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BACKGROUND: Pulmonary vascular microthrombi are a proposed mechanism of COVID-19 respiratory failure. We hypothesized that early administration of tissue plasminogen activator (tPA) followed by therapeutic heparin would improve pulmonary function in these patients. RESEARCH QUESTION: Does tPA improve pulmonary function in severe COVID-19 respiratory failure, and is it safe? STUDY DESIGN AND METHODS: Adults with COVID-19-induced respiratory failure were randomized from May14, 2020 through March 3, 2021, in two phases. Phase 1 (n = 36) comprised a control group (standard-of-care treatment) vs a tPA bolus (50-mg tPA IV bolus followed by 7 days of heparin; goal activated partial thromboplastin time [aPTT], 60-80 s) group. Phase 2 (n = 14) comprised a control group vs a tPA drip (50-mg tPA IV bolus, followed by tPA drip 2 mg/h plus heparin 500 units/h over 24 h, then heparin to maintain aPTT of 60-80 s for 7 days) group. Patients were excluded from enrollment if they had not undergone a neurologic examination or cross-sectional brain imaging within the previous 4.5 h to rule out stroke and potential for hemorrhagic conversion. The primary outcome was Pao2 to Fio2 ratio improvement from baseline at 48 h after randomization. Secondary outcomes included Pao2 to Fio2 ratio improvement of > 50% or Pao2 to Fio2 ratio of ≥ 200 at 48 h (composite outcome), ventilator-free days (VFD), and mortality. RESULTS: Fifty patients were randomized: 17 in the control group and 19 in the tPA bolus group in phase 1 and eight in the control group and six in the tPA drip group in phase 2. No severe bleeding events occurred. In the tPA bolus group, the Pao2 to Fio2 ratio was significantly (P < .017) higher than baseline at 6 through 168 h after randomization; the control group showed no significant improvements. Among patients receiving a tPA bolus, the Pao2 to Fio2 ratio at 48 h (16.9% [interquartile range (IQR), -8.3% to 36.8%] vs 29.8% [IQR, 4.5%-88.7%]; P = .11), the composite outcome (11.8% vs 47.4%; P = .03), VFD (0.0 [IQR, 0.0-9.0] vs 12.0 [IQR, 0.0-19.0]; P = .11), and in-hospital mortality (41.2% vs 21.1%; P = .19) did not reach statistically significant differences when compared with those of control participants. The patients who received a tPA drip did not experience benefit. INTERPRETATION: The combination of tPA bolus plus heparin is safe in severe COVID-19 respiratory failure. A phase 3 study is warranted given the improvements in oxygenation and promising observations in VFD and mortality. TRIAL REGISTRY: ClinicalTrials.gov; No.: NCT04357730; URL: www.clinicaltrials.gov.

BACKGROUND Trauma teams are often faced with patients on antithrombotic drugs, which is challenging when bleeding occurs. We sought to compare the effects of different antithrombotic medications on head injury severity and hypothesized that antithrombotic reversal would not improve mortality in severe TBI patients. METHODS An EAST-sponsored prospective, multi-centered, observational study of 15 trauma centers was performed. Patient demographics, injury burden, comorbidities, antithrombotic agents, and reversal attempts were collected. Outcomes of interest were head injury severity and in-hospital mortality. RESULTS Analysis was performed on 2793 patients. The majority of patients were on aspirin (ASA, 46.1%). Patients on a platelet chemoreceptor blocker (P2Y12) had the highest mean injury severity score (ISS, 9.1 ± 8.1). Patients taking P2Y12 inhibitors ± ASA, and ASA + warfarin had the highest head AIS mean (1.2 ± 1.6). On risk adjusted analysis, warfarin + ASA was associated with a higher head AIS (OR 2.43; 95% CI: 1.34-4.42) after controlling for injury severity score (ISS), Charlson Comorbidity Index (CCI), initial Glasgow Coma Score (I-GCS) and initial systolic blood pressure (I-SBP). Among patients with severe TBI (head AIS > 3) on antiplatelet therapy, reversal with desmopressin (DDAVP) and/or platelet transfusion did not improve survival (82.9% reversal vs 90.4% none, p = 0.30). In severe TBI patients taking Xa inhibitors who received prothrombin complex concentrate (PCC), survival was not improved (84.6% reversal vs 84.6% none, p = 0.68). With risk adjustment as described previously, mortality was not improved with reversal attempts (antiplatelet agents OR 0.83. 85% CI: 0.12-5.9, p = 0.85, Xa inhibitors OR 0.76, 95% CI: 0.12-4.64, p = 0.77). CONCLUSIONS Reversal attempts appear to confer no mortality benefit in severe TBI patients on antiplatelet agents or Xa inhibitors. Combination therapy was associated with severity of head injury among patients taking preinjury antithrombotic therapy, with ASA + warfarin possessing the greatest risk. LEVEL OF EVIDENCE Level II; prognostic. STUDY TYPE prospective observation.

Trauma teams are often faced with patients on antithrombotic (AT) drugs, which is challenging when bleeding occurs. We sought to compare the effects of different AT medications on head injury severity and hypothesized that AT reversal would not improve mortality in severe traumatic brain injury (TBI) patients.An Eastern Association for the Surgery of Trauma-sponsored prospective, multicentered, observational study of 15 trauma centers was performed. Patient demographics, injury burden, comorbidities, AT agents, and reversal attempts were collected. Outcomes of interest were head injury severity and in-hospital mortality.Analysis was performed on 2,793 patients. The majority of patients were on aspirin (acetylsalicylic acid [ASA], 46.1%). Patients on a platelet chemoreceptor blocker (P2Y12) had the highest mean Injury Severity Score (9.1 ± 8.1). Patients taking P2Y12 inhibitors ± ASA, and ASA-warfarin had the highest head Abbreviated Injury Scale (AIS) mean (1.2 ± 1.6). On risk-adjusted analysis, warfarin-ASA was associated with a higher head AIS (odds ratio [OR], 2.43; 95% confidence interval [CI], 1.34-4.42) after controlling for Injury Severity Score, Charlson Comorbidity Index, initial Glasgow Coma Scale score, and initial systolic blood pressure. Among patients with severe TBI (head AIS score, ≥3) on antiplatelet therapy, reversal with desmopressin (DDAVP) and/or platelet transfusion did not improve survival (82.9% reversal vs. 90.4% none, p = 0.30). In severe TBI patients taking Xa inhibitors who received prothrombin complex concentrate, survival was not improved (84.6% reversal vs. 84.6% none, p = 0.68). With risk adjustment as described previously, mortality was not improved with reversal attempts (antiplatelet agents: OR 0.83; 85% CI, 0.12-5.9 [p = 0.85]; Xa inhibitors: OR, 0.76; 95% CI, 0.12-4.64; p = 0.77).Reversal attempts appear to confer no mortality benefit in severe TBI patients on antiplatelet agents or Xa inhibitors. Combination therapy was associated with severity of head injury among patients taking preinjury AT therapy, with ASA-warfarin possessing the greatest risk.Prognostic, level II.

Trauma by electricity imposes mechanical, electrical, and thermal forces on the human body. Often, the delicate cardiac electrophysiology is disrupted causing dysrhythmia and subsequent cardiac arrest. Anoxic brain injury (ABI) is the most severe consequence and the main cause of mortality following cardiac arrest. Establishing a working protocol to treat patients who are at risk for ABI after suffering a cardiac arrest is of paramount importance. There has yet to be sufficient exploration of combination therapy of therapeutic hypothermia (TH) and progesterone as a neuroprotective strategy in patients who have suffered cardiac arrest after electric shock. The protocol required TH initiation upon transfer to the ICU with a target core body temperature of 33°C for 18 hours. This was achieved through a combination of cooling blankets, ice packs, chilled IV fluids, nasogastric lavage with iced saline, and intravascular cooling devices. Progesterone therapy at 80-100 mg intramuscularly every 12 hours for 72 hours was initiated shortly after admission to the ICU. We present a case series of three patients (mean age = 29.3 years, mean presenting Glasgow Coma Score = 3) who suffered ventricular fibrillation (VF) cardiac arrest from non-lightning electric shock, and who had considerably improved outcomes following the TH-progesterone combination therapy protocol. The average length of stay was 13.7 days. The cases presented suggest that there may be a role for neuroprotective combination therapy in post-resuscitation care of VF cardiac arrest. While TH is well documented as a neuroprotective measure, progesterone administration is a safe therapy with promising, albeit currently inconclusive, neuroprotective effect. Future protocols involving TH and progesterone combination therapy in these patients should be further explored.

Hemorrhagic shock remains the leading cause of potentially preventable death following traumatic injuries. Resuscitative Endovascular Balloon Occlusion of the Aorta (REBOA) has demonstrated promising results in the control of non-compressible torso hemorrhage. The purpose of this review is to summarize the indications, procedural techniques, and complications of REBOA in order to help define practice management guidelines. Recent studies suggest that REBOA is advantageous in aiding hemodynamic stabilization as a bridge to definitive hemorrhage control. REBOA is a feasible option for non-compressible torso hemorrhage as well as traumatic cardiac arrest and has the potential to improve morbidity and mortality in select patient populations. Despite favorable emerging data, varying results in the literature indicate the need for further high-quality reproducible data and multicenter trials to identify the ideal clinical scenarios for REBOA. This review discusses special considerations and future directions for next generation REBOA use.

Foot crush injury is a difficult problem both from the complexity of the injury pattern standpoint and also the significant clinical and socioeconomic burden that it represents to the patient. Scoring systems exist to predict limb salvage, but the accuracy and implementation of these are varied, and thus clinical judgment must always be employed when attempting limb salvage. This case report describes the first use of a reversed saphenous interposition graft repair of a transected dorsalis pedis in a patient after sustaining crush injuries to the distal lower extremity. The patient was able to undergo partial limb salvage with the use of revascularization and judicious fasciotomies.

The objective of this study was to describe the atypical presentation of combined intrapleural and extrapleural hematomas in patients on anticoagulant therapy and explain the best workup and treatment for this pathology. This case report details the presentation, initial treatment, initial workup, and subsequent final treatment and workup of an elderly female patient that arrived at our trauma facility after suffering a blunt force trauma. The patient received anticoagulation therapy for her comorbidities prior to this incident. The outcome of interest was to better understand the best diagnostic and treatment modalities for treating combined intrapleural and extrapleural hematomas.

BACKGROUND: Early recognition of bowel and mesenteric injury following blunt abdominal trauma remains difficult. We hypothesized that patients with intra-abdominal adhesions from prior laparotomy would be subjected to visceral sheering deceleration forces and increased risk for bowel and mesenteric injury following blunt abdominal trauma. METHODS: We performed a multicenter retrospective cohort analysis of 267 consecutive adult trauma patients who underwent operative exploration following moderate-critical (abdominal injury score 2–5) blunt abdominal trauma, comparing patients with prior laparotomy (n = 31) to patients with no prior laparotomy (n = 236). Multivariable regression was performed to identify predictors of bowel or mesenteric injury. RESULTS: There were no significant differences between groups for injury severity scores or findings on abdominal ultrasound, diagnostic peritoneal aspirate/lavage, pelvic radiography, or preoperative CT scan. The prior laparotomy cohort had greater incidence of full thickness bowel injury (26 vs. 9%, p = 0.010) and mesenteric injury (61 vs. 31%, p = 0.001). The proportion of bowel and mesenteric injuries occurring at the ligament of Treitz or ileocecal region was greater in the no prior laparotomy group (52 vs. 25%, p = 0.003). Prior laparotomy was an independent predictor of bowel or mesenteric injury (OR 5.1, 95% CI 1.6–16.8) along with prior abdominal inflammation and free fluid without solid organ injury (model AUC: 0.81, 95% CI 0.74–0.88). CONCLUSIONS: Patients with a prior laparotomy are at increased risk for bowel and mesenteric injury following blunt abdominal trauma. The distribution of bowel and mesenteric injuries among patients with no prior laparotomy favors embryologic transition points tethering free intraperitoneal structures to the retroperitoneum.

Background Following blunt abdominal trauma, bowel injuries are often missed on admission computed tomography (CT) scan. Methods Multicenter retrospective analysis of 176 adults with moderate-critical blunt abdominal trauma and admission CT scan who underwent operative exploration. Patients with a bowel injury missed on CT (n = 36, 20%) were compared to all other patients (n = 140, 80%). Results The missed injury group had greater incidence free fluid without solid organ injury on CT scan (44% vs. 25%, p = 0.038) and visceral adhesions (28% vs. 6%, p = 0.001). Independent predictors of missed bowel injury included prior abdominal inflammation (OR 3.74, 95% CI 1.37–10.18), CT evidence of free fluid in the absence of solid organ injury (OR 2.31, 95% CI 1.03–5.19) and intraoperative identification of visceral adhesions (OR 4.46, 95% CI 1.52–13.13). Conclusions Patients with visceral adhesive disease and indirect evidence of bowel injury on CT scan were more likely to have occult bowel injury.

Patient: Female, 36 Final Diagnosis: Thyroid hemorrhage Symptoms: Shortness of breath Medication: — Clinical Procedure: Thyroidectomy Specialty: Surgery Objective: Rare disease Background: Spontaneous goiter hemorrhage is a rare entity that can lead to life-threatening respiratory compromise. Goiter hemorrhages are usually due to effects of anticoagulation or neoplastic processes. The hormonal effects of pregnancy may also lead to such life-threatening goiter hemorrhages in the immediate postpartum period. Case Report: We report the case of a 36-year-old woman who complained of progressive neck swelling as well as eventual shortness of breath in the immediate postpartum period. Computed tomography scans and ultrasound of the neck revealed an enlarged and heterogenous thyroid with airway compression. The patient underwent an emergent subtotal thyroidectomy to alleviate the mass effect on the airway. Upon resection, the thyroid was noted to contain a goiter hemorrhage with no signs of neoplastic degeneration on pathology. Conclusions: Pregnancy is a known hormonal stressor that routinely increases the size of the thyroid and also predisposes patients to goiter formation. In rare cases, thyroid goiters may be predisposed to hemorrhage, causing airway obstruction and necessitating urgent surgical intervention.