Faculty Bibliography

Prone ventilation refers to the delivery of mechanical ventilation with the patient lying in the prone position. The improvement of oxygenation during prone ventilation is multifactorial, but occurs mainly by reducing lung compression and improving lung perfusion. CT imaging modeling data demonstrated that the asymmetry of lung shape leads to a greater induced pleural pressure gravity gradient when supine as compared to prone positioning. Although proning is indicated in patients with severe ARDS who are not responding to other ventilator modalities, this technique has moved away from a salvage therapy for refractory hypoxemia to an upfront lung-protective strategy intended to improve survival in severe ARDS, especially due to the current COVID-19 pandemic. In view of different roles, we surgeons had to take during the COVID-19 pandemic, it is of importance to learn how to implement this therapeutic measure, especially in a surgical critical care unit setting. As such, this article aims to review the physiological principles and effects of the prone ventilation, positioning, as well as its contraindications and complications.

INTRODUCTION/BACKGROUND:Stop the Bleed (STB) program was launched by the White House, for the use of bleeding control techniques at the scene of traumatic injury. The purpose of this study was to conduct an STB course in private security and law enforcement personnel. METHODS:Pre- and post-questionnaire using the Likert scale was shared with participants on their knowledge and comfort level with the use of tourniquets. Participants were also observed while placing tourniquets and the time for placement recorded. The didactic portion and practical session of the STB was then taught and participants were again observed placing tourniquets and a questionnaire distributed. Fisher's exact tests or Wilcoxon matched-pairs signed-ranks tests were used to compare pre-post measurements. RESULTS:A total of 151 subjects were enrolled over the course of seven sessions. The tourniquet was applied correctly by 17.2% (26/151) and 92.7% (140/151) at the pre- and post-instruction assessments, respectively (p < 0.001). Mean times to apply the tourniquet were 29.8 ± 18.5 and 18.7 ± 6.7 s, respectively (p < 0.001). Subjects reported their level of comfort with the tourniquet to be 5.1 ± 3.3 and 8.8 ± 2.2, respectively (p < 0.001), and their familiarity with anatomy and bleeding control to be 5.2 ± 3.1 and 8.2 ± 2.4, respectively (p < 0.001). At the end of the course, the mean score in response to a question about the extent to which the explanation had helped was 9.0 ± 1.9 (95% CI 8.7-9.4) and to a question about the extent to which teaching would make them feel more secure and safe was 9.2 ± 1.9 (95% CI 8.9-9.5). CONCLUSIONS:STB course improved correct tourniquet placement, demonstrated dramatic improvements in application time, and increased levels of comfort. These findings validate the need for ongoing teaching and education.

Inequity exists in surgical training and the workplace. The Eastern Association for the Surgery of Trauma Equity, Quality and Inclusion in Trauma Surgery Ad Hoc Task Force (EAST4ALL) sought to raise awareness and provide resources to combat these inequities.

BACKGROUND:Suspension trauma syndrome is a life-threatening event that occurs when a person is "trapped" in a prolonged passive suspension. It is most commonly seen in people who engage in occupational or sport activities that require harness suspension. The aim of this study is to identify the predisposing factors, pathophysiology, and management of suspension trauma. METHODS:A review and analysis of the literature published in English and Spanish from 1972 to 2020 on suspension trauma were performed. Search sources were PubMed, Medline, Cochrane Library, MeSH, UpToDate, and Google Scholar. Articles referring to suspension trauma associated with other injury mechanisms (traumatic impact injuries, drowning, asphyxiation, or bleeding), case reports, and pediatric population were excluded. RESULTS:Forty-one articles were identified. Of these, 29 articles related to mechanism, pathophysiology, and management of individuals who suffered prolonged suspension trauma without associated traumatic injuries were included in the study. We encountered several controversies describing the putative pathophysiology, ranging from blood sequestration in the lower extremities versus accumulation of metabolic waste and hyperkalemia to dorsal hook-type harness as a trigger cause of positional asphyxia; to vascular compression of femoral vessels exerted by the harness causing decreased venous return. Pstients suspended in a full-body harness with dorsal hook showed more hemodynamic alterations in response to the compressive effect on the rib cage, causing a reduction in perfusion by presenting a decrease in pulse pressure. Management strategies varied across studies. CONCLUSIONS:Progress has been made in individualizing the population at risk and in the management of suspension trauma. We recommend the formation of consensus definitions, larger cohort or registry studies to be conducted, and experimental animal models to better understand the mechanisms in order to develop management and life support guidelines from a trauma and emergency medicine perspective.

Gunshot wounds to the cardiac region usually result in devastating injuries. However, if bullets embolize into the myocardium without significant damage to the organ, optimal evaluation and management remains unclear. We present the case of a hemodynamically stable gunshot wound patient who presented with a bullet to the heart. Sternotomy revealed that the bullet had embolized through the superior vena cava and embedded into the apex of the right ventricle. The patient was managed without retrieval of the bullet and continues to be well despite a retained intracardiac bullet. We discuss cases of bullet embolization to the heart and the emergence of minimally-invasive approaches for management.

Sinking skin flap syndrome is a rare syndrome leading to increased intracranial pressure, known to neurosurgeons, yet uncommon and hardly ever reported in trauma patients. In a hospitalized trauma patient with declining neurological status, rarely do we encounter further deterioration by elevating the patients' head, diuresis and hyperventilation. However, after craniectomy for trauma, a partially boneless cranium may be compressed by the higher atmospheric pressure, that intracranial pressure rises to dangerous levels. For such cases, paradoxical supportive management with intravenous fluid infusion, and reverse Trendelenburg positioning, is used to counteract the higher atmospheric pressure, as a bridge to definitive treatment with cranioplasty. These steps constitute an urgent and easily applied intervention to reduce further neurological deterioration, of which every trauma healthcare provider should be aware.

Optimal management of post-concussion symptoms (PCS) remains ill-defined but includes multimodal, symptom-guided plans of care. Osteopathic manipulative treatment (OMT) may be used as an adjunct treatment for PCS. We present a case of a motor vehicle collision victim whose PCS improved directly and progressively after OMT. To our knowledge, this is the first report of OMT utilized for PCS management after polytrauma and as part of an organized trauma system. Previous studies discuss potential benefits of OMT for patients with PCS after sports-related injuries, and none account for management of multiply injured patients as part of an organized trauma system. Further study of OMT for PCS is warranted and would benefit by recruiting patients from trauma centers in order to observe a range of mechanisms of injury that result in concussion.