Intraosseous infusion rates under high pressure: a cadaveric comparison of anatomic sites.

Background: When traditional vascular access methods fail, emergency access through the intraosseous (IO) route can be lifesaving. Fluids, medications, and blood components have all been delivered through these devices. We sought to compare the performance of IO devices placed in the sternum, humeral head, and proximal tibia using a fresh human cadaver model.

Basic endovascular skills for trauma course: bridging the gap between endovascular techniques and the acute care surgeon.

Background: The use of catheter-based skills is increasing in the field of vascular trauma. Virtual reality simulation (VRS) is a well-established means of endovascular skills training, and potentially lifesaving skills such as resuscitative endovascular balloon occlusion of the aorta (REBOA) may be obtained through VRS.

Methods: Thirteen faculty members in the Division of Trauma and Critical Care performed REBOA six times on the Vascular Intervention System Training Simulator-C after a didactic and instructional session.

Time to first take-back operation predicts successful primary fascial closure in patients undergoing damage control laparotomy.

Background: Failure to achieve primary fascial closure (PFC) after damage control laparotomy is costly and carries great morbidity. We hypothesized that time from the initial laparotomy to the first take-back operation would be predictive of successful PFC.

Methods: Trauma patients managed with open abdominal techniques after damage control laparotomy were prospectively followed at 14 Level 1 trauma centers during a 2-year period.

How are you really feeling? A prospective evaluation of cognitive function following trauma.

Background: Mild traumatic brain injury is associated with persistent cognitive difficulties. However, these symptoms may not be specific to the head injury itself. We sought to evaluate the prevalence of these symptoms in patients following trauma.

Can intramuscular glucose levels diagnose compartment syndrome?

Background: Compartment syndrome is difficult to diagnose, particularly in patients who are not able to undergo adequate clinical examination. Current methods rely on pressure measurements within the compartment, have high false-positive rates, and do not reliably indicate presence of muscle ischemia. We hypothesized that measurement of intramuscular glucose and oxygen can identify compartment syndrome with high sensitivity and specificity.

A clinical series of resuscitative endovascular balloon occlusion of the aorta for hemorrhage control and resuscitation.

Background: A requirement for improved methods of hemorrhage control and resuscitation along with the translation of endovascular specialty skills has resulted in reappraisal of resuscitative endovascular balloon occlusion of the aorta (REBOA) for end-stage shock. The objective of this report was to describe implementation of REBOA in civilian trauma centers.

Methods: Descriptive case series of REBOA (December 2012 to March 2013) used in scenarios of end-stage hemorrhagic shock at the University of Maryland, R.

Perioperative supplemental oxygen to reduce surgical site infection after open fixation of high-risk fractures: a randomized controlled pilot trial.

Background: Higher concentrations of fraction of inspired oxygen (FIO2) have been shown to be associated with lower risk for surgical site infection in multiple studies outside the domain of orthopedic surgery. We evaluated the efficacy of high FIO2 administered during the perioperative period to reduce the rate of surgical site infection after open fixation of lower-extremity fractures at high risk of infection.

Methods: We conducted a randomized controlled, parallel design, double-blind study.

Early application of airway pressure release ventilation may reduce mortality in high-risk trauma patients: a systematic review of observational trauma ARDS literature.

Background: Adult respiratory distress syndrome is often refractory to treatment and develops after entering the health care system. This suggests an opportunity to prevent this syndrome before it develops. The objective of this study was to demonstrate that early application of airway pressure release ventilation in high-risk trauma patients reduces hospital mortality as compared with similarly injured patients on conventional ventilation.

Surface anatomy of the middle division of the facial nerve: Zuker's point.

Background: The anatomy of the facial nerve and its branches has been well documented. The course of the extratemporal facial nerve, its anatomical planes, and the surface landmarks of the temporal division and marginal mandibular division are well known. However, the surface landmark of the middle division of the facial nerve has not been studied to date.

Total face, double jaw, and tongue transplantation: an evolutionary concept.

Background: The central face high-energy avulsive injury has been frequently encountered and predictably managed at the R Adams Cowley Shock Trauma Center. However, despite significant surgical advances and multiple surgical procedures, the ultimate outcome continues to reveal an inanimate, insensate, and suboptimal aesthetic result.

Methods: To effectively address this challenging deformity, a comprehensive multidisciplinary approach was devised.

Early postoperative outcomes associated with the anterolateral thigh flap in Gustilo IIIB fractures of the lower extremity.

Purpose: A core concept in plastic surgery has been the replacement of "like-with-like" tissue. Applying this concept to the lower extremity, the anterolateral thigh (ALT) perforator flap has become a frequently used free flap for restoration of soft tissue defects involving the distal lower extremity. The objective of this study was to evaluate the rate of early postoperative complications associated with the ALT perforator free flap for coverage of high-energy traumatic open fractures of the lower extremity (Gustilo IIIB) and explore related patient risk factors.

Total face, double jaw, and tongue transplant research procurement: an educational model.

Background: Transplantation of a facial vascularized composite allograft is a highly complex procedure that requires meticulous planning and affords little room for error. Although cadaveric dissections are an essential preparatory exercise, they cannot simulate the true clinical experience of facial vascularized composite allograft recovery.

Methods: After obtaining institutional review board approval to perform a facial vascularized composite allograft research procurement, a 66-year-old, brain-dead donor was identified.

Secondary refinements of free perforator flaps for lower extremity reconstruction.

Background: The aim of lower extremity reconstruction has focused on early wound coverage and functional recovery but rarely aesthetics. Free muscle flaps provide durable coverage; however, they require skin graft coverage and result in muscle atrophy limiting future revisions. Perforator-based flap reconstructions can be easily elevated to allow for both orthopedic and contouring procedures.

Frontobasal fractures: anatomical classification and clinical significance.

Background: Frontobasal injury is a classic craniomaxillofacial fracture affecting the anterior cranial base. No data exist regarding the degree of frontobasal injury and associated midfacial fractures. The authors propose a classification of frontobasal and midface fractures involving the cranial base based on cadaveric experiments and comprehensive clinical experience.

Definitive treatment of persistent frontal sinus infections: elimination of dead space and sinonasal communication.

Background: Frontal sinus injury involving nasofrontal outflow tract obstruction is routinely managed by obliteration or cranialization; however, a small percentage of patients develop persistent indolent infections despite routine measures. The authors discuss the course of persistent infection following frontal sinus fractures and propose a novel treatment that definitively obliterates and separates the nasofrontal outflow tract from the cranium in these patients.

Methods: Seven consecutive patients with persistent indolent infections associated with frontal sinus fractures were identified and treated at the R Adams Cowley Shock Trauma Center and The Johns Hopkins Hospital from 2005 to 2008.

Twenty-six-year experience treating frontal sinus fractures: a novel algorithm based on anatomical fracture pattern and failure of conventional techniques.

Background: Frontal sinus fracture treatment strategies lack statistical power. The authors propose statistically valid treatment protocols for frontal sinus fracture based on injury pattern, nasofrontal outflow tract injury, and complication(s).

Methods: An institutional review board-approved retrospective review was conducted on frontal sinus fracture patients from 1979 to 2005.

Preservation of contour in periorbital and midfacial craniofacial microsurgery: reconstruction of the soft-tissue elements and skeletal buttresses.

Background: Microsurgical reconstructive algorithms for craniofacial defects have focused on soft-tissue flaps with or without conventional bone grafts. However, volumetric loss from muscle atrophy, bone resorption, and soft-tissue contraction limits long-term preservation of facial contour. Applying craniofacial principles of skeletal buttress support, the authors used composite vascularized bone flaps to reconstruct the soft tissue and the vertical and horizontal buttresses of the face.

Abdominal wall reconstruction following severe loss of domain: the R Adams Cowley Shock Trauma Center algorithm.

Background: Large, complex, posttraumatic and recurrent abdominal hernias present a reconstructive challenge. Multiple techniques have been described to restore the integrity of the abdominal wall, although the indications and applications can be difficult to navigate. The authors propose an algorithm that facilitates the assessment and treatment of secondary large ventral defects.

Percutaneous endoscopic gastrostomy in the supermorbidly obese patient.

Introduction: Obesity is reaching epidemic proportions in the United States, and as patients at the extremes of morbid obesity come under the care of surgeons, routine procedures may become increasingly complex in the face of greater body mass. We prospectively evaluated the success rate of percutaneous endoscopic gastrostomy (PEG) placement in a group of morbidly obese patients outside the current classification systems used to stratify obesity.

Methods: Patients with a body mass index (BMI) greater than 60 kg/m2 who presented for PEG over a one year period were prospectively enrolled.

Breastfeeding problems following anesthetic administration.

Research literature supports the notion that maternal comfort should be considered a priority and that mothers should receive adequate information regarding any drug prior to receiving that drug. Some studies indicate that difficulties with breastfeeding may be related to the amount of the anesthetic or analgesic that is administered to the mother. Thus, it seems wise to administer the lowest possible dose to the mother in order to minimize the amount of drug (or metabolite) exposure to the nursing infant.

Mentors decrease compliance with best sterile practices during central venous catheter placement in the trauma resuscitation unit.

Background: In the academic trauma unit during initial evaluation and resuscitation of trauma victims, central venous catheters are often placed by multiple operators. There are few data on compliance with accepted, standard sterile practices during such procedures.

Methods: Prospective data were tabulated from video capture of 144 consecutive central venous catheterizations in a trauma resuscitation unit, during peak hours, by a team of trained video technicians.