Shock Trauma Research Articles

Pathophysiology of Trauma-Induced Coagulopathy and Management of Critical Bleeding Requiring Massive Transfusion.

Trauma-induced coagulopathy is caused by multiple factors, such as anemia, hemodilution, hypothermia, acidosis, shock, and serious trauma itself, which affects patient outcomes due to critical bleeding requiring massive transfusion. Disseminated intravascular coagulation (DIC) with the fibrinolytic phenotype directly caused by trauma and/or traumatic shock has been considered to be the primary pathophysiology of trauma-induced coagulopathy. The key to controlling DIC is vigorous treatment of the underlying disorder, that is, trauma itself and hemorrhagic shock. Damage control resuscitation, consisting of damage control surgery, permissive hypotension, and hemostatic resuscitation, aims to control severe trauma and critical bleeding, which is equivalent to managing the underlying disorder of DIC. At present, however, evidence-based practices for damage control resuscitation are lacking. A robust prospective outcome study for damage control resuscitation that considers DIC with the fibrinolytic phenotype as the main pathological condition of trauma-induced coagulopathy affecting patient outcome is essential for improving therapeutic strategies.

The Cost of Deploying a Role 2 Medical Asset to Afghanistan.

The costs of military assets, including medical resources, are necessary for military planners when determining their force make up. The monetary cost of operating a Role 3 unit, the most comprehensive medical asset in the combat theater, has been determined. The cost of operating a Role 2 (R2) facility-the less comprehensive but more common asset-has not been assessed. Here we estimate the cost of operating an R2 medical asset in Afghanistan. Personnel costs were assessed by combining the U.S. Department of Defense estimate for personnel cost with the replacement costs for deployed staff. Manning was for a U.S. Marine Corps Shock Trauma Platoon and Forward Resuscitative Surgical System. It costs $2,956,873 a month to operate an R2 medical facility in Afghanistan. It also takes the place of a rifle platoon and disrupts the domestic military health care mission. The costs of operating an R2 medical facility are significant and should be considered when the medical benefits of an R2 are unclear.

Assessment of early lymphopenia after cardiac arrest

A significant decrease in circulating lymphocytes can occur after septic shock and severe trauma and is associated with a poor outcome. After cardiac arrest (CA), the return of spontaneous circulation is associated with a significant inflammatory response that can also mimic the same alterations, but lymphocyte count has not been studied in this setting.

Baltimore Health Department Helps Affected Citizens After Riots

Baltimore Health Department Helps Affected Citizens After Riots

Emergency department crowding and the performance of damage control resuscitation in major trauma patients with hemorrhagic shock.

Uncontrolled hemorrhagic shock is the leading cause of potentially preventable death in major trauma patients. Damage control resuscitation (DCR), a strategy combining the techniques of permissive hypotension, hemostatic resuscitation, and damage control surgery, has been highly recommended for trauma patients. This study investigated whether emergency department (ED) crowding was associated with poor performance of the DCR strategies in treating hemorrhagic shock trauma patients. This was a retrospective cohort study in an urban tertiary hospital conducted from January 2010 to December 2013. Major trauma patients who presented to the ED with hemorrhagic shock were included. ED crowding, measured by ED occupancy rate, was categorized into three groups (low, medium, and high). The performance of DCR and inpatient outcomes were analyzed using multivariate logistic analysis. Of the 3,037 major trauma patients assessed, 852 met the inclusion criteria and were enrolled in the study. Patients in the high-crowding group had delayed initiation of transfusion (high vs. medium and low, 2.5 hours vs. 2.1 hours and 1.0 hours, respectively, p = 0.01), received less blood products in the ED (both comparisons p < 0.01), and experienced delays in procedures (4.5 hours vs. 3.3 hours and 2.4 hours, p < 0.01). However, the amount of crystalloid solution was similar among patients in all three groups (p = 0.17). In multivariate analysis, more patients from the high-crowding group developed traumatic coagulopathy in the intensive care unit (29.7% vs. 24.1% and 16.3%, p < 0.01), while no clear relationship was found between ED crowding and 30-day mortality or early lactate clearance rate (p > 0.05). ED crowding was associated with poor performance of DCR for major trauma patients in the ED. New strategies should be implemented to ameliorate crowded conditions and potential adverse outcomes.

Strain echocardiography identifies impaired longitudinal systolic function in patients with septic shock and preserved ejection fraction.

BackgroundMyocardial dysfunction is recognized in sepsis. We hypothesized that mechanical left (LV) and right (RV) ventricular function analysed using 2-dimensional speckle-tracking echocardiography in a cohort of early severe sepsis or septic shock patients, would be different to that of a group of critically ill, non-septic patients.MethodsCritically ill adult patients with early, severe sepsis/septic shock (n = 48) and major trauma patients with no sepsis (n = 24) were included retrospectively, as well as healthy controls (n = 16). Standard echocardiographic examinations, including right (RV) left (LV) volumes and mitral, aortic and pulmonary vein Doppler flow profiles, were retrospectively identified and the studies were then reanalysed for assessment of myocardial strain using speckle-tracking echocardiography. Endocardial tracing of the LV was performed in apical four-chamber (4-Ch), two-chamber (2-Ch), apical long-axis (3-Ch) and apical views of RV determining the longitudinal LV and RV free wall strain in each subject.ResultsIn septic patients, heart rate was significantly higher (p = 0.009) and systolic (p < 0.001) and mean arterial pressures (p < 0.001), as well as systemic vascular resistance (p < 0.001) were significantly lower when compared to the non-septic trauma group. Ninety-three per cent of the septic patients and 50 % of the trauma patients were treated with norepinephrine (p < 0.001). LV ejection fraction (LVEF) was lower in the septic patients (p = 0.019). In septic patients with preserved LVEF (>50 %, n = 34), seventeen patients (50 %) had a depressed LV global longitudinal function, defined as a LV global strain > −15 %, compared to two patients (8.7 %) in the non-septic group (p = 0.0014). In septic patients with preserved LVEF, LV global and RV free wall strain were 14 % (p = 0.014) and 17 % lower (p = 0.008), respectively, compared to the non-septic group with preserved LVEF. There were no significant differences between groups with respect to LV end-diastolic or end-systolic volumes, stroke volume, or cardiac output. There were no signs of diastolic dysfunction from the mitral or pulmonary vein Doppler profiles in the septic patients.ConclusionsLV and RV systolic function is impaired in critically ill patients with early septic shock and preserved LVEF, as detected by Speckle-tracking 2D echocardiography. Strain imaging may be useful in the early detection of myocardial dysfunction in sepsis.Electronic supplementary materialThe online version of this article (doi:10.1186/s12947-015-0025-4) contains supplementary material, which is available to authorized users.

Association Between Arterial Hyperoxia and Outcome in Subsets of Critical Illness: A Systematic Review, Meta-Analysis, and Meta-Regression of Cohort Studies.

Oxygen is vital during critical illness, but hyperoxia may harm patients. Our aim was to systematically evaluate the methodology and findings of cohort studies investigating the effects of hyperoxia in critically ill adults. A meta-analysis and meta-regression analysis of cohort studies published between 2008 and 2015 was conducted. Electronic databases of MEDLINE, EMBASE, and Web of Science were systematically searched for the keywords hyperoxia and mortality or outcome. Publications assessing the effect of arterial hyperoxia on outcome in critically ill adults (≥ 18 yr) admitted to critical care units were eligible. We excluded studies in patients with chronic obstructive pulmonary disease, extracorporeal life support or hyperbaric oxygen therapy, and animal studies. Due to a lack of data, no studies dedicated to patients with acute lung injury, sepsis, shock, or multiple trauma could be included. Studies were included independent of admission diagnosis and definition of hyperoxia. The primary outcome measure was in-hospital mortality, and results were stratified for relevant subgroups (cardiac arrest, traumatic brain injury, stroke, post-cardiac surgery, and any mechanical ventilation). The effects of arterial oxygenation on functional outcome, long-term mortality, and discharge variables were studied as secondary outcomes. Twenty-four studies were included of which five studies were only for a subset of the analyses. Nineteen studies were pooled for meta-analyses and showed that arterial hyperoxia during admission increases hospital mortality: adjusted odds ratio, 1.21 (95% CI, 1.08-1.37) (p = 0.001). Functional outcome measures were diverse and generally showed a more favorable outcome for normoxia. In various subsets of critically ill patients, arterial hyperoxia was associated with poor hospital outcome. Considering the substantial heterogeneity of included studies and the lack of a clinical definition, more evidence is needed to provide optimal oxygen targets to critical care physicians.

Mannitol dosing error during interfacility transfer for intracranial emergencies.

Mannitol is commonly used to treat elevated intracranial pressure (ICP). The authors analyzed mannitol dosing errors at peripheral hospitals prior to or during transport to tertiary care facilities for intracranial emergencies. They also investigated the appropriateness of mannitol use based on the 2007 Brain Trauma Foundation guidelines for severe traumatic brain injury. The authors conducted a retrospective review of the Shock Trauma Air Rescue Society (STARS) electronic patient database of helicopter medical evacuations in Alberta, Canada, between 2004 and 2012, limited to patients receiving mannitol before transfer. They extracted data on mannitol administration and patient characteristics, including diagnosis, mechanism, Glasgow Coma Scale score, weight, age, and pupil status. A total of 120 patients with an intracranial emergency received a mannitol infusion initiated at a peripheral hospital (median Glasgow Coma Scale score 6; range 3-13). Overall, there was a 22% dosing error rate, which comprised an underdosing rate (<0.25 g/kg) of 8.3% (10 of 120 patients), an overdosing rate (>1.5 g/kg) of 7.5% (9 of 120), and a nonbolus administration rate (>1 hour) of 6.7% (8 of 120). Overall, 72% of patients had a clear indication to receive mannitol as defined by meeting at least one of the following criteria based on Brain Trauma Foundation guidelines: neurological deterioration (11%), severe traumatic brain injury (69%), or pupillary abnormality (25%). Mannitol administration at peripheral hospitals is prone to dosing error. Strategies such as a pretransport checklist may mitigate this risk.

Lethal now or lethal later: The natural history of Grade 4 blunt cerebrovascular injury.

Grade 4 blunt cerebrovascular injury (BCVI4) has a known, significant rate of stroke. However, little is known about the natural history of BCVI4 and the pathophysiology of subsequent stroke formation. A 4-year review of patients with BCVI4 at the R Adams Cowley Shock Trauma Center was performed. Rates of BCVI4-related stroke, stroke-related mortality, and overall mortality were calculated. The relationship of change in vessel characteristics and BCVI4-related stroke was examined, as was the mechanism of stroke formation. There were 82 BCVI4s identified, with 13 carotid artery (ICA) and 69 vertebral artery BCVI4s. BCVI4-related stroke rate was 2.9% in vertebral artery BCVI4 and 70% in ICA BCVI4 patients surviving to reimaging. Stroke mechanisms included embolic strokes, thrombotic strokes, and combined embolic and thrombotic strokes. Peristroke vessel recanalization and an embolic stroke mechanism were seen in 100% of ICA BCVI4-related strokes developing after admission. BCVI4-related stroke occurred within 10 hours of hospital admission in 67% of the patients with strokes. Contraindications to anticoagulation were present in most patients with BCVI4-related stroke developing after admission. Multiple etiologies of stroke formation exist in BCVI4. Early risk-benefit analysis for initiation of anticoagulation or antiplatelet agents should be performed in all patients with BCVI4, and the use of endovascular vessel occlusion should be considered in those with true contraindications to anticoagulation. However, more aggressive medical therapy may be needed to lessen BCVI4-related stroke development. Prognostic study, level IV; therapeutic study, level V.

Mo2024 Remifentanil Preconditioning Protects Intestine Against Ischemia/Reperfusion Injury in Rats Through Inhibiting Intestinal Mucosal Epithelial Apoptosis via δ- and μ-Opioid Receptors

Objective: Intestinal ischemia/reperfusion (I/R) frequently occurs after major surgery, various types of shock and severe trauma, and it is associated with a high morbidity and mortality in the critical clinical settings. Intestinal I/R results in the injury of intestinal mucosal immunity and gut bacterial communities, however, little is known about the mechanisms and corresponding therapy for these damages. Immunoglobulin (Ig) A class switch recombination (CSR) plays a major role in gut IgA synthesis, and transforming growth factor (TGF)-β1 can potently induce other Ig isotypes CSR to IgA. Here, we aimed to investigate the effect of TGF-β1 on gut IgA generation and microbiota after intestinal I/R attack, and explore the underlying mechanisms. Methods: The 8-10 weeks Balb/c mice were randomly allocated into 5 groups. In the Sham group, the mice underwent laparotomy without occlusion of the superior mesenteric artery (SMA); whereas, the SMA was clamped for 1 hour in the Injury group; the mice of the TGF group received intravenous infusion of recombinant TGFβ1 before ischemia. In addition, SB-431542, a specific inhibitor of TGF-β receptor I/II, was administered alone (SB group) in intestinal ischemic mice or prior to TGF-β1 (TGF+SB group) to block its inductive effect on IgA CSR. The biomarkers of IgA CSR and IgA mRNA were detected by real-time PCR; the number of IgA+, IgM+ B cells and the percentage of bacteria coated with IgA were detected by flow cytometry; sIgA concentration was detected by ELISA; gut bacterial communities were detected by high-throughput 16S rRNA gene sequencing; and the mortality was analyzed by survival analysis. Results: Intestinal I/R disturbed the process of IgA CSR, and then caused severe disruptions of IgA production and microbiota in the gut. TGF-β1 significantly increased the activation biomarkers of IgA CSR (Fig. 1) and rectified the imbalance of IgA+ and IgM+ B cells in both the peyer's patches and lamina propria, and therefore enhanced gut IgA synthesis and bacteria-binding capacity (Fig. 2A-B). Meanwhile, induction of IgA CSR by TGF-β1 relieved the alterations of gut bacterial richness, diversity and compositions following intestinal I/R (Fig. 2C). Further, the mortality of mice was dramatically reduced. And SB-431542 diminished almost all the protective effects of TGF-β1 on I/R injury. Conclusions: The inhibition of IgA CSR was involved in the pathogenesis of intestinal I/R injury. TGF-β1 improved IgA dysfunction and enteric dysbacteriosis caused by intestinal I/R partly by increasing IgA generation and bacteriabinding capacity via inducing gut IgA CSR.

Mo2023 Induction of Immunoglobulin a Class Switch Recombination by Transforming Growth Factor-β1 Improves Enteric Immunoglobulin a Dysfunction and Dysbacteriosis Following Intestinal Ischemia/Reperfusion in Mice

Objective: Intestinal ischemia/reperfusion (I/R) frequently occurs after major surgery, various types of shock and severe trauma, and it is associated with a high morbidity and mortality in the critical clinical settings. Intestinal I/R results in the injury of intestinal mucosal immunity and gut bacterial communities, however, little is known about the mechanisms and corresponding therapy for these damages. Immunoglobulin (Ig) A class switch recombination (CSR) plays a major role in gut IgA synthesis, and transforming growth factor (TGF)-β1 can potently induce other Ig isotypes CSR to IgA. Here, we aimed to investigate the effect of TGF-β1 on gut IgA generation and microbiota after intestinal I/R attack, and explore the underlying mechanisms. Methods: The 8-10 weeks Balb/c mice were randomly allocated into 5 groups. In the Sham group, the mice underwent laparotomy without occlusion of the superior mesenteric artery (SMA); whereas, the SMA was clamped for 1 hour in the Injury group; the mice of the TGF group received intravenous infusion of recombinant TGFβ1 before ischemia. In addition, SB-431542, a specific inhibitor of TGF-β receptor I/II, was administered alone (SB group) in intestinal ischemic mice or prior to TGF-β1 (TGF+SB group) to block its inductive effect on IgA CSR. The biomarkers of IgA CSR and IgA mRNA were detected by real-time PCR; the number of IgA+, IgM+ B cells and the percentage of bacteria coated with IgA were detected by flow cytometry; sIgA concentration was detected by ELISA; gut bacterial communities were detected by high-throughput 16S rRNA gene sequencing; and the mortality was analyzed by survival analysis. Results: Intestinal I/R disturbed the process of IgA CSR, and then caused severe disruptions of IgA production and microbiota in the gut. TGF-β1 significantly increased the activation biomarkers of IgA CSR (Fig. 1) and rectified the imbalance of IgA+ and IgM+ B cells in both the peyer's patches and lamina propria, and therefore enhanced gut IgA synthesis and bacteria-binding capacity (Fig. 2A-B). Meanwhile, induction of IgA CSR by TGF-β1 relieved the alterations of gut bacterial richness, diversity and compositions following intestinal I/R (Fig. 2C). Further, the mortality of mice was dramatically reduced. And SB-431542 diminished almost all the protective effects of TGF-β1 on I/R injury. Conclusions: The inhibition of IgA CSR was involved in the pathogenesis of intestinal I/R injury. TGF-β1 improved IgA dysfunction and enteric dysbacteriosis caused by intestinal I/R partly by increasing IgA generation and bacteriabinding capacity via inducing gut IgA CSR.

Editorial introductions

Editorial introductions

2066741 Surgical Critical Care and Ultrasound Training: Changing the Paradigm

The ideal method to train physicians in point of care ultrasound (POCUS) remains unclear. In surgical critical care, there is no standard. The training for Fellows at the Shock Trauma center (STC) includes a one month rotation in the Critical Care Ultrasound Program (CCUP), with an emphasis on US for trauma and hemodynamic echocardiography. Noting gaps in our training, we have modernized our training pathway and aim to validate it against historical means. Outgoing Critical Care Fellows from the 2013-2014 year group were tested in the areas of US knowledge, image interpretation, acquisition and technical skills. FAST, lung, cardiac, vascular, and US physics were tested. Confidence was also evaluated. Incoming fellows completed an identical testing algorithm prior to the academic year and again after taking ‘The Leading Edge,’ a one day ultrasound introduction course. Fellows have continued assessments quarterly as the new algorithm is validated. Eleven outgoing and 30 incoming fellows (Surgical and Medical) comprised the study group (n=41). 59% were surgeons. Pre-identified training gaps included image interpretation, advanced cardiac imaging, and lung ultrasound. Knowledge and skills scores were significantly less in both incoming fellows groups than the OF group. Image interpretation was not different amongst the groups. After a one day course, incoming fellows skills significantly increased from initial testing (p=0.007, 0.0001 respectively), and approached skills of the OF group. Notably, after the one day course there continued to be a significant difference in the post scores between the ISF and IMF (p=0.0029). Knowledge gaps in our current curriculum prompted a change in training, which remains to be validated. Preliminary results reveal that the one day and one month courses led to equivalent skills and knowledge for Critical Care fellows. A significant difference existed amongst those from a medical background regarding the FAST exams. The prior training led to improved confidence and self-reported competence in all other categories amongst OF group. Long term retention of knowledge and skills remains to be seen, and we have ongoing data collection directed at answering this question.

656

1University of Maryland Medical Center R Adams Cowley Shock Trauma Center, Baltimore, MD 2University of Maryland School of Medicine, Baltimore, MD 3University of Maryland Medical Center, Baltimore, MD

Predictors of Flap and Limb Salvage Failure in Trauma Reconstruction

PURPOSE: Free and soft tissue transfers are an important part of military and civilian extremity reconstruction after trauma. However, most outcomes research is based on relatively small series because devastating soft tissue loss in civilian trauma is uncommon. Outcomes between military and civilian institutions are similar and can be compared across patient populations. The purpose of this study is to determine whether there are any predictors of flap and limb salvage failure to help guide extremity reconstruction. METHODS: This is a multi-institution retrospective review of patients treated with tissue transfer for extremity trauma at R Adams Cowley Shock Trauma Center (STC) and Walter Reed National Military Medical Center (WRNMMC) between 2005 and 2012. RESULTS: From 2005 to 2012, 610 tissue transfers were performed for extremity trauma, 359 at WRNMMC and 251 at STC. Half of these flaps were free tissue transfers. Patients were mostly male (91%) aged 15 to 81 years (mean 31, SD 12) with an injury severity score of 1 to 57 (mean 18, SD 10). Mechanism of injury (MOI) included blast (n=270), blunt (n=261), and penetrating (n=30). Flap failure occurred in 56 flaps (10%) and failed limb salvage resulting in amputation occurred after 79 flaps (14%). Using univariate analysis, there were no independent predictors of flap failure. Using multivariate analysis, there were also no independent predictors of flap failure. However, proximal vascular injury, free flaps, and flap failure were predictors of amputation (Table 1).Table 1: Table 1.CONCLUSIONS: While there were no independent predictors of flap failure, the presence of proximal vascular injury, use of a free flap, and flap failure were predictors of amputation. These variables also portend a greater need for amputation before attempted reconstruction. The decision to attempt limb salvage in a patient with these characteristics should be carefully considered because the likelihood of late amputation is significantly higher.

Admission Red Cell Distribution Width: A Novel Predictor of Massive Transfusion after Injury

Admission red cell distribution width (aRDW) has been shown to predict mortality in trauma patients by an unclear mechanism. It has been speculated that aRDW is a marker of chronic health status, but elevated RDW may also reflect recent hemorrhage. We hypothesized that aRDW is a predictor of major hemorrhage in trauma patients. Shock trauma patients at a Level I trauma center over 6.5 years were evaluated. Patients were stratified by aRDW quintile (Q1: less than 13%, Q2: 13.1 to 13.5%, Q3: 13.6 to 14.0%, Q4: 14.1 to 14.9%, Q5: 15.0% or greater). Massive transfusion (MT) was defined as 10 or more packed red blood cells in the first 24 hours. From multiple logistic regression, odds ratios with 95 per cent confidence intervals (CIs) were determined to evaluate the association between aRDW quintile and MT. Three thousand nine hundred ninety-four met study criteria. Overall MT incidence was 10 per cent and in-hospital mortality was 17 per cent. MT and mortality increased in a stepwise fashion by aRDW quintile (P < 0.0001). From logistic regression, a threefold increased odds of MT was associated with aRDW Q4 (CI, 1.81 to 4.92), and a 3.5-fold increased odds of MT was associated with aRDW Q5 (CI, 2.70 to 5.83). aRDW independently predicted MT, suggesting that elevated aRDW is an indicator of major hemorrhage in trauma patients. The association between aRDW and mortality in trauma patients may be explained by acute hemorrhage rather than chronic health status.

Cervical spine injury from gunshot wounds.

Gunshot wounds (GSWs) to the cervical spine have been examined in a limited number of case series, and operative management of this traumatic disease has been sparsely discussed. The current literature supports and the authors hypothesize that patients without neurological deficit need neither surgical fusion nor decompression. Patients with GSWs and neurological deficits, however, pose a greater management challenge. The authors have compiled the experience of the R Adams Cowley Shock Trauma Center in Baltimore, Maryland, over the past 12 years, creating the largest series of such injuries, with a total number of 40 civilian patients needing neurosurgical evaluation. The current analysis examines presenting bone injury, surgical indication, presenting neurological examination, and neurological outcome. In this study, the authors characterize the incidence, severity, and recovery potential of cervical GSWs. The rate of unstable fractures requiring surgical intervention is documented. A detailed discussion of surgical indications with a treatment algorithm for cervical instability is offered. A total of 144 cervical GSWs were retrospectively reviewed. Of these injuries, 40 had documented neurological deficits. No neurosurgical consultation was requested for patients without deficit. Epidemiological and clinical information was collected on patients with neurological deficit, including age, sex, timing, indication, type of surgery, initial examination after resuscitation, follow-up examination, and imaging data. Twenty-eight patients (70%) presented with complete neurological deficits and 12 patients (30%) presented with incomplete injuries. Fourteen (35%) of the 40 patients underwent neurosurgical intervention. Twelve patients (30%) required intervention for cervical instability. Seven patients required internal fixation involving 4 anterior fusions, 2 posterior fusions, and 1 combined approach. Five patients were managed with halo immobilization. Two patients underwent decompression alone for neurological deterioration and persistent compressive injury, both of whom experienced marked neurological recovery. Follow-up was obtained in 92% of cases. Three patients undergoing stabilization converted at least 1 American Spinal Injury Association (ASIA) Impairment Scale (AIS) grade and the remaining operative cases experienced small ASIA motor score improvement. Eighteen patients underwent inpatient MRI. No patient suffered complications or neurological deterioration related to retained metal. Three of 28 patients presenting with AIS Grade A improved to Grade B. For those 12 patients with incomplete injury, 1 improved from AIS Grade C to D, and 3 improved from Grade D to E. Spinal cord injury from GSWs often results in severe neurological deficits. In this series, 30% of these patients with deficits required intervention for instability. This is the first series that thoroughly documents AIS improvement in this patient population. Adherence to the proposed treatment algorithm may optimize neurological outcome and spine stability.

Preface

This year marks the 75th anniversary of the introduction to modern surgery of the revolutionary nail developed by Prof G. Kuntscher. His intuitions and studies as well as his techniques of closed intramedullary (IM) nailing of long bone fractures, continue to remain a pivotal cornerstone in orthopedic culture and practice. In Italy in the early 80s, the widespread use of IM nailing for mid-shaft femur or tibia fractures was relegated to major academic hospitals. The Rizzoli Institute in Bologna that I attended as an orthopedic resident was one of them, where innovative surgeons such as L. Gui and M. Campanacci were practicing. Bob D’ Ambrosia from New Orleans was always fascinated and interested with new techniques or implants. In the mid 80s he took me to Strasbourg, France to observe firsthand the results of the modified Kuntscher nail that Arsene Grosse had developed, the G-K nail. Subsequently, I exchanged Ilizarov’s know-how with nailing technique pearls in Memphis with Charlie Taylor, of the closed-section Russell-Taylor nail. Then I had the opportunity to learn the tip and tricks of IM nailing directly from the TIO Editor-in-Chief, Bruce Browner, in Houston, in the late 80s, working at Hermann Hospital. Dr Browner was introduced to the system by “Sig” Hansen from Seattle and subsequently mastered his experience at Shock Trauma in Baltimore with colleagues such as Brumback, Burgess, and Poka. Thus, not only I learned from the masters, but I have been a first-line spectator of historical changes in intramedullary stabilization of long bone fracture with reamed nails. Intramedullary nailing, truly one of my passions in orthopedic traumatology, remains a challenging art, an act of surgery that is performed daily on thousands of individuals all over the globe and where no single fracture is identical to the other. Major successions of changes and improvements have been made in nail design, metallurgy, and radiographic imaging. Still, preoperative planning, positioning of the patient and selection of treatment options continue to remain of paramount importance. This issue of Techniques in Orthopaedics contains the first of two parts dedicated to “Updates on Intramedullary Nailing.” I have selected some of the most comprehensive new aspects of intramedullary nailing, in traumatology as well as in reconstructive surgery. An international faculty shares it expertise, presenting new management approaches to help understanding and solving old problems, from limb lengthening to stabilization of femur, tibia, and femoral neck fractures. Articles that discuss up-to-date clinical evidence of compartment syndrome as well as original improved contemporary technical optional approach for tibia fractures are included. Contributions from Europe in the field of antibiotic-coated implants as well as the latest on lengthening over a nail are presented. A major thank you goes to Bruce Browner, who never ceases to impress me with his extraordinary, contagious enthusiasm about new projects. I hope that I have been able to pass it myself to some other young orthopedic trauma surgeon. This two-part TIO series is dedicated to all those whom I have lost and in particular to Mrs Florence L. Nathan: without her I would have not been where I am and a lot might have not been achieved.

Damage control strategies in the management of acute injury.

Traumatic injury is the leading cause of death worldwide. The rapid evaluation and correction of injuries in these patients is paramount to preventing uncontrolled decompensation and death. Damage control strategies are a compendium of techniques refined over decades of surgical care that focus on the rapid correction of deranged physiology, control of contamination and blood loss, and resuscitation of critical patients. Damage control resuscitation (DCR) focuses on the replacement of lost blood volume in a manner mimicking whole blood, control of crystalloid administration, and permissive hypotension. Damage control laparotomy controls gastrointestinal contamination and bleeding in the operative suite, allowing rapid egress to the intensive care unit for ongoing resuscitation. Pelvic packing, an adjunct to DCR, provides a means to control hemorrhage from severe pelvic fractures. Temporary vascular shunts restore perfusion, while resuscitation and reconstruction are ongoing. Taken together, these strategies provide the trauma surgeon with a powerful arsenal to preserve life in the transition from injury to the shock trauma room to the intensive care unit.

Gerinnungsmanagement bei Polytrauma mit Hilfe viskoelastischer Tests

Exsanguination represents the most common and potentially preventable cause of death in major trauma patients. Rapid surgical intervention coupled with an early and aggressive hemostatic therapy not only results in survival benefits of coagulopathic trauma patients, but also reduces the incidence of complications and costs. Standard coagulation tests are not suitable to adequately characterize the complexity of trauma-induced coagulopathy (TIC). This fact has led to a renaissance of viscoelastic tests, such as rotational thromboelastometry (ROTEM®) and thrombelastography (TEG®), which can be used as point-of-care monitors. In some trauma centers treatment algorithms have been developed, where hemostatic therapy is based on viscoelastic test results. Shock and tissue trauma activate profibrinolytic pathways which in turn result in premature dissolution of formed clots. Tranexamic acid rapidly and inexpensively blocks hyperfibrinolysis. ROTEM®/TEG® measurements revealed that diminished clot strength is associated with an increased bleeding tendency. Depending on the underlying cause, administration of fibrinogen concentrate and/or platelet concentrate administration improves clot firmness. Thrombin generation is initially less compromised and can be improved by the administration of plasma, prothrombin complex concentrate, or with restrictiveness by recombinant activated factorVII.