Journal of Endovascular Resuscitation and Trauma Management
Resuscitative Endovascular Balloon Occlusion of the Aorta (REBOA) is an endovascular procedure wh... more Resuscitative Endovascular Balloon Occlusion of the Aorta (REBOA) is an endovascular procedure which utilises a catheter based balloon device to achieve aortic occlusion. The aim of this resuscitative measure is to improve blood pressure proximal to the occlusion site and therefore preserve cardiac and cerebral perfusion in order to prevent cardiac arrest; additionally there is a relative reduction in arterial inflow to the site of injury. Endovascular techniques are gaining acceptance for the in-hospital management of haemorrhage, however their use in pre-hospital care is still limited. This is due to a number of factors including the technical challenges, training and skill sets of pre-hospital care teams and the potential for harm of REBOA, particularly with extended balloon occlusion times. However, non compressible torso haemorrhage is associated with a mortality of approximately 50% and a significant proportion of these deaths occur in the pre-hospital phase of care. In the e...
Background: Glutathione (GSH) is an endogenous antioxidant that is added to University of Wiscons... more Background: Glutathione (GSH) is an endogenous antioxidant that is added to University of Wisconsin (UW) organ preservation solution on the premise that it protects against oxidative stress during cold ischaemia. This study assessed vascular endothelial function in tissues subjected to cold ischaemia in UW solutions with or without GSH and examined some of the chemical consequences of GSH inclusion in UW solution. Methods: Isolated aortic rings from male Wistar rats were stored for 48 hours in cold, hypoxic conditions in standard UW solution with or without 3 mM GSH supplementation. Aortic rings were then placed in warm, oxygenated Krebs solution and endothelial function assessed using myography in terms of acetylcholine (ACh)-induced relaxation of rings following precontraction with phenylephrine. The effects of GSH were further assessed using electron paramagnetic resonance (EPR) to determine oxygen-centred free radical generation. Results: Dose-response curves to phenylephrine-induced contraction were not significantly different between tissues stored in UW solution with or without GSH supplementation. However, endothelium-dependent relaxation was significantly impaired in tissues stored in GSH-supplemented UW solution (see Table). There was a trend toward greater generation of oxygen-derived free radicals in GSH-supplemented UW solution. UW UW + GSH P * Phenylephrine pEC 50 − 7 − 6•7 N S Acetylcholine pIC 50 − 6•5 − 5•7 < 0•01 Mean percentage change in EPR signal 67 97 NS *Two-way ANOVA/paired t-test. Conclusions: GSH supplementation of UW solution exacerbates endothelial dysfunction caused by cold ischaemia. Its addition to organ preservation solutions may confer a detrimental effect by exacerbating oxidative stress.
Background: Glutathione (GSH) is an endogenous antioxidant that is added to University of Wiscons... more Background: Glutathione (GSH) is an endogenous antioxidant that is added to University of Wisconsin (UW) organ preservation solution on the premise that it protects against oxidative stress during cold ischaemia. This study assessed vascular endothelial function in tissues subjected to cold ischaemia in UW solutions with or without GSH and examined some of the chemical consequences of GSH inclusion in UW solution. Methods: Isolated aortic rings from male Wistar rats were stored for 48 hours in cold, hypoxic conditions in standard UW solution with or without 3 mM GSH supplementation. Aortic rings were then placed in warm, oxygenated Krebs solution and endothelial function assessed using myography in terms of acetylcholine (ACh)-induced relaxation of rings following precontraction with phenylephrine. The effects of GSH were further assessed using electron paramagnetic resonance (EPR) to determine oxygen-centred free radical generation. Results: Dose-response curves to phenylephrine-induced contraction were not significantly different between tissues stored in UW solution with or without GSH supplementation. However, endothelium-dependent relaxation was significantly impaired in tissues stored in GSH-supplemented UW solution (see Table). There was a trend toward greater generation of oxygen-derived free radicals in GSH-supplemented UW solution. UW UW + GSH P * Phenylephrine pEC 50 − 7 − 6•7 N S Acetylcholine pIC 50 − 6•5 − 5•7 < 0•01 Mean percentage change in EPR signal 67 97 NS *Two-way ANOVA/paired t-test. Conclusions: GSH supplementation of UW solution exacerbates endothelial dysfunction caused by cold ischaemia. Its addition to organ preservation solutions may confer a detrimental effect by exacerbating oxidative stress.
Scandinavian Journal of Trauma, Resuscitation and Emergency Medicine
Background: Resuscitative thoracotomy is a damage control procedure with an established role in t... more Background: Resuscitative thoracotomy is a damage control procedure with an established role in the immediate treatment of patients in extremis or cardiac arrest secondary to cardiac tamponade however Its role in resuscitation of patients with abdominal exsanguination is uncertain. Objective: The primary objective of this systematic review was to estimate mortality based on survival to discharge in patients with exsanguinating haemorrhage from abdominal trauma in cardiac arrest or a peri arrest clinical condition following a resuscitative thoracotomy. Methods: A systematic literature search was performed to identify original research that reported outcomes in resuscitative thoracotomy either in the emergency department or pre-hospital environment in patients suffering or suspected of suffering from intra-abdominal injuries. The primary outcome was to assess survival to discharge. The secondary outcomes assessed were neurological function post procedure and the role of timing of intervention on survival. Results: Seventeen retrospective case series were reviewed by a single author which described 584 patients with isolated abdominal trauma and an additional 1745 suffering from polytrauma including abdominal injuries. Isolated abdominal trauma survival to discharge ranged from 0 to 18% with polytrauma survival of 0-9.7% with the majority below 1%. Survival following a thoracotomy for abdominal trauma varied between studies and with no comparison non-intervention group no definitive conclusions could be drawn. Timing of thoracotomy was important with improved mortality in patients not in cardiac arrest or having the procedure performed just after a loss of signs of life. Normal neurological function at discharge ranged from 100 to 28.5% with the presence of a head injury having a negative impact on both survival and long-term morbidity. Conclusions: Pre-theatre thoracotomy may have a role in peri-arrest or arrested patient with abdominal trauma. The best outcomes are achieved with patients not in cardiac arrest or who have recently arrested and with no head injury present. The earlier the intervention can be performed, the better the outcome for patients, with survival figures of up to 18% following a resuscitative thoracotomy. More high-quality evidence is required to demonstrate a definitive mortality benefit for patients.
Background Injured patients are at risk of developing acute kidney injury (AKI), which is associa... more Background Injured patients are at risk of developing acute kidney injury (AKI), which is associated with increased morbidity and mortality. The aim of this study is to describe the incidence, timing, and severity of AKI in a large trauma population, identify risk factors for AKI, and report mortality outcomes. Methods A prospective observational study of injured adults, who met local criteria for trauma team activation, and were admitted to a UK Major Trauma Centre. AKI was defined by the Kidney Disease Improving Global Outcomes (KDIGO) criteria. Multivariable logistic regression and Cox proportional hazard modelling was used to analyse parameters associated with AKI and mortality. Results Of the 1410 patients enrolled in the study, 178 (12.6%) developed AKI. Age; injury severity score (ISS); admission systolic blood pressure, lactate and serum creatinine; units of Packed Red Blood Cells transfused in first 24 hours and administration of nephrotoxic therapy were identified as independent risk factors for the development of AKI. Patients that developed AKI had significantly higher mortality than those with normal renal function (47/ 178 [26.4%] versus 128/1232 [10.4%]; OR 3.09 [2.12 to 4.53]; p<0.0001). After adjusting for other clinical prognostic factors, AKI was an independent risk factor for mortality. Conclusions AKI is a frequent complication following trauma and is associated with prolonged hospital length of stay and increased mortality. Future research is needed to improve our ability to rapidly identify those at risk of AKI, and develop resuscitation strategies that preserve renal function in trauma patients.
Giant colonic diverticulum is a rare complication of diverticulosis, which may present in the acu... more Giant colonic diverticulum is a rare complication of diverticulosis, which may present in the acute or chronic setting. Colonic resection and en bloc resection of the diverticulum are the favored management, however, conservative treatment remains an option that could be considered in asymptomatic patients with minimal symptoms.
stenosis >50% was found in 0% and 33% (P ¼ .0474) of patients in the infraclavicular and supracla... more stenosis >50% was found in 0% and 33% (P ¼ .0474) of patients in the infraclavicular and supraclavicular approaches, respectively. Infraclavicular thoracic outlet decompression was associated with fewer postoperative symptoms, 0 (0%) vs 8 (53.3%; P ¼ .0022), and infraclavicular thoracic outlet decompression demonstrated superior patency, 15 (100%) vs 8 (66.7%; P ¼ .0282). In addition, there was a trend toward fewer reinterventions in the infraclavicular group, 0.27 6 0.8 vs 0.87 6 1.5 (P ¼ .1984). Mean combined follow-up was 8.47 6 10.8 months. Conclusions: Infraclavicular thoracic outlet decompression for the surgical management of VTOS was associated with fewer postoperative symptoms and superior axillosubclavian vein patency compared with the supraclavicular approach. Prospective analysis is warranted to determine long-term outcomes after infraclavicular decompression.
The journal of trauma and acute care surgery, 2018
To describe the long-term outcomes of military lower-extremity vascular injuries, and the decisio... more To describe the long-term outcomes of military lower-extremity vascular injuries, and the decision making of surgeons treating these injuries. Lower-extremity vascular trauma is an important cause of preventable death and severe disability, and decisions on amputation or limb salvage can be difficult. Additionally, the complexity of the condition is not amenable to controlled study, and there is limited data to guide clinical decision making and establish sensible treatment expectations during rehabilitation. A cohort study of 554 US service members who sustained lower-extremity vascular injury in Iraq or Afghanistan (March 2003 to February 2012) was performed using the military's trauma registry, its electronic health record, patient interviews, and quality-of-life surveys. Long-term surgical and functional outcomes, and the timing and rationale of surgical decisions, were analyzed. Of 579 injured extremities, 49 (8.5%) underwent primary amputation and 530 (91.5%) an initial at...
Background: Pre-hospital endotracheal intubation is frequently used for trauma patients in many e... more Background: Pre-hospital endotracheal intubation is frequently used for trauma patients in many emergency medical systems. Despite a wide range of publications in the field, it is debated whether the intervention is associated with a favourable outcome, when compared to more conservative airway measures. Methods: A systematic literature search was conducted to identify interventional and observational studies where the mortality rates of adult trauma patients undergoing pre-hospital endotracheal intubation were compared to those undergoing emergency department intubation. Results: Twenty-one studies examining 35,838 patients were included. The median mortality rate in patients undergoing pre-hospital intubation was 48% (range 8-94%), compared to 29% (range 6-67%) in patients undergoing intubation in the emergency department. Odds ratios were in favour of emergency department intubation both in crude and adjusted mortality, with 2.56 (95% CI: 2.06, 3.18) and 2.59 (95% CI: 1.97, 3.39), respectively. The overall quality of evidence is very low. Twelve of the twenty-one studies found a significantly higher mortality rate after pre-hospital intubation, seven found no significant differences, one found a positive effect, and for one study an analysis of the mortality rate was beyond the scope of the article. Conclusions: The rationale for wide and unspecific indications for pre-hospital intubation seems to lack support in the literature, despite several publications involving a relatively large number of patients. Pre-hospital intubation is a complex intervention where guidelines and research findings should be approached cautiously. The association between pre-hospital intubation and a higher mortality rate does not necessarily contradict the importance of the intervention, but it does call for a thorough investigation by clinicians and researchers into possible causes for this finding.
Journal of Endovascular Resuscitation and Trauma Management
Resuscitative Endovascular Balloon Occlusion of the Aorta (REBOA) is an endovascular procedure wh... more Resuscitative Endovascular Balloon Occlusion of the Aorta (REBOA) is an endovascular procedure which utilises a catheter based balloon device to achieve aortic occlusion. The aim of this resuscitative measure is to improve blood pressure proximal to the occlusion site and therefore preserve cardiac and cerebral perfusion in order to prevent cardiac arrest; additionally there is a relative reduction in arterial inflow to the site of injury. Endovascular techniques are gaining acceptance for the in-hospital management of haemorrhage, however their use in pre-hospital care is still limited. This is due to a number of factors including the technical challenges, training and skill sets of pre-hospital care teams and the potential for harm of REBOA, particularly with extended balloon occlusion times. However, non compressible torso haemorrhage is associated with a mortality of approximately 50% and a significant proportion of these deaths occur in the pre-hospital phase of care. In the e...
Background: Glutathione (GSH) is an endogenous antioxidant that is added to University of Wiscons... more Background: Glutathione (GSH) is an endogenous antioxidant that is added to University of Wisconsin (UW) organ preservation solution on the premise that it protects against oxidative stress during cold ischaemia. This study assessed vascular endothelial function in tissues subjected to cold ischaemia in UW solutions with or without GSH and examined some of the chemical consequences of GSH inclusion in UW solution. Methods: Isolated aortic rings from male Wistar rats were stored for 48 hours in cold, hypoxic conditions in standard UW solution with or without 3 mM GSH supplementation. Aortic rings were then placed in warm, oxygenated Krebs solution and endothelial function assessed using myography in terms of acetylcholine (ACh)-induced relaxation of rings following precontraction with phenylephrine. The effects of GSH were further assessed using electron paramagnetic resonance (EPR) to determine oxygen-centred free radical generation. Results: Dose-response curves to phenylephrine-induced contraction were not significantly different between tissues stored in UW solution with or without GSH supplementation. However, endothelium-dependent relaxation was significantly impaired in tissues stored in GSH-supplemented UW solution (see Table). There was a trend toward greater generation of oxygen-derived free radicals in GSH-supplemented UW solution. UW UW + GSH P * Phenylephrine pEC 50 − 7 − 6•7 N S Acetylcholine pIC 50 − 6•5 − 5•7 < 0•01 Mean percentage change in EPR signal 67 97 NS *Two-way ANOVA/paired t-test. Conclusions: GSH supplementation of UW solution exacerbates endothelial dysfunction caused by cold ischaemia. Its addition to organ preservation solutions may confer a detrimental effect by exacerbating oxidative stress.
Background: Glutathione (GSH) is an endogenous antioxidant that is added to University of Wiscons... more Background: Glutathione (GSH) is an endogenous antioxidant that is added to University of Wisconsin (UW) organ preservation solution on the premise that it protects against oxidative stress during cold ischaemia. This study assessed vascular endothelial function in tissues subjected to cold ischaemia in UW solutions with or without GSH and examined some of the chemical consequences of GSH inclusion in UW solution. Methods: Isolated aortic rings from male Wistar rats were stored for 48 hours in cold, hypoxic conditions in standard UW solution with or without 3 mM GSH supplementation. Aortic rings were then placed in warm, oxygenated Krebs solution and endothelial function assessed using myography in terms of acetylcholine (ACh)-induced relaxation of rings following precontraction with phenylephrine. The effects of GSH were further assessed using electron paramagnetic resonance (EPR) to determine oxygen-centred free radical generation. Results: Dose-response curves to phenylephrine-induced contraction were not significantly different between tissues stored in UW solution with or without GSH supplementation. However, endothelium-dependent relaxation was significantly impaired in tissues stored in GSH-supplemented UW solution (see Table). There was a trend toward greater generation of oxygen-derived free radicals in GSH-supplemented UW solution. UW UW + GSH P * Phenylephrine pEC 50 − 7 − 6•7 N S Acetylcholine pIC 50 − 6•5 − 5•7 < 0•01 Mean percentage change in EPR signal 67 97 NS *Two-way ANOVA/paired t-test. Conclusions: GSH supplementation of UW solution exacerbates endothelial dysfunction caused by cold ischaemia. Its addition to organ preservation solutions may confer a detrimental effect by exacerbating oxidative stress.
Scandinavian Journal of Trauma, Resuscitation and Emergency Medicine
Background: Resuscitative thoracotomy is a damage control procedure with an established role in t... more Background: Resuscitative thoracotomy is a damage control procedure with an established role in the immediate treatment of patients in extremis or cardiac arrest secondary to cardiac tamponade however Its role in resuscitation of patients with abdominal exsanguination is uncertain. Objective: The primary objective of this systematic review was to estimate mortality based on survival to discharge in patients with exsanguinating haemorrhage from abdominal trauma in cardiac arrest or a peri arrest clinical condition following a resuscitative thoracotomy. Methods: A systematic literature search was performed to identify original research that reported outcomes in resuscitative thoracotomy either in the emergency department or pre-hospital environment in patients suffering or suspected of suffering from intra-abdominal injuries. The primary outcome was to assess survival to discharge. The secondary outcomes assessed were neurological function post procedure and the role of timing of intervention on survival. Results: Seventeen retrospective case series were reviewed by a single author which described 584 patients with isolated abdominal trauma and an additional 1745 suffering from polytrauma including abdominal injuries. Isolated abdominal trauma survival to discharge ranged from 0 to 18% with polytrauma survival of 0-9.7% with the majority below 1%. Survival following a thoracotomy for abdominal trauma varied between studies and with no comparison non-intervention group no definitive conclusions could be drawn. Timing of thoracotomy was important with improved mortality in patients not in cardiac arrest or having the procedure performed just after a loss of signs of life. Normal neurological function at discharge ranged from 100 to 28.5% with the presence of a head injury having a negative impact on both survival and long-term morbidity. Conclusions: Pre-theatre thoracotomy may have a role in peri-arrest or arrested patient with abdominal trauma. The best outcomes are achieved with patients not in cardiac arrest or who have recently arrested and with no head injury present. The earlier the intervention can be performed, the better the outcome for patients, with survival figures of up to 18% following a resuscitative thoracotomy. More high-quality evidence is required to demonstrate a definitive mortality benefit for patients.
Background Injured patients are at risk of developing acute kidney injury (AKI), which is associa... more Background Injured patients are at risk of developing acute kidney injury (AKI), which is associated with increased morbidity and mortality. The aim of this study is to describe the incidence, timing, and severity of AKI in a large trauma population, identify risk factors for AKI, and report mortality outcomes. Methods A prospective observational study of injured adults, who met local criteria for trauma team activation, and were admitted to a UK Major Trauma Centre. AKI was defined by the Kidney Disease Improving Global Outcomes (KDIGO) criteria. Multivariable logistic regression and Cox proportional hazard modelling was used to analyse parameters associated with AKI and mortality. Results Of the 1410 patients enrolled in the study, 178 (12.6%) developed AKI. Age; injury severity score (ISS); admission systolic blood pressure, lactate and serum creatinine; units of Packed Red Blood Cells transfused in first 24 hours and administration of nephrotoxic therapy were identified as independent risk factors for the development of AKI. Patients that developed AKI had significantly higher mortality than those with normal renal function (47/ 178 [26.4%] versus 128/1232 [10.4%]; OR 3.09 [2.12 to 4.53]; p<0.0001). After adjusting for other clinical prognostic factors, AKI was an independent risk factor for mortality. Conclusions AKI is a frequent complication following trauma and is associated with prolonged hospital length of stay and increased mortality. Future research is needed to improve our ability to rapidly identify those at risk of AKI, and develop resuscitation strategies that preserve renal function in trauma patients.
Giant colonic diverticulum is a rare complication of diverticulosis, which may present in the acu... more Giant colonic diverticulum is a rare complication of diverticulosis, which may present in the acute or chronic setting. Colonic resection and en bloc resection of the diverticulum are the favored management, however, conservative treatment remains an option that could be considered in asymptomatic patients with minimal symptoms.
stenosis >50% was found in 0% and 33% (P ¼ .0474) of patients in the infraclavicular and supracla... more stenosis >50% was found in 0% and 33% (P ¼ .0474) of patients in the infraclavicular and supraclavicular approaches, respectively. Infraclavicular thoracic outlet decompression was associated with fewer postoperative symptoms, 0 (0%) vs 8 (53.3%; P ¼ .0022), and infraclavicular thoracic outlet decompression demonstrated superior patency, 15 (100%) vs 8 (66.7%; P ¼ .0282). In addition, there was a trend toward fewer reinterventions in the infraclavicular group, 0.27 6 0.8 vs 0.87 6 1.5 (P ¼ .1984). Mean combined follow-up was 8.47 6 10.8 months. Conclusions: Infraclavicular thoracic outlet decompression for the surgical management of VTOS was associated with fewer postoperative symptoms and superior axillosubclavian vein patency compared with the supraclavicular approach. Prospective analysis is warranted to determine long-term outcomes after infraclavicular decompression.
The journal of trauma and acute care surgery, 2018
To describe the long-term outcomes of military lower-extremity vascular injuries, and the decisio... more To describe the long-term outcomes of military lower-extremity vascular injuries, and the decision making of surgeons treating these injuries. Lower-extremity vascular trauma is an important cause of preventable death and severe disability, and decisions on amputation or limb salvage can be difficult. Additionally, the complexity of the condition is not amenable to controlled study, and there is limited data to guide clinical decision making and establish sensible treatment expectations during rehabilitation. A cohort study of 554 US service members who sustained lower-extremity vascular injury in Iraq or Afghanistan (March 2003 to February 2012) was performed using the military's trauma registry, its electronic health record, patient interviews, and quality-of-life surveys. Long-term surgical and functional outcomes, and the timing and rationale of surgical decisions, were analyzed. Of 579 injured extremities, 49 (8.5%) underwent primary amputation and 530 (91.5%) an initial at...
Background: Pre-hospital endotracheal intubation is frequently used for trauma patients in many e... more Background: Pre-hospital endotracheal intubation is frequently used for trauma patients in many emergency medical systems. Despite a wide range of publications in the field, it is debated whether the intervention is associated with a favourable outcome, when compared to more conservative airway measures. Methods: A systematic literature search was conducted to identify interventional and observational studies where the mortality rates of adult trauma patients undergoing pre-hospital endotracheal intubation were compared to those undergoing emergency department intubation. Results: Twenty-one studies examining 35,838 patients were included. The median mortality rate in patients undergoing pre-hospital intubation was 48% (range 8-94%), compared to 29% (range 6-67%) in patients undergoing intubation in the emergency department. Odds ratios were in favour of emergency department intubation both in crude and adjusted mortality, with 2.56 (95% CI: 2.06, 3.18) and 2.59 (95% CI: 1.97, 3.39), respectively. The overall quality of evidence is very low. Twelve of the twenty-one studies found a significantly higher mortality rate after pre-hospital intubation, seven found no significant differences, one found a positive effect, and for one study an analysis of the mortality rate was beyond the scope of the article. Conclusions: The rationale for wide and unspecific indications for pre-hospital intubation seems to lack support in the literature, despite several publications involving a relatively large number of patients. Pre-hospital intubation is a complex intervention where guidelines and research findings should be approached cautiously. The association between pre-hospital intubation and a higher mortality rate does not necessarily contradict the importance of the intervention, but it does call for a thorough investigation by clinicians and researchers into possible causes for this finding.
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Papers by Zane Perkins