Ultrasound is an informative technique for assessing muscles of patients in the ICU, and lower extremity muscles demonstrated increased homogeneity during ICU stays. This technique should be examined further for diagnosing and tracking those with ICU-AW.

HighlightsWe present a case of a 19 year old male with massive hemothorax and refractory, class IV hemorrhagic shock due to proximal left posterior intercostal artery injury with uncontrollable bleeding secondary to a left chest gunshot wound in the 4th intercostal space (ICS).The patient was emergently taken to the operating room for thoracotomy and left chest exploration and found to have massive ongoing massive from his left posterior chest with severe hemodynamic instability and profound levels of hemorrhagic shock. Despite multiple attempts to surgically stop the bleeding intraoperatively as well as using various hemostatic measures, we were unable to control the excessive bleeding.The patient developed refractory class IV hemorrhagic shock with sinus tachycardia to the 170′s and persistent hypotension with systolic blood pressures in the 70′s, which was not amenable to surgical control.Consequently, the patient was taken to the angiography suite in radiology where thoracic aortography was performed and revealed active bleeding from the left 7th posterior intercostal artery < 3 cm from the aorta.The patient underwent thoracic angiography with percutaneous catheter-based embolization of the bleeding intercostal artery. The bleeding arterial segment was controlled with coils and gelfoam along with the vessels immediately above and below the area of extravasation.The patient's hemodynamics significantly stabilized. He was transferred to the surgical ICU for ongoing resuscitation. The patient survived and was ultimately discharged to home in satisfactory condition.This is the first report in the literature of using thoracic angiography with selective catheter based embolization to arrest bleeding of an injured posterior intercostal artery due to penetrating injury or gunshot wound of the chest.

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extremities. Pulmonary embolus (PE) is thought to arise from lower extremity DVT. Lower extremity DVT surveillance is commonly used in trauma patients considered at risk for DVT. Methods: A 23 year, comprehensive DVT surveillance literature review was performed to assess the effect of surveillance on DVT and PE rates, the efficacy of chemoprophylaxis (CP) and mechanical prophylaxis (MP), and the relationship between DVT and PE. Twenty-four publications with >13,000 patients were reviewed. Results: DVT rates are significantly higher when surveillance is used, 8.5% (n=12,423) than with no surveillance, 2.6% (n=823; p<0.001). PE rate without surveillance was 1.3% (n=823), similar to 1.1% (n=12,184) with surveillance (p=0.6093). There is no association between DVT and PE rates (p=0.7574). CP administration was associated with reduced DVT rate (4.4%, n=5,801) compared to no CP (11.7%, n=4,966; p<0.0001; RR=2.7). PE rate was lower with CP (0.8%, n=5,662) than no CP (1.5%, n=4,866; p=0.00004). MP also decreased DVT rate (7.9%, n=8,827) compared to no MP (13%, n=600; p<0.0001; RR=1.7). PE rate was similar, 1.5% (n=600) not on MP compared to 1.2% (n=8,748) with MP (p=0.4340). Of 600 who received no CP and no MP, DVT rate was 13% and PE rate was 1.5%. When CP and/or MP were given, DVT rate was 7.8% (n=9,128; p<0.0001) and PE rate was 1.2% (n=8,989; p=0.4317). Conclusions: DVT surveillance of the lower extremities appears effective in diagnosing DVT; however the risk of PE is not decreased. Our data suggest that PE rates are not associated with lower extremity DVT. The historical notion that lower extremity DVT is associated with PE development is in question. New paradigms need to be developed, e.g. considering DVT in the vena cava and pelvic veins and assessing for hyper-coagulation.Learning Objectives: Trisomy 13 (T13) and Trisomy 18 (T18) are fatal chromosomal disorders associated with multiple congenital anomalies with only 5-10% of children surviving past the first year. Extracorporeal membrane oxygenation (ECMO) is an invaluable means of cardiopulmonary support in the care of patients with reversible cardiac and or pulmonary disease refractory to other medical treatment. Determination of ECMO eligibility is based on center specific guidelines, ECMO team consensus and physician opinion. Historically, patients with T13 and T18 were not considered to be candidates for ECMO. However, in the recent era more of these infants are undergoing invasive procedures including cardiac surgery. There are no multicenter studies reporting outcomes of patients with T13 and T18 on ECMO. Methods: Pediatric patients ≤18 yr of age with T13 and T18 in the Extracorporeal Life Support Organization (ELSO) Registry were included. The primary outcome of interest was death before hospital discharge. Between group comparisons (non trisomy patients (nonT) and T13 and T18 patients) were performed using t-test, chi-square and fisher's exact test. Results: Twenty-three patients with T13 and T18 were included. ECMO use in T13 and T18 patients has incr...