Identification of major hemorrhage in trauma patients in the prehospital setting: diagnostic accuracy and impact on outcome.

Background: Hemorrhage is the most common cause of potentially preventable death after injury. Early identification of patients with major hemorrhage (MH) is important as treatments are time-critical. However, diagnosis can be difficult, even for expert clinicians. This study aimed to determine how accurate clinicians are at identifying patients with MH in the prehospital setting. A second aim was to analyze factors associated with missed and overdiagnosis of MH, and the impact on mortality. Methods: Retrospective evaluation of consecutive adult (≥16 years) patients injured in 2019-2020, assessed by expert trauma clinicians in a mature prehospital trauma system, and admitted to a major trauma center (MTC). Clinicians decided to activate the major hemorrhage protocol (MHPA) or not. This decision was compared with whether patients had MH in hospital, defined as the critical admission threshold (CAT+): administration of ≥3 U of red blood cells during any 60-minute period within 24 hours of injury. Multivariate logistical regression analyses were used to analyze factors associated with diagnostic accuracy and mortality. Results: Of the 947 patients included in this study, 138 (14.6%) had MH. MH was correctly diagnosed in 97 of 138 patients (sensitivity 70%) and correctly excluded in 764 of 809 patients (specificity 94%). Factors associated with missed diagnosis were penetrating mechanism (OR 2.4, 95% CI 1.2 to 4.7) and major abdominal injury (OR 4.0; 95% CI 1.7 to 8.7). Factors associated with overdiagnosis were hypotension (OR 0.99; 95% CI 0.98 to 0.99), polytrauma (OR 1.3, 95% CI 1.1 to 1.6), and diagnostic uncertainty (OR 3.7, 95% CI 1.8 to 7.3). When MH was missed in the prehospital setting, the risk of mortality increased threefold, despite being admitted to an MTC. Conclusion: Clinical assessment has only a moderate ability to identify MH in the prehospital setting. A missed diagnosis of MH increased the odds of mortality threefold. Understanding the limitations of clinical assessment and developing solutions to aid identification of MH are warranted. Level of evidence: Level III-Retrospective study with up to two negative criteria. Study type: Original research; diagnostic accuracy study.

Updating and recalibrating causal probabilistic models on a new target population.

OBJECTIVE: Very often the performance of a Bayesian Network (BN) is affected when applied to a new target population. This is mainly because of differences in population characteristics. External validation of the model performance on different populations is a standard approach to test model's generalisability. However, a good predictive performance is not enough to show that the model represents the unique population characteristics and can be adopted in the new environment. METHODS: In this paper, we present a methodology for updating and recalibrating developed BN models - both their structure and parameters - to better account for the characteristics of the target population. Attention has been given on incorporating expert knowledge and recalibrating latent variables, which are usually omitted from data-driven models. RESULTS: The method is successfully applied to a clinical case study about the prediction of trauma-induced coagulopathy, where a BN has already been developed for civilian trauma patients and now it is recalibrated on combat casualties. CONCLUSION: The methodology proposed in this study is important for developing credible models that can demonstrate a good predictive performance when applied to a target population. Another advantage of the proposed methodology is that it is not limited to data-driven techniques and shows how expert knowledge can also be used when updating and recalibrating the model.

Understanding pre-hospital blood transfusion decision-making for injured patients: an interview study.

BACKGROUND: Blood transfusion for bleeding trauma patients is a promising pre-hospital intervention with potential to improve outcomes. However, it is not yet clear which patients may benefit from pre-hospital transfusions. The aim of this study was to enhance our understanding of how experienced pre-hospital clinicians make decisions regarding patient blood loss and the need for transfusion, and explore the factors that influence clinical decision-making. METHODS: Pre-hospital physicians, from two air ambulance sites in the south of England, were interviewed between December 2018 and January 2019. Participants were involved in teaching or publishing on the management of bleeding trauma patients and had at least 5 years of continuous and contemporary practice at consultant level. Interviews were semi-structured and explored how decisions were made and what made decisions difficult. A qualitative description approach was used with inductive thematic analysis to identify themes and subthemes related to blood transfusion decision-making in trauma. RESULTS: Ten pre-hospital physicians were interviewed and three themes were identified: recognition-primed analysis, uncertainty and imperfect decision analysis. The first theme describes how participants make decisions using selected cues, incorporating their experience and are influenced by external rules and group expectations. What made decisions difficult for the participants was encapsulated in the uncertainty theme. Uncertainty emerged regarding the patient's true underlying physiological state and the treatment effect of blood transfusion. The last theme focuses on the issues with decision-making itself. Participants demonstrated lapses in decision awareness, often incomplete decision evaluation and described challenges to effective learning due to incomplete patient outcome information. CONCLUSION: Pre-hospital clinicians make decisions about bleeding and transfusion which are recognition-primed and incorporate significant uncertainty. Decisions are influenced by experience and are subject to bias. Improved understanding of the decision-making processes provides a theoretical perspective of how decisions might be supported in the future.

Comprehensive assessment of the management of acute cholecystitis in Scotland: population-wide cohort study.

BACKGROUND: Acute cholecystitis is one of the most common diagnoses presenting to emergency general surgery and is managed either operatively or conservatively. However, operative rates vary widely across the world. This real-world population analysis aimed to describe the current clinical management and outcomes of patients with acute cholecystitis across Scotland, UK. METHODS: This was a national cohort study using data obtained from Information Services Division, Scotland. All adult patients with the admission diagnostic code for acute cholecystitis were included. Data were used to identify all patients admitted to Scottish hospitals between 1997 and 2019 and outcomes tracked for inpatients or after discharge through the unique patient identifier. This was linked to death data, including date of death. RESULTS: A total of 47 558 patients were diagnosed with 58 824 episodes of acute cholecystitis (with 27.2 per cent of patients experiencing more than one episode) in 46 Scottish hospitals. Median age was 58 years (interquartile range (i.q.r.) 43-71), 64.4 per cent were female, and most (76.1 per cent) had no comorbidities. A total of 28 741 (60.4 per cent) patients had an operative intervention during the index admission. Patients who had an operation during their index admission had a lower risk of 90-day mortality compared with non-operative management (OR 0.62, 95% c.i. 0.55-0.70). CONCLUSION: In this study, 60 per cent of patients had an index cholecystectomy. Patients who underwent surgery had a better survival rate compared with those managed conservatively, further advocating for an operative approach in this cohort.

Methods used to evaluate usability of mobile clinical decision support systems for healthcare emergencies: a systematic review and qualitative synthesis.

Objective: The aim of this study was to determine the methods and metrics used to evaluate the usability of mobile application Clinical Decision Support Systems (CDSSs) used in healthcare emergencies. Secondary aims were to describe the characteristics and usability of evaluated CDSSs. Materials and Methods: A systematic literature review was conducted using Pubmed/Medline, Embase, Scopus, and IEEE Xplore databases. Quantitative data were descriptively analyzed, and qualitative data were described and synthesized using inductive thematic analysis. Results: Twenty-three studies were included in the analysis. The usability metrics most frequently evaluated were efficiency and usefulness, followed by user errors, satisfaction, learnability, effectiveness, and memorability. Methods used to assess usability included questionnaires in 20 (87%) studies, user trials in 17 (74%), interviews in 6 (26%), and heuristic evaluations in 3 (13%). Most CDSS inputs consisted of manual input (18, 78%) rather than automatic input (2, 9%). Most CDSS outputs comprised a recommendation (18, 78%), with a minority advising a specific treatment (6, 26%), or a score, risk level or likelihood of diagnosis (6, 26%). Interviews and heuristic evaluations identified more usability-related barriers and facilitators to adoption than did questionnaires and user testing studies. Discussion: A wide range of metrics and methods are used to evaluate the usability of mobile CDSS in medical emergencies. Input of information into CDSS was predominantly manual, impeding usability. Studies employing both qualitative and quantitative methods to evaluate usability yielded more thorough results. Conclusion: When planning CDSS projects, developers should consider multiple methods to comprehensively evaluate usability.

Sonorheometry versus rotational thromboelastometry in trauma: a comparison of diagnostic and prognostic performance.

BACKGROUND: Rotational thromboelastometry (ROTEM) is used to rapidly identify trauma-induced coagulopathy (TIC) and direct targeted interventions in hemorrhaging trauma patients. A novel technology, Quantra System (HemoSonics), utilizes sonic estimation of elasticity via resonance sonorheometry, avoids mechanical clot interference, and may increase diagnostic accuracy, but there are limited data on bleeding in major trauma patients. OBJECTIVES: To compare the performance of Quantra with that of ROTEM for rapid diagnosis of TIC and prediction of transfusion requirements and mortality. METHODS: Samples were collected from adult trauma patients enrolled in a perpetual cohort study upon admission to a single level 1 trauma center between 2020 and 2021. Samples were analyzed using Quantra, ROTEM, multiple electrode aggregometry, and conventional coagulation assays. RESULTS: Samples from 209 patients were analyzed. Correlations were strong between Quantra and ROTEM parameters (for all, p < .001): clot stiffness (CS) and tissue factor-activated ROTEM (EXTEM) clot amplitude at 5 minutes (A5) (r = 0.90); fibrinogen contribution to CS and tissue factor-activated ROTEM with cytochalasin D (FIBTEM) A5 (r = 0.85); and platelet contribution to CS and EXTEM-FIBTEM A5 (r = 0.73). Although CS showed higher discrimination than EXTEM A5 in detecting TIC (international normalized ratio, >1.2; area under the receiver operating characteristic curve, 0.83 vs 0.79; p = .038), the ability of fibrinogen contribution to CS to detect hypofibrinogenemia (a fibrinogen level of <2g/L) was good but lower than that of FIBTEM A5 (area under the receiver operating characteristic curve, 0.79 vs 0.84; p = .027). There was no difference between Quantra and ROTEM in detecting a platelet count of <150 × 109/L, predicting rapid transfusion or mortality at 6 hours. CONCLUSION: Quantra and ROTEM have similar diagnostic performances in evaluating TIC and predicting clinically relevant outcomes. Larger studies are required to determine the utility of Quantra for goal-directed treatment of TIC.

Diagnostic accuracy of clinical examination to identify life- and limb-threatening injuries in trauma patients.

BACKGROUND: Timely and accurate identification of life- and limb-threatening injuries (LLTIs) is a fundamental objective of trauma care that directly informs triage and treatment decisions. However, the diagnostic accuracy of clinical examination to detect LLTIs is largely unknown, due to the risk of contamination from in-hospital diagnostics in existing studies. Our aim was to assess the diagnostic accuracy of initial clinical examination for detecting life- and limb-threatening injuries (LLTIs). Secondary aims were to identify factors associated with missed injury and overdiagnosis, and determine the impact of clinician uncertainty on diagnostic accuracy. METHODS: Retrospective diagnostic accuracy study of consecutive adult (≥ 16 years) patients examined at the scene of injury by experienced trauma clinicians, and admitted to a Major Trauma Center between 01/01/2019 and 31/12/2020. Diagnoses of LLTIs made on contemporaneous clinical records were compared to hospital coded diagnoses. Diagnostic performance measures were calculated overall, and based on clinician uncertainty. Multivariate logistic regression analyses identified factors affecting missed injury and overdiagnosis. RESULTS: Among 947 trauma patients, 821 were male (86.7%), median age was 31 years (range 16-89), 569 suffered blunt mechanisms (60.1%), and 522 (55.1%) sustained LLTIs. Overall, clinical examination had a moderate ability to detect LLTIs, which varied by body region: head (sensitivity 69.7%, positive predictive value (PPV) 59.1%), chest (sensitivity 58.7%, PPV 53.3%), abdomen (sensitivity 51.9%, PPV 30.7%), pelvis (sensitivity 23.5%, PPV 50.0%), and long bone fracture (sensitivity 69.9%, PPV 74.3%). Clinical examination poorly detected life-threatening thoracic (sensitivity 48.1%, PPV 13.0%) and abdominal (sensitivity 43.6%, PPV 20.0%) bleeding. Missed injury was more common in patients with polytrauma (OR 1.83, 95% CI 1.62-2.07) or shock (systolic blood pressure OR 0.993, 95% CI 0.988-0.998). Overdiagnosis was more common in shock (OR 0.991, 95% CI 0.986-0.995) or when clinicians were uncertain (OR 6.42, 95% CI 4.63-8.99). Uncertainty improved sensitivity but reduced PPV, impeding diagnostic precision. CONCLUSIONS: Clinical examination performed by experienced trauma clinicians has only a moderate ability to detect LLTIs. Clinicians must appreciate the limitations of clinical examination, and the impact of uncertainty, when making clinical decisions in trauma. This study provides impetus for diagnostic adjuncts and decision support systems in trauma.

Emergency general surgery: impact of distance and rurality on mortality.

BACKGROUND: There is debate about whether the distance from hospital, or rurality, impacts outcomes in patients admitted under emergency general surgery (EGS). The aim of this study was to determine whether distance from hospital, or rurality, affects the mortality of emergency surgical patients admitted in Scotland. METHODS: This was a retrospective population-level cohort study, including all EGS patients in Scotland aged 16 years or older admitted between 1998 and 2018. A multiple logistic regression model was created with inpatient mortality as the dependent variable, and distance from hospital (in quartiles) as the independent variable of interest, adjusting for age, sex, co-morbidity, deprivation, admission origin, diagnosis category, operative category, and year of admission. A second multiple logistic regression model was created with a six-fold Scottish Urban Rural Classification (SURC) as the independent variable of interest. Subgroup analyses evaluated patients who required operations, emergency laparotomy, and inter-hospital transfer. RESULTS: Data included 1 572 196 EGS admissions. Those living in the farthest distance quartile from hospital had lower odds of mortality than those in the closest quartile (OR 0.829, 95 per cent c.i. 0.798 to 0.861). Patients from the most rural areas (SURC 6) had higher odds of survival than those from the most urban (SURC 1) areas (OR 0.800, 95 per cent c.i. 0.755 to 0.848). Subgroup analysis showed that these effects were not observed for patients who required emergency laparotomy or transfer. CONCLUSION: EGS patients who live some distance from a hospital, or in rural areas, have lower odds of mortality, after adjusting for multiple covariates. Rural and distant patients undergoing emergency laparotomy have no survival advantage, and transferred patients have higher mortality.

Emergency general surgery: Impact of hospital and surgeon admission case volume on mortality.

BACKGROUND: Emergency general surgery (EGS) is a high-volume and high-risk surgical service. Interhospital variation in EGS outcomes exists, but there is disagreement in the literature as to whether hospital admission volume affects in-hospital mortality. Scotland collects high-quality data on all admitted patients, whether managed operatively or nonoperatively. Our aim was to determine the relationship between hospital admission volume and in-hospital mortality of EGS patients in Scotland. Second, to investigate whether surgeon admission volume affects mortality. METHODS: This national population-level cohort study included EGS patients aged 16 years and older, who were admitted to a Scottish hospital between 2014 and 2018 (inclusive). A logistic regression model was created, with in-hospital mortality as the dependent variable, and admission volume of hospital per year as a continuous covariate of interest, adjusted for age, sex, comorbidity, deprivation, surgeon admission volume, surgeon operative rate, transfer status, diagnosis, and operation category. RESULTS: There were 376,076 admissions to 25 hospitals, which met our inclusion criteria. The EGS hospital admission rate per year had no effect on in-hospital mortality (odds ratio [OR], 1.000; 95% confidence interval [CI], 1.000-1.000). Higher average surgeon monthly admission volume increased the odds of in-hospital mortality (>35 admissions: OR, 1.139; 95% CI, 1.038-1.250; 25-35 admissions: OR, 1.091; 95% CI, 1.004-1.185; <25 admissions was the referent). CONCLUSION: In Scotland, in contrast to other settings, EGS hospital admission volume did not influence in-hospital mortality. The finding of an association between individual surgeons' case volume and in-hospital mortality warrants further investigation. LEVEL OF EVIDENCE: Care management, Level IV.

Current and Projected Financial Burden of Emergency General Surgery for Adults in Scotland's Single Payer Healthcare System: A Cost Analysis of Hospital Admissions.

OBJECTIVE: To calculate the current and projected financial burden of EGS hospital admissions in a single-payer healthcare system. SUMMARY OF BACKGROUND DATA: EGS is an important acute care service, which demands significant healthcare resources. EGS admissions and associated costs have increased over time, associated with an aging demographic. The National Health Service is the sole provider of emergency care in Scotland. METHODS: Principal, high and low Scottish population projections were obtained for 2016 until 2041. EGS admission data were projected using an ordinary least squares linear regression model. An exponential function, fitted to historical length of hospital stay (LOS) data, was used to project future LOS. Historical hospital unit cost per bed day was projected using a linear regression model. EGS cost was calculated to 2041 by multiplying annual projections of population, admission rates, LOS, and cost per bed day. RESULTS: The adult (age >15) Scottish population is projected to increase from 4.5 million to 4.8 million between 2016 and 2041. During this time, EGS admissions are expected to increase from 83,132 to 101,090 per year, cost per bed day from £786 to £1534, and overall EGS cost from £187.3 million to £202.5 million. CONCLUSIONS: The future financial burden of EGS in Scotland is projected to increase moderately between 2016 and 2041. This is in sharp contrast to previous studies from settings such as the United States. However, if no further reductions in LOS or cost per bed day are made, especially for elderly patients, the cost of EGS will rise dramatically.

Impact of deprivation and comorbidity on outcomes in emergency general surgery: an epidemiological study.

BACKGROUND: The impact of socioeconomic deprivation and comorbidities on the outcome of patients who require emergency general surgery (EGS) admission is poorly understood. The aim of this study was to examine the effect of deprivation and comorbidity on mortality, discharge destination and length of hospital stay (LOS) in patients undergoing EGS in Scotland. METHODS: Prospectively collected data from all Scottish adult patients (aged >15 years) requiring EGS admitted between 1997 and 2016 were obtained from the Scottish Government. Data included age, sex, Scottish Index of Multiple Deprivation (SIMD), 5-year Charlson Comorbidity Index (CCI), whether an operation took place and outcomes including mortality, discharge destination and LOS. Logistic regression was used for the analysis of mortality and discharge destination and Poisson regression was used for LOS. RESULTS: 1 477 810 EGS admissions were analyzed. 16.2% were in the most deprived SIMD decile and 5.6% in the least deprived SIMD decile. 75.6% had no comorbidity, 20.3% had mild comorbidity, 2.5% had moderate comorbidity and 1.6% had severe comorbidity. 78.6% were discharged directly home. Inpatient, 30-day, 90-day and 1-year crude mortality was 1.7%, 3.7%, 7.2% and 12.4%, respectively. Logistic regression showed that severe comorbidity was associated with not being discharged directly to home (OR 0.38, 95% CI 0.37 to 0.39) and higher inpatient mortality (OR 13.74, 95% CI 13.09 to 14.42). Compared with the most affluent population, the most deprived population were less likely to be discharged directly to home (OR 0.97, 95% CI 0.95 to 0.99) and had higher inpatient mortality (OR 1.36, 95% CI 1.8 to 1.46). Poisson analysis showed that severe comorbidity (OR 1.69, 95% CI 1.68 to 1.69) and socioeconomic deprivation (OR 1.11, 95% CI 1.11 to 1.12) were associated with longer LOS. DISCUSSION: Increased levels of comorbidity and, to a lesser extent, socioeconomic deprivation are key drivers of mortality, discharge destination and LOS following admission to an EGS service. LEVEL OF EVIDENCE: III (prospective/retrospective with up to two negative criteria). STUDY TYPE: Epidemiological/prognostic.

Thrombolysis for acute graft occlusion during elective endovascular aortic aneurysm repair.

A 65-year-old man developed acute arterial thrombosis with stent graft occlusion, during elective endovascular aneurysm repair, with bilateral acute lower limb ischaemia. We describe successful endovascular and pharmacological management using a combination of mechanical disruption of the thrombus (using the access sheaths) followed by intra-arterial thrombolysis (Actilyse) infusion. Within 4-h the endograft had completely re-canalized. The patient made an uncomplicated recovery and was discharged on the second post-operative day.

The Changing Face of Emergency General Surgery: A 20-year Analysis of Secular Trends in Demographics, Diagnoses, Operations, and Outcomes.

OBJECTIVE: The aim of the study was to evaluate secular trends in the epidemiology of emergency general surgery (EGS), by analyzing changes in demographics, diagnoses, operations, and outcomes between 1997 and 2016. SUMMARY BACKGROUND DATA: The provision and delivery of EGS services is a globally and regionally important issue. The impact of changing demographics and surgical disease incidence on EGS services is not well understood. METHODS: Data from all EGS hospital episodes of adults (aged >15) in Scotland between 1997 and 2016 were prospectively collected, including ICD-10 diagnostic codes and OPCS-4 procedure codes. The number and age- and sex-standardized rates per 100,000 population, per year, of the most common diagnoses and operations were calculated. We analyzed demographic changes over time using linear regression, and changes in characteristics, diagnoses, operations, and outcomes using Poisson analysis. RESULTS: Data included 1,484,116 EGS hospital episodes. The number and age- and sex-standardized rate, per 100,000 population, of EGS admissions have increased over time, whereas that of EGS operations have decreased over time. Male admissions were unchanged, but with fewer operations over time, whereas female admissions increased significantly over time with no change in the operation rate. Poisson analysis demonstrated secular trends in demographics, admissions, operations, and outcomes in depth. CONCLUSIONS: This 20-year epidemiological study of all EGS hospital episodes in Scotland has enhanced our understanding of secular trends of EGS, including demographics, diagnoses, operations, and outcomes. These data will help inform stakeholders in EGS service planning and delivery, as well as in surgical training, what has occurred in recent history.

Functional inclusivity of trauma networks: a pilot study of the North West London Trauma Network.

BACKGROUND: Metrics exist to assess and validate trauma system outcomes; however, these are clinically focused and do not evaluate the appropriateness of admission patterns, relative to geography and triage category. We propose the term "functional inclusivity", defined as the number and proportion of triage-negative, and/or nonseverely injured patients, who were injured in proximity to a level II/III trauma center but admitted to a level I facility. The aim of this study was to evaluate this metric in the North West London Trauma Network. METHODS: Retrospective, geospatial, observational analysis of registry data from the North West London Trauma Network. We included all adult (≥16 years) patients transported to the level I trauma center at St. Mary's Hospital between 1/1/13-31/12/16. Incident location data were geocoded into longitude/latitude, and drive times were calculated from incident location to each hospital in London's Trauma System, using Google Maps. RESULTS: Of 2051 patients, 907 (44%) were severely injured (injury severity score [ISS] ≥15), and 1144 (56%) were nonseverely injured (ISS 1-15). Seven hundred ninety five of the 1144 nonseverely injured patients (69%) were injured in proximity to a level II/III but taken to the level I facility. A total of 488 (24%) patients were triage-negative, and 229 (47%) of these were injured in proximity to a level II/III, but taken to the level I trauma center. CONCLUSIONS: This study has demonstrated the concept of functional inclusivity in characterizing trauma system performance. Further work is required to establish what constitutes an acceptable level of functional inclusivity and what the denominator should be, as well as validating and further evaluating the concept of functional inclusivity.

Emergency general surgery in the United Kingdom: A lot of general, not many emergencies, and not much surgery.

BACKGROUND: The provision of emergency general surgery services is a global issue, with important implications for patients and workforce. The aim of this study was to analyze the characteristics of emergency general surgical patients in the United Kingdom, with reference to diagnostic case mix, operative workload, comorbidity, discharge destination, and outcomes, to facilitate comparisons and future service development. METHODS: This is a cross-sectional population-based study based in the National Health Service in Scotland, one of the home nations of the United Kingdom. All patients aged 16 or older admitted under the care of a general surgeon, as an emergency, to a National Health Service hospital in Scotland, in 2016, were included. RESULTS: There were 81,446 emergency general surgery admissions by 66,498 patients. Median episode age was 53 years. There were more female patients than male (55% vs 45%, p < 0.0001). The most common diagnoses were nonspecific abdominal pain (20.2%), cholecystitis (7.2%), constipation (3.4%), pancreatitis (3.1%), diverticular disease (3.1%), and appendicitis (3.1%). Only 25% of patients had operations (n = 20,292). The most frequent procedures were appendicectomy (13.1%), endoscopy (11.3%), and drainage of skin lesions (9.7%). Diagnoses and operations differed with age. Overall median length of stay was 1 day. With a 6-month follow-up, patients older than 75 years had a 19.8% mortality rate. CONCLUSIONS: Emergency general surgery in the United Kingdom is a high-volume, diagnostically diverse, and low-operative volume specialty with high short-term mortality rate in elderly patients. Consideration should be given to alternative service delivery models, which make better use of surgeons' skills while also ensuring optimal care for patients who are increasingly elderly and have complex chronic health problems. LEVEL OF EVIDENCE: Epidemiologic study, level III.

Cannulated Lag Screw Fixation of Displaced Lateral Humeral Condyle Fractures Is Associated With Lower Rates of Open Reduction and Infection Than Pin Fixation.

BACKGROUND: Open reduction/internal fixation remains the most common way to surgically stabilize displaced pediatric lateral humeral condyle fractures, but closed reduction and internal fixation is being increasingly used. Our goal was to compare the clinical and functional results of treating displaced pediatric lateral humeral condylar fractures with traditional smooth or threaded pin fixation versus single cannulated screw fixation. METHODS: From 1998 through 2012, the lateral humeral condyle fractures of 48 patients were treated with pin fixation (22 patients, until 2006) or cannulated, partially threaded screw fixation (26 patients, from 2006 onward). In each, closed reduction with percutaneous fixation was attempted first, followed by open reduction if anatomic reduction was not achieved. For the pin and screw groups, preoperative maximum radiographic displacement averaged 8.4 mm (range, 3.8 to 18.4 mm) and 6.3 mm (range, 2.2 to 15.5 mm), respectively; follow-up averaged 4.3 months (range, 1.5 to 20 mo) and 10.3 months (range, 2 to 30 mo), respectively. We reviewed preoperative and postoperative images and all follow-up clinical examination findings; serially assessed initial displacement, Baumann and carrying angles, range of motion limitations, and clinical alignment; evaluated functional results via the system of Hardacre and colleagues; and investigated all complications. RESULTS: Open reduction was required in 73% (16/22) and 15% (4/26) of the pin and screw groups, respectively (P<0.001). All fractures were reduced to <1 mm postoperative displacement. Postoperative immobilization averaged 5.9 weeks (range, 4 to 11 wk) and 4.5 weeks (range, 3 to 8 wk) for the pin and screw groups, respectively. The only significant difference in complications was the infection rate: 5 (1 deep) in the pin group and none in the screw group (P<0.05). CONCLUSIONS: Closed reduction and percutaneous 4.5-mm lag screw fixation of displaced pediatric lateral humeral condyle fractures is safe and reliable, enabling a higher rate of closed reduction, significantly lower infection rate, and earlier mobilization than traditional pin fixation. LEVEL OF EVIDENCE: Level III-Therapeutic.

Sudden loss of ventilation through a double-lumen endotracheal tube requiring a surgical bronchotomy.

A left completion pneumonectomy for primary lung cancer (left lower lobectomy) was complicated by sudden loss of ability to ventilate the patient through the double-lumen endotracheal tube. The problem could not be overcome by the anesthesiologist. In the face of impending cardiorespiratory arrest, a single-lumen tube was introduced through an incision in the left main bronchus through to the right main bronchus. This life-saving maneuver safeguarded the airway and permitted a successful outcome to the operation.