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Prehospital Emergency Care 2022Traumatic hemorrhage is the leading cause of preventable death, and its effects are often evident within the first 24 hours of hospital admission. We investigated the...
Traumatic hemorrhage is the leading cause of preventable death, and its effects are often evident within the first 24 hours of hospital admission. We investigated the relationship between prehospital lactate measurement and administration of hospital blood products and life-saving interventions (LSIs) within 24 hours of hospital admission. We included trauma patients with recorded prehospital venous lactate transported by a single critical care transport service to a Level I trauma center between 2012 and 2019. We abstracted vital signs, mission type, anatomic location of injury, prehospital administration of crystalloid and blood products, and hospital LSIs started within 24 hours of admission. We used logistic regression to determine the association of prehospital lactate and in-hospital administration of blood products in groups with or without hypotensive patients. We investigated the effect of prehospital lactate concentration on secondary outcomes such as LSIs and mortality. We included 2,170 patients transported from the scene or emergency department (ED), of whom 1,821 (84%) were normotensive. The median concentration of prehospital lactate was 2.10 mmol/L for the main population (IQR = 1.40-3.30) and 2.00 mmol/L for the normotensive subgroup (IQR = 1.30-2.90). A higher prehospital lactate concentration was associated with higher odds of needing early hospital blood products in the whole study population (OR = 1.12, (95% CI 1.06-1.20), p < 0.01) and in the normotensive subgroup (OR = 1.13, (95% CI 1.03-1.22), p = 0.01). These positive associations were also observed with the secondary outcome of hospital LSIs, and higher prehospital lactate was also associated with higher odds of mortality (OR = 1.32, (95% CI 1.20-1.45), p < 0.01). Higher concentrations of prehospital lactate were associated with the need for in-hospital blood transfusion within 24 hours of admission. The relationship between lactate and blood transfusion persisted among normotensive patients. Further work is needed to incorporate prehospital lactate into decision support tools for prehospital blood administration.
Topics: Emergency Medical Services; Emergency Service, Hospital; Humans; Injury Severity Score; Lactic Acid; Retrospective Studies; Trauma Centers; Vital Signs; Wounds and Injuries
PubMed: 34550050
DOI: 10.1080/10903127.2021.1983096 -
European Journal of Trauma and... Feb 2021Venous thromboembolisms (VTE) are a major concern after acute survival from trauma. Variations in treatment protocols for trauma patients exist worldwide. This study... (Comparative Study)
Comparative Study
PURPOSE
Venous thromboembolisms (VTE) are a major concern after acute survival from trauma. Variations in treatment protocols for trauma patients exist worldwide. This study analyzes the differences in the number of VTE events and the associated complications of thromboprophylaxis between two level I trauma populations utilizing varying treatment protocols.
METHODS
International multicenter trauma registry-based study was performed at the University Medical Center Utrecht (UMCU) in The Netherlands (early commencement chemical prophylaxis), and Harborview Medical Center (HMC) in the United States (restrictive early chemical prophylaxis). All severely injured patients (ISS ≥ 16), aged ≥ 18 years, and admitted in 2013 were included. Primary outcomes were VTE [deep venous thrombosis (DVT) (no screening), pulmonary embolism (PE)], and hemorrhagic complications.
RESULTS
In UMCU, 279 patients were included and in HMC, 974 patients. Overall, 75% of the admitted trauma patients in UMCU and 81% in HMC (p < 0.001) received thromboprophylaxis, of which 100% in and 75% at, respectively, UMCU and HMC consisted of chemical prophylaxis. From these patients, 72% at UMCU and 47% at HMC (p < 0.001) were treated within 48 h after arrival. At UMCU, 4 patients (1.4%) (PE = 3, DVT = 1) and HMC 37 patients (3.8%) (PE = 22, DVT = 16; p = 0.06) developed a VTE. At UMCU, a greater percent of patients with VTE had traumatic brain injuries (TBI). Most VTE occurred despite adequate prophylaxis being given (75% UMCU and 81% HMC). Hemorrhagic complications occurred in, respectively, 4 (1.4%) and 10 (1%) patients in UMCU and HMC (p = 0.570). After adjustment for age, ISS, HLOS, and injury type, no significant difference was demonstrated in UMCU compared to HMC for the development of VTE, OR 2.397, p = 0.102 and hemorrhagic complications, OR 0. 586, p = 0.383.
CONCLUSIONS
A more early commencement protocol resulted in almost twice as much chemical prophylaxis being started within the first 48 h in comparison with a more delayed initiation of treatment. Interestingly, most episodes of VTE developed while receiving recommended prophylaxis. Early chemical thromboprophylaxis did not significantly increase the bleeding complications and it appears to be safe to start early.
Topics: Adult; Aged; Female; Humans; Injury Severity Score; Male; Middle Aged; Netherlands; Registries; Risk Factors; Trauma Centers; Venous Thromboembolism; Washington; Wounds and Injuries
PubMed: 31471670
DOI: 10.1007/s00068-019-01208-z -
Radiographics : a Review Publication of... Feb 2023The range of intracranial venous anomalies in children differs from that in adults. As a commonly encountered highly morbid disease, sinovenous thrombosis has been...
The range of intracranial venous anomalies in children differs from that in adults. As a commonly encountered highly morbid disease, sinovenous thrombosis has been discussed extensively in the literature, and the associated imaging considerations are similar in pediatric and adult patients. The authors shift the focus to less frequently discussed cerebral venous diseases in pediatric patients. First, the practical embryology pertinent to malformations, syndromes, and variants such as vein of Galen aneurysmal malformation, Sturge-Weber syndrome, and developmental venous anomalies are discussed. Second, anatomic considerations that are applicable to neuroimaging in pediatric patients with cerebral venous anomalies are reviewed. In the discussion of anatomy, special attention is given to the medullary venous system that serves the cerebral white matter, superficial cortical veins (tributaries of the dural venous sinuses), and bridging veins, which carry blood from the superficial cortical veins through the potential subdural space into the dural venous sinuses. Third, the selection of imaging modalities (US, CT and CT venography, and MRI) is addressed, and various MR venographic pulse sequences (time-of-flight, phase-contrast, and contrast-enhanced sequences) are compared. Finally, a broad variety of congenital and acquired superficial and deep venous diseases in children are reviewed, with emphasis on less frequently discussed entities involving the medullary (eg, deep medullary venous engorgement and thrombosis, periventricular hemorrhagic venous infarction due to germinal matrix hemorrhage), cortical (eg, cortical venous thrombosis), and bridging (eg, acute and chronic manifestations of injury in abusive head trauma) veins, as well as the deep veins and dural venous sinuses (eg, varix). RSNA, 2023 Quiz questions for this article are available through the Online Learning Center. and
Topics: Adult; Humans; Child; Cerebral Veins; Magnetic Resonance Imaging; Sinus Thrombosis, Intracranial; Cranial Sinuses; Craniocerebral Trauma; Varicose Veins
PubMed: 36656758
DOI: 10.1148/rg.220129 -
European Review For Medical and... Jun 2021Timely intervention is the key to the successful management of penetrating injuries to jugular veins; however, the optimal clinical management of these perforations and...
OBJECTIVE
Timely intervention is the key to the successful management of penetrating injuries to jugular veins; however, the optimal clinical management of these perforations and associated risk factors for mortality are not fully established. This study examined the trauma characteristics, vital signs, and in-hospital mortality in penetrating external and internal jugular vein injuries (PEJVI and PIJVI, respectively).
PATIENTS AND METHODS
In this National Trauma Data Bank database study on patients with penetrating jugular vein injuries (PJVIs), details pertaining to demographics, comorbidities, type of injury, mechanism and intent of injury, Injury Severity Score (ISS), vital signs, treatment, and outcome, were abstracted. Multivariate logistic regression was used to identify the risk factors of in-hospital mortality.
RESULTS
A total of 548 patients with PJVIs were included in the final analysis. Patients with PEJVI were more likely to have a self-inflicted injury (p<.001) than those with PIJVI. In both groups, hemorrhage control surgery was performed in almost 60% of the patients within 24 hrs. of the injury (p=.767). Systolic blood pressure (OR 0.99, 95% CI: 0.98-1.00, p=.043), Glasgow coma scale (OR 0.88, 95% CI: 0.81-0.95, p<.001), ISS (OR 1.10, 95% CI: 1.06-1.14, p<.001), and the firearm as a mechanism of injury (OR 2.85, 95% CI: 1.19-6.79, p=.018) were found to be independently associated with the risk of in-hospital mortality.
CONCLUSIONS
The injury severity, hemodynamic stability, comma scale, intent, and mechanism of injury differed significantly in PEJVI and PIJVI; however, the type of PJVI did not have an independent association with in-hospital mortality.
Topics: Adult; Databases, Factual; Female; Glasgow Coma Scale; Hospital Mortality; Humans; Injury Severity Score; Jugular Veins; Logistic Models; Male; Middle Aged; Risk Factors; Wounds and Injuries; Wounds, Penetrating
PubMed: 34227070
DOI: 10.26355/eurrev_202106_26144 -
Scientific Reports Mar 2022Intracranial pressure (ICP) includes the brain, optic nerve, and spinal cord pressures; it influences blood flow to those structures. Pathological elevation in ICP...
Intracranial pressure (ICP) includes the brain, optic nerve, and spinal cord pressures; it influences blood flow to those structures. Pathological elevation in ICP results in structural damage through various mechanisms, which adversely affects outcomes in traumatic brain injury and stroke. Currently, invasive procedures which tap directly into the cerebrospinal fluid are required to measure this pressure. Recent fluidic engineering modelling analogous to the ocular vascular flow suggests that retinal venous pulse amplitudes are predictably influenced by downstream pressures, suggesting that ICP could be estimated by analysing this pulse signal. We used this modelling theory and our photoplethysmographic (PPG) retinal venous pulse amplitude measurement system to measure amplitudes in 30 subjects undergoing invasive ICP measurements by lumbar puncture (LP) or external ventricular drain (EVD). We estimated ICP from these amplitudes using this modelling and found it to be accurate with a mean absolute error of 3.0 mmHg and a slope of 1.00 (r = 0.91). Ninety-four percent of differences between the PPG and invasive method were between - 5.5 and + 4.0 mmHg, which compares favourably to comparisons between LP and EVD. This type of modelling may be useful for understanding retinal vessel pulsatile fluid dynamics and may provide a method for non-invasive ICP measurement.
Topics: Brain Injuries, Traumatic; Humans; Intracranial Pressure; Optic Nerve; Retinal Vein; Spinal Puncture
PubMed: 35338201
DOI: 10.1038/s41598-022-09151-7 -
Journal of Endovascular Therapy : An... Dec 2021Bullet fragment embolization is a rare but potentially fatal complication of traumatic gunshot injury. Herein, we present a case of a patient who demonstrated migration...
PURPOSE
Bullet fragment embolization is a rare but potentially fatal complication of traumatic gunshot injury. Herein, we present a case of a patient who demonstrated migration of a bullet fragment from the lower chest into the left common iliac vein. Continual identification of foreign bodies on trauma imaging is of the utmost importance. Identifying and treating this rare entity can help vascular interventionalists improve patient outcomes.
CASE REPORT
Our patient presented to the emergency room after sustaining 2 gunshot wounds to the right axilla. Initial imaging demonstrated 2 bullet fragments: one in the right axilla and another in the lower chest overlying the heart. A subsequent trauma computed tomography was performed 13 minutes later and demonstrated a bullet fragment in the left common iliac vein, which had embolized from the original location in the lower chest. Interventional radiology was consulted to perform foreign body removal. A transcutaneous approach was utilized, and the bullet embolus was removed successfully without complication.
CONCLUSION
Bullet fragment embolization is a rare entity with complications ranging from critical limb ischemia to venous thrombosis or obstruction. This case helps to demonstrate the importance of identifying and accounting for bullet fragments in gunshot trauma imaging.
Topics: Embolism; Foreign Bodies; Foreign-Body Migration; Humans; Iliac Vein; Treatment Outcome; Wounds, Gunshot
PubMed: 34212776
DOI: 10.1177/15266028211028216 -
The American Surgeon Jul 2024Iliac and femoral venous injuries represent a challenging dilemma in trauma surgery with mixed results. Venous restoration of outflow (via repair or bypass) has been...
BACKGROUND
Iliac and femoral venous injuries represent a challenging dilemma in trauma surgery with mixed results. Venous restoration of outflow (via repair or bypass) has been previously identified as having higher rates of VTE (venous thromboembolism) compared to ligation. We hypothesized that rates of VTE and eventual amputation were similar whether restoration of venous outflow vs ligation was performed at initial operation.
METHODS
Patients in the 2019-2021 National Trauma Data Bank with iliac and femoral vein injuries were abstracted and analyzed. The primary outcomes of interest were in-hospital lower extremity amputation and VTE.
RESULTS
A total of 2642 patients with operatively managed iliac and femoral vein injuries were identified VTE was found in 10.8% of patients. Multivariable logistic regression was performed and identified bowel injury, higher ISS, older age, open repair, and longer time to VTE prophylaxis initiation as independent predictors of VTE. Amputation was required in 4.2% of patients. Multivariable logistic regression identified arterial or nerve injury, femur or tibia fracture, venous ligation, percutaneous intervention, fasciotomy, bowel injury, and higher ISS as independent factors of amputation.
CONCLUSION
Venous restoration was not an independent predictor of VTE. Venous ligation on index operation was the only modifiable independent predictor of amputation identified on regression analysis.
Topics: Humans; Female; Male; Venous Thromboembolism; Adult; Femoral Vein; Middle Aged; Risk Factors; Amputation, Surgical; Quality Improvement; Iliac Vein; Vascular System Injuries; Retrospective Studies; Ligation
PubMed: 38527489
DOI: 10.1177/00031348241241645 -
Biochemical and Biophysical Research... May 2020Smoke inhalation injury (SII) affects more than 50,000 people annually causing carbon monoxide (CO) poisoning. Although the increased blood level of carboxyhemoglobin...
Blood carboxyhemoglobin elimination curve, half-lifetime, and arterial-venous differences in acute phase of carbon monoxide poisoning in ovine smoke inhalation injury model.
Smoke inhalation injury (SII) affects more than 50,000 people annually causing carbon monoxide (CO) poisoning. Although the increased blood level of carboxyhemoglobin (CO-Hb) is frequently used to confirm the diagnosis of SII, knowledge of its elimination in the acute phase is still limited. The aim of this study is to determine CO-Hb elimination rates and their differences in arterial (aCO-Hb) and mixed-venous (vCO-Hb) blood following severe SII in a clinically relevant ovine model. Forty-three chronically instrumented female sheep were subjected to SII (12 breaths, 4 sets) through tracheostomy tube under anesthesia and analgesia. After the SII, sheep were awakened and placed on a mechanical ventilator (FiO = 1.0, tidal volume 12 mL/kg, and PEEP = 5cmHO) and monitored. Arterial and mixed-venous blood samples were withdrawn simultaneously for blood gas analysis at various time points to determine CO-HB half-lifetime and an elimination curve. The mean of highest aCO-Hb level during SII was 70.8 ± 13.9%. The aCO-Hb elimination curve showed an approximated exponential decay during the first 60 min. Per mixed linear regression model analysis, aCO-Hb significantly (p < 0.001) declined (4.3%/minute) with a decay constant lambda of 0.044. With this lambda, mean lifetime and half-lifetime of aCO-Hb were 22.7 and 15.7 min, respectively. The aCO-Hb was significantly lower compared to vCO-Hb at all-time points (0-180 min). To our knowledge, this is the first report describing CO-Hb elimination curve in the acute phase after severe SII in the clinically relevant ovine model. Our data shows that CO-Hb is decreasing in linear manner with supportive mechanical ventilation (0-60 min). The results may help to understand CO-Hb elimination curve in the acute phase and improvement of pre-hospital and initial clinical care in patients with CO poisoning.
Topics: Acute Disease; Animals; Arteries; Carbon Monoxide Poisoning; Carboxyhemoglobin; Disease Models, Animal; Female; Half-Life; Hemodynamics; Sheep; Smoke Inhalation Injury; Veins
PubMed: 32199614
DOI: 10.1016/j.bbrc.2020.03.048 -
Journal of Orthopaedic Surgery (Hong... 2020Venous anastomosis is the key procedure for Ishikawa zone Ⅱ fingertip replantation. Both palmar and lateral veins provide efficient venous drainage. This study... (Comparative Study)
Comparative Study
PURPOSE
Venous anastomosis is the key procedure for Ishikawa zone Ⅱ fingertip replantation. Both palmar and lateral veins provide efficient venous drainage. This study compared the clinical effects between these venous anastomoses for fingertip replantation.
METHODS
In 2016-2018, 61 patients underwent Ishikawa zone Ⅱ fingertip replantation with venous anastomosis (28 and 33 cases with palmar and lateral anastomoses, respectively). Retrospective comparative analyses evaluated surgical technique and function, including operative time; rates of finger survival, venous congestion, and infection; sensation; joint motion; cold intolerance symptom severity (CISS), Disabilities of the Arm, Shoulder, and Hand (DASH), and Vancouver scar scores; and chronic regional pain syndrome (CRPS) rates.
RESULTS
There were 33 patients with lateral vein anastomosis and 28 patients with palmar vein anastomosis. The average patient follow-up was 18.2 months. The survival rates did not differ significantly between groups (87.8% (29/33) vs. 85.7% (24/28), > 0.05); however, the operative time was shorter in the lateral vein group than in the palmar vein group (78.57 ± 7.08 min vs. 67.88 ± 5.77 min, < 0.05). Venous congestion and infection rates did not differ significantly between groups ( > 0.05). The replanted finger function, including joint motion, sensation, DASH scores, Vancouver scar scores, and CRPS rates, did not differ significantly between groups ( > 0.05). However, the CISS score was higher in the palmar vein group than in the lateral vein group (44.39 ± 5.16 vs. 38.09 ± 4.49, < 0.05).
CONCLUSIONS
Venous anastomosis with either palmar or lateral veins showed high survival rates and good function in fingertip replantation. The lateral vein had a shorter operative time and benefit to arterial revision and was especially suitable for patients with finger pulp damage.
Topics: Adult; Amputation, Traumatic; Anastomosis, Surgical; Female; Finger Injuries; Fingers; Humans; Male; Middle Aged; Operative Time; Replantation; Retrospective Studies; Veins; Young Adult
PubMed: 33034253
DOI: 10.1177/2309499020962861 -
Journal of Vascular Surgery Dec 2019Trauma remains a leading cause of morbidity and mortality worldwide. Vascular injuries are present in approximately 1% to 2% of trauma patients, with the majority of...
BACKGROUND
Trauma remains a leading cause of morbidity and mortality worldwide. Vascular injuries are present in approximately 1% to 2% of trauma patients, with the majority of injuries occurring to the extremities. Trauma patients with vascular injuries have been shown to have increased morbidity and mortality as well as the need for increased resources compared with those without vascular injuries. This study aimed to determine predictors of poor outcomes in infrainguinal bypasses performed for traumatic arterial injury.
METHODS
All patients admitted between September 1999 and July 2015 who underwent infrainguinal arterial bypass for trauma at a single level I trauma center were included for analysis. The primary outcome was a composite of thrombosis leading to graft abandonment, revision, amputation, or death. Data were analyzed by univariate descriptive and multiple logistic regression analyses. Long-term data were analyzed by Kaplan-Meier method.
RESULTS
During the study period, 108 patients presented with and underwent infrainguinal arterial bypass for traumatic arterial injury. The cohort had a mean age of 35.8 years (16/108 female [15%]). The average Injury Severity Score was 15.2; admission glomerular filtration rate, 79.3 mL/min/1.73 m; Mangled Extremity Severity Score (MESS), 6; and injury to operating room time, 5.1 hours. Of 108 patients, 37 (34%) had penetrating injury, 71 (66%) had blunt injury, 10 (9.3%) had diabetes mellitus, and 76 (70.4%) had a below-knee target for bypass. Univariate risk factors for poor outcome included age >40 years (odds ratio [OR], 3.27 [1.40-7.65]; P < .01), MESS ≥7 (OR, 5.19 [2.08-19.97]; P < .01), blunt mechanism (OR, 3.35 [1.24-9.07]; P = .02), popliteal artery injury (OR, 3.04 [1.22-7.6]; P = .02), and below-knee target vessel (OR, 4.32 [1.37-13.58]; P = .01). Concomitant orthopedic injuries (P = .08) were not associated with poor outcome. Baseline renal function, type of repair performed (end-to-side vs interposition bypass), injury to surgery time, surgeon's specialty, and associated venous injuries were not significantly predictive of poor outcome. MESS was strongly predictive of poor outcome, with probability rising as high as 95% when MESS reached 12. A score ≥7 (high MESS) was 73% sensitive and 70% specific to predict poor outcomes. Age (OR, 1.03/y; P < .05) and MESS ≥7 (OR, 3.6; P < .03) were persistent predictors of poor outcome in multivariable analysis.
CONCLUSIONS
Poor outcomes in infrainguinal bypass for trauma are significantly predicted by the MESS, with poor outcomes occurring >50% of the time when MESS is ≥9 and >75% of the time when MESS is ≥11. Whereas amputation vs revascularization is a decision that also depends on nerve and soft tissue damage and other comorbidities, the MESS helps frame the data for the clinician and can aid in decision-making. Patients and family should understand that poor outcomes are more likely when MESS is ≥9. For patients with MESS ≥11, primary amputation can be considered.
Topics: Adult; Arteries; Cohort Studies; Female; Humans; Lower Extremity; Male; Middle Aged; Prognosis; Retrospective Studies; Treatment Outcome; Vascular Surgical Procedures; Vascular System Injuries; Wounds, Nonpenetrating; Wounds, Penetrating
PubMed: 31248764
DOI: 10.1016/j.jvs.2019.03.056