Surgical Emergencies in Patients with Significant Comorbid Diseases.

Emergency surgery in patients with significant comorbidities benefits from a structured approach to preoperative evaluation, intra-operative intervention, and postoperative management. Providing goal concordant care is ideal using shared decision-making. When operation cannot achieve the patient's goal, non-operative therapy including Comfort Care is appropriate. When surgical therapy is offered, preoperative physiology-improving interventions are far fewer than in other phases. Reevaluation of clinical care progress helps define trajectory and inform goals of care. Palliative Care Medicine may be critical in supporting loved ones during a patient's critical illness. Outcome evaluation defines successful strategies and outline opportunities for improvement.

Non-surgical management and analgesia strategies for older adults with multiple rib fractures: A systematic review, meta-analysis, and joint practice management guideline from the Eastern Association for the Surgery of Trauma and the Chest Wall Injury Society.

BACKGROUND: Chest wall injury in older adults is a significant cause of morbidity and mortality. Optimal nonsurgical management strategies for these patients have not been fully defined regarding level of care, incentive spirometry (IS), noninvasive positive pressure ventilation (NIPPV), and the use of ketamine, epidural, and other locoregional approaches to analgesia. METHODS: Relevant questions regarding older patients with significant chest wall injury with patient population(s), intervention(s), comparison(s), and appropriate selected outcomes were chosen. These focused on intensive care unit (ICU) admission, IS, NIPPV, and analgesia including ketamine, epidural analgesia, and locoregional nerve blocks. A systematic literature search and review were conducted, our data were analyzed qualitatively and quantitatively, and the quality of evidence was assessed per the Grading of Recommendations Assessment, Development, and Evaluation methodology. No funding was used. RESULTS: Our literature review (PROSPERO 2020-CRD42020201241, MEDLINE, EMBASE, Cochrane, Web of Science, January 15, 2020) resulted in 151 studies. Intensive care unit admission was qualitatively not superior for any defined cohort other than by clinical assessment. Poor IS performance was associated with prolonged hospital length of stay, pulmonary complications, and unplanned ICU admission. Noninvasive positive pressure ventilation was associated with 85% reduction in odds of pneumonia ( p < 0.0001) and 81% reduction in odds of mortality ( p = 0.03) in suitable patients without risk of airway loss. Ketamine use demonstrated no significant reduction in pain score but a trend toward reduced opioid use. Epidural and other locoregional analgesia techniques did not affect pneumonia, length of mechanical ventilation, hospital length of stay, or mortality. CONCLUSION: We do not recommend for or against routine ICU admission. We recommend use of IS to inform ICU status and conditionally recommend use of NIPPV in patients without risk of airway loss. We offer no recommendation for or against ketamine, epidural, or other locoregional analgesia. LEVEL OF EVIDENCE: Systematic Review/Meta-analysis; Level IV.

Outcomes of surgical versus nonsurgical treatment for multiple rib fractures: A US hospital matched cohort database analysis.

BACKGROUND: Treatment for multiple rib fractures includes surgical stabilization of rib fractures (SSRF) or nonoperative management (NOM). Meta-analyses have demonstrated that SSRF results in faster recovery and lower long-term complication rates versus NOM. Our study evaluated postoperative outcomes for multiple rib fracture patients following SSRF versus NOM in a real-world, all-comer study design. METHODS: Multiple rib fracture patients with inpatient admissions in the PREMIER hospital database from October 1, 2015, to September 30, 2020, were identified. Outcomes included discharge disposition, and 3- and 12-month lung-related readmissions. Demographics, comorbidities, concurrent injuries at index, Abbreviated Injury Scale and Injury Severity Scores, and provider characteristics were determined for all patients. Patients were excluded from the cohort if they had a thorax Abbreviated Injury Scale score of <2 (low severity patient) or a Glasgow Coma Scale score of ≤8 (extreme high severity patient). Stratum matching between SSRF and NOM patients was performed using fine stratification and weighting so that all patient data were kept in the final analysis. Outcomes were analyzed using generalized linear models with quasinormal distribution and logit links. RESULTS: A total of 203,450 patients were included, of which 200,580 were treated with NOM and 2,870 with SSRF. Compared to NOM, patients with SSRF had higher rates of home discharge (62% SSRF vs. 58% NOM) and lower rates of lung-related readmissions (3 months, 3.1% SSRF vs. 4.0% NOM; 12 months, 6.2% SSRF vs. 7.6% NOM). The odds ratio (OR) for home or home health discharge in patients with SSRF versus NOM was 1.166 (95% confidence interval [CI], 1.073-1.266; p = 0.0002). Similarly, ORs for lung-related readmission at 3- and 12-month were statistically lower in the patients treated with SSRF versus NOM (OR [3 months], 0.764 [95% CI, 0.606-0.963]; p = 0.0227 and OR [12 months], 0.799 [95% CI, 0.657-0.971]; p = 0.0245). CONCLUSION: Surgical stabilization of rib fractures results in greater odds of home discharge and lower rates of lung-related readmissions compared with NOM at 12 months of follow-up. LEVEL OF EVIDENCE: Therapeutic/Care Management; Level III.

Necrotizing soft tissue infections.

Necrotising soft tissue infection (NSTI) presents unique challenges in diagnosis and management. The key to a successful outcome is a high index of suspicion in appropriate clinical settings. Type II NSTI tends to occur on an extremity in younger, healthier patients with a history of known trauma, and to be monomicrobial. Type I NSTI tends to occur on the trunk of older, less healthy patients without an obvious history of trauma, and tends to be polymicrobial. Other, rarer types exist as well. The pathophysiology of both types involves superantigen acticivty, as well as a number of microbial byproducts which collectively decrease the viscosity of pus, facilitating its spread along deep tissue planes and ultimately causing diffuse deep thrombosis and aggressive systemic sepsis. The most important physical finding is tenderness to palpation beyond the area of redness, and the lack of crepitus should not be seen as a reassuring sign. Suspected cases should undergo early surgical exploration for diagnosis, which may be performed at bedside through a small incision. Most imaging techniques are not sufficiently specific to warrant a delay in surgical exploration. The Laboratory Risk Indicator for Necrotising Fasciitis (LRINEC) shows promise as a tool for excluding suspected cases. Successful outcomes in cases of NSTI require early and aggressive serial debridement and a multidisciplinary critical care approach.

Penetrating neck trauma: a review of management strategies and discussion of the 'No Zone' approach.

The evaluation and management of hemodynamically stable patients with penetrating neck injury has evolved considerably over the previous four decades. Algorithms developed in the 1970s focused on anatomic neck "zones" to distinguish triage pathways resulting from the operative constraints associated with very high or very low penetrations. During that era, mandatory endoscopy and angiography for Zone I and III penetrations, or mandatory neck exploration for Zone II injuries, became popularized, the so-called "selective approach." Currently, modern sensitive imaging technology, including computed tomographic angiography (CTA), is widely available. Imaging triage can now accomplish what operative or selective evaluation could not: a safe and noninvasive evaluation of critical neck structures to identify or exclude injury based on trajectory, the key to penetrating injury management. In this review, we discuss the use of CTA in modern screening algorithms introducing a "No Zone" paradigm: an evidence-based method eliminating "neck zone" differentiation during triage and management. We conclude that a comprehensive physical examination, combined with CTA, is adequate for triage to effectively identify or exclude vascular and aerodigestive injury after penetrating neck trauma. Zone-based algorithms lead to an increased reliance on invasive diagnostic modalities (endoscopy and angiography) with their associated risks and to a higher incidence of nontherapeutic neck exploration. Therefore, surgeons evaluating hemodynamically stable patients with penetrating neck injuries should consider departing from antiquated, invasive algorithms in favor of evidence-based screening strategies that use physical examination and CTA.

Enhancing the tissue donor pool through donation after death in the field.

INTRODUCTION: Tissue transplantation is an important adjunct to modern medical care and is used daily to save or improve patient lives. Tissue allografts include bone, tendon, corneas, heart valves and others. Increasing utilization may lead to tissue shortages, and tissue procurement organizations continue to explore ways to expand the cadaveric donor pool. Currently more than half of all deaths occur outside the acute care setting. HYPOTHESIS: Many who suffer prehospital deaths might be eligible for non-organ tissue donation. METHODS: A retrospective review of electronic prehospital medical records was conducted from May 1, 2008 through December 31, 2009. All prehospital deaths were included irrespective of cause. Once identified, additional medical history was obtained from prehospital, inpatient, and emergency department records. Age, medical history, and time of death were compared to exclusion criteria for four tissue procurement organizations (MTF, LifeNet, LifeCell, EyeBank). After analysis, percentages of eligible donors were calculated. RESULTS: Over 50,000 prehospital records were reviewed; 432 subjects died in the field and were eligible for analysis. Ages ranged from four to 103 years of age; the average was 68.3 (SD = 20.1) years. After exclusion for age, medical conditions, and time of death, 185 unique patients (42.8%) were eligible for donation to at least one of the four tissue procurement organizations (range 11.6%-34.3%). CONCLUSIONS: After prehospital death, many individuals may be eligible for tissue donation. These findings suggest that future prospective studies exploring tissue donation after prehospital death are indicated. These studies should aim to clarify eligibility criteria, create protocols and infrastructure, and explore the ethical implications of expanding tissue donation to include this population.

Creation of an emergency surgery service concentrates resident training in general surgical procedures.

INTRODUCTION: Emergency general surgery (EGS) is increasingly being provided by academic trauma surgeons in an acute care surgery model. Our tertiary care hospital recently changed from a model where all staff surgeons (private, subspecialty academic, and trauma academic) were assigned EGS call to one in which an emergency surgery service (ESS), staffed by academic trauma faculty, cares for all EGS patients. In the previous model, many surgeries were "not covered" by residents because of work-hour restrictions, conflicting needs, or private surgeon preference. The ESS was separate from the trauma service. We hypothesize that by creating a separate ESS, residents can accumulate needed and concentrated operative experience in a well-supervised academic environment. METHODS: A prospectively accrued EGS database was retrospectively queried for the 18-month period: July 2010 to June 2011. The Accreditation Council for Graduate Medical Education (ACGME) databases were queried for operative numbers for our residency program and for national resident data for 2 years before and after creating the ESS. The ACGME operative requirements were tabulated from online sources. ACGME requirements were compared with surgical cases performed. RESULTS: During the 18-month period, 816 ESS operations were performed. Of these, 307 (38%) were laparoscopy. Laparoscopic cholecystectomy and appendectomy were most common (138 and 145, respectively) plus 24 additional laparoscopic surgeries. Each resident performed, on average, 34 basic laparoscopic cases during their 2-month rotation, which is 56% of their ACGME basic laparoscopic requirement. A diverse mixture of 70 other general surgical operations was recorded for the remaining 509 surgical cases, including reoperative surgery, complex laparoscopy, multispecialty procedures, and seldom-performed operations such as surgery for perforated ulcer disease. Before the ESS, the classes of 2008 and 2009 reported that only 48% and 50% of cases were performed at the main academic institution, respectively. This improved for the classes of 2010 and 2011 to 63% and 68%, respectively, after ESS creation. CONCLUSION: An ESS rotation is becoming essential in large teaching hospitals by helping to fulfill ACGME requirements and by providing emergent general surgical skills an efficient and well-supervised academic environment. Movement toward concentrating EGS on a single service can enhance resident education and may decrease the need to supplement certain aspects of general surgery education with away rotations.

Evidence-based appendicitis: the initial work-up.

In this article we provide an evidence-based review of appendicitis, which is one of the most challenging conditions to diagnose in patients presenting with abdominal pain. Almost all clinicians are faced with the diagnostic work-up of these patients, and missing the diagnosis can result in patient decompensation. We review the literature from the initial description of McBurney's point to the clinical presentation, as well as the most appropriate imaging testing. Additionally, we review the usefulness of specific diagnostic laboratory tests. The use of computed tomography scans has reduced negative appendectomy rates when combined with a physical examination, and assists in ruling out appendicitis. Computed tomography scans with no contrast or just rectal contrast are becoming the standard in many institutions. It is essential that when the diagnosis of abdominal pain of unclear etiology is suspected, the clinician's discussion with the patient is well documented on the patient's chart.

Emergency department thoracotomy for penetrating injuries of the heart and great vessels: an appraisal of 283 consecutive cases from two urban trauma centers.

BACKGROUND: Historically, patients with penetrating cardiac injuries have enjoyed the best survival after emergency department thoracotomy (EDT), but further examination of these series reveals a preponderance of cardiac stab wound (SW) survivors with only sporadic cardiac gunshot wound (GSW) survivors. Our primary study objective was to determine which patients requiring EDT for penetrating cardiac or great vessel (CGV) injury are salvageable. METHODS: All patients who underwent EDT for penetrating CGV injuries in two urban, level I trauma centers during 2000 to 2007 were retrospectively reviewed. Demographics, injury (mechanism, anatomic injury), prehospital care, and physiology (signs of life [SOL], vital signs, and cardiac rhythm) were analyzed with respect to hospital survival. RESULTS: The study population (n = 283) comprised young (mean age, 27.1 years +/- 10.1 years) men (96.1%) injured by gunshot (GSW, 88.3%) or SWs (11.7%). Patients were compared by injury mechanism and number of CGV wounds with respect to survival (SW, 24.2%; GSW, 2.8%; p < 0.001; single, 9.5%; multiple, 1.4%; p = 0.003). Three predictors-injury mechanism, ED SOL, and number of CGV wounds-were then analyzed alone and in combination with respect to hospital survival. Only one patient (0.8%) with multiple CGV GSW survived EDT. CONCLUSION: When the cumulative impact of penetrating injury mechanism, ED SOL, and number of CGV wounds was analyzed together, we established that those sustaining multiple CGV GSWs (regardless of ED SOL) were nearly unsalvageable. These results indicate that when multiple CGV GSWs are encountered after EDT, further resuscitative efforts may be terminated without limiting the opportunity for survival.

Two partially embedded rings resulting in chronic erosion of a finger.

Embedded rings in the fingers may cause neurovascular, tendinous, or bony injury. These are very rare injuries usually found in patients with mental illness. To minimize the potentially serious complications, mentally-challenged individuals should have tight rings removed. We present a case of a 41-year-old gentleman with schizophrenia who had two partially embedded rings on his left index finger but consistently refused to have the rings removed. Following appointment of a guardian, the patient was returned for surgery to remove the rings. He recovered without further sequelae.