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25. Vascular Injuries

Author

Parker, William J., DesPain, Robert W., Bradley, Matthew J., Rasmussen, Todd E., Callaway, David W., editor, and Burstein, Jonathan L., editor

Published
2020
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31. The mangled extremity score and amputation

Author

Loja, Melissa N, Sammann, Amanda, DuBose, Joseph, Li, Chin-Shang, Liu, Yu, Savage, Stephanie, Scalea, Thomas, Holcomb, John B, Rasmussen, Todd E, and Knudson, M Margaret

Subjects
Rehabilitation, Clinical Research, Physical Injury - Accidents and Adverse Effects, Patient Safety, Injuries and accidents, Adolescent, Adult, Aged, Aged, 80 and over, Amputation, Child, Child, Preschool, Female, Humans, Injury Severity Score, Leg Injuries, Length of Stay, Limb Salvage, Male, Middle Aged, Prognosis, Registries, United States, Mangled, trauma, vascular, extremity, amputation, AAST PROOVIT Study Group, Amputation, Surgical, Cardiorespiratory Medicine and Haematology, Clinical Sciences, Nursing, Emergency & Critical Care Medicine
Abstract

BackgroundThe Mangled Extremity Severity Score (MESS) was developed 25 years ago in an attempt to use the extent of skeletal and soft tissue injury, limb ischemia, shock, and age to predict the need for amputation after extremity injury. Subsequently, there have been mixed reviews as to the use of this score. We hypothesized that the MESS, when applied to a data set collected prospectively in modern times, would not correlate with the need for amputation.MethodsWe applied the MESS to patient data collected in the American Association for the Surgery of Trauma PROspective Vascular Injury Treatment registry. This registry contains prospectively collected demographic, diagnostic, treatment, and outcome data.ResultsBetween 2013 and 2015, 230 patients with lower extremity arterial injuries were entered into the PROspective Vascular Injury Treatment registry. Most were male with a mean age of 34 years (range, 4-92 years) and a blunt mechanism of injury at a rate of 47.4%. A MESS of 8 or greater was associated with a longer stay in the hospital (median, 22.5 (15, 29) vs 12 (6, 21); p = 0.006) and intensive care unit (median, 6 (2, 13) vs 3 (1, 6); p = 0.03). Of the patients' limbs, 81.3% were ultimately salvaged (median MESS, 4 (3, 5)), and 18.7% required primary or secondary amputation (median MESS, 6 (4, 8); p < 0.001). However, after controlling for confounding variables including mechanism of injury, degree of arterial injury, injury severity score, arterial location, and concomitant injuries, the MESS between salvaged and amputated limbs was no longer significantly different. Importantly, a MESS of 8 predicted in-hospital amputation in only 43.2% of patients.ConclusionTherapeutic advances in the treatment of vascular, orthopedic, neurologic, and soft tissue injuries have reduced the diagnostic accuracy of the MESS in predicting the need for amputation. There remains a significant need to examine additional predictors of amputation following severe extremity injury.Level of evidenceProspective, prognostic study, level III.

Published
2017

36. Extending resuscitative endovascular balloon occlusion of the aorta

Author

Williams, Timothy Keith, Neff, Lucas P, Johnson, Michael Austin, Ferencz, Sarah-Ashley, Davidson, Anders J, Russo, Rachel M, and Rasmussen, Todd E

Subjects
Biomedical and Clinical Sciences, Clinical Sciences, Bioengineering, Cardiovascular, Animals, Aorta, Balloon Occlusion, Disease Models, Animal, Endovascular Procedures, Hemodynamics, Liver, Resuscitation, Shock, Hemorrhagic, Swine, REBOA, endovascular variable aortic control, hemorrhage control, aortic occlusion, swine, Clinical sciences, Nursing
Abstract

BackgroundThe duration of use and efficacy of resuscitative endovascular balloon occlusion of the aorta (REBOA) is limited by distal ischemia. We developed a hybrid endovascular-extracorporeal circuit variable aortic control (VAC) device to extend REBOA duration in a lethal model of hemorrhagic shock to serve as an experimental surrogate to further the development of endovascular VAC (EVAC) technologies.MethodsNine Yorkshire-cross swine were anesthetized, instrumented, splenectomized, and subjected to 30% liver amputation. Following a short period of uncontrolled hemorrhage, REBOA was instituted for 20 minutes. Automated variable occlusion in response to changes in proximal mean arterial pressure was applied for the remaining 70 minutes of the intervention phase using the automated extracorporeal circuit. Damage-control surgery and whole blood resuscitation then occurred, and the animals were monitored for a total of 6 hours.ResultsSeven animals survived the initial surgical preparation. After 20 minutes of complete REBOA, regulated flow was initiated through the extracorporeal circuit to simulate VAC and provide perfusion to distal tissue beds during the 90-minute intervention phase. Two animals required circuit occlusion for salvage, while five animals tolerated sustained, escalating restoration of distal blood flow before surgical hemorrhage control. Animals tolerating distal flow had preserved renal function, maintained proximal blood pressure, and rapidly weaned from complete REBOA.ConclusionWe combined a novel automated, extracorporeal circuit with complete REBOA to achieve EVAC in a swine model of uncontrolled hemorrhage. Our approach regulated proximal aortic pressure, alleviated supranormal values above the balloon, and provided controlled distal aortic perfusion that reduced ischemia without inducing intolerable bleeding. This experimental model serves as a temporary surrogate to guide future EVAC catheter designs that may provide transformational approaches to hemorrhagic shock.

Published
2016

45. Selective Prehospital Advanced Resuscitative Care – Developing a Strategy to Prevent Prehospital Deaths From Noncompressible Torso Hemorrhage

Author

Qasim, Zaffer, Butler, Frank K., Holcomb, John B., Kotora, Joseph G., Eastridge, Brian J., Brohi, Karim, Scalea, Thomas M., Schwab, C. William, Drew, Brendon, Gurney, Jennifer, Jansen, Jan O., Kaplan, Lewis J., Martin, Matthew J., Rasmussen, Todd E., Shackelford, Stacy A., Bank, Eric A., Braude, Darren, Brenner, Megan, Guyette, Francis X., Joseph, Bellal, Hinckley, William R., Sperry, Jason L., and Duchesne, Juan

Published
2022
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