Search

Background: Corticosteroids are part of the treatment guidelines for COVID-19 and have been shown to improve mortality. However, the impact corticosteroids have on the development of secondary infection in COVID-19 is unknown. We sought to define the rate of secondary infection in critically ill patients with COVID-19 and determine the effect of corticosteroid use on mortality in critically ill patients with COVID-19. Study Design and Methods: One hundred and thirty-five critically ill patients with COVID-19 admitted to the Intensive Care Unit (ICU) at the University of Maryland Medical Center were included in this single-center retrospective analysis. Demographics, symptoms, culture data, use of COVID-19 directed therapies, and outcomes were abstracted from the medical record. The primary outcomes were secondary infection and mortality. Proportional hazards models were used to determine the time to secondary infection and the time to death. Results: The proportion of patients with secondary infection was 63%. The likelihood of developing secondary infection was not significantly impacted by the administration of corticosteroids (HR 1.45, CI 0.75-2.82, P = 0.28). This remained consistent in sub-analysis looking at bloodstream, respiratory, and urine infections. Secondary infection had no significant impact on the likelihood of 28-day mortality (HR 0.66, CI 0.33-1.35, P = 0.256). Corticosteroid administration significantly reduced the likelihood of 28-day mortality (HR 0.27, CI 0.10-0.72, P = 0.01). Conclusion: Corticosteroids are an important and lifesaving pharmacotherapeutic option in critically ill patients with COVID-19, which have no impact on the likelihood of developing secondary infections. more...

Background Critical care ultrasound (CCUS) is essential in modern practice, with CCUS including cardiac and noncardiac ultrasound. The most effective CCUS training is unknown, with a diverse skill set and knowledge needed for competence. The objective of this project was to evaluate the effect of a surgical intensivist-led training program on CCUS competence in critical care fellows. Methods This was a single institution retrospective review from 2016 to 2018 at the R Adams Cowley Shock Trauma Center. Our yearlong surgical intensivist (SI)-led CCUS training program for critical care fellows includes a daylong CCUS training class, CCUS lectures, a CCUS rotation, and bedside CCUS instruction during rotations. Fellows take a knowledge test and skills test before (pretest) and after (posttest) this program. Critical care ultrasound skill was graded on a scale from 1-5, with 4 (minimal help) or 5 (no help) considered competent. Emergency medicine, surgery, and medicine-trained critical care fellows were included. Results Forty-two critical care fellows were included. Mean posttest scores increased significantly for 21/22 (96%) of skills tested and for 14/30 (47%) of knowledge questions compared to pretest scores. The mean composite skill score increased from 3.25 to 4.82 from pretest to posttest ( P < .001). The mean composite knowledge score increased from 60% to 80% from pretest to posttest ( P < .001). Conclusion SI-led training improves CCUS competence and knowledge despite the breadth of CCUS. more...

Evaluating and treating traumatic cardiac arrest remains a challenge to the emergency medicine provider. Guidelines have established criteria for patients who can benefit from treatment and resuscitation versus those who will likely not survive. Patient factors that predict survival are penetrating injury, signs of life with emergency medical services or on arrival to the Emergency Department, short length of prehospital cardiopulmonary resuscitation, cardiac motion on ultrasound, pediatric patients, and those with reversible causes including pericardial tamponade and tension pneumothorax. Newer technologies such as resuscitative endovascular balloon occlusion of the aorta, selective aortic arch perfusion, and extracorporeal membrane oxygenation may improve outcomes, but remain primarily investigational. more...

Background Changes in Doppler flow patterns of hepatic veins (HV), portal vein (PV) and intra-renal veins (RV) reflect right atrial pressure and venous congestion; the feasibility of obtaining these assessments and the clinical relevance of the findings is unknown in a general ICU population. This study compares the morphology of HV, PV and RV waveform abnormalities in prediction of major adverse kidney events at 30 days (MAKE30) in critically ill patients. Study design and methods We conducted a prospective observational study enrolling adult patients within 24 h of admission to the ICU. Patients underwent an ultrasound evaluation of the HV, PV and RV. We compared the rate of MAKE-30 events in patients with and without venous flow abnormalities in the hepatic, portal and intra-renal veins. The HV was considered abnormal if S to D wave reversal was present. The PV was considered abnormal if the portal pulsatility index (PPI) was greater than 30%. We also examined PPI as a continuous variable to assess whether small changes in portal vein flow was a clinically important marker of venous congestion. Results From January 2019 to June 2019, we enrolled 114 patients. HV abnormalities demonstrate an odds ratio of 4.0 (95% CI 1.4–11.2). PV as a dichotomous outcome is associated with an increased odds ratio of MAKE-30 but fails to reach statistical significance (OR 2.3 95% CI 0.87–5.96), but when examined as a continuous variable it demonstrates an odds ratio of 1.03 (95% CI 1.00–1.06). RV Doppler flow abnormalities are not associated with an increase in the rate of MAKE-30 Interpretation Obtaining hepatic, portal and renal venous Doppler assessments in critically ill ICU patients are feasible. Abnormalities in hepatic and portal venous Doppler are associated with an increase in MAKE-30. Further research is needed to determine if venous Doppler assessments can be useful measures in assessing right-sided venous congestion in critically ill patients. more...

Background A lower profile, FDA-approved device for aortic occlusion (AO) is available for REBOA. Methods Patients who received AO with the new device from February 2016 to February 2017 at 2 urban tertiary care centers were enrolled. Results 60 consecutive patients underwent REBOA; 44 (73.3%) following blunt trauma. 52 (88.1%) were male; mean age of 40 ± 18 years. 49 REBOAs were deployed in Zone 1, 11 in Zone 3.67.7% of patients in arrest achieved return of spontaneous circulation (ROSC). Overall in-hospital survival was 43%; 19% for patients in arrest and 69% for patients with refractory hypotension. Access and vascular procedural complications included iliac intimal injury requiring stent-graft (1), patch angioplasty of the CFA (1), and balloon ruptures (3). 5 amputations were required; 2 immediate completion amputations due to initial injury, and 3 delayed amputations after efforts to salvage severely mangled extremities were unsuccessful. Conclusion Smaller introducer sheaths for REBOA are safe and effective but do not eliminate the need for surgical common femoral artery access. Patients can benefit from REBOA with acceptable survival rates. more...

The arterial pressure waveform is a composite of multiple interactions, and there may be more sensitive and specific features associated with hemorrhagic shock and intravascular volume depletion than systolic and/or diastolic blood pressure (BP) alone. The aim of this study was to characterize the arterial pressure waveform in differing grades of hemorrhage. Ten anesthetized swine (70–90 kg) underwent a 40% controlled exponential hemorrhage. High-fidelity arterial waveform data were collected (500 Hz) and signal-processing techniques were used to extract key features. Regression modeling was used to assess the trend over time. Short-time Fourier transform (STFT) was utilized to assess waveform frequency and power spectrum density variance. All animals tolerated instrumentation and hemorrhage. The primary antegrade wave (P1) was relatively preserved while the renal (P2) and iliac (P3) reflection waves became noticeably attenuated during progressive hemorrhage. Several features mirrored changes in systolic and diastolic BP and plateaued at approximately 20% hemorrhage, and were best fit with non-linear sigmoidal regression modeling. The P1:P3 ratio continued to change during progressive hemorrhage (R2 = 0.51). Analysis of the first three harmonics during progressive hemorrhage via STFT demonstrated increasing variance with high coefficients of determination using linear regression in frequency (R2 = 0.70, 0.93, and 0.76, respectively) and power spectrum density (R2 = 0.90, 0.90, and 0.59, respectively). In this swine model of volume-controlled hemorrhage, hypotension was a predominating early feature. While most waveform features mirrored those of BP, specific features such as the variance may be able to distinguish differing magnitudes of hemorrhage despite little change in conventional measures. more...

Rapid delivery of an intravenous fluid bolus is commonly used in pediatric emergency care for the treatment of shock and hypotension. Early fluid delivery targeted at shock reversal results in improved patient outcomes, yet current methods of fluid resuscitation often limit the ability of providers to achieve fluid delivery goals. We report on the early clinical experience of a new technique for rapid fluid resuscitation. The LifeFlow® infuser is a manually operated device that combines a syringe, automatic check valve, and high-flow tubing set with an ergonomic handle to enable faster and more efficient delivery of fluid by a single health care provider. LifeFlow is currently FDA-cleared for the delivery of crystalloid and colloids. Four cases are presented in which the LifeFlow device was used for emergent fluid resuscitation: a 6-month-old with septic shock, a 2-year-old with intussusception and shock, an 11-year-old with pneumonia and septic shock, and a 15-year-old with trauma and hemorrhagic shock. more...

Background Coronavirus disease-2019 (COVID-19) is associated with hypercoagulability and increased thrombotic risk in critically ill patients. To our knowledge, no studies have evaluated whether aspirin use is associated with reduced risk of mechanical ventilation, intensive care unit (ICU) admission, and in-hospital mortality. Methods A retrospective, observational cohort study of adult patients admitted with COVID-19 to multiple hospitals in the United States between March 2020 and July 2020 was performed. The primary outcome was the need for mechanical ventilation. Secondary outcomes were ICU admission and in-hospital mortality. Adjusted hazard ratios (HRs) for study outcomes were calculated using Cox-proportional hazards models after adjustment for the effects of demographics and comorbid conditions. Results Four hundred twelve patients were included in the study. Three hundred fourteen patients (76.3%) did not receive aspirin, while 98 patients (23.7%) received aspirin within 24 hours of admission or 7 days before admission. Aspirin use had a crude association with less mechanical ventilation (35.7% aspirin versus 48.4% nonaspirin, P = .03) and ICU admission (38.8% aspirin versus 51.0% nonaspirin, P = .04), but no crude association with in-hospital mortality (26.5% aspirin versus 23.2% nonaspirin, P = .51). After adjusting for 8 confounding variables, aspirin use was independently associated with decreased risk of mechanical ventilation (adjusted HR, 0.56, 95% confidence interval [CI], 0.37-0.85, P = .007), ICU admission (adjusted HR, 0.57, 95% CI, 0.38-0.85, P = .005), and in-hospital mortality (adjusted HR, 0.53, 95% CI, 0.31-0.90, P = .02). There were no differences in major bleeding (P = .69) or overt thrombosis (P = .82) between aspirin users and nonaspirin users. Conclusions Aspirin use may be associated with improved outcomes in hospitalized COVID-19 patients. However, a sufficiently powered randomized controlled trial is needed to assess whether a causal relationship exists between aspirin use and reduced lung injury and mortality in COVID-19 patients. more...

Background Point-of-care transthoracic echocardiography (POC-TTE) is essential in shock management, allowing for stroke volume (SV) and cardiac output (CO) estimation using left ventricular outflow tract diameter (LVOTD) and left ventricular velocity time integral (VTI). Since LVOTD is difficult to obtain and error-prone, the body surface area (BSA) or a modified BSA (mBSA) is sometimes used as a surrogate (LVOTDBSA, LVOTDmBSA). Currently, no models of LVOTD based on patient characteristics exist nor have BSA-based alternatives been validated. Methods Focused rapid echocardiographic evaluations (FREEs) performed in intensive care unit patients over a 3-year period were reviewed. The age, sex, height, and weight were recorded. Human expert measurement of LVOTD (LVOTDHEM) was performed. An epsilon-support vector regression was used to derive a computer model of the predicted LVOTD (LVOTDCM). Training, testing, and validation were completed. Pearson coefficient and Bland-Altman were used to assess correlation and agreement. Results Two hundred eighty-seven TTEs with ideal images of the LVOT were identified. LVOTDCM was the best method of SV measurement, with a correlation of 0.87. LVOTDmBSA and LVOTDBSA had correlations of 0.71 and 0.49 respectively. Root mean square error for LVOTDCM, LVOTDmBSA, and LVOTDBSA respectively were 13.3, 37.0, and 26.4. Bland-Altman for LVOTDCM demonstrated a bias of 5.2. LVOTDCM model was used in a separate validation set of 116 ideal images yielding a linear correlation of 0.83 between SVHEM and SVCM. Bland Altman analysis for SVCM had a bias of 2.3 with limits of agreement (LOAs) of − 24 and 29, a percent error (PE) of 34% and a root mean square error (RMSE) of 13.9. Conclusions A computer model may allow for SV and CO measurement when the LVOTD cannot be assessed. Further study is needed to assess the accuracy of the model in various patient populations and in comparison to the gold standard pulmonary artery catheter. The LVOTDCM is more accurate with less error compared to BSA-based methods, however there is still a percentage error of 33%. BSA should not be used as a surrogate measure of LVOTD. Once validated and improved this model may improve feasibility and allow hemodynamic monitoring via POC-TTE once it is validated. more...

BACKGROUND Resuscitative endovascular balloon occlusion of the aorta (REBOA) is a torso hemorrhage control adjunct. Aortic branch vessel flow (BVF) during REBOA is poorly characterized and has implications for ischemia-reperfusion injury. The aim of this study is to quantify BVF in hypovolemic shock with and without REBOA. METHODS Female swine (79-90 kg) underwent anesthesia, 40% controlled hemorrhage and sonographic flow monitoring of the carotid, hepatic, superior mesenteric, renal, and femoral arteries. Animals were randomized to REBOA (n = 5) or no-REBOA (n = 5) for 4 hours, followed by full resuscitation and balloon deflation for 1 hour. RESULTS All animals were successfully induced into hemorrhagic shock with a mean decrease of flow in all vessels of 50% from baseline (p < 0.001). Deployment of REBOA resulted in a 200% to 400% increase in carotid flow, but near complete abolition of BVF distal to the balloon. The no-REBOA group saw recovery of BVF to 100% of baseline in all measured vessels, except the hepatic at 50% to 75%. two-way analysis of variance confirmed a significant difference between the groups throughout the protocol (p < 0.001). During resuscitation, the REBOA group saw BVF restore to between 25% and 50%, but never achieving baseline values. The lactate at 4 hours was significantly higher in the REBOA versus no-REBOA group (17.2 ± 0.1 vs. 4.9 ± 1.4; p < 0.001). CONCLUSION REBOA not only abolishing BVF during occlusion, but appears to have a post-REBOA effect, reducing visceral perfusion. This may be a source of REBOA associated ischemia-reperfusion injury and warrants further investigation in order to mitigate this effect. more...

BACKGROUND A wire-free device is available for resuscitative endovascular balloon occlusion of the aorta (REBOA) providing aortic occlusion (AO) without lengthy platform guide-wires and large sheaths. METHODS This was a retrospective, single-institution review of patients who received REBOA from May 2014 to September 2017. Timing of procedural steps was measured in seconds using time-stamped videography. RESULTS Seventy-four patients received REBOA: 29 with a platform guidewire, 12-Fr sheath, and balloon catheter (W group), and 45 with a 7-Fr sheath and wire-free device (WF group). Mean age (p = 0.22) and ISS (p = 0.80) were similar between groups. Fifty-nine patients received REBOA at Zone 1, 15 patients at Zone 3. There was no difference in median [interquartile range] time to common femoral artery (CFA) access between the WF (194 [98-313] seconds) and W (193 [126-280] seconds) groups (p = 0.96). Both median time to AO after CFA access (WF, 158 [109-264] seconds vs. W, 307 [222-390] seconds, p < 0.001) and median total procedural time (WF, 366 [263-596] seconds vs. W, 511 [441-597] seconds; p = 0.012) were significantly shorter with the wire-free system. The rates of percutaneous versus open CFA access was not different between groups (p = 0.48). Both groups had a similar physiologic response to AO as measured by pre- and post-AO SBP (p = 0.86). Overall mortality rate was 74%, 90% in the W group, and 64% in the WF group (p = 0.027). The procedure-related complication rate was not significantly different between groups with regard to compartment syndrome (W, 3% vs. WF, 4%, p = 1.0), access-related complications (W, 0 vs. WF, 6%, p = 0.28), or systemic complication (W, 0 vs. WF, 9%, p = 0.15). CONCLUSION Once CFA access is obtained, AO with a smaller wire-free device reduces procedural time by approximately 50%. When perfusion to proximal organs is essential, the seconds saved to achieve AO may contribute to improved mortality. Time to obtain CFA access is not dependent on introducer sheath size. LEVEL OF EVIDENCE Therapeutic, level V. more...

Resuscitative endovascular balloon occlusion of the aorta (REBOA) is emerging as an alternative to resuscitative thoracotomy for proximal aortic control in select patients with exsanguinating hemorrhage below the diaphragm. The purpose of this study is to compare interruptions in closed chest compression or open chest cardiac massage during REBOA versus resuscitative thoracotomy.From May 2014 to December 2016, patients in arrest who received aortic occlusion with REBOA or resuscitative thoracotomy were included. Total cardiac compression time was defined as the total time that closed chest compression was performed for REBOA patients and the total time that closed chest compression (before resuscitative thoracotomy) and open chest cardiac massage (after thoracotomy) were performed for resuscitative thoracotomy patients. Cardiac compression fraction was defined as the time compressions occurred during the entire resuscitation phase. All resuscitations were captured by multiview, time-stamped videography.Fifty patients with aortic occlusion after arrest were enrolled: 22 REBOA and 28 resuscitative thoracotomy. Most were men (86%) (median age 30.2 years, interquartile range [IQR] 24.9 to 42.3; median Injury Severity Score 27, IQR 16 to 42; neither differed between groups). The median duration of total cardiac compression time was 945 seconds (IQR 697 to 1,357) for REBOA versus 496 seconds (IQR 375 to 933) for resuscitative thoracotomy. During initial resuscitation, compressions occurred 86.5% of the time (SD 9.7%) during resuscitation with REBOA versus 35.7% of the time (SD 16.4%) in patients receiving resuscitative thoracotomy. Cardiac compression fraction improved after open cross clamp in resuscitative thoracotomy patients to 73.2% of the time (SD 18.0%) but remained significantly less than the same period for REBOA (86.7%; SD 9.4%). Mean cardiac compression fraction for REBOA was significantly improved over that for resuscitative thoracotomy (86.2% [SD 9.1%] versus 55.3 [SD 17.1%]; mean difference 31.0%; 95% confidence interval for difference 22.7% to 39.23%; P.001). Median pause in resuscitation related to procedural tasks was 0 seconds (IQR 0 to 13) for REBOA and 148 seconds (IQR 118 to 223) in resuscitative thoracotomy.Total duration of interruptions of cardiac compressions is shorter for patients receiving REBOA versus resuscitative thoracotomy before and during resuscitation with aortic occlusion. Markers for perfusion during resuscitation must be examined to understand the effects of cardiac compressions and aortic occlusion on patients in arrest because of hemorrhagic shock. more...

The purpose of this study is to compare end-tidal carbon dioxide (EtCO2) during resuscitation of open-chest cardiac massage (OCCM) with aortic cross-clamp (ACC) versus receiving resuscitative endovascular balloon occlusion of the aorta (REBOA) with closed-chest compressions (CCCs). Patients who received REBOA were compared with patients receiving OCCM for traumatic arrest using continuous vital sign monitoring and videography. Thirty-three patients were enrolled in the REBOA group and 18 patients were enrolled in the OCCM group. Of the total patients, 86.3 per cent were male with a mean age of 36.2 ± 13.9 years. Ninety-four percent of patients suffered penetrating trauma in the OCCM group compared with 30.3 per cent of the REBOA group ( P = 2 values, but mean, median, peak, and final EtCO2 values were lower in OCCM ( P < 0.005). During CPR after AO, the initial, mean, and median values were higher with REBOA ( P = 0.015, 0.036, and 0.038). The rate of return of spontaneous circulation was higher in REBOA versus OCCM (20/33 [60.1%] vs 5/18 [33.3%]; P = 0.04), and REBOA patients survived to operative intervention more frequently ( P = 0.038). REBOA patients had greater total cardiac compression fraction (CCF) before AO than OCCM (85.3 ± 12.7% vs 35.2 ± 18.6%, P < 0.0001) and after AO (88.3 ± 7.8% vs 71.9 ± 24.4%, P = 0.0052). REBOA patients have higher EtCO2 and cardiac compression fraction before and after AO compared with patients who receive OCCM. more...

Long-term retention of trauma procedural core-competency skills and need for re-training after a 1-day cadaver-based course remains unknown. We measured and compared technical skills for trauma core competencies at mean 14 months (38 residents), 30 months (35 practicing surgeons), and 46 months (10 experts) after training to determine if skill degradation occurs with time. Technical performance during extremity vascular exposures and lower-extremity fasciotomy in fresh cadavers measured by validated individual procedure score (IPS) was the primary outcome.We performed a prospective study between May 2013 and September 2016.Practicing surgeons had lower IPS and IPS component scores (p = 0.02 to 0.001) than residents (p 0.05) and experts (p0.002) for vascular procedures. Frequencies of errors were no different among residents and experts. Practicing surgeons made more critical errors (p0.05) than experts or residents. Experts had shortest time to proximal vascular control. Fasciotomy procedural errors occurred in all participants. Cluster analysis of anatomy vs procedural steps identified tertiles of performance and wide variance (32.5% practicing surgeons, 26.5% residents vs 13% experts) for vascular procedures. Vascular control duration20 minutes (n = 21) and failure to decompress fasciotomy compartments were correlated with incorrect landmarks and skin incisions. Modeling found interval trauma skills experience, not time since training, was associated with lower IPS.Practicing surgeons with low trauma skills experience since training had lower IPS and component scores (p = 0.02 to 0.001) and more errors compared with experts and residents (p0.05). Surgeons, including experts with low interval experience performing trauma procedures, may benefit from refreshing of correct landmarks and skin incision placement identification. more...

Aortic occlusion is a potentially valuable tool for early resuscitation in patients nearing extremis or in arrest from severe hemorrhage.The American Association for the Surgery of Trauma's Aortic Occlusion in Resuscitation for Trauma and Acute Care Surgery registry identified trauma patients without penetrating thoracic injury undergoing aortic occlusion at the level of the descending thoracic aorta (resuscitative thoracotomy [RT] or zone 1 resuscitative endovascular balloon occlusion of the aorta [REBOA]) in the emergency department (ED). Survival outcomes relative to the timing of CPR need and admission hemodynamic status were examined.Two hundred and eighty-five patients were included: 81.8% were males, with injury due to penetrating mechanisms in 41.4%; median age was 35.0 years (interquartile range 29 years) and median Injury Severity Score was 34.0 (interquartile range 18). Resuscitative thoracotomy was used in 71%, and zone 1 REBOA in 29%. Overall survival beyond the ED was 50% (RT 44%, REBOA 63%; p = 0.004) and survival to discharge was 5% (RT 2.5%, REBOA 9.6%; p = 0.023). Discharge Glasgow Coma Scale score was 15 in 85% of survivors. Prehospital CPR was required in 60% of patients with a survival beyond the ED of 37% and survival to discharge of 3% (all p0.05). Patients who did not require any CPR before had a survival beyond the ED of 70% (RT 48%, REBOA 93%; p0.001) and survival to discharge of 13% (RT 3.4%, REBOA 22.2%, p = 0.048). If aortic occlusion patients did not require CPR but presented with hypotension (systolic blood pressure90 mmHg; 9% [65% RT; 35% REBOA]), they achieved survival beyond the ED in 65% (p = 0.009) and survival to discharge of 15% (RT 0%, REBOA 44%; p = 0.008).Overall, REBOA can confer a survival benefit over RT, particularly in patients not requiring CPR. Considerable additional study is required to definitively recommend REBOA for specific subsets of injured patients. more...

Resuscitative endovascular balloon occlusion of the aorta (REBOA) is a less invasive method of proximal aortic occlusion compared with resuscitative thoracotomy with aortic cross-clamping (RTACC). This study compared time to aortic occlusion with REBOA and RTACC, both including and excluding time required for common femoral artery (CFA) cannulation.This was a retrospective, single-institution review of REBOA or RTACC performed between February 2013 and January 2016. Time of skin incision to aortic cross-clamp for RTACC, time required for CFA cannulation by percutaneous and open methods, and time from guide-wire insertion to balloon inflation at Zone 1 for REBOA, were obtained from videographic recordings.Eighteen RTACC and 21 REBOAs were performed. Median (Q1, Q3) time from skin incision to aortic cross-clamping was 317 seconds (227, 551 seconds). Median (Q1, Q3) time from start of arterial access to Zone 1 balloon occlusion was 474 seconds (431, 572 seconds) (vs. RTACC, p = 0.01). All REBOA procedures were performed with the same device. The median time to complete CFA cannulation was 247 seconds (range, 164-343 seconds), with no difference between percutaneous or open procedures (p = 0.07). The median (Q1, Q3) time to aortic occlusion in REBOA once arterial access had been established was 245 seconds (179, 295.5 seconds), which was significantly shorter than RTACC (p = 0.003).Once CFA access is achieved, time to aortic occlusion is faster with REBOA. Time to aortic occlusion is less than the time required to cannulate the CFA either by percutaneous or open approaches, emphasizing the importance of accurate and expedient CFA access. Resuscitative endovascular balloon occlusion of the aorta may represent a feasible alternative to thoracotomy for aortic occlusion. Time to aortic occlusion will likely decrease with the advent of newer REBOA technology. The rate-limiting portion of REBOA continues to be obtaining CFA access.Therapeutic, level V. more...

Background: Non compressible torso hemorrhage continues to be the leading cause of preventable death in combat operations. Resuscitative endovascular balloon occlusion of the aorta (REBOA) has emerged as an alternative hemorrhage control strategy, with morbidity advantages over resuscitative thoracotomy. We report the first ever use of REBOA in a combat casualty in Afghanistan. Case Report: An 18 year old Afghan male was injured by a single high velocity gunshot wound during partnered operations. He was treated with a damage control operation at the role 2 level, with significant presacral and pelvic bleeding controlled with combat gauze packing. The patient continued to be hemodynamically labile, with ongoing transfusion requirements and required emergent re-exploration. Upon transfer from the gurney to the operating table the patient was noted to be hypotensive with a blood pressure of 62/38. An ER-REBOA catheter was measured for Zone 1 occlusion and placed without difficulty. The patient’s hemodynamics normalized, which allowed for sterile entry into the abdomen and vascular control. After 10 minutes of occlusion the balloon was deflated. Surgical repair was completed and patient survived to discharge. Conclusions: REBOA is an adjunct to hemorrhagic shock that provides temporary proximal control bridge to definitive surgical hemostasis while avoiding the morbidity of a resuscitative thoracotomy. This case represents the first reported use of REBOA in the Afghanistan Theater. This case further supports increased consideration for use of REBOA in the forward setting. more...

Thoracic endovascular aortic repair (TEVAR) has largely replaced traditional open aortic repair for anatomically suitable lesions, however, long-term outcomes are unknown.All patients who underwent TEVAR from December 2004 to October 2015 at a single tertiary care institution were included. Demographics, injury pattern, operative details, outcomes, and surveillance were reviewed. Follow-up ranged from 2 to 132 months and was obtained from clinic notes and imaging reports.A total of 88 patients underwent TEVAR; all suffered from blunt mechanisms, 72.7% were men. Median age, Injury Severity Score, and Trauma and Injury Severity Score was 47 (19.7), 38 (13.5), 0. 8 (0.34). Injuries included 2% grade II, 90% grade III, and 8% grade IV. Overall mortality was 6.8%, TEVAR-related mortality was 0%. Overall in-hospital complication rate was 57%, whereas TEVAR-related complication rate was 9.1%: four typ 1a endoleaks, two typ 2, and two typ 3. Of the typ 1 endoleaks, all required reoperation, whereas all types 2 and 3 endoleaks resolved on subsequent imaging. The left subclavian artery (LSCA) was intentionally covered at index operation in 19 patients (21.6%), and 7 patients (8%) had partial LSCA coverage. The rate of postoperative left upper extremity ischemia was 0%. Left carotid-subclavian bypasses were performed prophylactically in two patients before LSCA coverage at index operation. Eighty-seven percent of endograft access was by performed by open femoral artery exposure and one via retroperitoneal conduit. Percutaneous TEVAR (pTEVAR) was performed more recently in 11.4% of patients with no complications. Heparin was administered intraoperatively in 23 patients with TBI, and 12 patients were not heparinized; no adverse events or outcomes resulted from its use or lack thereof. First, second, and third surveillance imagings occurred at mean intervals of 14 days, 4 months, and 1 year, respectively. Percent of patients followed at 1, 3, and 5 years from operation was 62.1%, 25%, 13.6%, respectively.TEVAR continues to be a feasible treatment modality for blunt traumatic aortic injury with minimal and early device and procedure-specific complications. Follow-up continues to be a significant challenge, and protocols for surveillance imaging are needed. This is the first study to describe access specific outcomes of pTEVAR in trauma patients. Long-term outcomes of TEVAR are still largely unknown; however, these data suggest that it may be at least comparable to open repair.Prognostic/epidemiologic study, level IV; therapeutic study, level V. more...

OBJECTIVES The aim of this study was to evaluate the effect of a recently active endovascular trauma service (ETS) on case volume and time to hemostasis, as a complement to an existing interventional radiology (IR) service. SUMMARY BACKGROUND DATA Endovascular techniques are vital for trauma care, but timely access can be a challenge. There is a paucity of data on the effect of a multispecialty team for delivery of endovascular hemorrhage control. METHODS The electronic medical record of trauma patients undergoing endovascular procedures between 2013 and 2018 was queried for provider type (IR or ETS). Case volume and rates were expressed per 100 monthly admissions, normalizing for seasonal variation. Interrupted time series analysis was used to model the case rate pre- and post-introduction of the ETS. Admission-to-procedure-time data were collected for pelvic angioembolization as a marker of patients requiring emergency hemostasis. RESULTS During 6 years, 1274 admission episodes required endovascular interventions. Overall case volume increased from 2.7 to 3.6 at a rate of 0.006 (P = 0.734) after introduction of the ETS. IR case volume decreased from 3.3 to 2.6 at a rate of 0.03 (P = 0.063). ETS case volume increased at a rate of 0.048 (P < 0.001), which was significantly different from the IR trend (P < 0.001). Median (interquartile range) time-to-procedure (hours) was significantly shorter for pelvic angioembolization [3.0 (4.4) vs 4.3 (3.6); P < 0.001] when ETS was compared to IR. CONCLUSION A surgical ETS increases case volume and decreases time to hemostasis for trauma patients requiring time sensitive interventions. Further work is required to assess patient outcome following this change. more...

Background The clinical course of patients with inflammatory bowel disease (IBD) after trauma is largely unknown. We sought to compare the clinical course of patients with IBD to those without. Methods We conducted a retrospective case-control study of adult patients admitted to a level-1 trauma center from January 1, 2008, through October 1, 2015. Seventy-five patients with IBD were identified. Cases were matched to controls by age, sex, injury severity, and mechanism using 4:1 propensity score-matching analysis. Injury characteristics, clinical course, and infectious and noninfectious complications were compared using bivariate and multivariate analysis. Results Participants had a mean age of 56 years and mean injury severity score of 15. Of the 75 cases, 44% had ulcerative colitis, 44% had Crohn’s disease, and 12% had undetermined type. More cases were on an immunosuppressant (19% vs 2%, P < 0.01) or steroids (8% vs 2%, P = 0.02) on admission compared with controls. More cases had prior abdominal surgery (P = 0.01). Cases had fewer brain injuries (P = 0.02) and higher admission Glasgow Coma Scale (P < 0.01) but required more neurosurgical intervention (P = 0.03). Cases required more orthopedic surgeries (P < 0.01) and more pain management consultations (P = 0.04). In multivariable analysis, IBD was associated with increased odds of operative intervention, pain management consultation, venous thromboembolism, and longer hospital stay (P < 0.05). Patients on immunosuppressants had increased odds of requiring surgery (P = 0.04), particularly orthopedic surgery (P < 0.01). Conclusions Baseline factors associated with inflammatory bowel disease may place patients at higher risk for surgery and complications after trauma. more...

The skill set of the acute care surgeon can be expanded by formal training. We report the first series of traumatic vascular injury (TVI) treated by acute care surgeons trained in endovascular techniques (ACSTEV).We retrospectively reviewed patients admitted to our trauma center with TVI over 5 months who survived for more than 24 hours and had catheter diagnosis and/or therapy by ACSTEV. Demographics, admission data, and outcomes were reviewed. Follow-up ranged from 0 day to 150 days.Most patients were male (63%) and sustained blunt mechanism (91%). Mean (SD) age was 48.2 (21.9) years, and mean (SD) Injury Severity Score was 32.1 (11.8). Mean (SD) admission systolic blood pressure, heart rate, Glasgow Coma Scale (GCS) score were 126.12 (30.4) mm Hg, 101.21 (28.2) beats per minute, and 10.8 (4.73), respectively. Forty-six patients underwent 48 endovascular procedures for TVI: 32 angiograms and 16 venograms were obtained. Two pelvic angiograms and one aortic arch angiogram were negative and required no treatment. One superficial femoral artery arteriogram showed minor luminal defects requiring anticoagulation only. Pseudoaneurysms were found in 17 vessels, vessel truncation in 4, active extravasation in 5, stenosis in 1, and dissection with thrombus in 1. Four patients had resuscitative endovascular balloon occlusion of the aorta performed before catheter intervention for pelvic hemorrhage. Procedures included aortic repair (4), pelvic embolization (13), splenic embolization (5), lumbar artery embolization (1), bronchial artery embolization (1), profunda artery embolization (1), common carotid artery stent (1), celiac artery stent (1), inferior vena cava filter placement (14) and retrieval (2), and pharmacomechanical thrombolysis (1). Treatment material included coils (12), Gelfoam (4), and nitinol plugs (3). No procedural or device-related complications occurred. Mortality was 14.7% unrelated to any endovascular procedure. One patient had repeat coil embolization of a pelvic pseudoaneurysm on postoperative Day 7.ACSTEV can safely treat TVI with good success. We performed nearly 10 procedures per month underscoring the role of the ACSTEV for training and care of TVI in a high-volume trauma center.Therapeutic study, level V. more...

Background Resuscitative thoracotomy (RT) is life-saving in select patients and can be accomplished through a left anterolateral (AT) or clamshell thoracotomy (CT). CT may provide additional exposure, facilitating certain operative procedures, but the added blood and heat loss and time to perform it may increase complications. No prospective multicenter comparison of techniques has yet been reported. Study Design The observational AAST Aortic Occlusion for Resuscitation in Trauma and Acute care surgery (AORTA) registry was used to compare AT and CT in RT. Results AORTA recorded 1,218 RTs at 46 trauma centers from June 2014 to January 2020. Overall survival after RT was 6.0% (AT 6.6%; [59 of 900]; CT 4.2% [13 of 296], p = 0.132). Among all RTs, 11.1% (142 of 1,278) surviving at least 24 hours were used tocompare AT (112) and CT (30). There was no difference between the 2 groups withregard to age, sex, Injury Severity Score, or mechanism of injury (Table 1). CT was significantly more likely to be used in patients needing resection of the lung or cardiac repair. CT was not associated with increased local thoracic/systemic complications, higher transfusion requirement, or greater ventilator, ICU, or hospital days compared with AT. Conclusions Clamshell thoracotomy facilitates thoracic life-saving procedures withoutincreased systemic or thoracic complications compared with AT in patients undergoing RT. more...

The purpose of this study is to compare end-tidal carbon dioxide (EtCO₂) during resuscitation of open-chest cardiac massage (OCCM) with aortic cross-clamp (ACC)

The arterial pressure waveform is a composite of multiple interactions, and there may be more sensitive and specific features associated with hemorrhagic shock and intravascular volume depletion than systolic and/or diastolic blood pressure (BP) alone. The aim of this study was to characterize the arterial pressure waveform in differing grades of hemorrhage.Ten anesthetized swine (70-90 kg) underwent a 40% controlled exponential hemorrhage. High-fidelity arterial waveform data were collected (500 Hz) and signal-processing techniques were used to extract key features. Regression modeling was used to assess the trend over time. Short-time Fourier transform (STFT) was utilized to assess waveform frequency and power spectrum density variance.All animals tolerated instrumentation and hemorrhage. The primary antegrade wave (P1) was relatively preserved while the renal (P2) and iliac (P3) reflection waves became noticeably attenuated during progressive hemorrhage. Several features mirrored changes in systolic and diastolic BP and plateaued at approximately 20% hemorrhage, and were best fit with non-linear sigmoidal regression modeling. The P1:P3 ratio continued to change during progressive hemorrhage (RIn this swine model of volume-controlled hemorrhage, hypotension was a predominating early feature. While most waveform features mirrored those of BP, specific features such as the variance may be able to distinguish differing magnitudes of hemorrhage despite little change in conventional measures. more...

Resuscitative endovascular balloon occlusion of the aorta (REBOA) is a temporizing maneuver used to decrease hemorrhage, and thus perfusion, below the level of aortic occlusion (AO). We sought to investigate lower extremity ischemia in patients who received REBOA. Between February 2013 and September 2016 patients at a tertiary center that received REBOA and survived more than six hours were enrolled. Thirty-one patients were identified, the mean ISS was 40 ± 14 and inhospital mortality was 39 per cent. Twenty received REBOA in zone 1 (distal thoracic aorta). Three (15%) developed lower extremity compartment syndrome (LECS) after zone 1 REBOA. Injury of iliofemoral arteries and veins was each associated with calf fasciotomies (both P = 0.005). A longer duration of AO at zone 1 was associated with calf and thigh fasciotomy (P = 0.046 and P = 0.048, respectively). Iliofemoral arterial injury was associated with thigh fasciotomy (P = 0.04). Eleven patients received REBOA in zone 3 (distal abdominal aorta). Five (45%) patients underwent fasciotomy; four (36%) due to LECS. Femoral arterial injury was associated with calf fasciotomies (P = 0.02). There was no association with sheath size or laterality and need for fasciotomy. Neither groin access for REBOA or AO solely caused limb loss or LECS. The contribution to distal ischemia by REBOA remains unclear in patients with lower extremity injury. more...

Aortic occlusion (AO) increases proximal perfusion and may improve rates of return of spontaneous circulation (ROSC). The objective of this study was to investigate the hemodynamic effects of cardiopulmonary resuscitation (CPR) and AO by REBOA on patients in traumatic cardiac arrest. Patients admitted between February 2013 and May 2017 at a tertiary center who suffered traumatic arrest, had an arterial line placed during resuscitation, and received CPR and REBOA which were included. In-hospital CPR data were obtained from videography. Arterial waveforms were recorded at 240 Hz. 11 consecutive patients were included, 82% male; mean (± SD) age 37 ± 19 years. 55% suffered blunt trauma and the remaining penetrating injuries. 64% arrested out of hospital. During compressions with AO, the mean systolic blood pressure (SBP) was 70 ± 22 mmHg, mean arterial pressure (MAP) 43 ± 19 mmHg, and diastolic blood pressure (DBP) 26 ± 17 mmHg. Nine (82%) had ROSC, with eight having multiple periods of ROSC and arrest in the initial period. In-hospital mortality was 82%. Cardiac ultrasonography was used during arrest in 73%. In two patients with arterial line data before and after AO, SBP (mmHg) improved from 51 to 73 and 55 to 96 during arrest after AO. High-quality chest compressions coupled with aortic occlusion may generate adequate perfusion pressures to increase the rate of ROSC. New technology capable of transducing central arterial pressure may help us to understand the effectiveness of CPR with and without aortic occlusion. REBOA may be a useful adjunct to high-quality chest compressions during arrest. more...

Background Resuscitative endovascular balloon occlusion of the aorta (REBOA) is used to decrease hemorrhage below the level of aortic occlusion (AO); however, the amount of collateral blood flow below the level of occlusion is unknown. Our aim was to investigate blood flow patterns during complete AO in patients who underwent CT scan after REBOA. Study Design Between February 2013 and January 2017, patients who received REBOA and underwent CT scan with intravenous contrast during full AO were included. Patients were excluded if they had a CT scan performed with the balloon partially or fully deflated. Results Nine patients (8 men) were included; all had blunt trauma. Mean Injury Severity Score (±SD) was 48 ± 8 and mean age was 45 ± 19 years. Four had supra-celiac AO, and 5 had infra-renal AO. Arterial contrast enhancement was noted below the level of AO in all patients, and distal to REBOA sheath placement in 5. Collateralization from arteries above and below the AO was identified in all patients. Contrast extravasation distal to AO was identified in 4 patients, and hematomas in 8. Distal vascular enhancement patterns varied by level of AO and contrast administration site. Conclusions Aortic occlusion appears to dramatically decrease, but does not completely impede, distal perfusion during REBOA due to multiple pathways of collateralization. Active extravasation and hematomas can still be detected in the setting of full AO, with purposefully timed contrast and image acquisition. Blood flow persists below the level of both the AO and in-dwelling sheath. Dynamic flow studies are needed to determine the contribution of AO and sheath placement to distal tissue ischemia. more...

Resuscitative endovascular balloon occlusion of the aorta (REBOA) is a percutaneous transfemoral balloon technique used in select centers for resuscitation and temporary hemostasis, often instead of emergency department thoracotomy. The ability to perform aortic occlusion (AO) with an intravascular device allows focused occlusion at the most distal level to perfuse proximal regions while slowing hemorrhage to injured areas.To describe what is to date the largest single-institution experience with REBOA in the United States.Use of REBOA at an urban tertiary care facility for severe traumatic hemorrhage, traumatic arrest (AR), or nontraumatic hemorrhage (NTH) was investigated from February 1, 2013, to January 31, 2017, among 90 patients who were not responsive or were transiently responsive to resuscitation measures, or were in arrest, from presumed hemorrhage below the diaphragm. Possible causes were trauma or nontrauma-related hemorrhage. Patients with ruptured aortic aneurysms were excluded.In-hospital mortality.Of the 90 patients in the study (15 women and 75 men; mean [SD] age, 41.5 [17.4] years), 29 underwent REBOA for severe traumatic hemorrhage, 50 for AR, and 11 for NTH. For the patients with severe traumatic hemorrhage and AR, the median age was 36.2 years (interquartile range, 25.3-55.5 years), mean (SD) admission Glasgow Coma Scale score was 6 (5), and median Injury Severity Score was 39 (interquartile range, 10-75). The distal thoracic aorta was occluded in 73 patients (81%), and in all patients with AR. A total of 17 patients (19%) had distal abdominal AO. Mean (SD) systolic blood pressure improved in patients with severe traumatic hemorrhage, from 68 (28) mm Hg prior to AO, to 131 (12) mm Hg after AO (P .001). Percutaneous access was used in 30 patients (33%), including 13 patients with AR (26%), and groin cutdown in 60 patients (67%), including 37 patients with AR (74%). Overall 30-day mortality was 62% (n = 56): 11 (39%) in patients with severe traumatic hemorrhage and 45 (90%) in patients with AR. Of the patients with AR, 29 (58%) had return of spontaneous circulation and 11 of those patients (38%) survived to the operating room. All patients who survived AR gained full neurologic recovery. No aortoiliac injury or limb loss occurred from REBOA use. Eleven patients underwent REBOA for NTH; 7 (64%) were in arrest. Overall in-hospital mortality for patients with NTH was 36% (n = 4). No procedural complications occurred in this group.REBOA is a minimally invasive alternative to emergency department thoracotomy with aortic cross-clamp to temporize noncompressible torso hemorrhage and obtain proximal control in both traumatic and nontraumatic causes of hemorrhage. REBOA can also be used for more targeted AO in the distal aorta for pelvic, junctional, or extremity hemorrhage. more...

The medical advancements made during the wars in Iraq and Afghanistan have resulted in an unprecedented survival rate, yet there is still a significant number of deaths that were potentially survivable. Additionally, the ability to deliver casualties to definitive surgical care within the "golden hour" is diminishing in many areas of conflict. Resuscitative endovascular balloon occlusion of the aorta (REBOA) has been implemented successfully in the hospital setting. REBOA may be a possible adjunct for the Role I and point-of-injury (POI) care to provide temporary control of noncompressible torso hemorrhage (NCTH) and junctional hemorrhage. Here the authors advocate for the development of the Role I Resuscitation Team (RT) and a training pathway to meet the challenge of the changing battlefield. more...

BACKGROUND The management of blunt thoracic aortic injury (BTAI) has evolved radically in the last decade with changes in the processes of care and the introduction of thoracic endovascular aortic repair (TEVAR). These changes have wrought improved outcome, but the direct effect of TEVAR on outcome remains in question as previous studies have lacked vigorous risk adjustment and long-term follow-up. To address these knowledge gaps, we compared the outcomes of TEVAR, open surgical repair, and nonoperative management for BTAI. METHODS Eight verified trauma centers recruited from the Western Trauma Association Multicenter Study Group retrospectively studied all patients with BTAI admitted between January 1, 2006, and June 30, 2016. Data included demographics, comorbidities, admitting physiology, injury severity, in-hospital care, and outcome. RESULTS We studied 316 patients with BTAI; 57 (18.0%) were in extremis and died before treatment. Of the 259 treated surgically, TEVAR was performed in 176 (68.0%), open in 28 (10.8%), hybrid in 4 (1.5%), and nonoperative in 51 (19.7%). Thoracic endovascular aortic repair and open repair groups had similar Injury Severity Scale score, chest Abbreviated Injury Scale score, Trauma and Injury Severity Score, and probability of survival, but differed in median age (open: 28 [interquartile range {IQR}, 19-51]; TEVAR: 46 [IQR, 28-60]; p < 0.007), zone of aortic injury (p < 0.001), and grade of aortic injury (open: 6 [IQR, 4-6]; TEVAR: 2 [IQR, 2-4]; p < 0.001). The overall in-hospital mortality was 6.6% (TEVAR: 5.7%, open: 10.7%, nonoperative: 3.9%; p = 0.535). Of the 240 patients who survived to discharge, two died (one at 9 months and one at 8 years); both were managed with TEVAR, but the deaths were unrelated to the aortic procedure. Stent graft surveillance computed tomography scans were not obtained in 37.6%. CONCLUSIONS The mortality of BTAI continues to decrease. Thoracic endovascular aortic repair, when anatomically suitable, should be the treatment of choice. Open repair remains necessary for more proximal injuries. Process improvement in computed tomography imaging in follow-up of TEVAR is warranted. LEVEL OF EVIDENCE Therapeutic/care management, level III. more...

BACKGROUND Work-hour restrictions have reduced operative experience for residents. The Advanced Surgical Skills for Exposure in Trauma (ASSET) course fills this training gap. Cadaver use has limitations including cost and availability. Hyper-realistic synthetic models may provide an alternative to cadavers. We compared same surgeon performance between synthetic and cadaveric models to determine interchangeability for formative evaluation. METHODS Forty residents ( more...

Large arterial sheaths currently used for resuscitative endovascular balloon occlusion of the aorta (REBOA) may be associated with severe complications. Smaller diameter catheters compatible with 7Fr sheaths may improve the safety profile.A retrospective review of patients receiving REBOA through a 7Fr sheath for refractory traumatic hemorrhagic shock was performed from January 2014 to June 2015 at five tertiary-care hospitals in Japan. Demographics were collected including method of arterial access; outcomes included mortality and REBOA-related access complications.Thirty-three patients underwent REBOA at Zone 1 (level of the diaphragm). Most patients were male (70%), with a mean age (+SD) 50 ± 18 years, mean BMI 23 ± 4, and a median [IQR] ISS of 38 [34, 52]. Ninety-four percent of patients presented after sustaining injuries from blunt mechanisms. Twenty-four percent underwent CPR before arrival, and an additional 15% received CPR after admission. Percutaneous arterial access without ultrasound or fluoroscopy was achieved in all patients. Systolic blood pressure increased significantly following balloon occlusion (mean 62 ± 36 to 106 ± 40 mm Hg, p0.001). Median total duration of complete initial occlusion was 26 [range 10-35] minutes. Sixteen patients (49%) survived beyond 24 hours, and 14 patients (42%) survived beyond 30 days. Twenty-four-hour and 30-day survival were 48% and 42%, respectively. Of the patients surviving 24 hours (n = 16), median duration of sheath placement was 28 [range 18-45] hours with all removed using manual pressure to achieve hemostasis. Of 33 REBOAs, 20 were performed by Emergency Medicine practitioners, 10 by Emergency Medicine practitioners with endovascular training, and 3 by Interventional Radiologists. No complication related to sheath insertion or removal was identified during the follow-up period, including dissection, pseudoaneurysm, retroperitoneal hematoma, leg ischemia, or distal embolism.7Fr REBOA catheters can significantly elevate systolic blood pressure with no access-related complications. Our results suggest that a 7Fr introducer device for REBOA may be a safe and effective alternative to large-bore sheaths, and may remain in place during the post-procedure resuscitative phase without sequelae.Therapeutic/care management, level V. more...

Medical schools provide many educational resources in their basic science curriculum, including slide-based lectures, handouts, study guides, reviews, textbooks, primary literature, and web-based links. We recently instituted a web-based lecture recording system, which synchronizes lecture audio with visual components, as opposed to previous audio-only recordings. This study sought to determine how this recording system was being used by students, whether its availability impacted class attendance, and whether this resource had a positive effect on student performance. First- and second-year medical students were surveyed regarding class attendance and their use of lecture recordings. In addition, students indicated their impression of how lecture recordings influenced exam performance for several of their basic science courses. Student perception was compared with actual exam results. Of 206 students who completed the survey, 80.1% (N = 165) utilized the lecture recording system. Of 91 second-year students using the resource, only 14.4% (N = 13) mentioned a decline in lecture attendance. Despite how it was used, first- and second-year medical students overwhelmingly responded in favor of these audiovisual-synchronized recordings. 90.3% of responding medical students using recordings felt this resource improved exam performance. While student perception was positive, our multidisciplinary data suggest otherwise. With the exception of the second-year Pharmacology course, lecture recordings did not have an impact, either in a positive or negative direction on exam performance across seven first- and second-year basic science courses. Lecture recordings can be viewed as another useful tool, in addition to traditional lectures, that allows for flexibility in study habits and self-directed learning. more...

Atraumatic splenic rupture (ASR) is an uncommon pathologic condition in which bleeding from the spleen occurs for a variety of nontraumatic reasons. While the current trend in traumatic splenic rupture is nonoperative management including transcatheter arterial embolization, the current recommendation for the treatment of most patients with ASR is splenectomy. In this report, we describe two cases of ASR presenting with hemorrhagic shock and complicated by anticoagulation therapy. In patients with severe hemorrhagic shock and coagulopathy, a damage control strategy is recommended. Our successful treatment of these patients included a three-step strategy as a damage control: (i) rapid transient hemostasis by splenic artery occlusion using a microballoon catheter, (ii) damage control resuscitation and (iii) splenectomy as a definitive hemostatic treatment. more...

Patients suffering from severe tracheobronchial obstruction are vulnerable to dyspnea, respiratory failure, obstructive pneumonia, and death. Treatment with a holmium:YAG laser, an alternative to the neodymium:YAG laser, may provide symptomatic relief. This is the largest case series to date describing the application of the holmium:YAG laser via bronchoscopy for benign and malignant obstructive disease. The data were retrospectively collected from 99 patients, with either benign or malignant tracheobronchial obstruction, who underwent 261 interventional bronchoscopy procedures in the operating room with laser ablation between January 2004 and November 2011. Categorical variables were analyzed with the chi-square and Fisher’s exact tests as appropriate in contingency tables, whereas Student’s t-test was performed for comparison of continuous variables. Patient follow-up was concluded on September 15, 2013. The holmium:YAG laser was used in 261 procedures performed on 99 patients with either benign or malignant disease. Symptomatic improvement was demonstrated in 90 % of all benign etiology cases and 77 % of all malignant etiology cases. Within the benign and malignant subgroups, improvement was dependent on anatomical location rather than etiology of the lesion. Complications occurred in 2.3 % of the procedures, with mortality in less than 1 % of procedures. Results confirm the usefulness and safety of the holmium:YAG laser in the treatment of patients with severe benign and malignant obstructive tracheobronchial obstructions. The holmium:YAG laser is an appealing alternative to the neodymium:YAG laser. more...