PH O2 fared worse or no better than those who did not receive it. This suggests that supplemental oxygen does not improve survival in traumatized patients who are not in respiratory distress. This has implications for the management of casualties in combat or austere environments. [ABSTRACT FROM AUTHOR]

The U.S.-based health care system of the International Space Station (ISS) provides the resources to care for an in-flight medical contingency. The current system was designed for use in conjunction with a return vehicle possessing medical capabilities that would allow rapid and safe transport of an ill or injured crew member to a terrestrial medical facility. Because plans for such a vehicle have been indefinitely delayed, a mismatch has been created between the limited onboard medical capabilities and the current mission profile. This has driven the medical concept of operations to one in which as many medical conditions as possible must be treated on orbit, with return to Earth delayed or avoided. This article describes this proposed new plan, the implementation of which will require numerous changes to the medical system, including modifications to training practices, treatment guidelines, diagnostic and therapeutic resources, and informatics. [ABSTRACT FROM AUTHOR]

Background: Recent military studies demonstrated an association between prehospital tourniquet use and increased survival. The benefits of this prehospital intervention in a civilian population remain unclear. The aims of our study were to evaluate tourniquet use in the civilian population and to compare outcomes to previously published military experience. We hypothesized that incorporation of tourniquet use in the civilian population will result in an overall improvement in mortality., Methods: This is a preliminary multi-institutional retrospective analysis of prehospital tourniquet (MIA-T) use of patients admitted to nine urban Level 1 trauma centers from January 2010 to December 2013. Patient demographics and mortality from a previous military experience by Kragh et al. (Ann Surg. 2009;249:1-7) were used for comparison. Patients younger than 18 years or with nontraumatic bleeding requiring tourniquet application were excluded. Data were analyzed using a two-tailed unpaired Student's t test with p < 0.05 as significant., Results: A total of 197 patients were included. Tourniquets were applied effectively in 175 (88.8%) of 197 patients. The average Injury Severity Score (ISS) for MIA-T versus military was 11 ± 12.5 versus 14 ± 10.5, respectively (p = 0.02). The overall mortality and limb amputation rates for the MIA-T group were significantly lower than previously seen in the military population at 6 (3.0%) of 197 versus 22 (11.3%) of 194 (p = 0.002) and 37 (18.8%) of 197 versus 97 (41.8%) of 232 (p = 0.0001), respectively., Conclusion: Our study is the largest evaluation of prehospital tourniquet use in a civilian population to date. We found that tourniquets were applied safely and effectively in the civilian population. Adaptation of this prehospital intervention may convey a survival benefit in the civilian population., Level of Evidence: Epidemiologic study, level V.

The Trauma Quality Improvement Program (TQIP) reports a feasible mortality prediction model. We hypothesize that our institutional characteristics differ from TQIP aggregate data, questioning its applicability. We conducted a 2-year (2008 to 2009) retrospective analysis of all trauma activations at a Level 1 trauma center. Data were analyzed using TQIP methodology (three groups: blunt single system, blunt multisystem, and penetrating) to develop a mortality prediction model using multiple logistic regression. These data were compared with TQIP data. Four hundred fifty-seven patients met TQIP inclusion criteria. Penetrating and blunt trauma differed significantly at our institution versus TQIP aggregates (61.9 vs 7.8%; 38.0 vs 92.2%, P < 0.01). There were more firearm mechanisms of injury and less falls compared with TQIP aggregates (28.9 vs 4.2%; 8.5 vs 34.8%, P < 0.01). All other mechanisms were not significantly different. Variables significant in the TQIP model but not found to be predictors of mortality included Glasgow Coma Score motor 2 to 5, systolic blood pressure greater than 90 mmHg, age, initial pulse rate in the emergency department, mechanism of injury, head Abbreviated Injury Score, and abdominal Abbreviated Injury Score. External benchmarking of trauma center performance using mortality prediction models is important in quality improvement for trauma patient care. From our results, TQIP methodology from the pilot study may not be applicable to all institutions.

Background: High ratios of fresh frozen plasma:packed red blood cells in damage control resuscitation (DCR) are associated with increased survival. The impact of volume and type of resuscitative fluid used during high ratio transfusion has not been analyzed. We hypothesize a difference in outcomes based on the type and quantity of resuscitative fluid used in patients that received high ratio DCR., Methods: A matched case control study of patients who received transfusions of ≥ four units of PRBC during damage control surgery over 4 1/2 y, was conducted at a Level I Trauma Center. All patients received a high ratio DCR, >1:2 of fresh frozen plasma:packed red blood cells. Demographics and outcomes of the type and quantity of resuscitative fluids used in combination with high ratio DCR were compared and analyzed. A Kaplan-Meier survival analysis was computed among four groups: colloid (median quantity = 1.0 L), <3 L crystalloid, 3-6 L crystalloid, and >6 L crystalloid., Results: There were 56 patients included in the analysis (28 in the crystalloid group and 28 in the colloid group). Demographics were statistically similar. Intraoperative median units of PRBC: crystalloid versus colloid groups was 13 (IQR 8-21) versus 16 (IQR 12-19), P = 0.135; median units of FFP: 12 (IQR 7-18) versus 12 (IQR 10-18), P = 0.440. OR for 10-d mortality in the crystalloid group was 8.41 [95% CI 1.65-42.76 (P = 0.01)]. Kaplan-Meier survival analysis demonstrated lowest mortality in the colloid group and higher mortality with increasing amounts of crystalloid (P = 0.029)., Conclusions: During high ratio DCR, resuscitation with higher volumes of crystalloids was associated with an overall decreased survival, whereas low volumes of colloid use were associated with increased survival. In order to improve outcomes without diluting the survival benefit of hemostatic resuscitation, guidelines should focus on effective low volume resuscitation when high ratio DCR is used. A multi-institutional analysis is needed in order to validate these results., (Published by Elsevier Inc.)

The impact on outcomes resulting from crystalloids used with hemostatic close ratio resuscitation (HCRR) in intraoperative hemorrhage (IOH) has not been analyzed. We hypothesize a survival advantage in patients with IOH managed with a low-volume resuscitation (LVR) protocol during HCRR. A 4-year case-control study was conducted to determine the impact on mortality of LVR versus conventional resuscitation efforts (CRE) during HCRR. A total of 45 patients managed with a HCRR + LVR protocol (combination Hextend® and 3% hypertonic saline) and 55 historical cohorts managed with HCRR + CRE (lactated Ringer's) were included. Patient demographics, number of intraoperative units of packed red blood cells (PRBCs) and fresh-frozen plasma (FFP) received, and FFP:PRBC ratio were similar between groups. The mean intraoperative fluid volume was 0.76 L in the HCRR + LVR group versus 4.7 L in the HCRR + CRE group (P = 0.003). In a linear regression model HCRR + LVR versus HCRR + CRE, mean trauma intensive care unit length of stay was 6 versus 11 days (P = 0.009); 30-day overall mortality was 11.1 versus 32.7 per cent (P = 0.009); perioperative mortality was 2.2 to 10.9 per cent (P = 0.13); and intensive care unit mortality 8.8 to 21.8 per cent (P = 0.07). LVR protocol conveyed a survival benefit to patients undergoing HCRR (odds ratio for mortality, 0.07 [95% confidence interval 0.07-0.54]). This is the first civilian study to analyze the impact of LVR in patients managed with HCRR during IOH. Patients with IOH managed with HCRR and a predefined LVR protocol with Hextend® and 3 per cent hypertonic saline had an overall survival advantage and shorter trauma intensive care unit length of stay. LVR can be an effective alternative to CRE when used in combination with HCRR in patients with IOH.

Background: Damage control resuscitation (DCR) conveys a survival advantage in patients with severe hemorrhage. The role of restrictive fluid resuscitation (RFR) when used in combination with DCR has not been elucidated. We hypothesize that RFR, when used with DCR, conveys an overall survival benefit for patients with severe hemorrhage., Methods: This is a retrospective analysis from January 2007 to May 2011 at a Level I trauma center. Inclusion criteria included penetrating torso injuries, systolic blood pressure less than or equal to 90 mm Hg, and managed with DCR and damage control surgery (DCS). There were two groups according to the quantity of fluid before DCS: (1) standard fluid resuscitation (SFR) greater than or equal to 150 mL of crystalloid; (2) RFR less than 150 mL of crystalloid. Demographics and outcomes were analyzed., Results: Three hundred seven patients were included. Before DCS, 132 (43%) received less than 150 mL of crystalloids, grouped under RFR; and 175 (57%) received greater than or equal to 150 mL of crystalloids, grouped under SFR. Demographics and initial clinical characteristics were similar between the study groups. Compared with the SFR group, RFR patients received less fluid preoperatively (129 mL vs. 2,757 mL; p < 0.001), exhibited a lower intraoperative mortality (9% vs. 32%; p < 0.001), and had a shorter hospital length of stay (13 vs. 18 days; p = 0.02). Patients in the SFR group had a lower trauma intensive care unit mortality (5 vs. 12%; p = 0.03) but exhibited a higher overall mortality. Patients receiving RFR demonstrated a survival benefit, with an odds ratio for mortality of 0.69 (95% confidence interval, 0.37-0.91)., Conclusion: To the best of our knowledge, this is the first civilian study that analyzes the impact of RFR in patients managed with DCR. Its use in conjunction with DCR for hypotensive trauma patients with penetrating injuries to the torso conveys an overall and early intraoperative survival benefit., Level of Evidence: Therapeutic study, level IV.

Damage control surgery emphasizes limited operations with control of bleeding and contamination. Traditional management centered upon correction of acidosis and hypotension with crystalloids. Damage control resuscitation (DCR) is permissive hypotension and early hemostatic resuscitation combined identified and corrects coagulopathy with fresh-frozen plasma (FFP), restricting use of crystalloids. We hypothesize a survival advantage in patients managed with DCR when compared with a historical cohort of patients. During the 2-year retrospective review, a 1-year period after institution of DCR was compared with a historical control. Resuscitation strategies were analyzed and stratified into emergency department (ED) resuscitation and intraoperative resuscitation. Univariate analysis of continuous data was done with Student's t test followed by multiple logistic regression. Fifty-seven and 61 patients were managed during the NonDCR and DCR periods respectively. Baseline demographic patient characteristics and physiologic variables were similar between groups. ED DCR patients received less crystalloids: 1.1 versus 4.7 liters (P = 0.0001), more FFP: 1.8 versus 0.5 (P = 0.001). NonDCR had a lower initial systolic pressure in the operating room when compared with DCR: 81 mm Hg versus 95 mm Hg (P = 0.03). DCR patients received less intraoperative crystalloids: 5.7 versus 15.8 liters (P = 0.0001) and more FFP: 15.1 versus 6.2 (P = 0.0001). DCR conveyed a survival benefit (Odds Ratio; 95% confidence interval: 0.40 (0.18-0.90), P = 0.024). NonDCR group had 13.2 days longer hospital length of stay. Damage control resuscitation, beginning in the ED, used more packed red blood cells and FFP minimizing crystalloids. DCR was associated with a survival advantage and shorter length of stay in patients with severe hemorrhage.

The aftermath and response to a disaster can be divided into four phases. The importance of each depends on the length of time without resupply and the resources that are required. This in turn depends on the time span of the disaster; the area involved; the number of the population affected; the resupply available; the extent of the devastation; and the size of the evacuation. The above phases are discussed using hurricane Katrina as an example. The phases are as follows: immediate response, evacuation, backfill and resupply, and restoration. The restoration phase is usually the longest and requires the most resources. This article addresses the situation of Katrina, the mistakes that were made, the lessons that were learned, and the solutions that are needed. Appropriate training and practice are required for all participants using realistic scenarios.

Background: Damage control laparotomy (DCL) improves outcomes when used in patients with severe hemorrhage. Correction of coagulopathy with close ratio resuscitation while limiting crystalloid forms a new methodology known as damage control resuscitation (DCR). We hypothesize a survival advantage in DCL patients managed with DCR when compared with DCL patients managed with conventional resuscitation efforts (CRE)., Methods: This study is a 4-year retrospective study of all DCL patients who required >or=10 units of packed red blood cells (PRBC) during surgery. A 2-year period after institution of DCR (DCL and DCR) was compared with the preceding 2 years (DCL and CRE). Univariate analysis of continuous data was done with Student's t test followed by multiple logistic regression., Results: One Hundred twenty-four and 72 patients were managed during the DCL and CRE and DCL and DCR time periods, respectively. Baseline patient characteristics of age, Injury Severity Score, % penetrating, blood pressure, hemoglobin, base deficit, and INR were similar between groups. There was no difference in quantity of intraoperative PRBC utilization between DCL and CRE and DCL and DCR study periods: 21.7 units versus 25.5 units (p = 0.53); however, when compared with DCL and CRE group, patients in the DCL and DCR group received less intraoperative crystalloids, 4.7 L versus 14.2 L (p = 0.009); more fresh frozen plasma (FFP), 18.2 versus 6.4 (p = 0.002); a closer FFP to PRBC ratio, 1 to 1.2 versus 1 to 4.2 (p = 0.002); platelets to PRBC ratio, 1:2.3 versus 1:5.9 (0.002); shorter mean trauma intensive care unit length of stay, 11 days versus 20 days (p = 0.01); and greater 30-day survival, 73.6% versus 54.8% (p < 0.009). The addition of DCR to DCL conveyed a survival benefit (odds ratio; 95% confidence interval: 0.19 (0.05-0.33), p = 0.005)., Conclusion: This is the first civilian study that analyses the impact of DCR in patients managed with DCL. During the DCL and DCR study period more PRBC, FFP, and platelets with less crystalloid solution was used intraoperatively. DCL and DCR were associated with a survival advantage and shorter trauma intensive care unit length of stay in patients with severe hemorrhage when compared with DCL and CRE.

Polytrauma patients needing aggressive resuscitation can develop intra-abdominal hypertension (IAH) with subsequent secondary abdominal compartment syndrome (SACS). After patients fail medical therapy, decompressive laparotomy is the surgical last resort. In patients with severe pancreatitis SACS, the use of linea alba fasciotomy (LAF) is an effective intervention to lower IAH without the morbidity of laparotomy. A pilot study of LAF was designed to evaluate its benefit in patients with SACS polytrauma. We conducted an observational study of blunt injury polytrauma patients undergoing LAF. Variables measured before and after LAF included intra-abdominal pressure (IAP, mmHg), abdominal perfusion pressure (APP, mmHg), right ventricular end diastolic volume index (RVEDVI, mL/m2), and ejection fraction. Of the five trauma patients with SACS, the mean age was 36 +/- 17, four (80%) male with an Injury Severity Score of 27 +/- 9. Pre- and post-LAF, IAP was 20.6 +/- 4.7 and 10.6 +/- 2.7 (P < 0.0001), APP 55.2 +/- 5.5 and 77.6 +/- 7.1 (P < 0.0001), RVEDVI 86.4 +/- 9.3 and 123.6 +/- 11.9 (P < 0.0001), and EF 27.6 +/- 4.2 and 40.8 +/- 5 (P < 0.0001), respectively. One patient needed full decompression for bile ascites from unrecognized liver injury. Linea alba fasciotomy, as a first-line intervention before committing to full abdominal decompression in patients with SACS trauma, improved physiological variables without mortality. Consideration for LAF as a bridge before full abdominal decompression needs further evaluation in patients with polytrauma SACS.

Intra-abdominal hypertension (IAH) after damage control laparotomy (DCL) is not unusual and because of this, patients are treated with open-abdomen techniques to prevent abdominal compartment syndrome (ACS). The occurrence of recurrent ACS (R-ACS) after abdominal wall closure under tension in patients managed with DCL can be a trigger factor for second hit syndrome. Outcomes in this subset have not been previously described. In this 1-year retrospective study of severely injured patients in a Level I trauma center managed with DCL and sequential abdominal wall closure, 26 patients were identified. After attempted abdominal wall closure, 13 (50%) patients had R-ACS and 13 (50%) non-R-ACS. R-ACS patients had a statistically significant higher incidence of multisystem organ failure, acute respiratory distress syndrome, and sepsis as well as requiring longer ventilator support and longer hospital length of stay. We concluded that failure to recognize and treat IAH with development of R-ACS after tension abdominal wall closure in patients with DCL will trigger the second hit syndrome with increased risk of morbidity. Institution of a management algorithm with intra-abdominal pressure/abdominal perfusion pressure surveillance at the time of abdominal wall closure can potentially ameliorate complications.

Open-book pelvic fractures (OBPF) with concomitant intra-abdominal injuries carry a high morbidity and mortality; the significance of associated perineal open wound (OBPF-POW) has not been defined. We hypothesize that the presence of perineal open wounds increases morbidity, mortality, and concomitant use of hospital resources. Patients diagnosed with OBPF over a 5-year period at a Level I trauma center were identified by trauma registry review, and were retrospectively reviewed under an Institutional Review Board-approved protocol. Patients with OBPF without a perineal open wound were compared with those with OBPF-POW. Data collected included patient demographics, injury details, management, and outcomes. A total of 1,635 patients with blunt pelvic fractures were identified, of which 177 (10.8%) had OBPF. OBPF-POW (36/177) significantly increased the use of angioembolization, occurrence of sepsis, pelvic sepsis, ARDS, and multi-organ system failure. Patients with OBPF-POW had an increase of 13 days in length of hospitalization compared with the OBPF group (P < 0.001), with cost of $120,647.30 and $62,952.72 respectively (P < 0.001). Perineal open wounds complicate open-book pelvic fractures with significant increase in hospital resource utilization. Aggressive multidisciplinary evaluation and management is appropriate to detect and prevent complications.

Background: Obesity is an independent predictor of increased morbidity and mortality in critically injured trauma patients. We hypothesized that obese patients in need of damage control laparotomy (DCL) will encounter an increase incidence of postsurgical complications with a concomitant increase mortality when compared with a cohort of nonobese patients., Methods: All adult trauma patients who underwent DCL during a 4-year period at a Level I Trauma Center were retrospectively reviewed. Patients were categorized into nonobese (body mass index [BMI] < or = 29 kg/m), obese (BMI 30-39 kg/m), and severely obese (BMI > or = 40 kg/m) groups. Outcome measures included the occurrence of postoperative infectious complications, failure of primary abdominal wall fascial closure, acute respiratory distress syndrome, acute renal insufficiency, multiple system organ failure, days of ventilator support, hospital length of stay, and death., Results: During a 4-year period, 12,759 adult trauma patients were admitted to our Level I Trauma Center of which 1,812 (14.2%) underwent emergent laparotomy. Of these, 104 (5.7%) were treated with DCL: nonobese, n = 51 (49%); obese, n = 38 (37%); and severely obese, n = 15 (14%). In a multivariate adjusted model, multiple system organ failure was 1.82 times more likely in severely obese (95% CI: 1.14-2.90) and 1.74 times more likely in the obese patients (95% CI: 1.14-2.66) when compared with patients with normal BMI after DCL (p < 0.01). In the severely obese patients undergoing DCL, significantly elevated prevalence ratios (PR) for development of postoperative infectious complications, acute renal insufficiency, and failure of primary abdominal wall fascial closure were 1.75, 3.07, and 2.62, respectively. Days of ventilator support, length of stay, and mortality rates were significantly higher in severely obese patients (24 days, 27 days, and 60%) compared with obese (14 days, 14 days, and 21%) and nonobese (9.8 days, 14 days, and 28%) patients., Conclusion: Severe obesity was significantly associated with adverse outcomes and increased resource utilization in trauma patients treated with DCL. Measures to improve outcomes in this vulnerable patient population must be directed at multiple levels of health care.

Background: Although hemostatic resuscitation with a 1:1 ratio of fresh-frozen plasma (FFP) to packed red blood cells (PRBC) after severe hemorrhage has been shown to improve survival, its benefit in patients with traumatic-induced coagulopathy (TIC) after >10 units of PRBC during operation has not been elucidated. We hypothesized that a survival benefit would occur when early hemostatic resuscitation was used intraoperatively after injury in patients with TIC., Methods: A 7-year retrospective study of patients with emergency department diagnosis of TIC after transfusion of >10 units of PRBC in the operating room. TIC was defined as initial emergency department international normalized ratio > 1.2, prothrombin time > 16 seconds, and partial thromboplastin time > 50 seconds. Patients were divided into FFP:PRBC ratios of 1:1, 1:2, 1:3, and 1:4. Patients with diagnosis of TIC who received transfusion of both FFP and PRBC during surgery were included. Other variables evaluated included age, gender, mechanism of injury, initial base deficit, mean operative time, trauma intensive care unit length of stay (TICU LOS) and Injury Severity Score. The primary outcome measure evaluated was the impact of the early FFP:PRBC ratio on mortality., Results: Four hundred thirty-five patients underwent emergency operations postinjury and received FFP with >10 units of PRBC in the operating room; 135 (31.0%) of these patients had TIC and 53 died (39.5% mortality). Mean operative time was 137 minutes (SD +/- 49). There were no differences with regard to age, gender, mechanism of injury, initial base deficit, or Injury Severity Score among all groups. A significant difference in mortality was found in patients who received >10 units of PRBC when FFP:PRBC ratio was 1:1 versus 1:4 (28.2% vs. 51.1%, p = 0.03). Intermediate mortality rates were noted in patients with 1:2 and 1:3 ratios (38% and 40%, respectively). From a linear regression model, 13 days of increased TICU LOS was observed among 1:4 group compared with 1:1 group (p < 0.01)., Conclusion: TIC is common after severe injury and is associated with a high mortality in patients transfused with >10 units of PRBC during surgery. Early hemostatic resuscitation during first hours after injury improves survival with shorter TICU LOS in patients with TIC.

Background: Although splenic angioembolization (SAE) has been introduced and adopted in many trauma centers, the appropriate selection for and utility of SAE in trauma patients remains under debate. This study examined the outcomes of proximal SAE as part of a management algorithm for adult traumatic splenic injury compared with splenectomy., Methods: A retrospective cohort analysis was performed on all hemodynamically stable (HDS) blunt trauma patients with isolated splenic injury and computed tomographic (CT) evidence of active contrast extravasation that presented to a level 1 Trauma Center over a period of 5 years. The cohorts were defined by two separate 30 month periods and included 78 patients seen before (group I) and 76 patients seen after (group II) the introduction of an institutional SAE protocol. Demographics, splenic injury grade, and outcomes of the two groups were compared using Student's t test, or chi2 test. Analysis was by intention-to-treat., Results: Six hundred eighty-two patients with blunt splenic injury were identified; 154 patients (29%) were HDS with CT evidence of active contrast extravasation. Group I (n = 78) was treated with splenectomy and group II (n = 76) was treated with proximal SAE. There was no difference in age (33 +/- 14 vs. 37 +/- 17 years), Injury Severity Score (31 +/- 13 vs. 29 +/- 11), or mortality (18% vs. 15%) between the two groups. However, the incidence of Adult Respiratory Distress Syndrome (ARDS) was 4-fold higher in those patients that underwent proximal SAE compared with those that underwent splenectomy (22% vs. 5%, p = 0.002). Twenty two patients failed nonoperative management (NOM) after SAE. This failure appeared to be directly related to the grade of splenic organ injury (grade I and II: 0%; grade III: 24%; grade IV: 53%; and grade V: 100%)., Conclusion: Introduction of proximal SAE in NOM of HDS splenic trauma patients with active extravasation did not alter mortality rates at a Level 1 Trauma Center. Increased incidence of ARDS and association of failure of NOM with higher splenic organ injury score identify areas for cautionary application of proximal SAE in the more severely injured trauma patient population. Better patient selection guidelines for proximal SAE are needed. Without these guidelines, outcomes from SAE will still lack transparency.

Background: The purpose of this study was to compare disaster preparedness of a Level I Trauma Center with performance in an actual disaster. Previous disaster response evaluations have shown that the key to succeeding in responding to a catastrophic event is to anticipate the event, plan the response, and practice the plan. The Emergency Management Team had identified natural disaster as the hospital's highest threat. The hospital also served as the regional hospital for the Louisiana Health Resources and Service Administration Bioterrorism Hospital Preparedness Program., Methods: The hospital master disaster plan, including the Code Gray annex, was retrospectively reviewed and compared with the actual events that occurred after Hurricane Katrina. Vital support areas were evaluated for adequacy using a systematic approach. In addition, a survey of 10 key personnel from trauma and emergency medicine present during Hurricane Katrina was conducted. The survey of vital support areas were scored as adequate (3 pts), partially adequate (2 pts), or inadequate (1 pt)., Results: Ninety-three percent of the line items on the Code Gray Checklist were accomplished before landfall of the storm. The results of the survey of vital support areas were water-3.0, food-2.4, sanitation-1.5, communication-1.4, and power-1.5., Conclusion: Despite identifying the threat of a major hurricane, preparing a response plan, and exercising the plan, a major medical center can be overwhelmed by a catastrophic disaster like Hurricane Katrina. We offer our lessons-learned as an aid for other medical centers that are developing and exercising their plans.

Background: Recent military experience reported casualties who receive > 10 units of packed red blood cells (PRBC) in 24 hours have 20% versus 65% mortality when the fresh-frozen plasma (FFP) to PRBC ratio was 1:1 versus 1:4, respectively. We hypothesize a similar improvement in mortality in civilian trauma patients that require massive transfusion and are treated with a FFP to PRBC ratio closer to 1:1., Methods: Four-year retrospective study of all trauma patients who underwent emergency surgery in an urban Level I Trauma Center. Patients were divided into two groups; those that received < or = 10 units or > 10 units of PRBC during and after initial surgical intervention. Only patients who received transfusion of both FFP and PRBC were included in the analysis. The primary research question was the impact of initial FFP:PRBC ratio on mortality. Other variables for analysis included patient age, gender, mechanism, and Injury Severity Scale score. Both univariate and multivariate analysis were used to assess the relationship between outcome and predictors., Results: A total of 2,746 patients underwent surgical intervention of which 1,985 (72.2%) received no transfusion. Of those that received transfusion, 626 (22.8%) received < or = 10 units of PRBC and 135 (4.9%) > 10 units of PRBC. Out of the 626 patients that received < or = 10 units of PRBC, 250 (39.9%) received FFP and 376 (60.1%) received no FFP. All the patients that received > 10 units PRBC received FFP. In univariate analysis, a significant difference in mortality was found in patients who received > 10 units of PRBC (26% vs. 87.5%) when FFP:PRBC ratio was 1:1 versus 1:4 (p = 0.0001). Multivariate analysis in the group of patients that received > 10 units of PRBC showed a FFP:PRBC ratio of 1:4 was consistent with increased risk of mortality (relative risk, 18.88; 95% CI, 6.32-56.36; p = 0.001), when compared with a ratio of 1:1. Patients who received < or = 10 units of PRBC had a trend toward increased mortality (21.2% vs.11.8%) when the FFP:PRBC ratio was 1:4 versus 1:1 (p: 0.06)., Conclusion: An FFP to PRBC ratio close to 1:1 confers a survival advantage in patients requiring massive transfusion.

Objectives: Only preliminary reports have evaluated the impact of telemedicine in trauma care. This study will analyze outcomes before (pre-TM) and after (post-TM) implementation of telemedicine in the management of rural trauma patients initially treated at local community hospitals (LCH) before trauma center (TC) transfer., Methods: Seven rural hospital emergency departments in Mississippi were equipped with dual video cameras with remote control capability. All trauma patients initially treated at these LCH with TC consultation were reviewed. Data included patient demographics, Injury Severity Score, institutional volume of patients, mode of transportation, length of stay in LCH, transfer time (TT), mortality, and hospital cost. Patients were grouped in the pre-TM and post-TM periods. Statistical testing was with two-sample Student's t test or chi analysis as appropriate., Results: During 5 years, 814 traumatically injured patients (pre-TM, n = 351; post-TM, n = 463) presented to the LCH. In the pre-TM period, 351 patients were transferred directly from the LCH for definitive management to the TC. In the post-TM period, 463 virtual consults were received, of which 51 patients were triaged to the TC. There were no differences in patient age, sex, or mode of transportation. When comparing post-TM with pre-TM era, patients had a higher Injury Severity Score (18 vs. 10, p < 0.001); less incidence of blunt trauma 35 (68%) versus 290 (82%), p < 0.05; a decrease in length of stay at LCH 1.5 hours versus 47 hours, p < 0.001; as well as TT LCH to TC 1.7 hours versus 13 hours, p < 0.001. After arrival to TC during the post-TM era patients received more units of packed red bed cell 13 units versus 5 units, p < 0.001 but without difference in mortality 4 (7.8%) versus 17 (4.8%), when compared with pre-TM era. Of statistical significance there was a dramatic decrease in hospital cost when comparing post-TM and pre-TM eras ($1,126,683 vs. $7,632,624, p < 0.001)., Conclusion: Telemedicine significantly improved rural LCH evaluation and management of trauma patients. More severely injured trauma patients were identified and more rapidly transferred to the TC. Total TC hospital costs were significantly decreased without significant changes in TC mortality. Introduction of telemedicine consultation to rural LCH emergency departments expanded LCH trauma capabilities and conserved TC resources, which were directed to more severely injured patients.

Background: Significant controversy surrounds the prehospital management of trauma patients., Methods: A questionnaire describing clinical scenarios was mailed to a random sample of 345 trauma practitioners., Results: The 182 trauma practitioners (52.8%) who returned the surveys were predominantly general or trauma surgeons (83.5%) in academic or university practice (68.1%). For a patient with a severe traumatic brain injury, 84.5% of trauma practitioners recommended that emergency medical services personnel attempt intubation at least once when transport time was 20 to 40 minutes. For a patient with a gunshot wound to the epigastrium in decompensated shock, the majority of trauma practitioners believed that a relatively hypotensive state should be maintained, regardless of transport time. Trauma practitioners (52.2%) have recommended the use of the pneumatic antishock garment for transports of 20 to 40 minutes for patients with an unstable pelvic fracture and decompensated shock., Conclusions: Most trauma practitioners believe that emergency medical services providers should attempt intubation for a patient with a severe traumatic brain injury, should treat decompensated shock in a patient with penetrating torso trauma but maintain the patient in a relatively hypotensive state, and should apply and inflate the pneumatic antishock garment for a suspected pelvic fracture accompanied by decompensated shock if the patient is 20 to 40 minutes from a trauma center. The recommendations of trauma practitioners regarding appropriate prehospital care are significantly influenced by the time required for transport to the trauma center.

Hyperbaric oxygen therapy (HBO) has been recommended as an adjunct treatment in acute traumatic ischemia and crush injury. Several animal models have shown better outcomes when HBO is used in crush injury and compartment syndrome. Animal and in vitro models have suggested that these beneficial effects may be mediated by attenuation of ischemia-reperfusion injury. We did a systematic review of the literature using the Eastern Association for the Surgery of Trauma (EAST) recommendations for evidence-based reviews. An electronic search using Medline, OVID technologies, and the Cochrane database was performed. Only clinical papers published between 1966 and December 2003 with at least five patients that included enough information to evaluate were selected. A group of trauma experts reviewed the selected articles and scored them applying the instrument developed by the EAST practice management guidelines committee. Nine documents fulfilled the inclusion criteria for a total of approximately 150 patients. Most documents were retrospective, uncontrolled, and case series lacking a standardized methodology (class III). There was one prospective controlled randomized trial with some limitations on its design. We determined that eight of nine studies showed a beneficial effect from HBO with only one major complication. We concluded that adjunctive HBO is not likely to be harmful and could be beneficial if administered early. Well designed clinical studies are warranted.

Traumatic injuries to the subclavian vessels are relatively uncommon and surgical repair may be technically challenging. With the increasing availability of endovascular techniques for nontraumatic arterial disease, an increase in the use of stenting for traumatic vascular injuries can be expected. This report describes the fifth successful endovascular repair with stenting of a pseudoaneurysm of the subclavian artery as a result of blunt trauma, and the first American report of such repair used in the acute or immediate management of blunt subclavian artery injury.

The Medical Center of Louisiana at New Orleans-Charity Hospital stands with pride as one of only two level I trauma centers in the state and one of the largest trauma centers in the United States, seeing over 4,000 trauma patients per year. Despite perennial funding issues, Charity Hospital's Emergency Department treated almost 200,000 patients in 2003. This brief report gives an overview of the emergency- and trauma-related services provided by Charity Hospital and underscores its value as a critical asset to healthcare in the Louisiana.