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Call for Abstracts Review – Trauma Home » Call for Abstracts Review – Trauma
Title of Paper: Decreasing the Incidence of Acute Kidney Injury in a Level 1 Trauma Center Abstract # 1 Presentation Objectives: Acute kidney injury (AKI) is a common complication in our trauma population. The purpose of this project is to identify possible reasons behind the high incidence of AKI in order to develop clinical care guidelines aimed at reducing this complication. Introduction: Acute kidney injury (AKI) is a common problem in critically ill patients and is associated with a significantly higher morbidity and mortality. In the trauma population, AKI can be caused by multiple factors and can manifest itself in a variety of ways ranging from a small increase in serum creatinine to acute, anuric renal failure requiring emergent renal replacement therapy. Despite advances in the management of critically ill trauma patients, the incidence of AKI remains high in our trauma population. The purpose of this study is to identify potential reasons behind the high incidence of AKI and to develop new clinical care guidelines designed to reduce this complication within our trauma patients. Methods: This was a retrospective chart review of all patients presenting to our Level 1 trauma center who subsequently developed AKI between July 1, 2015 and September 30, 2016. The Acute Kidney Injury Network (AKIN) criteria was used to determine which stage of AKI each patient reached. Data collected included patient demographics, intensive-care unit (ICU) and hospital length of stay (LOS), fluid requirements, the duration of renal replacement therapy, medications given, and other complications. Results: A total of 80 patients met inclusion criteria for this study and overall mortality was 42.5% (34/80). The majority of patients were male (82.5%, 66/80) and suffered from a blunt mechanism of trauma (72.5%, 58/80). Continuous renal replacement therapy (CRRT) was utilized in 43.8% (35/80) of all patients with an average duration of 8.5±16.3 days. A total of 45 patients (55%) progressed to stage 3 AKI, and 8 patients (10%) required hemodialysis after discharge. When considering hospital management, patients underwent an average of 3.1±3.2 trips to the operating room and received 200.3±196.6 mL of intravenous contrast. Fluid requirements within the first 24 hours were 6295.4±7463.3 mL and urine output was 1774.6±1307.6 mL. The most common medications given were piperacillin/tazobactam (46.3%, 37/80), vancomycin (80.0%, 64/80), and the combination of vancomycin and piperacillin/tazobactam (56.1%, 37/66). Sepsis (55%, 44/80) and pneumonia (48.8%, 39/80) were the two most common complications. Conclusion: AKI in the trauma population is a complex problem that not only affects in-patient mortality, but also leads to increased morbidity outside of the hospital as patients are at increased risk of developing chronic kidney disease and subsequent dialysis dependence. In our trauma patients, infectious complications and the administration of nephrotoxic medications appear to be contributing to the high incidence of AKI. The next step in this project is to design and implement new patient management protocols aimed at lowering the incidence of AKI. Multiple Choice Question for Self-Assessment Credit/Answer: What complication was most often seen in patients who developed AKI? A. Pulmonary embolus (PE) B. Sepsis C. Acute respiratory distress syndrome (ARDS) D. Surgical site infection Correct Answer: B
Title of Paper: Survival after severe acidosis in blunt trauma: A case report Abstract # 10 Presentation Objectives: Objectives: To demonstrate the utility of base deficit in the decision to initiate massive transfusion protocol and the need for emergency intervention by way of case presentation. Introduction: Base deficit has long been accepted as a measure of injury severity, possible need for intervention and marker of resuscitation. Patients with a higher base deficit have been shown to have higher mortality, longer hospital stays and need for massive transfusion. This case report demonstrates the utility of base deficit in the decision to initiate massive transfusion protocol and the need for emergency intervention in an unstable patient with a negative FAST Methods: This is a case based study performed at a single institution in a large urban community hospital. Results: : This is a 44 year old female who was involved in a motor vehicle accident. She was intubated on route by EMS for a GCS of 7. Her initial vitals included a HR in the 140’s. A left chest tube was placed for presumed pneumothorax. FAST was negative. She quickly became hypotensive and nonresponsive to blood products. On secondary survey, she had obvious left femur and humerus deformities. Her initial blood gas included a pH of 6.77 and a base deficit of -25. Massive transfusion protocol was initiated and she was taken to the operating room for exploration, in which a zone 2 hematoma was noted. Supraceliac control was achieved and a left nephrectomy, splenectomy and diaphragm repair was performed. The patient’s acidosis had largely corrected after MTP and she was transferred to the ICU post-operatively. Her course was complicated by a return to the operating room for bleeding and facial closure, pancreatic leak, anastomotic leak, wound dehiscence, and chyle leak. She continued to improve on the floor with wound care, parenteral nutrition and chest tube drainage. She was discharged home after a 3 week hospitalization. Conclusion: This case demonstrates the utility of base deficit as a marker of resuscitation, need for massive transfusion, marker of injury severity, and need for emergency intervention. Multiple Choice Question for Self-Assessment Credit/Answer: Base deficit has been shown to be an accepted measure of: A. Injury severity B. Adequacy of resuscitation C. Mortality D. All of the Above Correct Answer: D
Title of Paper: Successful Treatment of Massive Hemothorax with Class IV Shock using Aortography with Transcatheter Embolization of Actively Bleeding Posterior Left Intercostal Arteries after Penetrating Chest Trauma: An Case for the Hybrid OR. Abstract # 11 Presentation Objectives: Here, we report a case of penetrating trauma with massive hemothorax associated with class IV hemorrhagic shock that resulted primarily from proximal left posterior intercostal artery bleeding, which was successfully treated with transcatheter-based arterial embolization (TAE) after failure to stop the hemorrhage during the exploratory thoracotomy. Introduction: Hemothorax is a common complication after thoracic injury. Whether it’s due to blunt trauma or penetrating injury, the etiology of bleeding may vary. Although the hemorrhage is typically secondary to disruption of pleural surfaces and its vasculature, or damage to the lung parenchyma itself, intercostal bleeding as a source of major intrathoracic hemorrhage is, nevertheless, a rare cause of massive hemothorax. Selective transcatheter embolization provides a minimally invasive, highly accurate and acceptable alternative and/or adjunct to thoracic surgical modalities for treatment of intercostal arterial injury leading to hemorrhagic shock due to refractory intrathoracic hemorrhage. Methods: The patient was emergently taken to the operating room for thoracotomy and left chest exploration. He was found to have a left diaphragm injury, damaged lung parenchyma with no active bleeding, and ongoing massive hemorrhage from the left posterior chest. Despite multiple attempts to surgically stop the bleeding intraoperatively using various hemostatic interventions, he developed refractory class IV hemorrhagic shock with tachycardia to the 170’s and systolic blood pressures persistent in the 70’s in addition to hypoxia with saturations less than 80%. Results: Thoracic aortography was performed and revealed active bleeding from the left 7th posterior intercostal artery ~ 3 cm from the aorta. The bleeding arterial segment was embolized with coils along with the vessels immediately above and below together with the left phrenic artery, which was identified to have a small amount of active extravasation. The patient’s hemodynamics significantly stabilized. The patient was transferred to the surgical ICU for ongoing resuscitation and ventilator management with a satisfactory postoperative convalescence. Conclusion: Massive hemothorax from intercostal arterial bleeding is a rare complication after blunt trauma and penetrating injury4. It can be arduous to treat, especially when the origin is in areas of the chest that is difficult to access, such as the posterior hemithorax. Selective, catheterbased embolization techniques provide a minimally invasive, highly accurate and acceptable alternative and/or adjunct to surgical modalities of therapy. The literature detailing this approach is limited to case reports and observational studies, the majority were due to blunt trauma. The presence of a hybrid operating room makes this approach a reasonable and feasible alternative to surgical intervention altogether or, at least, decrease the incidents where a disabling procedure is necessary to gain exposure. More research and studies might be needed to assess and confirm Multiple Choice Question for Self-Assessment Credit/Answer: All theses approached have been described in the literature to control intercostal bleeding from the posterior thoracic cavity except. A. damage control thoracotomy B. transcatheter-based arterial embolization (TAE) C. Hemostatic agents D. Clamshell thoracotomy Correct Answer: D
Title of Paper: Acute Aortic Occlusion due to Thoracic Vertebral Subluxation after Blunt Chest Trauma Abstract # 12 Presentation Objectives: The case presented highlights a rare case of traumatic thoracic aortic occlusion due to vertebral subluxation and subsequent acute mesenteric ischemia and lower extremity paralysis Introduction: Acute thoracic aortic occlusion from vertebral subluxation is a very rare and emergent vascular event . These patients have to be managed in an efficient manner to achieve the best outcomes. Aortography is important to the diagnosis and has traditionally been recommended to be completed prior to surgery. Several surgical options exist based on stability: endovascular, ECMO, and axillobifemoral bypass. Even with aggressive surgical management and postoperative care, these patients tend to have uncertain, complicated postoperative courses. Methods: Patient was a 16 year old male who was involved in a motorcycle versus truck crash with acute mesenteric ischemia with complete bowel necrosis due to traumatic proximal aortic occlusion from thoracic vertebral subluxation following this high energy trauma. The vascular surgery team subsequently intervened and performed a femoral cut down and aortogram, which showed a truncation of contrast in the aorta at the level of T10. The decision was made to perform an axillo-bifemoral bypass anastomosis to restore flow to the mesentery and lower extremities. However, at this point, the bowel was re-inspected and noted to be dark and dusky consistent with mesenteric infarction. Spy angiography confirmed there was no arterial supply to the viscera. Thus, the decision was made to abort any attempt at surgical revascularization by the vascular surgery team as the injury was deemed to be catastrophic. Fatalities from traumatic aortic injury have been quoted as high as 30%. In the case presented, the aorta was tethered from the displaced thoracic vertebral fracture leading to aortic occlusion. Due to the mechanism and severity, the catheter from the aortogram was unable to be passed through the thoracic aorta at the level of occlusion leading ultimately to the patient’s demis Results: Complications one must monitor for are neurological injuries and acute mesenteric ischemia (AMI ). There have been several methods described as treatment options: endovascular, ECMO, and axillo-bifemoral bypass. Even with these options, treatment becomes very challenging in the unstable polytraumatic patient. Conclusion: In conclusion, the case presented highlights a rare clinical condition of traumatic thoracic aortic occlusion due to vertebral subluxation and subsequent acute mesenteric ischemia and lower extremity paralysis. Literature for similar cases is currently very scarce and definitive treatment in the unstable trauma patient is difficult Multiple Choice Question for Self-Assessment Credit/Answer: What is the incidence of aortic trauma ranges out of all major arterial injuries? A. 1% to 9% B. 20-30% C. 15-30% D. 0.1-1% Correct Answer: A
Title of Paper: INSTITUTIONAL REVIEW OF LONGTERM POST-OPERATIVE HARDWARE COMPLICATIONS AFTER OPEN RIB FIXATION Abstract # 15 Presentation Objectives: To investigate the longterm sequelae of rib plating on the bony thorax. Introduction: Rib fractures after chest wall trauma are a common injury; however, they carry a significant associated morbidity and mortality. Rib plating as definitive treatment is gaining popularity for blunt or penetrating injury. As this treatment methodology continues to evolve and become widely accepted, there exists limited literature on the longterm sequelae of this intervention – specifically incidences of periprosthetic fractures, hardware displacement or migration, heterotypic ossifications or spurring, or nonunion. Controversy exists in the Orthopedic literature regarding the necessity of routine explantation after plate fixation due to the concerns of the aforementioned. We hypothesis that at one-year follow up, there are no complications associated with hardware failure or malfunction. Methods: With IRB approval, we performed a retrospective review of post-operative pain radiograph obtained after open rib fixation. Rib fixation was performed using either the Synthes MatrixRIB® Fixation System, RibLoc® Rib Fracture Plating System, BioMet RibFix Blu® System, or KLS Martin IXOS® Radius Plate System. We reviewed plain film radiography one-year or later after fixation to evaluate for hardware complications. Results: A total of 153 patients were reviewed who underwent open rib fixation at our institution from April 2009 to July 2017. Rib fixation was performed using Synthes (N=146), RibLoc (N=12), BioMet (N=3), KLS (N=1). Nine patients in our review underwent bilateral open rib fixation. Two cases required hardware explantation due to infection. Six of 153 patients had repeat chest wall trauma after undergoing fixation and none were discovered to have periprosthetic fractures or hardware displacement (average time to repeat trauma was 2.3years). Forty-five of the 120 patients one year or more out from rib fixation had plain radiographs available for review; average time of plain radiograph 1.6 years (min=1.0, max=7.6). There were zero cases identified with any longterm unwanted skeletal issues at one-year follow up. Conclusion: Rib fixation is becoming a more widely accepted treatment methodology for chest wall trauma. Advantages in outcome improvement is an area of continued research. Our review suggests routine hardware explantation is not necessary after rib fixation for chest wall trauma, as patients with implanted rib plating systems for osteosynthesis appear to have no unwanted or longterm sequelae. Multiple Choice Question for Self-Assessment Credit/Answer: Absolute indications for hardware removal include: A. Soft tissue irritation by prominent metal B. Cartilage damage by intra-articular screws C. Infection D. All of the above Correct Answer: D
Title of Paper: THE IMPACT OF HEMODYNAMIC TRANSESOPHAGEAL ECHOCARDIOGRAPHY ON ACUTE KIDNEY INJURY MANAGEMENT AND USE OF CONTINUOUS RENAL REPLACEMENT THERAPY IN TRAUMA Abstract # 16 Presentation Objectives: To analyze the effects of using hTEE as an objective measurement of resuscitation on the management of acute kidney injuries and the use of continuous renal replacement therapy in trauma patients. Introduction: Fluid resuscitation in critically ill trauma patients is an often precarious task that is fraught with complications. One of the many consequences of imprecise fluid management is acute renal injury(AKI) after underestimating resuscitation needs. When AKI progresses to where renal insufficiency is deemed deleterious to patient survival, Continuous renal replacement therapy (CRRT) is implanted as a salvage maneuver but it is not without risks, complications and expense. Hemodynamic transesophageal echocardiography (hTEE) is a valuable resource that can provide objective data to aid decisions in resuscitation. We hypothesize that the risk of AKI progressing to CRRT need can be decreased with the use of hTEE. Methods: We retrospectively reviewed 2,413 patients that were admitted to a level 1 trauma ICU and placed on CRRT between 2009 and 2015. There were 23 trauma patients that were placed on CRRT prior to hTEE initiation in 2013. 13 trauma patients were placed on CRRT after the initiation of hTEE. The groups were then compared with respect to their serum creatinine and AKIN score prior to starting CRRT. We then reviewed 59-trauma patients whose resuscitation was aided with the use of hTEE between 2013 and 2014. These patients were then compared to the pre-hTEE group that received CRRT with respect to their serum creatinine and AKIN score. Results: Patients were started on CRRT at an average Cr of 2.7, and had an average AKIN score of 1.6 prior to initiation of CRRT. After hTEE was initiated CRRT was started at an average Cr of 3.54, and an average AKIN score of 2.61. Of the 59 patients that were evaluated with hTEE there was 13 patients that had an AKI. 10 of these patients had a Cr greater than 2.7 and were not started on CRRT. Conclusion: Using hTEE as an imaging modality to guide complex resuscitations is a valuable tool to allow for more tailored fluid delivery. By using hTEE the use of CRRT can be decreased as AKIs can be managed with more precise fluid management. Multiple Choice Question for Self-Assessment Credit/Answer: While assessing a hypotensive patients fluid status on hTEE a SVC collapsibility index can be obtained to assess for fluid responsiveness. Which of the following SVC collapsibility index indicates potential fluid responsiveness? A. .15 or greater B. .24 or greater C. .36 or greater D. .45 or greater Correct Answer: C
Title of Paper: Celiac Artery Injury in the Setting of Blunt Abdominal Trauma: A Rare Cause of a Common Injury Abstract # 2 Presentation Objectives: Discuss the diagnosis and management of celiac artery dissection due to blunt trauma Introduction: Penetrating abdominal injuries are by far the most common causes of traumatic abdominal vascular injuries, including the visceral blood vessels, and account for 90% to 95% of these injuries. Blunt abdominal vascular trauma occurs less commonly, with an incidence of approximately 5% to 10%. Our literature review found only 10 newly reported cases of blunt traumatic celiac injury reported since 1998. Methods: None- this was a case study Results: See conclusion Conclusion: In this case presentation, the celiac artery was injured but surgical management was initially withheld due to the patient having a patent superior mesenteric artery. We believe that in the setting of blunt trauma, sacrificing the celiac artery is still viable as long as organ perfusion can be maintained. Due to the rarity of this injury in a blunt trauma setting, there is not much literature available on the subject. A meta-analysis review of traumatic blunt celiac artery dissections should be done to better analyze treatment methods and determine the indications for laparotomy in such cases. Multiple Choice Question for Self-Assessment Credit/Answer: Which of the following is NOT a direct branch of the Celiac Trunk? A. Left Gastric Artery B. Gastroduodenal Artery C. Splenic Artery D. Common Hepatic Artery Correct Answer: B
Title of Paper: Weight-Adjusted versus Standard-Dose Enoxaparin for Venous Thromboembolism Prophylaxis in Trauma Patients Abstract # 3 Presentation Objectives: Discuss venous thromboembolism prophylaxis in trauma patients, including mild-tt=o-moderate traumatic brain injury patients, with standard dose enoxaparin and weight-adjusted dosing of enoxaparin Introduction: Traumatic injury is a major risk factor for the development of venous thromboembolic events (VTE), and is associated with increased bleeding risk. VTEs increase length of stay, cost and are associated with elevated morbidity and mortality in trauma patients. Optimal VTE pharmacologic prophylaxis in trauma patients remains unknown. Recent studies suggest that standard dosing of enoxaparin (30mg SQ Q12hrs) leads to sub-therapeutic levels of anti-Factor Xa, which are associated with increased risk for the development of VTE. We aimed to determine the efficiency of standard-dose versus weight-adjusted dose of enoxaparin. Methods: As a quality improvement measure for medication use evaluation we conducted a retrospective registry review and data analysis. Patients with an initial trauma admission from January-December 2016 who received standard-dose (STD) or weight-adjusted (WT) enoxaparin were included. Patients