Building Consensus to Decrease Firearm Injuries and Death in the USA: Engaging Medical and Public Health Organizations to Find Common Ground
Abstract Purpose of Review Firearm injury deaths are rising and as of 2017 exceed motor vehicle crash deaths in the USA. We as healthcare professionals treat many of the injured, including those cared for in the network of over 560 ACS-verified trauma centers. In order to address this public health crisis that affects us all, we need to develop a multifaceted public health strategy to decrease and prevent firearm injuries and deaths. Recent Findings While personal opinions about firearm ownership vary significantly across the USA, an inclusive, consensus-based, public health approach to reducing firearm deaths is possible. This article reviews recent literature on this approach, first building consensus among surgeons and then extending across the entire healthcare professional community. Summary There is broad support for a public health approach which focuses on the understanding and addressing the underlying causes of violence while also making firearm ownership as safe as possible. This approach requires the expertise and committed support of healthcare and public health providers, along with their professional organizations, healthcare systems, and public health networks which they lead. To achieve the goals of eliminating preventable firearm-related death and disability also requires engaging firearm owners and members from vulnerable communities as key stakeholders in the public health solution. In order to achieve the goals of the public health approach, increased federal and philanthropic research funding is required to identify and evaluate the most effective injury prevention initiatives.
The Scope of the Problem: Gun Violence in the USA
Abstract Purpose of Review To update current understanding of the extent and impact of firearm violence in the USA. Recent Findings In the past decade, rates of firearm injury have increased in the USA, both absolutely and in comparison to other high-income countries. Firearm homicides, firearm suicides, and public mass shootings have all been increasing. Firearm homicide rates remain highest for young non-White males in urban areas, and firearm suicide rates remain highest for older White males in rural areas. The burden of all these shootings falls not only directly on the victims themselves but also can impact their families, friends, and communities. These more indirect costs include medical care, grief, fear, hopelessness, and PTSD. The negative effects of exposure to firearm violence have been highlighted in the literature. Individual and community efforts to prepare for and prevent the shootings entail additional costs and burdens. Summary The scope of the US gun problem in 2019 is far greater than is indicated merely by medical costs and body counts.
A Review of Gun Buybacks
Abstract Purpose of Review This reviews the history of gun buybacks and the literature to determine their impact and efficacy, as well as highlighting salient critiques. Finally, we discuss potential avenues that would enhance our understanding of buybacks and methods to address gun violence. Recent Findings Gun buybacks have become more prominent since their inception in the 1970s and often come in response to a tragic local event. The largest scale buyback was in the mid-1990s in Australia, which collected over 650,000 guns. Buybacks are a cost-effective method of reducing the number of weapons in the general public. Summary Gun buybacks are a cost-effective means to reduce the number of unwanted firearms in the general public and also provide a means for education regarding injury prevention. Buybacks in conjunction with other methods have been shown to be successful in reducing the number of firearms that could lead to injury and death.
A Review of Whole Blood: Current Trauma Reports
Abstract Purpose of Review Interest in whole blood transfusion, particularly in trauma resuscitations, has been growing over the last decade. This has led to more data from civilian trauma centers on the efficacy of whole blood compared to component therapy, the safety profile, and the hemostatic effects of cold-storage. Recent Findings The summation of recent data suggests that whole blood is at least as effective as component therapy in trauma resuscitation although data is limited to relatively small volumes (< 6 units). The effect of leukoreduction on platelet function and other hemostatic markers appears to be small in vitro, but clinical data is lacking. There is virtually no data on massive resuscitation with whole blood (> 10 units) except for case reports. Summary Resuscitation with whole blood appears to be safe and offers some advantages over component therapy. More clinical data is needed on the safety of whole blood in massive resuscitation and the potential hemostatic effects of whole blood transfusion.
Platelet Contributions to Trauma-Induced Coagulopathy: Updates in Post-injury Platelet Biology, Platelet Transfusions, and Emerging Platelet-Based Hemostatic Agents
Abstract Purpose The purpose of this review is to summarize the current understanding of the role of aberrant platelet biology in trauma-induced coagulopathy (TIC), discuss the evidence for platelet transfusions in the management of hemorrhaging trauma patients, and review emerging platelet-based hemostatic adjuncts. Recent Findings Advances in the study of post-injury platelet biology have led to the discovery of pathways associated with altered platelet activation and aggregation observed in the context of TIC. Impaired platelet aggregation after injury has recently been associated with histone driven modifications in platelet structureand function, alterations in calcium signaling, and alterations in von Willebrand factor (v
WF) platelet interactions. Furthermore, studies have identified several soluble factors in plasma which may play a role in inhibiting platelets after injury. Lastly, loss of the normal regulatory and bidirectional relationships of platelets with the endothelium and with fibrinolytic pathways may additionally play key roles in TIC. Importantly, the use of platelet transfusions as a treatment for hemorrhage control is not “one size fits all”—the benefit in several circumstances may be outweighed by risks, and there is a lack of demonstrated effectiveness for certain populations. Therefore, current efforts are underway to develop platelet based and platelet mimetic hemostatic agents, and to improve the effectiveness of platelet transfusions while mitigating the risks. Summary Our understanding of how injury leads to altered platelet behavior contributing to TIC has grown substantially but remains incomplete. Decoding the complex biologic interface of platelets with the endothelium, fibrinolysis, and inflammatory pathways will lead to a more complete understanding of platelets and of TIC. Platelet transfusions remain the mainstay of treatment as part of balanced and goal-directed resuscitation, but through advancing knowledge of the underlying biology, safer, targeted, and more effective therapies may emerge.
School Nurses Share Their Voices, Trauma, and Solutions by Sounding the Alarm on Gun Violence
Abstract Purpose of Review The purpose of this review is to discuss the impact of gun violence within schools from the perspective of school nurses. School nurses are first responders whose skills are crucial to ensuring the health and safety of students, staff, and faculty within schools and the surrounding community. Recent Findings In the USA, fear has long dictated how schools invest their resources in response to gun violence. In the wake of a series of school shootings that began in the 1990s, school safety is now a multi-billion-dollar industry. Although school shootings remain rare events, the response to potential gun violence has been an implementation of active shooter drills in 95% of US schools. School districts are faced with difficult choices that balance the safety concerns of school communities and the plethora of industry vendors who claim they have the most effective method to take action and keep their students safe. Summary There is a critical need for research that guides the selection of evidence-based safety programs that consider the developmental and the mental health needs of school communities. School nurses are healthcare providers embedded in schools whose expertise and collaboration is critical to the design and implementation of these programs that keep students safe and ready to learn.
#ThisIsOurLane: Incorporating Gun Violence Prevention into Clinical Care
Abstract Purpose of Review This article reviews the medical community’s evolving perspective on its role in gun violence prevention efforts, particularly evaluating the evidence for and potential impact of patient education and firearm safety counseling. Recent Findings Growing numbers of physicians and professional medical societies recognize gun violence as a public health crisis and are increasingly supporting a more active role for the profession to address it. In spite of this urging, relatively few physicians routinely address firearm safety with their patients, in part driven by a lack of standardized education about how to incorporate gun violence prevention into clinical care. Summary Clinicians have a unique opportunity to prevent firearm-related injuries and death by performing firearm safety screening and violence prevention counseling at the bedside. With growing evidence for the effectiveness of such counseling and increasing number of widely available resources, clinicians across medical disciplines are well positioned to address this unmet need.
Combat Casualty Care Statistics as Outcome Measures for Medical Treatment on the Battlefield: A Review and Reconsideration of the Data
Abstract Purpose of Review This review focuses on the use of the case fatality rate (CFR), the killed in action percentage (%KIA) and died of wounds (%DOW) as battlefield medical outcome measures and reports the current statistical data for recent conflicts. Further, the review defines each statistic, and identifies their usefulness and limitations in medical research. Recent Findings The CFR, %KIA, and %DOW have been used by many authors since the beginning of the conflicts in Afghanistan and Iraq in 2001. However, these statistics are primarily derived from administrative databases maintained by the Defense Casualty Analysis System, and their primary purpose is not to evaluate the effectiveness of medical treatment. We believe both the magnitude of the improvements in CFR and %KIA and impact of medical treatment on these statistics have been in some cases overstated. Summary Battlefield lethality is significantly impacted by non-medical factors. Some medical researchers, likely unknowingly, continue to use these statistics, especially the CFR, without taking all battlefield confounders into account. The Department of Defense Trauma Registry provides opportunity for improved data collection, performance improvement, and standardization of the combat casualty care statistics thereby allowing for meaningful comparisons and a better understanding of battlefield trauma care.
Mechanisms of Traumatic Hyperfibrinolysis and Implications for Antifibrinolytic Therapy
Abstract Purpose of the Review To provide an update on the current knowledge of mechanisms that regulate hyperfibrinolysis and implications of recent findings for use of antifibrinolytics. Recent Findings New data demonstrate a role for both platelet and endothelial dysfunction, as well as novel mechanisms for activated protein C in the pathophysiology of hyperfibrinolysis. Although randomized clinical trial data in mature trauma centers is lacking, most analyses support the early use of tranexamic acid in the treatment of all severely injured patients experiencing hemorrhagic shock. Summary Hyperfibrinolysis is a devastating complication of trauma and hemorrhagic shock. Currently available antifibrinolytics are largely considered safe and effective and further research is needed before restricting antifibrinolytic use in the sub-population of patients with fibrinolytic shutdown. Future development of novel therapeutics to reverse hyperfibrinolysis could improve treatment of this hemostatic disorder.
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.