case study of trauma patient

Trauma Case 1: Stab to Left Chest

Boston medical center – trauma case of the month, case #1: diagnostic laparoscopy in penetrating chest trauma.

by Rie Aihara, M.D. and Wayne LaMorte, M.D., Ph.D., M.P.H.

Pre-Hospital Data

A 17 year-old male from Michigan was visiting his cousins and friends in Boston, when he became a victim of a stabbing. This all began when the victim confronted an old friend about a personal conflict which occurred between them years ago. What started out as a verbal argument eventually resulted in physical violence. The victim sustained a single stab wound to the left chest in the mid axillary line, just below the level of the nipple. He was transported to our emergency department by Boston EMS. He was noted to be awake and alert throughout the entire transport.

Past Medical/Surgical History: Asthma Family History: Non-significant Medications: Inhalers as needed Allergy: No Known Drug Allergy (NKDA)

Trauma Room Assessment:

The patient was moved from the stretcher onto the examination table, and the only complaint obtained from the patient was shortness of breath.

Cardiac monitors, blood pressure-cuff and oxygen saturation probes were then placed on the patient.

Vital signs:

Heart rate- 90/min Blood Pressure- 130/70 Respiratory rate 25 Temperature- 97 F

Primary Survey:

Airway- patent airway as demonstrated by his ability to talk. Breathing- decreased breath sounds at the left base.

Oxygen mask with 100% FiO2 was placed; & an oxygen saturation of 100% was obtained

Circulation – no active external bleeding Deficits – neurological exam grossly intact Exposure – the patient’s clothes were removed to throughly examine for other injuries Secondary survey: HEENT: no lacerations, no hematomas, no fractures palpated Neck: midline trachea, no JVD, no crepitus Chest: clear on right, single stab wound to the left chest in the mid-axillary line in the 4 th intercostal space, no crepitus, no bleeding, decreased breath sounds at the left base Cardiac: regular rate and rhythm (RRR), normal S1 and S2 Abdomen: present bowel sounds, soft, non-tender, non-distended Extremities: warm, present distal pulses Neuro: awake, GCS 15, no focal deficits

Radiological Survey:

Chest X-ray: left sided hemopneumothorax

An upright CXR was obtained. We were able to sit the patient up because he had an isolated penetrating injury to the chest, and the mechanism of injury did not warrant spinal precautions. A pelvis and lateral C-spine films were also not obtained because of the isolated nature of the injury.

Other Pertinent Studies:

Transthoracic Echocardiogram: no pericardial effusion

Because the weapon can be aimed at any direction (medially, superiorly, inferiorly), the heart can be potentially injured. A pericardial tamponade is lethal unless discovered and treated quickly.

Blood Work Ordered:

Type and screen
Coagulation panel
Complete blood count (CBC)
Arterial blood gas
Toxicology screen

ER Procedures:

Chest tube placement: drained 300cc of frank blood

Change in status:

The patient at this time began complaining of a new subscapular pain, or pain between the shoulder blades. This was alarming to the trauma team for the following reasons.

Patients with diaphragmatic injuries and irritation from the blood frequently exhibit referred pain in this distribution. If the knife wound had projected inferiorly penetrating the diaphragm, there was also a high likelihood of intraabdominal injuries. Therefore, it was decided that the patient required surgical exploration, and the patient was taken to the operating room.

Operating Room:

The surgical team performed a diagnostic laparoscopy in order to determine whether or not the diaphragm had been penetrated. The laparoscopy demonstrated an obvious defect in the diaphragm, as shown here.

View of diaphragm from the abdomen via laparoscope

Inspection within the abdomen demonstrated blood clots on the anterior surface of the stomach and the left lateral segment of the liver. In order to more carefully assess the extent of intra-abdominal injuries and carry out repair, the procedure was converted to an open laparotomy.

Upon exploration, there were three lacerations on the surface of the liver which required suture closure. There was also a 2 cm perforation of the anterior surface of the stomach which was closed primarily in two layers.

In order to assess the extent of intrathoracic injuries more closely, the laparoscope was advanced from the abdomen into the thorax through the diaphragmatic defect.

View of the thoracic cavity via a laparoscope advanced through the diaphragmatic defect

Examination of the pericardium showed no evidence of bleeding, contusion, or penetration.

We therefore proceeded to close the diaphragmatic perforation with interrupted Ethibond suture with pledgets.

Upon completion of the procedure the patient recovered without complications and was discharged to home in four days.

Major Teaching Points:

Arterial blood gas is a better indicator of hemorrhage than hematocrit for the reasons described above.
The peritoneal cavity can extend into the thoracic cavity as high as the 4th intercostal space. Any penetrating chest injury at or below that level has the potential to injure intra-abdominal organs.
The presence of subscapular pain in a patient with a penetrating injury to the chest strongly suggests penetration of the diaphragm and a high risk of associated intra-abdominal injuries. This situation warrants surgical evaluation of the abdomen in the operating room.

Surgical exploration can be undertaken in one of two ways: a) the conventional approach is to perform an open laparotomy, and b) the alternate approach is to do a diagnostic laparoscopy. The primary purpose of the laparoscopy is to determine the presence of diaphragmatic perforation. If the diaphragm is intact, then there should be no intra-abdominal injuries. In this case, a midline incision can be avoided, and the recovery period will be shortened significantly. This can be beneficial to high risk patients such as those with pulmonary disease, cardiac disease and morbid obesity where a long midline incision can be a source of morbidity such as infection and respiratory compromise

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The patient was intubated by EMS and brought by helicopter to your level 1 trauma center. A foley catheter is placed. She’s had CT of her head, neck, chest and pelvis. Her initial assessment reveals the following:

GCS 6 (No eye opening, no speech, withdraws to painful stimuli)
Gross hematuria noted in urine drainage bag
Profuse bleeding from head and open right tib/fib fracture

The patient is taken to emergency surgery for a decompressive craniotomy with bone flap, EVD placement and exploratory laparotomy with bladder repair. She is then brought to you in the surgical ICU. What do you expect to see and do for this patient? Let’s use LATTE! If you don’t know what LATTE is, check it out here!

L = LOOK: After a decompressive craniotomy with a flap, your patient will have a large gauze dressing on her head. In this case she also has an EVD (extraventricular drain). She will be on a ventilator because her GCS is still 6. And, due to the exploratory laparotomy, she’ll also have an abdominal dressing and possibly a drain. If C-spine is involved, she’ll be wearing a collar, but our gal’s C-spine was cleared…yay!

A = ASSESS: The main assessments you will be doing on this patient are neurological and hemodynamics. What is she doing neurologically? What is her GCS? Are her pupils equal? Are there signs of shock? Is she bleeding anywhere? And, because she’s vented, you’ll be keeping an eye on her respiratory status as well…is she compliant with the vent? How do her lungs sound? What’s her O2 saturation? Is she breathing spontaneously? What kind of tidal volumes are we getting?

T = TESTS: You’ll do an ABG at some point to make sure she’s being ventilated adequately. You’ll also want to keep a close eye on CBC and coags as you monitor for bleeding and infection. Other labs include a chem panel to keep those electrolytes optimized! Expect to be taking this patient to CT a few times to keep an eye on the bleeding into her brain and any hydrocephalus that may be present. She’ll get a chest X-Ray daily since she’s on a vent and has rib/clavicle fractures. She may also get cystogram studies to keep an eye on how her bladder is doing. Remember she had hematuria…so they’ll want to keep a close eye on that.

T = TREATMENTS: How will this patient be treated? If you read my book, Nursing School Thrive Guide, you’ll recall that I talk quite a bit about prioritizing continuously. The treatments you provide at 0300 could be vastly different from the treatments you’re providing at 0600, based on the patient’s condition. For a fresh post-op patient who’s had a decompressive craniotomy many of your treatments/interventions are going to be focused on keeping the ICP within normal limits. You’ll also be administering pain and sedation meds as well as antibiotics. Depending on blood loss, you may be giving packed red blood cells. Note that we haven’t fixed her open fracture yet…that has to wait until morning when the ortho doc can get to her. So for now we’re just adding additional dressings to the site and keeping an eye on bleeding.

E = EDUCATION: At this point, you’re not providing education to the patient with a GCS of 6. However, you will be educating the family. In this acute phase, you don’t want to overwhelm them with information…it’s going to go in one ear and out the other. The highlights to hit on include: ICP management, pain control and sedation.

It is now 0430 and your monitor alarm starts going off for elevated ICP. It’s 23. Whatcha gonna do? (For a refresher on ICP management, check out this post here!)

First things first…assess your patient, not the monitor. You enter the room and do a quick assessment…this is what you find: head crooked off to one side, knees gatched, temp elevated, tachypnea and dyssynchrony with the ventilator, no drainage since you last drained the EVD an hour ago. Hmmm….what’s wrong with this picture?

Step 1: Straighten the patient’s neck to allow CSF to drain more freely. Step 2: Un-gatch the knees to reduce intrathoracic pressure Step 3: Looks like she might be fighting the vent…increase sedation and pain medication Step 4: Check EVD…make sure there are no kinks in the tubing. In most facilities, policy states that you can BRIEFLY drop the level of the drainage bag to ensure patency…you do this and note drainage in the bag…so there are no kinks or clots. Hmmm… Step 5: Initiate cooling measures…IV Tylenol works great as do ice packs. Be careful of shivering, though! Shivering increases ICP. Step 6: Give it a few minutes and re-assess.

Thankfully the rest of your shift goes smoothly. You report off to Super Nurse, RN and head home for a day of blissful sleep. When you come back in that evening, this is what you hear in report:

Pt went to surgery at 1000 that morning for ORIF of the right tib/fib fracture, right ulnar/radial fracture and right femur fracture.
Hgb dropped from 8.5 to 7.2…you are now doing serial Hgb and Hct every six hours. Your next draw is due at 2200.
Temp spiked to 39.1, cultures drawn, antibiotics continued.
ICPs still hovering around 18-20. Neurosurgeon changed the height of the EVD from 10mm Hg to 5mm Hg…EVD drainage has been steady at 10ml/hr throughout shift.
GCS remains at 6.
Pt still on ventilator.
Plan is for pt to have pelvic fracture fixed the next day.

Upon your initial assessment you note the following:

BP lower than it was last night…hovering around 95 systolic.
O2 sats a bit lower than the night before. They were 98% then, they’re 93-95% now.
Temp is better…that’s good!
Lung sounds are mildly coarse.
ICP 19-20. EVD drainage is good and she’s adequately sedated.

An hour later, you’re at the nurse’s station doing an ungodly amount of charting, when your monitor alarm goes off. ICP is 22. You do all your checks…positioning, temp, EVD patency…all looks good. But her ICPs are still high. As you are doing your assessment, the ICP creeps up to 23-24. Time to notify the neurosurgeon on call.

SBAR Communication

“This is Nurse Sam, calling about your patient Ramirez in Trauma ICU bed 10. She had a decompressive craniotomy yesterday. Her ICPs are holding steady in the 23-24 range. She’s afebrile, well-sedated, compliant with vent. GCS remains at 6 and EVD drainage is averaging about 10ml/hr. What do you think about trying mannitol?”

So, your neurosurgeon thinks this is a fantastic idea and orders Mannitol q 4 hr prn ICP > 20; Check serum sodium prior to each dose; Hold for serum sodium > 146. You give your first dose and watch the monitor as the ICP drops down bit by bit to a more acceptable 14. Go you!

A few hours hours later, at 2230, you notice your patient’s O2 sats have dropped dramatically…they’re now 74%. What the heck? You hustle into the room and amp up the ventilator to give 100% FiO2. As you place your stethoscope into your ears, you quickly assess the ET tube to ensure it hasn’t become dislodged. You listen to her lungs and hear no lung sounds on the right…the same site as her rib fractures and lung contusion. You call for help and immediately take her off the vent and manually breathe for her using the BVM. When your nurse friends show up, you ask one to call RT, one to call the doc and another to put in an order for a stat Chest X-RAY. What is going on?

As you are bagging the patient, waiting for the RT to show up and take over, you notice tracheal deviation off to the left and BP has dropped to 83/54. You relay this to the nurse who is on the phone with the MD, stressing that she needs to get up there STAT! Your patient has a pneumothorax and seconds count. The respiratory therapist arrives to take over the airway and you ask one of your friends to obtain a large-bore needle. You ask another to grab a chest tube kit…it’s time to get serious folks.

The MD arrives, agrees with your assessment of tension pneumothorax and, using the large-bore needle, performs an emergent pleural decompression. You watch in amazement as the patient’s O2 saturation levels quickly start to climb back to 93%. You prep the pleuravac and monitor the patient while the MD inserts a chest tube on the right side. Good catch!

While you have the doc there, you notify her that the 2200 H&H showed a hemoglobin of 6.9. She orders 2 units packed red cells. You give the blood and, happily, the patient’s O2 saturation and blood pressure both improve. And, with a couple of Mannitol doses your patient’s ICP hangs around 14 for the rest of the night. Nice job…you go home and sleep a beautiful sleep.

When you come on that night, the off-going nurse reports the following:

Your patient had her pelvic fractures repaired that day, returning from surgery at 1120 with hemovac drain at surgical site.
The tachycardia that has been present since admission has slowed to normal sinus rhythm, likely due to decreased pain now that all her fractures are repaired.
Urine output averaging 75ml/hr.
The biggest news is that her GCS has improved dramatically…she’s now a 9 (opens eyes to speech (3 points), no verbal response due to ETT (1 point) and localizes to pain (5 points). This is a massive improvement! Guess she likes that EVD and all that lovely Mannitol.
The plan is to let her rest overnight, and lighten up her sedation early in the morning with the neurosurgeon rounds.

Your initial assessment reveals the following:

ICP 11 (yay!) with 5ml CSF from last hour…looks like drainage is slowing down.
BP 129/67; HR 85
Surgical dressing across abdomen and at right hip. Both are clean, dry, intact. Belly is soft, flat; pt grimaces and moves hands toward abdomen as you palpate…likely very tender.
All other dressings from prior surgeries also clean, dry, intact.
Lung sounds equal bilaterally; chest tube is patent; O2 saturation 98% on 30% FiO2.
GCS remains at 9…she is slowly but steadily improving. Whew!

At 2300, you notice that your patient’s blood pressure is trending down and heart rate is trending up. You aren’t alarmed yet…though you are keeping a careful eye on things. Currently, her O2 saturation is 94%, BP is 109/63, HR is 104, urine output 45/hr. Nothing scary yet, but you don’t like how the trend is going. An hour later, at 0000 you notice O2 sat is now 92 %, BP is 98/62, HR is 115 and urine output for the past hour is 25. You definitely don’t like how this is going. At all. You perform your midnight assessment and notice that your hemovac is full…it was empty two hours ago…what’s going on? You drain the hemovac and pull back the patient’s gown. You immediately see that her belly isn’t quite as flat…and when you touch it it feels much more firm. You immediately go call the ortho surgeon…you’re getting pretty good at waking docs up in the middle of the night, so this SBAR should be a no-brainer!

“This is Nurse Sam, calling about your patient Ramirez in Trauma ICU bed 10. You performed an ORIF on her pelvis today and I’m concerned she may be bleeding into the abdomen. BP has dropped 30 points since 1900, most of the past hour. HR is up from 85 to 115, O2 sats are down to 91 from 98, and urine output is decreasing. Her belly is a bit rounded and more firm than on my initial assessment. I’d like to get a stat Abdominal scan, a stat CBC and coags, and ask you to come see this patient.”

The ortho surgeon agrees with your order requests and states she is going to call the general surgeon who is on site at the hospital right now. If the patient is bleeding, she’s going to need to go to surgery asap. You anticipate this happening, so you get ready:

You assign a friend to draw a rainbow (this means you’re going to draw the three main studies…a chemistry panel, a CBC and a coagulation panel…these are in different colored tubes so we call it a “rainbow”).
Another nurse calls blood bank to ensure the patient has units on hold and also calls CT to tell them they’ve got a stat patient coming in.
You call RT so they can come put the patient on the portable ventilator.
You get the patient packed up and ready to transport to CT. They quickly run the scan and a few minutes after you return to the room the general surgeon shows up. She assesses the patient, agrees with your findings, and logs into the computer to view the scan which has miraculously been processed amazingly fast! She notes blood in the abdominal space and says what you’ve been anticipating for the past hour…”We’re going to surgery.”
You wheel the patient down to surgery, report off to the circulating RN and anesthesiologist and decide this is a perfect time for your lunch break. Nice work, you!

The patient comes back from the OR 90 minutes later. The surgeon tells you she’d had a large hematoma in one of her pelvic vessels that ultimately burst, causing the drop in pressure and distended abdomen. The patient received four units packed red blood cells in the OR and you’re back to doing q 6-hr H & Hs. BP has improved to 115/67, HR Is 94 and O2 saturation is 98%. That was a close one! Thankfully, the rest of your night goes off without a hitch. When the neurosurgeon rounds at 0600, you’ve had sedation off for about 20 minutes. The patient is moving much more and opening eyes spontaneously. She is not, however, following commands…but her total GCS is now 10. The neurosurgeon likes what he sees and states that if she continues to improve she could likely be weaned from the ventilator soon.

Your relief arrives right on time, you report off and tell her you’re back again that night for your fourth shift in a row. You feel like this patient has really put you through the wringer and hope your last night of the week is easier than the last three! Off you go to sleep.

When you arrive that night, you receive the following information in report:

GCS is now 11…patient is following commands and trying to write notes! Sedation is minimal.
Pt has been on CPAP for the past three hours and doing great with RR 14-22 and O2 saturation levels > 95%. She’s pulling good tidal volumes and on a measly 30% FiO2. Awesome!
ICP has been 4-8 all day with minimal drainage from EVD.
The PM doc is planning to be by around 2000 to assess pt. You are to have an ABG done at that time to assess for readiness to extubate. You cross your fingers!
All other VS stable, all dressings CDI and hemovac draining an appropriate amount of serosanguinous fluid.

When the doc comes by at 2000, you’ve got sedation completely off and your ABG done. After a review of that morning’s CXR and a glance at your patient’s fantastic ABG results, the MD decides to write an order to extubate. Finally some real progress!

You contact your respiratory therapist, grab a towel and a 12 ml syringe. You suction the patient’s mouth and oropharynx thoroughly, making sure you get all the secretions cleared from above the ET cuff. The RT loosens the ET holder from the patient’s face while you get the nasal cannula ready to go with 2L O2. The RT then deflates the cough, tells the patient to cough and pulls the tube. You place the nasal cannula on the patient and instruct her not to talk for a little while. You encourage her to take slow, deep breaths through her nose and cough periodically to keep her lungs clear. Her O2 saturation is 99% and when you ask her how she’s doing she gives you a thumbs up to indicate she is doing fine. You did it!

Now that you’ve got an awake pt who could potentially move around a lot in bed, you need to be extra careful you don’t over drain through the EVD. You explain to the patient (and the patient’s family) that she is not to abruptly change position or move the head of the bed. She nods to indicate understanding and then mouths the words, “What happened?” You give her a brief synopsis…something along the lines of,

“You were in an accident four days ago and badly injured. You’ve had several surgeries for a head injury and broken bones. You currently have a drain in your head to keep the swelling in your brain under control. You also have a chest tube in place to keep your lungs expanding normally. You also have a catheter in your bladder draining urine. Currently everything looks good. Your vital signs are stable and your neuro status is improving. The short term plan is to keep your pain controlled and monitor your neuro status throughout the night. To do that I’ll have to wake you every couple of hours. Do you understand? Now, I know this is a lot to take in and I want you to try not to worry…that’s my job. I’ll be right out there all night and I’m watching over you continuously. You are hooked up to monitors that may occasionally make noise…a lot of times those noises are false alarms and nothing to be concerned about so try not to let it upset you. As long as I’m not alarmed, you don’t need to be alarmed. OK? Now, what is your pain level on a 0-10 scale?”

Throughout the rest of the night, you’re on dilaudid duty and neuro-assessment duty. The patient is scoring a 14 by the time morning rolls around and you report off to the oncoming nurse feeling like you’ve done an awesome job these past four nights. You rock!

I hope you enjoyed this scenario-based look at caring for a post-surgical trauma patient. Luckily I haven’t had a patient with this many complications, but the point is you are always on the lookout for what COULD go wrong. Being ready when the shizzle hits the fan can mean the difference between life and death…but you’re an awesome nurse and you got this!

Note I couldn’t cover every contingency, assessment, treatment, med and diagnostic test in this one case study…this is just an example and I sincerely hope it helped paint a picture for you! Got a story to share about how you caught a problem before it got too big? Got questions about post-op care? Let’s talk about it in our Facebook Group, Thriving Nursing Students .

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Case Report
Open access
Published: 25 November 2008

A case of PTSD presenting with psychotic symptomatology: a case report

Georgios D Floros 1 ,
Ioanna Charatsidou 1 &
Grigorios Lavrentiadis 1

Cases Journal volume 1 , Article number: 352 ( 2008 ) Cite this article

30k Accesses

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Metrics details

A male patient aged 43 presented with psychotic symptomatology after a traumatic event involving accidental mutilation of the fingers. Initial presentation was uncommon although the patient responded well to pharmacotherapy. The theoretical framework, management plan and details of the treatment are presented.

Recent studies have shown that psychotic symptoms can be a hallmark of post-traumatic stress disorder [ 1 , 2 ]. The vast majority of the cases reported concerned war veterans although there were sporadic incidents involving non-combat related trauma (somatic or psychic). There is a biological theoretical framework for the disease [ 3 ] as well as several psychological theories attempting to explain cognitive aspects [ 4 ].

Case presentation

A male patient, aged 43, presented for treatment with complaints tracing back a year ago to a traumatic work-related event involving mutilation of the distal phalanges of his right-hand fingers. Main complaints included mixed hallucinations, irritability, inability to perform everyday tasks and depressive mood. No psychic symptomatology was evident before the event to him or his social milieu.

Mental state examination

The patient was a well-groomed male of short stature, sturdy build and average weight. He was restless but not agitated, with a guarded attitude towards the interviewer. His speech pattern was slow and sparse, his voice low. He described his current mood as 'anxious' without being able to provide with a reason. Patient appeared dysphoric and with blunted affect. He was able to maintain a linear train of thought with no apparent disorganization or irrational connections when expressing himself. Thought content centred on his amputated fingers with a semi-compulsive tendency to gaze to his (gloved) hand. The patient was typically lost in ruminations about his accident with a focus on the precise moment which he experienced as intrusive and affectively charged in a negative and painful way. He could remember wishing for his fingers to re-attach to his hand almost as the accident took place. A trigger in his intrusive thoughts was the painful sensation of neuropathic pain from his half-mutilated fingers, an artefact of surgery.

He denied and thoughts of harming himself and demonstrated no signs of aggression towards others. Hallucinations had a predominantly depressive and ego-dystonic character. He denied any perceptual disturbances at the time of the examination. Their appearance was typically during nighttime especially in the twilight. Initially they were visual only, involving shapes and rocks tumbling down towards the patient, gradually becoming more complex and laden with significance. A mixed visual and tactile hallucination of burning rain came afterwards while in the time of examination a tall stranger clad in black and raiding a tall steed would threaten and ridicule the patient. He scored 21 on a MMSE with trouble in the attention, calculation and recall categories. The patient appeared reliable and candid to the extent of his self-disclosure, gradually opening up to the interviewer but displayed a marked difficulty on describing his emotions and memories of the accident, apparently independent of his conscious will. His judgement was adequate and he had some limited Insight into his difficulties, hesitantly attributing them to his accident.

He was married and a father of three (two boys and a girl aged 7–12) He had no prior medical history for mental or somatic problems and received no medication. He admitted to occasional alcohol consumption although his relatives confirmed that he did not present addiction symptoms. He had some trouble making ends meet for the past five years. Due to rampant unemployment in his hometown, he was periodically employed in various jobs, mostly in the construction sector. One of his children has a congenital deformity, underwent several surgical procedures with mixed results and, before the time of the patient's accident, it was likely that more surgery would be forthcoming. The patient's father was a proud man who worked hard but reportedly was victimized by his brothers, they reaping the benefits of his work in the fields by manipulating his own father. He suffered a nervous breakdown attributed to his low economic status after a failed economic endeavour ending in him being robbed of the profits, seven years before the accident. There was no other relevant family history.

Before the accident the patient was a lively man, heavily involved as a participant and organizer in important local social events from a young age. He was respected by his fellow villagers and felt his involvement as a unique source of pride in an otherwise average existence. Prior to his accident, the patient was repeatedly promised a permanent job as a labourer and fate would have it that his appointment was supposedly approved immediately after the accident only to be subsequently revoked. He viewed himself as an exploited man in his previous jobs, much the same way his father was, while he harboured an extreme bitterness over the unavailability of support for his long-standing problems. His financial status was poor, being in sick-leave from his previous job for the last four months following the accident and hoping to receive some compensation. Although his injuries were considered insufficient for disability pension he could not work to his full capacity since the hand affected was his primary one and he was a manual labourer.

Given that the patient clearly suffered a high level of distress as a result of his hallucinatory experiences he was voluntary admitted to the 2nd Psychiatric Department of the Aristotle University of Thessaloniki for further assessment, observation and treatment. A routine blood workup was ordered with no abnormalities. A Rorschach Inkblot Test was administered in order to gain some insight into patient's dynamics, interpersonal relations and underlying personality characteristics while ruling out any malingering or factitious components in the presentation as suggested in Wilson and Keane [ 5 ]. Results pointed to inadequate reality testing with slight disturbances in perception and a difficulty in separating reality from fantasy, leading to mistaken impressions and a tendency to act without forethought in the face of stress. Uncertainty in particular was unbearable and adjustment to a novel environment hard. Cognitive functions (concentration, attention, information processing, executive functions) were impaired possibly due to cognitive inability or neurological disease. Emotion was controlled with a tendency for impulsive behaviour; however there was difficulty in processing and expressing emotions in an adaptive manner. There were distinct patterns of aggression and anger towards others but expressing those patterns was avoided, switching to passivity and denial rather than succumbing to destructive urges or mature competitiveness. Self-esteem was low with feelings of inferiority and inefficiency.

A neurological examination revealed a left VI cranial nerve paresis, reportedly congenital, resulting in diplopia while gazing to the extreme left, which did not significantly affect the patient. The patient had a chronic complaint of occasional vertigo, to which he partly attributed his accident, although the symptoms were not of a persisting nature.

Initial diagnosis at this stage was 'Psychotic disorder NOS' and pharmacological treatment was initiated. An MRI scan of the brain with gadolinium contrast was ordered to rule out any focal neurological lesions. It was performed fifteen days later and revealed no abnormalities.

Patient was placed on ziprasidone 40 mg bid and lorazepam 1 mg bid. He reported an immediate improvement but when the attending physician enquired as to the nature of the improvement the patient replied that in his hallucinations he told the tall raider that he now had a tall doctor who would help him and the raider promptly left (sic). Apparently, the random assignment of a strikingly tall physician had an unexpected positive effect. Ziprasidone gradually increased to 80 mg bid within three days with no notable effect to the perceptual disturbances but with the development of akathisia for which biperiden was added, 1 mg tid. Duloxetine was added, 60 mg once-daily, in a hope that it could have a positive effect to his mood but also to this neuropathic pain which was frequent and demoralising. The patient had a tough time accommodating to the hospital milieu, although the grounds were extended and there was plenty of opportunity for walks and other activities. He preferred to stay in bed sometimes in obvious agony and with marked insomnia. He presented a strong fear for the welfare of his children, which he could not reason for. Due to the apparent inability of ziprasidone to make a dent in the psychotic symptomatology, medication was switched to amisulpride 400 mg bid and the patient was given a leave for the weekend to visit his home. On his return an improvement in his symptoms was reported by him and close relatives, although he still had excessive anxiety in the hospital setting. It was decided that his leave was to be extended and the patient would return for evaluation every third day. After three appointments he had a marked improvement, denied any psychotic symptoms while his sleep pattern improved. A good working relationship was established with his physician and the patient was with a schedule of follow-up appointments initially every fifteen days and following two months, every thirty days. His exit diagnosis was "Psychotic disorder Not Otherwise Specified – PTSD". He remained asymptomatic for five months and started making in-roads in a cognitively-oriented psychotherapeutic approach but unfortunately further trouble befell him, his wife losing a baby and his claim to an injury compensation rejected. He experienced a mood loss and duloxetine was increased to 120 mg per day to some positive effect. His status remains tenuous but he retains a strong will to make his appointments and work with his physician. A case conceptualization following a cognitive framework [ 6 ] is presented in Figure 1 .

Case formulation – (Persistent PTSD, adapted from Ehlers and Clark [ 6 ] ) . Case formulation following the persistent PTSD model of Ehlers and Clark [ 6 ]. It is suggested that the patient is processing the traumatic information in a way which a sense of immediate threat is perpetuated through negative appraisals of trauma or its consequences and through the nature of the traumatic experience itself. Peri-traumatic influences that operate at encoding, affect the nature of the trauma memory. The memory of the event is poorly elaborated, not given a complete context in time and place, and inadequately integrated into the general database of autobiographical knowledge. Triggers and ruminations serve to re-enact the traumatic information while symptoms and maladaptive coping strategies form a vicious circle. Memories are encoded in the SAM rather than the VAM system, thus preventing cognitive re-appraisal and eventual overcoming of traumatic experience [ 4 ].

The value of a specialized formulation is made clear in complex cases as this one. There is a relationship between the pre-existing cognitive schemas of the individual, thought patterns emerging after the traumatic event and biological triggers. This relationship, best described as a maladaptive cognitive processing style, culminates into feelings of shame, guilt and worthlessness which are unrelated to similar feelings, which emerge during trauma recollection, but nonetheless acts in a positive feedback loop to enhance symptom severity and keep the subject in a constant state of psychotic turmoil. Its central role is addressed in our case formulation under the heading "ruminations" which best describes its ongoing and unrelenting character. The "what if" character of those ruminations may serve as an escape through fantasy from an unbearably stressful cognition. Past experience is relived as current threat and the maladaptive coping strategies serve as negative re-enforcers, perpetuating the emotional suffering.

The psychosocial element in this case report, the patient's involvement with a highly symbolic activity, demonstrates the importance of individualising the case formulation. Apparently the patient had a chronic difficulty in expressing his emotions and integrating into his social surroundings, a difficulty counter-balanced somewhat with his involvement in the local social events which gave him not only a creative way out from any emotional impasse but also status and recognition. His perceived inability to continue with his symbolic activities was not only an indicator of the severity of his troubles but also a stressor in its own right.

Complex cases of PTSD presenting with hallucinatory experiences can be effectively treated with pharmacotherapy and supportive psychotherapy provided a good doctor-patient relationship is established and adverse medication effects rapidly dealt with. A cognitive framework and a Rorschach test can be valuable in deepening the understanding of individuals and obtaining a personalized view of their functioning and character dynamics. A biopsychosocial approach is essential in integrating all aspects of the patients' history in a meaningful way in order to provide adequate help.

Patient's perspective

"My life situation can't seem to get any better. I haven't had any support from anyone in all my life. Leaving home to go anywhere nowadays is hard and I can't seem to be able to stay anyplace else for a long time either. Just getting to the hospital [where the follow-up appointments are held] makes me very nervous, especially the minute I walk in. Can't seem to stay in place at all, just keep pacing while waiting for my appointment. I am only able to open up somewhat to my doctor, whom I thank for his support. Staying in hospital was close to impossible; I was very stressed and particularly concerned for my children, not being able to be close to them. I still need to have them near-by. Getting the MRI scan was also a stressful experience, confined in a small space with all that noise for so long. I succeeded only after getting extra medication.

I hope that things will get better. I don't trust anyone for any help any more; they should have helped me earlier."

Written informed consent was obtained from the patient for publication of this case report and accompanying images. A copy of the written consent is available for review by the Editor-in-Chief of this journal.

Abbreviations

stands for 'Post Traumatic Stress Disorder'

for 'Verbally Accessible Memory'

for 'Situationally Accessible Memory'

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Acknowledgements

The authors wish to acknowledge the valuable support and direction offered by the department's chair, Professor Ioannis Giouzepas who places the utmost importance in creating a suitable therapeutic environment for our patients and a superb learning environment for the SHO's and registrars in his department.

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Georgios D Floros, Ioanna Charatsidou & Grigorios Lavrentiadis

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GF was the attending SHO and the major contributor in writing the manuscript. IC performed the psychological evaluation and Rorschach testing and interpretation. GL provided valuable guidance in diagnosis and handling of the patient. All authors read and approved the final manuscript.

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Floros, G.D., Charatsidou, I. & Lavrentiadis, G. A case of PTSD presenting with psychotic symptomatology: a case report. Cases Journal 1 , 352 (2008). https://doi.org/10.1186/1757-1626-1-352

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A patient with severe polytrauma with massive pulmonary contusion and hemorrhage successfully treated with multiple treatment modalities: a case report

Futoshi Nagashima 1 na1 ,
Satoshi Inoue 1 na1 &
Miho Ohta 1

Journal of Medical Case Reports volume 14 , Article number: 69 ( 2020 ) Cite this article

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The mortality rate is very high for patients with severe multiple trauma with massive pulmonary contusion containing intrapulmonary hemorrhage. Multiple treatment modalities are needed not only for a prevention of cardiac arrest and quick hemostasis against multiple injuries, but also for recovery of oxygenation to save the patient’s life.

Case presentation

A 48-year-old Japanese woman fell down stairs that had a height of approximately 4 m. An X-ray showed pneumothorax, pulmonary contusion in her right lung, and an unstable pelvic fracture. A chest drain was inserted and preperitoneal pelvic packing was performed to control bleeding, performing resuscitative endovascular balloon occlusion of the aorta. A computed tomography scan revealed massive lung contusion in the lower lobe of her right lung, pelvic fractures, and multiple fractures and hematoma in other areas. An emergency thoracotomy was performed, and then we performed wide wedge resection of the injured lung, clamping proximal to suture lines with two Satinsky blood vessel clamps. The vessel clamps were left in the right thoracic cavity. The other hemorrhagic areas were embolized by transcatheter arterial embolization. However, since her respiratory functions deteriorated in the intensive care unit, veno-venous extracorporeal membrane oxygenation was used for lung assist. Planned reoperation under veno-venous extracorporeal membrane oxygenation was performed on day 2. Since her respiratory condition improved gradually, the veno-venous extracorporeal membrane oxygenation circuit was withdrawn on day 7. She was transferred to the psychiatric ward of our hospital on day 75.

Utilizing multiple treatment modalities such as resuscitative endovascular balloon occlusion of the aorta, damage control surgery, transcatheter arterial embolization, and veno-venous extracorporeal membrane oxygenation with appropriate timing saves a patient with severe polytrauma with massive pulmonary contusion including intrapulmonary hemorrhage.

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The mortality of multiple trauma with severe chest trauma of Abbreviated Injury Scale (AIS) > 3 is very high: 15.1% in all ages and 28.4% in those 65 years or older [ 1 ]. Quick hemostasis and treatments with appropriate prioritization for injured organs are essential to rescue patients with polytrauma, especially severe truncal trauma with pulmonary contusion with massive hemorrhage. Severe lung contusion can lead to massive hemothorax and severe tracheobronchial bleeding. Emergency surgery is determined based on the chest drainage volume in cases of hemothorax. However, it is relatively difficult to find tracheobronchial bleeding due to positive airway pressure ventilation at the early phase of injury. Massive amounts of tissue factor are released due to the lung contusion, which worsens coagulopathy and results in an increased amount of bleeding. Respiratory dysfunction can also be caused from blood flowing into the normal lung area from the pulmonary contusion area. In such cases, it is very difficult to maintain respiratory function with conventional respiratory management of a respirator only. Therefore, veno-venous extracorporeal membrane oxygenation (VV-ECMO) may be the best option, as well as the last resort, to save those patients’ lives.

Here we report a case of severe polytrauma of a 48-year-old woman with massive pulmonary contusion containing intrapulmonary hemorrhage; we were able to successfully save her life utilizing multiple treatment modalities, including resuscitative endovascular balloon occlusion of the aorta (REBOA), damage control surgery (DCS), transcatheter arterial embolization (TAE), intrabronchial block balloon, and VV-ECMO.

A 48-year-old Japanese woman fell down stairs that had a height of approximately 4 m. Her family called 119 (a direct-dial emergency number that connects the caller to the fire and emergency medical services) and the fire station simultaneously dispatched a “doctor-helicopter” from our hospital. She had past medical history including cholecystectomy and schizophrenia, and no remarkable family history. Her respiratory rate was 30 breaths/minute and blood oxygen saturation (SpO 2 ) was 90% with oxygen at 10 L/minute. Her breath sound in her right chest was diminished. Her pulse rate was 130 beats/minute and her blood pressure was 88/55 mmHg. Her extremities were cold with sweat present, suggesting she was in a shock status. A focused assessment sonography for trauma (FAST) revealed hemoperitoneum in the pelvic space and a hemothorax in the right side of her chest. Her consciousness levels were 12 points (E3, V4, M5) according to the Glasgow Coma Scale at first contact and no coarse paralysis of limbs was observed. She was brought to our hospital by a doctor-helicopter, undergoing initial fluid resuscitation and respiratory assist with a bag valve mask (BVM).

Her hemodynamics deteriorated remarkably with a pulse rate of 120 beats per minute and 50 mmHg systolic blood pressure on arrival. SpO 2 was below 90% under respiratory assist with BVM. She was given 6 units of type O Rh plus red blood cells (RBC). A 7-French aortic occlusion catheter (Rescue Balloon®, Tokai Medical Products, Aichi, Japan) was inserted from her right femoral artery and was inflated with 20 ml distilled water to maintain her systolic blood pressure above 90 mmHg. A chest X-ray showed pneumothorax and pulmonary contusion in her right lung (Fig. 1 a). A pelvis X-ray revealed an unstable fracture (Fig. 1 b). The FAST showed a moderate hemothorax in the right side of her chest and a small amount of hemoperitoneum in Morison’s pouch and Douglas pouch. A 28-French chest drain was inserted, and preperitoneal pelvic packing (PPP) was performed to control bleeding from the unstable pelvic fracture, followed by application of a pelvic binder. A whole-body contrast-enhanced computed tomography (CT) scan was performed. The chest CT scan revealed massive lung contusion with major active extravasation of contrast media in the lower lobe of her right lung and moderate lung contusion in the lower lobe of her left lung (Fig. 1 c). The abdominal CT revealed liver injuries with extravasation of contrast media, as well as massive hematoma in an erector spinae muscle with extravasation of contrast media and fractures of transverse process of lumbar vertebra (Fig. 1 d, e). The pelvic CT confirmed multiple pelvic fractures involving moderate hematoma with extravasation of contrast media in retroperitoneal pelvic space (Fig. 1 f).

X-ray and computed tomography findings on admission. a Chest X-ray showing heavy contusion and hemopneumothorax in the right lung. b Pelvis X-ray showed disruption of bilateral sacroiliac articulation and fractures of bilateral pubic bone. c A chest computed tomography scan revealed massive lung contusion with major active extravasation ( white arrow ) in the lower lobe of the right lung and moderate lung contusion in the lower lobe of the left lung. d Abdominal computed tomography scan revealed liver injuries with extravasation ( black arrow ). e , f Pelvic computed tomography showed massive hematoma with extravasation ( white arrow head ) in erector spinae muscle and fractures of transverse process of lumbar vertebrae ( e ) and multiple pelvic fractures involving moderate hematoma with extravasation of contrast media in retroperitoneal pelvic space ( f )

The laboratory data on initial arrival are shown in Table 1 . The Injury Severity Score (ISS) in this case was 48 and the probability of survival was calculated as 29.1%. We first decided to perform damage control thoracotomy since the right severe pulmonary contusion was thought to be a main bleeding source based on CT. Hemorrhage influx into the lumen of our patient’s trachea from the right pulmonary contusion was observed in a tracheal tube when she returned to the operation room (OR) in our emergency department (ED) from the CT room. A double lumen tracheal tube was replaced with a single lumen tracheal tube to prevent blood influx into healthy lung areas before emergency thoracotomy in a supine position. The amount of bleeding in the right thoracic cavity was approximately 1500 ml. The main sources of bleeding in her chest were the lung contusion area of the lower lobe of her right lung and multiple rib fractures. Intrathoracic packing with surgical gauze was performed as a temporary hemostasis to control bleeding from the sites of fractures of ribs. Since the right lung contusion had extended to near the hilum of lung (Fig. 2 a), the hilum of lung was clamped for temporary hemostasis of the lung. At that time, her body temperature was 35.2 °C, base excess and pH of arterial blood gas analysis (BGA) were 10.5 mmol/L and 7.099, respectively, and a persistent oozing of blood from a non-surgical site was recognized. Therefore, we decided to perform wide wedge resection of the lung using a surgical stapling device as a DCS instead of an anatomical lobectomy. We converted the hilum clamp to a limited clamp to the injured lobe with two Satinsky blood vessel clamps. The vessel clamps were left in the right thoracic cavity, clamping proximal to suture lines. Then, therapeutic intrathoracic packing for hemorrhage from multiple rib fractures was performed. Surgical packing gauzes were mainly put in the dorsal and lower side in right thoracic cavity in order to maintain respiratory function of the upper and middle lobes of her right lung, and the vessel clamps were stabilized with additional surgical towels. After the placement of a chest drain, a temporary vacuum packing chest closure was performed and DCS was finished (total surgical time was 55 minutes).

The findings during damage control thoracotomy and views of the surgical site and operation room just before planned reoperation. a The lower lobe of right lung is remarkably swollen due to intrapulmonary hemorrhage and hematoma ( white arrow head ). b The removed lower lobe of right lung is shown ( white arrow head ). c Two vascular clamps were placed at the proximal site of the resected area to avoid unexpected rebleeding. d Pulmonary function was well maintained by veno-venous extracorporeal membrane oxygenation during the surgery

After the DCS for the chest, TAE was performed for severe liver injuries including medial segment and right lobe with gelatin sponge. Furthermore, her left subcostal artery, left first and fourth lumbar arteries, right first to fourth lumbar arteries, right superior gluteal artery, bilateral iliolumbar arteries, right obturator artery, and left lateral sacral artery were embolized in the same fashion (total procedure time was 118 minutes). Meanwhile, her respiratory status worsened including decreased partial pressure of oxygen in arterial blood (PaO 2 )/fraction of inspired oxygen (FiO 2 ) (P/F) ratio and elevation of partial pressure of carbon dioxide (pCO 2 ) on arterial blood gas. In the intensive care unit (ICU), her respiratory functions deteriorated with a P/F ratio below 50: pCO 2 on BGA over 70 mmHg, pH of 7.099, and base deficit of − 12 mmol/L. Since a ventilator was no longer sufficient to maintain her respiratory condition, VV-ECMO was initiated as a lung assist: FiO 2 1.0, oxygen flow 2.0 L/minute, and veno-venous (VV) blood flow 4.5〜5.0 L/minute (Fig. 3 b). A bronchial block balloon was inserted into her right lower bronchus to reduce pressure to the suture lines of the lung. Blood and clots in the other side of the trachea and bronchus were toileted with a bronchoscope. Her hemodynamics and respiratory function improved gradually with these treatments. A blood transfusion continued to maintain the following: hemoglobin (Hb) > 9.0 g/dl, fibrinogen > 150 mg/dl, and platelet > 10 × 10 4 /μl. The total blood transfusion for 24 hours included 82 units of RBC, 136 units of fresh frozen plasma (FFP), and 70 units of platelet concentrate (PC).

Chest X-ray findings post operation. a Chest X-ray findings following damage control surgery (thoracotomy). The bleeding source was clamped ( black arrowhead ) and intrathoracic packing was performed. b Chest X-ray findings post establishment of veno-venous extracorporeal membrane oxygenation system. The catheter to establish the veno-venous extracorporeal membrane oxygenation was placed from the right internal jugular vein (feeding catheter, white arrow ) and right femoral vein (drainage catheter, black arrow ). c Chest X-ray findings after planned reoperation on day 2. d Chest X-ray findings on day 15 showed a significant improvement in both lung areas

The planned reoperation for her chest and pelvis under VV-ECMO was performed on day 2 (Fig. 2 c, d). When Satinsky blood vessel clamps were cautiously removed, there was a slight oozing of blood from the suture line at the resection site of the lower lobe of her right lung. The vessel forceps were reclamped and the stump was interruptedly sutured with two pairs of Teflon pledgets for hemostasis. We closed her chest with two chest drains placed following additional suture for hemorrhage from the multiple rib fractures area (Fig. 3 c). Since slight bleeding continued from the right side of her pelvic retroperitoneal space after removal of PPP gauze, repacking and external fixation for pelvic fracture were also performed. On day 3, RBC and PC were appropriately transfused as our patient’s Hb and platelets were decreased due to VV-ECMO. Her respiratory function was completely dependent on VV-ECMO. Fluid infusion was restricted and a diuretic was administered to make her run on the dry side and her bloody and mucinous phlegm was deliberately removed by a bronchoscope. On day 5, the PPP gauze was removed and the wound was definitively closed. Her respiratory condition improved gradually, and P/F ratio became over 250, and her pCO 2 level was within the normal limit when FiO 2 and blood flow of VV-ECMO were decreased. The VV-ECMO circuit was withdrawn and the bronchial block balloon was removed on day 7. Our patient’s clinical course with intervention and examination and the change in lactate levels and P/F ratio until day 8 are shown in Fig. 4 . On day 15, her respiratory condition was improved to the desired extent with no need for a ventilator (Fig. 3 d). Pneumonia and right intrathoracic infection subsequently occurred and were treated by antibiotics. She needed another 45 days of rehabilitation to be able to walk independently, and was transferred to the psychiatric ward of our hospital on day 75.

Clinical course and treatment. Elapsed course of intervention and examination were shown with a value of lactate and partial pressure of oxygen in arterial blood/fraction of inspired oxygen ratio. On day 1, preperitoneal pelvic packing was performed introducing resuscitative endovascular balloon occlusion of the aorta as hemostatic treatment strategy. Emergency thoracotomy after computed tomography examination was performed, and transcatheter arterial embolization was sequentially performed to stop the bleeds from multiple injuries. Veno-venous extracorporeal membrane oxygenation was performed because of a deterioration of the patient’s pulmonary function with a partial pressure of oxygen in arterial blood/fraction of inspired oxygen ratio of below 50 just after admission to the intensive care unit. The partial pressure of oxygen in arterial blood/fraction of inspired oxygen ratio was remarkably improved by veno-venous extracorporeal membrane oxygenation, and the patient was successfully weaned off from the veno-venous extracorporeal membrane oxygenation on day 7. There was an obvious inverse correlation between lactate level and partial pressure of oxygen in arterial blood/fraction of inspired oxygen ratio. The lactate value was affected by hypoxia as well as hemorrhagic shock. On day 2, the planned reoperations for the chest and pelvis were performed and the hemorrhages in the thoracic injuries were successfully stopped. Since bleeding from the pelvic fracture could not be fully controlled, preperitoneal pelvic repacking was performed, and packing gauze was removed on day 5. A bronchial block balloon was inserted into the right lower bronchus to protect the stump of lung resection site from collapse due to excess intrabronchial pressure. We performed tracheostomy on day 5 as the patient was required to be on mechanical ventilation for a long period of time. CT computed tomography, DCS damage control surgery, ICU intensive care unit, IVR interventional radiology, P / F partial pressure of oxygen in arterial blood/fraction of inspired oxygen, PPDP preperitoneal pelvic depacking, PPP preperitoneal pelvic packing, PPRP preperitoneal pelvic repacking, REBOA resuscitative endovascular balloon occlusion of the aorta, VV - ECMO veno-venous extracorporeal membrane oxygenation

The present case was on the verge of cardiac and respiratory arrest due to a serious polytrauma with severe hemorrhagic shock, which required a rapid control of bleeding using a damage control strategy and respiratory management utilizing VV-ECMO.

We determined to control the massive bleeding with REBOA according to FAST and X-ray findings, and control the shock caused by severe hemorrhage. In this case, time from admission to successful temporary aortic occlusion (TAO) with REBOA was only 12 minutes. In the American Association for the Surgery of Trauma (AAST) prospective Aortic Occlusion for Resuscitation in Trauma and Acute Care Surgery (AORTA) registry, TAO was not significantly different in the time between an open aortic occlusion (OAO) and REBOA: median/interquartile range (IQR) of 15.0/70 and 30.5/36 minutes, respectively [ 2 ]. Our TAO with REBOA was very short and was performed as quickly as the time it took for OAO. REBOA was placed appropriately and smoothly by experienced trauma surgeons as almost all the things needed for REBOA insertion were well prepared in advance. All required preparations for REBOA, including equipment, staffing, place (OR), and activation of the DCS were ordered from the accident scene by a doctor-helicopter staff member. Utilizing REBOA in combination with PPP is a very powerful strategy to achieve hemostasis for both the artery and vein in patients with severe unstable pelvic fracture, especially when they are performed quickly and timely.

A CT scan revealed the severe pulmonary contusion with massive intrapulmonary hematoma, which probably required surgery, and multiple injuries with extravasations of contrast media on liver, spine, and pelvis, which required TAE. We determined to perform surgery on her chest first because the pulmonary contusion had a great risk of severe intrathoracic and tracheal bleeding, which would lead to severe coagulopathy due to the release of a multitude of tissue factors and subsequent pulmonary failure. We observed a lung laceration reaching to near the pulmonary hilum, as well as other multiple injuries such as the thoracic wall and sites of fractures of ribs that were causing continuous bleeding on the operation. We decided to perform wide wedge resection of the injured lung as a DCS. It is reported that damage control thoracic surgery is suitable for patients with severe chest trauma with physiological derangement [ 3 ]. Mortality was increased in an extent-dependent manner for lung resection: pneumonectomy at 62%, lobectomy at 35%, and wedge resection at 22% [ 4 ]. Wedge resection can be performed with a simple and quick procedure and is often applied as a DCS. However, wide wedge resection of the injured lung which reaches near hilum of lung, such as in the present case, is a risky procedure. If large blood vessels and bronchus exist in the excision site, a surgical automatic suturing device occasionally cannot seal them completely, which may result in major bleeding and large air leak with traumatic coagulopathy. Furthermore, repair of such bleeding and air leakage from the suture line may be very difficult, because the resection site tends to move into the inner part of the mediastinum. Therefore, we determined to leave the vessel forceps clamped proximal to suture lines in the intrathoracic space until the planned reoperation was performed. The vessel clamps were secured by putting gauze around them so they did not move from their original positions. Packing gauze was also applied to control minor venous bleeding and oozing from multiple sites of fractures of ribs. The chest was temporarily closed by vacuum packing system. Although it has been reported that intrathoracic packing is an effective method of hemostasis for severe chest trauma as a DCS [ 5 , 6 ], it may also cause respiratory dysfunction and hemodynamic instability. Interestingly, it has been previously demonstrated that the peak airway pressure in vacuum packing closure (VPC) using intrathoracic packing group was lower than that in the definitive thoracic closure group in studies of chest closure of patients who underwent emergent thoracotomy [ 3 , 7 , 8 ]. We found that intrathoracic packing with temporary closure using VPC was very effective in a case of polytrauma which required control of bleeds from multiple sites simultaneously.

In the present case, VV-ECMO was applied for her severe respiratory failure refractory to conventional ventilator support, which was progressed after DCS and TAE. There are some reports regarding application and usage of VV-ECMO in trauma cases [ 9 ]. Previous studies demonstrated that survival rate was improved by VV-ECMO when utilized for patients with lung trauma with no signs of improvement of hypoxia and hypercapnia on conventional ventilator [ 9 , 10 ]. The mean time from injury to initiation of VV-ECMO was 3.2 days (9) and 4.6 days (10) in these reports, whereas time in our case was approximately 8 hours. In these reports, VV-ECMO was performed for trauma-induced acute respiratory distress syndrome (ARDS) that occurred a few days after the injury. It is known that early application of VV-ECMO for patients with severe trauma is highly challenging when bleeding is not fully controlled since an insufficient fluid volume in the patient’s circulation leads to possible VV-ECMO circuit failure, including blood drainage or infusion failure. However, appropriate hemostasis and blood transfusion were performed in our case, and thus VV-ECMO worked perfectly without any specific troubles, and it could also be initiated in the early stage after the injury.

Utilizing multiple treatment modalities such as REBOA, DCS, TAE, intrabronchial block balloon, and VV-ECMO with appropriate timing saves a patient with severe polytrauma with massive pulmonary contusion including intrapulmonary hemorrhage.

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Abbreviations

American Association for the Surgery of Trauma

Resuscitative endovascular balloon occlusion of the aorta

Damage control surgery

Transcatheter arterial embolization

Veno-venous

Veno-venous extracorporeal membrane oxygenation

Intensive care unit

Interquartile range

Abbreviated Injury Scale

Focused assessment sonography for trauma

Fraction of inspired oxygen

Bag valve mask

Partial pressure of carbon dioxide

Preperitoneal pelvic packing

Red blood cells

Blood oxygen saturation

Computed tomography

Injury Severity Score

Operation room

Emergency department

Blood gas analysis

Partial pressure of oxygen in arterial blood (PaO 2 )/fraction of inspired oxygen (FiO 2 )

Fresh frozen plasma

Platelet concentrate

Temporary aortic occlusion

Aortic Occlusion for Resuscitation in Trauma and Acute Care Surgery

Open aortic occlusion

Vacuum packing closure

Acute respiratory distress syndrome

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Acknowledgements

We would like to acknowledge the patient and the patient’s family for allowing the case to be published.

No funding was utilized for this report.

Author information

Futoshi Nagashima and Satoshi Inoue contributed equally to this work.

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Department of Trauma Surgery and Surgical Critical Care, Saga University, Faculty of Medicine, 5-1-1 Nabeshima, Saga, 849-8501, Japan

Futoshi Nagashima, Satoshi Inoue & Miho Ohta

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FN and SI contributed equally to write this manuscript. All authors contributed to the diagnosis, the treatment including the surgery, and the intensive care and the clinical management of the patient. All authors read and approved the final manuscript.

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Nagashima, F., Inoue, S. & Ohta, M. A patient with severe polytrauma with massive pulmonary contusion and hemorrhage successfully treated with multiple treatment modalities: a case report. J Med Case Reports 14 , 69 (2020). https://doi.org/10.1186/s13256-020-02406-9

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Knowledge gap and future perspectives, case scenario: management of trauma-induced coagulopathy in a severe blunt trauma patient.

Received from the Department of Anesthesiology and Critical Care, Lyon Sud University Hospital, Hospices Civils de Lyon, Pierre Bénite, France and Charles Merieux School of Medicine, Université Claude Bernard Lyon 1, Oullins, France. Submitted for publication August 30, 2012. Accepted for publication February 4, 2013. Support was provided solely from institutional and/or departmental sources. Figures 1–5 were drawn by Annemarie B. Johnson, C.M.I., Medical Illustrator, Wake Forest University School of Medicine Creative Communications, Wake Forest University Medical Center, Winston-Salem, North Carolina.

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Jean-Stephane David , Anne Godier , Yesim Dargaud , Kenji Inaba; Case Scenario: Management of Trauma-induced Coagulopathy in a Severe Blunt Trauma Patient. Anesthesiology 2013; 119:191–200 doi: https://doi.org/10.1097/ALN.0b013e31828fc627

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COAGULOPATHY-RELATED diffuse bleeding, which is complex and difficult to manage, is observed in around 20–30% of all severe trauma patients. 1 , 2 Its management remains critical to patient survival; however, the optimal approach to treatment remains a matter of debate. 3 Early recognition and adequate aggressive management of this Trauma-induced Coagulopathy (TIC) has been shown to substantially reduce mortality and improve outcomes in severely injured bleeding patients. 3 , 4 To date, the use of fresh frozen plasma (FFP) is an integral part of massive transfusion protocols in most trauma centers and its early use has been advocated. 2–4 Moreover, the use of FFP is associated with well-established risks such as multiple organ failure or transfusion-related acute lung injury (TRALI), and there is insufficient evidence to guide the optimal use of this resource. 5–7 To overcome these weaknesses, several European authors advocate the use of fibrinogen concentrates and/or prothrombin complex concentrates (PCC), 4 , 8 with preliminary clinical studies suggesting an increased efficiency based on biological parameters and a reduction of mortality. 9 , 10 Hence, recent European guidelines recommend the use of fibrinogen concentrates and suggest increasing the fibrinogen target level to 1.5–2.0 g/l. 3

The purpose of this case scenario is to identify key points essential for the treatment of TIC.

A 26-yr-old man, without significant medical history and weighting around 100 kg, sustained a severe motorbike collision. He was initially admitted to a general hospital after being transported by a fire rescue team. On the first clinical examination, the patient was hemodynamically stable and alert. X-rays showed multiple fractures (open humerus and closed femur diaphysis, wrist). A whole-body computed tomography showed a traumatic rupture of the aortic arch, a bilateral pulmonary contusion with small hemothorax, a renal contusion, and multiple pelvic fractures (left acetabulum, and bilateral inferior and superior ramus of the pubic bone) without contrast extravasation. Progressively the patient became hemodynamically unstable, 3 units of packed erythrocytes were given together with 1 g of tranexamic acid (TXA, 10 mg/kg) and 1000 ml hydroxyethyl starch (Voluven ® , Fresenius, Germany). Pelvic stabilization was done with a pelvic belt (SAM Pelvic Sling II, SAM Medical Products, Tualatin, OR). General anesthesia was induced after rapid sequence induction, with etomidate and succinylcholine, and mechanical ventilation was started. General anesthesia was maintained with an association of midazolam and sufentanyl. The patient was therefore sent to our trauma center. During helicopter transport, hemodynamic control had necessitated both fluid infusion (normal saline and Voluven ® [1000 ml]) and continuous infusion of norepinephrine (1 mg/h). One gram of TXA was also injected during the transport.

At admission, patient’s hemodynamic status was as follows: systolic blood pressure, 110 mmHg; heart rate, 100 beats/min. Because of the absence of severe traumatic brain injury, norepinephrine was immediately decreased to 0.5 mg/h to reduce blood loss. The initial admission hemoglobin was 9.7 g/dl and the International Normalized Ratio determined by the Coaguchek® (Roche, Meylan, France) was 0.9. Despite the results of the Coagucheck®, rotational thromboelastometry (ROTEM®, Tem International GmbH, Munich, Germany) showed a typical pattern of coagulopathy with decreased clot amplitude on EXTEM ( fig. 1A ) and FIBTEM ( fig. 1B ), suggesting, respectively, an increase in prothrombin time (PT) and a decrease in fibrinogen level. Twenty U/kg of PCCs (2000 U, Kanokad®, LFB Laboratoire, Courtaboeuf, France) and 45 mg/kg of fibrinogen (4.5 g, Clottafact®, LFB Laboratoire) were therefore administered to the patient and resulted to the correction of coagulation abnormalities on EXTEM ( fig. 1C ) and FIBTEM channels ( fig. 1D ).

Fig. 1. Rotational thromboelastometry (ROTEM®, Tem International GmbH, Munich, Germany) tracing of the patient described in the case section, depicting coagulopathy as attested by an increase in the clotting time (CT) as well as a decrease in the clot amplitude at 5 (A5), 10 (A10) and 15 min (A15), in the EXTEM (A) and FIBTEM (B) channels. Normal values are indicated in the brackets and dashed lines demonstrate the limits of a normal tracing. Coagulopathy was confirmed by standard laboratory values and was seen to be improved after the administration of fibrinogen and prothrombin complex concen Tem International GmbH, Munich, Germany) trates, both on ROTEM® (EXTEM, C and FIBTEM, D) and standard laboratory tests, as detailed in the case section. Clotting time (CT), clot formation time (CFT), A (clot amplitude) at 5 (A5), 10 (A10), 15 (A15), and 20 min (A20), maximum clot firmness (MCF). RT = running time; ST = standing time.

Rotational thromboelastometry (ROTEM®, Tem International GmbH, Munich, Germany) tracing of the patient described in the case section, depicting coagulopathy as attested by an increase in the clotting time (CT) as well as a decrease in the clot amplitude at 5 (A5), 10 (A10) and 15 min (A15), in the EXTEM ( A ) and FIBTEM ( B ) channels. Normal values are indicated in the brackets and dashed lines demonstrate the limits of a normal tracing. Coagulopathy was confirmed by standard laboratory values and was seen to be improved after the administration of fibrinogen and prothrombin complex concen Tem International GmbH, Munich, Germany) trates, both on ROTEM® (EXTEM, C and FIBTEM, D ) and standard laboratory tests, as detailed in the case section. Clotting time (CT), clot formation time (CFT), A (clot amplitude) at 5 (A5), 10 (A10), 15 (A15), and 20 min (A20), maximum clot firmness (MCF). RT = running time; ST = standing time.

Laboratory parameter analysis from blood sample drawn at admission subsequently confirmed the coagulopathy (fibrinogen, 1.1 g/l; PT, 18 s; platelets, 102,000/ml) which was associated with a moderate metabolic acidosis (lactate, 3.1 m m ; base excess, −6.3). Interestingly, it should be observed that the results of blood sample analysis done at admission were available only after completion of the second ROTEM® analysis. As observed with the ROTEM® analysis, hemostasis parameters improved with the administration of factor concentrates (fibrinogen, 2.2 g/l; PT, 14.8 s).

The patient was taken to the operating room for plate fixation of left humerus and intramedullary femur nailing. Two orthopedic surgeons did the procedures simultaneously to reduce surgery time, as part of the damage control surgery principle. During orthopedic surgery, an additional 2 packed erythrocytes units were given together with 669 ml of blood saver restitution (Cell Saver 5, Haemonetics, Braintree, MA) and 1 g of TXA. Then, after a period of stabilization and rewarming in the postanesthesia care unit, the patient was sent to the cardiac surgery unit and a stent was inserted in the aortic arch (Medtronic Valiant, Santa Rosa, CA).

No platelet administration or additional blood product was necessary during the first 24 h. Platelet count remained always up to 100,000/ml. Blood gas analysis which was repeated by 2 h during the first 12 h showed that metabolic acidosis remained moderate (maximum lactate level, 5.0 m m and maximum base excess, −8.2).

Thromboembolism prophylaxis was started on day 2 with enoxaparin (40 mg/day). Extubation was done on day 5 and he was transferred to the ward the days after. No thromboembolic complication was observed during the course. The patient was finally discharged from the hospital to a rehabilitation care unit on postinjury day 28.

Pathophysiology of TIC

Severe trauma with direct injury to major blood vessels and organs can induce hypovolemic shock and exsanguination if treatment is not provided immediately. The genesis of TIC is complex and multifactorial. 1 , 2 , 11 It involves initially an endogenous coagulopathy ( acute traumatic coagulopathy ) resulting from the combination of tissue trauma and systemic hypoperfusion, characterized by systemic anticoagulation and hyperfibrinolysis, putatively through endothelial activation of protein C. 12 , 13 Acidosis and hypothermia with dilution induced by fluid resuscitation contribute to a further impairment of coagulation that will exacerbate the acute traumatic coagulopathy, resulting in TIC ( fig. 2 ). 2 , 11 , 14

Early Diagnosis and Point-of-care Devices

One of the key challenges during the management of trauma remains the early recognition of TIC. 2 Urgent diagnostic and therapeutic decisions are often necessary to avoid multiorgan failure resulting from prolonged hemorrhagic shock. 3 , 4 In addition to the vital signs (arterial pressure and heart rate) and visual estimation of blood loss, these decisions often require serial measurements of blood coagulation parameters to react promptly to persistent or recurrent bleeding. Clinically, the treatment of coagulopathic bleeding is compromised by current coagulation monitoring test that can take from 45 to 60 min. 15 The entire blood volume of the bleeding patient may have been exchanged several times during this time interval, making the results of the laboratory test obsolete. Different point-of-care devices have been developed to rapidly determine PT (and/or International Normalized Ratio, Coaguchek®, INRatio® [Alere, San Diego, CA]), 12 , 15 or to describe viscoelastic continuous profiles of whole blood clot formation by utilizing the ROTEM® (Tem International GmbH) or the TEG® (Haemonetics Corp.; fig. 3 ). 16 , 17 Point-of-care PT can help in the triage process; however, the potential for false-negative results remains, as described in the case section. 12 , 15 ROTEM® and TEG® both utilize the principles of thrombelastography. The primary difference between instruments is that the TEG® operates by moving a cup filled with blood in a limited arc. This blood engages a pin/wire which transduces the increase in viscosity as clot formation occurs. The ROTEM®, on the contrary, has an immobile cup containing blood. Here, the pin/wire oscillates and captures the changing viscosity with clotting. 11 The computer-processed signal from either thrombelastography is presented as a tracing of clot formation ( figs. 3 and 4 ). The two instruments can identify accurately coagulopathic patients early, often within 5 min. 12 , 17 Hence, in coagulopathic patients, ROTEM® analysis shows that 5 min after activating coagulation with tissue factor (EXTEM) or inhibiting platelets with cytochalasin D (FIBTEM), clot amplitude is decreased and coagulation time is increased ( fig. 1 ) compared to a normal tracing ( fig. 4 ). Good correlation has been shown between standard coagulation parameters and ROTEM ® or TEG ® parameters; for example, between the clot amplitude at 15 min (EXTEM) and the PT or the fibrinogen level and the amplitude of the clot (FIBTEM) at 10 min. 16 ROTEM ® and TEG ® may also be effective in predicting the need for massive transfusion. 12 , 17

In addition to global coagulation parameter monitoring, it is now also possible with the ROTEM ® or the TEG ® to specifically target coagulation defects that have been traditionally difficult to quantify at the bedside, including hyperfibrinolysis ( fig. 5 ), or a fibrinogen deficit. 18 , 19 However, it should be mentioned that according to a recent report, the TEG ® (using kaolin) was not able to distinguish coagulopathies caused by dilution from that caused by thrombocytopenia. 20

What Are the Goals of TIC Management?

TIC is observed in up to 30% of severe trauma patients at admission in the trauma bay and increases mortality. 1 , 2 Early correction of TIC is, therefore, an important goal of the resuscitation process together with the correction of the other components of the lethal triad ( i.e. , hypothermia and acidosis). Recent European guidelines emphasize the need for early diagnosis of TIC together with rapid correction through early replacement of FFP and platelets, with specific recommended targets for hemoglobin, platelets, PT, and fibrinogen ( table 1 ). 3

Some of the European Guidelines for the Management of Coagulopathy 3

Transfusion-based Strategy: FFP and Platelet Concentrates

Platelet transfusion..

Regarding platelet transfusion, European guidelines recommend that platelets be administered to maintain a platelet count above 50 × 10 9 /l and suggest maintaining a platelet count above 100 × 10 9 /l in patients with multisystem trauma who are severely bleeding. 3 Recent studies have concluded that platelet transfusion decreases mortality during massive transfusion and that a high ratio of platelet to packed erythrocytes was correlated with improved survival. 21

Plasma Transfusion.

Recent military and civilian experiences indicate that for patients requiring massive transfusion, an initial plasma (P) to erythrocytes (E) unit ratio (P:E ratio) approaching 1:1 is independently associated with improved survival. 2–5 , 22 However, most of the data are derived from retrospective studies that have missing data and analytical biases, limiting the conclusions that can be drawn from these results. 6 , 23 The most important source of bias comes from the impact of survival because patients who survive are more likely to receive FFP than patients who die, creating an artifactual association of survival with higher P:E ratios. 6 , 23 A very recent work, however, suggests that the observed mortality benefit associated with high component transfusion ratios is unlikely owing to survivor bias and that early attainment of high transfusion ratios may significantly lower the risk of mortality in patients receiving massive transfusion. 22 These data support the importance of immediate recognition of patients with TIC, patients who can then benefit from an early and massive transfusion.

FFP administration exposes patients to side effects, including increased susceptibility to infection, transfusion-associated circulatory overload, transfusion-related immunomodulation, and TRALI. 5 , 6 In the United Kingdom, the Serious Hazards of Transfusion (SHOT) database documented 162 cases of TRALI over an 8-year study period including 36 deaths and 93 cases of major morbidity, and identified TRALI as the most prominent cause of transfusion-related morbidity and mortality. 24 FFP from female donors has been particularly implicated in the pathogenesis of TRALI, and antileukocyte antibodies are found in 15–17% of female donors and 25% of multiparous donors but are rare in male donors. 25 To reduce this risk, blood centers have adopted policies to produce plasma components primarily from male donors. 26 Increasing the aggressive use of emergency plasma replacement also leads to the transfusion of ABO nonidentical units. These adverse events can be observed in all patients receiving FFP, and not only in those receiving a massive transfusion. 27 In trauma patients specifically, a similar negative outcome was seen with exposure to ABO nonidentical plasma being associated with increasing complications including acute respiratory distress syndrome and sepsis. 28

Acting quickly is critical because coagulopathy appears immediately after trauma at the site of the injury. 29 The efficacy of plasma transfusion plays out in the first few hours of resuscitation, and there is a temporal relationship between aggressive plasma transfusions and survival. 30 Reducing the delay to transfusion requires the implementation of massive transfusion protocols, which incorporate local agreements with blood banks and trauma packs. As FFP is not immediately available due to the thawing process, other solutions have to be considered. 31 Thawed AB group or low titer group A plasma, which can be stored for 5 days, and freeze-dried plasma allow immediate delivery of plasma in the first trauma pack, followed by immediate thawing of conventional FFP for the subsequent packs. 26 , 31 Some high-volume centers will maintain a thawed plasma bank, allowing immediate access to group-specific plasma.

With the emergence of new data supporting the use of high P:E:Platelet ratios, the content of these packs will also need to be reorganized in order to provide the best possible resuscitation to these critically injured patients within the golden hour. The goal of increasing the P:E:Platelet ratio is to use component therapy to administer products roughly equivalent to whole blood in order to rapidly reverse or avoid development of coagulopathy during the initial resuscitation of an exsanguinating patient. Implementation of massive transfusion protocols, rather than treatment based on the case-by-case discretion of each provider, leads to early delivery of blood products which may result in a more rapid control of coagulopathy. The use of a massive transfusion protocol had been linked to a decrease in blood product use and mortality with minimal wastage of blood products. 32

As immediate delivery of blood products is challenging, another strategy based on immediately available factor concentrates has been suggested.

Concentrates-based Strategy: Fibrinogen and PCC

A more selective approach to the correction of TIC has been suggested by a few European teams, using specific coagulation factor concentrates according to deficiencies identified by ROTEM ® . 2 , 4 , 9 Indeed, fibrinogen concentrates and PCC are already licensed in several European countries for the treatment of congenital and acquired deficiencies and have previously been given with success to trauma patients, 8 , 10 , 33 , 34 and in other settings. 35

Fibrinogen Concentrate.

Fibrinogen is a key protein for hemostasis and clot formation. 36 During trauma, fibrinogen metabolism is altered by hemorrhage and acidosis (accelerating fibrinogen breakdown), hypothermia (inhibiting fibrinogen synthesis), and hydroxyethyl starch infusion (abnormalities of fibrinogen polymerization). 11 , 35 Fibrinogen is, therefore, one of the first blood components to decrease to suboptimal levels early during the course of trauma coagulopathy. 29 , 37 Thus, fibrinogen supplementation is recommended in patients with massive bleeding to maintain plasma fibrinogen levels above 1.5–2.0 g/l. 3 Fibrinogen may be administered as a part of a massive transfusion protocol ( e.g. , systematic administration of 3 g (or 50 mg/kg) after each 6 erythrocytes units), based on standard laboratory results or guided by thromboelastometry/graphy as a part of early goal-directed coagulation management. 2 , 4 , 10 Fibrinogen contributes to hemorrhage control by increasing clot firmness. 14

The use of PCC has been studied recently for use in trauma resuscitation. 4 , 8 , 22 , 38 PCC is a concentrated formulation of vitamin K-dependent clotting factors (II, IX, and X), designed to treat hemophilia B and widely used to reverse the effect of vitamin K antagonists. 39 In the United States, these are referred as three-factor PCCs ( e.g. , Profilnine ® SD, BD Pharma, Columbia, SC; Bebulin ® VH, Baxter Healthcare Corporation, Westlake Village, CA), whereas in Europe, four-factor PCCs, with additional factor VII (Kanokad ® , LFB Laboratoire; Octaplex ® , Octapharma, Boulogne, France; Beriplex ® P/N, CSL Behring, Paris, France), are available. Experimental and clinical data suggest that PCCs may be effective in reversing TIC; however, high level of evidence is still lacking and thus, it is not possible to support their routine use in clinical practice. 3 , 8 , 40 However, it should also be mentioned that all of the published data showing a benefit with the use of PCCs in trauma hemorrhage has been done with four-factor PCCs. Use of factor concentrates in the setting of trauma hemorrhage is attractive because they are immediately available, eliminating the time delay associated with cross-matching, thawing, and transfusion of FFP. They may also be beneficial by reducing transfused volumes and reducing the potential harmful risks associated with allogeneic blood transfusions. 10 Moreover, the PCC manufacturing process includes at least one step of viral reduction or elimination, which minimizes the risk of transmitting infectious agents. Pharmacovigilance data from the World Federation of Hemophilia ‖ have demonstrated that no cases of proven infection transmission have been reported with PCC use. 41 According to an in vitro model, PCC has an important effect on thrombin generation but acts only modestly on clot firmness. 14 Use of PCC has been described in association with fibrinogen concentrates with the administration of both products guided by the ROTEM ® as part of an early goal-directed coagulation management protocol ( fig. 1 ). 4 , 9 , 10 With this goal-directed strategy, Schochl et al. 9 have demonstrated the possibility of treating TIC without FFP with favorable outcomes. In a second retrospective study, they have suggested that ROTEM ® -guided hemostatic therapy may reduce the exposure of trauma patients to allogeneic blood products, a laudable goal. 10 These data are very promising and support further randomized trials which are necessary for incorporating the use of PCC into routine practice. PCC carries its own risks. Thromboembolic complications are the major risk of PCC therapy. 41 The thromboembolic risk also depends on the composition of the PCC and, in particular, the balance between activators and inhibitors, the absence of activated factors, and the presence of heparin or antithrombin, protein C, and protein S. 39 , 42 Significant improvements in PCC preparations have been made in the last 20 years. Measures have been taken against the thrombogenic potential of these drugs. Therefore, the composition of PCCs should meet the precise criteria recommended by the European Medical Agency # such as the presence of antithrombin in addition to heparin, no overloading with factor II and factor X, and low factor VII and factor IX potencies. 43 An increase in the risk of thromboembolism and disseminated intravascular coagulation has been recently suggested in an experimental model of hemorrhagic shock when high doses (50 U/kg) of PCC were used. 42 The imbalance between pro- and anticoagulant factors may be responsible for these effects that were not observed when standard doses of 35 U/kg were used. Furthermore, the long-term safety of PCC has never been assessed.

At this time, the most effective strategy for the management of TIC remains unclear. 4 It is compulsory that the relative contributions of coagulation factor replacement and early diagnosis of factor deficiency are prospectively assessed.

Hyperfibrinolysis is frequent in severe trauma and is related to the extent of injury and severity of shock. 44 In response to a trauma, a physiologic fibrinolysis is observed, which may become pathological in some cases (hyperfibrinolysis, fig. 5 ). Antifibrinolytic therapy, using agents such as TXA, is presumably effective in preserving a weak fibrin clot that is otherwise susceptible to plasmin. However, beyond clot lysis, inhibition of plasmin may be beneficial because plasmin may also play a role in coagulation through the transformation of prothrombin to thrombin, activation of fibrinogenolysis, and the cleavage of receptors on platelets. 45 In addition, proinflammatory effects have also been reported with plasmin activation, which therefore is susceptible to multiple organ failure or infection. 45

Tranexamic acid is a synthetic antifibrinolytic derivative of the aminoacid lysine that inhibits fibrinolysis by blocking the lysine-binding sites on plasminogen. It reduces blood loss in patients with both normal and exaggerated fibrinolytic responses to surgery and has been used for more than 25 years for reducing blood loss in elective surgery. 46 , 47 In trauma, the Clinical Randomisation of an Antifibrinolytic in Significant Haemorrhage-2 trial has recently demonstrated that if given early (<3 h), TXA reduces mortality in trauma patients. 48 , 49 Many of the included patients were not severely injured or bleeding, making the interpretation of the study findings difficult to put into context. However, with randomization of more than 20,000 patients in 40 countries, this double blind, placebo-controlled trial established TXA as an effective treatment for traumatic hemorrhage. It should be observed that the reduction of mortality related to bleeding was less than 1% (4.9 vs. 5.7%), and there were no statistically significant differences in transfusion volumes between groups, suggesting beneficial effects of plasmin inhibition other than on fibrinolysis, as suggested earlier. 49 In a recent study, Morrisson et al. described the use of TXA in a population of wounded soldiers in Afghanistan. Although the study was retrospective, the authors found in patients receiving at least one unit of erythrocytes an independent association of TXA with survival on multivariate analysis. 50 Moreover, the benefit was more prominent in patients requiring massive transfusion. In addition to the findings of these studies, TXA is inexpensive and in these trials demonstrated a neutral thromboembolic complication rate. Thus, the risk/benefit ratio is in favor of TXA, when given during the first 3 h after a trauma, ideally during the prehospital phase.

Recombinant Factor VIIa

Recombinant factor VIIa (rFVIIa), a potent procoagulant agent approved for controlling or preventing bleeding in hemophilia patients with inhibitors, has been widely used, off-label, for trauma patients. 51 However, its efficacy with respect to mortality outcomes has never been proven. 52 It is also highly expensive and may expose treated patients to an increased risk for thromboembolism. 53 A Cochrane review conducted by Stanworth et al. 54 who evaluated 13 trials demonstrated that the administration of rFVIIa was shown to reduce blood product administration (relative risk: 0.85) with an elevation of the thromboembolic risk (relative risk: 1.25). Therefore, rFVIIa should be considered relatively late in the management of refractory life-threatening hemorrhage, primarily in blunt trauma, when all conventional measures to control bleeding have failed (including embolization and surgery) and is not a substitute for the aggressive best-practices use of blood components. 3

Damage Control Concept and Others Goals

The first goal of this concept is to stop bleeding by the way of surgical intervention or angioembolization. As severe trauma patients do not tolerate prolonged operative procedures, effective hemorrhage control is accomplished with the concept of damage control surgery (abbreviated initial surgery) by applying temporary, yet life-saving surgical procedures immediately after injury. Definitive planned surgery is performed after the patient has been stabilized in the intensive care unit. 4

The second step is reversing hypoperfusion to reduce further cellular and organ injury. Permissive hypotension was suggested to limit fluid infusion and then to reduce dilutional coagulopathy and hypothermia as well as all the events linked to aggressive resuscitation with saline-based regimens including abdominal compartiment syndrome, acute respiratory distress syndrome, multiple organ failure, and mortality. However, if the extend and duration of hypotension and perfusion that can be tolerated remain unclear, a target systolic arterial pressure of 90 mmHg is usually recommended, in the absence of severe brain injury, until bleeding is controlled. 3

The third goal is to correct the factors, which impair the TIC, including hypothermia, acidosis, hypocalcemia, consumption, and the dilution of clotting factors after administration of crystalloids and colloids. 11 , 44 Effective interventions for these conditions may improve trauma outcomes. Maintaining a normal body temperature is a first-line, effective strategy to improve hemostasis during massive transfusion. Erythrocytes play an important role in coagulation and a hematocrit higher than 30% may be required to sustain hemostasis. Hydroxyethyl starch solutions induce dilutional coagulopathy caused by acquired fibrinogen deficiency. 35 The clinical significance of this side effect remains unclear, but should be considered even when hydroxyethyl starch is used within their prescribed limits, especially in hemodynamically unstable patients. 3 Alternatively, plasma represents a volume expander with high oncotic pressures, proteins, and coagulation factors.

New Anticoagulant Agents

A new challenge for clinicians comes from the management of trauma patients taking the new anticoagulant agents that specifically target either factor Xa (rivaroxaban, apixaban) or thrombin (dabigatran). 55 , 56 Their use is recommended for thromboprophylaxis after elective surgery, such as hip replacement, as well as for the treatment of pulmonary embolism and for the prevention of stroke and systemic embolism in atrial fibrillation. 57 The first difficulty with their use comes from the absence of an accurate method to quantify the anticoagulation level. Although routine monitoring is not required, in certain clinical scenarios such as trauma, bleeding, or overdose, precisely knowing the anticoagulation level may be important.

The conventional laboratory tests are useful as a qualitative tool to determine normal from abnormal coagulation or to simply detect the presence of the drug. Increases in activated partial thromboplastin time and/or the thrombin clotting time suggest the presence of dabigatran, whereas a normal thrombin clotting time effectively rules out the presence of dabigatran. Direct antifactor Xa causes a prolongation of PTs in a concentration-dependent fashion, but PTs cannot be used to evaluate the pharmacodynamic effect. More recently, an antifactor Xa assay that uses rivaroxaban-containing plasma calibrators has been developed and may provide an optimal method for determining plasma rivaroxaban concentrations, although this method is not widely available. 55

The lack of an available solution to effectively reverse the effects of these new anticoagulant agents is of great concern to trauma and emergency physicians. Currently, the only reversal option is emergency dialysis for dabigatran. However, performing a rapid dialysis in severely injured and bleeding patients remains, even in the most experienced trauma centers, a huge challenge. In this case, it is considered that 2 h of dialysis will remove approximately 62% of circulating dabigatran. 58

Patients treated with rivaroxaban, apixaban, or dabigatran sustaining a severe trauma should receive the usual bleeding resuscitation, including erythrocytes. FFP is also likely useful to replace the loss of coagulation factors but, according to a recent review, 59 is probably inefficient for reversing the new anticoagulant agents. The use of coagulation factors has been suggested including nonactivated PCC, activated PCC (factor eight inhibitor bypass activity), and rFVIIa. rFVIIa induced a decrease in the bleeding time in rats taking dabigatran or rivaroxaban, but it does not reverse the effect of the drug. Nonactivated PCCs have been shown to normalize the PTs in human volunteers who received rivaroxaban, but did not normalize the activated partial thromboplastin time or thrombin time in subjects who received dabigatran. In humans, a recent ex vivo study suggests that rFVIIa, factor eight inhibitor bypass activity, and PCC appear to be able to reverse the anticoagulant activity of rivaroxaban and dabigatran. 60 However, there is no study evaluating the effect of these coagulation factors in the bleeding patient. Whether the use of PCCs will be effective in stopping critical bleeding in this situation remains to be demonstrated with high-level studies.

This case report not only illustrates the rapidity by which coagulopathy develops in a patient with severe trauma, but also emphasizes the new modalities of diagnosis and treatment of TIC.

Recent years have seen the development of new techniques for the rapid evaluation of hemostasis which allows not only the early diagnosis of TIC but also the determination of which specific component is involved in the coagulopathic process. Of particular interest is the fibrinogen deficit which can be diagnosed with the ROTEM ® or the TEG ® . However, it remains to be clearly demonstrated that the use of this point-of-care device will improve outcomes or result in a reduction of blood products consumption.

At the therapeutic level, we will have to definitively demonstrate with high-quality studies that using a high P:E:Platelet ratio is associated with an improvement in outcome without any increase in adverse events such as TRALI or infection. In North America, a multicenter randomized trial of two blood product ratios (P:E:Platelet: 1:1:1 vs. 1:2:1) called the Pragmatic, Randomized Optimal Platelet and Plasma Ratios trial has been initiated and is currently in the process of enrolling patients. In order to avoid potential adverse events linked to these blood products, but also because the availability of blood product is becoming difficult, European authors have suggested using specific coagulation factors. These coagulation factors (fibrinogen, prothrombin complex, and rFVIIa) are immediately available with a very short preparation time. Administration of these factors may decrease the specific adverse effects linked to the use of blood products. However, although experimental evidence and small clinical studies are available with encouraging results, high-quality clinical studies are still required. Because of a theoretical risk of thromboembolic complication when coagulation factors are used, special attention will be required in these studies.

In conclusion, future research efforts will have to focus on the accuracy of early diagnosis of coagulopathy together with the use of both factor concentrates and/or high P:E:Platelet ratios.

Mechanisms of trauma-induced coagulopathy. INR = International Normalized Ratio; PT = prothrombin time.

Fig. 3. Schema depicting the main parameters of the rotational thromboelastometry (ROTEM®, Tem International GmbH, Munich, Germany) tracing, note the clot amplitude (A10 and MCF) and the CT.

Schema depicting the main parameters of the rotational thromboelastometry (ROTEM®, Tem International GmbH, Munich, Germany) tracing, note the clot amplitude (A10 and MCF) and the CT.

Fig. 4. Example of a patient admitted after a motor vehicle crash. On rotational thromboelastometry (ROTEM®, Tem International GmbH, Munich, Germany) analysis, a normal pattern (clotting time [CT] and clot amplitude in the normal range) was observed after addition of tissue factor (EXTEM), cytochalasine D (FIBTEM), and aprotinin to the EXTEM (APTEM). Normal hemostasis was confirmed later by standard laboratory analysis (activated partial thrombin time, 28.8s; prothrombin time, 14.7s; International Normalized Ratio, 1.13; fibrinogen, 3.0 g/l). Clot formation time (CFT); A (clot amplitude) at 5 (A5), 10 (A10), 15 (A15), and 20 min (A20); maximum clot firmness (MCF).

Example of a patient admitted after a motor vehicle crash. On rotational thromboelastometry (ROTEM®, Tem International GmbH, Munich, Germany) analysis, a normal pattern (clotting time [CT] and clot amplitude in the normal range) was observed after addition of tissue factor (EXTEM), cytochalasine D (FIBTEM), and aprotinin to the EXTEM (APTEM). Normal hemostasis was confirmed later by standard laboratory analysis (activated partial thrombin time, 28.8s; prothrombin time, 14.7s; International Normalized Ratio, 1.13; fibrinogen, 3.0 g/l). Clot formation time (CFT); A (clot amplitude) at 5 (A5), 10 (A10), 15 (A15), and 20 min (A20); maximum clot firmness (MCF).

Fig. 5. Patient admitted after a motor vehicle crash and cardiac arrest (different from the one described in the case section). Rotational thromboelastometry (ROTEM®, Tem International GmbH, Munich, Germany) analysis (EXTEM) showed a typical pattern of hyperfibrinolysis with an important reduction in clot amplitude and an immediate breakdown of the clot. After addition of aprotinin (antifibrinolytic agent, APTEM), the clot improved and became stable. In parallel, the FIBTEM was completely flat indicating a severe fibrinogen deficiency. Coagulopathy was confirmed by standard biology (activated partial thrombin time, 122 s; prothrombin time, 24 s; International Normalized Ratio, 2.1; fibrinogen, 1.1 g/l). Normal values are indicated in brackets and dashed lines demonstrate the limits of a normal tracing. Clotting time (CT); clot formation time (CFT), A (clot amplitude) at 5 (A5), 10 (A10), 15 (A15), and 20 min (A20); maximum clot firmness (MCF).

Patient admitted after a motor vehicle crash and cardiac arrest (different from the one described in the case section). Rotational thromboelastometry (ROTEM®, Tem International GmbH, Munich, Germany) analysis (EXTEM) showed a typical pattern of hyperfibrinolysis with an important reduction in clot amplitude and an immediate breakdown of the clot. After addition of aprotinin (antifibrinolytic agent, APTEM), the clot improved and became stable. In parallel, the FIBTEM was completely flat indicating a severe fibrinogen deficiency. Coagulopathy was confirmed by standard biology (activated partial thrombin time, 122 s; prothrombin time, 24 s; International Normalized Ratio, 2.1; fibrinogen, 1.1 g/l). Normal values are indicated in brackets and dashed lines demonstrate the limits of a normal tracing. Clotting time (CT); clot formation time (CFT), A (clot amplitude) at 5 (A5), 10 (A10), 15 (A15), and 20 min (A20); maximum clot firmness (MCF).

Available at: www.wfh.org . Accessed January 22, 2013.

Available at: http://www.ema.europa.eu/docs/en_GB/document_library/Scientific_guideline/2009/09/WC500003518.pdf . Accessed January 22, 2013.

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Trauma nursing: an advanced practice case study

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1 University of Prince Edward Island School of Nursing.
PMID: 10418360

Trauma is the leading cause of death in people less than 40 years of age. Blunt or penetrating trauma injuries may be a result of gunshot wounds, stabbings, head injuries,burns, falls or motor vehicle collisions. Unlike other patients entering the health care system, trauma victims have no time for hospital preparation. The physiologic and psychosocial complications resulting directly from the traumatic incident provide response patterns not typical of other patients. Further to this unpredictability, the trauma patient usually sustains multiple system injuries, making it difficult to design critical pathways in care plans. The complexity is heightened by the patient's unique perception of the traumatic event, which can be even more important than the physical injury in determining the ultimate impact of the trauma.

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Case Report: Blunt Trauma

Case Report: Pediatric Blunt Trauma and Resuscitated Arrest Heidi Altamirano, RN, MS Program Director for Burn, Adult and Pediatric Trauma, and Telemedicine

Pre-Hospital: The patient is a 12 year old female with no previous medical history and was snowmobiling in a rural area with her father. She was wearing a helmet and was on her own snowmobile. She was found by her father pinned between her snowmobile and a tree with her head in the snow. He estimated she had been there for 10 minutes. EMS was called and CPR was initiated as the patient was apneic without a pulse. She was transported to the local critical access facility about 20 minutes away. The helicopter was dispatched in preparation of transfer to the pediatric trauma center over 2 hours from this community.

In the community hospital, CPR was performed for nearly 60 minutes, along with placement of IVs, an endotracheal tube, orogastric tube, and Foley catheter. In addition, 2 liters of crystalloid, followed by 2 units of blood, were given. The patient was also placed on Epinephrine and Norepinephrine drips.

The flight crew called to notify the hospital that they couldn�t land at the community hospital due to a snowstorm. They recommend driving 30 minutes to another small community hospital where they were still able to land and take off from, as the weather had not impacted that area at that time. The patient left the community hospital to meet the flight crew 30 miles away.

Upon arrival at the second community hospital, the weather was now an issue, precluding a flight from there as well. The flight crew jumped in the ambulance and transported the patient by ground transport to the Level I Pediatric Trauma Center over two hours away. The timeframe from arrival at the community hospital to transport to the second community hospital to begin the ground transport was 2 hours and 46 minutes.

The patient remained critically ill. She received another liter of crystalloid, 2 more units of blood on the warmer, and a Ketamine drip was started. TXA was also given. The patient remained on the Epinephrine and Norepinephrine drips. The patient remained hypotensive throughout the 2 hour and 20 minute transport to the trauma center. The crew noted that the airway pressures were increasing en route and bilateral needle thoracostomies were performed. There was blood coming from the ETT.

Level I Trauma Center: The patient arrived at the Level I Pediatric Trauma Center nearly 5 hours and 10 minutes after the injury. The patient arrived with a BP of 68/45 and HR of 74. Her temperature was 84.2 rectally. She remained on the Epinephrine, Norepinephrine, Ketamine, and TXA drips. The massive transfusion protocol was initiated and the FAST exam appeared positive. Mannitol was given after noting that the patient had fixed and dilated pupils. Bilateral chest tubes were also placed with serosanguinous drainage and the patient was transported to the OR for an exploratory laparotomy.

Operating Room The patient was emergently prepped and the abdomen opened. The abdominal contents protruded immediately upon entering the abdomen and blood pressure improved. The bowel appeared dusky yet viable. There was bleeding noted near the liver, which was packed. The rest of the abdomen was examined, without injury noted, so a damage control closure was initiated. The patient became bradycardic once again and pulseless. CPR was initiated and the bleeding increased from the endotracheal tube. CPR was deemed to be futile and stopped after 15 minutes. The patient was transported out of the operating room to be with family.

Topic Review: Blunt trauma with traumatic arrest complicated by extended transport times.

The decision to stop resuscitation in a pediatric patient with blunt traumatic injury is tremendously difficult, particularly in a small rural community where EMS and hospital medical providers know the patient and family. In this complex case, ROSC was obtained in the community hospital, but not until nearly 60 minutes of CPR. In addition, the effects of the weather significantly extended the transport time to the trauma center. During this time, hypotension and hypothermia further complicated the clinical course.

There is a body of literature relating to blunt traumatic arrest both in adult and pediatric patients with recommendations and outcome predictions. The Western Trauma Association , for example, found no survivors of blunt trauma with >10 minutes of prehospital CPR and penetrating trauma within >15 minutes of prehospital CPR.(1) The patient in this case had >60 minutes of CPR initially, followed by additional rounds en route and at the pediatric trauma center.

Another study by Duron, et al. examined the National Trauma Data Bank to analyze survival of pediatric blunt trauma patients presenting with no signs of life in the field. This group determined that the survival of pediatric blunt trauma patients in the field without signs of life is dismal. In addition, resuscitative thoracotomy poses a heightened risk of blood-borne pathogen exposure to involved health care workers and is associated with a significantly lower survival rate.(2)

Finally, the American College of Surgeons Committee on Trauma , American College of Emergency Physicians Pediatric Emergency Medicine Committee , National Association of EMS physicians , and American Academy of Pediatrics Committee on Pediatric Emergency Medicine collaborated on a literature review and created recommendations for out-of-hospital termination of resuscitation.(3)

The two points made were;

"If there is any doubt as to the circumstances or timing of the traumatic cardiopulmonary arrest, under the current status of limiting termination of resuscitation in the field to persons older than 18 years in most states, resuscitation should be initiated and continued until arrival to the appropriate facility."

"If the patient has arrested, resuscitation has already exceeded 30 minutes, and the nearest facility is more than 30 minutes away, involvement of parents and family of these children in the decision-making process with assistance and guidance from medical professionals should be considered as part of an emphasis of family-centered care because the evidence suggests that either death or a poor outcome is inevitable."(3)

In this case example, the literature suggests that resuscitation efforts could have ceased at the community hospital, however as mentioned, this is extremely difficult for both the health care team as well as the family.

References:

Adler E. Defining the limits of resuscitative emergency department thoracotomy: A contemporary Western Trauma Association perspective. Journal of Emergency Medicine 2011; 41(2):231-232.

Duron V, Burke RV, Bliss D, et al. Survival of pediatric blunt trauma patients presenting with no signs of life in the field. J Trauma Acute Care Surg 2014; Sep 77(3): 422-6.

American College of Surgeons Committee on Trauma, American College of Emergency Physicians Pediatric Emergency Medicine Committee, National Association of EMS Physicians, American Academy of Pediatrics Committee on Pediatric Emergency Medicine, Fallat ME. Withholding or termination of resuscitation in pediatric out-of-hospital traumatic cardiopulmonary arrest. Pediatrics 2014; Apr 133(4):e1104-16.

Open access
Published: 31 May 2024

Patterns and outcomes of patients with abdominal injury: a multicenter study from Iran

Sara Mirzamohamadi 1 ,
Mohammad Navid HajiAbbasi 2 ,
Vali Baigi 1 , 3 ,
Payman Salamati 1 ,
Vafa Rahimi-Movaghar 1 ,
Mohammadreza Zafarghandi 1 ,
Mehdi Nasr Isfahani 4 ,
Esmaeil Fakharian 5 ,
Seyed Houssein Saeed-Banadaky 6 ,
Morteza Hemmat 7 ,
Akram Zolfaghari Sadrabad 8 ,
Salman Daliri 9 ,
Sobhan Pourmasjedi 1 ,
Seyed Mohammad Piri 1 ,
Khatereh Naghdi 1 &
Seyed Amir Miratashi Yazdi 1

BMC Emergency Medicine volume 24 , Article number: 91 ( 2024 ) Cite this article

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Metrics details

Injury is one of the leading causes of death worldwide, and the abdomen is the most common area of trauma after the head and extremities. Abdominal injury is often divided into two categories: blunt and penetrating injuries. This study aims to determine the epidemiological and clinical characteristics of these two types of abdominal injuries in patients registered with the National Trauma Registry of Iran (NTRI).

This multicenter cross-sectional study was conducted with data from the NTRI from July 24, 2016, to May 21, 2023. All abdominal trauma patients defined by the International Classification of Diseases; 10th Revision (ICD-10) codes were enrolled in this study. The inclusion criteria were one of the following: hospital length of stay (LOS) of more than 24 h, fatal injuries, and trauma patients transferred from the ICU of other hospitals.

Among 532 patients with abdominal injuries, 420 (78.9%) had a blunt injury, and 435 (81.7%) of the victims were men. The most injured organs in blunt trauma were the spleen, with 200 (47.6%) and the liver, with 171 (40.7%) cases, respectively. Also, the colon and small intestine, with 42 (37.5%) cases, had the highest number of injuries in penetrating injuries. Blood was transfused in 103 (23.5%) of blunt injured victims and 17 (15.2%) of penetrating traumas ( p = 0.03). ICU admission was significantly varied between the two groups, with 266 (63.6%) patients in the blunt group and 47 (42%) in penetrating ( p < 0.001). Negative laparotomies were 21 (28%) in penetrating trauma and only 11 (7.7%) in blunt group ( p < 0.001). In the multiple logistic regression model after adjusting, ISS ≥ 16 increased the chance of ICU admission 3.13 times relative to the ISS 1–8 [OR: 3.13, 95% CI (1.56 to 6.28), P = 0.001]. Another predictor was NOM, which increased ICU chance 1.75 times more than OM [OR: 1.75, 95% CI (1.17 to 2.61), p = 0.006]. Additionally, GCS 3–8 had 5.43 times more ICU admission odds than the GCS 13–15 [OR:5.43, 95%CI (1.81 to 16.25), P = 0.002] respectively.

This study found that the liver and spleen are mostly damaged in blunt injuries. Also, in most cases of penetrating injuries, the colon and small intestine had the highest frequency of injuries compared to other organs. Blunt abdominal injuries caused more blood transfusions and ICU admissions. Higher ISS, lower GCS, and NOM were predictors of ICU admission in abdominal injury victims.

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Introduction

Trauma is one of the leading causes of death worldwide [ 1 , 2 , 3 ] and the leading cause of death in people under 44 years old [ 4 , 5 ]. According to the WHO report, in 2019, about 4.4 million deaths due to injuries were recorded, which includes 8% of all causes of death. Among the causes of death due to injuries, road accidents, drowning, falls, burns, and violence against oneself and others are pointed out [ 6 ]. Also, 14,000 deaths due to injury are recorded daily, expected to increase by 40% in 2030 [ 7 ].

One-fifth of injury mortalities are caused by severe abdominal injuries [ 8 ]. Also, the highest prevalence of abdominal injury occurs between the ages of 20 and 40, dramatically impacting the workforce and society’s economy [ 8 ]. The abdomen is the third most common region of the body after the head and extremity that suffered from trauma. Around the world, the mortality rate due to abdominal injury is reported between 1 and 20%. Also, in the study of Wiik Larsen J et al., the prevalence of abdominal injury was reported as 7.2 per 100,000 people [ 3 ].

In the United States (US) and Korea, road-related accidents (including bicycle, pedestrian, motorcycle) were the leading cause of blunt abdominal injury [ 9 , 10 ]. Other causes include falls, sports injuries, and industrial accidents. Blunt abdominal injury can cause damage to internal organs and internal bleeding. The liver, spleen, and intestine are the most common organs affected by this type of injury, and due to the indirect nature of this injury, diagnosis is difficult and often time-consuming. Although the outcome of patients with blunt abdominal injury has improved in the last two decades, in patients with multiple organ injuries, the in-hospital mortality rate was reported as 3–10% [ 10 ]. Also, according to reports, about 90% of abdominal injuries are blunt [ 5 , 9 , 11 ]. Penetrating abdominal injury is usually caused by stabs and gunshots; most organs damaged in this type include the small intestine, large intestine, liver, and intra-abdominal vessels. Penetrating abdominal trauma accounts for 35% of referrals to urban trauma centers in the US [ 4 ]. In Turkey’s studies as a Middle Eastern country, the mortality rate of abdominal trauma was reported at 10.1–19.4% [ 11 ].

This study aims to compare epidemiological characteristics and clinical outcomes between blunt and penetrating abdominal injuries in the National Trauma Registry of Iran (NTRI).

Study design

NTRI is a hospital-based registry launched in 2016 at Sina Hospital [ 12 , 13 ], Tehran, that includes 24 trauma centers. This cross-sectional study was conducted with NTRI data from July 24, 2016, to May 21, 2023, in Sina Hospital of Tehran, Imam Hossein Hospital of Shahroud, Shahid Rahnemoon Hospital of Yazd, Shahid Modarres Hospital of Saveh, Imam Khomeini Hospital of Urmia, Al-Zahra Hospital of Isfahan, Shahid Beheshti Hospital of Kashan, and Taleghani Hospital of Kermanshah.

Study population

All patients with abdomen injuries defined by the diagnostic International Classification of Diseases, 10th Revision (ICD-10) code admitted to trauma registry member hospitals with one of the following criteria included: hospital length of stay (LOS) more than 24 h, fatal injuries, and trauma patients transferred from the ICU of other hospitals. The patients who were excluded from the study did not have abdominal organ damage and were discharged after examination and imaging or had a laceration in the abdominal wall that did not pass through the peritoneum, and the wound was closed.

Data collection

The NTRI included 109 variables that two registered nurses completed through interviews with patients and the hospital information system at each trauma hospital. This data is sent to physicians in an electronic system for quality review. In this study, we used the following variables: gender, age, education, cause of injury, injury severity score (ISS), hospitalization in an intensive care unit (ICU), length of stay (LOS), organ injured, multiple or single trauma, pulse rate on arrival, systolic blood pressure on arrival, treatment, death, and blood transfusion. Demographic data, including gender and age, were collected from the patient records. Education level and cause of injury were collected from patient review by a nurse, and a physician measured vital signs, including systolic blood pressure and pulse rate, during the visiting time at the emergency room. A nurse collected LOS, ICU admission, blood transfusion, injured organ, treatment, and death in the hospital from patients’ documents.

This study divided the abdomen injury into two groups: blunt and penetrating. Penetrating injuries are every injury crossing the peritoneum and penetrating the abdomen cavity. Blunt injuries had several causes, including road traffic incidents (RTI), falls, and forces. RTI included injuries to pedestrians, bikers, car occupants, bicycles, and heavy vehicle accidents. Penetrating causes of injuries included stabs/cuts and firearms (shotgun and gunshot).

The sum of squared AIS calculates ISS for the three most severe injuries in each part of the body. This study categorized ISS as 1–8, 9–15, and ≥ 16 [ 14 ]. Patients entered one of these groups according to their education years and degrees: no formal education (0 years), primary (1–5 years), secondary (6–12 years), and higher education with a university degree. Hypovolemia criteria included SBP < 90 and/or pulse rate above 120. Also, we calculated the shock index based on heart rate divided by SBP. Patients with a shock index of more than one are considered to have hypovolemic shock. Patient treatment is divided into operative management (OM) and non-operative management (NOM). Number of injuries included two groups: Multiple trauma (MT) considered as other body part injuries in addition to the abdomen injury, only abdomen injury.

Statistical analysis

The nominal and categorical variables were presented as counts and percentages. Also, continuous variables with normal distribution were described by mean ± standard deviation (SD). The chi-square test was used to compare nominal or categorical variables, and the independent t-test was used to compare continuous variables between blunt and penetrating injuries. P -value < 0.05 accepted statistical significance in all the tests. Data analysis was done using STATA 14.

Of the 50,000 patients registered in the NTRI between 2016 and 2023, 1,181 patients complained of an abdominal injury. Of 532 patients in our study, 435 (81.7%) were men, and 97 (18.2%) were women. Four- hundred twenty (78.9%) patients had the blunt, and 112 (21.0%) had the penetrating injury. In both injury types, most of the victims were men. The mean (SD) of age was 30.9 (SD = 17.6) in the blunt group and 31.6 (SD = 13.1) in the penetrating group. Age distribution between the two groups had statistically significant differences. The age group 21 to 40 in blunt group was 173 (41.2%) vs. 69 (61.6%) in penetrating ( p = 0.001). RTI was the cause of injury in most blunt injuries, with 319 (76%) cases, while stab/cut wounds, with 94 (83.9%) cases, were the leading cause of penetrating injuries significantly ( p < 0.001)—figure 1 . The baseline and clinical characteristics of patients compared between blunt and penetrating abdominal injury are shown in Table 1 .

Causes of injury in blunt and penetrating abdominal trauma

RTI: Road Traffic Injury

Two hundred sixty-six (63.3%) patients with blunt injury had injuries to other parts of the body in addition to the abdomen, while in the penetrating group, most victims, 76 (67.9%), had abdomen injury solely ( p < 0.001). Chest trauma, with 26 (23.2%) cases, was the most concomitant injury in penetrating injury. In contrast, in blunt injury, head, neck, and face with 113 (27%), chest with 114 (32%), and extremity with 135 (32.2%) cases more than other body parts suffered from abdominal injury. Ten (2.4%) victims in the blunt group and 79 (70.5%) in the penetrating were injured by the assault ( p < 0.001) (Table 2 ).

The most damaged organs due to blunt injury were the spleen, with 200 cases (47.6%), and the liver, with 171 patients (40.7%), whereas 42 (37.5%) of the penetrating group had intestine and colon injuries.

Two hundred and five (48.8%) patients in the blunt trauma group and 81 (72.3%) patients in the penetrating group had ISS of 1 to 8, respectively ( p < 0.001). In the blunt group, 205 (48.8%) patients had ISS 1 to 8, and in the penetrating group, 81 (72.3%) of them had the same ISS( p < 0.001). One hundred-three (23.5%) patients with blunt injury and 17 (15.2%) people in the penetrating group had a blood transfusion ( p < 0.03). Also, 277 (66%) patients with blunt trauma were treated with NOM, and 132 (31.4%) were treated with OM. In the penetrating group, 37 (33%) patients with NOM and 54 (48.2%) with OM ( p < 0.001). Eleven (7.7%) patients in the blunt and 21 (28%) victims in the penetrating group had negative laparotomy ( p < 0.001). In-hospital mortality occurred in 21 (5%) blunt-injury victims and 3 (2.7%) patients in the penetrating group. Blunt-injury victims (63.6%) were significantly admitted to the ICU more than penetrating injuries (42%) ( p < 0.001). LOS of patients with blunt injury was more prolonged than penetrating victims significantly ( p = 0.001) (Table 3 ).

ICU admission. Univariate logistic regression revealed 21-40-year-old patients had a 0.68 times lower chance than the > 40-year-old to ICU admission [OR:0.68, 95% CI (0.44 to 1.05), p = 0.09]. Other predictors of ICU admission were blunt injury [OR:2.43, 95% CI (1.59 to 3.72), p < 0.001], hypovolemia [OR: 2.15, 95%CI (1.24 to 3.7), p = 0.001], MT [OR:1.19, 95% CI (1.34 to 2.72), p < 0.001], NOM [OR:1.87, 95%CI (1.31 to 2.66), p < 0.001], GCS 9–12 relative to the 13–15 [OR:4.14,95% CI (1.79 to 9.54), p = 0.006] and GCS 3–8 relative to the 13–15 [OR:8.1, 95%CI (2.84 to 23.08), p < 0.001], ISS 9–15 relative to the 1–8 [OR:1.72, 95% CI (1.14 to 2.61), p < 0.001] and ISS ≥ 16 relative to the 1–8 [OR:5.08, 95%CI (2.9 to 8.88), p < 0.001].

In the multiple logistic regression model after adjusting, ISS ≥ 16 increased the chance of ICU admission 3.13 times, and ISS 9–15 increased 1.79 times relative to the ISS 1–8 [OR: 3.13, 95% CI (1.56 to 6.28), p = 0.001], [OR:1.79, 95% CI (1.05 to 3.04), p = 0.03]. Another predictor was NOM, which increased ICU chance 1.75 times more than OM [OR: 1.75, 95% CI (1.17 to 2.61), p = 0.006]. Alao, GCS 9–12 had 3.36 times more odds of ICU admission, and GCS 3–8 had 5.43 times more odds compared to the GCS 13–15 [OR:3.36, 95% CI (1.34 to 8.37), p = 0.009], [OR:5.43, 95%CI (1.81 to 16.25), p = 0.002] respectively—Table 4 .

Blood transfusion. Univariate logistic regression revealed blunt trauma increased the chance of blood transfusion 1.83 times more than penetrating [OR: 1.83, 95% CI (1.04 to 3.22), p = 0.034]. Also, MT with 5.2 OR [OR: 5.2, 95% CI (3.09 to 8.72), p < 0.001], hypovolemia with 2.27 more odds [OR: 2.27, 95% CI (1.35 to 3.82), p = 0.002], and shock index more than one with 2.02 OR [OR: 2.02, 95% CI (1.2 to 3.4), p = 0.008] increased blood transfusion chance. Other predictors were ISS 9–15 [OR: 4.75, 95%CI (2.81 to 8.02), p < 0.001], and ≥ 16 [ OR: 6.56, 95% CI (3.79 to 11.38), p < 0.001] compared to ISS 1–8. In addition, patients who were candidates for OM had a 1.65 times more chance for blood transfusion than the NOM [OR: 1.65, 95% CI (1.09 to 2.49), p = 0.016], respectively.

In the multiple logistic regression after adjustment, ISS ≥ 16 increased the chance of ICU admission 3.53 times, and ISS 9–15 increased three times relative to the ISS 1–8 [OR: 3.53, 95% CI (1.79 to 6.96), p = 0.001], [OR: 3, 95% CI (1.6 to 5.62), p < 0.001]. Other predictors were M.T with 2.28 OR [OR: 2.28, 95% CI (1.17 to 4.43), p = 0.015], and OM with 1.89 OR relative to the NOM [OR: 1.89, 95% CI (1.19 to 2.98), p = 0.006]—Table 5 .

In our study, among 532 patients with an abdomen injury, 78.9% of them were caused by blunt trauma and 76% by RTI. Most victims were men and middle-aged people, like our previous report about gender differences in trauma and other trauma reports [ 15 , 16 , 17 ]. Most abdominal injury victims had primary education, as a previous study from NTRI observed primary education as a predominant educational level [ 18 ]. Our findings comparing blunt and penetrating abdomen injuries included that blunt injuries had higher ISS, blood transfusion, mortality, and ICU admission rates. Blunt victims managed non-operative in two-thirds of cases. In contrast, penetrating injuries were related to OM and negative laparotomy. The most organ damage was spleen and liver in blunt trauma, similar to other studies [ 15 ], and intestine and colon in penetrating injuries. We demonstrated that higher ISS, lower GCS, and NOM were predictors of ICU admission.

At first, Shaftan in 1960 described the observation of abdomen injuries with no significant mortality and morbidity [ 19 ]. In our study, we demonstrated blunt injuries were managed non-operative while penetrating victims were managed operative mainly. In cases where patients with blunt injuries are stable, studies have shown that non-operative management is favored as the primary form of treatment. While in penetrating injuries, OM and NOM could be performed. NOM is increasing because of decreasing LOS, hospital costs, and negative laparotomy rates [ 20 , 21 ], performed in patients with stable hemodynamics without peritonitis signs [ 22 ]. Based on the studies, selective NOM in patients with shotgun injuries was better than OM because of better outcomes and lower complications [ 23 ]. The study from the USA reported that one-quarter of patients with firearm injuries and one-third of those who suffered from stabs were managed non-operatively. Also, they showed an increase in the NOM rate and a decrease in negative laparotomy [ 24 ].

Blunt injury victims had worse trauma outcomes compared to penetrating injuries. Compared to penetrating injuries, they had a higher mortality rate non-significantly and higher LOS, ICU admission, and blood transfusion. In contrast, a study from Germany observed that unstable hemodynamics, mortality rate, and emergency surgery indication were higher in penetrating trauma than in blunt injuries [ 17 ]. Another study with a 9.5% mortality rate in abdomen trauma observed that non-survivors suffered from blunt trauma mostly [ 25 ]. In the blunt group, ICU admission and LOS were higher than penetrating because of the higher rate of extra abdominal injuries and NOM in this group. Two-thirds of patients with blunt trauma managed non-operatively. In NOM, patients were admitted to the ICU for observation. Besides, these patients had injuries in other body parts besides the abdomen. Multiple trauma patients had a higher chance of ICU admission compared to others. In this line, a study from the Scottland trauma registry showed that patients with injuries in several other body parts besides the abdomen had longer LOS [ 25 ]. Blunt victims had non-significantly lower hypovolemia, higher Shock index, and significantly higher blood transfusion compared to the penetrating. However, blunt trauma was not a predictor of blood transfusion; on the contrary, OM, MT, and higher ISS led to blood transfusion.

Blunt trauma had higher ISS than penetrating. ISS ≥ 16 in the blunt group and 1 < ISS < 8 in the penetrating group were more frequent. Based on the studies, higher ISS is associated with a higher ICU admission rate chance [ 26 ]. In this line, our blunt victims had higher ISS and more ICU admissions.

In this study, 186 laparotomies were performed for patients from both groups; in total, 17.2% had negative laparotomy, similar to other countries that reported 6 to 25% negative laparotomy [ 10 , 15 , 27 ]. Two-thirds of negative laparotomy belongs to penetrating injuries because of more OM in this group. Eight patients were admitted to ICU after negative laparotomy, and two had a blood transfusion. According to the studies, laparotomy is necessary for patients with hemodynamically unstable, unreliable abdominal examination and abdomen tenderness. There are two recommendations for laparotomy: performing laparotomy earlier in patients with a wound entering the abdomen cavity, whereas newer publications recommend a decision based on the clinical features [ 27 , 28 , 29 ]. The first policy indicated that negative laparotomy did not need organ repair. This situation led to some complications, including wound infection, abscess, and organ laceration [ 27 ]; therefore, decreasing negative laparotomy is crucial.

Based on the studies, laparotomy, and abdomen organ repair surgery had some complications, including wound infection, abscess, and laceration [ 27 ]. These complications may affect patients’ outcomes, for example, longer LOS, ICU admission, blood transfusion, intubation, dialysis or death. On the other hand, the NOM strategy could lead to failure and delayed operation that affected outcomes. Therefore, comparing complications is necessary. Unfortunately, our outcome analysis was performed without considering complications.

Our study had some limitations. Death before arrival at the hospital is not recorded in our trauma registry. Therefore, our mortality rate is confined to hospital stays. Our data did not include other abdominal injury examinations, including diagnostic peritoneal lavage (DPL) and serial examination. Also, Surgical complications after discharge are not recorded in our registry.

We concluded blunt abdominal injuries had worse outcomes, including ICU admission, LOS, and mortality, compared to penetrating, while there were no worse physiologic signs and symptoms, including GCS and hypovolemia. Because blunt abdominal trauma had more concomitant trauma, had higher ISS than penetrating, and blunt victims were candidates for NOM more than penetrating. Therefore, physicians must pay more attention to blunt victims with normal signs and symptoms. In addition, penetrating victims had a higher rate of negative laparotomy. We recommended developing NOM for penetrating injuries more than current experiences to decrease negative laparotomy and its complications.

Data availability

The datasets used and analyzed during the current study are available from Dr. Payman Salamati, director of the NTRI project, on reasonable request.

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Acknowledgements

The authors are grateful for the cooperation of the NTRI.

This paper was extracted from a project financially supported by NTRI.

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Sara Mirzamohamadi, Vali Baigi, Payman Salamati, Vafa Rahimi-Movaghar, Mohammadreza Zafarghandi, Sobhan Pourmasjedi, Seyed Mohammad Piri, Khatereh Naghdi & Seyed Amir Miratashi Yazdi

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Trauma Research Center, Kashan University of Medical Sciences, Kashan, Iran

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SM and MNHA contributed to writing the manuscript, VB contributed to analysis and interpretation, PS contributed to the conception and design and critical revision of the manuscript, VRM and MRZ contributed to the conception and design of the study, MNI, EF, SHSB, MH, AZS, SD, SP, SMP, and KN contributed to data collection and revised the manuscript, SAMY contributed to conception and design and critical revision of the manuscript.

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Mirzamohamadi, S., HajiAbbasi, M.N., Baigi, V. et al. Patterns and outcomes of patients with abdominal injury: a multicenter study from Iran. BMC Emerg Med 24 , 91 (2024). https://doi.org/10.1186/s12873-024-01002-0

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Case Report
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Published: 27 May 2024

A complex case study: coexistence of multi-drug-resistant pulmonary tuberculosis, HBV-related liver failure, and disseminated cryptococcal infection in an AIDS patient

Wei Fu 1 , 2 na1 ,
Zi Wei Deng 3 na1 ,
Pei Wang 1 ,
Zhen Wang Zhu 1 ,
Zhi Bing Xie 1 ,
Yong Zhong Li 1 &
Hong Ying Yu 1

BMC Infectious Diseases volume 24 , Article number: 533 ( 2024 ) Cite this article

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Hepatitis B virus (HBV) infection can cause liver failure, while individuals with Acquired Immunodeficiency Virus Disease (AIDS) are highly susceptible to various opportunistic infections, which can occur concurrently. The treatment process is further complicated by the potential occurrence of immune reconstitution inflammatory syndrome (IRIS), which presents significant challenges and contributes to elevated mortality rates.

Case presentation

The 50-year-old male with a history of chronic hepatitis B and untreated human immunodeficiency virus (HIV) infection presented to the hospital with a mild cough and expectoration, revealing multi-drug resistant pulmonary tuberculosis (MDR-PTB), which was confirmed by XpertMTB/RIF PCR testing and tuberculosis culture of bronchoalveolar lavage fluid (BALF). The patient was treated with a regimen consisting of linezolid, moxifloxacin, cycloserine, pyrazinamide, and ethambutol for tuberculosis, as well as a combination of bictegravir/tenofovir alafenamide/emtricitabine (BIC/TAF/FTC) for HBV and HIV viral suppression. After three months of treatment, the patient discontinued all medications, leading to hepatitis B virus reactivation and subsequent liver failure. During the subsequent treatment for AIDS, HBV, and drug-resistant tuberculosis, the patient developed disseminated cryptococcal disease. The patient’s condition worsened during treatment with liposomal amphotericin B and fluconazole, which was ultimately attributed to IRIS. Fortunately, the patient achieved successful recovery after appropriate management.

Enhancing medical compliance is crucial for AIDS patients, particularly those co-infected with HBV, to prevent HBV reactivation and subsequent liver failure. Furthermore, conducting a comprehensive assessment of potential infections in patients before resuming antiviral therapy is essential to prevent the occurrence of IRIS. Early intervention plays a pivotal role in improving survival rates.

Peer Review reports

HIV infection remains a significant global public health concern, with a cumulative death toll of 40 million individuals [ 1 ]. In 2021 alone, there were 650,000 deaths worldwide attributed to AIDS-related causes. As of the end of 2021, approximately 38 million individuals were living with HIV, and there were 1.5 million new HIV infections reported annually on a global scale [ 2 ]. Co-infection with HBV and HIV is prevalent due to their similar transmission routes, affecting around 8% of HIV-infected individuals worldwide who also have chronic HBV infection [ 3 ]. Compared to those with HBV infection alone, individuals co-infected with HIV/HBV exhibit higher HBV DNA levels and a greater risk of reactivation [ 4 ]. Opportunistic infections, such as Pneumocystis jirovecii pneumonia, Toxoplasma encephalitis, cytomegalovirus retinitis, cryptococcal meningitis (CM), tuberculosis, disseminated Mycobacterium avium complex disease, pneumococcal pneumonia, Kaposi’s sarcoma, and central nervous system lymphoma, are commonly observed due to HIV-induced immunodeficiency [ 5 ]. Tuberculosis not only contributes to the overall mortality rate in HIV-infected individuals but also leads to a rise in the number of drug-resistant tuberculosis cases and transmission of drug-resistant strains. Disseminated cryptococcal infection is a severe opportunistic infection in AIDS patients [ 6 ], and compared to other opportunistic infections, there is a higher incidence of IRIS in patients with cryptococcal infection following antiviral and antifungal therapy [ 7 ]. This article presents a rare case of an HIV/HBV co-infected patient who presented with MDR-PTB and discontinued all medications during the initial treatment for HIV, HBV, and tuberculosis. During the subsequent re-anti-HBV/HIV treatment, the patient experienced two episodes of IRIS associated with cryptococcal infection. One episode was classified as “unmasking” IRIS, where previously subclinical cryptococcal infection became apparent with immune improvement. The other episode was categorized as “paradoxical” IRIS, characterized by the worsening of pre-existing cryptococcal infection despite immune restoration [ 8 ]. Fortunately, both episodes were effectively treated.

A 50-year-old male patient, who is self-employed, presented to our hospital in January 2022 with a chief complaint of a persistent cough for the past 2 months, without significant shortness of breath, palpitations, or fever. His medical history revealed a previous hepatitis B infection, which resulted in hepatic failure 10 years ago. Additionally, he was diagnosed with HIV infection. However, he ceased taking antiviral treatment with the medications provided free of charge by the Chinese government for a period of three years. During this hospital visit, his CD4 + T-cell count was found to be 26/μL (normal range: 500–1612/μL), HIV-1 RNA was 1.1 × 10 5 copies/ml, and HBV-DNA was negative. Chest computed tomography (CT) scan revealed nodular and patchy lung lesions (Fig. 1 ). The BALF shows positive acid-fast staining. Further assessment of the BALF using XpertMTB/RIF PCR revealed resistance to rifampicin, and the tuberculosis drug susceptibility test of the BALF (liquid culture, medium MGIT 960) indicated resistance to rifampicin, isoniazid, and streptomycin. Considering the World Health Organization (WHO) guidelines for drug-resistant tuberculosis, the patient’s drug susceptibility results, and the co-infection of HIV and HBV, an individualized treatment plan was tailored for him. The treatment plan included BIC/TAF/FTC (50 mg/25 mg/200 mg per day) for HBV and HIV antiviral therapy, as well as linezolid (0.6 g/day), cycloserine (0.5 g/day), moxifloxacin (0.4 g/day), pyrazinamide (1.5 g/day), and ethambutol (0.75 g/day) for anti-tuberculosis treatment, along with supportive care.

The patient’s pulmonary CT scan shows patchy and nodular lesions accompanied by a small amount of pleural effusion, later confirmed to be MDR-PTB

Unfortunately, after 3 months of follow-up, the patient discontinued all medications due to inaccessibility of the drugs. He returned to our hospital (Nov 12, 2022, day 0) after discontinuing medication for six months, with a complaint of poor appetite for the past 10 days. Elevated liver enzymes were observed, with an alanine aminotransferase level of 295 IU/L (normal range: 0–40 IU/L) and a total bilirubin(TBIL) level of 1.8 mg/dL (normal range: 0–1 mg/dL). His HBV viral load increased to 5.5 × 10 9 copies/ml. Considering the liver impairment, elevated HBV-DNA and the incomplete anti-tuberculosis treatment regimen (Fig. 2 A), we discontinued pyrazinamide and initiated treatment with linezolid, cycloserine, levofloxacin, and ethambutol for anti-tuberculosis therapy, along with BIC/TAF/FTC for HIV and HBV antiviral treatment. Additionally, enhanced liver protection and supportive management were provided, involving hepatoprotective effects of medications such as glutathione, magnesium isoglycyrrhizinate, and bicyclol. However, the patient’s TBIL levels continued to rise progressively, reaching 4.4 mg/dL on day 10 (Fig. 3 B). Suspecting drug-related factors, we discontinued all anti-tuberculosis medications while maintaining BIC/TAF/FTC for antiviral therapy, the patient’s TBIL levels continued to rise persistently. We ruled out other viral hepatitis and found no significant evidence of obstructive lesions on magnetic resonance cholangiopancreatography. Starting from the day 19, due to the patient’s elevated TBIL levels of 12.5 mg/dL, a decrease in prothrombin activity (PTA) to 52% (Fig. 3 D), and the emergence of evident symptoms such as abdominal distension and poor appetite, we initiated aggressive treatment methods. Unfortunately, on day 38, his hemoglobin level dropped to 65 g/L (normal range: 120–170 g/L, Fig. 3 A), and his platelet count decreased to 23 × 10 9 /L (normal range: 125–300 × 10 9 /L, Fig. 3 C). Based on a score of 7 on the Naranjo Scale, it was highly suspected that “Linezolid” was the cause of these hematological abnormalities. Therefore, we had to discontinue Linezolid for the anti-tuberculosis treatment. Subsequently, on day 50, the patient developed recurrent fever, a follow-up chest CT scan revealed enlarged nodules in the lungs (Fig. 2 B). The patient also reported mild dizziness and a worsening cough. On day 61, the previous blood culture results reported the growth of Cryptococcus. A lumbar puncture was performed on the same day, and the cerebrospinal fluid (CSF) opening pressure was measured at 130 mmH 2 O. India ink staining of the CSF showed typical encapsulated yeast cells suggestive of Cryptococcus. Other CSF results indicated mild leukocytosis and mildly elevated protein levels, while chloride and glucose levels were within normal limits. Subsequently, the patient received a fungal treatment regimen consisting of liposomal amphotericin B (3 mg/kg·d −1 ) in combination with fluconazole(600 mg/d). After 5 days of antifungal therapy, the patient’s fever symptoms were well controlled. Despite experiencing bone marrow suppression, including thrombocytopenia and worsening anemia, during this period, proactive symptom management, such as the use of erythropoietin, granulocyte colony-stimulating factor, and thrombopoietin, along with high-calorie dietary management, even reducing the dosage of liposomal amphotericin B to 2 mg/kg/day for 10 days at the peak of severity, successfully controlled the bone marrow suppression. However, within the following week, the patient experienced fever again, accompanied by a worsened cough, increased sputum production, and dyspnea. Nevertheless, the bilirubin levels did not show a significant increase. On day 78 the patient’s lung CT revealed patchy infiltrates and an increased amount of pleural effusion (Fig. 2 C). The CD4 + T-cell count was 89/μL (normal range: 500–700/μL), indicating a significant improvement in immune function compared to the previous stage, and C-reactive protein was significantly elevated, reflecting the inflammatory state, other inflammatory markers such as IL-6 and γ-IFN were also significantly elevated. On day 84, Considering the possibility of IRIS, the patient began taking methylprednisolone 30 mg once a day as part of an effort to control his excessive inflammation. Following the administration of methylprednisolone, the man experienced an immediate improvement in his fever. Additionally, symptoms such as cough, sputum production, dyspnea, and poor appetite gradually subsided over time. A follow-up lung CT showed significant improvement, indicating a positive response to the treatment. After 28 days of treatment with liposomal amphotericin B in combination with fluconazole, liposomal amphotericin B was discontinued, and the patient continued with fluconazole to consolidate the antifungal therapy for Cryptococcus. Considering the patient’s ongoing immunodeficiency, the dosage of methylprednisolone was gradually reduced by 4 mg every week. After improvement in liver function, the patient’s anti-tuberculosis treatment regimen was adjusted to include bedaquiline, contezolid, cycloserine, moxifloxacin, and ethambutol. The patient’s condition was well controlled, and a follow-up lung CT on day 117 indicated a significant improvement in lung lesions (Fig. 2 D).

Upon second hospitalization admission ( A ), nodular lesions were already present in the lungs, and their size gradually increased after the initiation of ART ( B , C ). Notably, the lung lesions became more pronounced following the commencement of anti-cryptococcal therapy, coinciding with the occurrence of pleural effusion ( C ). However, with the continuation of antifungal treatment and the addition of glucocorticoids, there was a significant absorption and reduction of both the pleural effusion and pulmonary nodules ( D )

During the patient's second hospitalization, as the anti-tuberculosis treatment progressed and liver failure developed, the patient’s HGB levels gradually decreased ( A ), while TBIL levels increased ( B ). Additionally, there was a gradual decrease in PLT count ( C ) and a reduction in prothrombin activity (PTA) ( D ), indicating impaired clotting function. Moreover, myelosuppression was observed during the anti-cryptococcal treatment ( C )

People living with HIV/AIDS are susceptible to various opportunistic infections, which pose the greatest threat to their survival [ 5 ]. Pulmonary tuberculosis and disseminated cryptococcosis remain opportunistic infections with high mortality rates among AIDS patients [ 9 , 10 ]. These infections occurring on the basis of liver failure not only increase diagnostic difficulty but also present challenges in treatment. Furthermore, as the patient’s immune function and liver function recover, the occurrence of IRIS seems inevitable.

HIV and HBV co-infected patients are at a higher risk of HBV reactivation following the discontinuation of antiviral drugs

In this case, the patient presented with both HIV and HBV infections. Although the HBV DNA test was negative upon admission. However, due to the patient’s self-discontinuation of antiretroviral therapy (ART), HBV virologic and immunologic reactivation occurred six months later, leading to a rapid increase in viral load and subsequent hepatic failure. Charles Hannoun et al. also reported similar cases in 2001, where two HIV-infected patients with positive HBsAg experienced HBV reactivation and a rapid increase in HBV DNA levels after discontinuing antiretroviral and antiviral therapy, ultimately resulting in severe liver failure [ 11 ]. The European AIDS Clinical Society (EACS) also emphasize that abrupt discontinuation of antiviral therapy in patients co-infected with HBV and HIV can trigger HBV reactivation, which, although rare, can potentially result in liver failure [ 12 ].

Diagnosing disseminated Cryptococcus becomes more challenging in AIDS patients with liver failure, and the selection of antifungal medications is significantly restricted

In HIV-infected individuals, cryptococcal disease typically manifests as subacute meningitis or meningoencephalitis, often accompanied by fever, headache, and neck stiffness. The onset of symptoms usually occurs approximately two weeks after infection, with typical signs and symptoms including meningeal signs such as neck stiffness and photophobia. Some patients may also experience encephalopathy symptoms like somnolence, mental changes, personality changes, and memory loss, which are often associated with increased intracranial pressure (ICP) [ 13 ]. The presentation of cryptococcal disease in this patient was atypical, as there were no prominent symptoms such as high fever or rigors, nor were there any signs of increased ICP such as somnolence, headache, or vomiting. The presence of pre-existing pulmonary tuberculosis further complicated the early diagnosis, potentially leading to the clinical oversight of recognizing the presence of cryptococcus. In addition to the diagnostic challenges, treating a patient with underlying liver disease, multidrug-resistant tuberculosis, and concurrent cryptococcal infection poses significant challenges. It requires considering both the hepatotoxicity of antifungal agents and potential drug interactions. EACS and global guideline for the diagnosis and management of cryptococcosis suggest that liposomal amphotericin B (3 mg/kg·d −1 ) in combination with flucytosine (100 mg/kg·d −1 ) or fluconazole (800 mg/d) is the preferred induction therapy for CM for 14 days [ 12 , 14 ]. Flucytosine has hepatotoxicity and myelosuppressive effects, and it is contraindicated in patients with severe liver dysfunction. The antiviral drug bictegravir is a substrate for hepatic metabolism by CYP3A and UGT1A1 enzymes [ 15 ], while fluconazole inhibits hepatic enzymes CYP3A4 and CYP2C9 [ 16 ]. Due to the patient's liver failure and bone marrow suppression, we reduced the dosage of liposomal amphotericin B and fluconazole during the induction period. Considering the hepatotoxicity of fluconazole and its interaction with bictegravir, we decreased the dosage of fluconazole to 600 mg/d, while extending the duration of induction therapy to 28 days.

During re-antiviral treatment, maintaining vigilance for the development of IRIS remains crucial

IRIS refers to a series of inflammatory diseases that occur in HIV-infected individuals after initiating ART. It is associated with the paradoxical worsening of pre-existing infections, which may have been previously diagnosed and treated or may have been subclinical but become apparent due to the host regaining the ability to mount an inflammatory response. Currently, there is no universally accepted definition of IRIS. However, the following conditions are generally considered necessary for diagnosing IRIS: worsening of a diagnosed or previously unrecognized pre-existing infection with immune improvement (referred to as “paradoxical” IRIS) or the unmasking of a previously subclinical infection (referred to as “unmasking” IRIS) [ 8 ]. It is estimated that 10% to 30% of HIV-infected individuals with CM will develop IRIS after initiating or restarting effective ART [ 7 , 17 ]. In the guidelines of the WHO and EACS, it is recommended to delay the initiation of antiviral treatment for patients with CM for a minimum of 4 weeks to reduce the incidence of IRIS. Since we accurately identified the presence of multidrug-resistant pulmonary tuberculosis in the patient during the early stage, we promptly initiated antiretroviral and anti-hepatitis B virus treatment during the second hospitalization. However, subsequent treatment revealed that the patient experienced at least two episodes of IRIS. The first episode was classified as “unmasking” IRIS, as supported by the enlargement of pulmonary nodules observed on the chest CT scan following the initiation of ART (Fig. 2 A). Considering the morphological changes of the nodules on the chest CT before antifungal therapy, the subsequent emergence of disseminated cryptococcal infection, and the subsequent reduction in the size of the lung nodules after antifungal treatment, although there is no definitive microbiological evidence, we believe that the initial enlargement of the lung nodules was caused by cryptococcal pneumonia. As ART treatment progressed, the patient experienced disseminated cryptococcosis involving the blood and central nervous system, representing the first episode. Following the initiation of antifungal therapy for cryptococcosis, the patient encountered a second episode characterized by fever and worsening pulmonary lesions. Given the upward trend in CD4 + T-cell count, we attributed this to the second episode of IRIS, the “paradoxical” type. The patient exhibited a prompt response to low-dose corticosteroids, further supporting our hypothesis. Additionally, the occurrence of cryptococcal IRIS in the lungs, rather than the central nervous system, is relatively uncommon among HIV patients [ 17 ].

Conclusions

From the initial case of AIDS combined with chronic hepatitis B, through the diagnosis and treatment of multidrug-resistant tuberculosis, the development of liver failure and disseminated cryptococcosis, and ultimately the concurrent occurrence of IRIS, the entire process was tortuous but ultimately resulted in a good outcome (Fig. 4 ). Treatment challenges arose due to drug interactions, myelosuppression, and the need to manage both infectious and inflammatory conditions. Despite these hurdles, a tailored treatment regimen involving antifungal and antiretroviral therapies, along with corticosteroids, led to significant clinical improvement. While CM is relatively common among immunocompromised individuals, especially those with acquired immunodeficiency syndrome (AIDS) [ 13 ], reports of disseminated cryptococcal infection on the background of AIDS complicated with liver failure are extremely rare, with a very high mortality rate.

A brief timeline of the patient's medical condition progression and evolution

Through managing this patient, we have also gained valuable insights. (1) Swift and accurate diagnosis, along with timely and effective treatment, can improve prognosis, reduce mortality, and lower disability rates. Whether it's the discovery and early intervention of liver failure, the identification and treatment of disseminated cryptococcosis, or the detection and management of IRIS, all these interventions are crucially timely. They are essential for the successful treatment of such complex and critically ill patients.

(2) Patients who exhibit significant drug reactions, reducing the dosage of relevant medications and prolonging the treatment duration can improve treatment success rates with fewer side effects. In this case, the dosages of liposomal amphotericin B and fluconazole are lower than the recommended dosages by the World Health Organization and EACS guidelines. Fortunately, after 28 days of induction therapy, repeat CSF cultures showed negative results for Cryptococcus, and the improvement of related symptoms also indicates that the patient has achieved satisfactory treatment outcomes. (3) When cryptococcal infection in the bloodstream or lungs is detected, prompt lumbar puncture should be performed to screen for central nervous system cryptococcal infection. Despite the absence of neurological symptoms, the presence of Cryptococcus neoformans in the cerebrospinal fluid detected through lumbar puncture suggests the possibility of subclinical or latent CM, especially in late-stage HIV-infected patients.

We also encountered several challenges and identified certain issues that deserve attention. Limitations: (1) The withdrawal of antiviral drugs is a critical factor in the occurrence and progression of subsequent diseases in patients. Improved medical education is needed to raise awareness and prevent catastrophic consequences. (2) Prior to re-initiating antiviral therapy, a thorough evaluation of possible infections in the patient is necessary. Caution should be exercised, particularly in the case of diseases prone to IRIS, such as cryptococcal infection. (3) There is limited evidence on the use of reduced fluconazole dosage (600 mg daily) during antifungal therapy, and the potential interactions between daily fluconazole (600 mg) and the antiviral drug bictegravir and other tuberculosis medications have not been extensively studied. (4) Further observation is needed to assess the impact of early-stage limitations in the selection of anti-tuberculosis drugs on the treatment outcome of tuberculosis in this patient, considering the presence of liver failure.

In conclusion, managing opportunistic infections in HIV patients remains a complex and challenging task, particularly when multiple opportunistic infections are compounded by underlying liver failure. Further research efforts are needed in this area.

Availability of data and materials

All data generated or analyzed during this study are included in this published article.

Abbreviations

Hepatitis B virus

Acquired immunodeficiency virus disease

Immune reconstitution inflammatory syndrome

Human immunodeficiency virus

Multi-drug resistant pulmonary tuberculosis

Bronchoalveolar lavage fluid

Bictegravir/tenofovir alafenamide/emtricitabine

Cryptococcal meningitis

World Health Organization

Computed tomography

Total bilirubin

Cerebrospinal fluid

European AIDS Clinical Society

Intracranial pressure

Antiretroviral therapy

Prothrombin activity

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Acknowledgements

We express our sincere gratitude for the unwavering trust bestowed upon our medical team by the patient throughout the entire treatment process.

This work was supported by the Scientific Research Project of Hunan Public Health Alliance with the approval No. ky2022-002.

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Wei Fu and Zi Wei Deng contributed equally to this work.

Authors and Affiliations

Center for Infectious Diseases, Hunan University of Medicine General Hospital, Huaihua, Hunan, China

Wei Fu, Pei Wang, Zhen Wang Zhu, Ye Pu, Zhi Bing Xie, Yong Zhong Li & Hong Ying Yu

Department of Tuberculosis, The First Affiliated Hospital of Xinxiang Medical University, XinXiang, Henan, China

Department of Clinical Pharmacy, Hunan University of Medicine General Hospital, Huaihua, Hunan, China

Zi Wei Deng

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Contributions

WF and ZWD integrated the data and wrote the manuscript, YHY contributed the revision of the manuscript, PW and YP provided necessary assistance and provided key suggestions, ZWZ, YZL and ZBX contributed data acquisition and interpretation for etiological diagnosis. All authors reviewed and approved the final manuscript.

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Correspondence to Hong Ying Yu .

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The study was approved by the Ethics Committee of the Hunan University of Medicine General Hospital (HYZY-EC-202306-C1), and with the informed consent of the patient.

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Fu, W., Deng, Z.W., Wang, P. et al. A complex case study: coexistence of multi-drug-resistant pulmonary tuberculosis, HBV-related liver failure, and disseminated cryptococcal infection in an AIDS patient. BMC Infect Dis 24 , 533 (2024). https://doi.org/10.1186/s12879-024-09431-9

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Published : 27 May 2024

DOI : https://doi.org/10.1186/s12879-024-09431-9

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Clinical Outcomes After Admission of Patients With COVID-19 to Skilled Nursing Facilities

1 Division of Geriatrics and Aging, Department of Medicine, University of Rochester, Rochester, New York
2 Anderson School of Management, UCLA (University of California, Los Angeles)
3 Department of Health Policy and Management, Harvard T. H. Chan School of Public Health, Boston, Massachusetts
4 Department of Public Health Sciences, University of Rochester School of Medicine and Dentistry, Rochester, New York
5 Division of General Internal Medicine and Primary Care, Brigham and Women’s Hospital, Boston, Massachusetts
Invited Commentary COVID-19 in Nursing Homes—Learning the Hard Way James S. Goodwin, MD; Huiwen Xu, PhD JAMA Internal Medicine

Question Were posthospital admissions to skilled nursing facilities (SNFs) of COVID-19–positive patients associated with worse clinical outcomes prior to availability of COVID-19 vaccines and outpatient treatment?

Findings In this cohort study of a matched group of 264 SNFs with initial admission of COVID-19–positive patients (exposed facilities) and 518 comparator SNFs without initial admission (control facilities), exposed facilities had significant increases in COVID-19 cases and COVID-19–related deaths among residents compared with control facilities. Facilities with personal protective equipment and potential staff shortages had larger increases in COVID-19 cases than those without such shortages.

Meaning Findings from this study suggest that admissions to SNFs of COVID-19–positive patients early in the pandemic likely played a role in preventable COVID-19 cases and mortality.

Importance During the COVID-19 pandemic, stabilized COVID-19–positive patients were discharged to skilled nursing facilities (SNFs) to alleviate hospital crowding. These discharges generated controversy due to fears of seeding outbreaks, but there is little empirical evidence to inform policy.

Objective To assess the association between the admission to SNFs of COVID-19–positive patients and subsequent COVID-19 cases and death rates among residents.

Design, Setting, and Participants This cohort study analyzed survey data from the National Healthcare Safety Network of the Centers for Disease Control and Prevention. The cohort included SNFs in the US from June 2020 to March 2021. Exposed facilities (ie, with initial admission of COVID-19–positive patients) were matched to control facilities (ie, without initial admission of COVID-19–positive patients) in the same county and with similar preadmission case counts. Data were analyzed from June 2023 to February 2024.

Exposure The week of the first observable admission of COVID-19–positive patients (defined as those previously diagnosed with COVID-19 and continued to require transmission-based precautions) during the study period.

Main Outcomes and Measures Weekly counts of new cases of COVID-19, COVID-19–related deaths, and all-cause deaths per 100 residents in the week prior to the initial admission. A stacked difference-in-differences approach was used to compare outcomes for 10 weeks before and 15 weeks after the first admission. Additional analyses examined whether outcomes differed in facilities with staff or personal protective equipment (PPE) shortages.

Results A matched group of 264 exposed facilities and 518 control facilities was identified. Over the 15-week follow-up period, exposed SNFs had a cumulative increase of 6.94 (95% CI, 2.91-10.98) additional COVID-19 cases per 100 residents compared with control SNFs, a 31.3% increase compared with the sample mean (SD) of 22.2 (26.4). Exposed facilities experienced 2.31 (95% CI, 1.39-3.24) additional cumulative COVID-19–related deaths per 100 residents compared with control facilities, representing a 72.4% increase compared with the sample mean (SD) of 3.19 (5.5). Exposed facilities experiencing potential staff shortage and PPE shortage had larger increases in COVID-19 cases per 100 residents (additional 10.97 [95% CI, 2.76-19.19] cases and additional 14.81 [95% CI, 2.38-27.25] cases, respectively) compared with those without such shortages.

Conclusion This cohort study suggests that admission of COVID-19–positive patients into SNFs early in the pandemic was associated with preventable COVID-19 cases and mortality among residents, particularly in facilities with potential staff and PPE shortages. The findings speak to the importance of equipping SNFs to adhere to infection-control best practices as they continue to face COVID-19 strains and other respiratory diseases.

Invited Commentary COVID-19 in Nursing Homes—Learning the Hard Way JAMA Internal Medicine

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Committee on Military Trauma Care's Learning Health System and Its Translation to the Civilian Sector; Board on Health Sciences Policy; Board on the Health of Select Populations; Health and Medicine Division; National Academies of Sciences, Engineering, and Medicine; Berwick D, Downey A, Cornett E, editors. A National Trauma Care System: Integrating Military and Civilian Trauma Systems to Achieve Zero Preventable Deaths After Injury. Washington (DC): National Academies Press (US); 2016 Sep 12.

A National Trauma Care System: Integrating Military and Civilian Trauma Systems to Achieve Zero Preventable Deaths After Injury.

Hardcopy Version at National Academies Press

A Case Studies

As an aid to understanding the military trauma care learning health system and its translation to the civilian sector, and in accordance with the committee's statement of task, this appendix presents case studies that illustrate a broad spectrum of battlefield injuries relevant also to the civilian sector: extremity hemorrhage, blunt trauma with vascular injury, pediatric burn, dismounted complex blast injury, and severe traumatic brain injury. Collectively, the cases provide information on the following topics specified in the committee's statement of task:

Levels of evidence used to develop military and civilian (as applicable) clinical guidelines for the spectrum of trauma care in each case.
Pertinent innovative changes (devices, medications, equipment, methods) that have been incorporated into the spectrum of trauma care for each case as a result of the U.S. Department of Defense's (DoD's) evidence-based improvement process.
Processes by which patient and injury information was collected, stored, reviewed and analyzed by the Joint Trauma System (JTS), including how this information was used for the JTS's evidence-based improvement process and made available for clinical and epidemiologic research.
How collection, storage, review and analysis of patient injury and management information differed for those killed in action versus those wounded in action (i.e., different system for those who die prior to arrival at a medical center, thus eliminating ability to study ways to improve survival).
Impact that evidence-supported changes in military trauma care and the JTS's evidence-supported process improvement may have had on survivability.
How the results of the military's Defense Health Program (DHP) research investment and elements of focused empiricism have been integrated into the JTS, its clinical practice guidelines, and usual military practice.
Evidence of how these changes may be effectively integrated into military training and doctrine (e.g., special units such as the Army Rangers) and how these lessons learned can be applied in the civilian sector.
Time elapsed between the compilation/publication of evidence and development and implementation of clinical guidelines.

For each case, the DoD authors listed below provided information related to interventions, outcomes, levels of evidence for clinical guidelines, and relevant learning health system context:

LTC (P) Andrew P. Cap, M.D., Ph.D., U.S. Army Institute of Surgical Research, FT Sam Houston, Texas
LTC Matthew A. Borgman, M.D., San Antonio Military Medical Center, FT Sam Houston, Texas
Dr. (COL ret) John F. Kragh, M.D., U.S. Army Institute of Surgical Research, FT Sam Houston, Texas
COL Kirby R. Gross, M.D., Joint Trauma System, U.S. Army Institute of Surgical Research, FT Sam Houston, Texas

Dr. Leon Dent, a Robert Wood Johnson Fellow and Associate Professor and Chair of Surgery at Meharry Medical College, Nashville, Tennessee, provided additional assistance in crafting the case studies.

The committee is grateful for their efforts in support of this study.

The cases were reviewed for

medical description of case (care provided, errors, factors that influenced outcome);
military learning process (data management; description of military clinical performance improvement processes, including clinical guideline development and education and training initiatives; and impact of DoD trauma research investment); and
knowledge transfer between the military and civilian sectors regarding best practices and lessons learned.
EXTREMITY HEMORRHAGE CASES

Case Description

In 2006, a male American soldier suffered blast injuries isolated to both lower limbs. The right limb had soft tissue loss, including a length of a major artery, and the left limb injury was a mid-thigh traumatic amputation. In a “scoop-and-run strategy,” he was flown to the emergency room of a nearby combat support hospital (“Baghdad ER”), arriving 6 minutes after injury. Neither in the field nor in the aircraft was an attempt made to control bleeding from his extremity wounds. Upon arrival at the hospital, the first attempt to control bleeding was made when he was found to be pulseless, in hemorrhagic shock. Emergency providers placed a field tourniquet on each lower limb and resuscitation was attempted, but the patient was soon declared dead from the prior exsanguination.

In a separate incident in 2006, a male American soldier was wounded when an explosion resulted in traumatic amputation of both lower limbs. One limb was amputated above the knee and the other below the knee; he had no other injuries. A fellow soldier, who was not a medic, placed tourniquets on both of the patient's extremities. Bleeding was controlled promptly, and the casualty was flown to the “Baghdad ER.” Upon arrival at the hospital, he was in shock and received a massive transfusion of blood. He was taken to the operating room, where his leg wounds were debrided, and he survived.

Case Discussion

These two cases highlight how application of tourniquets in the prehospital setting has a significant impact on outcomes for this injury pattern. In Case 2, the tourniquet was applied at the point of injury by a nonmedic, indicating that the soldiers had been trained to use tourniquets and had tourniquets available. Prompt control of hemorrhage led to the patient's survival despite traumatic amputation of both lower limbs. Case 1 had a similar injury pattern but did not survive because the tourniquets were not applied until the patient reached the hospital. The key point is that tourniquet application in Case 2 was prehospital, illustrating the importance of timely intervention focused on preventing blood loss and death.

Tourniquets were distributed to deployed service personnel in 2005, so it is possible that the device was available and could have been applied to Case 1 in the field, although this was not documented explicitly in the after-action review. Early in the war, poor outcomes resulted from a lack of knowledge regarding the proper use of tourniquets and their consequential application as a tool of last resort. The culture of the military as a whole and of this unit in particular had not yet incorporated practices of tactical combat casualty care (TCCC), which called for the use of tourniquets. Subsequent on-the-ground feedback to Case 1's unit commanding officer resulted in immediate training in tourniquet use and equipping of the unit with tourniquets. In the years that followed this preventable fatality, TCCC guidelines for tourniquets were adopted widely. This case was used as an impetus for incremental improvements in the trauma care system, which in turn improved survival rates. From 2005 to 2011, an estimated 1,000 to 2,000 lives were saved by widespread tourniquet distribution to deploying U.S. military service members ( Andersen et al., 2012 ). During this time period, the annual rate of deployed U.S. military service members dying from limb exsanguination decreased sixfold ( Eastridge et al., 2012 ). Tourniquets are the most important lifesaving intervention during the war.

The Military Learning Process

Data management.

Important efforts in data collection regarding tourniquet use included debriefs of personnel from Special Operations Forces after they had redeployed, evaluations of data on preventable deaths through the office of the Armed Forces Medical Examiner (AFME), and several surveys of caregiver performance at the Baghdad combat support hospital. These data were used to refine best tourniquet practices. Intellectual aspects of decision making on whether to use a tourniquet were studied empirically to provide useful evidence. Under an institutional review board (IRB)-approved protocol and via the registry process, the in-theater research teams helped collect data, enabling rapid analysis and dissemination of information on the safety of tourniquets and the requirement for their prehospital application. Separate analyses conducted in 2005 and 2006 showed a transition to more frequent tourniquet use and improved outcomes ( Beekley et al., 2008 ; Kragh et al., 2008 ). These findings were shared within the Joint Trauma System (JTS) communication network, leading to changes in care.

AFME data have been studied to determine whether fatally injured service members—such as the soldier described in Case 1—could potentially have survived in order to inform performance improvement efforts and identify medical capability gaps for further research and development. The U.S. Army Institute for Surgical Research (USAISR) worked with AFME to conduct a preventable death analysis in 2004 ( Kragh et al., 2013a ). This analysis yielded reports ( Holcomb et al., 2007 ; Kelly et al., 2008 ) noting that significant numbers of preventable deaths were due to extremity hemorrhage from tourniquet-amenable injuries. These findings spurred efforts to improve tourniquet distribution and use. Such studies have shown the importance of capturing data on dead (killed in action [KIA] and died of wounds [DOW]) and wounded casualties (including rehabilitation) and integrating these data into one registry to enable examination of the entire wounding continuum for new knowledge that can improve outcomes. However, these data are currently fragmented across multiple systems.

All patients admitted to Role 3 facilities (e.g., combat support hospitals) are captured in the Department of Defense Trauma Registry (DoDTR), and the Pre-Hospital Trauma Registry (PHTR) now captures data from the point of injury to support performance improvement initiatives. Kotwal and colleagues (2011) demonstrated the importance and effectiveness of a PHTR in the 75th Ranger Regiment. Although impeded initially by information assurance concerns, JTS efforts to develop a U.S. Department of Defense (DoD)-wide PHTR were eventually successful, and the PHTR was fielded in summer 2013. As of November 2015, the care records of approximately 770 patients had been entered in the PHTR. Prior to the creation of the PHTR, data on patients deemed KIA (i.e., died before reaching a treatment facility) and casualties who died at Role 2 military treatment facilities (MTFs) were not captured for inclusion in a DoD trauma registry other than the AFME system. 1 Given the sensitive nature of KIA information, these data are housed separately from the medical records and the trauma registries.

All combat deaths undergo postmortem examination. However, case-specific results are not immediately available to individual providers, and preventable death analyses are not routinely performed. Currently, an effort is under way to provide definitions and a framework for preventable death analyses. Eastridge and colleagues (2012) report that nearly 1,000 servicemembers killed in action between 2001 and 2011 died of wounds that were potentially survivable). However, their objective was merely to review deaths from an anatomic perspective. A true preventable death analysis requires consideration of additional features, such as the tactical situation at the time of the casualty's injury. The capability to conduct such analyses is difficult to develop, but is essential for a complete understanding of where resources need to be applied.

Performance Improvement

The need for tourniquets was recognized in the very first papers on TCCC dating back to 1996 ( Butler et al., 1996 ), and tourniquet use was taught at the military's joint trauma training center at Ben Taub Trauma Center in 2001 ( Kragh et al., 2013b ). However, tourniquets were not widely issued to troops until a Baltimore Sun article in 2005 prompted multiple congressional inquiries ( Kragh et al., 2013b ). It was difficult to overcome inertia and conventional wisdom regarding tourniquets, and they were often used incorrectly as a last resort. After limb exsanguination deaths were recognized to be both common and preventable, the services changed their practice to the use of tourniquets as a means of first aid. Surveys of tourniquet use in Baghdad, including Case 2 above, were published to broadcast the findings to the widest possible audience. The importance of bleeding control was made clear, and by 2009, when the Combat Lifesaver Course book was revised, almost all soldiers had been trained in tourniquet use. This common experience soon helped change the culture of caregiving.

Widespread implementation of tourniquet use has been achieved through such efforts as improvement of clinical performance, refinement of logistic supply management, improvement of leadership in key organizations, improvement in training of all persons at risk, amendment of doctrinal practices, advancement of laboratory research, development of both medical devices and best practices, and use of intermittent surveys to measure progress in caregiving. Connections among medical, logistics, and training stakeholders were instrumental in ensuring the eventual inclusion of tourniquets in first-aid kits issued to all deploying soldiers and the eventual training of all soldiers in using tourniquets effectively. Implementation was initially uneven as Special Operations Forces implemented tourniquet use much earlier, more rapidly, and more thoroughly relative to the conventional military services. Knowledge was disseminated via consultant visits in theater, in-theater trauma conferences, JTS and TCCC guidelines, predeployment training sites, e-mail, presentations at military and civilian meetings, and journal publications.

Impact of DoD Trauma Research Investment

USAISR funded an early (2003) tourniquet distribution effort and, more important, a testing program for tourniquets. Laboratory studies showed that four out of seven tested tourniquets approved by the U.S. Food and Drug Administration (FDA) were not adequately effective at stopping bleeding ( Walters et al., 2005 ). As a result of this effort, the combat application tourniquet (CAT) was selected as the TCCC tourniquet of choice, with subsequent widespread distribution. This capability to test approved devices in military laboratories and identify a single recommended device is crucial, as no other independent laboratories have this capability. Initial experience with tourniquet testing prepared USAISR for later efforts in evaluating junctional tourniquets designed to control bleeding from vascular injuries in the groin and axilla. This work is discussed in the case study on dismounted complex brain injury later in this appendix.

Transfer of Knowledge Between Military and Civilian Sectors

The civilian sector's implementation of best practices in tourniquet use has lagged behind that of the military. A majority of civilian trauma centers (55.1 percent) responding to a recent survey reported that fewer than 20 percent of patients who could have benefited from a tourniquet arrived with one in place ( Haider et al., 2015 ). This lag in civilian use of tourniquets is due in part to the lack of reliable integrated prehospital, hospital, and medical examiner data that collectively describe the problem of preventable deaths from limb wound exsanguination. In addition, very few traumatic amputations or massive tissue disruption injuries resulting from high-velocity gunshots or artillery shell fragments occur in the civilian sector, making it difficult to promote tourniquet use among civilians. Only in the last few years have papers been published regarding civilian tourniquet use; an evidence-based clinical care guideline for external hemorrhage control was released by the American College of Surgeons in 2014 ( Bulger et al., 2014 ).

Despite the lag, the success of tourniquet use on the battlefield has translated to successful use in civilian prehospital care, seen most clearly following the Boston Marathon bombings, where “without a doubt, tourniquets were a difference-maker and saved lives” ( Elster et al., 2013 ). Recently, the Hartford Consensus Committee—a joint committee convened by the American College of Surgeons—developed recommendations for improving the outcomes from exsanguinating limb hemorrhage due to active shooter and other mass casualty events. The group recommends that a continuum of care be implemented that incorporates not only emergency medical services (EMS) response but also initiation of care by law enforcement officers and potentially lay bystanders as well. The foundation for this new paradigm is the body of guidelines issued by the U.S. Military's Committee on Tactical Combat Casualty Care and its civilian counterpart, the Committee on Tactical Emergency Casualty Care. In October 2015, the White House launched a “Stop the Bleed” campaign to empower American civilians to stop life-threatening hemorrhage. Beyond raising awareness, the campaign is working to expand personal and public access to bleeding control kits that contain, among other items, tourniquets. The timeline for the development of greater tourniquet use in military and civilian sectors is summarized in Box A-1 .

TIMELINE FOR GREATER TOURNIQUET USE.

Andersen RC, Shawen SB, Kragh JF Jr., Lebrun CT, Ficke JR, Bosse MJ, Pollak AN, Pellegrini VD, Blease RE, Pagenkopf EL. Special topics. Journal of the American Academy of Orthopaedic Surgeons. 2012; 20 (Suppl. 1):S94–S98. [ PubMed : 22865147 ]
Beekley AC, Sebesta JA, Blackbourne LH, Herbert GS, Kauvar DS, Baer DG, Walters TJ, Mullenix PS, Holcomb JB. Prehospital tourniquet use in Operation Iraqi Freedom: Effect on hemorrhage control and outcomes. Journal of Trauma. 2008; 64 (Suppl. 2):S28–S37. [ PubMed : 18376169 ]
Bulger EM, Snyder D, Schoelles K, Gotschall C, Dawson D, Lang E, Sanddal ND, Butler FK, Fallat M, Taillac P. An evidence-based prehospital guideline for external hemorrhage control: American College of Surgeons Committee on Trauma. Prehospital Emergency Care. 2014; 18 (2):163–173. [ PubMed : 24641269 ]
Butler FK, Hagmann J, Butler EG. Tactical combat casualty care in special operations. Military Medicine. 1996; 161 (Suppl.):3–16. [ PubMed : 8772308 ]
Eastridge BJ, Mabry RL, Seguin P, Cantrell J, Tops T, Uribe P, Mallett O, Zubko T, Oetjen-Gerdes L, Rasmussen TE, Butler FK, Kotwal RS, Holcomb JB, Wade C, Champion H, Lawnick M, Moores L, Blackbourne LH. Death on the battlefield (2001-2011): Implications for the future of combat casualty care. Journal of Trauma and Acute Care Surgery. 2012; 73 (6 Suppl. 5):S431–S437. [ PubMed : 23192066 ]
Elster E, Schoomaker E, Rice C. The laboratory of war: How military trauma care advances are benefiting soldiers and civilians. Health Affairs Blog. 2013 [May 21, 2015]; http: //healthaffairs .org/blog/2013/12/18 /the-laboratory-of-war-how-military-trauma-care-advances-are-benefiting-soldiers-and-civilians .
Haider AH, Piper LC, Zogg CK, Schneider EB, Orman JA, Butler FK, Gerhardt RT, Haut ER, Mather JP, MacKenzie EJ. Military-to-civilian translation of battlefield innovations in operative trauma care. Surgery. 2015; 158 (6):1686–1695. [ PubMed : 26210224 ]
Holcomb JB, McMullin NR, Pearse L, Caruso J, Wade CE, Oetjen-Gerdes L, Champion HR, Lawnick M, Farr W, Rodriguez S, Butler FK. Causes of death in U.S. Special Operations Forces in the Global War on Terrorism: 2001-2004. Annals of Surgery. 2007; 245 (6):986–991. [ PMC free article : PMC1876965 ] [ PubMed : 17522526 ]
Kelly JF, Ritenour AE, McLaughlin DF, Bagg KA, Apodaca AN, Mallak CT, Pearse L, Lawnick MM, Champion HR, Wade CE, Holcomb JB. Injury severity and causes of death from Operation Iraqi Freedom and Operation Enduring Freedom: 2003-2004 versus 2006. Journal of Trauma. 2008; 64 (Suppl. 2):S21–S26. [ PubMed : 18376168 ]
Kotwal RS, Montgomery HR, Kotwal BM, Champion HR, Butler FK Jr., Mabry RL, Cain JS, Blackbourne LH, Mechler KK, Holcomb JB. Eliminating preventable death on the battlefield. Archives of Surgery. 2011; 146 (12):1350–1358. [ PubMed : 21844425 ]
Kragh JF Jr., Walters TJ, Baer DG, Fox CJ, Wade CE, Salinas J, Holcomb JB. Practical use of emergency tourniquets to stop bleeding in major limb trauma. Journal of Trauma. 2008; 64 (Suppl. 2):S38–S49. [ PubMed : 18376170 ]
Kragh JF Jr., Beebe DF, O'Neill ML, Beekley AC, Dubick MA, Baer DG, Blackbourne LH. Performance improvement in emergency tourniquet use during the Baghdad surge. American Journal of Emergency Medicine. 2013a; 31 (5):873–875. [ PubMed : 23481155 ]
Kragh JF Jr., Walters TJ, Westmoreland T, Miller RM, Mabry RL, Kotwal RS, Ritter BA, Hodge DC, Greydanus DJ, Cain JS, Parsons DS, Edgar EP, Harcke T, Baer DG, Dubick MA, Blackbourne LH, Montgomery HR, Holcomb JB, Butler FK. Tragedy into drama: An American history of tourniquet use in the current war. Fort Belvoir, VA: Defense Technical Information Center; 2013b. [ PubMed : 24048983 ]
Little R. Modern combat lacking in old medical supply. Baltimore Sun. 2005 [February 24, 2016]; http://articles .baltimoresun .com/2005-03-06 /news/0503060023_1 _tourniquet-american-soldier-combat .
Walters TJ, Wenke JC, Greydanus DJ, Kauvar DS, Baer DG. Laboratory Evaluation of Battlefield Tourniquets in Human Volunteers. Fort Sam Houston, TX: 2005. (USAISR Technical Report).
BLUNT TRAUMA WITH VASCULAR INJURY CASE

A 27-year-old male soldier was ejected from the turret at the top of his vehicle when it rolled over. He sustained multiple blunt injuries, including complex vascular, nerve, and soft tissue damage to the right upper extremity. He also sustained bilateral humeral fractures. The medic at the scene noted no loss of consciousness, but the patient was observed to have deformities of both upper extremities. Initial vital signs were systolic blood pressure (SBP) 90 mmHg (no diastolic blood pressure could be measured), heart rate (HR) 90 beats per minute (bpm), respiratory rate (RR) 20 breaths per minute (rpm), Glasgow coma score (GCS) 15. Upon the patient's arrival at the receiving Role 3 MTF, the right upper extremity was pulseless, and no motor function or sensation was observed. The right upper extremity had suffered a laceration and soft tissue loss in the axilla and exhibited minimal bleeding. A computed tomography (CT) scan with contrast (see Figure A-1 ) revealed no flow in the right axillary artery, a left pneumothorax, a left lung contusion, and a nondisplaced left sixth rib fracture. Abdominal CT images revealed a grade I hilar splenic injury and a nondisplaced L5 pars interarticularis fracture. There was no hemoperitoneum. Bilateral humeral fractures were present (see Figure A-2 ). A transected right axillary artery and vein were identified at the time of injury (see Figure A-3 ), in addition to anatomic disruption of the ulnar nerve.

The top figures show left pneumothorax (yellow), lung contusion, and nondisplaced sixth rib fracture (red). The bottom figure shows splenic injury (black); femoral line contrast injection results in beam-hardening artifact from density of contrast in (more...)

The image on the left shows right humerus fracture and axillary soft tissue injury. The image on the right shows left humerus fracture.

Imaging shows transected right axillary artery.

Role of Care

In the field, bulky dressings were applied to a right upper extremity open fracture, and a cervical collar was placed. The patient was rapidly evacuated in a 5-minute flight to a Role 3 MTF capable of providing subspecialty surgical care.

Role 3 Care

In the MTF operating room (OR), a left chest tube was placed, the left upper extremity was reduced and splinted, and a vascular shunt was placed from the axillary to the brachial artery. An external fixator was applied to the right humerus. Subsequently, the patient underwent arterial reconstruction, venous interposition, and fasciotomy (incomplete) of the right forearm. He was transfused 7 units of red blood cells, 6 units of fresh frozen plasma, and 1 apheresis unit of platelets. On post-injury day 1, he was transferred to the Role 3 strategic evacuation (STRATEVAC) hub. Repeat CT scanning at the STRATEVAC hub demonstrated a pneumothorax with the chest tube incorrectly placed in the extrapleural space. No bleeding from the spleen was noted. The patient was taken to the OR, where the right arm vascular repair was reassessed; the axillary artery had good flow, but the vein was thrombosed. The right forearm fasciotomy was completed, and a latissimus dorsi muscle flap was mobilized to repair the axillary soft tissue defect and cover the vascular repair. Wounds were covered with negative-pressure dressings, and the patient was extubated prior to transfer to Germany on post-injury day 3.

The overall good outcome of this patient was due to rapid evacuation (5 minutes) from the point of injury to the combat support hospital and prompt resuscitation from hemorrhagic shock. Prompt revascularization resulted in limb salvage. The use of a vascular shunt to delay definitive vascular repair was appropriate in this case given the nature of the polytrauma, the complex vascular injury, and the patient's compromised hemodynamic status. A lengthy vascular repair performed in an austere environment by a surgeon who may perform vascular surgery infrequently is suboptimal. However, several errors in patient management were noted. The error in chest tube placement, resulting in a persistent pneumothorax, was potentially dangerous because of the possibility of the patient's developing a life-threatening tension pneumothorax, particularly during air transport. The importance of obtaining a confirmatory chest x-ray following insertion of a chest tube is a long-held tenet of trauma surgery. The omission of a follow-up chest x-ray was most likely an oversight but may point to inadequate training. The incomplete fasciotomy probably contributed to the loss of the venous graft. Further opening of the forearm fascial compartments was performed on the patient in this case at the Role 3 air hub. This patient's rehabilitation would have been aided by targeted nerve implantation of the axillary nerve roots into the pectoralis muscle. Targeted nerve implantation into muscle has been demonstrated to reduce the formation of painful neuromas, which occur in 13-32 percent of amputees ( Pet et al., 2014 ), limiting or preventing the use of prosthetic devices. This procedure has been used in advanced civilian trauma centers since 2005, but has not been widely adopted.

The acquisition and storage of patient data have evolved within the military in recent years. To mitigate the problem of lost patient data and to assist with performance improvement efforts, patient information is now captured and stored in an electronic medical record (EMR), the Theater Medical Data Store. This system was built over the course of Operation Iraqi Freedom/Operation New Dawn and Operation Enduring Freedom as the need for an EMR was recognized. In addition, JTS abstractors gathered data for inclusion in the DoDTR to support performance improvement.

Patients such as the case presented herein undergo several transfers in care before returning to the United States. These transfers often entail loss of pertinent clinical information from one level of care to the next. Patient information from the point of injury to the initial MTF is transmitted primarily by verbal report from the flight medic to the receiving providers. For only 7 percent of casualties can a TCCC card be identified in the medical chart. Records from the Role 2 MTF are copied and transferred physically with the casualty to the Role 3 MTF. After the theater of operations became mature, nearly all Role 2 facilities had computers that could link to the Theater Medical Data Store to upload patient records. However, because of bandwidth limitations and periods during which the Internet was blocked as a result of operational security concerns, the most reliable means of ensuring that care provided at a Role 2 MTF was relayed to a Role 3 MTF was by hard copy. Entries made into the Theater Medical Data Store by the Role 2 MTF would eventually be available to the Role 3 MTF, where information technology support was much more robust. Before transfer out of theater, however, the entire medical record was copied and then moved physically with the patient. Hard-copy records could be useful to the critical care air transport teams during the 8- to 10-hour transport period out of theater. To further assist successive medical teams along the continuum of care by ensuring efficient transfer of patient data, clinical information sheets were created and transported with the patient. To indicate whether patients with a blunt mechanism of injury had met criteria for clearance of the cervical spine, for example, a spine clearance documentation sheet was included in accordance with the JTS Cervical Spine Evaluation Clinical Practice Guideline. This sheet (see Figure A-4 ) was completed for each casualty with a blunt injury mechanism and accompanied the patient during movement out of theater.

Cervical spine clearance documentation sheet.

During the early experience of Operation Iraqi Freedom, colleagues at Landstuhl Regional Medical Center (Role 4) identified a higher-than-expected rate of incomplete fasciotomies. Many general surgeons lacked training in or experience with extremity injuries, as their orthopedic or vascular colleagues frequently manage these wounds. In the deployed environment, orthopedic surgeons may not be present at all MTFs. To provide feedback to downrange providers and correct deficiencies such as incomplete fasciotomy, a weekly Thursday Combat Casualty Care teleconference connecting in-theater MTFs with Landstuhl and U.S. MTFs was established in 2006. This teleconference provides near-real-time feedback to downrange providers. Early in the conflicts, 15 to 20 cases per week were discussed in this forum, which afforded a chance to provide feedback regarding outcomes as well as opportunities for improvement.

The weekly Thursday Combat Casualty Care teleconference also serves to facilitate recognition of system-wide issues that may need to be addressed through the development of clinical practice guidelines (CPGs) and other performance improvement methods (e.g., educational campaigns). The process by which new CPGs are generated and existing CPGs are updated is described on the JTS CPG webpage ( http:www.usaisr.amedd.army.mil/cpgs.html ). Topics under consideration are presented to a theater trauma leader or the JTS director. An initial draft of the CPG is generated and reviewed by theater trauma leadership; theater trauma subject matter experts; and, subsequently, military trauma subject-matter experts (from each service) who are not currently deployed. Trauma directors at the stateside facilities that receive combat casualties also are asked to provide input. Input from these subject matter experts is collated by the chief of performance improvement at the JTS. Ideally, the JTS director, the chief performance improvement officer of the JTS, and theater trauma leadership reach consensus. The JTS director is the final clinical approval authority; however, the director may convene subject matter experts in an effort to achieve consensus. Current CPGs relevant to blunt trauma with vascular injury are listed in Box A-2 .

JOINT TRAUMA SYSTEM CLINICAL PRACTICE GUIDELINES RELEVANT TO BLUNT TRAUMA WITH VASCULAR INJURY.

The compartment syndrome and fasciotomy CPG, which prescribes complete release of all compartments through full skin and fascial incisions when indicated in patients with ischemic extremities, was developed in June 2009, even though the problem of incomplete fasciotomies was identified as early as 2004. Measurement of the effectiveness of JTS performance improvement initiatives and compliance with CPGs is facilitated by core performance/adherence measures written into a performance improvement monitoring section of each CPG. For example, the core measures for compartment syndrome and fasciotomy CPG are that (1) when fasciotomy is performed, there is complete release of all compartments through full skin and fascial incisions, and (2) when indicated in patients with ischemic extremities, fasciotomy is performed at the time of revascularization. In an October 2012 audit filter review of core measure (1) only 2 of 144 patients undergoing revascularization were found to have required further fasciotomy. For core measure (2) fasciotomy was performed in 69 percent of cases of revascularization. Reviews of data on compliance with core measures during the weekly Thursday Combat Casualty Care teleconference proved to be an effective way of providing feedback on compliance with the CPGs.

The weekly Thursday Combat Casualty Care teleconference, now called the Combat Casualty Care Curriculum, has evolved from a strictly performance improvement focus to an educational forum. Each week a continuing medical education (CME) topic relevant to deployed care is selected, and one or two appropriate cases are presented.

General surgery residents completing their research year at San Antonio Military Medical Center have been directed by their general surgery program director to attend the weekly teleconferences so they can benefit from the lessons learned over the past decade of combat medicine. No other military physicians in training have been directed by leadership to participate in these teleconferences, even though they are an ideal way to meet military-specific education requirements for physicians in training and introduce them to the trauma system in which they will likely be participating. Topics chosen for CME presentations during the Thursday teleconferences are specific to combat casualty care. The topics are sequenced to coincide with the graduate medical education academic year, and all major topics of relevance to combat casualty care are discussed. Trauma system topics are covered early in the academic year. The curriculum also incorporates presentations by military medical historians and military medical research leaders.

The teleconferences will be continued indefinitely to ensure that the technical infrastructure for cross-theater communications is maintained, to reinforce the importance of the trauma system, and to provide combat casualty care education. Based on its demonstrated value in the U.S. Central Command (CENTCOM) area of operations, U.S. Pacific Command (PACOM) has established a similar teleconference, which reviews trauma cases, addresses trauma system issues, and serves as an educational forum. Ideally, all U.S. combatant commands will establish a similar teleconference in their areas of responsibility.

Techniques to restore blood flow through injured vessels to prevent ischemic injury and limb loss have evolved through a continuous transfer of knowledge between military and civilian sectors. Despite evidence during World Wars I and II of the potential value of intravascular tubular devices for bridging arterial injuries and maintaining perfusion, interest in such devices waned during the Korean and Vietnam Wars as focus shifted to vascular repair approaches ( Hancock et al., 2010 ). During this period, commercially available vascular shunts were developed in the civilian sector to permit flow during open, elective vascular procedures but there remained little investigation into the use of shunts for trauma applications until a significant burden of vascular injury during the wars in Afghanistan and Iraq generated the necessity. Vascular shunts were incorporated into damage control strategies at forward surgical sites (Role 2) early during the war in Iraq and were shown to be effective at restoring extremity perfusion until the patient could be evacuated to higher levels of care for definitive reconstructive vascular surgery ( Hancock et al., 2010 ). Having shown that the use of vascular shunts extends the window of opportunity for limb salvage, efforts are under way to develop vascular shunts with specific application to military trauma management. The features useful in vascular shunts for trauma care would be a side port for blood pressure monitoring, anticoagulant administration, and contrast injection. Local anticoagulant administration would ensure that therapeutic dosage could be administered directly to a compromised extremity. Also, since combat trauma commonly involves multilevel injury, the distal vascular structures may benefit from radiographic imaging for identification of multilevel vascular injury prior to definitive vascular repair.

Hancock H, Rasmussen TE, Walker AJ, Rich NM. History of temporary intravascular shunts in the management of vascular injury. Journal of Vascular Surgery. 2010; 52 (5):1405–1409. [ PubMed : 20615647 ]
Kragh JF Jr., San Antonio J, Simmons JW, Mace JE, Stinner DJ, White CE, Fang R, Aden JK, Hsu JR, Eastridge BJ. Compartment syndrome performance improvement project is associated with increased combat casualty survival. Journal of Trauma and Acute Care Surgery. 2013; 74 (1):259–263. [ PubMed : 23147175 ]
Pet MA, Ko JH, Friedly JL, Mourad PD, Smith DG. Does targeted nerve implantation reduce neuroma pain in amputees? Clinical Orthopaedics and Related Research. 2014; 472 (10):2991–3001. http://doi .org/10.1007/s11999-014-3602-1 . [ PMC free article : PMC4160473 ] [ PubMed : 24723142 ]
White JM, Stannard A, Burkhardt GE, Eastridge BJ, Blackbourne LH, Rasmussen TE. The epidemiology of vascular injury in the wars in Iraq and Afghanistan. Annals of Surgery. 2011; 253 (6):1184–1189. [ PubMed : 21217514 ]
Zonies D, Eastridge BJ. Combat management of splenic injury: Trends during a decade of conflict. Journal of Trauma and Acute Care Surgery. 2012; 73 (2 Suppl. 1):S71–S74. [ PubMed : 22847099 ]
PEDIATRIC BURN CASE

In fall 2004, a 2-year-old male presented to the 31st Combat Support Hospital emergency room (“Baghdad ER”) after a vehicle explosion. He had been seated in the back seat of a vehicle stopped at a checkpoint that exploded after being struck from behind by another vehicle. He suffered approximately 30 percent total body surface area flame burn (partial to full thickness) to the face, anterior torso, abdomen, bilateral hands, bilateral legs (left leg circumferentially), and lower back. His past medical history, surgical history, medications, and allergies were all unknown. His social history also was unknown, other than that his mother and brother had perished in the fire. The time of injury to presentation was not documented, but was presumed to be less than 2 hours. Upon arrival at the hospital, he was awake and crying, Glascow coma score (GCS) was 15. Initial vital signs were blood pressure 156/67, heart rate 124, respiratory rate 34, saturation 100 percent on supplemental oxygen delivered by nonrebreather mask. His estimated weight was 10 kg. He was breathing comfortably but had soot noted in the airway; his lungs were clear to auscultation. A venous blood gas measurement revealed acidosis and hypoxia: pH 7.12, pO 2 62 mmHg, pCO 2 31 mmHg, bicarbonate 20 mEq/L, base excess 9 mEq/L.

The patient was intubated and brought immediately to the operating room for debridement and dressing of burns. Lateral escharatomies were performed on the left leg and the dorsum of each foot. He received a total of 700 mL of crystalloid and had minimal blood loss. He was transferred to the intensive care unit (ICU) for continued care, with good pulmonary compliance noted. The child developed significant capillary leak and fluid overload in the initial 72 hours. Additional extremity escharatomies were performed on days 1 and 2 for compartment syndrome. A peritoneal drain was placed on day 3 for abdominal compartment syndrome. The child also developed severe acute respiratory distress syndrome. No advanced forms of invasive ventilation were available to treat his worsening pulmonary compliance, and he required peak inspiratory pressures of 90 mm Hg and positive-end expiratory pressure of 20 mmHg, as well as prone positioning, to maintain oxygen saturations greater than 85 percent and pH greater than 7.2. He required a total of approximately 25 days on the ventilator. Ultimately, he was successfully weaned to room air and was discharged to home on hospital day 40. He was able to receive limited physical therapy and rehabilitation while admitted.

This case highlights several challenges in the care of burn patients, and pediatric patients in general. U.S. and Coalition military patients with severe burns are quickly evacuated out of theater by critical care air transport teams, and patients with the most severe burns are transported by a specialized burn team from the U.S. Army Institute of Surgical Research in San Antonio, Texas. In contrast, this patient, like other host nation citizens with significant burns, could not be evacuated to an alternative hospital with a specialized burn team and long-term rehabilitation capabilities (including nutritional and psychosocial resources).

This patient benefited from the care of a pediatric intensivist who happened to be deployed to Baghdad at the time. This kind of specialty care is not commonly available in a war zone. Although a good outcome was achieved, several deficiencies hampered the care of this child. No advanced forms of invasive ventilation, such as high-frequency oscillatory ventilation or inhaled nitric oxide support, were available to treat his worsening pulmonary compliance and edema. Devices for accurately measuring intra-abdominal pressure also were not available. Innovative use of bedside ultrasound in the hospital made it possible to determine that the patient was hypervolemic based on superior vena cava diameter and atrial size. This determination assisted in the diagnosis of abdominal compartment syndrome as the cause of the child's anuria and renal failure. Overall, this patient was overresuscitated, as evidenced by his abdominal compartment syndrome. Where in the chain of care this occurred is unclear, but it was probably in the hospital stage. Documentation of prehospital care for this patient was not available.

Burn injury accounted for 14 percent of all pediatric patients seen at DoD Role 3 or 2b MTFs in Afghanistan and Iraq from 2003 through 2011. The average hospital length of stay was 10 days (range 0 to 171 days). Because of longer lengths of stay, children accounted for 11 percent of all bed days during this period, although representing only 5.8 percent of admissions. Their overall mortality was 13.3 percent ( Borgman et al., 2015 ).

Despite the substantial numbers of pediatric patients cared for at expeditionary military hospitals, resources are inadequate for the acute and long-term care of critically ill children (and adult host nation burn patients). Early in the conflicts, clinicians had to improvise pediatric-sized medical equipment. In 2006, with input from pediatricians, the U.S. Army Medical Materiel Agency made available a set of pediatric supplies, which ultimately resulted in the assembly of the current pediatric humanitarian assistance augmentation medical equipment set. Even after 2006, however, when complete sets of pediatric equipment and medication had been developed, lack of communication about the existence of these kits impaired the implementation of their use, as the kits had to be specially requested.

Although optimal supplies and personnel may not have been available to treat a pediatric casualty in a combat environment, the care the child in this case report received far exceeded that which was (and is) available in Baghdad. This was just one of many cases indicating the need to deploy a set of pediatric equipment and physicians trained in pediatric critical care to combat support hospitals in theater. Military doctrine still has not evolved to ensure the availability of critical care for pediatric combat casualties.

The Military's Learning Process

Although the DoDTR was initially envisaged as a means of tracking and informing the care of U.S. casualties, it is also a robust repository of data on severely injured children. Pediatric cases admitted to Role 3 MTFs are entered into the DoDTR; otherwise, data collection on these patients is extremely limited (case reports). DoDTR data enabled an in-depth epidemiological study of pediatric burn injuries in combat, which identified factors associated with mortality based on burn severity ( Borgman et al., 2015 ). However, entry of pediatric data into the DoDTR has not been a priority, and as a result, there generally has been a considerable lag between the occurrence of pediatric cases and their entry into the system for analysis. Armed Forces Medical Examiner (AFME) data are not available to inform preventable death analyses for pediatric patients since the AFME performs autopsies on U.S. service members killed in action, not on host country nationals.

Resources for deployed physicians treating burn and pediatric patients were developed by the JTS primarily by expert consensus, but also informed by ongoing analysis of clinical data from the DoDTR. When this case occurred, no definitive guidance on the care of pediatric burns was available. The JTS Burn Care CPG ( JTS, 2013 ) has evolved since this case occurred to include issues useful in the management of children with burns. However, there are no CPGs specific to pediatric burn care. The recommendations added to the burn care CPG with regard to children are more like rules of thumb and are not based on a rigorous analysis of CENTCOM outcomes in these patients (which would be hard to perform for long-term outcomes since host national patients are eventually discharged out of the military system). Very few clinical trials have been conducted in these areas, so guidelines are frequently based on Level 3 evidence.

While capabilities to care for these complex pediatric patients generally have improved since the start of the wars, pediatric host national cases are not rigorously analyzed for performance improvement purposes, and there are no published studies on improvement in these patients over time nor is there any pediatric-specific monitoring of CPG compliance. Even when performance improvement processes such as mortality and morbidity reviews were carried out at combat support hospitals, transmission of the resultant lessons learned to the next group of physicians was a challenge. Lessons learned were often distributed by word of mouth and in a textbook that was published years later ( Fuenfer and Creamer, 2010 ). To address potential knowledge and training deficits, the U.S. Army Medical Department Center and School developed a 5-day course—the Joint Forces Combat Trauma Management Course—that addresses burns, pediatric patients, and other topics relevant specifically to those providers deploying to Role 2 or 3 MTFs. Specialty-specific e-mail listservs (including separate teleconsultation groups for burn trauma and pediatrics) also were created so that deployed providers could rapidly contact specialists in the United States should complex clinical questions arise.

The recent experience in Afghanistan and Iraq has led to significant improvements in the U.S. military's ability to provide advanced care to adult burn patients in the deployed setting. For example, the recurrent problems encountered with fluid overload in burn management led to the development of the Burn Resuscitation Decision Support System (BRDSS) by the U.S. Combat Casualty Care Research Program. The BRDSS can enable providers to accurately resuscitate burn patients from the point of injury to definitive care using an algorithm that automatically generates patient-specific fluid rate recommendations for resuscitation. This medical device, available for use in hospitals and the field (mobile format deployed in 2014), started as a research project within the U.S. Army Medical Research and Materiel Command and was the first device to undergo advanced development and go from FDA approval to the field. Its success represents a development model that is also enabling progress in closing other combat casualty care capability gaps ( DoD, 2015 ). However, the BRDSS is not currently indicated for pediatric patients (under 18 years of age), although future versions may include a pediatric module. Research on optimal clinician training and configuration of equipment sets and systems-level integration of host national pediatric and burn care into the overall DoD trauma system represent opportunities for further refinement of expeditionary medicine.

Care for pediatric burn patients provides a rich opportunity for military and civilian knowledge transfer and collaboration to fill gaps in both sectors. Several civilian pediatric burn centers have established protocols for care for pediatric burn patients that include timing of surgery, wound care management, sedation and analgesia, nutrition, pharmacology, and psychosocial care. These protocols could be adapted to resources available for pediatric burn care in an austere environment. As these protocols are not published, the process for knowledge transfer could involve subject matter experts teaming with military providers to create a best practices protocol.

Civilian pediatric trauma centers rarely encounter blast-related penetrating injuries, but this type of injury is commonplace in a war zone, enabling military researchers to conduct research that would be difficult or even infeasible in the civilian sector. For example, Borgman and colleagues (2011) used the DoDTR to develop the pediatric “BIG” trauma score for predicting mortality on admission in pediatric trauma patients. This method was later validated with data from German pediatric civilians as well as Canadian blunt trauma patients ( Borgman et al., 2011 ; Davis et al., 2015 ), and may have use in a variety of civilian trauma and research centers.

Military experience with adult burn patients also has informed burn care in the civilian sector. For example, military data from burned soldiers were used to develop a revised fluid resuscitation formula (Modified Brooke) that has been widely applied to avoid fluid overload at civilian burn centers. In addition, the computerized decision support tool developed at the U.S. Army Institute of Surgical Research Burn Center to help guide fluid management has supported care for both civilian burned casualties and service members being evacuated out of theater.

Borgman MA, Maegele M, Wade CE, Blackbourne LH, Spinella PC. Pediatric trauma BIG score: Predicting mortality in children after military and civilian trauma. Pediatrics. 2011; 127 (4):e892–e897. [ PubMed : 21422095 ]
Borgman MA, Matos RI, Blackbourne L, Spinella PC. Ten years of military pediatric care in Afghanistan and Iraq. Journal of Trauma and Acute Care Surgery. 2012; 73 (6 Suppl. 5):S509–S513. [ PubMed : 23192078 ]
Borgman MA, Matos RI, Spinella PC. Isolated pediatric burn injury in Iraq and Afghanistan. Pediatric Critical Care Medicine. 2015; 16 (2):e23–e27. [ PubMed : 25560430 ]
Chung KK, Wolf SE, Cancio LC, Alvarado R, Jones JA, McCorcle J, King BT, Barillo DJ, Renz EM, Blackbourne LH. Resuscitation of severely burned military casualties: Fluid begets more fluid. Journal of Trauma and Acute Care Surgery. 2009; 67 (2):231–237. [ PubMed : 19667873 ]
Davis AL, Wales PW, Malik T, Stephens D, Razik F, Schuh S. The BIG score and prediction of mortality in pediatric blunt trauma. Journal of Pediatrics. 2015; 167 (3):593–598. [ PubMed : 26118931 ]
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Fuenfer MM, Creamer KM. Pediatric surgery and medicine for hostile environments. Washington, DC: Office of The Surgeon General, Borden Institute, Walter Reed Army Medical Center; 2010.
JTS (Joint Trauma System). Clinical practice guideline: Burn care. San Antonio, TX: JTS; 2013. [July 1, 2015]. http://www .usaisr.amedd .army.mil/cpgs/Burn_Care_13_Nov_13 .pdf .
DISMOUNTED COMPLEX BLAST INJURY CASE

A 29-year-old male service member sustained injuries in 2009 from an improvised explosive device while on patrol. His injuries included traumatic amputation of his left lower extremity and a compound right lower extremity fracture (see Figure A-5 ). There was extensive soft tissue injury to both lower extremities. The field medic noted that the patient had a palpable radial pulse, heart rate 110, respiratory rate 15, Glasgow coma score 15, and severe pain. Further evaluation during tactical evacuation revealed a large perineal wound that later was shown to extend from the right groin through the perineum to the perirectal area (see Figure A-6 ). A computed tomography (CT) scan showed widening and misalignment of the patient's symphysis pubis (see Figure A-7 ).

This 3-D CT image with representative axial images shows bilateral lower-extremity below-the-knee amputations (incomplete on the right lower extremity) with extensive soft tissue injury with debris, fragments, and lower extremity fractures. Bilateral (more...)

Axial CT images demonstrate a soft tissue injury tract along the right groin extending to the perirectal region (yellow) with adjacent surgical packing. Soft tissue gas and pelvic hematoma are found along the tract. Note small amount of air in right hip (more...)

3-D image of the pelvis demonstrates subtle widening and misalignment of the symphysis pubis. There is a displaced fracture of the right sacrum as well as a nondisplaced left sacral alar fracture involving the neuroforamina (arrow). Overlying pelvic binder (more...)

Role 1 Care

At the point of injury, the field medic applied the following interventions: two SOF-T tourniquets to the left lower extremity, makeshift splinting of the right lower extremity, pressure dressing application to the right lower extremity and right groin, a pelvic binder, saline lock placement, ketamine 50 mg intravenous for pain, and a hypothermia prevention and management kit. The patient exhibited signs of hemorrhagic shock (a thready pulse) and subsequently was given 300 ml saline.

Tactical Evacuation

During tactical evacuation, intraosseous vascular access was established, and further bleeding control measures were taken (packing and pressure on the perineal wound, and transfusion with 1 unit each of red blood cells and fresh frozen plasma). Additional ketamine was administered in an effort to manage pain.

At the receiving Role 3 MTF, pneumatic tourniquets were applied, and the patient received further resuscitation with whole blood and tranexamic acid (TXA). In the operating room, the colon was divided at the rectosigmoid junction and left in discontinuity. A temporary abdominal closure was applied. During the same operative intervention, a pelvic external fixator was placed, and both lower extremities were amputated through the knees. On the day following the injury, the patient was transported by a critical care air transport team to a Role 3 strategic evacuation (STRATEVAC) hub, where washouts of the lower extremity wounds were performed and negative pressure dressings applied, the pelvic external fixator was adjusted, and an end colostomy was fashioned. Nasoenteral feeding access was placed during an exploratory laparotomy by advancing a tube into the proximal jejunum. Subsequently, the fascia was closed.

Evacuation Out of Theater

The patient was transported out of theater on day 2 post-injury by a critical care air transport team. During the 8.5-hour flight, the patient received another transfusion with 4 units of red blood cells and 3 units of fresh frozen plasma to counter ongoing blood loss.

Role 4 Care

Upon arrival at Landstuhl Regional Medical Center in Germany, the patient's wounds were washed out, and he was extubated. An oblique fracture of the third metacarpal bone and a ruptured tympanic membrane were identified. The patient remained in Germany for 3 days before being moved to the United States.

Role 5 Care

During the patient's treatment at a U.S. MTF, both lower extremity amputations were revised to above the knee, and the sacroiliac joint was transfixed.

This case typifies the dismounted complex blast injury (DCBI) pattern, caused by exposure of warfighters on foot patrol to blast and high-velocity fragments generated by the detonation of buried or concealed ground-level explosive devices. The injury pattern includes a traumatic amputation of at least one leg, a severe injury to another extremity, and pelvic, abdominal, or urogenital wounding. This pattern of injury was formally described as DCBI in 2010.

In this case, the medic's actions to control blood loss (prompt application of tourniquets and packing of the groin wound) and prevent hypothermia in the field were consistent with TCCC guidelines and were key to this patient's survival. According to TCCC guidelines, the patient might also have benefited from administration of TXA, antibiotics, and blood products for resuscitation (whole blood or red blood cells and plasma) in the field, as well as application of a junctional tourniquet. Currently, however, DoD has fielded junctional tourniquets on a very limited basis. Whole blood and freeze-dried plasma are available only in Special Operations units, and red blood cells and plasma are available only on a limited basis for medical evacuation (MEDEVAC), not for field care.

The patient described in this case received prehospital and hospital-based care. Data from his medical records for these two phases of care are currently entered into separate DoD databases. Point-of-injury care is abstracted into the Pre-Hospital Trauma Registry (PHTR), and data from Role 3, Role 4, and Role 5 MTFs are captured in the DoDTR. Patient data collected during tactical evacuation (intratheater) are abstracted into a separate TACEVAC (formerly called MEDEVAC) database developed by the JTS. Data capture for care provided at the point of injury and during transport between theater MTFs has been reliable since 2009. Because DoDTR inclusion criteria prior to 2013 required an admission to a Role 3 MTF, data on casualties who received care at a Role 2 facility were not abstracted into the DoDTR if (1) they did not require evacuation to a Role 3 facility or (2) they died at the Role 2 facility. Care provided to patients in these two categories was abstracted into a Role 2 database by Role 2 clinical staff. The separate databases for the different levels of care represent a suboptimal system design. Ideally, an integrated registry would be developed that is oriented less to the role of care and more to the casualty. Despite these limitations, however, the DoDTR was a critical resource in the identification of the DCBI injury pattern and subsequent efforts to improve care for service members sustaining these devastating injuries. In its absence, the ability to detect distinct and evolving wounding patterns may have been significantly delayed.

DoDTR data were analyzed in 2010 in response to concerns from deployed line and medical communities regarding an apparent increase in multiple limb amputations concomitant with severe genitourinary injury. This analysis revealed a clear increase in the frequency of the injury pattern described as DCBI. These data and the severe nature of the injuries prompted the Army Surgeon General to appoint a task force charged with studying the causation, prevention, protection, treatment, and long-term care options for this injury pattern. The task force's report was released in June 2011.

Many of the best practices identified by the task force and applied to the care of DCBI patients represented advances made in the earlier years of conflicts in Afghanistan and Iraq. For example, the task force echoed TCCC recommendations to use tourniquets at the point of injury for hemorrhaging extremity injuries and to avoid large-volume crystalloid resuscitation. CPGs—introduced initially in December 2004 as the deployed trauma system's means of avoiding variation in care—had already been developed for the topics of resuscitation, management of war wounds, hypothermia prevention, and intratheater transport and were well accepted by the time of the dramatic increase in the DCBI wounding pattern. Recognition of DCBI prompted renewed attention to CPG implementation, education, and performance improvement measures. (CPGs relevant to DCBI are listed in Box A-3 .)

JOINT TRAUMA SYSTEM CLINICAL PRACTICE GUIDELINES RELEVANT TO DISMOUNTED COMPLEX BLAST INJURY.

A new CPG—the Invasive Fungal Infection CPG—was developed by the JTS in direct response to complications seen with this pattern of injury. The development of invasive fungal infections associated with DCBI was noted among marines injured during dismounted patrol in Helmand Province returning for treatment to the National Naval Medical Center (now the Walter Reed National Military Medical Center 2 ). Trauma leadership at the National Naval Medical Center informed the JTS of these fungal infections, and infectious disease colleagues at Landstuhl Regional Medical Center and the Trauma Infectious Disease Outcomes Study Group at the Uniformed Services University of the Health Sciences undertook the development of the Invasive Fungal Infection in War Wounds CPG. The CPG, which was distributed in 2012, identified casualties at risk for invasive fungal infections and directed that these patients have Dakin's solution applied to wounds as a countermeasure effective at low concentrations against fungus ( Rodriguez et al., 2014 ). Evidence supporting this CPG is Level 3 and is based on retrospective review of a prospectively gathered database.

Other changes in the deployed trauma system were made in response to recommendations from the DCBI task force's report. For example, the report prompted the deployment of urologists to Role 3 MTFs to improve care of genitourinary injuries in the DCBI context and the equipping of MEDEVAC helicopters with supplies to enable blood-product-based resuscitation (specifically plasma and red blood cell units delivered in a 1:1 ratio) for certain missions. To facilitate early blood-based resuscitation, the task force also called for a major effort to deliver a freeze-dried plasma product to the battlefield. Freeze-dried plasma lacks FDA approval, but freeze-dried plasma produced by the French Army was procured under an Expanded Access Investigational New Drug protocol for U.S. Special Operations Forces. No FDA-approved product is widely available to deployed troops.

Collectively, the changes in JTS guidance and care practices likely led to improvement in survivability. However, no data exist with which to determine impacts on outcomes associated with specific changes in practice, and quality-of-life metrics for survivors remain a significant gap in reporting as the focus has been on mortality. The JTS does not currently have the resources to obtain long-term functional recovery and quality-of-life data on combat casualties.

Impact of DoD Research Investment

The DCBI task force and related research efforts expanded on TCCC methods to incorporate use of junctional tourniquets to aid in the control of groin bleeding. Service members on foot patrol suffering improvised explosive device blasts may have very proximal traumatic amputations precluding effective application of extremity tourniquets. Dr. John Kragh at the U.S. Army Institute of Surgical Research demonstrated effective techniques for a junctional tourniquet (the combat-ready clamp) as early as 2012. To date, DoD's Combat Casualty Care Research Program has yielded several junctional tourniquet models that have been approved by the FDA and fielded on a limited basis.

DCBI, which is associated with significant soft tissue injury and hemorrhage leading to the coagulopathy of trauma, also prompted a particular focus on evaluation of the use of TXA, an antifibrinolytic agent, to improve combat trauma mortality, based on the findings of the CRASH-2 (Clinical Randomization of an Antifibrinolytic in Significant Haemorrhage) trial, published in 2010 ( Shakur et al., 2010 ). Initially, the JTS decided not to add TXA to resuscitation guidelines because of questions about the applicability of the CRASH-2 study results to combat injuries. However, the Military Application of Tranexamic Acid for Trauma Emergency Resuscitation (MATTERs) study, a retrospective observational cohort study, demonstrated an association between TXA use and improved mortality outcomes in patients treated in deployed U.K.–U.S. MTFs ( Morrison et al., 2012 ). Based on these research data, TXA was added to the Central Command (CENTCOM) formulary, and a recommendation for its use was added to the JTS Damage Control Resuscitation CPG in 2011, even though it has not been approved by the FDA for the treatment of hemorrhage. 3 Because of continued concerns regarding potential adverse effects of TXA (e.g., thromboembolic events), its use and the associated risk of complications remain closely monitored through JTS performance improvement processes. DoD has funded several prospective randomized controlled trials of TXA that are currently under way at civilian trauma centers across the United States.

Overall, the recognition of DCBI, the work of the DCBI task force, and related research and development efforts have had a major impact on DoD medical doctrine, training, and materiel. Similar research, development, and education efforts were undertaken by the U.K. military, deepening already significant collaboration between the U.S. and U.K. military medical communities.

Although injury patterns like those associated with DCBI are rare in the civilian sector, valuable concepts from the battlefield warrant transfer to nonmilitary settings. For example, lessons learned related to massive hemorrhage control, including hemorrhage control and transfusion practices, have applicability to other types of injuries more commonly encountered in the United States.

As described above, bidirectional translation of knowledge between the military and civilian sectors and collaborative clinical investigations have been paramount in ongoing efforts to determine the safety and efficacy of TXA for treatment of hemorrhage. Damage control resuscitation more generally represents a notable example of successful translation of military experience to the civilian sector. Early in the wars, the military approach to resuscitation was based on civilian Advanced Trauma Life Support practices for care of acute trauma, but the opportunity to observe a high number of severe traumatic injuries requiring massive transfusion over a short period of time quickly led to the development and adoption of an alternative approach. In response to observations of worsening acidosis and coagulopathy attributed in part to dilution of hemostatic factors following administration of crystalloid and colloid, DoD resuscitative measures evolved to include early resuscitation with blood products (plasma and red blood cells) at a 1:1 or 1:2 ratio ( Holcomb et al., 2007 ). A retrospective study using data from the Joint Theater Trauma Registry showed improved survival associated with use of a 1:1 plasma to red blood cell ratio during massive transfusion ( Borgman et al., 2007 ). Subsequently, inclusion of platelets in massive transfusion was shown to be associated with improved survival, prompting adoption of the 1:1:1 red blood cells:plasma:platelets ratio ( Perkins et al., 2009 ). Massive transfusion practices developed empirically in theater were later validated in large-scale clinical trials conducted in collaboration with the civilian sector. The 2013 PRospective, Observational, Multicenter, Major Trauma Transfusion (PROMMTT) prospective cohort study ( Holcomb et al., 2013 ) and the 2015 Pragmatic, Randomized Optimal Platelet and Plasma Ratios (PROPPR) randomized controlled trial ( Holcomb et al., 2015 ) provided strong, high-quality evidence for early, balanced massive transfusion ratios.

Military damage control resuscitation practices have since been widely adopted in the civilian sector. In a national survey of trauma medical directors, 67 percent of respondents reported use of a 1:1:1 ratio of red blood cells:plasma:platelets in massive transfusions ( Haider et al., 2015 ). Additional survey data led researchers to conclude that exposure to providers previously affiliated with the military and demonstrated benefits reported in the civilian literature contributed to civilian uptake of the military damage control resuscitation practices.

DCBI results in massive wounds and hemorrhage in the groin and perineum that are difficult to manage with pressure alone. Hemostatic gauze dressings impregnated with kaolin, chitosan, or zeolite have been used successfully on the battlefield to help control bleeding. These hemostatic adjuncts have proven effective and safe in civilian environments as well.

Borgman MA, Spinella PC, Perkins JG, Grathwohl KW, Repine T, Beekley AC, Sebesta J, Jenkins D, Wade CE, Holcomb JB. The ratio of blood products transfused affects mortality in patients receiving massive transfusions at a combat support hospital. Journal of Trauma. 2007; 63 (4):805–813. [ PubMed : 18090009 ]
Bridges E, Evers K. Wartime critical care air transport. Military Medicine. 2009; 174 (4):370–375. [ PubMed : 19485106 ]
Cap AP, Baer DG, Orman JA, Aden J, Ryan K, Blackbourne LH. Tranexamic acid for trauma patients: A critical review of the literature. Journal of Trauma. 2011; 71 (1 Suppl.):S9–S14. [ PubMed : 21795884 ]
Cap AP, Spinella PC, Borgman MA, Blackbourne LH, Perkins JG. Timing and location of blood product transfusion and outcomes in massively transfused combat casualties. Journal of Trauma and Acute Care Surgery. 2012; 73 (2 Suppl. 1):S89–S94. [ PubMed : 22847102 ]
Holcomb JB, Jenkins D, Rhee P, Johannigman J, Mahoney P, Mehta S, Cox ED, Gehrke MJ, Beilman GJ, Schreiber M, Flaherty SF, Grathwohl KW, Spinella PC, Perkins JG, Beekley AC, McMullin NR, Park MS, Gonzalez EA, Wade CE, Dubick MA, Schwab CW, Moore FA, Champion HR, Hoyt DB, Hess JR. Damage control resuscitation: Directly addressing the early coagulopathy of trauma. Journal of Trauma. 2007; 62 (2):307–310. [ PubMed : 17297317 ]
Holcomb JB, del Junco DJ, Fox EE, Wade CE, Cohen MJ, Schreiber MA, Alarcon LH, Bai Y, Brasel KJ, Bulger EM. The PRospective, Observational, Multicenter, Major Trauma Transfusion (PROMMTT) study: Comparative effectiveness of a time-varying treatment with competing risks. JAMA Surgery. 2013; 148 (2):127–136. [ PMC free article : PMC3740072 ] [ PubMed : 23560283 ]
Holcomb JB, Donathan DP, Cotton BA, Del Junco DJ, Brown G, Wenckstern TV, Podbielski JM, Camp EA, Hobbs R, Bai Y, Brito M, Hartwell E, Duke JR, Wade CE. Prehospital transfusion of plasma and red blood cells in trauma patients. Prehospital Emergency Care. 2015; 19 (1):1–9. [ PubMed : 24932734 ]
Krueger CA, Wenke JC, Ficke JR. Ten years at war: Comprehensive analysis of amputation trends. Journal of Trauma and Acute Care Surgery. 2012; 73 (6 Suppl. 5):S438–S444. [ PubMed : 23192067 ]
Langan NR, Eckert M, Martin MJ. Changing patterns of in-hospital deaths following implementation of damage control resuscitation practices in US forward military treatment facilities. JAMA Surgery. 2014; 149 (9):904–912. [ PubMed : 25029432 ]
Morrison JJ, DuBose JJ, Rasmussen TE, Midwinter MJ. Military Application of Tranexamic Acid in Trauma Emergency Resuscitation (MATTERs) study. Archives of Surgery. 2012; 147 (2):113–119. [ PubMed : 22006852 ]
Morrison JJ, Ross JD, DuBose JJ, Jansen JO, Midwinter MJ, Rasmussen TE. Association of cryoprecipitate and tranexamic acid with improved survival following wartime injury: Findings from the MATTERs II study. JAMA Surgery. 2013; 148 (3):218–225. [ PubMed : 23670117 ]
O'Reilly DJ, Morrison JJ, Jansen JO, Apodaca AN, Rasmussen TE, Midwinter MJ. Prehospital blood transfusion in the en route management of severe combat trauma: A matched cohort study. Journal of Trauma and Acute Care Surgery. 2014; 77 (3 Suppl. 2):S114–S120. [ PubMed : 25159344 ]
Perkins JG, Cap AP, Spinella PC, Blackbourne LH, Grathwohl KW, Repine TB, Ketchum L, Waterman P, Lee RE, Beekley AC, Sebesta JA, Shorr AF, Wade CE, Holcomb JB. An evaluation of the impact of apheresis platelets used in the setting of massively transfused trauma patients. Journal of Trauma. 2009; 66 (Suppl. 4):S77–S84. [ PubMed : 19359974 ]
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Shakur H, Roberts I, Bautista R, Caballero J, Coats T, Dewan Y, El-Sayed H, Gogichaishvili T, Gupta S, Herrera J, Hunt B, Iribhogbe P, Izurieta M, Khamis H, Komolafe E, Marrero MA, Mejia-Mantilla J, Miranda J, Morales C, Olaomi O, Olldashi F, Perel P, Peto R, Ramana PV, Ravi RR, Yutthakasemsunt S. Effects of tranexamic acid on death, vascular occlusive events, and blood transfusion in trauma patients with significant haemorrhage (CRASH-2): A randomised, placebo-controlled trial. Lancet. 2010; 376 (9734):23–32. [ PubMed : 20554319 ]
SEVERE TRAUMATIC BRAIN INJURY CASE

A 29-year-old male service member suffered a gunshot wound to the head while on patrol. In the field, he was noted to have strong carotid pulses, a heart rate (HR) of 130 beats per minute (bpm), and a respiratory rate (RR) of 75 breaths per minute. He was unresponsive and exhibited decorticate posturing.

In the field, a cricothyroidotomy was performed, and a surgical airway was placed. The patient was also wrapped in a hypothermia prevention blanket.

The patient was evacuated within 5 minutes of the request for evacuation. Transport to a Role 3 MTF required an hour, and on arrival the flight medics noted the following vital signs: blood pressure (BP) 80 mmHg (systolic only), HR 135 bpm, RR 30, Glasgow coma score (GCS) 3, oxygen saturation (SpO 2 ) 95 percent. Both pupils were reactive; the right pupil measured 3 mm and the left pupil 4 mm. The patient had significant bleeding from his head wound, leading to concern about hypovolemia and shock. Hypertonic saline was administered, and he was transfused 2 units of red blood cells en route. He continued to exhibit decorticate posturing. Ventilation was maintained by bag-valve-mask, and SpO 2 was sustained at 100 percent.

Upon the patient's arrival at the Role 3 MTF, a CT scan revealed the gunshot wound to the vertex of the skull with displacement of multiple bone fragments (see Figures A-8 and A-9 ). The patient showed diffuse cerebral edema, intraparenchymal hematoma, subarachnoid hemorrhage, subdural hemorrhage, and epidural hemorrhage at the vertex in association with disruption of the middle third of the superior sagittal sinus. He was urgently taken to the operating room for decompressive hemicraniectomy, evacuation of subdural hematoma, and placement of a right-sided external ventricular drain (EVD). The 7.5F field cricothyroidotomy tube was replaced by an 8.0F tracheostomy. The patient was administered thyroxin on a standard T4 protocol, as well as 3 percent sodium chloride (NaCl). A second EVD was placed on the left side to control increased intracranial pressure measurement of 23 cm H 2 O resulting from bifrontal cerebral hemorrhaging. Following this intervention, intracranial pressure improved to 8-10 cm H 2 O, and the patient had a cerebral perfusion pressure of 60 mmHg. Tranexamic acid (TXA) was also infused in an effort to control bleeding. Ultimately, the patient's GCS improved to 7T, with a motor score of 4. He underwent bronchoscopy to evaluate the effects of the surgical airway procedures and was found to have no evidence of tracheal injury.

Axial (left) and coronal (center) images demonstrate the displaced skull fragments within the brain parenchyma and adjacent hemorrhage. Low attenuation (R>L) is consistent with edema. Adjacent extraparenchymal hemorrhage is present as well. A (more...)

3-D image (left) frontal view shows extension of fracture anteriorly to right orbit. Note metallic hardware from prior jaw surgery at maxilla (arrow). 3-D image cutaway view (center) shows intracranial calvarial fragments and 3-D image looking down (right) (more...)

The patient was transferred out of theater on post-injury day 1 via the critical care air transport team. Cerebral protective strategies were maintained throughout transport. Sedation was increased prior to transport, resulting in a drop in GCS from 6T to 3T. In flight, cerebral perfusion pressure was maintained at greater than 60 mmHg with low-dose vasopressors, and intracranial pressure was maintained at less than 20 mmHg. The patient was transfused 2 units of red blood cells and a 300-mL bolus of normal saline. His hemoglobin increased from 8.2 to 9.2 g/dL. Upon arrival at Landstuhl Regional Medical Center in Germany, his GCS returned to 6T.

Upon arrival at Landstuhl, the patient was rapidly weaned off vasopressors and was evaluated by a neurosurgeon. His GCS was initially 5T, with intracranial pressure less than 20 cm H 2 O, and his brain stem reflexes were intact. A repeat CT scan revealed intraventricular and large intraparenchymal hemorrhages (see Figure A-10 ). His intracranial pressure gradually increased to greater than 20 mmHg, and he was taken back to the operating room for evacuation of hematomas and drain placement. Following surgery, his intracranial pressure improved, and enteral feeding and prophylaxis for deep venous thrombosis were initiated. He was evacuated to the United States with a GCS of 4T.

FIGURE A-10

Post-decompressive craniectomy changes are depicted. Axial CT images left and center demonstrate the skull defect and increased intraparenchymal hematoma (R>>L). Note ventriculostomy catheter (arrow) with adjacent blood in the lateral (more...)

On arrival in the United States, the patient was hemodynamically stable but febrile. The infectious diseases service was consulted and confirmed a diagnosis of right lower lobe pneumonia. The patient was administered antibiotics and antifungals, resulting in resolution of the pneumonia. His brain edema gradually resolved, and his GCS increased to 5T with a normal intracranial pressure. He was transitioned to Emerging Consciousness Rehabilitation after the ventriculostomies were removed on post-injury day 35. There, early rehabilitation was initiated with a multidisciplinary team specializing in this type of care. Long-term follow-up demonstrated the patient's dramatically improved mental status. He can communicate reliably and is fully oriented. However, he does exhibit several cognitive deficits, such as reduced attention span, reduced visual-spatial skills, and left-sided neglect, as well as some memory impairment. His physical status also has improved; he is able to use his right upper extremity and has modest antigravity strength in his right lower extremity. He has severe impairment of his left upper and lower extremities due to the site of his brain injury. He tolerates sitting for greater than 4 hours per day and can stand for 40 minutes at a time. His tracheostomy was removed, and he can eat a regular diet.

Care for severe traumatic brain injury (TBI) fundamentally involves maintaining perfusion of the brain with oxygenated blood. This treatment applies whether the patient is injured on a highway in the United States or on a dismounted patrol in Afghanistan. In this case, the actions taken by the medic in the field to prevent hypoxia and secondary brain injury, prompt evacuation of the patient to a Role 3 MTF, rapid resuscitation to restore cerebral perfusion and ensure oxygenation, damage control resuscitation, aggressive neurosurgical interventions, and early multidisciplinary rehabilitation ( Nakase-Richardson et al., 2013 ) all contributed to the successful outcome for this patient despite the challenges of caring for severe TBI cases in a remote, austere environment.

This case demonstrates how providing a more advanced resuscitative capability closer to the point of injury might improve outcomes in severe TBI. Hypoxia has been shown to be associated with poor outcomes for TBI in both the military and civilian literature ( Badjatia et al., 2008 ). This patient immediately received measures to control his airway to ensure oxygenation. The cricothyroidotomy was an essential prehospital task performed by the field medic, especially in light of the anticipated transport, and indicates a high level of medic training. Administration of 3 percent saline by pre-MTF providers was introduced to the TCCC guidelines at the start of the recent conflicts; however, neuroprotective measures were not mentioned in the original TCCC article in 1996. Another example of increased capability for pre-MTF providers in the updated TCCC guidelines is the guidance to administer TXA.

This case also illustrates the military's highly aggressive approach to managing service members with severe TBI. Cerebral resuscitation began during the tactical evacuation. The patient presented with hypotension, a neurologic emergency in the context of severe TBI ( Badjatia et al., 2008 ). Administering blood products and hyperosmolar therapy and ensuring adequate oxygenation were essential in anticipation of the 1-hour transport time to surgical intervention ( Brain Trauma Foundation et al., 2007 ). In the Role 3 MTF, the patient underwent prompt surgery for hematoma evacuation, decompressive craniectomy, and EVD placement to control intracranial pressure. These interventions accord with the JTS Management of Severe Brain Trauma CPG ( JTS, 2014 ) and Brain Trauma Foundation guidelines ( Brain Trauma Foundation et al., 2007 ).

Retrospective studies using DoDTR data have informed changes in military trauma care practices, codified through the JTS CPGs. DoD clinical investigators may submit queries to the JTS Data Analysis Branch if they wish to receive information from the DoDTR. A clinical investigator's proposal is reviewed by his or her local regulatory group to determine whether the investigation is research or a performance improvement effort. If the clinical investigation is deemed research, a formal institutional review board review must be conducted.

While initially drawing heavily on civilian sector best practice guidelines for care of brain trauma (e.g., Brain Trauma Foundation guidelines), the JTS CPGs evolved as data showing the benefit of aggressive neurosurgical intervention and critical care management accumulated ( DuBose et al., 2011 ). For example, a large retrospective analysis of Joint Theater Trauma Registry (JTTR) 4 data for patients with severe TBI led to recommendations for early hemicraniectomy as part of damage control in anticipation of overseas transport ( Bell et al., 2010 ). (The JTS CPGs relevant to severe TBI are listed in Box A-4 .)

JOINT TRAUMA SYSTEM CLINICAL PRACTICE GUIDELINES RELEVANT TO SEVERE TRAUMATIC BRAIN INJURY.

Another important intervention discussed in this case—the use of a hypothermia prevention blanket—represents an intervention implemented after review of JTTR data indicated worse outcomes in hypothermic TBI patients ( Arthurs et al., 2006 ). Hypothermia is a major concern in the management of trauma patients, largely because of the impact of hypothermia on traumatic coagulopathy ( Morrison et al., 2013 ). In 2006, the JTS released a CPG on hypothermia prevention, monitoring, and management, resulting in a significant reduction in hypothermia incidence ( Nesbitt et al., 2010 ; Palm et al., 2012 ).

In contrast to previous conflicts, in which patients with severe TBI would have been treated as expectant, deployed medical providers in Afghanistan and Iraq adopted a highly aggressive posture in managing service members with these injuries ( Bell et al., 2010 ). This approach has been supported by patient outcome data. With respect to short-term outcomes, 32 percent of casualties with an admission GCS of 3 to 5 progressed to functional independence ( Weisbrod et al., 2012 ). Colleagues at Department of Veterans Affairs rehabilitation centers reported that most patients (64 percent) enrolled in a disorders-of-consciousness program emerged to regain consciousness during rehabilitation ( Nakase-Richardson et al., 2013 ). Despite these encouraging outcome data, however, neurosurgical interventions for severe TBI are controversial in the civilian sector.

A study of severe TBI published in 2011 revealed that mortality outcomes in military patients compared favorably with those in the civilian population ( DuBose et al., 2011 ). In this study, military TBI patients in the DoDTR meeting inclusion criteria were propensity matched to similar patients from the National Trauma Data Bank ( DuBose et al., 2011 ). Military patients were much more likely to undergo any operative intervention (21.5 percent versus 7.2 percent in the civilian population) such as invasive intracranial pressure monitoring, craniectomy, or craniotomy. The overall mortality rate was approximately 3 times lower for military patients relative to their civilian counterparts (7.7 percent versus 21.0 percent). The difference in mortality outcomes was even more striking when the analysis was restricted to penetrating brain injury (5.6 percent and 47.9 percent for military and civilian patients, respectively). This differential is surprising in light of the complex patient movements required for care of combat casualties with these severe injuries, and indicates that the civilian sector may benefit from evaluating and, as appropriate, adopting military approaches to the care of severe TBI. Currently, it is impossible to identify any one factor that may account for this differential, and there are significant differences in military and civilian settings (e.g., destructive force of weaponry, personal protective gear) that need to be considered. Prospective studies are needed to validate the application of aggressive TBI management practices in the civilian population and inform changes to civilian guidelines, such as those of the Brain Trauma Foundation and the Trauma Quality Improvement Program.

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CoTCCC (Committee on Tactical Combat Casualty Care). Tactical combat casualty care guidelines. 2014. http://www .usaisr.amedd .army.mil/pdfs/TCCC _Guidelines_140602.pdf .
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Trauma registries are designed to capture data relating to the quality of care provided by a trauma system. Patients who are KIA may or may not have received any care, depending on the mechanism and timing of their fatal injury.

Walter Reed Army Medical Center and the National Naval Medical Center came under one roof as a joint facility in Bethesda, Maryland, in August 2011.

TXA is FDA-approved for prevention or reduction of bleeding during dental procedures for patients with hemophilia and for control of heavy menstrual cyclic bleeding.

The JTTR was the precursor of the DoDTR.

Cite this Page Committee on Military Trauma Care's Learning Health System and Its Translation to the Civilian Sector; Board on Health Sciences Policy; Board on the Health of Select Populations; Health and Medicine Division; National Academies of Sciences, Engineering, and Medicine; Berwick D, Downey A, Cornett E, editors. A National Trauma Care System: Integrating Military and Civilian Trauma Systems to Achieve Zero Preventable Deaths After Injury. Washington (DC): National Academies Press (US); 2016 Sep 12. A, Case Studies.
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A 24-year-old Female Traumatic Patient Following a Car Accident
A healthy 24-year-old female presented at the emergency department (ED) after a car accident with ambulance while injured severely after the bus got run over her lower limb. As the trauma team was activated, her primary survey was started: Ac (Airway and cervical collar): She was awake and could talk. Cervical collar was fixed, oxygenation with ...
Trauma Case 1: Stab to Left Chest
Trauma Room Assessment: The patient was moved from the stretcher onto the examination table, and the only complaint obtained from the patient was shortness of breath. Cardiac monitors, blood pressure-cuff and oxygen saturation probes were then placed on the patient. Vital signs: Heart rate- 90/min Blood Pressure- 130/70 Respiratory rate 25
Case Examples in the Treatment of Posttraumatic Stress Disorder
Philip, a 60-year-old who was in a traffic accident (PDF, 294KB) This case example from the European Journal of Psychotraumatology details an assisted self-study application of cognitive therapy for PTSD. Philip developed PTSD and comorbid major depression following a traffic accident. He was treated in six sessions of cognitive therapy with ...
Severe Traumatic Brain Injury: A Case Report
In the United State alone, there are approximately 1.5 million traumatic brain injuries (TBI) per year, and TBI is the leading cause of death among individuals under the age of 45 [ 1, 2 ]. Annually, these injuries result in approximately 50 000 deaths and about 80 000-90 000 cases of debilitating head injuries [ 2 ].
CASE STUDY Victor (post-traumatic stress disorder)
Case Study Details. Victor is a 27-year-old man who comes to you for help at the urging of his fiancée. He was an infantryman with a local Marine Reserve unit who was honorably discharged in 2014 after serving two tours of duty in Iraq. His fiancé has told him he has "not been the same" since his second tour of duty and it is impacting ...
Trauma Case Study: Mike
Trauma Case Study: Johnny Tsunami. 38. End of Life Care. 39. Burn Case Study: Fatima Jafar. 40. Digital Storytelling Project: Case Study Summary. VII. Respiratory. ... The patient's vital signs were a BP: 92/54, HR: 120, RR: 22, T 100.7F, O2: 96% on room air, and a pain of 9/10. Performing a full head-to-toe assessment revealed:
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Trauma Nursing Case Study. It's your first shift of four-in-a-row and little do you know that you are in for a tough stretch! Your shift starts out calmly enough, but at 0200 you take report on a 23-yr old post-surgical trauma patient who came in through the ED due to a pedestrian vs auto incident. The patient was crossing the road on a dark ...
Case Report: Traumatic brain injury and the evidence for its management
A 29-year-old man presented to a major trauma centre with traumatic brain injury. Following cranial decompression, the patient was admitted to the intensive care unit for medical management and monitoring. This case report reviews the evidence for the management of traumatic brain injury.
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guide the application of the nursing process using patient-centered care to create safety, the first princi-ple in TIC. Here, the authors discuss the application of these core principles in nursing through a deiden-tified case study. Keywords: nursing care, patient-centered care, trauma, trauma-informed care
A case of PTSD presenting with psychotic symptomatology: a case report
Case formulation - (Persistent PTSD, adapted from Ehlers and Clark []).Case formulation following the persistent PTSD model of Ehlers and Clark [].It is suggested that the patient is processing the traumatic information in a way which a sense of immediate threat is perpetuated through negative appraisals of trauma or its consequences and through the nature of the traumatic experience itself.
A patient with severe polytrauma with massive pulmonary contusion and
Background The mortality rate is very high for patients with severe multiple trauma with massive pulmonary contusion containing intrapulmonary hemorrhage. Multiple treatment modalities are needed not only for a prevention of cardiac arrest and quick hemostasis against multiple injuries, but also for recovery of oxygenation to save the patient's life. Case presentation A 48-year-old Japanese ...
PDF Case-Based Learning Scenarios
trauma team. 4) Perform the skills necessary to assess a trauma patient through multi-sensory perception. 5) Demonstrate the physical ability required to treat and transport a trauma patient. What are the Attributes of Case-Based Learning? Case-based learning creates the ability to address the cognitive, affective and psychomotor domains of ...
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Chest and Abdominal Trauma Case Studies Case #1 Scenario: EMS is dispatched to a 2-car MVC with head on collision. The posted speed limit is marked at 40 MPH. Upon EMS arrival to the scene an unrestrained adult driver is found inside the vehicle with noted + steering wheel deformity. The patient is A & O X 3 but appears restless and agitated.
Case Scenario: Management of Trauma-induced Coagulopathy in a Severe
COAGULOPATHY-RELATED diffuse bleeding, which is complex and difficult to manage, is observed in around 20-30% of all severe trauma patients.1,2 Its management remains critical to patient survival; however, the optimal approach to treatment remains a matter of debate.3 Early recognition and adequate aggressive management of this Trauma-induced Coagulopathy (TIC) has been shown to ...
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PHN RESIDENCY FOR NEW GRADUATES. Objectives. 1. Provide examples of nursing behaviors that promote development of trusting nurse/client relationships. 2. Give examples of strategies to decrease confusion between personal and professional roles. 3. Discuss the components of trauma-informed care and the interventions needed to promote a trauma ...
Trauma nursing: an advanced practice case study
Abstract. Trauma is the leading cause of death in people less than 40 years of age. Blunt or penetrating trauma injuries may be a result of gunshot wounds, stabbings, head injuries,burns, falls or motor vehicle collisions. Unlike other patients entering the health care system, trauma victims have no time for hospital preparation.
Case Study
Tuesday 15 October 2019, 12:00am to , : Add to calendar. The NSW Institute of Trauma and Injury Management, in collaboration with the trauma service of the John Hunter Hospital, proudly present the John Hunter Trauma Evening. The Trauma Evening consists of presentations and discussions delivered by experienced trauma clinicians who endeavour to ...
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PTS
The Western Trauma Association, for example, found no survivors of blunt trauma with >10 minutes of prehospital CPR and penetrating trauma within >15 minutes of prehospital CPR.(1) The patient in this case had >60 minutes of CPR initially, followed by additional rounds en route and at the pediatric trauma center. Another study by Duron, et al ...
Case study 9 Case Study, Chapter 42, Management of Patients With
Week 8: Case Studies Case Study, Chapter 42, Management of Patients With Musculoskeletal Trauma. Melinda Woods, a 14-year-old girl, was on a hiking trip with her family. Melinda slipped on a wet rock and fell on her right arm. She immediately began crying with pain. The skin is intact, but there is an obvious deformity to the right lower arm.
Full article: Trauma-Informed Care Practices in a Forensic Setting
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Patterns and outcomes of patients with abdominal injury: a multicenter
Injury is one of the leading causes of death worldwide, and the abdomen is the most common area of trauma after the head and extremities. Abdominal injury is often divided into two categories: blunt and penetrating injuries. This study aims to determine the epidemiological and clinical characteristics of these two types of abdominal injuries in patients registered with the National Trauma ...
A case of fatal trauma evaluated using a portable X-ray system at the
Abstract. Objective: To demonstrate the use of a portable X-ray system at the scene. Patient: A 59-year-old man collapsed under a small power shovel and was discovered by his colleague. The fire department dispatched an ambulance and requested the dispatch of a doctor helicopter (DH) immediately after receiving the emergency call.
Surgical Firework Injury of the Thumb: Injury Pattern and Treatment
Firework blast trauma most commonly affects the hands and occurs along a spectrum of severity ranging from minor burns to mangling injuries. This study presents a retrospective chart review of patients surgically treated for upper-extremity firework injuries at a major metropolitan level-l trauma center with a focus on injuries involving the thumb. A detailed treatment algorithm is proposed ...
Review of Muslim Patient Needs and Its Implications on Healthcare
In this study, patients and healthcare providers completed separate questionnaires regarding their healthcare experience. ... descriptive, controlled, cohort, case-studies, cross-sectional, mixed method, and qualitative publications ... these studies show how trauma and perceived discrimination can manifest as negative impacts on well-being in ...
Dr. Boris Zelle earns 2024 Diversity Award from the American Academy of
Zelle has led several studies revealing barriers to care for the underserved Boris A. Zelle, MD, FAAOS, FAOA, professor, vice-chair of research and chief of orthopaedic trauma in the Department of Orthopaedics at The University of Texas Health Science Center at San Antonio (UT Health San Antonio), recently received the American Academy of Orthopaedic Surgeons […]
Medicina
Background and Objectives: Although statins are recommended for secondary prevention of acute ischemic stroke, some population-based studies and clinical evidence suggest that they might be used with an increased risk of intracranial hemorrhage. In this nested case-control study, we used Taiwan's nationwide universal health insurance database to investigate the possible association between ...
A complex case study: coexistence of multi-drug-resistant pulmonary
In this case, the patient presented with both HIV and HBV infections. Although the HBV DNA test was negative upon admission. However, due to the patient's self-discontinuation of antiretroviral therapy (ART), HBV virologic and immunologic reactivation occurred six months later, leading to a rapid increase in viral load and subsequent hepatic ...
Clinical Outcomes After Admission of Patients With COVID-19 to SNFs
Conclusion This cohort study suggests that admission of COVID-19-positive patients into SNFs early in the pandemic was associated with preventable COVID-19 cases and mortality among residents, particularly in facilities with potential staff and PPE shortages. The findings speak to the importance of equipping SNFs to adhere to infection ...
Case Studies
A Case Studies. A. Case Studies. As an aid to understanding the military trauma care learning health system and its translation to the civilian sector, and in accordance with the committee's statement of task, this appendix presents case studies that illustrate a broad spectrum of battlefield injuries relevant also to the civilian sector ...

Trauma Case 1: Stab to Left Chest

Pre-Hospital Data

Trauma Room Assessment:

Vital signs:

Primary Survey:

Radiological Survey:

Other Pertinent Studies:

Blood Work Ordered:

ER Procedures:

Change in status:

Operating Room:

Major Teaching Points:

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A patient with severe polytrauma with massive pulmonary contusion and hemorrhage successfully treated with multiple treatment modalities: a case report

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Pathophysiology of TIC

Early Diagnosis and Point-of-care Devices

What Are the Goals of TIC Management?

Transfusion-based Strategy: FFP and Platelet Concentrates

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Concentrates-based Strategy: Fibrinogen and PCC

Fibrinogen Concentrate.

Recombinant Factor VIIa

Damage Control Concept and Others Goals

New Anticoagulant Agents

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Case Report: Blunt Trauma

Patterns and outcomes of patients with abdominal injury: a multicenter study from Iran

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