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Introduction Upper extremity arterial injury is associated with significant morbidity and mortality for trauma patients, but there is a paucity of data to guide the clinician in the management of these injuries. The goals of this review were to characterize the demographics, presentation, clinical management, and outcomes, and to evaluate how time to intervention associates with outcomes in trauma patients with upper extremity vascular injuries. Methods The National Trauma Data Bank (NTDB) Research Data Set for the years 2007–2016 was queried in order to identify adult patients (age ≥ 18) with an upper extremity arterial injury. Patients with brachiocephalic, subclavian, axillary, or brachial artery injury using the 1998 and 2005 versions of the Abbreviated Injury Scale were included. Patients with non-survivable injuries to the brain, traumatic amputation, or other major arterial injuries to the torso or lower extremities were excluded. Results The data from 7908 patients with upper extremity arterial injuries was reviewed. Of those, 5407 (68.4%) underwent repair of the injured artery. The median Injury Severity Score (ISS) was 10 (IQR = 7–18), and 7.7% of patients had a severe ISS (≥ 25). Median time to repair was 120 min (IQR = 60–240 min). Management was open repair in 52.3%, endovascular repair in 7.3%, and combined open and endovascular repairs in 8.8%; amputation occurred in 1.8% and non-operative management was used in 31.6% of patients. Blunt mechanism of injury, crush injury, concomitant fractures/dislocations, and nerve injuries were associated with amputation, whereas simultaneous venous injury was not. There was a significant decrease in the rate of amputation when patients undergoing surgical revascularization did so within 90 min of injury (P = 0.007). Conclusion Injuries to arteries of the upper extremity are managed with open repair, endovascular repair, and, rarely, amputation. Expeditious transport to the operating room for revascularization is the key for limb salvage.

The ideal conduit for traumatic arterial repair is controversial. Autologous vein was compared with synthetic interposition grafts in the acute setting. The primary outcome was in-hospital reoperation or endovascular intervention.The American Association for the Surgery of Trauma PROspective Observational Vascular Injury Treatment registry from November 2013 to January 2019 was queried for arterial injuries requiring interposition vein or graft repair. Patients with no recorded Injury Severity Score were excluded, and multiple imputation was used for other missing data. Patients treated with synthetic grafts (SGs) were propensity matched to patients with vein grafts (VGs) to account for preoperative differences.Four hundred sixty from 19 institutions were identified, with 402 undergoing VG and 58 SG. In the SG group, 45 were PTFE grafts, 5 were Dacron, and 8 had other conduits. The SG group was more severely injured at admission with more gunshot wounds and higher mean Injury Severity Score, lactate, and first-24-hour transfusion requirement. In addition, the SG cohort had significantly lower admission systolic blood pressure, pH, and hemoglobin. After propensity matching, 51 patients with SG were matched with 87 patients with VG. There were no differences in demographics, clinical parameters, or diagnostic evaluation techniques postmatch. The need for reoperation or endovascular intervention between the matched groups was equivalent (18%; p = 0.8). There was no difference in any secondary outcome including thrombosis, stenosis, pseudoaneurysm, infection, or embolic event, and hospital and intensive care unit length of stay were the same.American Association for the Surgery of Trauma PROspective Observational Vascular Injury Treatment registry data demonstrate that SGs are used in more critically ill patients. After controlling for relevant clinical factors and propensity matching, there is no in-hospital difference in rate of reoperation or endovascular intervention, or any secondary outcome between VG and SG.Prognostic and Epidemiolgic, Level III.

Background Splenorrhaphy was once used to achieve splenic preservation in up to 40% of splenic injuries. With increasing use of nonoperative management and angioembolization, operative therapy is less common and splenic injuries treated operatively are usually high grade. Patients are often unstable, making splenic salvage unwise. Modern surgeons may no longer possess the knowledge to perform splenorrhaphy. Methods The records of adult trauma patients with splenic injuries from September 2014 to November 2018 at an urban level I trauma center were reviewed retrospectively. Data including American Association for the Surgery of Trauma splenic organ injury scale, type of intervention, splenorrhaphy technique, and need for delayed splenectomy were collected. This contemporary cohort (CC) was compared to a historical cohort (HC) of splenic injuries at a single center from 1980 to 1989 (Ann Surg 1990; 211: 369). Results From 2014 to 2018, 717 adult patients had splenic injuries. Initial management included 157 (21.9%) emergent splenectomy, 158 (22.0%) angiogram ± embolization, 371 (51.7%) observation, and only 10 (1.4%) splenorrhaphy. The HC included a total of 553 splenic injuries, of which 313 (56.6%) underwent splenectomy, while splenorrhaphy was performed in 240 (43.4%). Those who underwent splenorrhaphy in each cohort (CC vs HC) were compared. Conclusion The success rate of splenorrhaphy has not changed. However, splenorrhaphy now involves only electrocautery with topical hemostatic agents and is used primarily in low-grade injuries. Suture repair and partial splenectomy seem to be “lost arts” in modern trauma care.

Major abdominal vascular injuries are noted in 5-10% of patients undergoing laparotomy for blunt trauma. In contrast, injuries to named abdominal vessels are present in 20-25% of patients undergoing laparotomy after gunshot wounds and in 10% after stab wounds. Hence, all surgeons performing laparotomies after abdominal trauma must be familiar with techniques for exposure and management of these injuries.

"Scoop and run" approaches for severely injured patients have been adopted by emergency medical services over the past 40 years. This has resulted in more patients with severe injuries including penetrating cardiac wounds arriving at trauma centers and other acute care hospitals. General surgery trauma teams and general surgeons taking trauma call are the first responders for diagnosis, resuscitation, and operative management of injured patients. By natural selection, 96% to 98% of patients with signs of life on arrival to the trauma center after sustaining a penetrating cardiac wound have injuries that are amenable to repair by a general surgeon, fellow, or senior surgical resident without the need for a cardiothoracic surgeon or cardiopulmonary bypass.This literature and experience-based review summarizes the diagnostic and operative approaches that should be known by all trauma teams and general surgeons taking trauma call. In addition, it describes when a cardiothoracic surgeon should be consulted and briefly reviews how complex penetrating cardiac injuries are repaired.

Introduction The use of antiplatelet (AP) and anticoagulation (AC) therapy after autogenous vein repair of traumatic arterial injury is controversial. The hypothesis in this study was that there is no difference in early postoperative outcomes regardless of whether AC, AP, both, or neither are used. Methods The American Association for the Surgery of Trauma (AAST) PROspective Observational Vascular Injury Treatment (PROOVIT) registry was queried from November, 2013, to January, 2019, for arterial injuries repaired with a vein graft. Demographics and injury characteristics were compared. Need for in-hospital reoperation was the primary outcome in this four-arm study, assessed with two ordinal logistic regression models (1. no therapy vs. AC only vs. AC and AP; 2. no therapy vs. AP only vs. AC and AP). Results 373 patients (52 no therapy, 88 AP only, 77 AC only, 156 both) from 19 centers with recorded Injury Severity Scores (ISS) were identified. Patients who received no therapy were younger than those who received AP (27.0 vs. 34.2, p = 0.02), had higher transfusion requirement ( p < 0.01 between all groups) and a different distribution of anatomic injury ( p < 0.01). After controlling for age, sex, ISS, platelet count, hemoglobin, pH, lactate, INR, transfusion requirement and anatomic location, there was no association with postoperative medical therapy and in-hospital operative reintervention, or any secondary outcome, including thrombosis ( p = 0.67, p = 0.22). Conclusions Neither AC nor AP alone, nor in combination, impact complication rate after arterial repair with autologous vein. These patients can be safely treated with or without antithrombotics, recognizing that this study did not demonstrate a beneficial effect.

Background Reoperative abdominal surgery is one of the most challenging endeavors that general surgeons face. The aim of this narrative review is to offer a detailed and nuanced discussion of preoperative patient and surgeon preparation and intraoperative surgical technique. Study Design The topics discussed in this review are based on both the current literature and the experiences of the authors with complex reoperations in general, trauma, acute care, and hepatopancreatobiliary surgery. Results Ten essential steps for reoperative abdominal surgery include the following: 1. Review all previous operative notes and discharge summaries; 2. Review all prior outside and current in-house imaging; 3. Assess the patient's overall health status, reverse nutritional deficits, and explain risks of reoperation to the patient and family; 4. Refer the patient to a plastic surgeon when future skin coverage of a prosthesis in the abdominal wall may be needed; 5. Do a bowel preparation preoperatively; 6. Use selected Enhanced Recovery After Surgery protocols; 7. Operative technique matters; 8. Restoring gastrointestinal continuity simultaneously with abdominal wall reconstruction is not recommended; 9. Technical tips for complex reoperations; and 10. Plan well for the day of the operation. Conclusions Successful reoperative abdominal surgery in the most complex patients after previous trauma or acute care laparotomies demands adequate preoperative patient preparation, a clear-cut plan for operation, superb intraoperative technique, and solid decision-making; ie an unwavering commitment to making the patient whole again.

Introduction Failure to perform adequate fasciotomy for a presumed or diagnosed compartment syndrome after revascularization of an acutely ischemic limb is a potential cause of preventable limb loss. When required, outcomes are best when fasciotomy is conducted with the initial vascular repair. Despite over 100 years of experience with fasciotomy, the actual indications for its performance among acute care and trauma surgeons performing vascular repairs are unclear. The hypothesis of this study was that there are many principles of fasciotomy that are uniformly accepted by surgeons and that consensus guidelines could be developed. Methods A 20-question survey on fasciotomy practice patterns was distributed to trauma and acute care surgeons of a major surgical society which had approved distribution. Results The response to the survey was 160/1066 (15 %). 92.5% of respondents were fellowship trained in trauma and acute care surgery, and 74.9% had been in practice for fewer than 10 years. Most respondents (71.9%) stated that they would be influenced to perform a preliminary fasciotomy (fasciotomy conducted prior to planned exploration and arterial repair) based upon specific signs and symptoms consistent with compartment syndrome—including massive swelling (55.6%), elevated compartment pressures (52.5%), delay in transfer >6 hours (47.5%), or obvious distal ischemia (33.1%). 20.6% responded that they would conduct exploration and repair first, regardless of these considerations. Prophylactic fasciotomies (fasciotomy without overt signs of compartment syndrome) would be performed by respondents in the setting of the tense compartment (87.5%), ischemic time >6 hours (88.1%), measurement of elevated compartment pressures (66.9%), and in the setting of large volume resuscitation requirements (31.3%). 69.4% of respondents selectively measure compartment pressures, with nearly three-fourths utilizing a Stryker needle device (72.5%). The most common sequence of repairs following superficial femoral artery injury with a >6-hour limb ischemia was cited as the initial insertion of a shunt, followed by fasciotomy, then vein harvest, and finally interposition repair. Conclusions While there is some general consensus on indications for fasciotomy, there is marked heterogeneity in surgeons’ opinions on the precise indications in selected scenarios. This is particularly surprising in light of the long history with fasciotomy in association with major arterial repairs and strongly suggests the need for a consensus conference and/or meta-analysis to guide further care.

A 59-year-old man presented to the trauma center with multiple stab wounds to his face, neck, chest, abdomen, bilateral arms, and bilateral hands. He did not complain of pain in any specific area of injury. The patient was able to state his name. His systolic blood pressure was 98 mm Hg, heart rate was 107 beats/min, and respiratory rate was 34 breaths/min with audible breath sounds bilaterally. There was a main 1.5 cm stab wound to his left neck posterior to the sternocleidomastoid muscle at the level of the thyroid cartilage. No air was bubbling out of this nor any of his other cervical wounds. In addition, there was no associated bleeding, hematoma, palpable thrill, or audible bruit. His neurologic examination revealed that his Glasgow Coma Scale score was 15, and he did not have any lateralizing signs or focal deficits. His cranial nerve examination was intact. On abdominal examination, he did have tenderness in all four quadrants, but did not have peritonitis. His pulse examination was normal in all four extremities. Which clinical finding would NOT warrant immediate exploration in the operating room? 1. Positive focused abdominal sonogram for trauma (FAST) with hypotension 2. Pulsatile bleeding from the neck wound 3. Peritonitis on abdominal examination 4. Crepitus on chest palpation After blood was drawn for type and cross-match, two large bore intravenous catheters were inserted. A chest X-ray and an extended focused abdominal sonogram for trauma (eFAST) examination were performed. The chest X-ray did not show any abnormalities, and the eFAST was negative. The patient’s repeat systolic blood pressure was 113 mm Hg. Because he had a normal blood pressure, did not have hard signs of a vascular or aerodigestive injury in his neck, and did not have a positive FAST nor peritonitis on abdominal examination, he underwent a CT scan of his abdomen and pelvis with …

A 48-year-old man playing cards was accused of cheating. An assailant with a shotgun wounded the victim in the area of the right biceps muscle. When personnel from emergency medical services arrived, they applied a pressure dressing to the right arm to control profuse hemorrhage. The patient was awake and alert with a heart rate of 130 beats per minute and a systolic blood pressure of 110 mm Hg. The pressure dressing over the right arm was saturated with blood and was removed. Findings on examination included the following: a 20×12 cm cavity in the anterior right arm; absence of much of the right biceps muscle; absence of the brachial artery and venae comitantes; an intact median nerve; limited function of the right elbow; intact function of the right wrist and fingers; and absent right radial and ulnar pulses at the wrist. A pressure dressing was reapplied to the open wound in the right arm. As a blood specimen was drawn for type and cross-match, resuscitation with a crystalloid solution was initiated. An X-ray of the right arm documented that the shotgun pellets were all in the area of the right biceps muscle (figure 1). After administration of a cephalosporin antibiotic, the patient was moved to the operating room. Figure 1 X-ray of the right humerus documents no fracture and limited distribution of pellets. Skin preparation and draping included the chest and the entire right upper extremity from the left nipple to the right fingernails and from below the umbilicus to the toenails bilaterally. After the pressure dressing was removed, there was profuse venous hemorrhage from the open wound in the anterior right arm. Attempts at suture and metal clip control of multiple open veins had an only modest effect on controlling the hemorrhage. Based on the injuries described, your choice …

Background: Endovascular repair has emerged as a viable repair option for axillosubclavian arterial injuries in select patients; however, further study of contemporary outcomes is warranted. Methods: The American Association for the Surgery of Trauma (AAST) PROspective Observational Vascular Injury Treatment (PROOVIT) registry was used to identify patients with axillo-subclavian arterial injuries from 2013 – 2019. Demographics and outcomes were compared between patients undergoing endovascular repair versus open repair. Results: 167 patients were identified, with intervention required in 107 (64.1%). Among these, 24 patients underwent open damage control surgery (primary amputation = 3, ligation = 17, temporary vascular shunt = 4). The remaining 83 patients (91.6% male; mean age 26.0 ± 16) underwent either endovascular repair (36, 43.4%) or open repair (47, 56.6%). Patients managed with definitive endovascular or open repair had similar demographics and presentation, with the only exception that endovascular repair was more commonly employed for traumatic pseudoaneurysms (p=0.004). Endovascular repair was associated with lower 24-hour transfusion requirements (p=0.012), but otherwise the two groups were similar with regards to in-hospital outcomes. Conclusion: Endovascular repair is now employed in > 40% of axillo-subclavian arterial injuries undergoing repair at initial operation and is associated with lower 24 hour transfusion requirements, but otherwise outcomes are comparable to open repair.

Introduction Injuries to the inferior vena cava (IVC), while uncommon, have a high mortality despite modern advances. The goal of this study is to describe the diagnosis and management in the largest available prospective data set of vascular injuries across anatomic levels of IVC injury. Methods The American Association for the Surgery of Trauma PROspective Observational Vascular Injury Treatment (PROOVIT) registry was queried from November 2013 to January 2019. Demographics, diagnostic modalities, injury patterns, and management strategies were recorded and analyzed. Comparisons between anatomic levels were made using non-parametric Wilcoxon rank-sum statistics. Results 140 patients from 19 institutions were identified; median age was 30 years old (IQR 23-41), 75% were male, and 62% had penetrating mechanism. The suprarenal IVC group was associated with blunt mechanism (53% vs 32%, P = .02), had lower admission systolic blood pressure, pH, Glasgow Coma Scale (GCS), and higher ISS and thorax and abdomen AIS than the infrarenal injury group. Injuries were managed with open repair (70%) and ligation (30% overall; infrarenal 37% vs suprarenal 13%, P = .01). Endovascular therapy was used in 2% of cases. Overall mortality was 42% (infrarenal 33% vs suprarenal 66%, PConclusions Current PROOVIT registry data demonstrate continued use of ligation extending to the suprarenal IVC, limited adoption of endovascular management, and no dramatic increase in overall survival compared to previously published studies. Survival is likely related to IVC injury location and total injury burden.

A 33-year-old female presented to the trauma center with multiple gunshot wounds to her left posterior axilla, right of midline in the upper back, and left lateral thigh. She complained that she did not have sensation in or an ability to move her left upper extremity. The patient was screaming and uncooperative during the examination. Her systolic blood pressure was 110 mm Hg, heart rate was 138 beats per minute, and respiratory rate was 33 breaths per minute with audible breath sounds bilaterally. There was significant bleeding from her left posterior axillary wound, and this was packed with gauze. Her left upper extremity was cool with no palpable radial pulse nor Doppler signal, and she had no strength or sensation in this extremity. Palpable pulses were present in all other extremities. After blood was drawn for type and cross-match, two large bore intravenous catheters were inserted. Given her agitation and inability to cooperate with an examination, she was intubated using rapid sequence induction with 100 mg lidocaine, 150 mg propofol, and 100 mg rocuronium. With induction, she became hypotensive to a systolic blood pressure of 70 mm Hg. With the rapid decline in the patient’s systolic blood pressure, your choice for the next step in management would be: 1. Focused abdominal sonography for trauma (FAST) examination 2. Transfusion of blood products 3. Infusion of 1 liter lactated Ringer’s solution 4. Stat CT aortogram with contrast A Cordis central venous catheter was placed in her right femoral vein under ultrasound guidance, and she was transfused 1 unit of whole blood with a rise in her systolic blood pressure to 140 mm Hg. An extended FAST examination was performed and was negative for any blood in the pericardium, bilateral pleural spaces, or abdomen. An X-ray of her chest showed bullet fragments over her right clavicle and no evidence of an intrathoracic injury, …

Background It is unknown how frequently damage control (DC) laparotomy is used across trauma centers in different countries. We conducted a cross-sectional survey of trauma centers in the United States, Canada, and Australasia to study variations in use of the procedure and predictors of more frequent use of DC laparotomy. Methods A self-administered, electronic, cross-sectional survey of trauma centers in the United States, Canada, and Australasia was conducted. The survey collected information about trauma center and program characteristics. It also asked how often the trauma program director estimated DC laparotomy was performed on injured patients at that center on average over the last year. Multivariable logistic regression was used to identify predictors of a higher reported frequency of use of DC laparotomy. Results Of the 366 potentially eligible trauma centers sent the survey, 199 (51.8%) trauma program directors or leaders responded [United States = 156 (78.4%), Canada = 26 (13.1%), and Australasia = 17 (8.5%)]. The reported frequency of use of DC laparotomy was highly variable across trauma centers. DC laparotomy was used more frequently in level-1 than level-2 or -3 trauma centers. Further, high-volume level-1 centers used DC laparotomy significantly more often than lower volume level-1 centers (p = 0.02). Nearly half (48.4%) of high-volume volume level-1 trauma centers reported using the procedure at least once weekly. Significant adjusted predictors of more frequent use of DC laparotomy included country of origin [odds ratio (OR) for the United States vs. Canada = 7.49; 95% confidence interval (CI) 1.39–40.27], level-1 verification status (OR = 6.02; 95% CI 2.01–18.06), and the assessment of a higher number of severely injured (Injury Severity Scale score > 15) patients (OR per-100 patients = 1.62; 95% CI 1.20–2.18) and patients with penetrating injuries (OR per-5% increase = 1.27; 95% CI 1.01–1.58) in the last year. Conclusions The reported frequency of use of DC laparotomy was highly variable across trauma centers. Those centers that most need to evaluate the benefit-to-risk ratio of using DC laparotomy in different scenarios may include high-volume, level-1 trauma centers, particularly those that often manage penetrating injuries.

Background Acute and chronic sleep deprivation are significantly associated with depressive symptoms and are thought to be contributors to the development of burnout. In-house call inherently includes frequent periods of disrupted sleep and is common among acute care surgeons. The relationship between in-house call and sleep deprivation among acute care surgeons has not been previously studied. The goal of this study was to determine prevalence and patterns of sleep deprivation in acute care surgeons. Study Design A prospective study of acute care surgeons with in-house call responsibilities from 2 level I trauma centers was performed. Participants wore a sleep-tracking device continuously over a 3-month period. Data collected included age, sex, schedule of in-house call, hours and pattern of each sleep stage (light, slow wave, and rapid eye movement [REM]), and total hours of sleep. Sleep patterns were analyzed for each night, excluding in-house call, and categorized as normal, acute sleep deprivation, or chronic sleep deprivation. Results There were 1,421 nights recorded among 17 acute care surgeons (35.3% female; ages 37 to 65 years, mean 45.5 years). Excluding in-house call, the average amount of sleep was 6.54 hours, with 64.8% of sleep patterns categorized as acute sleep deprivation or chronic sleep deprivation. Average amount of sleep was significantly higher on post-call day 1 (6.96 hours, p = 0.0016), but decreased significantly on post-call day 2 (6.33 hours, p = 0.0006). Sleep patterns with acute and chronic sleep deprivation peaked on post-call day 2, and returned to baseline on post-call day 3 (p = 0.046). Conclusions Sleep patterns consistent with acute and chronic sleep deprivation are common among acute care surgeons and worsen on post-call day 2. Baseline sleep patterns were not recovered until post-call day 3. Future study is needed to identify factors that affect physiologic recovery after in-house call and further elucidate the relationship between sleep deprivation and burnout.

Incidence and treatment of blunt thoracic aortic injury (BTAI) has evolved, likely from improved imaging and emergence of endovascular techniques; however, multicenter data demonstrating this are lacking. We examined trends in incidence, management, and outcomes in BTAI.The American College of Surgeons National Trauma Databank (2003 to 2013) was used to identify adults with BTAI. Management was categorized as nonoperative repair, open aortic repair (OAR), or thoracic endovascular repair (TEVAR). Outcomes included demographics, management, and outcomes.There were 3,774 patients. Median age was 46.0 years (interquartile range [IQR] 29.3, 62.0 years), with 70.8% males, and median Injury Severity Score (ISS) of 34.0 (IQR 26.0, 45.0). The number of BTAIs diagnosed over the decade increased 196.8% (p0.001), median ISS decreased from 38 to 33 (p0.001), and significantly more patients were treated at a level I trauma center (p0.001). After FDA approval of TEVAR devices, there was a significant increase in endovascular repair overall (1.0% to 30.6%, p0.001) and in those treated operatively (0.0% to 94.9%, p0.001), with a marked decrease in OAR. Use of TEVAR was associated with significantly reduced median ICU LOS (9.0 vs 12.0 days, p = 0.048) and mortality (9.3% vs 16.6%; p = 0.015) compared with OAR. In modern BTAI care, TEVAR has nearly completely replaced OAR.The diagnosis of BTAI has increased, likely due to more sensitive imaging. Nearly 70% of patients get nonoperative care. Treatment with TEVAR improves outcomes relative to OAR. Part of the proportional increase in TEVAR use may represent overtreatment of lower grade BTAI amenable to medical management, and warrants further investigation.

This is a literature review on the history of venous trauma since the 1800s, especially that to the common femoral, femoral and popliteal veins, with focus on the early 1900s, World War I, World War II, Korean War, Vietnam War, and then civilian and military reviews (1960-2020). In the latter two groups, tables were used to summarize the following: incidence of venous repair versus ligation, management of popliteal venous injuries, patency of venous repairs when assessed30 days from operation, patency of venous repairs when assessed30 days from operation, clinical assessment (edema or not) after ligation versus repair, incidence of deep venous thrombosis after ligation versus repair, and incidence of pulmonary embolism after ligation versus repair.There is a lack of the following in the literature on the management of venous injuries over the past 80 years: standard definition of magnitude of venous injury in operative reports, accepted indications for venous repair, standard postoperative management, and timing and mode of early and later postoperative assessment.Multiple factors have entered into the decision on venous ligation versus repair after trauma for the past 60 years, but a surgeon's training and local management protocols have the most influence in both civilian and military centers. Ligation of venous injuries, particularly those in the lower extremities, is well tolerated in civilian trauma, although there is the usual lack of short- and long-term follow-up as noted in many of the articles reviewed.Review article, levels IV and V.

A 35-year-old man presented to the trauma center with two gunshot wounds to the left thigh that were reportedly from a handgun. Prehospital transport time was about 15 minutes and he received 1 L of intravenous crystalloid fluid for hypotension. It was reported that the patient fell after he was shot and that he hit his head and lost consciousness. The patient was pale and diaphoretic on arrival at the trauma center. His blood pressure was 83/53, heart rate was 82 beats per minute, respiratory rate was 18 breaths per minute, and oxygen saturation was 98% on room air. There was a missile wound in the proximal lateral left thigh and another in the distal posterior thigh. He had hard signs of an arterial injury in the left thigh, including arterial bleeding from the distal gunshot wound, an expanding hematoma, and a pulseless left foot, as well as decreased motor function and sensation in the left foot. A massive transfusion protocol was initiated as X-rays of the left lower extremity were completed (no fracture). After pressure dressing was applied to the site of hemorrhage in the left thigh (distal gunshot wound), the patient was taken to the CT scanner to evaluate for a traumatic brain injury and then to the operating room emergently for exploration of the left thigh. Skin preparation was applied from the umbilicus to the toes bilaterally and was circumferential on the lower extremities. An incision was made along the left medial thigh to expose the superficial femoral artery (SFA). Nearly circumferential injuries to the distal SFA and popliteal vein at the adductor hiatus (Hunter’s canal) were identified. Proximal and distal control with the application of vascular clamps to both vessels was obtained, and systemic heparin (7000 units, or approximately 100 U/kg) was administered …

An 18-year-old man presented to the trauma center with four gunshot wounds to the following areas: left lower flank, left lower quadrant of the abdomen, left supraclavicular region and left scapula. The patient was awake but alternated between periods of agitation and lethargy. He had a heart rate of 140 beats/min, a blood pressure of 100/60 mmHg, a respiratory rate of 12 breaths/min, and appeared pale with cool and clammy skin. Breath sounds were clear bilaterally. His left supraclavicular wound did not exhibit any signs of overt bleeding, nor was there an expanding hematoma, and he had a palpable left radial pulse. His abdominal examination was significant for the gunshot wounds as described earlier and tenderness over the left flank. Large bore intravenous access was obtained, and transfusion with whole blood was initiated. A Focused Assessment for the Sonographic Evaluation of the Trauma Patient (FAST) documented a fluid stripe in the right hepatorenal fossa. A foreign body X-ray series was then performed (figure 1). The patient was taken to the operating room where an emergency exploratory laparotomy was performed. A moderate amount of hemoperitoneum and bile staining was noted in the lesser sac. Figure 1 Foreign body series demonstrating retained bullets in the right upper quadrant. The following injuries were noted: (1) anterior and posterior perforations of the stomach, (2) a through-and-through central injury to the left lobe of the liver, (3) a perforation of the right hemidiaphragm and (4) an injury to the edge of the inferior pole of the spleen. The right upper quadrant of the abdomen was packed with laparotomy pads, and this appeared to control the bleeding. The tip of the spleen was inspected again and found to be hemostatic. The gastric injuries were then oversewn with a 3–0 polydioxanone (PDS) suture. Because of a concern about the …

A 24-year-old man presented to the trauma center with obvious distress and a gunshot wound above the left nipple. The patient was speaking but was confused and diaphoretic with a systolic blood pressure of 80 mm Hg, heart rate of 110 beats per minute and a respiratory rate of 20 breaths per minute. He had a single gunshot wound 5 cm superior to the left nipple and decreased breath sounds over the left hemithorax. After blood was drawn for type and cross-match, two #14 gauge intravenous catheters were inserted into the antecubital veins and lactated Ringer’s infusions were started. A surgeon-performed extended ultrasound focused assessment for the sonographic evaluation of the trauma patient (FAST) examination documented the absence of pleural sliding and of a comet tail artifact in the left hemithorax. Also, there was no pericardial fluid noted. A 36-Fr thoracostomy tube was inserted through the left fifth intercostal space, and a rush of air from the left hemithorax was noted. A stat chest X-ray was performed (figure 1). Figure 1 Gunshot wound to superior mediastinum injured posterior left common carotid artery at its origin on the transverse arch, left innominate vein and distal innominate artery. Patient had a contained hematoma and was transported to the operating room. From Feliciano.14 The patient’s systolic blood pressure remained at 80 mm Hg. In addition to intubation and transfusion of blood, your choice for the next step in management would be: 1. emergent left anterolateral thoracotomy. 2. contact the endovascular specialist. 3. CT aortogram with contrast. 4. median sternotomy in the operating room. The surgical team felt that the contained hematoma in the superior mediastinum reflected an injury to a great vessel. A median sternotomy was performed, and three separate vascular injuries were noted as follows

A 25-year-old man presented to the trauma center with gunshot wounds to the left shoulder and left lower quadrant. The patient was combative and diaphoretic with a systolic blood pressure of 100 mm Hg and a heart rate of 132 beats per minute. He had a single gunshot wound to the soft tissue of the superior aspect of the left shoulder, with normal pulses at the left wrist and a normal neurological examination in the left upper extremity. His abdominal examination was significant for a gunshot entrance wound in the left lower quadrant and diffuse peritonitis. The right femoral pulse was not palpable. After blood was drawn for type and cross-match, a surgeon-performed ultrasound was ‘negative’ for a hemopericardium and a left hemopneumothorax. A massive transfusion protocol was initiated, and a cephalosporin antibiotic was administered. On the first set of arterial blood gases, the pH was 7.11 with a base deficit of −17.5. After transport to the operating room, the patient was intubated, a midline exploratory laparotomy was performed and 2 L of hemoperitoneum were evacuated. There were multiple enterotomies in the small bowel, transection of the right external and internal iliac arteries and near transection of the right spermatic cord. Intestinal clamps were rapidly placed at the sites of enterotomies. Progressive hypotension mandated manual compression of the supraceliac abdominal aorta. A vascular clamp was then applied to the right common iliac artery, and the distal end of the right internal iliac artery was clamped and ligated. As the distal end of the right external iliac artery had retracted under the inguinal ligament, the midline abdominal incision was extended obliquely across the inguinal ligament into the right groin. A vascular clamp was then applied to the distal end of the right external iliac artery. The right spermatic cord was ligated. …

Background Despite advances in management of extremity vascular injuries, "hard signs" remain the primary criterion to determine need for imaging and urgency of exploration. We propose that hard signs are outdated and that hemorrhagic and ischemic signs of vascular injury may be of greater clinical utility. Methods Extremity arterial injuries from the American Association for the Surgery of Trauma PROspective Observational Vascular Injury Treatment registry were analyzed to examine the relationships between hard signs, ischemic signs, and hemorrhagic signs of extremity vascular injury with workup, diagnosis, and management. Results Of 1,910 cases, 1,108 (58%) had hard signs of vascular injury. Computed tomography angiography (CTA) was more commonly used as the diagnostic modality in patients without hard signs, while operative exploration was primarily used for diagnosis in hard signs. Patients undergoing CTA were more likely to undergo endovascular or hybrid repair (EHR) (10.7%) compared with patients who underwent exploration for diagnosis (1.5%). Of 915 patients presenting with hemorrhagic signs, CTA was performed 14.5% of the time and was associated with a higher rate of EHR and observation. Of the 490 patients presenting with ischemic signs, CTA was performed 31.6% of the time and was associated with higher rates of EHR and observation. Hemorrhagic signs were associated with arterial transection, while ischemic signs were associated with arterial occlusion. Patients with ischemic signs undergoing exploration for diagnosis received more units of packed red blood cells during the first 24 hours. There was no difference in amputation rate, reintervention rate, hospital length of stay, or mortality in comparing groups who underwent CTA versus exploration. Conclusion Hard signs have limitations in identification and characterization of extremity arterial injuries. A strategy of using hemorrhagic and ischemic signs of vascular injury is of greater clinical utility. Further prospective study is needed to validate this proposed redefinition of categorization of presentations of extremity arterial injury. Level of evidence Diagnostic, level III.

Isolated injuries to the pancreas and duodenum from either blunt or penetrating trauma are infrequent, and early mortality is usually due to associated vascular injuries in the upper abdomen. Delays in diagnosis after blunt trauma are less common in the modern era due to the availability of multidetector CT. Pancreatic injuries without involvement of the main duct are managed nonoperatively, while ductal injuries are treated with resection of the body and tail or head and a rare Roux-en-Y reconstruction in most circumstances. The most common complication after resection continues to be a pancreatic fistula. Duodenal perforations are treated with transverse or oblique closure, Roux-en-Y duodenojejunostomy, or resection. Pyloric exclusion with gastrojejunostomy is still used for selected combined pancreatoduodenal or complex duodenal injuries.

A 22-year-old man presented to the trauma center with a single gunshot wound to the right upper quadrant. The patient’s systolic blood pressure was reported to be 80 mm Hg in the field. The patient was alert and responsive on arrival. His initial vital signs were a heart rate of 120 beats per minute, a systolic blood pressure of 138 mm Hg, and a respiratory rate of 20/min. His abdominal examination was significant for a gunshot wound approximately 10 cm inferior to the right costal margin and 6 cm lateral to the midline. In addition, his abdomen was distended and diffusely tender to palpation. After blood was drawn for type and cross-match, the patient was moved to the operating room. A massive transfusion protocol was initiated, and a cephalosporin antibiotic was administered. After intubation, a midline exploratory laparotomy was performed. A significant hemoperitoneum was evacuated. At this point, the anesthesiologist stated that the patient’s systolic blood pressure had dropped to 80 mm Hg. On rapid inspection of the abdominal cavity, through-and-through wounds to the prepyloric gastric antrum, through-and-through wounds to the head of the pancreas, and a large midline supramesocolic hematoma were noted. Division of the gastrocolic omentum allowed for exposure and suture repair of the anterior and posterior holes in the prepyloric antrum. A few peripancreatic bleeders were ligated as the head of the pancreas was inspected. The location of the through-and-through wounds in the head of the pancreas suggested that neither the common bile duct nor the main pancreatic duct of Wirsung was injured. The most appropriate next step at operation is: 1. Left anterolateral thoracotomy/cross-clamp descending thoracic aorta 2. Add median sternotomy to midline laparotomy incision 3. Left medial mobilization maneuver 4. Cattell-Braasch maneuver At this point, the midline supramesocolic hematoma was larger than when first observed. It was approached by a left medial mobilization maneuver …

Introduction Morbidity from the treatment of extremity compartment syndrome is underappreciated. Closure technique effectiveness has yet to be definitively established. Methods A randomized non-blinded prospective study was performed involving patients who underwent an extremity fasciotomy following trauma. Shoelace wounds were strapped with vessel loops under tension and VAC wounds were treated with a standard KCI VAC dressing. After randomization, patients returned to the OR every 96 h until primarily closed or skin grafted. Results 21 patients were consented for randomization with 11 (52%) successfully closed at the first re-operation. After interim analysis the study was closed early with 5/5 (100%) of wounds treated with the shoelace technique closed primarily and only 1/9 (11%) of VAC wounds closed primarily (p = 0.003). Overall primary closure was achieved in 74% of patients. Conclusions Aggressive attempts at wound closure lead to an increased early closure rate. For wounds that remain open after the first re-operation, a simple shoelace technique is more successful than a wound VAC for achieving same hospital stay skin closure.

Objectives Fasciotomy to treat or prevent compartment syndromes in patients with truncal or peripheral arterial injuries is a valuable adjunct. The objective of this study was to document the current incidence, indications, and outcomes of below knee fasciotomy in patients with femoropopliteal arterial injuries. Methods The PROspective Observational Vascular Injury Treatment registry of the American Association for the Surgery of Trauma was utilized to identify patients undergoing two-incision four-compartment fasciotomy of the leg after repair of a femoropopliteal arterial injury. Outcomes after therapeutic versus prophylactic (surgeon label) fasciotomy were compared as was the technique of closure, that is, primary skin closure or application of a split-thickness skin graft (STSG). Results From 2013 to 2018, fasciotomy was performed in 158 patients overall, including 95.6% (151/158) at the initial operation. In the group of 139 patients who survived to discharge, fasciotomies were labeled as therapeutic in 58.3% (81/139) and prophylactic in 41.7% (58/139). There were no significant differences between the therapeutic and prophylactic groups in amputation rates (14.8% vs. 8.6%, P = .919). Primary skin closure was achieved at a median of 5.0 days vs. 11.0 days for STSG ( P = .001). Conclusions Over 55% of patients undergoing repair of an injury to a femoral or popliteal artery have a fasciotomy performed at the same operation. A “therapeutic” indication for fasciotomy continues to be more common than “prophylactic,” while outcomes are identical in both groups.

Background High-energy missiles can cause cardiac injury regardless of entrance site. This study assesses the adequacy of the anatomic borders of the current "cardiac box" to predict cardiac injury. Methods Retrospective autopsy review was performed to identify patients with penetrating torso gunshot wounds (GSWs) 2011 to 2013. Using a circumferential grid system around the thorax, logistic regression analysis was performed to detect differences in rates of cardiac injury from entrance/exit wounds in the "cardiac box" versus the same for entrance/exit wounds outside the box. Analysis was repeated to identify regions to compare risk of cardiac injury between the current cardiac box and other regions of the thorax. Results Over the study period, 263 patients (89% men; mean age, 34 years; median injuries/person, 2) sustained 735 wounds (80% GSWs), and 239 patients with 620 GSWs were identified for study. Of these, 95 (34%) injured the heart. Of the 257 GSWs entering the cardiac box, 31% caused cardiac injury, whereas 21% GSWs outside the cardiac box (n = 67) penetrated the heart, suggesting that the current "cardiac box" is a poor predictor of cardiac injury relative to the thoracic non-"cardiac box" regions (relative risk [RR], 0.96; p = 0.82). The regions from the anterior to posterior midline of the left thorax provided the highest positive predictive value (41%) with high sensitivity (90%) while minimizing false-positives, making this region the most statistically significant discriminator of cardiac injury (RR, 2.9; p = 0.01). Conclusion For GSWs, the current cardiac box is inadequate to discriminate whether a GSW will cause a cardiac injury. As expected, entrance wounds nearest to the heart are the most likely to result in cardiac injury, but, from a clinical standpoint, it is best to think outside the "box" for GSWs to the thorax. Level of evidence Therapeutic/care management, level IV.

Despite advances in trauma care, a subset of patients surviving damage control cannot achieve fascial closure and require split-thickness skin grafting (STSG) of their open abdomen. Controversy exists as to whether reconstruction of the gastrointestine (GI) should be staged or performed at the time of abdominal wall reconstruction (AWR). Many surgeons do not believe that operations through the STSG can be completed safely or without loss of graft. This series reviews the outcomes of operations for GI reconstruction performed through the elevated healed STSG. Concurrent series on all patients undergoing abdominal operation through the STSG. The technique involves elevating the STSG, lysing adhesions only as needed, avoid detaching underlying omentum or viscera to avoid devascularization, and then reattaching the elevated STSG to the abdominal wall with simple sutures. From 1995 to 2017, 27 patients underwent 40 distinct procedures during 36 separate abdominal reoperations (89% GI) through the elevated STSG approach at three Level I trauma centers at a mean interval of 11 months from application of the STSG. One STSG was lost (patient closed with skin flaps), one patient had 30 per cent loss of the STSG (regrafted), and one patient had 10 per cent loss of the STSG (allowed to granulate). One patient required a small bowel resection for intraoperative enterotomy during a difficult operative dissection. There were no GI complications, intraabdominal infections, or deaths, and all patients were deemed fit to undergo AWR after three months. Major intraabdominal reoperations can be readily and safely accomplished through the elevated STSG approach with a

A minimally invasive (MI) approach using small incisions and vessel loops for drainage of simple perianal abscesses has been described in the pediatric population with decreased postoperative pain and comparable results to the traditional incision and drainage (I&D). The hypothesis was MI I&D will yield similar outcomes in adults. Patients who underwent I&D of perianal abscesses at an urban hospital from January 2008 to December 2015 were identified by Current Procedural Terminology code. Patients below 18 years of age, with inflammatory bowel diseases, or fistulae were excluded. Recurrences, readmissions, operative time, length of stay, complications, and costs were compared. There were 47 traditional and 96 MI I&D with no significant differences in demographics, average body mass index, and abscess size. No significant differences were noted in recurrences, readmissions, length of stay, operative time, or costs (P > 0.05). Postoperative complications occurred more frequently in the traditional group (P < 0.01) with a lower rate of follow-up (P < 0.05). MI I&D for simple anal abscesses in adults is associated with better compliance and fewer complications than the traditional approach. Although further studies are needed to determine if MI I&D confers superiority, this approach should be considered as first-line treatment for uncomplicated perirectal abscesses in adults.

Objective:To review the history of the innovation of damage control (DC) for management of trauma patients.Background:DC is an important development in trauma care that provides a valuable case study in surgical innovation.Methods:We searched bibliographic databases (1950–2015), conference abstracts

Approximately 15% of patients with penetrating thoracic trauma require an emergency center or operating room thoracotomy, usually for hemodynamic instability or persistent hemorrhage. The hypothesis in this study was that admission physiology, not vital signs, predicts the need for operating room thoracotomy.We conducted a trauma registry review, 2002 to 2017, of adult patients undergoing operating room thoracotomy within 6 hours of admission (emergency department thoracotomies excluded). Demographics, injuries, admission physiology, time to operating room (OR), operations, and outcomes were reviewed. Data are reported as mean (SD) or median (IQR).Of the 301 consecutive patients in this 15-year review, 75.6% were male, mean age was 31.1 years (11.5), and 41.5% had gunshot wounds. The median Injury Severity Score was 25 (range 16 to 29), time to operating room was 38 minutes (interquartile range [IQR] 19 to 105 minutes), and 21.9% had a thoracic damage control operation. Mean admission systolic blood pressure was 115 mmHg (SD 37 mmHg), with only 23.9%90 mmHg; however, admission pH 7.22 (SD 0.14), base deficit 7.6 (SD 6.1), and lactate 7.2 (SD 4.5) were markedly abnormal. Overall, there were 136 (45.2%) patients with significant pulmonary injuries treated with 112 major nonanatomic resections, 17 lobectomies, and 7 pneumonectomies; respective mortalities were 2.7%, 11.8%, and 42.9%. There were 100 (33.2%) cardiac, 30 (9.9%) great vessel, 14 (4.7%) aerodigestive, and 58 (19%) combined thoracic injuries. Mortalities for cardiac, great vessel, and aerodigestive injuries were 7%, 0%, and 14.3%, respectively. Overall mortality was 6.6%, 15.2% after damage control, and 4.3% for all others.Shock characterized by acidosis, but not hypotension, is the most common presentation in patients who will need operating room thoracotomy after penetrating thoracic trauma. Survival rates are excellent unless a pneumonectomy or damage control thoracotomy is required.

Penetrating injury to the neck can be devastating because of the multiple vital structures in close proximity. In the event of injury to the carotid artery, there is a significantly increased likelihood of morbidity or mortality. The purpose of this study was to assess presenting characteristics associated with penetrating injury to the carotid artery and directly compare approaches to surgical management.Data from the National Trauma Data Bank from 2002-2016 were accessed to evaluate adult patients sustaining penetrating injury to the common or internal carotid artery. Management (operative versus nonoperative) and surgical approach (open versus endovascular) were evaluated based on presentation characteristics, and outcomes were compared after propensity score matching.Three thousand three hundred ninety-one patients fitting inclusion criteria and surviving past the emergency department were included in analyses (nonoperative: 1,976 [58.3%] patients and operative: 1,415 [41.7%] patients). The operative group was further classified by intervention as open = 1,192 patients and endovascular: 154 patients. On presentation, the nonoperative group demonstrated significantly higher prevalence of coma (Glasgow Coma Scale ≤8: nonoperative = 49.3% versus operative = 40.8%, P 0.001), severe overall injury burden (Injury Severity Score ≥25: nonoperative = 42.3% versus operative = 33.3%, P 0.001), and severe head injury (Abbreviated Injury Score ≥ 3: nonoperative = 44.9% versus operative = 22.0%, P 0.001). After propensity score matching, the nonoperative group demonstrated higher mortality (nonoperative = 28.9% versus operative = 18.5%, P 0.001), and lower rates of stroke (nonoperative = 6.6% versus operative - = 10.5%, P 0.001). There were no differences in outcomes relating to surgical approach.These results indicate that nonoperative patients often present with a more severe overall injury burden, particularly injury to the head, and not surprisingly, have higher rates of mortality. The lack of significant differences in outcomes relating to surgical approach indicates open versus endovascular invention should be individualized to the patient-for example, based on presenting characteristics and the location of the injury.

A 24-year-old man presented to the trauma center with gunshot wounds to the neck, chest and back. The patient was awake but lethargic with a heart rate of 120 beats per minute, a systolic blood pressure of 80 mm Hg and absent breath sounds on the right. He was noted to have an expanding hematoma of the left neck under a gunshot wound, a gunshot wound to the left chest at the level of the nipple, a gunshot wound overlying the left scapula, and a fourth gunshot wound penetrating the left deltoid muscle. The most appropriate first step in management of this patient in addition to resuscitation is: 1. Foreign body X-ray series. 2. Left anterolateral thoracotomy. 3. Orotracheal intubation/right thoracostomy tube. 4. Pressure dressing to left neck. The patient underwent orotracheal intubation, insertion of a right thoracostomy tube, and transfusion of blood through large bore intravenous catheters. A foreign body series demonstrated a deep sulcus sign on the left with a pulmonary contusion, a retained bullet in the region of the right shoulder and several bullet fragments in the left shoulder (figure 1). Subsequently, a left-sided thoracostomy tube was inserted with drainage of a hemothorax. After transfusion of 3 units of packed red blood cells and 3 units of plasma, the patient’s systolic blood pressure increased to 120 mm Hg and his heart rate decreased to 80 beats per minute. As the patient’s cervical hematoma was stable, a CT scan of the neck and chest was performed with a single load of intravenous contrast. The CT scan demonstrated an intimal defect in the left common carotid artery and a trajectory highly concerning for esophageal perforation (figure 2). Figure 1 Paper clips mark gunshot wounds. Red arrows are anterior and blue arrows are posterior. Figure 2 CT scan demonstrating carotid (red arrow) and esophageal (blue arrow) injuries. The most …

A 53-year-old woman standing next to a car in a parking deck was struck by another car when the driver lost control. The patient’s right knee and leg were crushed between the bumpers of both cars. The patient was ‘fortunate’ in that a Level I trauma center was only six blocks away. On arrival in the trauma room, the patient was awake and alert with a heart rate of 120 beats per minute and a systolic blood pressure of 90 mm Hg. The right lower extremity was mangled with a dislocation of the knee, large wound in soft tissue with oozing behind the knee, and disrupted muscles in the exposed posterior compartments. No arterial pulses were present in the right foot, but there was sensation and some weak dorsiflexion and plantar flexion in the ankle joint. The most appropriate first step in the management of this patient in addition to resuscitation is: 1. CT arteriography. 2. Administer unfractionated heparin. 3. Obtain consent for amputation. 4. Move patient to operating room. The patient was moved to the operating room to control bleeding from disrupted soft tissue, assess the magnitude of injuries to the right knee and leg and to obtain X-rays of the same. After preparation of the skin from the umbilicus to the toenails bilaterally, the right foot was placed in a plastic bag to allow for later observation of skin color changes and palpation of pedal pulses. The remainder of both lower extremities was draped in the usual fashion. As there was no major arterial hemorrhage from disrupted soft tissues, X-rays of the right knee and leg were performed. A Grade IIIC open dislocation of the right knee joint was confirmed, and there was a Grade II open transverse fracture of the right tibia, as well. A distal medial right popliteal incision was …

Blunt carotid artery injury (BCI) is present in approximately 1.0% to 2.7% of all blunt trauma admissions and can result in significant morbidity and mortality. Management ranges from antithrombotic therapy alone to surgery, where potential indications include pseudoaneurysm, failed or contraindication to medical therapy, and progression of neurologic symptoms. Still, optimal management, including approach and timing, continues to be an active area for debate. The goal of this study was to assess the epidemiologic characteristics of BCI, and, after controlling for presenting features intrinsic to the data, compare outcomes based on management, operative approach, and timing of intervention.A retrospective review was conducted of adult BCI patients identified within the National Trauma Data Bank from 2002 to 2016. The National Trauma Data Bank is the largest trauma database in the United States, collating data from each trauma admission for more than 900 trauma centers. Independent variables of interest included nonoperative versus operative management (OM); endovascular versus open intervention, and early (within 24 hours) versus delayed (after 24 hours) intervention. For each independent variable, groups were compared after propensity score matching to control for presenting factors and patterns of injury.There were 9190 patients who met the inclusion criteria, 812 of whom underwent operative intervention (open, n = 288; endovascular, n = 481, both: n = 43). During the review, there was no difference in proportion of OM over time, although there was a statistically significant decrease in the proportion of open intervention (0.48% per year; P .05). For outcomes, operative versus nonoperative management (nOM) resulted in no difference in mortality, but the operative group demonstrated an increased risk of stroke (11.8% vs 6.5%), longer hospital and intensive care length of stay, and more days on mechanical ventilation (P .001 for each). With regard to timing: mortality was increased for early intervention (early, 16% vs delayed, 6.3%; P .001), which was predominantly driven by the endovascular cohort (early, 19.2% vs delayed, 2.5%; P .001).In this study, there was no significant trend in the overall volume of operative or nOM; however, when considering approach to OM, there was a significant decrease in open procedures. Consistent with previous literature, injury to the neck, head, and chest was significant associated with BCI. Also outcomes demonstrated an increased prevalence of stroke after operative relative to nOM. Importantly, after critically assessing the timing to intervention, results strongly suggested that, if possible, intervention should be delayed for at least 24 hours.

Background: The United States is currently experiencing a heroin epidemic. Recent reports have demonstrated a three-fold increase in heroin use among Americans since 2007 with a shift in demographics to more women and white Americans. Furthermore, there has been a correlation between the recent opioid epidemic and an increase in heroin abuse. Much has been written about epidemiology and prevention of heroin abuse, but little has been dedicated to the surgical implications, complications, and resource utilization. Discussion: This article focuses on the surgical problems encountered from heroin abuse and how to manage them in a constant effort to improve morbidity and mortality for these heroin abusers.