Trauma: Lessons from the Military

Educational Objectives

The goal of this program is to improve the management of trauma patients. After hearing and assimilating this pro­gram, the clinician will be better able to:

Recognize signs that suggest a trauma patient requires a damage control (DC) procedure.

Describe recommended DC techniques for managing trauma patients with injuries in the liver, spleen, gastrointes­tinal tract, and pancreas.

Discuss how military experience may be applied in the civilian patient population.

Explain the importance of quality improvement efforts in the intensive care unit (ICU).

Describe effective ways to implement quality improvement strategies in the ICU.

Faculty Disclosure

In adherence to ACCME Standards for Commercial Support, Audio-Digest requires all faculty and members of the planning commit­tee to disclose relevant financial relationships within the past 12 months that might create any personal conflicts of interest. Any iden­tified conflicts were resolved to ensure that this educational activity promotes quality in health care and not a proprietary business or commercial interest. For this program, the following has been disclosed: Dr. Holcomb is on the Advisory Board for Novo Nordisk and is a consultant for HemCon Medical Technologies. Drs. Feliciano and DuBose and the planning committee reported nothing to disclose.

Acknowledgements

Dr. Feliciano was recorded at the 72nd annual course, Advances in Trauma and Critical Care Surgery, held June 4-6, 2008, in Minneapolis, MN, and presented by the University of Minnesota Medical School, Department of Surgery. Dr. Holcomb spoke at the Detroit Trauma Symposium, held November 6-7, 2008, in Detroit, MI, and presented by Detroit Receiving Hospital and Wayne State University School of Medicine. Dr. DuBose was recorded at the 15th An­nual USC Trauma/Critical Care Symposium, held May 12-13, 2008, in Pasadena, CA, and presented by the Keck School of Medicine of the University of Southern California and the Institute of Continuing Education for Nurses, Department of Nursing, Los Angeles County USC Medical Center. The Audio-Digest Foundation thanks the speakers and the sponsors for their cooperation in the production of this program.

Update on Damage Control Laparotomy

David V. Feliciano, MD, Professor of Surgery, Emory University School of Medicine, and Surgeon-in-Chief, Grady Memorial Hospital, Atlanta, GA

Introductory remarks: when patient presents with shock and is cold or acidotic, certain numerical values (eg, body temperature <34ºC) suggest surgeon should perform damage control (DC) surgery (DCS) rather than long defini­tive operation; most surgeons consider DC 3-step process that includes 1) limited initial operation, 2) good recov­ery and resuscitation in intensive care unit (ICU), and 3) re-exploration at 24 to 96 hr to complete repairs and, occasionally, to complete fascial closure

Thoracic DC: in past, patient bleeding from lacerations in lung treated by oversewing holes (approach now seen as suboptimal); today, surgeon can occasionally use linear stapler to close holes, and then do selective ligation of ves­sels (“good smart damage control”)

Abdominal DC: comparative look at 2 studies showed incidence of DCS for managing penetrating abdominal inju­ries increased from »7% in 1998 to »18% in 2003; currently, »1 in 5 abdominal trauma patients who undergoes lap­arotomy may actually require DCS

Techniques of abdominal DC

Liver: mattress sutures work well; unless extremely experienced, avoid hepatic resection; hepatotomy, selective li­gation, or resectional debridement, and omental packing; balloon catheter tamponade; vicryl mesh tamponade; perihepatic packing; need for DC based on patient’s physiologic state, not on size of anatomic injury

Spleen: techniques include suture splenorrhaphy; vicryl mesh tamponade and perisplenic packing

Gastrointestinal (GI) tract: 30% to 40% of patients with gunshot wounds have multiple small bowel injuries; op­tions include closing holes (eg, one-layer closure with 3-0 or 4-0 Prolene), isolating holes (tying off section of bowel with umbilical tape), and resecting holes (staples can save time) without anastomosis (delay until reop­eration); if patient has multiple pellet holes in jejunum, do jejunectomy (without anastomosis)

Colon: primary repair of injury possible in 90% to 93% of cases; in »10% of cases, where there is too much con­tami-nation or loss of wall, colectomy without anastomosis appropriate DC technique (safe to do anastomosis later, if it can be done within 3-5 days of initial operation)

Pancreaticoduodenal region: pancreatic defect that does not involve duct (fill with omentum); in cases in which py­loric exclusion indicated, reserve for reoperation; transection of pancreas near C-loop of duodenum (put pack over injury and drain under it, and revisit in 1-2 days; do distal resection at reoperation); patient with devascular­ized duodenum and macerated pancreas (do Whipple procedure at reoperation)

Abdominal arteries: celiac artery (can ligate artery for exposure or if injured); renal artery (nephrectomy at time of initial procedure or reoperation); superior mesenteric artery (SMA) common or external iliac (requires shunt; if speaker has to shunt iliac artery, he has patient return in £6 hr to protect lower extremity)

Abdominal veins: can ligate nearly every vein in abdomen (except for suprarenal or suprahepatic vena cava); many ways to manage transpelvic injuries (eg, free omental plug); retrohepatic vena cava (if patient not actively bleed­ing, do not operate; pack injury instead)

Open abdomen in trauma patients: reasons for leaving abdomen open after DCS  —  no time to close; patient has enlarged midgut; avoidance of abdominal compartment syndrome; reoperation necessary (eg, patients with perihe­patic or diffuse intra-abdominal packs)

Comments: options for removal of temporary silo and closure after DC in hemodynamically stable patient – vacuum assisted closure (VAC; most common); components closure of fascia; AlloDerm; absorbable mesh, delayed split-thickness skin graft

Abdominal DC and patient outcomes: 1997 study reported mortality rate of »50%; in 2006 study of 56 consecutive patients with DC laparotomy, mortality rate »27% (majority of patients readmitted for fistulas, hernia closure, or reconnection of bowel, but late mortality from readmissions »0%)

Lessons Learned from the Iraq Conflict

John B. Holcomb, MD, Professor of Surgery, Chief, Division of Acute Care Surgery, and Director, Center for Translational Injury Research, University of Texas Health Science Center, Houston

Data on military deaths: currently, »14% of soldiers die from wounds before reaching hospital; overall case fatality rate »50% lower than that in Vietnam; causes of death  —  recent study by speaker et al that reviewed causes of death among United States Special Operations Forces in Iraq found »80% of fatalities nonpreventable; among deaths classified as potentially preventable, »50% due to truncal hemorrhage

New medical practices adapted during recent military action: placement of ICU teams in theater of war; hypo­thermia prevention; use of Joint Theater Trauma System (JTTS) and Registry (JTTR); critical care air transport; tourniquets; hemostatic dressings; DC resuscitation; Tactical Combat Casualty Care

Data: medical interventions driven by data; JTTR currently has information on »30  000 casualties (majority battle in­juries); trauma injury and severity scores (TRISS) being used to look at observed deaths vs expected deaths; inter­ested in conducting near real-time analysis (as things change dramatically in battlefield)

Training: critically important; in civilian community, training for management of acute trauma includes courses such as advanced trauma life support (ATLS) and prehospital trauma life support (PHTLS); physicians trained to start management with, first, stabilization of airway with cervical spine protection, then stabilization of breathing, and after that, circulation with hemorrhage control (ABCs); in military environment, things handled differently; few blunt injuries (although many penetrating injuries) or cases involving drugs and alcohol; military physicians first stabilize circulation, then breathing, and then airway (CBA); physician in battlefield cannot carry as much equip­ment as can be carried in ambulance; training meets with operational realities, and results in very different guide­lines and policies

Research: improved trauma care one outcome of prolonged war; for past few years, research teams working in the­ater of battle, gathering data and turning data into publications and presentations; goal to transition information quickly to civilian world

Hypothermia: example of wounded Marine being flown over Iraq during winter; hypothermia leads to negative out­come (increased death rate) for both civilian and military trauma patients (wounding agents different, but physio­logic response almost exactly same); solutions for preventing hypothermia in battlefield  —  medical maintenance officer used hair dryer and cardboard box to create “bear hugger” device; Marines transported wounded soldiers in body bags with opening for face; eventually developed hypothermia prevention and management kit (includes warming blanket and hypothermia cap)

Blood transfusion: study by Borgman et al examined blood products given to soldiers with severe traumatic injuries who required massive transfusions; determined that plasma/red blood cell (RBC) ratio very important; more plasma associated with improved survival (in patients who received »1:1 ratio, overall mortality rate »19%); suggests that more plasma and less crystalloid should be given as primary resuscitative fluid (contradicts traditional teachings); speaker and others implemented this strategy in battlefield and saw improved survival; another study looking at 16 civilian level I trauma centers reported essentially same findings

Tourniquets: trauma physicians traditionally taught that tourniquets bad; speaker considers this “100% wrong”; ex­ample of soldier (double amputee) who survived because of tourniquets placed on his wounds by nonmedical per­sonnel; multiple tourniquets very common; many military-related injuries severe extremity injuries (civilian injury usually does not involve all 4 extremities, but not uncommon in war); study by Craig et al looked at 232 military patients who presented over 6 mo with extremity injuries; use of tourniquets resulted in significant improvement in patient survival (forthcoming study confirms finding); appears that significantly more lives saved through prehospi­tal use; very small (»1%) complication rate and no amputations associated with tourniquet use

Hemorrhage control: at start of war in Iraq, gauze sponge used to control bleeding on battlefield; worked well for mild or moderate but not for severe bleeding; in past few years, number of hemostatic dressings have become avail­able (all of which superior to gauze); guidelines of Tactical Combat Casualty Core (TCCC) recommend WoundStat and Combat Gauze; effective, no known complications, and relatively inexpensive

Selective nonoperative management of penetrating torso trauma: typical explosion patient has penetrating wounds from head to toe; thousands of cases in battlefield, and possible in future in civilian ED if improvised ex­plosive device (IED) detonated during terrorist attack; military physicians now obtaining computed tomography (CT) for these cases; if patient hemodynamically stable and CT showed no peritoneal penetration (or, in opinion of attending surgeon and radiologist, no damage to bowel or vessels), patient simply observed (none of these patients required laparotomy in next 7-10 days); previous teaching that all such patients require surgery; in fact, »50% do not need surgery

Keeping the Plane in the Air: Effect of a Quality Improvement Checklist

Joseph J. DuBose, MD, Clinical Instructor in Surgery, Division of Trauma and Critical Care, and Assistant Unit Chief, Trauma “A” Service, Keck School of Medicine of the University of Southern California, Los Angeles

Importance of quality improvement (QI): in health care  —preventable adverse medical events account for £98  000 deaths annually (eighth leading cause of death in United States; exceeds mortality attributable to motor vehicle ac­cidents); in ICU  —  improvements in care and prophylactic measures implemented in fragmented fashion; care complex and expensive

Ventilator-associated pneumonia (VAP): common in ICU; associated with increase in number of ventilator days, ICU length of stay (LOS), and hospital LOS; adds estimated cost of $50  000 to hospital trauma admission

VAP bundle: series of prophylactic measures to prevent VAP; elevation of head of bed; daily “sedation vacations” and assessment of readiness to extubate; prophylaxis against peptic ulcer disease and deep venous thrombosis

ICU daily quality rounds checklist (QRC): VAP bundle; invasive device evaluation; other ventilator-related pro­phylactic measures; glucose control parameters; daily measures (eg, code status; nutrition; antibiotics review); 22 data points/patient daily and 16 prophylactic measures; »2 min/patient to complete

Previously reported 3-mo pilot study: prospective “before-after” design; study assessed baseline compliance with prophylactic measures for 1-mo blinded phase, followed by 3 mo active implementation of use; each month’s utili­zation of QRC followed by multidisciplinary review; results  —  significantly improved compliance with VAP pre­vention measures; significant and sustained decrease in number of patients ventilated for prolonged period in ICU; decreases in mean monthly rates/10 000 device days of VAP (16.3 vs 8.9), central line infections (11.3 vs 5.8), and self-extubation (7.8 vs 2.2)

Study looking at 1 yr of QRC use: results  —  saw either sustainment of improvement or further increase in compli­ance with all VAP bundle measures; comparison of pre-implementation and post-QRC patient populations showed no statistically significant differences in any comparative parameters; other outcomes  —  no difference in mortality (or in GI hemorrhage, pulmonary embolism, or ICU or hospital LOS); effect of QRC on VAP  —  more ventilator days post-QRC, but fewer cases of VAP; this equated to decrease in VAP rate from 12.41 to 8.74/1000 device days; adjusted mean difference, 6.65; impact of compliance on VAP rates  —  compared patients with full vs partial VAP bundle compliance; no difference in mortality, but achieving full compliance associated with sta­tistically significant decrease in number of VAPs, ICU days, hospital days, and hospital charges; VAP rate with partial compliance 9.23/1000 device days vs 5.29 with full compliance

Suggested Reading

Asensio JA et al: Reliable variables in the exsanguinated patient which indicate damage control and predict outcome. Am J Surg 182:743, 2001; Barillo DJ et al: An emergency medical bag set for long-range aeromedical transportation. Am J Di­saster Med 3:79, 2008; Beekley AC et al: Prehospital tourniquet use in Operation Iraqi Freedom: effect on hemorrhage control and outcomes. J Trauma 64(2 Suppl):S28, 2008; Beekley AC et al: Selective nonoperative management of penetrat­ing torso injury from combat fragmentation wounds. J Trauma 64(2 Suppl):S108, 2008; Butler FK Jr et al: Tactical com­bat casualty care 2007: evolving concepts and battlefield experience. Mil Med 172(11 Suppl):1, 2007; Cocanour CS et al: Decreasing ventilator-associated pneumonia in a trauma ICU. J Trauma 61:122, 2006; DuBose JJ et al: Measurable out­comes of quality improvement in the trauma intensive care unit: the impact of a daily quality rounding checklist. J Trauma 64:22, 2008; Fabian TC: Damage control in trauma: laparotomy wound management acute to chronic. Surg Clin North Am 87:73, 2007; Gerhardt RT et al: Out-of-hospital combat casualty care in the current war in Iraq. Ann Emerg Med 53:169, 2009; Germanos S et al: Damage control surgery in the abdomen: an approach for the management of severe injured pa­tients. Int J Surg 6:246, 2008; Hess JR et al: Giving plasma at a 1:1 ratio with red cells in resuscitation: who might benefit? Transfusion 48:1763, 2008; Hess JR, Holcomb JB: Transfusion practice in military trauma. Transfus Med 18:143, 2008; Holcomb JB: Clinical outcomes from the war: introduction. J Trauma 64(2 Suppl):S1, 2008; Holcomb JB: Damage con­trol resuscitation. J Trauma 62(6 Suppl):S36, 2007; Holcomb JB et al: Causes of death in U.S. Special Operations Forces in the global war on terrorism: 2001-2004. Ann Surg 245:986, 2007; Holcomb JB et al: Increased plasma and platelet to red blood cell ratios improves outcome in 466 massively transfused civilian trauma patients. Ann Surg 248:447, 2008; Kelly JF et al: Injury severity and causes of death from Operation Iraqi Freedom and Operation Enduring Freedom: 2003-2004 versus 2006. J Trauma 64(2 Suppl):S21, 2008; Kragh JF Jr et al: Practical use of emergency tourniquets to stop bleeding in major limb trauma. J Trauma 64(2 Suppl):S38, 2008; Miller PR et al: Colonic resection in the setting of damage control laparotomy: is delayed anastomosis safe? Am Surg 73:606, 2007; Nicholas JM et al: Changing patterns in the management of penetrating abdominal trauma: the more things change, the more they stay the same. J Trauma 55:1095, 2003; Schreiber MA et al: A comparison between patients treated at a combat support hospital in Iraq and a Level I trauma center in the United States. J Trauma 64(2 Suppl):S118, 2008; Seamon MJ et al: Pancreatic injury in damage control laparotomies: Is pancreatic resection safe during the initial laparotomy? Injury 40:61, 2009; Sutton E et al: Long term impact of damage control surgery: a preliminary prospective study. J Trauma 61:831, 2006; Swan KG Jr et al: Tourniquets revisited. J Trauma 66:672, 2009.