CONTINUING MEDICAL EDUCATION PROGRAM
Featured Articles for CME Credit November 2014 The peril of thoracoabdominal firearm trauma: 984 civilian injuries reviewed Regan J. Berg, Kenji Inaba, Obi Okoye, Efstathios Karamanos, Aaron Strumwasser, Konstantinos Chouliaras, Pedro G. Teixeira, and Demetrios Demetriades. (J Trauma Acute Care Surg. 2014;77(5):684Y684)
Erythropoietin for critically ill trauma patients: A missed opportunity? Howard L. Corwin and Lena M. Napolitano. (J Trauma Acute Care Surg. 2014;77(5):774Y779)
CME ARTICLE 1 The peril of thoracoabdominal firearm trauma: 984 civilian injuries reviewed Regan J. Berg, Kenji Inaba, Obi Okoye, Efstathios Karamanos, Aaron Strumwasser, Konstantinos Chouliaras, Pedro G. Teixeira, and Demetrios Demetriades. (J Trauma Acute Care Surg. 2014;77(5):684Y691)
Impact Statement: Patients who present with concomitant penetrating firearm trauma to both the chest and abdomen present significant diagnostic and therapeutic challenges. Review of this injury pattern across a large patient population of will assist in making recommendations for patient management.
Learning Objective: To assist in the development of clinical management strategies for patients with thoracoabdominal firearm trauma through the review of injury patterns, surgical management and clinical outcomes across a large population. QUESTION 1: Which of the following is the most accurate statement regarding injury patterns and operative management in patients experiencing thoracoabdominal firearm trauma? A. Patients arresting prior to hospital presentation demonstrated higher incidences of head or severe abdominal trauma than patients who arrived alive. B. Thoractomy was required in 75% of this population overall, making this the most common operative procedure, although resuscitative thoracotomies accounted for the majority of these procedures. C. Only 10% of patients arriving alive with cardiac injury had additional major thoracic or abdominal, accounting for the high survival rate seen in this particular patient group. 802
D. Either hollow viscus or diaphragmatic injury occurred in 75% of patients arriving alive, representing a significant rate-limiting factor to use of non-operative management strategies in this population.
QUESTION 2: Which of the following statements is most accurate regarding diaphragmatic injuries (DI) in patients with thoracoabdominal trauma? A. Non-operative management strategies are too high risk to ever be considered in this population due to the high incidence of diaphragmatic injury. B. Diaphragmatic injury occurs with slightly less frequency than is seen in patients with thoacoabdominal stab wounds, due to the greater kinetic energy associated with firearm injury. C. Diaphragmatic injury can significantly contribute to the diagnostic challenge of this population as it can potentially lead to the misinterpretation of chest tube output. D. Diagnostic laparoscopy is the most common means of diagnosing diaphragmatic injury in patients with thoracoabdominal firearm trauma.
QUESTION 3: Which of the following is not a significant factor that directly contributes to surgical misequencing in patients with thoracoabdominal firearm trauma? A. Significant abdominal injury burden also requiring operative intervention. B. The published high sensitivity of ultrasound in excluding cardiac injury. J Trauma Acute Care Surg Volume 77, Number 5
Copyright © 2014 Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.
J Trauma Acute Care Surg Volume 77, Number 5
C. Widespread injury patterns both above and below the diaphragm due to the significant kinetic energy of firearm trauma. D. The potential for pericardial disruption to result in a false negative cardiac FAST. QUESTION 4: A 43-year-old male presents with a history of multiple gunshots with entry and exit sites involving both the thorax and abdomen. Although he arrives alert and alive, he subsequently develops a blood pressure of 85/60 during resuscitation and assessment in the trauma bay, despite receiving 1 L of crystalloid followed by 1 unit of O negative blood. Initial chest radiography suggests a left-sided hemopneumothorax and a chest tube is placed with immediate egress of 500cc of blood and considerable improvement in his respiratory status. An extended FAST is performed, revealing no evidence of pericardial blood but obvious hepatorenal and pelvic fluid. Repeat blood pressure finds the patient to be consistently hemodynamically unstable with a blood pressure of 83/67, although he is still communicating with the trauma team. Based on the current article and its recommendations, what would be the most appropriate next step in the management of this patient? A. Emergent CT scan to assess for cardiac injury, once the patient is intubated and central-line access assured, with the trauma team in attendance to manage any subsequent hemodynamic change. B. Immediate laparotomy with trans-diaphragmatic pericardial window if a significant intra-abdominal injury is not detected. C. Emergency department thoracotomy as the patient is about to arrest. D. Rapid transport to the operating room for safe intubation and then thoracotomy as major thoracic injuries are the most common cause of hemodynamic instability in this group.
Learning Objective: To review studies of ESA administration in trauma patients and impact on reduction in mortality, and to review new findings regarding the non-hematopoietic actions of erythropoietin and the pathophysiology of anemia in trauma and critical illness. QUESTION 1: What is the underlying mechanism of anemia in trauma? A. B. C. D.
Decreased hepcidin concentrations Increased hepcidin concentrations No change in hepcidin concentrations Increased erythropoietin concentrations
QUESTION 2: The administration of ESA (epoetin alpha) was associated with significantly reduced mortality in trauma patients in large randomized clinical trials. Which trauma cohort had the greatest mortality reduction with ESA therapy? A. B. C. D.
Patients with hemorrhagic shock Low injury severity score (ISS G 15) High injury severity score (ISS Q 25) Patients with traumatic brain injury
QUESTION 3: What new hormone has been identified that mediates hepcidin suppression and results in anemia resolution? A. B. C. D.
Erythroferrone (ERFE) Epoetin alpha Betatrophin R-spondin2
Erythropoietin for critically ill trauma patients: A missed opportunity? Howard L. Corwin and Lena M. Napolitano. (J Trauma Acute Care Surg. 2014;77(5):774Y779)
QUESTION 4: A 45-year-old female with no comorbidities sustained multiple injuries and hemorrhage in a motor vehicle crash, and the hemoglobin on post-injury day 4 is 6.5 g/dL. Is an erythropoietinstimulating agent (ESA) indicated?
Impact Statement: The administration of an erythropoietin-stimulating agent (ESA, epoetin alpha) was associated with increased survival in trauma patients in multiple large randomized clinical trials, which represents a missed opportunity for potential improved outcomes in our trauma patients.
A. B. C. D.
CME ARTICLE 2
Yes, for treatment of anemia. Yes, to reduce trauma-related mortality. No, the hemoglobin is adequate. No, ESAs did not reduce allogeneic RBC transfusions in trauma patients.
* 2014 Lippincott Williams & Wilkins
Copyright © 2014 Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.
803
Featured Articles for CME Credit November 2014 The peril of thoracoabdominal firearm trauma: 984 civilian injuries reviewed Regan J. Berg, Kenji Inaba, Obi Okoye, Efstathios Karamanos, Aaron Strumwasser, Konstantinos Chouliaras, Pedro G. Teixeira, and Demetrios Demetriades. (J Trauma Acute Care Surg. 2014;77(5):684Y684)
Erythropoietin for critically ill trauma patients: A missed opportunity? Howard L. Corwin and Lena M. Napolitano. (J Trauma Acute Care Surg. 2014;77(5):774Y779)
CME ARTICLE 1 The peril of thoracoabdominal firearm trauma: 984 civilian injuries reviewed Regan J. Berg, Kenji Inaba, Obi Okoye, Efstathios Karamanos, Aaron Strumwasser, Konstantinos Chouliaras, Pedro G. Teixeira, and Demetrios Demetriades. (J Trauma Acute Care Surg. 2014;77(5):684Y691)
Impact Statement: Patients who present with concomitant penetrating firearm trauma to both the chest and abdomen present significant diagnostic and therapeutic challenges. Review of this injury pattern across a large patient population of will assist in making recommendations for patient management.
Learning Objective: To assist in the development of clinical management strategies for patients with thoracoabdominal firearm trauma through the review of injury patterns, surgical management and clinical outcomes across a large population. QUESTION 1: Which of the following is the most accurate statement regarding injury patterns and operative management in patients experiencing thoracoabdominal firearm trauma? A. Patients arresting prior to hospital presentation demonstrated higher incidences of head or severe abdominal trauma than patients who arrived alive. B. Thoractomy was required in 75% of this population overall, making this the most common operative procedure, although resuscitative thoracotomies accounted for the majority of these procedures. C. Only 10% of patients arriving alive with cardiac injury had additional major thoracic or abdominal, accounting for the high survival rate seen in this particular patient group. 802
D. Either hollow viscus or diaphragmatic injury occurred in 75% of patients arriving alive, representing a significant rate-limiting factor to use of non-operative management strategies in this population.
QUESTION 2: Which of the following statements is most accurate regarding diaphragmatic injuries (DI) in patients with thoracoabdominal trauma? A. Non-operative management strategies are too high risk to ever be considered in this population due to the high incidence of diaphragmatic injury. B. Diaphragmatic injury occurs with slightly less frequency than is seen in patients with thoacoabdominal stab wounds, due to the greater kinetic energy associated with firearm injury. C. Diaphragmatic injury can significantly contribute to the diagnostic challenge of this population as it can potentially lead to the misinterpretation of chest tube output. D. Diagnostic laparoscopy is the most common means of diagnosing diaphragmatic injury in patients with thoracoabdominal firearm trauma.
QUESTION 3: Which of the following is not a significant factor that directly contributes to surgical misequencing in patients with thoracoabdominal firearm trauma? A. Significant abdominal injury burden also requiring operative intervention. B. The published high sensitivity of ultrasound in excluding cardiac injury. J Trauma Acute Care Surg Volume 77, Number 5
Copyright © 2014 Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.
J Trauma Acute Care Surg Volume 77, Number 5
C. Widespread injury patterns both above and below the diaphragm due to the significant kinetic energy of firearm trauma. D. The potential for pericardial disruption to result in a false negative cardiac FAST. QUESTION 4: A 43-year-old male presents with a history of multiple gunshots with entry and exit sites involving both the thorax and abdomen. Although he arrives alert and alive, he subsequently develops a blood pressure of 85/60 during resuscitation and assessment in the trauma bay, despite receiving 1 L of crystalloid followed by 1 unit of O negative blood. Initial chest radiography suggests a left-sided hemopneumothorax and a chest tube is placed with immediate egress of 500cc of blood and considerable improvement in his respiratory status. An extended FAST is performed, revealing no evidence of pericardial blood but obvious hepatorenal and pelvic fluid. Repeat blood pressure finds the patient to be consistently hemodynamically unstable with a blood pressure of 83/67, although he is still communicating with the trauma team. Based on the current article and its recommendations, what would be the most appropriate next step in the management of this patient? A. Emergent CT scan to assess for cardiac injury, once the patient is intubated and central-line access assured, with the trauma team in attendance to manage any subsequent hemodynamic change. B. Immediate laparotomy with trans-diaphragmatic pericardial window if a significant intra-abdominal injury is not detected. C. Emergency department thoracotomy as the patient is about to arrest. D. Rapid transport to the operating room for safe intubation and then thoracotomy as major thoracic injuries are the most common cause of hemodynamic instability in this group.
Learning Objective: To review studies of ESA administration in trauma patients and impact on reduction in mortality, and to review new findings regarding the non-hematopoietic actions of erythropoietin and the pathophysiology of anemia in trauma and critical illness. QUESTION 1: What is the underlying mechanism of anemia in trauma? A. B. C. D.
Decreased hepcidin concentrations Increased hepcidin concentrations No change in hepcidin concentrations Increased erythropoietin concentrations
QUESTION 2: The administration of ESA (epoetin alpha) was associated with significantly reduced mortality in trauma patients in large randomized clinical trials. Which trauma cohort had the greatest mortality reduction with ESA therapy? A. B. C. D.
Patients with hemorrhagic shock Low injury severity score (ISS G 15) High injury severity score (ISS Q 25) Patients with traumatic brain injury
QUESTION 3: What new hormone has been identified that mediates hepcidin suppression and results in anemia resolution? A. B. C. D.
Erythroferrone (ERFE) Epoetin alpha Betatrophin R-spondin2
Erythropoietin for critically ill trauma patients: A missed opportunity? Howard L. Corwin and Lena M. Napolitano. (J Trauma Acute Care Surg. 2014;77(5):774Y779)
QUESTION 4: A 45-year-old female with no comorbidities sustained multiple injuries and hemorrhage in a motor vehicle crash, and the hemoglobin on post-injury day 4 is 6.5 g/dL. Is an erythropoietinstimulating agent (ESA) indicated?
Impact Statement: The administration of an erythropoietin-stimulating agent (ESA, epoetin alpha) was associated with increased survival in trauma patients in multiple large randomized clinical trials, which represents a missed opportunity for potential improved outcomes in our trauma patients.
A. B. C. D.
CME ARTICLE 2
Yes, for treatment of anemia. Yes, to reduce trauma-related mortality. No, the hemoglobin is adequate. No, ESAs did not reduce allogeneic RBC transfusions in trauma patients.
* 2014 Lippincott Williams & Wilkins
Copyright © 2014 Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.
803
