|
Article 1
Point of injury tourniquet application during Operation Protective Edge- what did we learn? Shlaifer A, Yitzhak A, Baruch EN, Shina A, Satanovsky A, Shovali A, Almog O, Glassberg E. J Trauma Acute Care Surg. 2017 Aug;83(2):278-283.
Background
Tourniquet application has been shown to be safe and effective to control extremity hemorrhage in both military and civilian settings. As educational campaigns in both military and civilians settings directed at non-medical providers are reaching larger and larger audiences, the impact thereof will need to be measured to quantify impact, both in hemorrhage control and consequences of unnecessary applications.
Methods/Results
This is a retrospective review from the Israeli Defense Forces’ experience with field tourniquet application during a six week military operation in 2014. This was the first large scale military campaign after the IDF implement a military-wide educational program for point of injury tourniquet application.
A total of 119 tourniquets were applied to 90 soldiers. There were 79 survivors with 97 tourniquets applied. Penetrating trauma, consistent of both explosive ordinances and gunshot wounds, accounted for 97.8% of injuries. The tourniquets were applied by non-medical combatants (22%), medics (32%) and advanced medical providers (34%) with the remaining 11% of providers undocumented. Of the tourniquets applied, 70% were effective in controlling hemorrhage, regardless of level of training of the provider.
The indications for tourniquet application were tactical (69.8%) and medical (53.9%) with providers siting multiple indications in several instances. Median evacuation time to the hospital was 110 minutes for the 69 casualties transported by air and 148 minutes for the remaining transported by ground.
Five patients subsequently required fasciotomy which could not be accounted for by injury and was attributed to tourniquet application. Six patients had neurological sequelae which could not be accounted for by injury. Including three with drop foot. The total complication rate was 11.7%.
Take Away Message
Tourniquets are effective at stopping blood loss and preventing death at the point of injury. The shortest possible duration of tourniquet application should be aggressively sought and tracked as prolonged tourniquet times (>2 hours) do lead to increased rescue procedures and neurological complications. Early and often application of fasciotomy to prevent long term neurological complications should be considered in all patients with prolonged tourniquet time.
Article 2
Genitourinary injuries and extremity amputation in Operations Enduring Freedom and Iraqi Freedom: Early findings from the Trauma Outcomes and Urogenital Health (TOUGH) project. Nnamani NS, Janak JC, Hudak SJ, Rivera JC, Lewis EA, Soderdahl DW, Orman JA. J Trauma Acute Care Surg. 2016 Nov;81(5 Suppl 2 Proceedings of the 2015 Military Health System Research Symposium):S95-S99.
Introduction
As war fighting has evolved, so have the injuries sustained by US Service Members. In contrast to previous wars in which genitourinary (GU) injuries were similar to civilian numbers (2-5%), 13% of combat casualties in Operations Iraqi and Enduring Freedom (OIF/OEF) have suffered GU injury. The incidence and severity of injury to the external genitalia increased dramatically. The concomitant presence of GU injuries and extremity amputations has not previously been studied.
Methods/Results
The Department of Defense Trauma Registry was queried for male service members who sustained GU injury between 2001 and 2013. Severe GU injury was defined by AIS > 3 or major to massive laceration to a GU organ. This group was then analyzed for frequency and type of extremity amputation.
A total of 1367 service members with GU injuries were identified. Of these, 433 (31.7%) also suffered one or more extremity amputations. Over 95% of these members were Soldiers and Marines and 97% of these injuries were caused by explosions. Those with both GU injury and amputation had higher GU AIS and overall ISS than those without amputation. Of the 1367 with GU injuries, 19.7% had lower extremity amputation, 8.9% had upper and lower extremity amputation and 3.4% had upper extremity only amputation. Three quarters of the lower extremity amputations were at or above the knee. Of those with lower extremity amputations, 56% had testicular injuries and 42% were categorized as severe.
Take Away Message
Male service members who suffer blast injuries commonly have a combination of extremity and GU injuries. GU injuries, specifically testicular injuries, have likely understudied and underappreciated effects on injury recovery based on the potential for short and long term endocrine dysfunction. The US and British militaries have altered their protective equipment in attempts to mitigate GU injuries. Whether this new equipment is decreasing the severity of injuries has not yet been studied.
Article 3
Impact of Volume Change Over Time on Trauma Mortality in the United States. Brown JB, Rosengart MR, Kahn JM, Mohan D, Zuckerbraun BS, Billiar TR, Peitzman AB, Angus DC, Sperry JL. Ann Surg. 2017 Jul;266(1):173-178.
Just as busy surgeons and centers have better outcomes for complex operative procedures, busy trauma centers should have better outcomes for critically injured patients. Practice is supposed to make perfect. Although the regionalization of trauma centers assumes this beneficial relationship between volume and outcomes, data supporting this correlation have been inconsistent and prior reports have each analyzed only one moment in time.
Rather than evaluating the volume-outcome relationship as a simple snapshot, Brown and his colleagues examined the association of volume change over time with mortality among United States trauma centers. 839,809 severely injured (ISS>15) patients from 287 centers during the 13 year study period from the National Trauma Databank were analyzed. After adjusting for demographics, mechanism, vital signs and injury severity, center-level standardized mortality ratios were constructed to evaluate observed to expected death ratios. Standardized mortality ratios were then analyzed with respect to preceding volume changes to find that increasing volume was associated with improved outcomes and decreasing volume with adverse outcomes. This is an important contribution to the existing body of literature with far–reaching implications. Not only does volume impact trauma system outcomes through center to center differences, but volume variations within each particular center itself also influence outcomes in severely injured patients.
Article 4
Organ Donation, an Unexpected Benefit of Aggressive Resuscitation of Trauma Patients Presenting Dead on Arrival. Alarhayem AQ, Cohn SM, Muir MT, Myers JG, Fuqua J, Eastridge BJ. J Am Coll Surg. 2017 May;224(5):926-932.
Survival after traumatic cardiopulmonary arrest is infrequent. Risks of maximal resuscitative efforts including anoxic brain injury, occupational exposure and costs must be weighed against the chance of patient survival. Although paramount, survival is not the only important outcome to consider. Organ donation after cardiopulmonary arrest should also impact these risk/benefit calculations.
To this end, Alarhayem et al. reviewed records of patients presenting without signs of life (SBP=0, HR=0, GCS=3) over a 15 year study period at their institution. Of 340 patients, 60% underwent prehospital CPR and 2% survived to discharge (1.5% functionally independent)—survival which was determined to be comparable to those described in the 2012 National Trauma Databank. Importantly, of the 333 non-survivors, 12 patients (3.6%) donated 24 organs yielding an overall 4.7% survival or organ donation rate. These findings suggest that organ donation is an under-recognized and beneficial outcome for aggressive resuscitation of trauma patients presenting in cardiopulmonary arrest.
|