During combat operations, extremities continue to be the most common sites of injury with associated high rates of infectious complications. Overall, ∼ 15% of patients with extremity injuries develop osteomyelitis, and ∼ 17% of those infections relapse or recur. The bacteria infecting these wounds have included multidrug-resistant bacteria such as Acinetobacter baumannii, Pseudomonas aeruginosa, extended-spectrum β-lactamase-producing Klebsiella species and Escherichia coli, and methicillin-resistant Staphylococcus aureus. The goals of extremity injury care are to prevent infection, promote fracture healing, and restore function. In this review, we use a systematic assessment of military and civilian extremity trauma data to provide evidence-based recommendations for the varying management strategies to care for combat-related extremity injuries to decrease infection rates. We emphasize postinjury antimicrobial therapy, debridement and irrigation, and surgical wound management including addressing ongoing areas of controversy and needed research. In addition, we address adjuvants that are increasingly being examined, including local antimicrobial therapy, flap closure, oxygen therapy, negative pressure wound therapy, and wound effluent characterization. This evidence-based medicine review was produced to support the Guidelines for the Prevention of Infections Associated With Combat-Related Injuries: 2011 Update contained in this supplement of Journal of Trauma.
Despite advances in resuscitation and surgical management of combat wounds, infection remains a concerning and potentially preventable complication of combat-related injuries. Interventions currently used to prevent these infections have not been either clearly defined or subjected to rigorous clinical trials. Current infection prevention measures and wound management practices are derived from retrospective review of wartime experiences, from civilian trauma data, and from in vitro and animal data. This update to the guidelines published in 2008 incorporates evidence that has become available since 2007. These guidelines focus on care provided within hours to days of injury, chiefly within the combat zone, to those combat-injured patients with open wounds or burns. New in this update are a consolidation of antimicrobial agent recommendations to a backbone of high-dose cefazolin with or without metronidazole for most postinjury indications, and recommendations for redosing of antimicrobial agents, for use of negative pressure wound therapy, and for oxygen supplementation in flight.
A 60-year-old man with new-onset chest and back pain was found at computed tomography to have a 6-cm pseudoaneurysm of the aortic arch at the site of open surgical repair of an arch aneurysm 6 years previously. The history was notable for severe chronic obstructive pulmonary disease, previous coronary artery stenting, and type IV thoracoabdominal aneurysm repair. An arch aortogram showed a wide-necked, saccular pseudoaneurysm of the aortic arch, originating opposite the left common carotid artery (A). Because of poor cardiopulmonary function and previous arch surgery, the patient was considered at prohibitive risk for traditional open aneurysm repair.Endovascular repair of the aortic arch pseudoaneurysm was performed with the patient under general anesthesia, with a branched modular stent-graft device and insertion procedure, described in an accompanying article in this issue of the Journal. 1 The bifurcated stent graft directed all flow from the ascending aorta into the innominate artery and descending thoracic aorta while excluding flow to the aneurysm. Preparatory reconstruction of the brachiocephalic circulation included carotid-carotid bypass grafting, transposition of the left subclavian artery, and implantation of the left vertebral artery into the left subclavian artery. The operation required 6 hours. Completion angiograms revealed proper graft placement, with perfusion of all brachiocephalic arteries and no endoleak (B). These findings were confirmed on postoperative computed tomography scans (C, Cover). Recovery was complicated by a week-long period of ventilatory support and an episode of atrial flutter. There were no cardiac or neurologic complications. The patient was discharged home with warfarin for prophylaxis against cerebral thromboembolism.Conventional repair of aortic arch aneurysm or dissection requires sternotomy and graft replacement, usually with deep hypothermic circulatory arrest, with high morbidity and mortality. 2 Despite the appeal of less invasive techniques, development of an endovascular system has been slowed by site-specific challenges such as the need to maintain uninterrupted cerebral perfusion. We believe that this case illustrates the advantages of a modular approach that combines well-tried stentgraft components and techniques in a new application. The only previously reported case of endovascular arch repair involved deployment of a complicated unibody, branched stent graft. Its successful deployment reflected a level of technical skill that has not been replicated. 3 If our method of aortic arch repair proves both durable and reproducible, potential applications might include not only aneurysms of the arch, but also some type A dissections.
Burns are a very real component of combat-related injuries, and infections are the leading cause of mortality in burn casualties. The prevention of infection in the burn casualty transitioning from the battlefield to definitive care provided at the burn center is critical in reducing overall morbidity and mortality. This review highlights evidence-based medicine recommendations using military and civilian data to provide the most comprehensive, up-to-date management strategies for initial care of burned combat casualties. Areas of emphasis include antimicrobial prophylaxis, debridement of devitalized tissue, topical antimicrobial therapy, and optimal time to wound coverage. This evidence-based medicine review was produced to support the Guidelines for the Prevention of Infections Associated With Combat-Related Injuries: 2011 Update contained in this supplement of Journal of Trauma.
Our cohort of medical school graduates had limited exposure to and knowledge of vascular surgery. Providing more clinical exposure in medical school appears necessary to ensure success of the modified pathways for primary certification in vascular surgery.
Thrombus debulking or removal with percutaneous mechanical thrombectomy devices may reduce the amount or duration of thrombolytic therapy required, making treatment of venous thoracic outlet syndrome safer. Moreover, patients with recurrent thrombosis after thoracic outlet decompression may be safely treated with percutaneous mechanical thrombectomy, even when thrombolytic therapy is contraindicated.
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