To identify and analyze the clinical presentation, management and outcome of patients with acute mechanical bowel obstruction along with the etiology of obstruction and the incidence and causes of bowel ischemia, necrosis, and perforation. This is a prospective observational study of all adult patients admitted with acute mechanical bowel obstruction between 2001 and 2002. Of the 150 consecutive patients included in the study, 114 (76%) presented with small bowel and 36 (24%) with large bowel obstruction. Absence of passage of flatus (90%) and/or feces (80.6%) and abdominal distension (65.3%) were the most common symptoms and physical finding, respectively. Adhesions (64.8%), incarcerated hernias (14.8%), and large bowel cancer (13.4%) were the most frequent causes of obstruction. Eighty-eight patients (58.7%) were treated conservatively and 62 (41.3%) were operated (29 on the first day). Bowel ischemia was found in 21 cases (14%), necrosis in 14 (9.3%), and perforation in 8 (5.3%). Hernias, large bowel cancer, and adhesions were the most frequent causes of bowel ischemia (57.2%, 19.1%, 14.3%), necrosis (42.8%, 21.4%, 21.4%), and perforation (50%, 25%, 25%). A significantly higher risk of strangulation was noticed in incarcerated hernias than all the other obstruction causes. Absence of passage of flatus and/or feces and abdominal distension are the most common symptoms and physical finding of patients with acute mechanical bowel obstruction, respectively. Adhesions, hernias, and large bowel cancer are the most common causes of obstruction, as well as of bowel ischemia, necrosis, and perforation. Although an important proportion of these patients can be nonoperatively treated, a substantial portion requires immediate operation. Great caution should be taken for the treatment of these patients since the incidence of bowel ischemia, necrosis, and perforation is significantly high.

Objective: We discuss the strengths of the medical response to the Boston Marathon bombings that led to the excellent outcomes. Potential shortcomings were recognized, and lessons learned will provide a foundation for further improvements applicable to all institutions. Background: Multiple casualty incidents from natural or man-made incidents remain a constant global threat. Adequate preparation and the appropriate alignment of resources with immediate needs remain the key to optimal outcomes. Methods: A collaborative effort among Boston's trauma centers (2 level I adult, 3 combined level I adult/pediatric, 1 freestanding level I pediatric) examined the details and outcomes of the initial response. Each center entered its respective data into a central database (REDCap), and the data were analyzed to determine various prehospital and early in-hospital clinical and logistical parameters that collectively define the citywide medical response to the terrorist attack. Results: A total of 281 people were injured, and 127 patients received care at the participating trauma centers on that day. There were 3 (1%) immediate fatalities at the scene and no in-hospital mortality. A majority of the patients admitted (66.6%) suffered lower extremity soft tissue and bony injuries, and 31 had evidence for exsanguinating hemorrhage, with field tourniquets in place in 26 patients. Of the 75 patients admitted, 54 underwent urgent surgical intervention and 12 (22%) underwent amputation of a lower extremity. Conclusions: Adequate preparation, rapid logistical response, short transport times, immediate access to operating rooms, methodical multidisciplinary care delivery, and good fortune contributed to excellent outcomes.

The Boston Marathon bombing was the first major, modern US terrorist event with multiple, severe lower extremity injuries. First responders, including trained professionals and civilian bystanders, rushed to aid the injured. The purpose of this review was to determine how severely bleeding extremity injuries were treated in the prehospital setting in the aftermath of the Boston Marathon bombing. A database was created and populated by all the Boston Level I trauma centers following the Boston Marathon bombing. Data regarding specific injuries, extremities affected, demographics, prehospital interventions (including tourniquet types), and outcomes were extracted. Of 243 injured, 152 patients presented to the emergency department within 24 hours. Of these 152 patients, there were 66 (63.6% female) experiencing at least one extremity injury, with age ranging from younger than 15 years to 71 years, and with a median Injury Severity Score (ISS) of 10 (range, 1-38). Of the 66 injured patients, 4 had upper limbs affected, 56 had injuries on the lower limbs only, and 6 had combined upper and lower limbs affected. The extremity Abbreviated Injury Scale (AIS) scores had a median of 3 (range, 1-4). There were 17 lower extremity traumatic amputations in 15 patients. In addition, there were 10 patients with 12 lower extremities experiencing major vascular injuries. Of 66 injured patients, 29 patients had recognized extremity exsanguination at the scene. In total, 27 tourniquets were applied: 16 of 17 traumatic amputations, 5 of 12 lower extremities with major vascular injuries, and 6 additional limbs with major soft tissue injury. All tourniquets were improvised, and no commercial, purpose-designed tourniquets were identified. Among all 243 patients, mortality was 0%. After the Boston Marathon bombings, extremity exsanguination at the point of injury was either left untreated or treated with an improvised tourniquet in the prehospital environment. An effective, prehospital extremity hemorrhage control posture should be translated to all civilian first responders in the United States and should mirror the military's posture toward extremity bleeding control. The prehospital response to extremity exsanguination after the Boston Marathon bombing demonstrates that our current practice is an approach, lost in translation, from the battlefield to the homeland. Epidemiologic study, level V.

Massive transfusion (MT) is defined as transfusion of at least 10 U of red blood cells (RBCs) within a 24-hour period, although alternate definitions, such as 3 U/h (critical administration threshold), are also used to more accurately reflect most transfusions that occur in the first 6 hours.¹ In addition to RBCs, fresh frozen plasma (FFP) and platelets may be transfused as a ratio of RBCs in an approach termed balanced resuscitation. For example, transfusing 1 U of FFP for every 2 U of RBCs is a 1:2 strategy. Although ratio-based resuscitation is not a new concept,² interest was rekindled in the past decade when retrospective studies from the US military reported improved survival when massively transfused injured soldiers received resuscitation with higher (compared with lower) amounts of FFP to RBCs (FFP:RBC ratio).³ Additional reports from civilian trauma centers supported these findings, and the practice of transfusing higher FFP:RBC ratios was quickly embraced by the trauma surgery and anesthesia community, with many hospitals implementing formal massive transfusion protocols (MTPs) with high FFP:RBC ratios.^4,5 Until recently, high-quality evidence supporting this practice had been lacking. The Prospective, Observational, Multicenter, Major Trauma Transfusion (PROMMTT) study described transfusion ratios and clinical outcomes in a prospective observational manner and concluded that higher ratios of FFP and platelets administered early in resuscitation were associated with decreased mortality in the first 24 hours.⁶ Quiz Ref ID However, the subsequent Pragmatic Randomized Optimal Platelet and Plasma Ratios (PROPPR) trial found no difference in 24-hour or 30-day survival outcomes when comparing a 1:1:1 (FFP to platelets to RBCs) resuscitation strategy with a 1:1:2 strategy.⁷ While it is now common practice for trauma patients who require MT to receive ratio-based resuscitation, the exact ratio continues to be explored.