Military trauma training at civilian centers: a decade of advancements

In the late 1990s, a Department of Defense subcommittee screened more than 100 civilian trauma centers according to the number of admissions, percentage of penetrating trauma, and institutional interest in relation to the specific training missions of each of the three service branches. By the end of 2001, the Army started a program at University of Miami/Ryder Trauma Center, the Navy began a similar program at University of Southern California/Los Angeles County Medical Center, and the Air Force initiated three Centers for the Sustainment of Trauma and Readiness Skills (C-STARS) at busy academic medical centers: R. Adams Cowley Shock Trauma Center at the University of Maryland (C-STARS Baltimore), Saint Louis University (C-STARS St. Louis), and The University Hospital/University of Cincinnati (C-STARS Cincinnati). Each center focuses on three key areas, didactic training, state-of-the-art simulation and expeditionary equipment training, as well as actual clinical experience in the acute management of trauma patients. Each is integral to delivering lifesaving combat casualty care in theater. Initially, there were growing pains and the struggle to develop an effective curriculum in a short period. With the foresight of each trauma training center director and a dynamic exchange of information with civilian trauma leaders and frontline war fighters, there has been a continuous evolution and improvement of each center's curriculum. Now, it is clear that the longest military conflict in US history and the first of the 21st century has led to numerous innovations in cutting edge trauma training on a comprehensive array of topics. This report provides an overview of the decade-long evolutionary process in providing the highest-quality medical care for our injured heroes

An observation-first strategy for liver injuries with blush on computed tomography is safe and effective.

INTRODUCTION: The management of liver injuries in hemodynamically stable patients is variable and includes primary treatment strategies of observation (OBS), angiography (interventional radiology [IR]) with angioembolization (AE), or operative intervention (OR). We aimed to evaluate the management of patients with liver injuries with active extravasation on computed tomography (CT) imaging, hypothesizing that AE will have more complications without improving outcomes compared with OBS. METHODS: This is a prospective, multicenter, observational study. Patients who underwent CT within 2 hours after arrival with extravasation (e.g., blush) on imaging were included. Exclusion criteria included cirrhosis, nontraumatic hemorrhage, transfers from outside facilities, and pregnancy. No hemodynamic exclusion criteria were used. The primary outcome was liver-specific complications. Secondary outcomes include length of stay and mortality. Angioembolization patients were compared with patients treated without AE. Propensity score matching was used to match based on penetrating mechanism, liver injury severity, arrival vital signs, and early transfusion. RESULTS: Twenty-three centers enrolled 192 patients. Forty percent of patients (n = 77) were initially OBS. Eleven OBS patients (14%) failed nonoperative management and went to IR or OR. Sixty-one patients (32%) were managed with IR, and 42 (69%) of these had AE as an initial intervention. Fifty-four patients (28%) went to OR+/- IR. After propensity score matching (n = 34 per group), there was no difference in baseline characteristics between AE and OBS. The AE group experienced more complications with a higher rate of IR-placed drains for abscess or biloma (22% vs. 0%, p = 0.01) and an increased overall length of stay ( p = 0.01). No difference was noted in transfusions or mortality. CONCLUSION: Observation is highly effective with few requiring additional interventions. Angioembolization was associated with higher rate of secondary drain placement for abscesses or biloma. Given this, a trial of OBS and avoidance of empiric AE may be warranted in hemodynamically stable, liver-injured patient with extravasation on CT. LEVEL OF EVIDENCE: Therapeutic/Care Management; Level II

Injuries of the Limbs in Polytrauma: Upper and lower limbs

Extremity injuries are the second most common traumatic injuries after head injuries and account until 80% of all cases of vascular trauma. Peripheral injuries are usually not immediately lethal, whether due to penetrating or blunt injuries; nevertheless, a prompt identification of the injuries is crucial for a correct management. There has been a growing role for both diagnostic and interventional radiology (IR) in all types of trauma affecting different areas of the body, with imaging becoming an integral part of the multidisciplinary approach to modern trauma care. Nowadays, successful revascularization with limb salvage is almost routine, and ischemic limb loss has become the rare exception. Despite success in arterial repair, desirable outcomes with regard to extremity function and disability more often depend on successful identification and treatment of the frequent coexisting injuries to the bone, nerves, and soft tissue. The aim of this chapter is to focalize on injuries of the limbs in polytraumatic patient and to the decision processes associated with the workup and the endovascular interventions (EVIs) of these injuries