Air Medical Blood Transfusion as a Trigger of Massive Transfusion Protocol.

Air medical services can improve access to blood products at the point of injury. Studies have shown that early activation of mass transfusion protocols (MTPs) can improve the survival of trauma patients by up to 25%. There are several scoring systems to guide early activation, but the use of a single criterion has been elusive. Our study sought to determine if air medical administration of blood products was a risk factor for massive transfusion activation and utilization of prehospital vital signs for calculation of the shock index. In our retrospective study, we evaluated adult trauma patients transfused by helicopter emergency medical services (HEMS) and as a control all patients in our institution receiving the MTP. Our study found HEMS blood transfusion was not a reliable trigger for MTP, although the sample size may have limited our findings. We found that HEMS care resulted in an overall reduction in the volume of transfusion and an improvement in hemodynamic parameters upon trauma center arrival. HEMS transfusion and a higher rate of tranexamic acid administration may have contributed to these findings. Of note, the assessment of blood consumption score and shock index were nonspecific in the study populations.

Length of Stay and ICU Stay Are Increased With Repair of Traumatic Superior Mesenteric Vein Injury.

BACKGROUND: Traumatic superior mesenteric vein (SMV) injury is rare, and the ideal treatment is controversial. We compared the outcomes of ligation versus repair of SMV injury using the National Trauma Databank. MATERIALS AND METHODS: All adult patients who suffered from traumatic SMV injury were identified from the National Trauma Databank (2002-2014) by International Classification of Diseases (ICD) codes. Patients were stratified by treatment modality into no repair, ligation, and surgical repair using ICD procedure codes. Patient characteristics were compared between ligation and surgical repair groups using the Kruskal-Wallis test for continuous variables and Fisher's exact test for categorical variables. Outcomes, including mortality, rates of small bowel resection, length of stay (LOS), and ventilation days were compared using logistic regression. RESULTS: Among 952 patients with SMV injury, 192 patients (20.2%) had ligation, 428 (50%) underwent surgical repair, and 332 patients (34.9%) had neither repair nor ligation of the SMV. Overall hospital mortality was 32%. Age, gender, injury severity score (ISS), and Glasgow Coma Scale (GCS) were similar between groups that underwent ligation and surgical repair. Although the mortality rate (29.4% versus 36.5%, P = 0.20) and bowel resection rate (4% versus 3%, P = 0.12) were similar, patients who underwent repair had significantly longer hospital LOS (19.4 ± 24.8 versus15.2 ± 24.4 d, P < 0.001) and ICU LOS (13 ± 17.1 versus 9.3 ± 11.8 d, P = 0.02) compared to ligation. Similar results were observed in multivariable analysis when adjusted for race, associated vascular injuries, and other associated injuries. CONCLUSIONS: In patients with traumatic SMV injury, surgical repair does not appear to confer a significant survival advantage over ligation and can be associated with greater LOS and ICU LOS. Ligation may be an acceptable option for management of a traumatic SMV injury, especially when surgical repair cannot be performed, without compromising patient mortality or bowel resection rates.

Evaluating the Utilization of Prophylactic Inferior Vena Cava Filters in Trauma Patients.

BACKGROUND: The lack of evidence-based guidelines on the use of prophylactic inferior vena cava filters (IVCFs) in patients after trauma has led to variation of its application. We seek to understand the national trend of the use of prophylactic IVCF in trauma population. METHODS: A retrospective review of the National Trauma Databank (2002-2014) was performed to identify patients who received an IVCF after trauma. Those without a preexisting venous thromboembolism or discharge diagnosis of VTE were classified as receiving prophylactic IVCF. Multivariable logistic regression analysis was used to examine associations between the use of prophylactic IVCF and risk factors for VTE. P value ≤0.05 was considered statistically significant. RESULTS: Among the 2,189,994 patients evaluated, 41,155 (2%) received a prophylactic IVCF. The rate of overall IVCF placement (2.9% in 2002-2006 to 1.6% in 2014, P < 0.001) and prophylactic IVCF placement (2.5% in 2002-2006 to 1.2% in 2014, P < 0.001) decreased over the study period. In multivariable analysis, significant risk factors associated with the use of prophylactic IVCF were male gender (OR 1.2, 95% CI 1.1-1.2), African-American race (OR 1.2, 95% CI 1.1-1.2), injury severity score ≥ 24 (OR 4.4, 95% CI 4.2-4.5), Glasgow Coma Scale <8 (OR 1.4, 95% CI 1.4-1.5), spinal cord injury with paraplegia (OR 5.1, 95% CI 4.7-5.6), pelvic fracture (OR 2.9, 95% CI 2.7-3.0), long bone fracture (OR 1.3, 95% CI 1.3-1.4), and solid organ injury (OR 1.2, 95% CI 1.2-1.3) (P < 0.001). Patients who were treated at a level-II trauma center (OR 1.1, 95% CI 1.1-1.2, P < 0.001), at a facility with ≥200 beds (OR 1.3, 95% CI 1.2-1.4, P < 0.001), and those with medical insurance coverage (OR 1.4, 95% CI 1.6-1.8, P < 0.001) were also more likely to receive a prophylactic IVCF. CONCLUSIONS: The utilization of prophylactic IVCF in trauma patients has decreased over time between 2008 and 2014. Considerable variation exists in its use, which is not fully accounted for by the VTE rate. Further study is required to evaluate appropriate indications for placement of prophylactic IVCF in trauma patients.

A Mullerian Cyst Resected From the Posterior Mediastinum.

Differential diagnoses of mediastinal masses are often based on the anatomic locations. Traditionally the posterior mediastinum has been home to esophageal and neurogenic cysts, but a new entity has been found to be prevalent since its initial report in 2005: the Müllerian cyst. We present a 49-year-old with history of cough who was found to have such a mass. We will discuss the surgical outcome and the details of this interesting entity. The literature pertinent to this type of cyst will be evaluated. In all cases reported, the literature demonstrates that surgical removal results in uneventful follow-up with no evidence of malignancy or cyst recurrence.

Obturator Hernia, 'The Little Old Lady Hernia'.

Obturator hernia is a rare type of abdominal hernia that classically presents in elderly women. We report the case of 78-year-old woman with progressive vomiting, obstipation, and abdominal pain. Contrast-enhanced computed tomography showed a left-sided obturator hernia, which was confirmed and treated at laparotomy. Demographics, symptoms, imaging findings, and management of obturator hernias is reviewed.

Jejunal Carcinoid Tumors Presenting as Small Bowel Obstruction.

Carcinoid tumors are the most common form of gut neuroendocrine tumors, however, they rarely present with small bowel obstruction. We present a case of a 65-year-old woman without prior abdominal operations who presented with symptoms of small bowel obstruction. Computed tomography (CT) showed multiple air fluid levels and a transition point in the left mesentery with two soft tissue densities at the same level. The patient was taken to the operating room for surgical exploration, which showed two intramural masses in the mid and distal jejunum, which surgical pathology showed to be stage IIIB carcinoid tumor.

Distance of the internal central venous catheter tip from the right atrium is positively correlated with central venous thrombosis.

Central venous catheters (CVCs) are associated with occlusive, infectious, and thrombotic complications. The aim of this study was to determine if internal CVC tip position was correlated with subsequent complications. This was an institutional review board approved single-center retrospective review of 169 consecutive patients who underwent placement of 203 semipermanent CVCs. Using post-placement chest X-rays, a de novo scale of internal catheter tip position was developed. Major complications were recorded. A logistic regression analysis was used to determine if catheter tip position predicted subsequent complications. There were 78 men and 91 women with a mean age of 48 ± 11 years. There were 21 catheter tips placed in the subclavian/innominate veins, 32 in the upper superior vena cava, 113 in the atriocaval junction, and 37 in the right atrium. There were 83 complications occurring in 61 (36.1 %) patients, including sepsis in 40 (23.7 %), venous thrombosis in 18 (10.7 %), catheter occlusion in 16 (9.5 %), internal catheter repositioning in 6 (3.6 %), pneumothorax in 2 (1.2 %), and death in 1 (0.6 %). An internal catheter tip position peripheral to the atriocaval junction resulted in a catheter that was more likely to undergo internal repositioning (p < 0.001) and venous thrombosis (p < 0.001). Patients with femoral catheters were more likely to develop sepsis (45 %) than patients whose catheters were inserted through the upper extremity veins (18 %) (p < 0.01). In conclusion, to reduce catheter-associated morbidity and potentially mortality, the internal catheter tip should be positioned at the atriocaval junction or within the right atrium and femoral insertion sites should be avoided whenever possible.

Acquired post-traumatic aortic coarctation presenting as new-onset congestive heart failure: treatment with endovascular repair.

Acquired coarctation of the thoracic aorta is a rare phenomenon in adults. The etiology is often idiopathic, but severe stenosis can develop from prior surgery, blunt thoracic aortic injuries, or severe atherosclerotic/atheroembolic disease. Common symptomatic presentations include refractory upper extremity hypertension and new-onset congestive heart failure. We present the case of a 52-year-old man who developed acquired thoracic aortic coarctation 30 years after a blunt trauma and deceleration injuries to the aorta requiring open surgical aortic repair. He presented with poorly controlled hypertension and new-onset heart failure and was treated surgically with endovascular repair.

Delayed traumatic lung herniation.

There are very few lung herniation cases described in literature. We present a case of a delayed lung herniation. In our case, the initial imaging was negative but patient developed a herniated lung during his hospital stay.

Syncope and Cardiac Arrhythmias Caused by a Paratracheal Mass.

Background: Syncope is a common complaint in clinical practice. The etiologies and mechanisms can be multiple and complex. Syncope caused by a mediastinal mass compressing the vagus nerve is rare. Case Report: We report the case of a patient who presented to the emergency department experiencing recurrent syncope. Imaging revealed a large, calcified mass in the right paratracheal region. After intracranial lesions, cardiac arrhythmias, and orthostatic hypotension were excluded, we suspected that the syncope was related to vagus nerve compression. The patient underwent surgical resection of a mediastinal mass and had complete resolution of syncopal episodes after surgery. Conclusion: This case outcome suggests that recurrent syncope could be the first symptom of an intrathoracic mass.

Penetrating thoracic injury requiring emergency pneumonectomy supported with two ECMO runs: A testament to multidisciplinary critical care medicine.

Post-traumatic pneumonectomies are uncommon and, if necessary, carry significant mortality. The use of extracorporeal membrane oxygenation (ECMO) for lung injury in trauma patient has demonstrated efficacy with minimal bleeding complications. We report a case of a young man with a penetrating thoracic injury that required a pneumonectomy supported with two separate ECMO runs for pulmonary failure postoperatively.

Assessment of Facial Injury by "Slock" in Incarcerated Patients.

A "slock" is a padlock in a sock used as a weapon in correctional facilities to induce trauma. This assessment examined the prevalence, pattern, and degree of slock- and padlock-induced facial fractures. This quality assessment initiative was performed through retrospective analysis of 435 incarcerated patients treated surgically for facial fractures at an academic medical center from 2011 to 2019. Fifty-seven patients (16%) described injury from a padlock, of whom 23 (6%) specified a slock. The prevalence of padlock-induced facial fractures doubled from 2012 to 2017. Padlock-induced facial fractures were determined to be more complex than those by a fist (p < .001). These findings support reducing the facial trauma in Louisiana correctional facilities by removing access to padlocks.

Traumatic bilateral carotid artery dissection.

INTRODUCTION: Bilateral carotid artery dissection following blunt trauma is a rare but potentially lethal injury if not diagnosed early and treated. CASE REPORT: We report a collision patient who suffered bilateral asymptomatic carotid artery dissections. He also had multiple fractures of the pelvis and upper and lower extremities. The patient was managed acutely with aspirin. He underwent open reduction and internal fixation of fractures without complication and was discharged home on aspirin. DISCUSSION: Carotid artery dissections are increasingly being recognized in blunt trauma patients. Management options include systemic anticoagulation versus antiplatelet therapy. The need to acutely address the carotid artery injury must be balanced with the need for hemostasis with associated solid organ injury and/or future operative procedures. CONCLUSIONS: Carotid artery dissections should be screened for in patients with appropriate mechanism of injury. This case report details the successful management of a patient of bilateral carotid artery dissection and other major orthopedic injuries using aspirin.

Appendectomy Hospital Stay: No Difference in Obese Adult or Pediatric Patient Length of Stay Compared to Nonobese Patients.

Background: Studies of adult and pediatric patients undergoing appendectomy have reported variable outcomes and operative metrics related to the effect of obesity. The purpose of this study was to investigate the effect of obesity in adult and pediatric patients undergoing appendectomy at our institution. Methods: This single-center retrospective study evaluated the relationship between length of hospital stay for appendectomy and body mass index (BMI). Data obtained from the electronic medical record included age, sex, weight, height, BMI, the number of hours the patient experienced symptoms prior to presentation to the emergency room, the number of hours the patient was admitted prior to surgery, the number of hours of hospital admission after surgery, perforated appendix, preoperative comorbidities, and evidence of preoperative sepsis. Results: During the 3-year study period, 118 adults and 38 children who underwent appendectomy composed the study groups. Patients were stratified by obese and nonobese, with obesity defined as BMI ≥30.0 kg/m2. In adults, we found no significant difference between length of stay in obese (n=45) and nonobese (n=73) patients (79.6 ± 65.5 hours vs 101.6 ± 123.0 hours; P=0.21). In children, we found no significant difference between length of stay in obese (n=9) and nonobese (n=29) patients (92.9 ± 64.6 hours vs 109.0 ± 93.5 hours; P=0.54). Conclusion: Obesity did not affect length of stay in adults and children who underwent appendectomy in the present series.

Lazarus phenomenon in trauma.

Lazarus phenomenon embodies auto-resuscitation, aka the return of spontaneous circulation following termination of cardiopulmonary resuscitation. Limited or no literature exists that describes auto-resuscitation in trauma. In the current report, we describe a case of an older woman that presented with poly-traumatic injuries following a motor vehicle collision. The aggressive resuscitation efforts failed, and the patient witnessed a pulseless electrical activity; however, nine-minutes after cessation of resuscitation efforts, the patient experienced auto-resuscitation. In addition to the sequel of events following the presentation, the report highlights the management dilemma and ethical implications relating to the observation period for auto-resuscitation in cases of donation after circulatory death, where the urgency to harvest the organs to ensure maximum viability is in direct opposition to ensuring enough time has elapsed to rule out auto-resuscitation. Guidelines on an appropriate period for observation in auto-resuscitation patients queued for organ donation are warranted, keeping in lieu viability of organs following death.

Acute splenic rupture following laparoscopic pneumoperitoneum: A case report.

INTRODUCTION: Splenic rupture after laparoscopic surgery is a very rare complication. In this study, we report a case of a splenic laceration that occurred during a laparoscopic gastrostomy tube placement. The theorized mechanism in this case was acute disruption of a peri-splenic hematoma. CASE REPORT: A 64-year-old African-American male presented after a motor vehicle accident with multiple injuries and was admitted to a surgical intensive care unit, where he declined from ICU days 6 through 11. The patient underwent tracheostomy and laparoscopic gastrostomy tube placement given his significant neurologic deficits. Intraoperatively, the patient developed hypotension, leading to the discovery of hemoperitoneum and necessitating an emergent open splenectomy. CONCLUSION: Splenic rupture following laparoscopic procedures is a very rare phenomenon. In this case, we believe the splenic rupture was secondary to an acute disruption of a previously hemostatic splenic hematoma involving the abdominal wall during creation of capnoperitoneum.

Comparing Surgical Site Infection for Open and Endoscopic Component Separation.

In March 2016, we reported the SSI rate at LSU Health for all abdominal wall hernia repairs performed between 2011 and 2013. Among the 263 repairs, the infection rate averaged 6.8 per cent. Given the diversity of repairs, this global percentage lacks relevance, but looking at subsets provides meaningful insights. For example, SSI was 1.8 per cent among 55/263 laparoscopic repairs and 8.2 per cent among 206/263 open repairs. The infection rate of 26.3 per cent among the 19 open component separation cases was especially noteworthy and bothersome. Even though there was no mortality in any subset, the vast majority of the morbidity and costs involved repairs with open component separations. A meta-analysis published in 2016 revealed a likely SSI benefit for the endoscopic component separation technique (ECST) over the open CST. Since that report, we have focused our quality improvement efforts on this subset of challenging cases and have replaced CST with ECST. Our data now include results from 33 hernia repairs with either CST or ECST that were performed between November 2011 and April 2018. Twenty-four of 33 patients had CST with an SSI rate of 37.5 per cent (9 of 24). Nine of 33 had ECST with 0 per cent SSI (P value = 0.039). These results mirror the findings reported in the meta-analysis.

Extracorporeal Carbon Dioxide Removal in the Management of Complex Bilateral Flail Chest Injury.

Flail chest is an uncommon consequence of traumatic injury. Medical management includes mechanical ventilation for internal pneumatic stabilization. Control of respiratory drive is necessary to avoid paradoxical movement and impairment of recovery. Traditional approaches include sedation and neuromuscular blockade, but these measures are at odds with current trends of keeping patients awake and implementing active rehabilitation. We hypothesized that extracorporeal carbon dioxide removal (ECCO2R) would suppress the respiratory drive sufficiently to permit synchronous mechanical ventilation, allowing rib fracture healing in an awake patient with extensive bilateral flail chest. A patient with 21 fractures underwent ECCO2R for 6 weeks to permit internal pneumatic stabilization with mechanical ventilation, targeting a partial pressure of carbon dioxide in arterial blood (PaCO2) of 25-30 mm Hg. The first 2 weeks were performed with extracorporeal membrane oxygenation (ECMO) for bilateral pulmonary contusions and acute respiratory distress syndrome. The last 4 weeks was with low-flow ECCO2R. Respiratory drive was suppressed during both ECMO and ECCO2R phases when the targeted hypocapnia range of 25-30 mm Hg was achieved, permitting synchronous positive pressure ventilation in an awake and cooperative patient undergoing active rehabilitation. Extracorporeal carbon dioxide removal targeting hypocapnia is a potential adjunct in extensive flail chest injury undergoing nonsurgical management.

Prophylactic Antibiotics for Elective Laparoscopic Cholecystectomy.

Surgical site infections with elective laparoscopic cholecystectomy are less frequent and less severe, leading some to suggest that prophylactic antibiotics (PA) are no longer indicated. We compared the incidence of surgical site infections before and after an institutional practice change of withholding PA for elective laparoscopic cholecystectomy. Between May 7, 2013, and March 11, 2015, no PA were given to patients selected for elective cholecystectomy by two surgeons at a single center. The only patients excluded were those who received antibiotics before surgery for any reason. All others, including those at high risk for infection, were included. The incidence and severity of infections were compared with historical controls treated with prophylaxis by the same two surgeons from November 6, 2011, to January 13, 2013. There were 268 patients in the study group and 119 patients in the control group. Infection occurred in 3.0 per cent in the study group compared with 0.9 per cent in the controls (P = 0.29). All infections were mild except one. Based on these data, the routine use of PA for elective laparoscopic cholecystectomy is not supported.

Occult lawn mower projectile injury presenting with hemoptysis.

We present the case of a 72-year-old man with hemoptysis after a thoracic projectile injury, which occurred while mowing the lawn. Chest radiograph followed by a computed tomography angiogram revealed a metallic foreign body in the right middle lobe of the lung. The patient underwent a right anterolateral thoracotomy where the object was successfully retrieved. The patient had an uneventful postoperative recovery.