Enterocutaneous fistulas (ECFs) are complex and resource-intensive complications in surgical and trauma care. Despite improvements in mortality over the past several decades, ECFs continue to be associated with significant morbidity, prolonged hospitalization, malnutrition, and impaired quality of life. This review examines contemporary principles of ECF management and highlights evolving therapeutic strategies. Modern management has shifted from prolonged bowel rest and exclusive parenteral nutrition toward a multidisciplinary approach emphasizing early source control, physiologic stabilization, and nutritional optimization with increasing focus on enteral rehabilitation when feasible. Adjunctive pharmacologic therapies, fistuloclysis, and advanced wound isolation techniques support stabilization and may improve spontaneous closure rates in select patients. Definitive surgical repair is generally delayed until inflammation has resolved and nutritional status has been optimized. Emerging therapies, including GLP-2 analogues, endoscopic closure techniques, biologic plugs, and regenerative strategies, have shown promise in early studies but require further validation. Optimal ECF management requires coordinated multidisciplinary care focused on sepsis control, nutritional rehabilitation, wound management, and individualized operative planning. Although outcomes have improved substantially, important controversies persist. Continued investigation and development of standardized care pathways are needed to refine management strategies and improve patient-centered outcomes.
Traumatic cardiac arrest (TCA) and the peri-arrest trauma patient represent one of the most challenging populations encountered by trauma teams. Contemporary evidence has demonstrated that TCA is frequently a reversible condition when the underlying pathophysiology is rapidly identified and treated. This review summarizes current evidence regarding the evaluation and management of injured patients in extremis, with particular emphasis on trauma-specific resuscitation priorities, the role of conventional advanced cardiac life support (ACLS) interventions, and indications for emergency department thoracotomy (EDT). Modern trauma resuscitation has shifted away from traditional ACLS algorithms toward rapid correction of reversible causes of arrest, emphasizing hemorrhage control, balanced blood product resuscitation, treatment of hypoxia, and management of obstructive shock etiologies (e.g. tension pneumothorax and cardiac tamponade). Contemporary evidence suggests that routine use of chest compressions, vasopressors, and mechanical compression devices provides limited benefit unless reversible causes have been addressed, while defibrillation should remain restricted to shockable rhythms. Patient selection for EDT continues to evolve, with current guidelines favoring a mechanism- and physiology-based approach. Emerging technologies, including resuscitative endovascular balloon occlusion of the aorta (REBOA), prehospital advanced resuscitative measures, and extracorporeal cardiopulmonary resuscitation (ECPR), may further improve outcomes in carefully selected patients. Successful management of TCA depends on timely recognition of reversible traumatic pathology and coordinated, trauma-specific resuscitation rather than adherence to conventional medical cardiac arrest algorithms. Continued advances in prehospital systems, damage control resuscitation, and emerging technologies will likely further refine patient selection and improve survival while reducing futile interventions.
The purpose of this review is to provide up to date information regarding use of parenteral nutrition (PN) in malnourished patients and patients at risk for malnutrition. The components, indications, and contraindications of PN as well as complications associated with modern PN use are important for providers to understand. The pharmacologic aspects of PN are also necessary to determine how and when to utilize PN for patients. Administration and utilization of PN in hospital systems is based on the American Society for Parenteral and Enteral Nutrition (ASPEN) and European Society for Clinical Nutrition and Metabolism (ESPEN). More recent research is focused on utilization of artificial intelligence (AI) for development of patient specific formulations. This research has mostly focused on neonates and further research is needed in adult populations. Additional research has focused on cost effectiveness and safety of different PN formulations (ready-to-use versus compounded formulations). In summary, PN is a form of organ replacement therapy that provides intravenous hydration and nutrition for patients with intestinal failure. ASPEN and ESPEN guidelines help providers to determine the appropriate use of PN in their patients. There is emerging research regarding the use of AI to assist in this decision-making process.
