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Improved Mortality from Penetrating Neck and Maxillofacial Trauma Using Foley Catheter Balloon Tamponade in Combat
The Journal of Emergency Medicine, Vol. 46, No. 2, pp. 321–325, 2014 Copyright Ó 2014 Published by Elsevier Inc. Printed in the USA 0736-4679/$ - see front matter
Abstracts , IMPROVED MORTALITY FROM PENETRATING NECK AND MAXILLOFACIAL TRAUMA USING FOLEY CATHETER BALLOON TAMPONADE IN COMBAT. Weppner J. J Trauma Acute Care Surg 2013;75:220–4 The military has promoted the use of a Foley catheter balloon to provide tamponade in the setting of penetrating neck or maxillofacial trauma. However, little evidence besides case reports or series has been published regarding its efficacy. This study was a retrospective cohort analysis of patients with persistent bleeding from neck and maxillofacial trauma between December 2009 and October 2011. Patients were eligible for the cohort if they were seen at a particular forward aid station (FAS)—a center staffed by one physician with six corpsmen with very limited resources—and had persistent bleeding from the wound. A Foley catheter was used if it was available at the time. Over the study period there were 77 patients who met the inclusion criteria, 44 had a Foley catheter placed and 35 had external pressure dressings applied. There was no significant difference in the demographics of the groups, including presenting Glasgow Coma Scale score, anatomical zone of injury, and Injury Severity Score. The first outcome that was evaluated was failure to achieve hemostasis or primary failure. There was no statistical difference in primary failure between the two groups, with 4% of patients in the Foley group and 11% in the external pressure group. All patients with primary failure exsanguinated at the FAS. There was a significant difference in delayed failure between the Foley group (7%) and external pressure group (26%); p < 0.05. Mortality was also significantly higher in the external pressure group (23%) than the Foley group (5%); p < 0.05. The patients that died all died from hemorrhagic shock. The patients who died in the Foley group were all part of the primary failure group. There were 8 patients who died in the external pressure group; 4 of them were in the primary closure group. Of the 4 additional patients, 3 died during transport and 1 died at the receiving facility. [Julia Dixon, MD Denver Health Medical Center, Denver, CO]
1990 to present, the authors characterized the incidence, risk factors, outcomes, and management approaches for various types of trauma in pregnant patients. Data for the review were drawn primarily from population-based studies, of which the majority had retrospective designs. Case reports and case series were also used, but only when more robust studies were not available. Of a total of 1164 abstracts reviewed, 225 were included in this review. Domestic violence (DV) or intimate partner violence (IPV) was the most frequent cause of trauma in pregnant patients, with an estimated incidence rate of 8307 cases per 100,000 live births. Motor vehicle crashes (MVCs) were the most common cause of accidental trauma in pregnancy, with 207 cases per 100,000 live births. ‘‘Falls and slips’’ were the next most common, with 48.9 cases per 100,000 live births, though some studies estimated that 1 of every 4 pregnant women suffer at least one fall during pregnancy. Burns, suicide, homicide, penetrating trauma, accidental poisonings, and electrocution were relatively infrequent. Of note, suicide and homicide were less frequent in pregnant patients than in the general population. Risk factors for DV/IPV included substance abuse, low education level, low socioeconomic status, unintended pregnancy, a history of witnessed DV/IPV as a child, and unmarried status of the pregnant patient. Alcohol use and ‘‘intoxicants’’ were associated with MVCs, and slippery floors, ‘‘hurrying,’’ and carrying heavy objects were risk factors for falls and slips. Likewise, rates of peripartum suicide were higher in females with a history of DV/IPV, substance abuse, fetal demise complicating pregnancy, or recent death of infant. Outcomes from trauma in pregnancy vary by the type of trauma and the severity of injury. In cases of intentional trauma, which include DV/IPV, studies showed a 2.7-fold increased risk of both maternal and fetal mortality, a 5.7-fold increased risk of low birth weight, and higher rates of spontaneous abortion, neonatal intensive care unit admission, preterm birth, and peripartum depression. Regarding MVCs, improper seatbelt use was associated with adverse outcomes, namely placental abruption. Likewise, after an MVC the risk of cesarean delivery rose, but the risk of preterm labor (PTL) and perinatal death was increased only if delivery occurred immediately after the MVC. According to the authors, increased incidence of PTL and perinatal death can be attributed to the severity of trauma in these cases. With respect to falls and slips, fractures of the lower extremities were the most common associated injuries. However, in one study among patients who were hospitalized after a fall while pregnant, there were higher rates of preterm labor, placental abruption, fetal distress, and fetal hypoxia, as compared to randomly selected controls. In cases of burns
Comment: This study is limited both by its retrospective design and very small sample size. Furthermore, its generalizability is very much in question. That said, this article at least lays the groundwork for a randomized prospective study to determine the utility of this technique in the prehospital management of these injuries. , TRAUMA IN PREGNANCY: AN UPDATED SYSTEMATIC REVIEW. Mendez-Figueroa H, Dahlke JD, Vrees RA, et al. Am J Obstet Gynecol 2013;209:1–10 Trauma is thought to complicate one in 12 pregnancies. In this systematic review of English-language literature from 321
Abstracts , IMPROVED MORTALITY FROM PENETRATING NECK AND MAXILLOFACIAL TRAUMA USING FOLEY CATHETER BALLOON TAMPONADE IN COMBAT. Weppner J. J Trauma Acute Care Surg 2013;75:220–4 The military has promoted the use of a Foley catheter balloon to provide tamponade in the setting of penetrating neck or maxillofacial trauma. However, little evidence besides case reports or series has been published regarding its efficacy. This study was a retrospective cohort analysis of patients with persistent bleeding from neck and maxillofacial trauma between December 2009 and October 2011. Patients were eligible for the cohort if they were seen at a particular forward aid station (FAS)—a center staffed by one physician with six corpsmen with very limited resources—and had persistent bleeding from the wound. A Foley catheter was used if it was available at the time. Over the study period there were 77 patients who met the inclusion criteria, 44 had a Foley catheter placed and 35 had external pressure dressings applied. There was no significant difference in the demographics of the groups, including presenting Glasgow Coma Scale score, anatomical zone of injury, and Injury Severity Score. The first outcome that was evaluated was failure to achieve hemostasis or primary failure. There was no statistical difference in primary failure between the two groups, with 4% of patients in the Foley group and 11% in the external pressure group. All patients with primary failure exsanguinated at the FAS. There was a significant difference in delayed failure between the Foley group (7%) and external pressure group (26%); p < 0.05. Mortality was also significantly higher in the external pressure group (23%) than the Foley group (5%); p < 0.05. The patients that died all died from hemorrhagic shock. The patients who died in the Foley group were all part of the primary failure group. There were 8 patients who died in the external pressure group; 4 of them were in the primary closure group. Of the 4 additional patients, 3 died during transport and 1 died at the receiving facility. [Julia Dixon, MD Denver Health Medical Center, Denver, CO]
1990 to present, the authors characterized the incidence, risk factors, outcomes, and management approaches for various types of trauma in pregnant patients. Data for the review were drawn primarily from population-based studies, of which the majority had retrospective designs. Case reports and case series were also used, but only when more robust studies were not available. Of a total of 1164 abstracts reviewed, 225 were included in this review. Domestic violence (DV) or intimate partner violence (IPV) was the most frequent cause of trauma in pregnant patients, with an estimated incidence rate of 8307 cases per 100,000 live births. Motor vehicle crashes (MVCs) were the most common cause of accidental trauma in pregnancy, with 207 cases per 100,000 live births. ‘‘Falls and slips’’ were the next most common, with 48.9 cases per 100,000 live births, though some studies estimated that 1 of every 4 pregnant women suffer at least one fall during pregnancy. Burns, suicide, homicide, penetrating trauma, accidental poisonings, and electrocution were relatively infrequent. Of note, suicide and homicide were less frequent in pregnant patients than in the general population. Risk factors for DV/IPV included substance abuse, low education level, low socioeconomic status, unintended pregnancy, a history of witnessed DV/IPV as a child, and unmarried status of the pregnant patient. Alcohol use and ‘‘intoxicants’’ were associated with MVCs, and slippery floors, ‘‘hurrying,’’ and carrying heavy objects were risk factors for falls and slips. Likewise, rates of peripartum suicide were higher in females with a history of DV/IPV, substance abuse, fetal demise complicating pregnancy, or recent death of infant. Outcomes from trauma in pregnancy vary by the type of trauma and the severity of injury. In cases of intentional trauma, which include DV/IPV, studies showed a 2.7-fold increased risk of both maternal and fetal mortality, a 5.7-fold increased risk of low birth weight, and higher rates of spontaneous abortion, neonatal intensive care unit admission, preterm birth, and peripartum depression. Regarding MVCs, improper seatbelt use was associated with adverse outcomes, namely placental abruption. Likewise, after an MVC the risk of cesarean delivery rose, but the risk of preterm labor (PTL) and perinatal death was increased only if delivery occurred immediately after the MVC. According to the authors, increased incidence of PTL and perinatal death can be attributed to the severity of trauma in these cases. With respect to falls and slips, fractures of the lower extremities were the most common associated injuries. However, in one study among patients who were hospitalized after a fall while pregnant, there were higher rates of preterm labor, placental abruption, fetal distress, and fetal hypoxia, as compared to randomly selected controls. In cases of burns
Comment: This study is limited both by its retrospective design and very small sample size. Furthermore, its generalizability is very much in question. That said, this article at least lays the groundwork for a randomized prospective study to determine the utility of this technique in the prehospital management of these injuries. , TRAUMA IN PREGNANCY: AN UPDATED SYSTEMATIC REVIEW. Mendez-Figueroa H, Dahlke JD, Vrees RA, et al. Am J Obstet Gynecol 2013;209:1–10 Trauma is thought to complicate one in 12 pregnancies. In this systematic review of English-language literature from 321