Damage Control Resuscitation Protocol and the Management of Open Abdomens in Trauma Patients

2014 ◽  
Vol 80 (8) ◽  
pp. 768-775 ◽  
Author(s):  
Matthew Bradley ◽  
Samuel Galvagno ◽  
Amit Dhanda ◽  
Carlos Rodriguez ◽  
Margaret Lauerman ◽  
...  
Keyword(s):  
Logistic Regression ◽  
Injury Severity ◽  
Damage Control ◽  
Fascial Closure ◽  
Trauma Patients ◽  
Damage Control Resuscitation ◽  
Total Blood ◽  
Independent Risk Factors ◽  
Student’S T ◽  
Admission Glasgow Coma Scale

Although the use of damage control laparotomy (DCL) is well established, the effect of damage control resuscitation (DCR) on the management of open abdomens is relatively poorly studied. The aim of the present study was to determine the predictors for failure to achieve primary fascial closure (PFC) after DCL in the setting of a massive transfusion (MT) and DCR. This is a retrospective review over a 12-year period of all patients that underwent MT and DCL. Patients who achieved PFC were compared with those who did not (NPFC). Student's t tests were used to compare the two groups. A multiple logistic regression model was performed to identify independent risk factors for failure to attain PFC. Of 174 patients, 101 achieved PFC. Mean (6 standard deviation) age was 35.6 ± 14.9 years for PFC and 36.3 ± 14.0 years for NPFC ( P = 0.75). Admission Glasgow Coma Scale score was 11.4 ± 4.6 for PFC and 10.6 ± 5.0 for NPFC ( P = 0.25). Initial lactate (7.3 ± 3.8 vs 7.7 ± 4.1, P = 0.50), hemoglobin (11.3 ± 1.9 vs 11.0 ± 2.2, P = 0.43), systolic blood pressure (108 ± 44 vs 107 ± 35, P = 0.82), Injury Severity Score (34 ± 14 vs 36 ± 15, P = 0.32), and abdominal Abbreviated Injury Score (3.6 ± 1.1 vs 3.9 ± 1.0, P = 0.13) were similar between the two groups. There was no difference in total blood products administered at 24 hours (46 ± 26 vs 49 ± 29 units, P = 0.45). Logistic regression identified increasing volume of crystalloid at 24 hours (odds ratio, 0.86; 95% confidence interval, 0.74 to 0.99; P = 0.047), earlier operative year (2.1; 1.52 to 2.91; P < 0.001), and increased number of procedures (0.32, 0.18 to 0.58; P < 0.001) as independent predictors for failure to obtain PFC. Injury severity is not associated with failure to achieve PFC, whereas administration of large-volume crystalloid resuscitation, increasing number procedures, and earlier year of DCL are independent predictors for failure to achieve PFC. Application of DCR to DCL techniques results in an improvement in ability to achieve PFC.

Multiple Laparotomies are a Predictor of Fascial Dehiscence in the Setting of Severe Trauma

2005 ◽  
Vol 71 (5) ◽  
pp. 402-405 ◽  
Author(s):  
Mamta Swaroop ◽  
Michael Williams ◽  
Wendy Ricketts Greene ◽  
Jack Sava ◽  
Kenneth Park ◽  
...  
Keyword(s):  
Wound Infection ◽  
Injury Severity ◽  
Damage Control ◽  
Wound Dehiscence ◽  
Severe Trauma ◽  
Outcome Data ◽  
Fascial Closure ◽  
Trauma Patients ◽  
Abdominal Abscess ◽  
Increased Risk

The purpose of this study was to determine the incidence of wound dehiscence after repeat trauma laparotomy. We performed a retrospective analysis of adult trauma patients who underwent laparotomy at an urban level 1 trauma center during the past 5 years. Patients were divided into single (SL) and multiple laparotomy (ML) groups. Demographic, clinical, and outcome data were collected. Data were analyzed using χ2, t testing, and ANOVA. Overall dehiscence rate was 0.7 per cent. Multiple laparotomy patients had damage control, staged management of their injuries, or abdominal compartment syndrome as the reason for reexploration. SL and ML patients had similar age and sex. ML patients had a higher rate of intra-abdominal abscess than SL patients (13.7% vs 1.2% P < 0.0001), but intra-abdominal abscess did not predict wound dehiscence in the ML group ( P = 0.24). This was true in spite of the fact that ML patients had a significantly higher Injury Severity Score (ISS) than SL patients (21.68 vs 14.35, P < 0.0001). Interestingly, wound infection did not predict dehiscence. Patients undergoing repeat laparotomy after trauma are at increased risk for wound dehiscence. This risk appears to be associated with intraabdominal abscess and ISS, but not wound infection. Surgeons should leave the skin open in the setting of repeat trauma laparotomy, which will allow serial assessment of the integrity of the fascial closure.

Correlation between surgical site infection and obesity after exploratory laparotomy in trauma patients

QJM ◽  
2021 ◽  
Vol 114 (Supplement_1) ◽  
Author(s):  
Ahmed Abdelaziz ◽  
Ahmed Sabry ◽  
Mohamed Fayek
Keyword(s):  
Surgical Site Infection ◽  
Abdominal Trauma ◽  
Damage Control ◽  
Exploratory Laparotomy ◽  
Fascial Closure ◽  
Wound Complications ◽  
Trauma Patients ◽  
Obese Patients ◽  
Site Infection ◽  
University Hospitals

Abstract Background Obesity has become a major contributor to the global burden of chronic disease and disability. Understanding the effect of obesity on the incidence of wound infections and other wound complications remains incomplete despite considerable attention to both the growing ‘‘epidemic’’ of obesity and the frequent occurrence of surgical site infection (SSI) after surgical procedures. Damage-control laparotomy specifically has been associated with a higher rate of infectious complications and a lower rate of primary fascial closure in obese patients. Aim of the work The aim of the study is to evaluate the correlation between obesity and surgical site infection (SSI) in patients undergoing exploratory laparotomy after abdominal trauma. Patients and methods A retrospective study performed on obese patients of both genders aged between 18 and 60 years old undergoing exploratory laparotomy after abdominal trauma at the surgery departments of Ain Shams University Hospitals, Al-Bank Al-Ahly Hospital, Al-Mataria Hospital and Al-Salam Hospital, Cairo, Egypt for two years (1st of January 2018 to 1st of January 2020). Patients with infected wounds, receiving antibiotic therapy at the time of injury, those with a known immunodeficiency, who died within 48 hours after injury, who had sustained burn injuries, who underwent surgery at another institution before admission to our hospital were excluded. The rate of 30-day SSI post-operatively among obese and non-obese patients were compared. Statistical analysis was also done. Results Out of 782 patients, only 480 of those patients for whom BMI data were available, 360 (75%) were males and 120 (25%) were females. Out of the 480 patients: 168 patients had BMI more than 30; 114 patients (67.8%) had SSI (P &lt; 0.05), 312 patients had BMI less than 30; 61 patients (19.5%) had SSI. All of the included patients were fulfilling the inclusion and the exclusion criteria. On multivariate analysis, obesity was the strongest predictor of SSI (odds ratio = 1.59; 95% confidence interval, 1.32-1.91) after adjustment for sex and age. Obese patients with SSI compared with the non-obese had longer hospital stays (mean, 9.5 vs 8.1 days, respectively; P &lt; .001) and markedly higher rates of hospital readmission (27.1% vs 6.5%, respectively; P &lt; .001). Conclusion Obesity is considered as one of the risk factors in causing surgical site infection. Thus, this study showed the relation of BMI and obesity with surgical site infection in case of exploratory laparotomy after abdominal trauma.

scholarly journals Blossoming contusions: identifying factors contributing to the expansion of traumatic intracerebral hemorrhage

2018 ◽  
Vol 129 (5) ◽  
pp. 1305-1316 ◽  
Author(s):  
Joseph A. Carnevale ◽  
David J. Segar ◽  
Andrew Y. Powers ◽  
Meghal Shah ◽  
Cody Doberstein ◽  
...  
Keyword(s):  
Logistic Regression ◽  
Glasgow Coma Scale ◽  
Injury Severity Score ◽  
Injury Severity ◽  
Expansion Rate ◽  
Blood Alcohol ◽  
Patient Disposition ◽  
Ordinal Response ◽  
Admission Glasgow Coma Scale

OBJECTIVETraumatic brain injury (TBI) remains a significant cause of neurological morbidity and mortality. Each year, more than 1.7 million patients present to the emergency department with TBI. The goal of this study was to evaluate the prognosis of traumatic cerebral intraparenchymal hemorrhage (tIPH), to develop subclassifications of these injuries that relate to prognosis, and to provide a more comprehensive assessment of hemorrhagic progression contusion (HPC) by analyzing the rate at which tIPH “blossom” (i.e., expansion), depending on a variety of intrinsic and modifiable factors.METHODSIn this retrospective study, 726 patients (age range 0–100 years) were admitted to a level 1 trauma center with tIPH during an 8-year period (2005–2013). Of these patients, 491 underwent both admission and follow-up head CT (HCT) within 72 hours. The change in tIPH volume over time, the expansion rate, was recorded for all 491 patients. Effects of prehospital and in-hospital variables were examined using ordinal response logistic regression analyses. These variables were further examined using multivariate linear regression analysis to accurately predict the extent to which a hemorrhage will progress.RESULTSOf the 491 (67.6%) patients who underwent both admission and follow-up HCT, 368 (74.9%) patients experienced HPC. These hemorrhages expanded on average by 61.6% (4.76 ml) with an average expansion rate of 0.71 ml per hour. On univariate analysis, certain patient characteristics were significantly (p < 0.05) related to HPC, including age (> 60 years), admission Glasgow Coma Scale score, blood alcohol level, international normalized ratio, absolute platelet count, transfusion of platelets, concomitant anticoagulation and antiplatelet medication, the initial tIPH volume on admission HCT, and ventriculostomy. Increased expansion rate was significantly associated with patient disposition to hospice or death (p < 0.001). To determine which factors most accurately predict overall patient disposition, an ordinal-response logistic regression identified systolic blood pressure, Injury Severity Score, admission Glasgow Coma Scale score, follow-up scan volume, transfusion of platelets, and ventriculostomy as predictors of patient discharge disposition following tIPH. A multivariate logistic regression identified several prehospital and in-hospital variables (age, Injury Severity Score, blood alcohol level, initial scan volume, concomitant epidural hematoma, presence of subarachnoid hemorrhage, transfusion of platelets, and ventriculostomy) that predicted the volumetric expansion of tIPH. Among these variables, the admission tIPH volume by HCT proved to be the factor most predictive of HPC.CONCLUSIONSSeveral factors contribute to the rate at which traumatic cerebral contusions blossom in the acute posttraumatic period. Identifying the intrinsic and modifiable aspects of cerebral contusions can help predict the rate of expansion and highlight potential therapeutic interventions to improve TBI-associated morbidity and mortality.

Placement of Surgical Feeding Tubes Among Patients With Severe Traumatic Brain Injury Requiring Exploratory Abdominal Surgery

2020 ◽  
Vol 86 (6) ◽  
pp. 635-642
Author(s):  
Peter I. Cha ◽  
Ronald M. Jou ◽  
David A. Spain ◽  
Joseph D. Forrester
Keyword(s):  
Length Of Stay ◽  
Abdominal Surgery ◽  
Injury Severity ◽  
Unit Length ◽  
Feeding Tube ◽  
Hospital Length ◽  
Hospital Length Of Stay ◽  
Fascial Closure ◽  
Trauma Patients ◽  
Percutaneous Endoscopic Gastrostomy Placement

Objectives The purpose of this study was to identify trauma patients who would benefit from surgical placement of an enteral feeding tube during their index abdominal trauma operation. Methods We performed a retrospective analysis of all patients admitted to 2 level I trauma centers between January 2013 and February 2018 requiring urgent exploratory abdominal surgery. Results Six-hundred and one patients required exploratory abdominal surgery within 24 hours of admission after trauma activation. Nineteen (3% of total) patients underwent placement of a feeding tube after their initial exploratory surgery. On multivariate analysis, an intracranial Abbreviated Injury Scale ≥4 (odds ratio [OR] = 9.24, 95% CI 1.09-78.26, P = .04) and a Glasgow Coma Scale ≤8 (OR = 4.39, 95% CI 1.38-13.95, P = .01) were associated with increased odds of requiring a feeding tube. All patients who required a feeding tube had an Injury Severity Score ≥15. While not statistically significant, patients with an open surgical feeding tube compared with interventional radiology/percutaneous endoscopic gastrostomy placement had lower median intensive care unit length of stay, fewer ventilator days, and shorter median total hospital length of stay. Conclusions Trauma patients with severe intracranial injury already requiring urgent exploratory abdominal surgery may benefit from early, concomitant placement of a feeding tube during the index abdominal operation, or at fascial closure.

Helicopter Transport of Trauma Patients Improves Survival Irrespective of Transport Time

2020 ◽  
pp. 000313482094356
Author(s):  
Andrew M. Schneider ◽  
Joseph A. Ewing ◽  
John D. Cull
Keyword(s):  
Injury Severity ◽  
Survival Rates ◽  
Trauma Patients ◽  
Mechanism Of Injury ◽  
Transport Time ◽  
Level 1 ◽  
Student’S T ◽  
Level 1 Trauma Center ◽  
Student’S T Test ◽  
Transportation Type

Objectives Helicopter transport of trauma patients remains controversial. We examined the survival rates of patients undergoing helicopter versus ground transport to a Level 1 trauma center. Methods Retrospective analysis was performed on trauma patients treated between 2014 and 2017. Student’s t-test was used to compare air versus ground transport times. A logistic regression was then used to examine the association of transportation type on survival controlling for demographics, mechanism of injury, transport time, field intubation, and injury severity. Results Of 3967 patients identified, 69.6% (2762) were male, and the average age was 40 years. Most patients suffered blunt injuries (86.8%, 3445), while the remaining had penetrating injuries (11.6%, 459) or burns (1.6%, 63). The majority of patients were transferred by ground (3449) with only 13% (518) transferred by air. Patients transported by air had increased Injury Severity Score (ISS) with a median of 17 (IQR 9-24) versus 9 (IQR 5-14), increased length of stay (LOS) at 6 days versus 3 ( P < .001), and increased mortality at 12.6% vs 6.5% ( P < .001). Patients transported by air arrived 16.6 ± 6.7 minutes faster compared with ground for the zip codes examined. When adjusting for the mechanism of injury, ISS, age, gender, intubation status, and transport time, air transport was associated with an increased likelihood of survival (odds ratio [OR] = 1.57, 95% CI = 1.06-2.40). Conclusion In our analysis of 3967 patients, those transported by air had a significant improvement in the likelihood of survival compared with those transported by ground even when adjusting for both ISS and time.

Prediction of venous thromboembolism using clinical and serum biomarker data from a military cohort of trauma patients

2020 ◽  
pp. bmjmilitary-2019-001393 ◽  
Author(s):  
Matthew Bradley ◽  
A Shi ◽  
V Khatri ◽  
S Schobel ◽  
E Silvius ◽  
...  
Keyword(s):  
Venous Thromboembolism ◽  
Injury Severity ◽  
Tissue Injury ◽  
Soft Tissue Injury ◽  
Area Under The Curve ◽  
Serum Biomarkers ◽  
Trauma Patients ◽  
Total Blood ◽  
Mortality And Morbidity ◽  
Clinical Measures

IntroductionVenous thromboembolism (VTE) is a frequent complication of trauma associated with high mortality and morbidity. Clinicians lack appropriate tools for stratifying trauma patients for VTE, thus have yet to be able to predict when to intervene. We aimed to compare random forest (RF) and logistic regression (LR) predictive modelling for VTE using (1) clinical measures alone, (2) serum biomarkers alone and (3) clinical measures plus serum biomarkers.MethodsData were collected from 73 military casualties with at least one extremity wound and prospectively enrolled in an observational study between 2007 and 2012. Clinical and serum cytokine data were collected. Modelling was performed with RF and LR based on the presence or absence of deep vein thrombosis (DVT) and/or pulmonary embolism (PE). For comparison, LR was also performed on the final variables from the RF model. Sensitivity/specificity and area under the curve (AUC) were reported.ResultsOf the 73 patients (median Injury Severity Score=16), nine (12.3%) developed VTE, four (5.5%) with DVT, four (5.5%) with PE, and one (1.4%) with both DVT and PE. In all sets of predictive models, RF outperformed LR. The best RF model generated with clinical and serum biomarkers included five variables (interleukin-15, monokine induced by gamma, vascular endothelial growth factor, total blood products at resuscitation and presence of soft tissue injury) and had an AUC of 0.946, sensitivity of 0.992 and specificity of 0.838.ConclusionsVTE may be predicted by clinical and molecular biomarkers in trauma patients. This will allow the development of clinical decision support tools which can help inform the management of high-risk patients for VTE.

Blood Transfusion is an Independent Predictor of Mortality after Blunt Trauma

2007 ◽  
Vol 73 (1) ◽  
pp. 1-5 ◽  
Author(s):  
Anthony Charles ◽  
Almaasa Shaikh ◽  
Madonna Walters ◽  
Susan Huehl ◽  
Richard Pomerantz
Keyword(s):  
Logistic Regression ◽  
Blood Transfusion ◽  
Blunt Trauma ◽  
Injury Severity ◽  
Trauma Registry ◽  
Blunt Injury ◽  
Trauma Patients ◽  
Trauma Population ◽  
Transfusion Requirements ◽  
Level 2

Allogeneic blood transfusion is associated with increased morbidity and mortality. The authors evaluated the affect of blood transfusion, independent of injury severity on mortality. The authors conducted a retrospective review of all patients, age ≥18 years with blunt injury admitted to their Level 2 trauma center from 1994 to 2004 by query of the NTRACS trauma registry. Initial systolic blood pressure and heart rate determined the shock index. Logistic regression was used to model the affect of blood transfusion on mortality. Transfusion requirements were categorized as follows: A, 0 U; B, 1 to 2 U; C, 3 to 5 U; D, ≥6 U blood. In this sample of 8215 blunt trauma patients, 324 patients received blood transfusion. Mortality rates between the transfused and nontransfused groups were 15.12 per cent and 1.84 per cent ( P < 0.000) respectively. In the logistic regression model, transfusion category B did not have a significant affect on the odds of death ( P = 0.176); the affect of transfusing 3 to 5 U and ≥6 U had a mortality odds ratio of 3.22 ( P = 0.002) and 4.87 ( P = 0.000) respectively. Transfusing ≥2U blood was strongly associated with mortality in this blunt trauma population. There must be a continuous attempt to limit blood transfusion when feasible and physiologically appropriate.

scholarly journals Coagulopathy and damage control resuscitation during transfer due to massive hemorrhage –a single-center retrospective study–

2020 ◽  
Author(s):  
Hiroyuki Takahashi ◽  
Tomohisa Shoko ◽  
Mitsuaki Kojima ◽  
Satoshi Nara
Keyword(s):  
Logistic Regression ◽  
Regression Analysis ◽  
Logistic Regression Analysis ◽  
Damage Control ◽  
Massive Hemorrhage ◽  
Categorical Variables ◽  
Stepwise Logistic Regression ◽  
Damage Control Resuscitation ◽  
Single Center ◽  
Factors Associated

Abstract Background: To assess medical procedures, particularly damage control resuscitation, at the time of transfer between hospitals for the purpose of treating massive hemorrhage.Methods: This study used a single-center retrospective observational design, enrolling patients referred to Teine Keijinkai Hospital from another hospital between April 2012 and March 2019 for the treatment of massive hemorrhage. We excluded patients who entered cardiac arrest before arriving at our center. Qualitative or categorical variables were compared using the χ2 or Fisher’s exact test, as appropriate. Quantitative continuous variables were compared using Mann-Whitney nonparametric tests, as appropriate. Risk factors associated with coagulopathy from univariate analyses (fibrinogen level £150 mg/dl; prothrombin time-international normalized ratio ³1.5) were entered into stepwise logistic regression analysis. Significance was defined for values of p < 0.05.Results: Multiple logistic regression analysis revealed trauma (odds ratio (OR) 4.800; 95% confidence interval (CI) 2.016–11.433; p < 0.001) and volume of crystalloid solution (OR 1.001; 95%CI 1.000–1.001; p = 0.008) as independent factors associated with coagulopathy. Patients with coagulopathy showed higher 24-h mortality rates (10.9%) than patients without coagulopathy (1.2%; p = 0.021), and cause of death was hemorrhagic shock for all cases of death within 24 h.Conclusion: In our area, withholding intravenous fluid to achieve permissive hypotension, early administration of fresh frozen plasma, and use of fibrinogen concentrate may improve the prognosis of patients with massive hemorrhage undergoing transfer between hospitals.Trial registration: UMIN, UMIN000041201. Registered 24 July 2020 – Retrospectively registered, https://upload.umin.ac.jp/cgi-open-bin/icdr_e/ctr_view.cgi?recptno=R000047048

Risk Factors for Delirium in Trauma Patients: The Impact of Ethanol Use and Lack of Insurance

2011 ◽  
Vol 77 (5) ◽  
pp. 621-626 ◽  
Author(s):  
Bernardino C. Branco ◽  
Kenji Inaba ◽  
Marko Bukur ◽  
Peep Talving ◽  
Matthew Oliver ◽  
...  
Keyword(s):  
Risk Factors ◽  
Cardiovascular Disease ◽  
Logistic Regression ◽  
Chronic Ethanol ◽  
Ethanol Ingestion ◽  
Stepwise Logistic Regression ◽  
Trauma Patients ◽  
Stepwise Logistic Regression Analysis ◽  
Independent Risk Factors ◽  
The Impact

The purpose of this study was to examine independent risk factors, and in particular the impact of alcohol on the development of delirium, in a cohort of trauma patients screened for ethanol ingestion on admission to hospital. The National Trauma Databank (v. 7.0) was used to identify all patients 18 years or older screened for ethanol on admission. Patients who developed delirium were compared with those who did not. Stepwise logistic regression analysis was used to identify independent risk factors for the development of delirium. A total of 504,839 patients with admission ethanol levels were identified. Of those, 2,909 (0.6%) developed delirium. Patients developing delirium were significantly older, more frequently male, and more likely to sustain thermal injuries and falls. Patients developing delirium had more comorbidities including chronic ethanol use (19.1% vs 4.5%, P < 0.001) and cardiovascular disease (21.5% vs 12.2%, P < 0.001). On admission, patients developing delirium were more likely to be intoxicated with ethanol (55.4% vs 26.5%, P < 0.001) and were more likely to be uninsured (17.8% vs 0.9%, P < 0.001). A stepwise logistic regression model identified lack of insurance, positive ethanol on admission, chronic ethanol use, Intensive Care Unit admission, age ≥ 55 years, burns, Medicare insurance, falls, and history of cardiovascular disease as independent risk factors for the development of delirium. The incidence of delirium in this trauma patient cohort was 0.6 per cent. The above risk factors were independently associated with the development of delirium. This data may be helpful in designing interventions to prevent delirium.

Sign in / Sign up

Export Citation Format

Share Document