Objectives:
Novel coronavirus-19 (COVID-19) has led to over 6 million fatalities globally. An estimated 75% of COVID-19 patients who require critical care admission develop acute respiratory distress ...syndrome (ARDS) needing invasive mechanical ventilation (IMV) and/or extracorporeal membrane oxygenation (ECMO). Due to prolonged ventilation requirements, these patients often also require tracheostomy. We performed a review of clinical outcomes in COVID-19 patients on ECMO at a high-volume tertiary care center in Hamilton, Ontario, Canada.
Methodology:
We performed a retrospective case series, including 24 adult patients diagnosed with COVID-19 who required IMV, veno-venous (ECMO), and tracheostomy. All patients were included from April to December 2021. We extracted demographic and clinical variables pertaining to the tracheostomy procedure and ECMO therapy. We performed descriptive statistical analyses. This study was approved by the Hamilton Integrated Research Ethics Board (14217-C).
Results:
We included 24 consecutive patients with COVID-19 who required tracheostomy while undergoing ECMO therapy. The mean age was 49.4 years standard deviation (SD): 7.33, the majority of patients were male (75%), with mean body mass index of 32 (SD: 8.81). Overall mortality rate was 33.3%. Percutaneous tracheostomy was performed most frequently (83.3%) and, similar to open tracheostomy, was associated with a low rate of perioperative bleeding complications. Within surviving patients, the mean time to IMV weaning and decannulation was 60.2 (SD: 24.6) and 49.4 days (SD: 21.8), respectively.
Conclusion:
Percutaneous tracheostomy appears to be safe in COVID-19 patients on ECMO and holding anticoagulation 24 hours prior to and after tracheostomy may limit bleeding events in these patients.
Severe pelvic trauma is a challenging condition. The pelvis can create multifocal hemorrhage that is not easily compressible nor managed by traditional surgical methods such as tying off a blood ...vessel or removing an organ. Its treatment often requires reapproximation of bony structures, damage control resuscitation, assessment for associated injuries, and triage of investigations, as well as multimodality hemorrhage control (external fixation, preperitoneal packing, angioembolization, REBOA resuscitative endovascular balloon occlusion of the aorta) by multidisciplinary trauma specialists (general surgeons, orthopedic surgeons, endovascular surgeons/interventional radiologists). This article explores this complex clinical problem and provides a practical approach to its management.
Surgical education is evolving under the dual pressures of an enlarging body of knowledge required during residency and mounting work-hour restrictions. Changes in surgical residency training need to ...be based on available educational models and research to ensure successful training of surgeons. Experiential learning theory, developed by David Kolb, demonstrates the importance of individual learning styles in improving learning. This study helps elucidate the way in which medical students, surgical residents, and surgical faculty learn.
The Kolb Learning Style Inventory, which divides individual learning styles into Accommodating, Diverging, Converging, and Assimilating categories, was administered to the second year undergraduate medical students, general surgery resident body, and general surgery faculty at the University of Alberta.
A total of 241 faculty, residents, and students were surveyed with an overall response rate of 73%. The predominant learning style of the medical students was assimilating and this was statistically significant (p < 0.03) from the converging learning style found in the residents and faculty. The predominant learning styles of the residents and faculty were convergent and accommodative, with no statistically significant differences between the residents and the faculty.
We conclude that medical students have a significantly different learning style from general surgical trainees and general surgeons. This has important implications in the education of general surgery residents.
Background Medical error is common in crises, and the majority of observed errors are nontechnical in nature. The long-term impact of teaching crisis nontechnical skills to residents has not been ...evaluated. The objective of this study was to determine the effect of simulation-based teaching of crisis nontechnical skills compared to controls one year after initial teaching. Methods This was a prospective study using both historical controls and a before-and-after methodology to evaluate the effect of a high-fidelity simulation curriculum that used crisis resource management principles to teach nontechnical skills. Postgraduate year 2 and 3 residents were invited to take part in a prospective training course over 2 years. The primary outcome was leader performance evaluated by expert raters using the previously validated 7-point Ottawa Global Rating Scale. Results Overall, 23 residents performed 30 simulations over the 2 years with the intervention group of 7 residents being assessed in both years. After adjustment, the postgraduate year 3 intervention group who received training the previous year had significantly higher overall performance scores than all postgraduate year 2 scores (1.09 95% confidence interval 0.70–1.47, P < .001) and the historical postgraduate year 3 cohort who received no prior training (1.20, 95% confidence interval 0.37–2.03, P = .005). There was no decay of skills noted over the course of the study. Conclusion Postgraduate year 3 residents who had prior training had significantly improved crisis performance compared to historical postgraduate year 3 controls and untrained postgraduate year 2 residents. There were no significant differences between the crisis performance of postgraduate year 2 residents and the untrained postgraduate year 3 controls. This confirms the beneficial effect and long-term retention after crisis nontechnical skill training.
Many patients who sustain penetrating abdominal trauma can be managed nonoperatively. The Eastern Association for the Surgery of Trauma (EAST) has published guidelines on selective nonoperative ...management (SNOM), and this approach is well established. The purpose of this study is to assess the management of penetrating abdominal trauma, including the selection of patients for SNOM and the use of this approach, at a Canadian level 1 trauma centre.
We used the Hamilton Health Sciences trauma registry to compile data on patients aged 16 years and older who sustained penetrating abdominal trauma from Jan. 1, 2011, to Dec. 31, 2017. Hemodynamically stable, nonperitonitic patients without evisceration or impalement were considered potentially eligible for SNOM. We compared the SNOM group of patients with the immediate operative (IOR) group. Our primary outcome was SNOM failure; secondary outcomes included length of stay, repeat imaging, computed tomography (CT) protocol, laparoscopy in left thoracoabdominal trauma, and nontherapeutic and negative laparotomies.
We included 191 patients with penetrating abdominal trauma; 123 underwent SNOM and 68 underwent IOR. Of the 68 patients in the IOR group, 4 underwent nontherapeutic laparotomies. Of the 123 patients in the SNOM group, this approach failed in 7 (5.7%). Patients who were successfully managed with SNOM had an average length of stay of 25.4 hours (7.9–43.0 h), with no repeat imaging in 34/35 (97.1%). Only 5 of the 47 patients with flank/back wounds had a CT scan that included luminal contrast. Only 3 of the 58 patients with left thoracoabdominal wounds underwent same-admission laparoscopy, all demonstrating diaphragmatic defects.
Our study demonstrates a high rate of compliance with the EAST SNOM guidelines, including minimal failure rate of SNOM and an efficient use of resources as demonstrated by reduced length of stay and minimal use of reimaging. We identified 2 opportunities for improvement: improved use of luminal contrast CT in patients with flank/back wounds and improved use of diagnostic laparoscopy in patients with left thoracoabdominal wounds.
Pediatric craniocerebral gunshot injuries (CGIs) occur both in the context of accidental and intentional trauma. The incidence and physiology of pediatric CGIs merit reexamination of prognostic ...factors and treatment priorities. This study characterizes the current understanding of mortality and prognostic factors in this patient population.
A systematic search was conducted. Selection criteria included all studies published since 2000, which described civilian isolated CGIs in pediatric patients. Data were analyzed qualitatively and quantitatively to identify factors prognostic for the primary outcome of mortality. Secondary outcomes included functional outcome status, requirement for surgery, and injury complications. Study quality was assessed with the Newcastle-Ottawa Scale. This study was registered with PROSPERO (CRD42019134231).
Initial search revealed 349 unique studies. Forty underwent full text screening, and eight studies were included in the final synthesis. The overall mortality rate was 44.8%. Most CGIs occurred in older teenagers. Aggressive surgical treatment was recommended by one author, while remaining studies emphasized clinical judgment. Reported prognostic factors include initial Glasgow Coma Scale, pupil reactivity, involvement of multiple lobes or deep nuclei, and bihemispheric injuries. Reported complications from CGIs included seizure, meningitis, abscess, cerebrospinal fluid leak, bullet migration, focal neurological deficits, endocrine abnormalities, cognitive deficits, and neuropsychological deficits. The Glasgow Outcome Scale was the predominant measure of function and demonstrated a moderate recovery in 17.4% and a good recovery in 27.3% of patients.
This systematic review analyzed the existing evidence for prognostic factors in the context of pediatric CGIs. Significant long-term clinical improvement is possible with interventions including urgent surgical therapy. Fixed bilateral pupils and low initial Glasgow Coma Scale correlate with mortality but do not predict all patient outcomes. Patients younger than 15 years are underreported and may have differences in outcome. The literature on pediatric CGIs is limited and requires further characterization.
Systematic Review, level IV.
Trauma patients are at increased risk of venous thromboembolism (VTE), including deep venous thrombosis (DVT) and/or pulmonary embolism (PE). We conducted a systematic review and meta-analysis ...summarizing the association between prognostic factors and the occurrence of VTE following traumatic injury.
We searched the EMBASE and MEDLINE databases from inception to August 2023. We identified studies reporting confounding adjusted associations between patient, injury or post-injury care factors and risk of VTE. We performed meta-analyses of odds ratios (ORs) using the random effects method and assessed individual study risk of bias using the QUIPS tool.
We included 31 studies involving 1,981,946 patients. Studies were predominantly observational cohorts from North America. Factors with moderate or higher certainty of association with increased risk of VTE include older age, obesity, male sex, higher injury severity score, pelvic injury, lower extremity injury, spinal injury, delayed VTE prophylaxis, need for surgery and tranexamic acid use. After accounting for other important contributing prognostic variables, a delay in the delivery of appropriate pharmacologic prophylaxis for as little as 24 to 48 hours independently confers a clinically meaningful two-fold increase in incidence of VTE.
These findings highlight the contribution of patient predisposition, the importance of injury pattern, and the impact of potentially modifiable post-injury care on risk of VTE after traumatic injury. These factors should be incorporated into a risk stratification framework to individualize VTE risk assessment and support clinical and academic efforts reduce thromboembolic events among trauma patients.Study TypeSystematic Review & Meta-Analysis.
Level II.
We aimed to determine the outcomes and prognostic factors in pediatric craniocerebral gunshot injury (CGI) patients. Pediatric patients may have significantly different physiology, neuroplasticity, ...and clinical outcomes in CGI than adults. There is limited literature on this topic, mainly case reports and small case series.
We queried the National Trauma Data Bank for all pediatric CGI between 2014 and 2017. Patients were identified using International Classification of Diseases, Ninth Revision, codes. Demographic, emergency department, and clinical data were analyzed. Subgroup analysis was attempted for groups with Glasgow Coma Scale (GCS) scores of 9 to 15 and ages 0 to 8 years.
In a 3-year period, there were 209 pediatric patients (aged 0-18 years) presenting to American hospitals with signs of life. The overall mortality rate was 53.11%. A linear relationship was demonstrated showing a mortality rate of 79% by initial GCS in GCS score of 3, 56% in GCS scores of 4 to 8, 22% in GCS scores of 9 to 12, and 5% in GCS scores of 13 to 15. The youngest patients, aged 0 to 8 years, had dramatically better initial GCS and subsequently lower mortality rates. Regression analysis showed mortality benefit in the total population for intracranial pressure monitoring (odds ratio, 0.267) and craniotomy (odds ratio, 0.232).
This study uses the National Trauma Data Bank to quantify the prevalence of pediatric intracranial gunshot wounds, with the goal to determine risk factors for prognosis in this patient population. Significant effects on mortality for invasive interventions including intracranial pressure monitoring and craniotomy for all patients suggest low threshold for use of these procedures if there is any clinical concern. The presence of a 79% mortality rate in patients with GCS score of 3 on presentation suggests that as long as there is not a declared neurologic death, intracranial pressure monitoring and treatment measures including craniotomy should be considered by the consulting clinician.
Prognostic and epidemiological, level III.
Abstract Background Haemorrhage in peripheral vascular injuries may cause life-threatening exsanguination. Tourniquets are used extensively by the military, with increased interest in the civilian ...setting to prevent deaths. This is a retrospective study of trauma patients at two large Canadian trauma centres with arterial injury after isolated extremity trauma. We hypothesized that tourniquet use may decrease mortality rate and transfusion requirements if applied early. Methods The study group was all adult patients at two Level 1 Trauma Centres in two Canadian cities in Canada, who had arterial injuries from extremity trauma. The study period was from January 2001 to December 2010. We excluded patients with significant associated injuries. The intervention in this study was prehospital tourniquet use. The main outcome was in-hospital mortality. Secondary outcomes were length of stay, compartment syndrome, amputation, and blood product transfusion. Results 190 patients were included in the study, and only 4 patients had a prehospital tourniquet applied. They arrived directly from the scene of injury, had improvised tourniquets by police or bystanders, and showed a trend to be more hypotensive and acidotic. Four other patients had tourniquets applied in the trauma bay within 1 h of injury. There were no differences in age, sex, injury severity or physiologic presentation between patients who had an early tourniquet applied and those who died without a tourniquet. However, six patients died without a tourniquet, and all bled to death. Of the eight patients who had early tourniquets applied, none died. Conclusions Tourniquets may prevent exsanguination in the civilian setting for patients suffering either blunt or penetrating trauma to the extremity. Future studies will help determine the utility of deploying tourniquets in the civilian setting, given the rarity of exsanguinating haemorrhage from isolated extremity trauma in this setting.
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