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Article 1
Beta blockers in critically ill patients with traumatic brain injury: Results from a multicenter, prospective, observational American Association for the Surgery of Trauma study. Ley EJ, Leonard SD, Barmparas G, Dhillon NK, Inaba K, Salim A, O'Bosky KR, Tatum D, Azmi H, Ball CG, Engels PT, Dunn JA, Carrick MM, Meizoso JP, Lombardo S, Cotton BA, Schroeppel TJ, Rizoli S, Chang DSJ, de León LA, Rezende-Neto J, Jacome T, Xiao J, Mallory G, Rao K, Widdel L, Godin S, Coates A, Benedict LA, Nirula R, Kaul S, Li T; Beta Blockers TBI Study Group Collaborators. J Trauma Acute Care Surg. 2018 Feb; 84(2):234-244.
There are currently few, if any, proven interventions to avoid progression of secondary brain injury after TBI. Progression of brain injury is thought to be partially mediated by catecholamine surge after initial injury. Several previous studies have shown some benefit to beta blocker administration in TBI patients; however, this has not become standard of care as of yet.
The study by Ley et al. was a two-year multicenter, prospective observational study through the AAST Multi-Institutional Trials Committee evaluating adult patients with traumatic brain injury requiring ICU admission at 15 trauma centers. 2252 patients were included in the analysis. 49.7% of the patients received beta blockers during their admission. The patients who received beta blockers were older, more likely to have fallen, more likely to be on a preadmission anticoagulants or beta blockers, and more likely to require intubation in the ED. The beta blocker group also had a higher rate of neurosurgical intervention (craniotomy, craniectomy, ICP monitor or EVD).
Unadjusted 30-day mortality was found to be significantly lower in patients who received beta blockers (13.8% vs 17.7%). This continued to be significant even with risk adjustment. Unadjusted Glasgow Outcome Score was better in the non-beta blocker group but was no longer significant after risk factor adjustment. Additional findings of the study demonstrated that 30-day mortality was significantly lower in patients who received propranolol as their beta blocker.
This study suggests potential benefit of beta blocker administration to patients who have suffered TBIs and a potentially even greater benefit if the beta blocker used is propranolol. Further study of this potential benefit should be evaluated with a randomized controlled trial.
Article 2
Contemporary management of rectal injuries at Level I trauma centers: The results of an American Association for the Surgery of Trauma multi-institutional study. Brown CVR, Teixeira PG, Furay E, Sharpe JP, Musonza T, Holcomb J, Bui E, Bruns B, Hopper HA, Truitt MS, Burlew CC, Schellenberg M, Sava J, VanHorn J, Eastridge PB, Cross AM, Vasak R, Vercruysse G, Curtis EE, Haan J, Coimbra R, Bohan P, Gale S, Bendix PG; AAST Contemporary Management of Rectal Injuries Study Group. J Trauma Acute Care Surg. 2018 Feb; 84(2):225-233.
The classic dogma of treatment of traumatic rectal injuries has been a combination of proximal diversion, presacral drainage and distal rectal washout. The treatment of these injuries continues to vary widely.
The study by Brown et al. is an AAST multicenter retrospective trial of 785 patients with traumatic rectal injuries at 22 Level 1 trauma centers from 2004-2015. The study evaluated both intra- and extra-peritoneal rectal injuries and their management. Results demonstrated that for intraperitoneal injuries, proximal diversion significantly increased the rate of intra-abdominal complications (22% vs 10%). However, on logistic regression, proximal diversion was not a risk factor for complications. There was no mortality difference between the two groups.
In extraperitoneal injuries, abdominal complications were significantly higher in patients who underwent proximal diversion, presacral drainage and distal rectal washout. Distal rectal washout and presacral drain placement were independent risk factors for abdominal complications. There was no difference in complication rate between patients whose extraperitoneal rectal injury was repaired and those whose were.
Based on the results of the study it seems that proximal diversion is likely not necessary, and may not be beneficial, in the treatment of intraperitoneal rectal injuries. Additionally, patients with extraperitoneal rectal injuries do not benefit from routine presacral drainage or distal rectal washout. These maneuvers may be helpful in very select patients, although this is not defined or clarified from this study. The results also suggest that some extraperitoneal injuries may be treated without diversion or primary repair. Some caution should be taken in interpreting the results as this is a retrospective review and there is limited information on the decision-making that led each surgery to choose their treatment strategy for each specific patient.
These findings are consistent with those of the recent EAST Practice Management Guideline regarding penetrating extraperitoneal rectal injuries which conditionally recommended proximal diversion and against routine presacral drainage and distal rectal washout.
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