Alone and Sometimes Unafraid : Military Perspective on Forward Damage Control Resuscitation on the Modern Battlefield
Abstract Purpose of Review The objective of this review is to describe the military experience and utilization of damage control resuscitation as well as explore future developments to push the best medicine far forward in the austere environment. Recent Findings The Global War on Terror has transitioned from mature combat theaters staged with rapid medical evacuation and robust medical facilities to more austere environments. Due to this transition, the military medical force has adopted the practice of sending providers and surgeons into forward deployed environments to provide Damage Control Resuscitation closer to the point of injury. Summary This review focuses on the key tenets of Damage Control Resuscitation and its development. It also describes how various military units have adopted damage control resuscitation principles.
Prehospital Hemorrhage Control and REBOA
Abstract Purpose of Review Review the current state of the art in prehospital hemorrhage control and the role of resuscitative endovascular balloon occlusion of the aorta (REBOA). Recent Findings Prehospital data demonstrate improved hemorrhage control and decreased blood product transfusions with tourniquet use. Minimal complications have been noted (temporary nerve palsy) and no tourniquet-related amputations have been reported in modern series. Junctional tourniquets are effective in stopping arterial flow and controlling bleeding in preclinical trials. Clinical data is lacking. Hemostatic bandages have been shown in animal studies to improve time to hemorrhage control and survival. Limited clinical data supports improved hemorrhage control and no morbidity. The REBOA catheter is a promising technology with a clear role in severe pelvic fractures. The role of REBOA in the prehospital setting remains undefined. Summary Preclinical and clinical data are supportive of both prehospital tourniquet and hemostatic bandages. Junctional tourniquets are promising but lack clinical data. The REBOA catheter is an effective bleeding control adjunct for which prehospital indications are still being defined.
Combat Vascular Trauma Management for the General Surgeon
Abstract Purpose of Review This review focuses on the initial management and stabilization of complex vascular injuries for the general surgeon within the combat zone. Recent Findings Recent conflicts in Iraq, Afghanistan, and Syria demonstrate that general surgeons are responsible for the initial surgical management of combat-related vascular trauma in damage control scenarios. These injuries display a more complex injury pattern and often require different management strategies than seen in civilian trauma. Summary Vascular trauma in combat settings is often accompanied by a multitude of life- and limb-threatening injuries. Definitive repair operations are often deferred for initial damage control surgery and resuscitation. Resultant strategies to restore perfusion and control bleeding are determined by the patient’s underlying physiology and frequently require the use of vascular shunts, ligation, primary anastomosis, or interposition grafting. While general surgeons in the combat zone are not typically responsible for definitive repair during initial damage control surgery, proper initial surgical management in the far-forward setting with an intimate understanding of future repair strategies remains critical aspects in assuring optimal definitive treatment.
Vascular Trauma—Open or Endovascular
Abstract Purpose of Review This review discusses the trends in management of vascular trauma comparing open management with endovascular strategies. Recent Findings Endovascular vascular approaches to vascular trauma has evolved significantly in the past several decades, providing an option for reduced morbidity and mortality in the carefully selected trauma patient. While open surgery is a critical skill to maintain, there are strategies more than ever before that can be applied to a hemorrhaging trauma patient which include stent-graft placement, the use of temporary vascular shunts, and vascular balloon occlusion. Summary Vascular trauma management has evolved over the last several decades, introducing promising endovascular treatment strategies, particularly in junctional and torso hemorrhage.
Damage Control Vascular Surgery
Abstract Purpose of Review Exsanguination is one of the most fearsome sequelae of trauma and is responsible for a large portion of both civilian and military mortality. The concept of damage control surgery is a critical development in the field of trauma largely driven by the growing understanding that coagulopathy and physiologic derangements are the primary cause of death in critically ill trauma patients. Damage control vascular surgery focuses on the rapid temporization of vascular injuries. Recent Findings Balloon occlusion can be utilized for rapid hemorrhage control (REBOA, foley catheter, retrohepatic caval balloon, etc.). In the setting of damage control, most veins can and should be ligated. Consideration of shunting should be made regarding the suprarenal inferior vena cava, the portal vein, and the superior mesenteric vein. The named arteries should be shunted and repaired when possible; however, redundant arterial beds can be safely ligated. Vessels of all sizes can be safely shunted with commercially available or improvised devices. Systemic heparinization is not necessary to maintain patency. More recently, the concept of using endovascular stents as long-term shunts has gained attention. These can be deployed traditionally under angiographic guidance or using the novel direct site endovascular repair (DSER) technique. Summary The rapidly evolving field of endovascular trauma management has afforded a host of new management strategies for the physiologically deranged critically ill trauma patient.
ECMO in the Burn Patient: the Time Has Come
Abstract Purpose The use of extracorporeal life support in the intensive care unit has exponentially increased in the last decade. Initially, its use in the burn population lagged behind the dramatic growth in other patient populations; however, in the last 2–3 years, there has been an increase in the number of publications related to its use in this population. In this article, we review the use of contemporary ECMO in the burn patient population and discuss future trends. Recent Findings Level 1 evidence for the use of ECMO in any patient population is scarce, and there is no level 1 evidence for the use of ECMO in burn patients. Recently, there has been an increase in case series and case reports describing the use of contemporary ECMO in burn patients. In addition, there are two large retrospective reviews of large registries utilizing ECMO in burn patients. Summary The results from these studies all indicate that outcomes using ECMO in this critically ill patient population has survival rates at least comparable to the survival found in other patient populations. There are still many unanswered questions, and future focus needs to address patient selection, timing of initiation, management, and the duration of ECMO therapy.
The Current State of Topical Burn Treatments: a Review
Abstract Purpose of Review The purpose of this review is to discuss commonly used dressings for burn treatments, including short-acting topicals and long-acting silver dressings. Recent Findings Recent literature supports the use of long-acting silver dressings over traditional daily use topical treatments. Longer acting topical dressings result in less frequent dressing changes, less pain, and greater ease of use, but have similar results in wound healing and infection prevention. Summary There are many topical agents on the market for use on burn wounds. Short-acting topicals can be divided into 3 generalized classes: antiseptics, antimicrobials, and enzymatic debridement agents. Longer acting applied dressings include silver-bonded nylon and fiber (Silverlon® Argentum, Clarendon Hills, IL); multilayer rayon, polyester silver-coated mesh polyethylene (Acticoat™ Smith & Nephew London, UK); silver sodium carboxymethylcellulose (Aquacel® Ag, Conva
Tec, Greensboro, NC); silver-containing soft silicone foam (Mepilex® Ag; Mölnlycke Health Care, Gothenburg); soft silicone silver (Mepitel Ag® Mölnlycke Health Care, Gothenburg). Tradition and surgeon preference are major influences on frequency of use. While recent literature supports using long-acting silver-based dressings over short-acting topicals, more research, particularly randomized controlled trials, is needed to provide evidence-based recommendations regarding their use.
Fluid Resuscitation in Burns: 2xa0cc, 3xa0cc, or 4xa0cc?
Abstract Purpose of Review A variety of burn resuscitation formulas, each with varying volumes and types of fluid being given, have been developed. The recommended fluid rate in these formulas ranges from 2 to 4 m
L/kg/%total body surface area (TBSA), which could lead to variability among practitioners. As such, the purpose of this study is to evaluate which starting fluid rate is optimal for burn resuscitation. Recent Findings Multiple small trials have shown that a lower starting intravenous fluid rate yields no difference with respect to ventilator days, mortality, or renal failure. However, the preponderance of smaller studies precludes definitive conclusions. Larger, prospective, randomized trials are needed in a variety of aspects of burn resuscitation. Summary In this review, we describe the history of burn resuscitation, summarize the data on fluid rates for burn resuscitation, discuss adjuncts to burn resuscitation, and highlight future research directions for burn care.
Post-Burn Pruritus and Its Management—Current and New Avenues for Treatment
Abstract Purpose of Review This article seeks to review the current literature on post-burn pruritus and its treatments, as well as to propose new treatments that may be of potential benefit for these patients. Recent Findings Post-burn pruritus has been reported to affect as many as 93% of patients after a burn injury. Pruritus is extremely distressing to these patients, yet the current state of treatment, mostly antihistamines and emollients, is still widely ineffective in providing relief of itch. Summary Therapies that are effective in treating pruritus and that may act as superior treatment options for patients suffering from post-burn pruritus include gabapentin and pregabalin, topical ketamine-lidocaine-amitriptyline, opioid medications, neurokinin-1 inhibitors, antidepressants, anti-cytokines, PAR-2 inhibitors, and botulinum toxin among others.
Current State of Selected Wound Regeneration Templates and Temporary Covers
Abstract Purpose of Review To review four wound coverage options—xenografts, allografts, Integra®, and Matri
Stem™—and outline considerations to help providers select the appropriate cover. Recent Findings Xenografts were the first skin substitutes used to cover wounds. They are inexpensive but inherently less similar to native host skin than cadaveric allografts, the current gold standard for temporary wound coverage. Integra® is an established dermal matrix that provides permanent coverage by naturally integrating into the wound to create a neo-dermis. Matri
Stem™ urinary bladder matrices are recently available products designed to promote wound healing. They have shown promising, albeit limited, results in clinical studies. Summary Each reviewed coverage option presents its own risk-benefit profile. The optimal choice for an individual patient depends on various wound- and patient-related factors that should be evaluated collectively. Adherence to wound management principles is paramount regardless of the coverage option. This review aims to facilitate the selection process for providers.
Amputation in Trauma—How to Achieve a Good Result from Lower Extremity Amputation Irrespective of the Level
Abstract Purpose of Review To provide an overview of patient management and surgical technique regarded as best practice in optimising outcome following primary and secondary amputation in trauma patients. This is supported by evidence where available. Recent Findings There is increasing evidence that primary amputation may offer superior outcome to reconstruction in severe open lower limb injuries, particularly segmental trauma involving the foot and tibia. Similarly, patients considering complex reconstructive procedures for failed trauma management should be counselled that reported outcomes are equivalent or better following amputation and are achieved faster and with less complications. Patients should be fully informed of this when making decisions about management, though this needs to be individualised. Various surgical techniques have been associated with improved outcome and these are described herein. Careful peri-operative pain management has been associated with faster rehabilitation, better psychological response and a reduced risk of chronic pain. On discharge, patients should be linked to rehabilitation, prosthetic and clinical psychology services and these should be integrated where possible. Summary A holistic, multidisciplinary approach is recommended in all aspects of care and should be available from the outset. Patients should be optimised medically and functionally, where possible pre-operatively. Psychological assessment and early information sharing are recommended. Where this is not possible due to acuity, these issues should be addressed as soon as possible post-amputation. Particularly where the limb is severely injured, careful planning and joint operating by senior Orthopaedic, Plastic and Vascular surgeons can achieve the best results.
Penetrating Neck Trauma: a Review
Abstract Purpose of Review This review focuses on the management of penetrating neck trauma and its evolution over the last several decades. Recent Findings Our increased experience with high-resolution computed tomography has changed the management of penetrating neck trauma from an anatomically zone-based approach to a “no zone” approach. Physical signs and symptoms of vascular, airway, and digestive track injuries still guide the basis of further radiographic and surgical workup. With the advancement and greater availability of multi-detector computed tomography (MDCT) technology, assessment of injuries has become easier and far more accurate. The hemodynamically stable patient may now be approached in a “no-zone” manner, and in certain cases managed safely with conservative measures. Summary Wartime experience and improved technology played major roles in the evolution of penetrating neck injury management. Aggressive surgical exploration had given way to selective management based on anatomical neck zones, to most currently a “no zone” approach.
Penetrating Cervical Vascular Injuries
Abstract Purpose of Review This article reviews penetrating cervical vascular injuries, with a focus on the initial control, diagnostic workup, and operative or endovascular management. The review highlights the change in management approach from one based on anatomical zones of the neck to the contemporary approach of using physical exam and computed tomographic angiography to guide decision making. Recent Findings The approach to penetrating neck injuries has evolved over the past 40 years with a resultant decrease in the rate of non-therapeutic operations, driven primarily by improvements in imaging technology. The role of endovascular techniques is now established for vertebral artery injuries and continues to evolve for non-emergent carotid injuries. Summary Penetrating cervical injuries pose a significant risk to life and triage of patients to the operating room or further imaging by computed tomographic angiography (CTA) must occur promptly based on the physical examination. In the operating room, the management of complex venous injuries consists of simple ligation. Vertebral injuries can be temporized with packing or bone wax and then managed with percutaneous endovascular interventions. Carotid injuries may generally be managed with arteriorrhaphy, primary repair, or reconstruction with venous or PTFE graft. In damage control situations, shunting is preferred.
Update on Prevention of Surgical Site Infections
Abstract Purpose of Review This review summarizes recent surgical site infection (SSI) prevention guidelines/guideline updates that are relevant to surgery and wound care after injury and reviews a sample of recent literature relevant to SSI. Recent Findings The quality of evidence supporting guidelines/guideline updates is quite variable. The strongest support is for appropriately timed preoperative antibiotics when indicated and for alcohol-based skin preparation before incision when feasible. Summary New guidelines for SSI prevention are available from the American College of Surgeons, the Centers for Disease Control, and the World Health Organization. There are recommendations common to all three reports that trauma/acute care surgeons should be aware of.
Neck Injuries: a Complex Problem in the Deployed Environment
Abstract Purpose of Review Evaluation and treatment of injuries to the neck has received a lot of attention over the past 20 years. New evaluation protocols and treatment recommendations have been developed. The goal of this review is to examine these strategies and evaluate their suitability for treatment of patients in a deployed setting. Recent Findings Studies from several large trauma centers have changed common practice with regard to both penetrating and blunt neck injuries. The requirement to explore all zone II neck injuries has largely been replaced by a selective exploration based on physical examination and imaging. Also, blunt cerebrovascular injuries, once thought to be rare, have been demonstrated to be common and treatment dramatically reduces the morbidity and mortality. Summary Injuries to the neck are a significant problem in the deployed environment. The blast injuries that are common in Iraq and Afghanistan produce multiple injured casualties. In addition to injuries to other body regions, injuries to the neck can involve both blunt and penetrating mechanisms as well as injuries to the spinal column. The extent and outcome of these complex injuries has not been fully evaluated and would remain an area worthy of study.
Blunt Pharyngoesophageal Injury: an Overview of a Rare Entity
Abstract Purpose of Review To characterize the epidemiology, diagnostic approach, management, and outcomes of blunt pharyngoesophageal injuries. Recent Findings These injuries remain exceedingly rare. Clinical symptoms and signs may not be revealing. Most recommendations regarding diagnosis and management are extrapolated from penetrating aerodigestive injuries. High-resolution computerized tomography has emerged as the most useful initial imaging modality that may guide the need for additional studies and/or intervention. Esophagography and endoscopic evaluation remain of paramount importance when an injury is confirmed or suspected as they can assist in determining therapeutic actions. Non-operative management is feasible and should be considered selectively to avoid septic complications. Summary Blunt pharyngoesophageal injuries can be managed similarly to those from penetrating mechanism. The use of computerized tomography should be more liberal to rule out associated injuries, as blunt trauma patients are at risk for having additional occult life-threatening injuries. Non-operative managements should be carefully deployed.
Update on Treatment of Blunt Cerebrovascular Injuries
Abstract Purpose of Review This article focuses on the recent practices and advancements in the treatment of blunt cerebrovascular injuries (BCVI), and also to identify areas of future study. Recent Findings It remains clear that antithrombotic therapy is the mainstay of therapy for preventing BCVI-related stroke. There is no difference in the type of antithrombotic therapy used, but it is critical that treatment be initiated as early as possible post-injury. The use of endovascular stents has declined dramatically from the previous decade, and their true utility in the treatment of these injuries remains unclear. One of the biggest challenges that remains in treating BCVI is when to initiate therapy in patients with concomitant injuries that may prevent treatment early post-injury, when treatment is in fact most critical. Summary Antithrombotic therapy remains effective in the treatment of BCVI. The BCVI-related stroke rates reported across the literature remain stable between 5 and 10%. The treatment will most likely remain similar for the foreseeable future; however, there remain unknowns regarding the nuances of treatment that are mostly attributable to the relative rarity of the injuries.
Blunt Cerebrovascular Injuries: Screening and Diagnosis
Abstract Purpose of Review This review focuses on the origins of research in blunt cerebrovascular injuries (BCVI) and highlights recent developments in BCVI screening and diagnosis. An emphasis is made on the evolution of screening guidelines and the role for a computed tomography angiography (CTA)-based approach to the diagnosis of BCVI. Recent Findings The expanded Denver criteria first published in 2012 have been widely adopted in many trauma centers. Increased awareness and broadened screening have led to an increased rate of diagnosis in BCVI among blunt trauma patients. Current research efforts are focused on refining and improving diagnostic algorithms to improve patient selection for screening and to avoid missed injuries among blunt trauma patients. Summary BCVI complicates between 1 and 3% of all blunt trauma admissions, and clinicians must have a high index of suspicion for this injury. Early and aggressive screening has decreased stroke rates and prevented unnecessary morbidity and mortality in this patient population. Future research will further improve institutional processes of identifying patients and instituting rapid treatment.
Penetrating Pharyngoesophageal Injuries
Abstract Purpose of Review Penetrating pharyngoesophageal injuries (PPEI) are relatively rare yet are associated with significant morbidity and even mortality. Even if diagnosed appropriately, their management is controversial. This monograph attempts to contextualize these injuries and provide evidence-based guidelines to assist with their recognition, diagnosis, and management. Recent Findings The pharynx and esophagus may be divided into a number of regions: the pharynx, the cervical esophagus, the intrathoracic esophagus, and the intra-abdominal esophagus. Management approaches differ depending on the site of the injury. Clinical examination is important but unreliable and the clinical signs of a PPEI are nonspecific. Imaging is essential to exclude or confirm the presence of a PPEI. CT angiography can accurately assess the vasculature in the neck and can exclude a PPEI. If there is still a suspicion of a PPEI, then a contrast study or a flexible endoscopy will accurately delineate the injury. There is no need to combine these two modalities routinely. If an injury to the oro/hypopharynx is identified, then nonoperative treatment is safe and effective. Injuries to the cervical esophagus are traditionally managed operatively, but in a select subset of patients, nonoperative management may well be both safe and effective. Injuries to the intrathoracic and intra-abdominal esophagus are rare and are treated operatively. Summary PPEI must be actively excluded by good clinical examination in conjunction with appropriate imaging. Injuries to the proximal part of the tract can be safely managed nonoperatively. More distal injuries traditionally are managed operatively but in a small subset of cases may be safely managed nonoperatively.
The Difficult Abdominal Wound: Management Tips
Abstract Purpose of Review This review aims to summarize therapeutic options for the management of complex surgical wounds of the abdomen especially in regard to emergency surgery and trauma patients. Recent Findings Wounds in emergency surgery and trauma patients are complex and have an elevated risk for surgical site infection and hernia. In addition, the open abdomen (OA) and damage control laparotomy (DCL) are techniques being increasingly used not just in trauma patients but in critically ill surgical patients as well. Although these techniques can be lifesaving, they can be complicated and difficult to manage especially in a patient that requires multiple takebacks and those with delayed closures requiring ongoing resuscitation. Summary This review article discusses the management options that facilitate wound closure and reduce wound complications in an emergency surgery and trauma patient. The article aims to provide a range of options that can be used regardless of resources and surgical expertise.