Mesenteric Ischemia.

Mesenteric ischemia occurs when perfusion of the visceral organs fails to meet normal metabolic requirements and subsequently results in abdominal symptoms such as diffuse postprandial pain, peritonitis, food fear, and weight loss. While generally divided into acute and chronic manifestations, mesenteric ischemia is commonly misdiagnosed at initial presentation due to the significant overlap with symptoms of other abdominal pathologies. Prompt recognition and diagnosis, mesenteric revascularization, and critical care management remain the mainstay of treatment in these patients for optimal outcomes.

Comparative evaluation of transcutaneous oxygen tension and ankle-brachial index as predictors of reoperation following below-knee amputation.

Objective: Decision-making regarding level of lower extremity amputation is sometimes challenging. Selecting an appropriate anatomic level for major amputation requires consideration of tradeoffs between postoperative function and risk of wound complications that may require additional operations, including debridement and/or conversion to above-knee amputation (AKA). We evaluated the utility of common, non-invasive diagnostic tests used in clinical practice to predict the need for reoperations among patients undergoing primary, elective, below knee-amputations (BKAs) by vascular surgeons.

Revascularization of acute inferior vena cava thrombosis and atresia in an adolescent.

Inferior vena cava (IVC) anomalies will remain silent until collateralized venous drainage has been lost. The initial signs can be subtle, including back pain, and are often missed initially until progressive changes toward motor weakness, phlegmasia cerulea dolens, and/or renal impairment have occurred. We have presented a case of acute occlusion of an atretic IVC and infrarenal collateral drainage in an adolescent patient, who had been treated with successful thrombolysis, thrombectomy, and endovascular revascularization for IVC stenting and reconstruction.

Performance of a novel temporary arterial shunt in a military-relevant controlled hemorrhage swine model.

Background: In military trauma, temporary vascular shunts restore arterial continuity until delayed vascular reconstruction, often for a period of hours. A novel US Air Force-developed trauma-specific vascular injury shunt (TS-VIS) incorporates an accessible side port for intervention or monitoring, which may improve patency under adverse hemodynamic conditions. Our objective was to evaluate TS-VIS patency in the setting of volume-limited resuscitation from hemorrhagic shock.

Risk factors for abdominal surgical site infection after exploratory laparotomy among combat casualties.

Background: Surgical site infections (SSIs) are well-recognized complications after exploratory laparotomy for abdominal trauma; however, little is known about SSI development after exploration for battlefield abdominal trauma. We examined SSI risk factors after exploratory laparotomy among combat casualties.

Methods: Military personnel with combat injuries sustained in Iraq and Afghanistan (June 2009 to May 2014) who underwent laparotomy and were evacuated to participating US military hospitals were included.

Outcomes of Exploratory Laparotomy and Abdominal Infections Among Combat Casualties.

Background: Abdominal injuries historically account for 13% of battlefield surgical procedures. We examined the occurrence of exploratory laparotomies and subsequent abdominal surgical site infections (SSIs) among combat casualties.

Methods: Military personnel injured during deployment (2009-2014) were included if they required a laparotomy for combat-related trauma and were evacuated to Landstuhl Regional Medical Center, Germany, before being transferred to participating US military hospitals.

Utility of the Mangled Extremity Severity Score in Predicting Amputation in Military Lower Extremity Arterial Injury.

Background: Effective amputation prediction may help inform appropriate early limb salvage efforts in military lower extremity (LE) arterial injury. The Mangled Extremity Severity Score (MESS) is the most commonly applied system for early amputation prediction but its utility in military trauma is unknown.

Methods: Retrospective cohort study of Iraq and Afghanistan casualties with LE arterial injury who underwent a vascular limb salvage attempt.

Endovascular Embolization Techniques in a Novel Swine Model of Fatal Uncontrolled Solid Organ Hemorrhage and Coagulopathy.

Background: Endovascular embolization is increasingly used in treating traumatic hemorrhage and other applications. No endovascular-capable translational large animal models exist and coagulopathy's effect on embolization techniques is unknown. We developed a coagulation-adaptable solid organ hemorrhage model in swine for investigation of embolization techniques.

Abdominal aortic and junctional tourniquet versus zone III resuscitative endovascular balloon occlusion of the aorta in a swine junctional hemorrhage model.

Background: Junctional hemorrhage is a leading contributor to battlefield mortality. The Abdominal Aortic and Junctional Tourniquet (AAJT) and infrarenal (zone III) resuscitative endovascular balloon occlusion of the aorta (REBOA) are emerging strategies for controlling junctional hemorrhage, with AAJT currently available in select forward deployed settings and increasing interest in applying REBOA in the military prehospital environment. This study compared the hemostatic, hemodynamic, and metabolic effects of these devices used for junctional hemorrhage control.

Differing Resuscitation With Aortic Occlusion in a Swine Junctional Hemorrhage Polytrauma Model.

Background: Resuscitative endovascular balloon occlusion of the aorta (REBOA) and Abdominal Aortic and Junctional Tourniquet (AAJT) have received much attention in recent as methods for temporary control of junctional hemorrhage. Previous studies typically used the animal's shed blood for resuscitation. With current interest in moving REBOA to prehospital environment, this study aimed to evaluate the hemodynamic and metabolic responses to different resuscitation fluids used with these devices.

Venovenous bypass using continuous renal replacement therapy and endovascular inferior vena cava reconstruction to treat bilateral massive iliocaval deep venous thrombosis.

Many inferior vena cava (IVC) anomalies remain asymptomatic because of collateral circulation, but thrombosis of these channels can cause acute deep venous thrombosis with serious sequelae. For those with threatened limbs, anticoagulation is the mainstay of treatment, with endovascular pharmacomechanical thrombolysis replacing open surgical thrombectomy. Described is a severe case of massive iliocaval deep venous thrombosis with bilateral lower extremity Rutherford IIb acute limb ischemia in a patient with congenital IVC atresia.

Effect of partial and complete aortic balloon occlusion on survival and shock in a swine model of uncontrolled splenic hemorrhage with delayed resuscitation.

Background: Resuscitative endovascular balloon occlusion of the aorta (REBOA) is accepted as a resuscitation adjunct and bridge to definitive hemostasis. The ischemic burden of REBOA may be mitigated by a partial REBOA (P-REBOA) strategy permitting longer occlusion times and military use for combat trauma. We evaluated REBOA and P-REBOA in a swine multiple trauma model with uncontrolled solid organ hemorrhage and delayed resuscitation and surgical hemostasis.

Predictors and timing of amputations in military lower extremity trauma with arterial injury.

Introduction: Military lower extremity arterial injuries present threats to life and limb. These injuries are common and limb salvage is a trauma system priority. Understanding the timing and predictors of amputation through the phases of casualty evacuation can help inform future limb salvage efforts.

Despite Trauma Center Closures, Trauma System Regionalization Reduces Mortality and Time to Definitive Care in Severely Injured Patients.

The Northern Ohio Trauma System (NOTS), consisting of multiple hospital systems, was established in 2010 to improve trauma outcomes. This study assessed its impact on mortality and time to definitive care, focusing especially on the severely injured patients. NOTS trauma registry was queried for all trauma activations from 2008 to 2013.

Current Pneumonia Surveillance Methodology: Similar Underestimation in Trauma and Surgical Patients in the Intensive Care Unit.

Background: In 2013, the Centers for Disease Control and Prevention (CDC) developed new surveillance definitions for ventilator-associated events (VAE), leading to concerns that hospitals may be underreporting the true incidence of ventilator-associated pneumonias (VAPs). We sought to compare rates of clinically diagnosed VAP with CDC defined possible VAPs (PVAPs) in patients with a VAE in the surgical/trauma intensive care unit (STICU).

Hypothesis: Significant difference exists between rates of clinical VAP and PVAP in patients with at least one VAE.

Leaving the Skin Incision Open May Not Be as Beneficial as We Have Been Taught.

Background: Currently, various methods of skin closures are used in contaminated and dirty abdominal wounds without solid, evidence-based guidance. This study investigates whether closure methods affect surgical site infection (SSI) and other incisional complications. We hypothesize that open management of the skin would have the lowest complications, including SSI.

Trauma system regionalization improves mortality in patients requiring trauma laparotomy.

Introduction: This study evaluates the impact of a regional trauma network (RTN) on patient survival, intensive care unit (ICU) length of stay, and hospital length of stay in patients who required trauma laparotomy.

Methods: Patients who required trauma laparotomy from January 2008 to December 2013 were analyzed. Patients admitted during 2008-2009 and 2011-2013 were designated as pre-RTN and RTN groups, respectively.

Benefit of TeamSTEPPS Rounding Improvement Project on Infection-Related Monitoring.

Background: Team Strategies and Tools to Enhance Performance and Patient Safety (TeamSTEPPS) was developed to improve teamwork and patient safety. It was shown to benefit patient care in complex clinical settings including intensive care units (ICUs). Our two trauma/surgical ICUs received TeamSTEPPS training, but only Unit 1 participated in a TeamSTEPPS Rounding Improvement Project (TRIP).

Traumatic vascular injuries: who are repairing them and what are the outcomes?

Background: Traumatic vascular injuries are infrequent but can be devastating. This study characterized their incidence and the need for vascular surgeons in their repair. Outcomes for patients repaired by vascular and trauma surgeons were compared.