Fracture related infection and sepsis in orthopedic trauma: A review.

Trauma is a leading cause of death in the United States for people under 45. Amongst trauma-related injuries, orthopedic injuries represent a significant component of trauma-related morbidity. In addition to the potential morbidity and mortality secondary to the specific traumatic injury or injuries sustained, sepsis is a significant cause of morbidity and mortality in trauma patients as well, and infection related to orthopedic trauma can be especially devastating. Therefore, infection prevention and early recognition of infections is crucial to lowering morbidity and mortality in trauma. Risk factors for fracture-related infection include obesity, tobacco use, open fracture, and need for flap coverage, as well as fracture of the tibia and the degree of contamination. Timely administration of prophylactic antibiotics for patients presenting with open fractures has been shown to decrease the risk of fracture-related infection, and in patients that do experience sepsis from an orthopedic injury, prompt source control is critical, which may include the removal of implanted hardware in infections that occur more than 6 weeks from operative fixation. Given that orthopedic injury constitutes a significant proportion of traumatic injuries, and will likely continue to increase in number in the future, surgeons caring for patients with orthopedic trauma must be able to promptly recognize and manage sepsis secondary to orthopedic injury.

Burnout in Trauma Surgeons During the COVID-19 Pandemic: a Long-standing Problem Worsens.

Purpose of Review: Physician burnout is well-described in the literature. We analyze the effects of the COVID-19 pandemic on burnout in trauma and acute care surgeons (TACS). Recent Findings: Along with other healthcare workers and trainees, TACS faced unprecedented clinical, personal, and professional challenges in treating a novel pathogen and were uniquely affected due to their skillset as surgeons, intensivists, and leaders. The pandemic and its consequences have increased burnout and are suspected to have worsened PTSD and moral injury among TACS. The healthcare system is just beginning to grapple with these problems. Summary: COVID-19 significantly added to the pre-existing burden of burnout among TACS. We offer prevention and mitigation strategies. Furthermore, to build upon the work done by individuals and organizations, we urge that national institutions address burnout from a regulatory standpoint.

Post-Trauma Discharge Instructions: Are We Dropping the Ball?

INTRODUCTION: Complex follow-up plans for polytrauma patients are compiled at the end of hospitalization into discharge instructions. We sought to identify how often patient discharge instructions incorrectly communicated specialist recommendations. We hypothesized that patients with more complex hospitalizations would have more discharge instruction errors (DI-errors). METHODS: We reviewed adult trauma inpatients (March 2017-March 2018), excluding those who left against medical advice or were expected to follow up outside our system. Complex hospitalizations were represented using injury severity (ISS), hospital length of stay (LOS), intensive care unit length of stay (iLOS), and number of consultants (NC). We recorded the type of consultant (surgical or nonsurgical), and consultant recommendations for follow-up. DI-errors were defined as either follow-up necessary but omitted or follow-up not necessary yet present on the instructions. Patients with DI-errors were compared to patients without DI-errors. Groups were compared using Wilcoxon rank sum or chi-square (alpha <.05). RESULTS: We included 392 patients (median age 45 [IQR 26-58], ISS 14 [10-21], LOS 6 [3-11]). 55 patients (14%) had DI-errors. Factors associated with DI-errors included the total number of consultants and use of nonsurgical consultants. ISS, LOS, iLOS, were not associated with DI-errors. CONCLUSION: Common measures of admission complexity were not associated with DI-errors, although the number and type of consultants were associated with DI-errors. Non-surgical specialty consultant recommendations were more likely to be omitted. It is crucial for patients to receive accurate discharge instructions, and systematic processes are needed to improve communication with the patients at discharge.

Provision of Defect-Free Care: Implementation Science in Surgical Patient Safety.

Implementation science is the study of the translation of evidence-based practices to real-world clinical environments. Implementation is measured with specific outcomes including acceptability, adoption, appropriateness, feasibility, fidelity, penetration, sustainability, and implementation cost. There are defined frameworks and models that outline implementation strategies and assist researchers in identifying barriers and facilitators to achieve implementation and conduct implementation research using methods such as qualitative analysis, parallel group, pre-/postintervention, interrupted time series, and cluster or stepped-wedge randomized trials. Deimplementation is the study of how to remove ineffective or unnecessary practices from the clinical setting and is an equally important component of implementation science.

A rare case of retained sabot after close-range shotgun injury.

BACKGROUND: Shotgun injuries are a relatively uncommon type of trauma, and therefore may present a challenge in management for trauma surgeons. This is particularly true in the case of surgeons unfamiliar with the unique characteristics of shotgun wounds and the mechanics of shotguns. In many cases, the shot pellets are the primary source of injury. However, a broad understanding of shotgun mechanics is important in recognizing alternative presentations. This article details a case of sabot (a stabilization device used with certain projectiles) retention after a close-range shotgun injury, reviews underlying shotgun mechanics, and discusses strategies for the detection and mitigation of these injuries. The aim of this case report is to increase awareness of and reduce the potential morbidity of close-range shotgun injuries. CASE PRESENTATION: A middle-aged female presented to the Emergency Department with wounds to her right hip and flank after suffering a shotgun injury. A contrast computed tomography scan demonstrated no evidence of hollow viscous or vascular injury, but was otherwise severely limited by scatter artifact from the numerous embedded pellets. The patient was admitted for wound care and discharged 2 days later with a clean wound bed and no evidence of tissue necrosis. Six days after injury, she reported an "unusual" smell associated with severe pain in her right hip wound. She was evaluated in clinic where examination revealed a retained foreign body, identified to be a shotgun shell sabot, which was removed in clinic. She presented again several days before scheduled follow-up with a persistent foul smell from her wound and was noted to have necrotic tissue at the base and margins of the wound that required hospital readmission for operative debridement and closure with negative pressure wound therapy. The patient had an uncomplicated recovery after surgical debridement. CONCLUSIONS: Although shotgun sabot penetration and retention are rare, they are associated with significant morbidity. Sabot penetration should be considered if injury narrative, physical examination, or radiographic characteristics indicate a distance from shotgun to patient of less than 2 m. A high degree of suspicion is indicated at less than 1 m.

Traffic stops do not prevent traffic deaths.

OBJECTIVES: Amid growing calls for police reform, it is imperative to reassess whether police actions designed to improve public safety are associated with injury prevention. This study aims to examine the relationship between the police traffic stops (PTSs) and motor vehicle crash (MVC) deaths at the state level. We hypothesize that increased PTSs would be associated with reduced MVC deaths. METHODS: We retrospectively analyzed PTSs and MVC deaths at the state level from 2004 to 2016. Police traffic stops data were from 33 state patrols from the Stanford Open Policing Project. The MVC deaths data were collected from the National Highway Traffic Safety Administration. The vehicle miles traveled data were from the Federal Highway Administration Office of Highway Policy Information. All data were adjusted per 100 million vehicle miles traveled (100MVMT) and were analyzed as state-level time series cross-sectional data. The dependent variable was MVC deaths per 100MVMT, and the independent variable was number of PTSs per 100MVMT. We performed panel data analysis accounting for random and fixed state effects and changes over time. RESULTS: Thirty-three state patrols with 235 combined years were analyzed, with a total of 161,153,248 PTSs. The PTS rate varied by state and year. Nebraska had the highest PTS rate (3,637/100MVMT in 2004), while Arizona had the lowest (0.17/100MVMT in 2009). Motor vehicle crash deaths varied by state and year, with the highest death rate occurring in South Carolina in 2005 (2.2/100MVMT) and the lowest in Rhode Island in 2015 (0.57/100MVMT). After accounting for year and state-level variability, no association was found between PTS and the MVC death rates. CONCLUSION: State patrol traffic stops are not associated with reduced MVC deaths. Strategies to reduce death from MVC should consider alternative strategies, such as motor vehicle modifications, community-based safety initiatives, improved access to health care, or prioritizing trauma system. LEVEL OF EVIDENCE: Retrospective epidemiological study, level IV.

Defining Outcomes after Colon Resection in Blunt Trauma: Is Diversion or Primary Anastomosis More Favorable?

Previous literature demonstrates the safety of primary repair in penetrating colon injury requiring resection, without the creation of a diverting ostomy. It is unknown whether a similar approach can be applied to patients with blunt colon injury. The aim of this study was to measure outcomes in patients who underwent colon resection with and without ostomy creation after blunt trauma injury to help direct future management. Using the National Trauma Data Bank for years 2008 to 2012, we identified patients with blunt trauma mechanisms who underwent colectomy. Patients were stratified into two groups: primary anastomosis and diversion with ostomy. Primary outcome was inpatient mortality. Secondary outcomes included length of stay and perioperative complications. All risk-adjusted analyses were performed using logistic regression with consideration of interactions. Five hundred eighty-one observations met our inclusion criteria. Baseline characteristics between the two groups were similar with the exception of age (37.3 vs 42.2 years, P < 0.001) and admission Glasgow coma score (13.2 vs 12.1, P = 0.002). Risk-adjusted mortality for the two groups was not statistically significant (2.3% vs 3.0%, P = 0.63); however, patients with primary anastomosis had a shorter length of stay (18.2 vs 28.1, P < 0.001), fewer days in the intensive care unit (10.9 vs 16.2, P < 0.001), and fewer ventilator days (10.5 vs 14.6, P = 0.01). In patients requiring colon resection after blunt trauma, mortality is not different for those who receive a primary anastomosis versus ostomy. Patients without diversion had shorter hospital stays, intensive care unit days, and ventilator days. These data support that primary anastomosis is safe in this patient population.

Suspected adrenal insufficiency in critically ill burned patients: etomidate-induced or critical illness-related corticosteroid insufficiency?-A review of the literature.

Adrenal insufficiency (AI), whether etomidate-induced or secondary to critical illness-related corticosteroid insufficiency (CIRCI), is a common and under appreciated problem in the intensive care unit intensive care unit (ICU). However, AI is often difficult to identify and diagnose in the critically ill. The pathophysiology and ideal management of etomidate-induced AI and CIRCI, especially in burn patients, is unknown. Many studies, however, have examined the prevalence of and risk factors for developing AI in critically ill populations as well as the effect of AI on morbidity and mortality. Observing a seemingly increased number of patients with suspected AI in our burn ICU, we sought to evaluate and summarize the current literature relating to adrenal insufficiency in the critically ill. We performed an electronic literature search on the PubMed and Ovid Medline databases using the key words "etomidate," "adrenal insufficiency," "CIRCI," and "burn injury." Relevant studies from the current burn and ICU era were selected to be included in this review of the literature. Among the critically ill, burn patients are at increased risk for developing adrenal insufficiency and the risk is greatest for elderly patients with large burns and inhalation injury. Both CIRCI and etomidate-induced AI are associated with high morbidity and mortality, therefore avoiding preventable causes of AI, such as choosing alternatives to etomidate for rapid sequence intubation (RSI) in the severely burn injured patient should be encouraged. Further research is indicated to investigate the biological relationship between AI and associated morbidity and mortality, whether etomidate-induced or secondary to critical illness; as well as how best to identify and diagnose patients with suspected adrenal insufficiency in the burn intensive care unit.