Injury
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The recent Afghanistan conflict caused a higher proportion of casualties with facial injuries due to both the increasing effectiveness of combat body armour and the insurgent use of the improvised explosive device (IED). The aim of this study was to describe all injuries to the face sustained by UK service personnel from blast or gunshot wounds during the highest intensity period of combat operations in Afghanistan. ⋯ The presence and pattern of facial fractures was significantly different in survivors and fatalities, which may reflect the power of the blast that these cohorts were exposed to. The Anatomical Injury Scoring of the Injury Severity Scale was inadequate for determining the extent of soft tissue facial injuries and did not predict morbidity of the injury.
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Observational Study
Hepatic dysfunction: A common occurrence in severely injured patients.
Hepatic dysfunction (HD) is a common finding in critically ill patients. The underlying pathophysiological process is one of either cholestasis or hypoxic liver injury (HLI). Using serum bilirubin, our study aimed to determine the incidence of HD in a critically ill trauma population, identify risk factors and analyse the impact on outcomes. ⋯ HD was common in our study population, and was associated with other organ dysfunction, increased mortality and length of stay.
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Observational Study
End-tidal CO2 on admission is associated with hemorrhagic shock and predicts the need for massive transfusion as defined by the critical administration threshold: A pilot study.
Critical administration threshold (≥3 units of packed red blood cells/h or CAT+) has been proposed as a new definition for massive transfusion (MT) that includes volume and rate of blood transfusion. CAT+ has been shown to eliminate survivor bias and be a better predictor of mortality than the traditional MT (>10 units/24h). End-tidal CO2 (ET CO2) negatively correlates with lactate and is an early predictor of shock in trauma patients. We conducted a pilot study to test the hypothesis that low ET CO2 on admission predicts CAT+. ⋯ This pilot study demonstrated that low ET CO2 had strong association with standard indicators for shock and was predictive of patients meeting CAT+ criteria in the first 6h after admission. Further study to verify these results and to elucidate CAT criteria's association with mortality will require a larger sample size.
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Applying manual pressure after hemorrhage is intuitive, cost-free, and logistically-simple. When direct abdominal-pelvic compression fails, clinicians can attempt indirect proximal-external-aortic-compression (PEAC), while expediting transfer and definitive rescue. This study quantifies the sustainability of simulated bi-manual PEAC both immediately on scene and during subsequent ambulance transfer. The goal is to understand when bi-manual PEAC might be clinically-useful, and when to prioritize compression-devices or endovascular-occlusion. ⋯ Survival following major abdominal-pelvic hemorrhage requires expedited operative/interventional rescue. Firstly, however, we must temporize pre-hospital exsanguination both on scene and during transfer. Despite limitations, our work suggests PEAC is feasible while waiting for, but not during, ambulance-transfer. Accordingly, we propose a chain-of-survival that cautions against over-reliance on manual PEAC, while supporting pre-hospital devices, endovascular occlusion, and expeditious but safe hospital-transfer.
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Intra-abdominal packing with laparotomy pads (LP) is a common and rapid method for hemorrhage control in critically injured patients. Combat Gauze™ and Trauma Pads™ ([QC] Z-Medica QuikClot®) are kaolin impregnated hemostatic agents, that in addition to LP, may improve hemorrhage control. While QC packing has been effective in a swine liver injury model, QC remains unstudied for human intra-abdominal use. We hypothesized QC packing during damage control laparotomy (DCL) better controls hemorrhage than standard packing and is safe for intracorporeal use. ⋯ While the addition of QC to LP packing did not confer additional benefit to standard packing, there was no additional morbidity identified with its use. The surgeons at our institution now select augmented packing with QC for sicker patients, as we believe this may have additional advantage over standard LP packing. A randomized controlled trial is warranted to further evaluate the intra-abdominal use of advanced hemostatic agents, like QC, for both hemostasis and associated morbidity.