Current Trauma Reports

Unaccompanied children (UC) migrating to the USA from the Central American countries of El Salvador, Guatemala, and Honduras are an underserved population at high risk for health, academic, and social problems. These children experience trauma, violence, and other risk factors that are shared among several types of interpersonal violence. The trauma and violence experienced by many unaccompanied children, and the subsequent implications for their healthy development into adulthood, indicate the critical need for a public health approach to prevention and intervention. This paper provides an overview of the violence experienced by unaccompanied children along their migration journey, the implications of violence and trauma for the health and well-being of the children across their lifespan, prevention and intervention approaches for UC resettled in the USA, and suggestions for adapted interventions to best address the unique needs of this vulnerable population.

The diagnosis and management of spinal cord injury (SCI) have continuously evolved over decades of clinical experience. We now understand that the injured spinal cord is in a precarious state, experiencing a complex cascade of inflammatory events and hemodynamic compromise. Careful navigation is required at each stage, from emergency personnel to the spinal surgeon who reconstructs the damaged spine, to minimize secondary injury and optimize neurological outcome. Future advances in SCI diagnosis will likely utilize novel MRI techniques that characterize spinal cord microstructure and functional connectivity. The acute management of SCI is likely to undergo a radical transformation, with numerous potential treatments used in combination, such as neuroprotective and regenerative pharmaceuticals, cellular transplantation, and implantation of structural scaffolds. In this review, we summarize current best practices in diagnosis and acute management of SCI, highlight areas of controversy, and introduce emerging therapies that are candidates for translation to clinical use.

The purpose of this study is to review recent advancements, trends, and recommendations in gastric and enteral feeding with a focus on critically ill patients. Enteral feeding continues to serve as the mainstay for nutritional support in critically ill patients and is favored over parenteral nutrition, though recent trials suggest no substantial difference in outcomes between the two methods. Radiologic and endoscopic guidance remain the most common methods for enteral access. Additionally, recent advancements in enteral access technique and trials on best practices for timing and composition of nutritional support in critically ill patients continue to reduce complications, improve outcomes, and reduce cost. Nutritional support improves outcomes in critically ill patients, and the safe and durable establishment of enteral access is an important component in the care of these patients.

Surgeons participating in humanitarian or disaster relief missions should expect trauma patients. Care follows established Advanced Trauma Life Support guidelines but may be impacted by available resources. This review provides treatment principles for the care of traumatically injured children in austere environments. Appropriate triage of patients is paramount in a resource-limited environment. Respiratory failure is a leading cause of cardiac arrest in children, airway management is paramount. Intraosseous access can be lifesaving in a child with difficult intravenous access; preferably placed in the proximal tibia. Resuscitation has transitioned to early use of blood products with improved survival. Malnutrition should be considered in all children. Transition of care discussions should begin during mission planning. Surgeons should be prepared to manage traumatically injured children while involved in humanitarian missions. Recognition of key differences in the management of children can assist with preparation and improve outcomes.

The rehabilitation of individuals with lower extremity injury is a common but complex problem for the surgical and rehabilitative teams. Basic science tenets of fracture and soft tissue reconstruction and healing guide postoperative weight-bearing and range of motion protocols. In addition to the physiological complications associated with the injury severity, patient outcomes are often influenced by other factors such as patient compliance, pain, depression, and the negative effects of immobility. As a result, novel rehabilitative protocols to include early weight bearing, continuous passive motion, psychosocial intervention, and multimodal pain management are becoming more popular to facilitate rehabilitation and improved patient outcomes. Further supporting the need for this shift in paradigm thinking are outcome studies of both civilian and military trauma patients that demonstrate the negative impact that psychological, social, and economical factors have on outcomes. This report highlights the experience that our team has had in instituting comprehensive rehabilitation strategies to treat injured service members with complex lower extremity trauma from combat.

The use of extracorporeal life support in the intensive care unit has exponentially increased in the last decade. Initially, its use in the burn population lagged behind the dramatic growth in other patient populations; however, in the last 2–3 years, there has been an increase in the number of publications related to its use in this population. In this article, we review the use of contemporary ECMO in the burn patient population and discuss future trends. Level 1 evidence for the use of ECMO in any patient population is scarce, and there is no level 1 evidence for the use of ECMO in burn patients. Recently, there has been an increase in case series and case reports describing the use of contemporary ECMO in burn patients. In addition, there are two large retrospective reviews of large registries utilizing ECMO in burn patients. The results from these studies all indicate that outcomes using ECMO in this critically ill patient population has survival rates at least comparable to the survival found in other patient populations. There are still many unanswered questions, and future focus needs to address patient selection, timing of initiation, management, and the duration of ECMO therapy.

The management of blunt abdominal trauma has evolved over time. While laparotomy is the standard of care in hemodynamically unstable patients, stable patients are usually treated by non-operative management (NOM), incorporating adjuncts such as interventional radiology. However, although NOM has shown good results in solid organ injuries, other lesions, namely those involving the hollow viscus, diaphragm, and mesentery, do not qualify for this approach and need surgical exploration. Laparoscopy can substantially reduce additional surgical aggression. It has both diagnostic and therapeutic potential and, when negative, may reduce the number of unnecessary laparotomies. Although some studies have shown promising results on the use of laparoscopy in blunt abdominal trauma, randomized controlled studies are lacking. Laparoscopy requires adequate training and experience as well as sufficient staffing and equipment.

Optimal management of penetrating abdominal trauma, especially for kidney and splenic injuries, is evolving. Opinions range from aggressive surgical exploration to expectant management. This report addresses the recent advancements in the diagnosis, grading, and management of penetrating injuries to the kidney and spleen. A special focus is provided on the shifting paradigm towards non-operative management. Penetrating renal trauma management has evolved significantly over the past few years. Advancements in diagnostic tools and evolution of injury grading have paved the way for selective non-operative management. Penetrating injuries to the spleen provide a unique management challenge. With the evolution of non-operative management, appropriate patient selection is mandatory. Optimal use of computed tomography scanning and angiography can improve the organ salvage rates; however, hemorrhage control is still the main goal.