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"damage control"
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Traumatic hemorrhage and chain of survival
Trauma is the number one cause of death among Americans between the ages of 1 and 46 years, costing more than $670 billion a year. Following death related to central nervous system injury, hemorrhage accounts for the majority of remaining traumatic fatalities. Among those with severe trauma that reach the hospital alive, many may survive if the hemorrhage and traumatic injuries are diagnosed and adequately treated in a timely fashion. This article aims to review the recent advances in pathophysiology management following a traumatic hemorrhage as well as the role of diagnostic imaging in identifying the source of hemorrhage. The principles of damage control resuscitation and damage control surgery are also discussed. The chain of survival for severe hemorrhage begins with primary prevention; however, once trauma has occurred, prehospital interventions and hospital care with early injury recognition, resuscitation, definitive hemostasis, and achieving endpoints of resuscitation become paramount. An algorithm is proposed for achieving these goals in a timely fashion as the median time from onset of hemorrhagic shock and death is 2 h.
Journal Article
Damage Control Laparotomy: High-Volume Centers Display Similar Mortality Rates Despite Differences in Country Income Level
Background
Comprehensive analysis of trauma care between high-, middle-, and low-income countries (HIC/MIC/LIC) is needed to improve global health. Comparison of HIC and MIC outcomes after damage control laparotomy (DCL) for patients is unknown. We evaluated DCL utilization among patients treated at high-volume trauma centers in the USA and South Africa, an MIC, hypothesizing similar mortality outcomes despite differences in resources and setting.
Methods
Post hoc analysis of prospectively collected trauma databases from participating centers was performed. Injury severity, physiologic, operative data and post-operative outcomes were abstracted. Univariate and multivariable analyses were performed to assess differences between HIC/MIC for the primary outcome of mortality.
Results
There were 967 HIC and 602 MIC patients who underwent laparotomy. DCL occurred in 144 MIC patients (25%) and 241 HIC (24%) patients. Most sustained (58%) penetrating trauma with higher rates in the MIC compared to the HIC (71 vs. 32%,
p
= 0.001). Between groups, no differences were found for admission physiology, coagulopathy, or markers of shock except for increased presence of hypotension among patients in the HIC. Crystalloid infusion volumes were greater among MIC patients, and MIC patients received fewer blood products than those in the HIC. Overall mortality was 30% with similar rates between groups (29 in HIC vs. 33% in MIC,
p
= 0.4). On regression, base excess and penetrating injury were independent predictors of mortality but not patient residential status.
Conclusion
Use and survival of DCL for patients with severe abdominal trauma was similar between trauma centers in HIC and MIC settings despite increased penetrating trauma and less transfusion in the MIC center. While the results overall suggest no gap in care for patients requiring DCL in this MIC, it highlights improvements that can be made in damage control resuscitation.
Journal Article
Framework for dynamic modelling of urban floods at different topographical resolutions
Urban flood risks and their impacts are expected to increase as urban development in flood prone areas continues and rain intensity increases as a result of climate change while aging drainage infrastructures limit the drainage capacity in existing urban areas. The research presented in this thesis addresses the problem of capturing small-scale features in coarse resolution urban flood models with the aim of improving flood forecasts in geometrically complex urban environments.
Book
Fork from camping utensils as a wounded shell caused severe vascular injury in a combat patient injured in the war in Ukraine: a case report
Background
The war in Ukraine is associated with severe injuries and challenges in the management of patients. There are various kinds of high-energy ballistic projectiles, but kitchen cutlery or camping utensils parts, such as forks, knives, or spoons, are not usually expected to be found in the gunshot wound, but might serve as a ballistic projectile causing severe damage to the human body. Vascular injury is also a challenge in war surgery, and the application of temporary arterial shunts is a good approach, as well as the application of damage control tactics. The aim of this study was to demonstrate the rare case of management of the combat patient who received a severe vascular injury to the femoral artery by fork from camping utensils after the strike by the KAB precision-guided munition, who was treated with temporary arterial shunts with application of DCR and DCS.
Case presentation
A 34-year-old Ukrainian soldier was wounded by a precision-guided munition (KAB) in East Ukraine. The injury resulted in severe trauma to the left lower extremity, including superficial femoral artery damage. Due to the persistent threat of drone attacks, the rapid evacuation to advanced medical facilities was delayed for 12 h. The Forward Surgical Team diagnosed the patient with arterial thrombosis of superficial femoral artery and a foreign metal mass, identified as a fork, which was a part of a camping utensil, embedded in the hip. Surgical intervention involved the removal of the foreign bodies and amputation below the upper third of the hip due to critical arterial ischemia. The patient was stabilized, transferred to a higher-level field hospital, and eventually discharged after 21 days for rehabilitation and prosthetic fitting.
Conclusions
The trajectory of a high-energy ballistic projectile might go through the various objects (e.g., cutlery forks, etc.), followed by their involvement in the injury process, and increase the severity of the wounds. Ongoing war in Ukraine is associated with the impossibility of wide use of the aeromedical evacuation due to tactical obstacles, resulting in prolongation of the time for patients’ evacuation to higher level of medical care and higher risk for extremity amputations in patients with vascular injury.
Journal Article
Comparison of trauma resuscitation practices by critical care anesthesiologists and non-critical care anesthesiologists
Approval was granted through the University of Southern California Health Sciences Campus Institutional Review Board and the requirement for written informed consent was waived by the Institutional Review Board. There was not a statistically significant difference between the CCA and NCCA groups with regards to PRBC transfusion, platelet transfusion, cryoprecipitate transfusion, estimated blood loss, change in lactate, base deficit, mortality, ventilator days or intensive care unit days.4 Discussion Critical care anesthesiologists offered benefit in trauma resuscitation in this investigation. The effect that this has on overall outcome is less clear.Author contribution statements All authors have made substantial contributions to all of the following: (1) the conception and design of the study, or acquisition of data, or analysis and interpretation of data, (2) drafting the article or revising it critically for important intellectual content, (3) final approval of the version to be submitted.Funding This research did not receive any specific grant from funding agencies in the public, commercial, or not-for-profit sectors.Declaration of competing interest The authors declare the following financial interests/personal relationships which may be considered as potential competing interests: JMT was at USC when the work was undertaken and is now vice president of clinical research at Masimo (no support of any kind was provided for this manuscript).
Journal Article