The intraosseous have it: A prospective observational study of vascular access success rate in patients in extremis using video review. Chreiman K, Dumas R, Seamon M, Kim P, Reilly P and Kaplan L. J Trauma Acute Care Surg. 2018 Apr; 84(4):558-563.
Expedient and reliable vascular access is imperative in trauma management and resuscitation. However, obtaining access can be challenging in profound hemorrhagic shock. Military combat experience and recommendation of American Heart Association increased the popularity of intraosseous (IO) access because it provided prompt administration of resuscitation agents with minimal interruption of chest compression in cardiac arrest. Using high definition video recordings of penetrating trauma patients presenting in extremis (defined as absence of pulse or no measurable blood pressure) who required resuscitative thoracotomy from April 2016 to July 2017, a total of 38 patients were included in this study. The primary outcome was the success of obtaining access comparing peripheral IV (PIV), IO and central venous catheters (CVC).
Each patient received a mean of 3.8 (SD 1.4) access attempts. Peripheral IV was the most commonly used initial access method in 53.6% followed by IO in 42% of patients.Tibial IO was successful in 92% while humeral access in 83% of patients. These rates were significantly higher compared to PIV and CVC (43% and 48% respectively). IO access were as fast as PIV and twice more successful. Return of spontaneous circulation (ROSC) occurred in 32% (12/38 patients) with overall survival of 5.3% (2 out of 38 patients). This study found no association between time to vascular access completion and ROSC.Major limitation of IO is low flow rate which averaged around 100-200 ml/min compared to PIV at 110-212 ml/min and CVC at 600 ml/min.However, this was not measured in this study and sternal IO which potentially has a higher flow rate compared to tibial and humeral was not included in this study since it can hamper chest compression. The authors recommended use of IO as first line therapy for trauma patients in extremis and can be used as a bridge for definitive line access.
Contemporary management of rectal injuries at Level I trauma centers: The results of an American Association for the Surgery of Trauma multi-institutional study. Brown R, Teixeira P, Furay E, Sharpe J, Musonza T, Holcomb J, Bui E, Bruns B, Hopper A, Truitt M, Burlew C, Schellenberg M, Sava J, VanHorn J, Eastbridge B, Cross A, Vasak R, Vercruysse G, Curtis E, Haan J, Coimbra R, Bohan P, Gale S, Bendix P and the AAST Contemporary Management of Rectal Injuries Study Group. J Trauma Acute Care Surg. 2018 Feb; 84(2):225-233.
Rectal injuries are uncommon and historically treated with combinations of modalities: direct repair, resection, proximal diversion, pre-sacral drainage and distal rectal washout. Rectal trauma management underwent evolutions over the years brought about by war experience, military combat experiences and several studies that challenged those dogmas leading to practice variations in the management of this relatively rare injury. The American Association for the Surgery of Trauma (AAST) undertook a multi-institutional retrospective study from 2004 to 2015 of all traumatic rectal injuries in 22 level 1 trauma centers to determine its optimal current management.Seven hundred eighty-five patients were included in this study. Two hundred and forty-eight patients had intraperitoneal injuries managed by primary repair alone, repair with proximal diversion, resection and primary anastomoses, resection and proximal diversion and no intervention.Logistic regression analysis showed that proximal diversion was associated with more abdominal complications (22% vs 10%, p = 0.003) but it did not lead to increased mortality. Four hundred fifty-nine patients with extraperitoneal rectal injuries were managed with primary repair alone, repair with proximal diversion, resection and diversion, and no intervention. Most patients (76%) with extraperitoneal injuries received proximal diversion. Adjunctive procedures such as distal rectal washout and presacral drainage were performed in 17% and 22% respectively. The study found that distal rectal washout and presacral drainage were both independent risk factors for developing abdominal complications (composite of fascial dehiscence, abdominal, pelvic, and retroperitoneal abscesses).
Due to the retrospective nature of this study, important variables that may alter rectal injury management were not directly addressed in this study. These variables include fecal contamination, blood loss, amount of blood transfused, antibiotic use and duration, and used of vasopressors. It is interesting to note that there were sub group of patients who sustained Grade I extraperitoneal and intraperitoneal rectal injuries who received diversions. Adjunctive procedures used in extraperitoneal rectal injuries such as distal rectal washout and presacral drain may have a role in some clinical scenarios. However, routine use is associated with abdominal complications as shown in this study. This AAST initiative updated our current concept of rectal trauma management but like any other medical management it is still in evolution.
Increased risk of fibrinolysis shutdown among severely injured trauma patient receiving tranexamic acid. Meizoso et al. J Trauma Acute Care Surg. 2018 Apr; 84(3): 426-432.
The coagulopathy of trauma is a ubiquitous and well-described phenomenon among the traumatically injured.Newly emerging studies have implicated hyperfibrinolysis as an important, if not the key element in the process. Multiple metanalysis have supported tranexamic acid’s effectiveness in attenuating this response. Consequently, it has gained wide-spread acceptance as a first-line intervention for traumatic hemorrhage in both the military and civilian populations.Further investigation has discovered another fibrinolytic phenotype whose affects mirror hyperfibrinolysis – fibrinolysis shutdown.Once hidden in obscurity, fibrinolysis shutdown has since emerged as the dominant fibrinolytic phenotype and portends a poor prognosis.As TXA competitively inhibits plasminogen, ultimately resulting in improved hemostasis, and even thrombosis if administered outside the optimal window, the authors endeavored to determine if the treatment worsened outcomes in patients experiencing fibrinolysis shutdown. Patients deemed high risk based on Greenfield’s Risk Assessment Profile who had a TEG drawn upon admission to the ICU were prospectively selected for enrollment.At the physician’s discretion, some of the patients were given TXA at the standard dosing regimen prior to TEG. 218 patients met enrollment criteria at a single Level-1 institution from August 2011 to January 2015. Analysis were performed to determine whether patients who received TXA had a higher incidence of fibrinolysis shutdown, and if these patients had worse outcomes as measured by mortality, hospital length of stay, and other parameters.
Only a small fraction of the population received TXA (16%). The TXA patients were more critically injured as evidenced by lower blood pressures, and higher base deficits and overall vasopressor and transfusion requirements, including massive transfusions, despite similar mechanisms of injury and ISS. Major outcomes such as mortality and incidence of venous thromboembolism were similar, however TXA patients experienced significantly less fibrinolysis as measured by LY30%.
Overall, 64% of the patients were found to be in fibrinolytic shutdown. Shutdown patients had higher incidences of acute lung and kidney injury, although primary outcomes such as hospital LOS and mortality were similar.Patients who received TXA were represented eight times more often than their counterparts (23 vs 4%, p .0001).TXA was found to be an independent risk factor for the development of shutdown (RR 1.57 [1.33-1.86], p<0.0001); the association remained after adjusting for confounders (RR 1.35, [1.10-1.64], p<.004). Because of the strong association between TXA and fibrinolysis shutdown, the authors conclude that the intervention should only be administered to patients with laboratory-confirmed evidence of hyperfibrinolysis.
Contemporary management of high-grade renal trauma: Results from the American Association for the Surgery of Trauma Genitourinary Trauma Study. Keihani et al for the Genito-Urinary Trauma Study Group. J Trauma Acute Care Surg. 2018 Apr; 84(3): 418-425.
Forward deployed surgeons represent the tip of the far-reaching spear of military medicine.They must be prepared to address a variety of injuries that often falls outside of their standard practice.In this environment specialists are rarely present and only occasionally accessible for consultation. Renal injuries are one such example as they are involved in up to 5% of all traumas.High-grade injuries are the exception; however, the literature has revealed a disconnect in the care provided by General Surgeons and their Urology colleagues.Similar to blunt trauma of other solid organs, injuries to the kidneys are increasingly managed non-operatively.Data from the National Trauma Data Bank suggest that General Surgeons are sluggish to adopt such an approach, as nearly 10% of all renal injuries result in nephrectomy. These rates rise exponentially when dealing with high-grade injuries (AAST grades III-V).To better define the incidence of nephrectomy among high-grade injuries and to identify the factors associated with the decision, the authors performed a prospective observational study at fourteen Level-I institutions from February 2014 to February 2017.Patients with high-grade injuries identified on CT imaging or intraoperatively were enrolled in the study.
In total 431 high-grade renal injuries were recorded; 80% were addressed via non-operative means.As expected, the degree of intervention correlated with the grade of injury, and was inversely correlated to its incidence.For example, despite accounting for only 12% of high-grade injuries, Grade V resulting in nephrectomy 62% of the time. Alternatively, the majority of injuries were Grade III (55%), however less than 1% progressed to nephrectomy; most of these injuries were addressed via expectant or conservative means.
The researchers identified several other clinical factors associated with nephrectomy (ie: ISS, concomitant injuries, serum lactate and base deficit, transfusion requirements), however after multivariate analysis only injury grade (OR 34, [11.1-104.2) and penetrating mechanism (OR 4.87, [1.7-14.] remained significant. The authors emphasize that renal exploration invariably leads to nephrectomy, regardless of the grade of injury, as evidenced by the 65% rate during open exploration. They recommend an attempt at conservative management with angioembolization as a way to decrease the number of renal explorations and subsequent nephrectomy.