The Role of Helicopter Transport in Trauma Systems (Continued from Page 1)

FALL 2018 FALL | TRAUMA | ROUNDS UPMC TRAUMA CARE SYSTEM CARE TRAUMA UPMC

Inside This Edition To Fly or Not to Fly: The Role of Helicopter 1 To Fly or Not to Fly: The Role of Helicopter Transport in Transport in Trauma Systems Trauma Systems by Joshua B. Brown, MD, MSc 2 Trauma in Pregnancy

6 Mechanical Bowel Obstruction Helicopter emergency medical services (HEMS) have become an integral component of modern trauma systems. As with many advances in trauma

care, HEMS arose from military experience.

The first medical evacuation by helicopter and mortality to 1.7%. The first civilian HEMS CME Credit occurred in April 1944 during World War II, less programs were developed in the late 1960s and Disclosures: Drs. Brown, Corcos, Train, than five years after the inaugural flight of the early 1970s. Today, there are more than 1,000 and Alarcon have reported no relevant relationships with entities producing modern rotorcraft. medical helicopters in service in the United States. health care goods or services. The Korean War brought the first large-scale Why Do We Use Helicopters Instructions: To take the CME implementation of helicopter transport for injured evaluation and receive credit, please troops, reducing the casualty evacuation time For Transport? visit https://cme.hs.pitt.edu/ISER from six hours to two hours, and mortality from There are several reasons why HEMS might (case-sensitive) and click on Trauma 5.8% to 2.4% when compared to World War II. be used to transport a patient to the trauma and Emergency. If this is your first visit, center, which generally fall into one of three you will need to create a free account. Helicopter transport of the injured was expanded in the Vietnam War with care initiated en route, mechanisms (see Figure 1). Accreditation Statement: The University further reducing evacuation times to one hour (Continued on Page 4) of Pittsburgh School of Medicine is accredited by the Accreditation Council for Continuing Medical Education (ACCME) to provide continuing medical Influencing Factors and Mechanisms of Potential HEMS Benefits to Trauma Patients education for physicians. The University of Pittsburgh School of Medicine designates • Service trauma volume/experience “Regionalized” this enduring material for a maximum • Volunteer vs. full-time providers prehospital of .5 AMA PRA Category 1 Credits™. • Training requirements trauma care Each physician should only claim credit commensurate with the extent of their • Ground ALS protocols Advanced crew participation in the activity. Other health • Availability of ground ALS capabilities care professionals are awarded .05 • HEMS crew configuration continuing education units (CEUs), which are equivalent to .5 contact hours. • Threshold for benefit • Distance from scene to trauma center HEMS faster due Improved outcomes in • Distance from scene to HEMS base to distance HEMS for trauma • HEMS activation timing

• Traffic congestion HEMS faster due • Route availability to delay • Regional geography

• Distribution of trauma centers • Closer lower level trauma center Trauma center access • Closer non-trauma center

Figure 1. Influencing factors and mechanisms of potential benefit of helicopter emergency medical services (HEMS) to trauma patients through advanced care (purple), speed (blue), or trauma center access (green).

Affiliated with the University of Pittsburgh School of Medicine, UPMC Presbyterian Shadyside is ranked among America’s Best Hospitals by U.S. News & World Report.

Aside from 1 manifest as either tachycardia or brady as either tachycardia manifest the which underscores fetus, in the cardia and why monitoring of fetal importance part of the such an integral it becomes patients. trauma for survey secondary is often the first heart rate Abnormal fetal hemorrhage. clinical sign of maternal a sudden from result labor may Preterm biochemical mediators, of numerous release catecholamines, including endogenous contractions. uterine leading to Fetal Physiology Fetal is unique, as the utero physiology Fetal the ability unit does not have placental it Therefore, autoregulation. undergo to flow blood on maternal exclusively relies vaso to sensitive while being extremely changes any and catecholamines; pressors vast can have circulation in maternal will This on the fetus. consequences

Finally, as Finally, 4 2 pregnancy progresses, the enlarging uterus uterus the enlarging progresses, pregnancy while organ an intra-abdominal becomes lining thins, making the uterus the uterine injury. to susceptible more the typical “shock” physiology we associate associate we “shock” physiology the typical the mother is apparent, with hemorrhage as is the child. distress, severe in is already requirements and oxygen rate Respiratory and at baseline in pregnancy increased are in functional with a decrease associated are lung volume). (reserve capacity residual important, as the mother becomes This hypoxia. risk for at increased are and fetus motility, gastric decreased Additionally, and decreased diaphragm, an elevated lead to tone sphincter esophageal lower of aspiration. risk increased often maintain adequate cardiac output often cardiac maintain adequate a 40% up to for and blood pressure once Therefore, (2.5 liters). hemorrhage

Although there are ostensibly two patients to consider, one the must take consider, to patients two ostensibly are there Although 1

2 Penetrating Penetrating 2

Studies have shown that both shown Studies have 2

mechanisms for acute blood loss and can blood loss acute mechanisms for Most pregnant women have well- have women Most pregnant compensatory cardiovascular developed Although this adaptation can serve as Although this adaptation can serve mechanism, it can also a protective mask a significant blood loss. to meet the increased demands in uterine demands in uterine meet the increased to an to what is essentially blood flow the fetus. system: additional organ trimester. From a cardiovascular standpoint, cardiovascular a From trimester. circulating in both is an increase there output cardiac and overall blood volume Physiologic changes associated with associated changes Physiologic organ virtually every affect pregnancy unique risks to and can contribute system particularly in the third and complications, Maternal Physiology Maternal blunt traumatic mechanism. blunt traumatic with gunshot is rare, in pregnancy trauma than stab wounds. common more wounds traumatic injury to the mother occur as a the mother occur to injury traumatic and 38% “minor” traumas, of these result with a is associated mortality of all fetal women. Although the vast majority of majority Although the vast women. considered are pregnancy during traumas with deaths associated most fetal minor, assault. and mortality in general injury traumatic common more are trauma from resulting than non-pregnant women in pregnant falls make up the majority of presentations. of majority the up make falls closely by this is followed Unfortunately, partner and intimate domestic violence While traumatic injuries during pregnancy injuries during pregnancy While traumatic of spectrum the entire across occur and crashes vehicle mechanisms, motor Epidemiology to 45% of maternal deaths. maternal of 45% to patients. both for best the ensure outcomes baby” the to save mother, the “save approach of Trauma patients are a unique population for firstresponders, unique a for are population patients and managingtrauma a patient pregnant Trauma trauma.by pregnancies all affected are of can 7-10% fraught. be especially An estimated causes, up for responsible highest morbidity the is cause andtrauma maternal mortality, obstetric of by Alainby Corcos, MD, and FACS, MD Kevin Train, Trauma in Pregnancy in Trauma

Critical Critical 90.10 (2014): 90.10 Journal of Obstetrics Obstetrics of Journal 37.6 (2015): 553-571. 37.6 Kevin Train, MD Train, Kevin a PGY-4 is currently Mercy in the UPMC Surgery General Train Dr. program. a bachelor’s received Case from degree Reserve Western Alain Corcos, MD, FACS MD, Corcos, Alain Division is chief of the Trauma of Multisystem in the Department of Mercy, at UPMC Surgery as he serves where director, medical trauma chief of academic Am Fam Physician. Physician. Am Fam 32.1 (2016): 109-117. 32.1 Care Clinics. Care Mendez-Figueroa, Hector, et al. “Trauma in et al. “Trauma Hector, Mendez-Figueroa, Review.” Systematic An Updated Pregnancy: and Gynecology. Journal of Obstetrics American (2013): 1-10. 209.1 Quinlan. “Trauma D. and Jeffrey Neil J., Murphy, and Management, Assessment, in Pregnancy: Prevention.” 717-722. the Management et al. “Guidelines for Jain, Venu, Patient.” Trauma Pregnant a of Canada. and Gynaecology “Trauma Lucia, Amie, and Susan E. Dantoni. Patient.” of the Pregnant Management

University and his medical degree from degree and his medical University School of Medicine. University Virginia West References 1 2 3 4 surgical residency, and head of the section residency, surgical He is also a clinical care. critical of surgical at the University of surgery professor assistant a bachelor’s received Corcos Dr. of Pittsburgh. and his University Brandeis from degree Health Services Oregon from degree medical in his residency He completed University. Division the in fellowship a and surgery general at Surgery and Thoracic of Cardiovascular in New Center Hospital St. Luke’s-Roosevelt he has participated Additionally, City. York and care critical in surgical in a fellowship of California, University at the trauma Center. San Diego Medical

stand Advanced Trauma Life Life Trauma Advanced 1 Have you been kicked, hit, punched, or hit, punched, been kicked, you Have someone within the otherwise hurt by past year? relation a previous a partner from Is there now? unsafe feel ship who is making you Do you feel safe in your current relationship? current in your safe feel Do you

changes associated with pregnancy and with pregnancy associated changes the significant impacts that these have. and appropriate this understanding With of chance the greatest comes monitoring both the mother and the fetus. for survival a patient can be adequately assessed. assessed. a patient can be adequately Conclusion are of all pregnancies While only 7-10% is significant there trauma, by affected with associated and mortality morbidity It is important under to trauma. any such thing as a “minor” is no that there the majority as while pregnant, trauma of minor as a result deaths occur of fetal a must have responders First traumas. of the physiologic solid understanding medical attention. asking the following Support® recommends questions: screening validated • • • in an important role play responders First be the only time as it may these scenarios, of continuous monitoring. If there are no are If there monitoring. of continuous in variations as findings, such concerning the patient can be discharged. heart rate, however, or concern, abnormality Any stay. in-patient a 24-hour necessitates Screening and violence domestic Unfortunately, 20% up to partnerintimate affects assault number and a significant of pregnancies, small with only a unreported of these go seeking number of patients actually which should be initiated immediately initiated should be which a potentially patient with pregnant in any after trauma. minor even viable pregnancy, at least six hours should have Patients

graphic monitoring, monitoring, graphic Once the mother is stabilized, the mother is stabilized, Once 3 This can be accomplished by by accomplished can be This 3

The gold standard for fetal assessment is assessment fetal for standard gold The cardiotoco continuous anecdotal reports of survival prior to this. prior to of survival reports anecdotal tested issue, it is generally accepted to begin to accepted it is generally issue, tested been have there although weeks 24 or 23 at is a con viability While fetal be overstated. the evaluation of a pregnant trauma patient, patient, trauma of a pregnant the evaluation monitoring cannotfetal of importance the as The obstetrical service has an integral role in in role has an integral service obstetrical The Fetal Monitoring Fetal at survival if the mother is healthy. if the mother is healthy. at survival as the fetus has the greatest chance has the greatest as the fetus perineum. on the fetus, can then focus providers abdominal pain, contractions, uterine uterine abdominal pain, contractions, a bulging and/or rigidity/tenderness conditions, including vaginal bleeding, including vaginal conditions, special attention must be paid to the signs must be paid to special attention with these associated and symptoms with uterine rupture and placental abruption, and placental rupture with uterine estimation of gestational age. Finally, given given Finally, age. estimation of gestational associated and mortality the high morbidity should be obtained, which includes an immobilized. In addition to the standard the standard In addition to immobilized. history questions, a full obstetric history flank or backboard if the patient is fully flank or backboard return. under the right or “bump” placing a roll, this compression and maximize venous venous and maximize this compression with their right side elevated, while with their right side elevated, relieve to maintaining spine precautions, compression of the inferior vena cava. vena of the inferior compression be positioned should immediately Patients to decrease venous return to the heart by heart the to by return venous decrease to pregnancy (beyond 20 weeks), the uterus the uterus 20 weeks), (beyond pregnancy enough and is large is an abdominal organ In the second and third trimesters of trimesters and third In the second aggressive fluid administration. fluid administration. aggressive supplementation is essential, as issupplementation is essential, the physiologic changes associated with associated changes the physiologic oxygen is best. Immediate pregnancy on appreciating and accommodating for and accommodating on appreciating mother, following the dictum: “save the the dictum: “save following mother, based An approach baby.” the save mother, trauma patient starts with stabilizing thetrauma As mentioned previously, despite having despite previously, As mentioned of a pregnant patients, the management two Trauma Management Trauma The Role of Helicopter Transport in Trauma Systems (Continued from Page 1)

The primary reason for using HEMS is speed. Does It Work? using HEMS transport for trauma patients, The goal is to get the patient to definitive care but how we can best identify the patients There has been significant debate about at the trauma center as quickly as possible, who would most likely benefit from it. the effectiveness of HEMS transport of which may reduce mortality in select patients. trauma patients. The cost and risk of this This requires the patient be far enough from intervention must be outweighed by the Picking the Right Patients the trauma center that the travel speed of the benefit, given that HEMS operating costs Identifying patients for helicopter transport helicopter overcomes the additional time to are more than five times that of ground remains challenging, particularly at the scene notify, respond to a safe landing zone, and emergency medical services (GEMS) and of injury. EMS providers have limited transfer care of the patient. Where this are more likely to have fatalities in the event resources and information on which to make distance threshold lies is debatable and can of a crash. Critics cite several studies that this decision quickly. Previous research has be anywhere from five miles to 45 miles showed no survival benefit for HEMS classified severely injured patients based on based on local geography. transport of injured patients, while a number information that is not available in the field. Other factors for EMS providers to consider of authors have demonstrated improved Furthermore, there are a number of both are traffic and weather patterns. Research survival. A systematic review examined logistical and medical considerations. In at UPMC has shown that during peak traffic 25 of these studies, concluding that there Pennsylvania, protocol states that HEMS hours, helicopter travel time becomes faster was some benefit in severely injured transport should be considered in category than ground transport even if moved over patients.8 However, even studies that one trauma patients if HEMS will be faster one mile closer to the trauma center.1 Local demonstrated survival benefits reported than ground transport or if the patient has EMS resources must also be considered, as high over-triage rates of minimally injured a GCS8 and the helicopter would arrive leaving an area uncovered or dependent on patients to HEMS. Based on this data, the before the patient could be at a trauma center mutual aid for EMS responses while trans- issue is no longer whether we should be via ground transportation (see Figure 2). porting long distances to a trauma center may be detrimental to the EMS system.

HEMS may also provide trauma center Considerations for Helicopter Transport from Pennsylvania EMS Protocols access to patients who would otherwise | 4 be taken to non-trauma centers initially. Category 1 Trauma Patient? Even with transfer to a trauma center after Physiologic Criteria: Anatomic Criteria: stabilization, some studies have shown that • GCS motor<6 • Penetrating injury to head, neck, torso, TRAUMA ROUNDS TRAUMA initial treatment at a trauma center increases • SBP<90mmHg proximal extremities survival.2 A national analysis demonstrated • RR <10 or >29 breaths/min • Chest wall instability that approximately 25% of the U.S. population • 2 or more proximal long bone fractures • Crushed/mangled/pulseless extremity has access to a trauma center within 60 • Amputation proximal to hand/foot minutes only because of HEMS transport.3 • Pelvic fracture • Paralysis | A third reason HEMS may benefit patients NO YES is the ability to provide advanced care. A growing body of literature suggests that Ground early transfusion of blood products improves Transport GCS≤8? outcomes in severely injured patients.4 A NO YES study at UPMC of patients receiving blood transfusion by a STAT MedEvac care team Ground transport to Helicopter to scene before level 1 or 2 trauma ground transport to closest demonstrated higher rates of early survival, center ≤45min? trauma center? less risk of shock, and fewer blood trans NO YES NO YES fusions at the trauma center.5 There is also evidence that availability of rapid sequence Helicopter to scene before Helicopter Transport to Ground Transport Helicopter Transport ground transport to level 3 trauma center before to closest to level 1 or 2 intubation techniques may lead to better or 4 trauma center? ground transport? trauma center trauma center

outcomes in patients with Glasgow Coma NO YES NO YES Scale (GCS) 8. Even if the helicopter is 6 slower than ground transport, patients Ground Helicopter Ground Helicopter transported via HEMS have better outcomes, Transport Transport Transport Transport to level 3 or 4 to level 1 or 2 to level 1 or 2 to level 1 or 2 as HEMS providers tend to have more trauma center trauma center trauma center trauma center experience and offer a higher level of care.7 This benefits patients in need of critical early Figure 2. Considerations for helicopter transport from Pennsylvania EMS protocols. All transport decisions interventions from the flight crew before must be based on EMS provider judgment including other mitigating factors that may make helicopter they can get to a trauma center. transport more or less favorable. FALL 2018 | 5 | UPMC TRAUMA CARE SYSTEM |

69(3) 69(3) 2017. J Trauma Acute J Trauma The Cochrane Database Database Cochrane The 264 (2016): 378-285. 264 Prehospital Emergency Emergency Prehospital 82(2) (2017): 270-279. 82(2) (220) (2015): 797-808. (220) JAMA Surg. Surg. JAMA 60(5) (2006): 997-1001. 3 (2013):CD009228. The Journal of Trauma. Journal of Trauma. The J Trauma Acute Care Surg. Surg. Care Acute J Trauma Ann Surg. Ann Surg. 19(1) (2014): 1-9. 293(21) (2005): 2626-2633. (2005): 293(21) J Am Coll Surg. Surg. J Am Coll 2018. The Journal of the American Medical Journal of the American The Helicopter Emergency Medical Services: A Cost- Medical Services: Emergency Helicopter Analysis.” effectiveness Improved Early Outcomes in Air Medical Trauma in Air Medical Trauma Early Outcomes Improved Patients.” MR, et al. “Speed Chen X, Gestring ML, Rosengart Who May Identifying Patients Is Not Everything: Faster Despite Transport Helicopter Benefit from Transport.” Ground (2018): 549-557. 84(4) L, et al. SM, Scanlon JM, Robinson Fakhry Head Intubation for Rapid Sequence “Prehospital Program.” a Successful for Conditions Trauma: Journal of Trauma. The C, et al. S, Stephens Thomas SM, Jr., Galvagno for Medical Services Emergency “Helicopter with Major Trauma.” Adults Reviews. of Systematic et al. FX, JB, Gestring ML, Guyette Brown of the Air Medical and Validation “Development of Transport Helicopter for Score Triage Prehospital Patients.” Trauma et al. FX, JB, Gestring ML, Guyette Brown of the Air Medical Prehospital Validation “External Likely Patients Identifying Trauma for Score Triage Transport.” Helicopter Scene Benefit from to Surg. Care Acute J Trauma “Comparing al. et ML, Gestring KJ, Smith JB, Brown With Score Triage the Air Medical Prehospital to Patients of Injured Triage for Practice Current Chen X, Gestring ML, Rosengart MR, et al. ML, Rosengart Chen X, Gestring and When Medical Transport: of Air “Logistics Reduce Transport Does Helicopter Where Trauma?” for Time Prehospital Surg. Care Gentilello L. J, E, Sperry Nirula R, Maier R, Moore and or Stay Center Trauma the and Run to “Scoop Hospital: Hospital Transfer’s at the Local Play on Mortality.” Effect 599-601. discussion (2010): 595-599; JC, et al. Williams EJ, MacKenzie CC, Branas States.” in the United Centers Trauma to “Access JAMA: Association. et al. BA, Cotton JB, Donathan DP, Holcomb Blood Red of Plasma and Transfusion “Prehospital Patients.” in Trauma Cells ofNational Association Official Journal of the Care: of State and the National Association EMS Physicians EMS Directors. A, Billiar TR, JB, Sperry JL, Fombona Brown Center “Pre-Trauma FX. AB, Guyette Peitzman with Is Associated Transfusion Blood Cell Red

6 7 8 9 10 11 References 1 2 3 4 5

1 1 1 1 1 1 2 Points Annals of Surgery. UPMC and received UPMC degree his medical the University from Joshua Brown, MD, MSc MD, Joshua Brown, care critical is a surgical He at UPMC. fellow his general completed at residency surgery points

2 ≥ Future research will focus on will focus research Future We have subsequently validated subsequently validated have We 10,11 9 of Rochester School of Medicine. of Rochester Air Medical Prehospital Triage Score (see (see Score Triage Air Medical Prehospital 1). Table patients between that it can differentiate HEMS and those who who benefit from that it is a and do not in Pennsylvania, current than approach cost-effective more practice. help EMS to logistical factors incorporating decisionbest transport the make providers their patients.for

fly * <92%, signs of tension physiology) of tension signs <92%, 2 Used with permission from Wolters Kluwer: Brown, Joshua B. MD; Gestring, Mark L. MD; Guyette, Joshua B. MD; Gestring, Mark L. MD; Guyette, Brown, Kluwer: Wolters from Used with permission Committee on Trauma national field triage guidelines national field triage on Trauma Committee Any 1 physiologic criterion plus any 1 anatomic criterion present from American College of Surgeons of Surgeons American College from present criterion 1 anatomic plus any criterion 1 physiologic Any 3 or more anatomic body regions injured injured body regions anatomic 3 or more Absence of breath sounds on affected hemithorax PLUS objective signs of respiratory distress signs of respiratory objective PLUS hemithorax sounds on affected breath of Absence (cyanosis, SpO (cyanosis, Any chest wall instability or deformity including flail chest or multiple ribs fractures on physical exam on physical flail chest or multiple ribs fractures including or deformity instability chest wall Any AMPT Score Criteria AMPT Score † ‡ § Consider Helicopter Transport if AMPT score Transport Helicopter Consider * Multisystem trauma ‡ trauma Multisystem PHY+ANA § Suspected hemothorax or pneumothorax† or hemothorax Suspected Paralysis Glasgow Coma Scale <14 Scale Coma Glasgow <10 or >29 breaths/min Rate Respiratory fractures Unstable chest wall Air Medical Prehospital Triage (AMPT) Score Triage Prehospital Air Medical Development_and_Validation_of_the_Air_Medical.28.aspx. Development_and_Validation_of_the_Air_Medical.28.aspx. Volume 264, Issue 2: 378-385. https://journals.lww.com/annalsofsurgery/Fulltext/2016/08000/ 2: 378-385. Issue 264, Volume Francis X. MD, MPH; Rosengart, Matthew R. MD, MPH; Stassen, Nicole A. MD; Forsythe, Raquel M. MD; Raquel M. A. MD; Forsythe, Nicole MPH; Stassen, R. MD, Matthew MPH; Rosengart, X. MD, Francis and Validation MPH. “Development Jason L. MD, B. MD; Sperry, Andrew R. MD; Peitzman, Timothy Billiar, Patients.” of Trauma Transport Helicopter for Score Triage of the Air Medical Prehospital Table 1. Table by HEMS. Out of this, we developed the developed HEMS. Out of this, we by of trauma triage criteria can identify patients criteria triage of trauma transportedwhen survival increased have who of trauma patients to evaluate if a subset evaluate patients to of trauma in developing specific criteria for air medical specific criteria in developing using a national database by began We triage. Researchers at UPMC have been interested been interested have at UPMC Researchers benefits of HEMS based on the mechanisms above. noted lead to over-triage and limit the potential over-triage lead to the trauma center. Extrapolating trauma trauma Extrapolating center. the trauma can air medical triage for criteria triage center is not the same as needing to to is not the same as needing center fundamentally different questions. Put fundamentally different the trauma to go needing to another way: However, it is important to remember that it is important remember to However, are and air medical triage triage trauma from the national field triage guidelines. field triage the national from This protocol is similar to other evidence- is similar to protocol This based on criteria based guidelines, largely

Patients with mechanical, Patients 3 length of stay compared to laparotomy. to compared length of stay intestinal of recurrent In addition, the rate be adhesions may obstruction due to after laparoscopy. lower shall not rise or set on a bowel obstruction” shall not rise or set on a bowel is indicated surgery Immediate applies here. obstruction patients with bowel for in the or signs of systemic of peritonitis presence hernia, strangulated or incarcerated toxicity, or volvulus, cecal intestinalis, pneumatosis On toxicity. with systemic sigmoid volvulus the other hand, patients with partial bowel a trial of for be admitted obstruction may to with a plan and serial exams, rest bowel resolve to obstruction fails if the operate hours. 72 within 48 to obstruction usually bowel for Surgery While or laparoscopy. entails laparotomy previously was open laparotomy classically shown studies have of choice, the procedure in select can be safe that laparoscopy laparoscopy who undergo patients. Patients open laparotomy to conversion require may to adhesions is difficult due if the dissection hands, experienced or inflammation. In obstruction has a bowel for laparoscopy and hospital rate complication overall lower Admission to Surgical Service Surgical to Admission should obstruction with bowel Patients service a surgical to usually be admitted 24/7, capable of timely intervention is service nonsurgical to as admission and morbidity with increased associated mortality. obstruction should undergo bowel complete after expeditious surgery immediate and and fluid of hypovolemia correction dictum, “the sun The disorders. electrolyte

CT CT 1 not may contrast Oral 2 The most common causes mechanical of small bowel 1 perfusion can be assessed. diagnosis of intestinal obstruction. diagnosis of intestinal early for a need findings that indicate intra- of free include the presence surgery obstruction, abdominal fluid, high grade ischemia, or closed loop obstruc intestinal 1). Figure tion (see ill and obstructed acutely by be tolerated the for patients and is usually not essential renal identification of obstruction. If CT of function permits, the administration imaging during CT contrast intravenous so that the intestinal is recommended the initial management of these patients. the initial management be may decompression Nasogastric of the incidence reduce to necessary and aspiration. vomiting routinely are Abdominal plain radiographs a of having obtained in patients suspected and but their sensitivity obstruction, bowel tomography Computed poor. are specificity determination allow scanning may (CT) of the etiology and location of intestinal the has become obstruction. As such, CT the for of choice modality radiographic is vital, even for cases where a trial of cases where for is vital, even is proposed. management nonoperative obstruction with mechanical bowel Patients with abdominal pain and often present and obstipation. nausea, vomiting, distention, simultaneous require typically They often as they resuscitation, and evaluation abnormalities physiologic with present electrolyte such as hypovolemia, azotemia. abnormalities, or prerenal and access Establishment of intravenous important parts of are resuscitation fluid Determining the need for and the timing for the need Determining is important when managing of surgery obstruction. Delay patients with intestinal of morbidity is a significant cause surgery to consultation Early surgical and mortality.

CT scan demonstrating high-grade scan demonstrating CT Coronal CT scan demonstrating small bowel small bowel scan demonstrating CT Coronal CT scan of a patient with small bowel scan of a patient with small bowel CT

(white arrow), concerning for intestinal ischemia. intestinal for concerning arrow), (white Figure 1c. Figure of the intestine pneumatosis obstruction shows arrow) and decompressed distal small intestine (white (white distal small intestine and decompressed arrow) of the obstruction. level the beyond arrow) Figure 1b. 1b. Figure (gray small intestine proximal obstruction with dilated and decompressed loops of small intestine. The The loops of small intestine. and decompressed is also seen colon descending decompressed (black arrow). Figure 1a. Figure point or obstruction with a transition small bowel distended between arrow) beak” (white “bird’s CT Scans of Bowel Obstructions CT Scans of Bowel due to cancer, diverticulitis, or volvulus. diverticulitis, cancer, due to Bowel obstruction is a common yet clinically challenging condition with more than 300,000 than more with challenging operations condition clinically a common is obstruction yet Bowel performed States. annuallyUnited the in and hernia, adhesions, most often is obstruction colonic while cancer, postoperative are obstruction by Louisby H. Alarcon, MD, FCCM FACS, Mechanical Bowel Obstruction Mechanical Bowel

| 6 | TRAUMA ROUNDS | FALL 2018 FALL Conclusion Louis Alarcon, MD, References FACS, FCCM, is medical Intestinal obstruction is a common 1 Maung AA, Johnson DC, Piper GL, et al. “Evaluation director of Trauma diagnosis and reason for hospital admission and Management of Small-Bowel Obstruction: Surgery at UPMC An Eastern Association for the Surgery of Trauma and surgical consultation. There are many Presbyterian and Practice Management Guideline.” The Journal of different etiologies of intestinal obstruction, co-director of the Trauma and Acute Care Surgery. 73 (5 Suppl 4) which vary based on the location and prior (2012): S362-369. UPMC Patient Blood history of the patient. CT scanning is the 2 Management Program. Kulvatunyou N, Pandit V, Moutamn S, et al. most accurate radiographic test to determine “A Multi-Institution Prospective Observational He is also a professor in the department of the location and nature of the obstruction Study of Small Bowel Obstruction: Clinical and Surgery and Critical Care Medicine at the and, along with clinical presentation, allows Computerized Tomography Predictors of Which University of Pittsburgh School of Medicine. determination of the need and urgency of Patients May Require Early Surgery.” The Journal Dr. Alarcon earned his medical degree from of Trauma and Acute Care Surgery. 79(3) (2015): surgery to manage this problem. Patients the University of Pittsburgh, where he also 393-398. who need urgent surgery include those completed surgical residency, research 3 Oyasiji T, Angelo S, Kyriakides TC, Helton SW. with perforation, peritonitis, strangulation, fellowship, and surgical critical care fellowship. “Small Bowel Obstruction: Outcome and Cost or complete intestinal obstruction. Early Implications of Admitting Service.” Am Surg. surgical consultation is critical, even for 76(7) (2010): 687-691. patients who are admitted with a plan 4 Lombardo S, Baum K, Filho JD, Nirula R. “Should for nonoperative management. Adhesive Small Bowel Obstruction Be Managed Laparoscopically? A National Surgical Quality Improvement Program Propensity Score Analysis.” The Journal of Trauma and Acute Care Surgery. 76(3) (2014): 696-703. | 7 | UPMC TRAUMA CARE SYSTEM | SYSTEM CARE TRAUMA | 7 UPMC

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Editor Louis Alarcon, MD, FACS, FCCM UPMC MedCall — 412-647-7000 or 1-800-544-2500 24-hour emergency consultation, referral, and transport arrangements Senior Outreach Liaison, Physician Services Division Cynthia A. Snyder, MHSA - NREMT-P, CCEMT-P, FP-C CONTINUING EDUCATION Director,Trauma Prehospital Rounds is published Care for Myron Rickens, EMT-P InstructionsInstructions: ForFor EMS EMS ProvidersProviders emergency medicine and trauma To take a Pennsylvania Department of Health-accredited To take a Pennsylvania Department of Health-accredited professionals by UPMC. UPMCUPMC prints prints Trauma Trauma Rounds Rounds with with an eyean eye toward toward helping helping emergency continuing education test for one hour of credit for FR and EMT-B, Managing Editor continuing education test for one hour of credit for FR and EMT-B, medicineemergency professionals medicine improve professionals their preparedness improve their and preparedness practice. EMT-P, and PHRN, visit UPMC.com/TraumaRounds. Diana Carbonell and practice. EMT-P, and PHRN, visit UPMC.com/TraumaRounds. Executive Editor UPMC Prehospital Care also hosts numerous continuing education Andrew B. Peitzman, MD, FACS For Physicians, APPs, and Nurses UPMC Prehospital Care also hosts numerous continuing education For Physicians, APPs, and Nurses classes in western Pennsylvania. For a full, up-to-date calendar and PleasePlease see see page front 1 for cover details for on details CME oncredit CME from credit the from Accreditation the classes in western Pennsylvania. For a full, up-to-date calendar and online registration, visit UPMC.com/PrehospitalClasses. Editor CouncilAccreditation for Continuing Council Medical for Continuing Education Medical (ACCME). Education (ACCME). online registration, visit UPMC.com/PrehospitalClasses. Louis Alarcon, MD, FACS, FCCM

Course Name Date(s) Contact Senior Outreach Liaison, Advanced Trauma Life Support at Full Course: September 24, 2018 Leigh Frederick Physician Services Division UPMC Presbyterian Recertification: September 25, 2018 [email protected], 412-647-4715 Cynthia A. Snyder, MHSA - NREMT-P, ccehs.upmc.com Full Course: November 12, 2018 CCEMT-P, FP-C ® Recertification: November 13, 2018

Advanced Trauma Life Support at Full Course: November 29, 2018 Sarah Mattocks CriticalDirector, Care TransportPrehospital Care UPMC Hamot Recertification: November 30, 2018 [email protected], 814-877-5687 1-800-633-7828Myron Rickens, EMT-P

Advanced Trauma Life Support at Full Course: November 8, 2018 Amy Stayer UPMCManaging is a member Editor of the Center UPMC Altoona Recertification: November 9, 2018 [email protected], 814-889-6098 for EmergencyDiana Carbonell Medicine of Western Pennsylvania, Inc.

A $19 billion world-renowned health care provider and insurer, Pittsburgh-based UPMC is inventing new models of patient-centered, cost-effective, accountable care. UPMC provides more than $900 million a year in benefits to its communities, including more care to the region’s most vulnerable citizens than any other healthAccreditation care institution. Statement: The largest The University nongovernmental of Pittsburgh employer School in Pennsylvania,of Medicine is UPMC accredited integrates by the 85,000 Accreditation employees, Council 40 hospitals, for Continuing 600 doctors’ Medical offices Education and outpatient(ACCME) sites, to provide and a 3.4 continuing million-member medical Insurance education Services for physicians. Division, The the University largest medical of Pittsburgh insurer in School western of MedicinePennsylvania. designates As UPMC this works enduring in close material collaboration for a withmaximum the University of .5 AMA of Pittsburgh PRA Category Schools 1 Credits™.of the Health Each Sciences, physician U.S. should News only& World claim Report credit consistently commensurate ranks withUPMC the Presbyterian extent of their Shadyside participation on its inannual the activity. Honor RollOther of America’s health care Best professionals Hospitals. UPMC are awarded Enterprises .05 functionscontinuing as education the innovation units and(CEU), commercialization which are equivalent arm of to UPMC, .5 contact and UPMChours. International provides hands-on health care and management services with partners around the world. For more information, go to UPMC.com. SYS508445 DC/SM 8/18 © 2018 UPMC Disclosures: The authors have no conflicts of interest to disclose. Instructions: To take the CME evaluation and receive credit, please visit https://cme.hs.pitt.edu/ISER (case-sensitive) and click on Trauma and Emergency. If this is your first visit, you will need to create a free account.

A $14 billion world-renowned health care provider and insurer, Pittsburgh-based UPMC is inventing new models of patient-centered, cost-effective, accountable Critical Care Transport care. UPMC provides nearly $900 million a year in benefits to its communities, including more care to the region’s most vulnerable citizens than any other health 1-800-633-7828 care institution. The largest nongovernmental employer in Pennsylvania, UPMC integrates 65,000 employees, more than 25 hospitals, 600 doctors’ offices and outpatient sites, and a 3.2 million-member Insurance Services Division, the largest medical and behavioral health services insurer in western Pennsylvania. Affiliated with the University of Pittsburgh Schools of the Health Sciences, UPMC ranks No. 12 in the prestigious U.S. News & World Report annual Honor Roll UPMC is a member of the Center of America’s Best Hospitals. UPMC Enterprises functions as the innovation and commercialization arm of UPMC, while UPMC International provides hands-on for Emergency Medicine of Western health care and management services with partners in 12 countries on four continents. For more information, go to UPMC.com. Pennsylvania, Inc. UPMC MedCall — 412-647-7000 or 1-800-544-2500 24-hour emergency consultation, referral, and transport arrangements SYS504323 QD/DC 5/17 © 2017 UPMC