Have echocardiograms affected recommended therapy in geriatric trauma patients?

GOAL: Geriatric trauma patients tend to have worse outcomes than their younger counterparts. The American Heart Association (AHA) recommends preoperative cardiac clearance to stratify patients according to perioperative cardiac risk. The utility of this in the trauma setting remains unclear. We sought to identify the role of preoperative echocardiograms (echo) in geriatric trauma patients. METHODS: We performed a retrospective review of geriatric trauma patients who required operative intervention over a 1-year period. Patients with echocardiograms performed were compared with those who did not. RESULTS: Three-hundred thirty geriatric trauma patients required an operation. A preoperative echo was performed in 25% (82/330). Abnormalities on echocardiogram were identified in 13% (11/82) of patients. One patient had a change in management based on the echo. None of the patients who died in the perioperative period had a management alteration as a result of the echo. Echo patients had a longer LOS and to operative intervention (P<.006). CONCLUSION: Echocardiograms had an exceeding low rate of management change in the acutely injured geriatric trauma patient. Further studies to evaluate the need for echocardiogram in this population are warranted.

Continuous intercostal nerve blockade for rib fractures: ready for primetime?

BACKGROUND: Providing analgesia for patients with rib fractures continues to be a management challenge. The objective of this study was to examine our experience with the use of a continuous intercostal nerve block (CINB). Although this technique is being used, little data have been published documenting its use and efficacy. We hypothesized that a CINB would provide excellent analgesia, improve pulmonary function, and decrease length of stay (LOS). METHODS: Consecutive adult blunt trauma patients with three or more unilateral rib fractures were prospectively studied over 24 months. The catheters were placed at the bedside in the extrathoracic, paravertebral location, and 0.2% ropivacaine was infused. Respiratory rate, preplacement (PRE) numeric pain scale (NPS) scores, and sustained maximal inspiration (SMI) lung volumes were determined at rest and after coughing. Parameters were repeated 60 minutes after catheter placement (POST). Hospital LOS comparison was made with historical controls using epidural analgesia. RESULTS: Over the study period, 102 patients met inclusion criteria. Mean age was 69 (21-96) years, mean injury severity score was 14 (9-16), and the mean number of rib fractures was 5.8 (3-10). Mean NPS improved significantly (PRE NPS at rest = 7.5 vs. POST NPS at rest = 2.6, p < 0.05, PRE NPS after cough = 9.4, POST after cough = 3.6, p < 0.05) which was associated with an increase in the SMI (PRE SMI = 0.4 L and POST SMI = 1.3 L, p < 0.05). Respiratory rate decreased significantly (p < 0.05) and only 2 of 102 required mechanical ventilation. Average LOS for the study population was 2.9 days compared with 5.9 days in the historical control. No procedural or drug-related complications occurred. CONCLUSION: Utilization of CINB significantly improved pulmonary function, pain control, and shortens LOS in patients with rib fractures.

Out with the old, in with the new: a novel approach to treating pain associated with rib fractures.

BACKGROUND: Rib fractures continue to be a challenging problem from both a pulmonary and analgesia standpoint. As a result, numerous modalities have been used to treat this condition, but none has proven universally available and efficacious. The objective of this pilot study was to assess the efficacy of a novel technique for placing an elastomeric infusion pump (EIP) catheter (On-Q; Lake Forest, CA, USA) in the extrathoracic paraspinous space to create a continuous intercostal nerve block. METHODS: This was a prospective, nonrandomized study conducted in the surgical intensive care unit (SICU) of an urban level II trauma center. We developed a novel technique for placing EIP catheters in the extrathoracic paraspinous space to provide continuous intercostal nerve blockade. We subsequently evaluated 30 consecutive blunt trauma patients with three or more unilateral rib fractures. The catheters were infused with local anesthetic, and the dose was titrated to achieve adequate analgesia. For each patient, preplacement numeric pain scale scores (NPSs) and sustained maximum inspiration (SMI) lung volumes were determined. Sixty minutes following placement of the catheters, the NPS and SMI were repeated. The patients were monitored for any procedural or drug-related complications. RESULTS: The mean age of the patients was 65 years (22-92 years); the mean ISS was 14 (9-16); and the mean number of rib fractures was 4.4 (3-8). Overall, the mean NPS significantly improved (preplacement NPS 9.03, postplacement NPS 3.06; p < 0.05) and was associated with a significant increase in the SMI (preplacement SMI 0.40 L, postplacement SMI 1.1 L; p < 0.05). The catheters remained in place for an average of 98 h (72-146 h), and there were no procedural- or drug-related complications. CONCLUSIONS: These pilot data indicate that the placement of EIP catheters in the extrathoracic paraspinous space may be a safe, viable, and efficacious procedure for ameliorating pain secondary to rib fractures.

Should age be a factor to change from a level II to a level I trauma activation?

BACKGROUND: Elderly trauma patients have a higher incidence of medical comorbidities when compared with their younger cohorts. Currently, the minimally accepted criteria established by the Committee on Trauma for the highest level of trauma activation (Level I) does not include age as a factor. Should patients older than 60 years with multiple injuries and/or a significant mechanism of injury be considered as part of the criteria for Level I activation? Would these patients benefit from a higher level of activation? METHODS: The National Trauma Data Bank was queried for the period of January 1, 1999, to December 31, 2008, for all trauma patients and associated injury severity score (ISS). The data abstracted were based on age and ISS. RESULTS: The National Trauma Data Bank contained 802,211 trauma patients. Seventy-nine percent were younger than 60 years, and 21% were older than 60 years. Our analysis shows that in all levels of injury, patients older than 60 years have an increased risk for morbidity and mortality. We found a threefold increase in morbidity and a fivefold increase in mortality among the older (age >60 years) population with a minor ISS. Elderly patients with a major ISS demonstrated a twofold increase in morbidity and a fourfold increase in mortality. CONCLUSION: Patients with an ISS between 0 and 15 are often triaged to Level II activation. Our data would suggest that patients older than 60 years should be a criterion for the highest level of trauma activation.

Is there a benefit to multidisciplinary rounds in an open trauma intensive care unit regarding ventilator-associated pneumonia?

Multidisciplinary rounds (MDRs) have been instituted for patient care since June 2005. Before June 2005, all care was provided by individual practitioners. MDRs include the surgical intensivist, surgical resident, patient's nurse, case manager, pharmacist, chaplain, nutritionist, and respiratory therapist. Our study examined the effect of MDRs on ventilator-associated pneumonia in trauma patients in open intensive care units (ICUs). Group 1 included patients from June 2003 to May 2005 before the implementation of MDRs, and Group 2 included patients after the institution of MDRs from June 2005 to May 2007. In Group 1, there were 83 ventilator-associated pneumonias (VAPs) during 2414 ventilator days. In Group 2, there were 49 VAPs during 2094 ventilator days. The ratio of VAPs per thousand ventilator days decreased from 34.4 to 23.4 between the two groups (P = 0.04). When comparing trauma patients in our open ICU with similar mean Injury Severity Score and mean Abbreviated Injury Score for chest and for head and neck, implementing MDRs significantly decreased our incidence of VAP.

Partial cholecystectomy in the setting of severe inflammation is an acceptable consideration with few long-term sequelae.

Open cholecystectomy is infrequently performed. For the general surgeon, open cholecystectomy is typically performed when a great degree of inflammation precludes safe laparoscopic removal. The degree of inflammation can also lead to an unacceptable risk of common bile duct injury during the dissection of the triangle of Calot. In this situation, the extent of dissection and amount of resection is not well established. We undertook a retrospective review and follow-up telephone questionnaire of all partial cholecystectomies performed. Partial cholecystectomy was performed in 26 cases with open, laparoscopic converted to open, and laparoscopic techniques. Postoperative complications occurred in seven (27%) patients with three (12%) experiencing more than one complication. There was a bile leak in three (12%), subhepatic abscess in three (12%), wound infection in two (8%), and retained common duct stone in one (4%). There were no common bile duct injuries and no deaths. Telephone interviews were conducted with 19 (73%) patients. Average length of follow up was 314 days. At the time of last contact, no ongoing complaints attributable to biliary pain were present. Our data suggest that partial cholecystectomy in the setting of severe inflammation is a reasonable operation with few long-term sequelae, good clinical results, and satisfactory symptom relief.

A major metropolitan "field amputation" team: a call to arms ... and legs.

BACKGROUND: As early as 1979, suggestions were made to establish amputation teams and protocols in major metropolitan areas. It was recognized that preplanning on such calls would be valuable to carrying out rescues of that nature. Since then, questionnaires and collegial conversations reveal the existence of such teams remains the exception in our nation's cities. METHODS: Our team was formed in 1984 after an emergency medical service request for a surgeon to perform an amputation on a person who had become entrapped with both arms in an industrial candy press was made. In its current form, the team consists of an attending trauma surgeon, a resident surgeon, a registered nurse, and a pilot, all hospital based. Equipment is limited to medications for sedation and pain control, two units of uncross-matched blood, and a prebundled duffle bag of bandages, a scalpel, various saws, and hemostats. Transportation to the scene is provided by the helicopter based at our level II trauma center. RESULTS: Since its inception, the team has been activated three to four times per year, resulting in nine amputation rescues. Three of these cases, presented here, are from an unusually busy 5 weeks during the spring of 2008. The first case involves a tree shredding device, the second, an industrial auger, and the third, a forklift and a steel toed boot. In these cases, the utilization of the amputation team resulted in successful patient rescues and outcomes. CONCLUSION: A field amputation team can be an integral part of any emergency medical service system, filling an infrequently used but helpful adjunct to emergency care.

Expanding the indications for laparoscopic gastric resection for gastrointestinal stromal tumors.

OBJECTIVE: Laparoscopic resection of large gastric gastrointestinal stromal tumors (GIST) has been controversial. This generally has been limited to small lesions. We hypothesize that laparoscopic mobilization and resection using, in some cases, extracorporeal anastomosis of the gastrointestinal (GI) tract is an oncologically safe alternative to open surgery even when tumors are large. METHODS: Four patients underwent a laparoscopic approach for gastric GIST tumors >2 cm at Methodist Dallas Medical Center over a 6-month period. Patient demographics, operative findings, postoperative course, and pathologic characteristics were examined. RESULTS: The mean age in this patient group was 58 years (range, 36 to 77). Gastrointestinal bleeding and dyspepsia were the most common symptoms. Seventy-five percent of the patients were females. Mean tumor size was 10 cm (range, 2.5 to 20) with distribution in the stomach as follows: 75% greater curvature and 25% antrum. Tumors were removed by wedge, sleeve, and partial gastrectomies. Two of these tumors showed a high grade and the other 2 a moderate grade of differentiation. The number of mitoses was <5/50 HPF in all the tumors. No intraoperative spillage occurred in any patients, even with the largest tumor (20 cm). Importantly, all tumors were excised with a negative gross and microscopic margin. Average length of stay was 4 days. No patients required reoperation, and there were no complications postoperatively. CONCLUSION: Minimally invasive assisted approaches may be an option to treat large GIST tumors. Obeying principles of minimal touch, no spillage, and obtaining a negative margin, a safe operation with a laparoscopic approach is feasible, even in giant tumors. The large size of diagnosed GIST tumors should not preclude a minimally invasive approach.

Car surfing: case studies of a growing dangerous phenomenon.

Car surfing is a dangerous new pastime for American youth. Car surfing is an activity that is defined as standing (or lying) on a vehicle while it is being driven. This activity frequently results in severe injuries that often require significant surgical intervention. Despite its destructive nature, however, there are many Internet sites that encourage this behavior and view it as amusing. As a result, car surfing is becoming increasingly popular. We conducted a retrospective chart review of all patients injured as a result of car surfing over the last 4 years at our Urban Level II trauma center. Data collected included Injury Severity Score (ISS), Revised Trauma Score (RTS), age, gender, injury pattern, surgical intervention, and length of stay. Eight car surfers were identified. The average age was 17. The average Revised Trauma Score was 6.8 with an average Injury Severity Score of 16.9. Five patients were admitted to the intensive care unit. Four of these five patients needed to be intubated for ventilatory support. Five of the eight patients had significant intracranial injuries. Two patients had epidural hematomas that required evacuation. Two other patients had subdural hematomas that were treated nonoperatively, and one patient had a subarachnoid hemorrhage that was also treated nonoperatively. Four of the eight patients required surgical intervention. There were no deaths in this study. Car surfing leads to severe injuries that can result in significant morbidity. American youth have access to Internet sites that project this activity as an acceptable behavior. Five of our eight patients had a significant intracranial injury. Trauma surgeons need to be more aware of this injury phenomenon.

Retroperitoneal leiomyosarcoma of the inferior vena cava mimicking a liver tumor.

Leiomyosarcoma of the inferior vena cava (IVC) is a rare sarcoma, but it is the most common primary malignancy of the IVC. It has an extremely poor prognosis. We describe a 60-year-old white female complaining of abdominal fullness for 7 weeks before she sought medical assistance. Initial work-up including sonography, computed tomography, and magnetic resonance showed a tumor in the right upper quadrant of the abdominal cavity originating from the liver with compression of the IVC and displacement of the right kidney. The patient underwent surgical resection of the tumor with clear margins and reconstruction of the IVC using a Dacron tubular graft. Postoperatively, she was placed on Coumadin and adjuvant chemotherapy was started. Subsequently, the patient developed metastasis into the liver and peripancreatic nodes during the follow-up period. Considering the aggressiveness of this tumor, early radical en block resection with clear margins is still the only chance for long-term survival.

Wandering spleen presenting as recurrent pancreatitis.

INTRODUCTION: A wandering spleen occurs when there is a laxity of the ligaments that fix the spleen in its normal anatomical position. CASE REPORT: We present the case of a wandering spleen in a 20-year-old female who presented with recurrent pancreatitis and underwent a laparoscopic splenectomy. DISCUSSION: The presentation of a wandering spleen varies from an asymptomatic mass to splenic infarct with an acute abdomen. Its correct diagnosis relies mostly on imaging studies. Treatment consists of performing either splenectomy or splenopexy. CONCLUSION: The diagnosis of wandering spleen can often be difficult due to the intermittent nature of the torsion. Computed tomography studies for diagnosis and laparoscopic surgery have changed the management of this interesting disease.

The pregnant female surgical resident.

BACKGROUND: Surgery continues to be an intense, time-consuming residency. Many medical students decide against surgery as a profession due to the long work hours and family strain. The pregnant female surgical resident has an added stress factor compared to her male counterpart. METHODS: We distributed an electronic, online 26-question survey to 32 general surgery programs in the southwestern region of the United States. Each program distributed our survey to the female surgical residents who had been pregnant during residency in the last 5 years. Each program was re-contacted 6 weeks after the initial contact. Most questions were in a 5-point Likert scale format. The responses were collected and analyzed using the Survey Monkey website. RESULTS: An unvalidated survey was sent to 32 general surgery programs and 26 programs responded (81%). Each program was asked for the total number of possible responses from female residents that met our criteria (60 female residents). Seven of the programs (27%) stated that they have had zero residents pregnant. We had 22 residents respond (37%). Over half of the residents (55%) were pregnant during their 2nd or 3rd year of residency, with only 18% pregnant during a research year. Thirty-one percent had a lower American Board of Surgery In-Training Exam (ABSITE) score. Ninety percent of the residents were able to take 4 weeks or more for maternity leave. Most of the residents (95%) stated that they would do this again during residency given the opportunity, but many of the residents felt that returning back to work with a child at home was the most difficult part. CONCLUSION: Our preliminary study shows that the programs surveyed were accommodating to the female surgical resident. Nevertheless, despite adequate support from their program and an overall positive experience, many residents indicated that they had a decline in their education and performance.

Medical admission of elderly trauma patients with isolated injuries.

We sought to evaluate the outcomes of trauma patients admitted to medical services rather than to the general trauma team, particularly those elderly patients with isolated injuries of a specialty nature. Over the 2-year retrospective study period, 3017 trauma patients were admitted. The trauma service directed care in 2740 (90.8%) of this group versus the 277 (9.2%) admitted to medical services (MS). The patients in each group were then classified according to age younger than 55 years or older than 55 years (elderly). Of the 277 patients admitted to the MS, 177 (63.8%) were elderly compared with only 13 per cent of the trauma service group. Smaller proportions (16.9%) of the elderly medical patients were admitted to the intensive care unit as compared with the trauma group (22.1%). There was a higher morbidity rate, 41.9 per cent, in the trauma service group as compared with the MS group, 20 per cent. No patients on the MS underwent a laparotomy for intraabdominal injuries nor were there any missed injuries of a general surgical nature. Allowing elderly trauma patients with isolated specialty injuries to be managed by the MS is not associated with increased morbidity or mortality.

Managing breast cancer in the renal transplant patient: a unique dilemma.

Improvements in immunosuppression have increased patient and graft survival in transplant recipients. As a result, there is greater risk of neoplastic processes such as breast cancer. Treatment in this population is complicated by the necessary immunosuppression, vascular accesses, and transplant grafts. General surgeons may expect to encounter more of these complex patients in the community setting. We sought to evaluate the surgical treatment of breast cancer in patients with renal transplants. Hospital and private physician records were queried to identify patients who developed breast cancer after a renal or pancreatic/renal transplantation. These charts were reviewed for demographics, type of breast cancer and treatment, location of dialysis access, and complications. From June 1, 1994, to May 31, 2004, 14 patients were identified. Eight patients had functioning transplants. All patients underwent operative interventions. Ten patients underwent adjuvant treatment. Three had functioning transplants and chose not to risk the graft with cessation of immunotherapy. However, no patient with functioning transplants who underwent chemotherapy developed organ failure. Breast cancer after transplantation poses a unique dilemma. The threat of transplanted organ failure is a major concern to these patients and often supersedes adjuvant therapies.

Abdominal wall abscess formation two years after laparoscopic cholecystectomy.

BACKGROUND: Spillage of gallstones within the subcutaneous tissue during laparoscopic cholecystecomy may lead to considerable morbidity. METHODS: We describe an abdominal wall abscess formation in a 50-year-old female that developed 24 months after a laparoscopic cholecystectomy. RESULTS: Spilled gallstones at the umbilical port site went undetected. Subsequently, an umbilical port-site abscess formed and was treated 2 years later. CONCLUSION: Any patient with a foreign body in the subcutaneous tissues after a laparoscopic cholecystectomy should be considered to have a retained stone. Use careful dissection, copious irrigation, and a retrieval device to avoid stone spillage. If spillage does occurs, percutaneous drainage and antibiotics followed by open retrieval of the stones should achieve adequate results during those delayed presentations of abdominal wall abscesses.

Laparoscopic converted to open cholecystectomy minimally prolongs hospitalization.

BACKGROUND: There has been little information about the length of stay (LOS) after laparoscopic converted to open cholecystectomy (CON) in the past few years. The aim of this study was to evaluate the LOS and postoperative complications for elective CON in a more recent time period. METHODS: A retrospective chart review was performed of all patients admitted to the Day Surgery Unit for elective laparoscopic cholecystectomy (LC) converted to open cholecystectomy (OC) from January 2000 through December 2003. Indications for CON, operative time, LOS, pain control, and complications were evaluated. RESULTS: The CON rate was 3%, and the reason for CON to open was most commonly cited as inability to identify anatomy. On average, patients were discharged on postoperative day 3 (range 2 to 8). The postoperative complication rate was 17%. CONCLUSIONS: When the dissection is tedious, the surgeon should feel comfortable in converting from laparoscopic to open cholecystectomy. This can be done with the knowledge that it does not add significant length of stay as previously reported.

Skip and save: utility of pelvic x-rays in the initial evaluation of blunt trauma patients.

BACKGROUND: The cost of medical care is an area of major emphasis in the current healthcare environment. Medical providers have a significant role in reducing costs. One way to achieve this goal is to eliminate practices that add little value to patient care. The pelvic x-ray (PXR) obtained during the initial evaluation of blunt trauma may be an example. The objective of this study was to explore the utility of the pelvic x-ray in the initial evaluation of blunt trauma patients. METHODS: Blunt trauma patients with pelvic fractures of any type admitted to our urban trauma center from January 2012 to December 2013 were reviewed. Demographics including age, sex, race, mechanism of injury, and outcomes were collected. Findings on PXR and computed tomography (CT) were compared for correlation. Patients requiring surgery for their pelvic fractures were identified. RESULTS: Of the 3,217 trauma admissions over the 2-year period, 153 patients sustained a pelvic fracture. Mean age was 50 years (15 to 97), male 54%, and Caucasian 46%, Hispanic 31%, African American 22%, and Asian 1%. The average injury severity score was 12.9. The main mechanism of injury was motor vehicle collisions 45%, followed by fall from standing 22% and auto and/or pedestrian accidents 12%. There were 22 patients that did not have both CT and pelvic imaging for comparison. Of the 131 patients with both CT and pelvic films, findings were the same in 43 (33%). CT identified one or more additional pelvic fractures in 88 (67%) patients compared with the PXR. In 29 patients (22%), pelvic fractures were not evident on PXR with fractures only identified by CT. The most common missed fractures on PXR were sacral and iliac injuries. Of the 153 patients with pelvic fractures, 24% required surgery for their pelvic injuries. Mortality was 4% for nonpelvic fracture-related causes. The PXR findings did not change management provided by trauma team in the emergency department. CONCLUSIONS: As expected, CT is more sensitive in identifying pelvic fractures compared with PXR. Most blunt trauma patients are undergoing further evaluation with CT. We therefore propose that in patients that are normotensive with no pelvic instability or hip dislocation on physical examination who are to undergo further imaging with CT, the pelvic film should be avoided as it adds little value to patient management. The Advanced Trauma Life Support (ATLS) guidelines should be revised to reflect a diminishing role of the PXR in blunt trauma patients.

The benefit of routine thoracic, abdominal, and pelvic computed tomography to evaluate trauma patients with closed head injuries.

BACKGROUND: The evaluation of multitrauma patients for blunt truncal injuries remains open for debate. We sought to evaluate the role of routine computed tomography (CT) of the chest, abdomen, and pelvis as a screening tool for patients already undergoing cranial CT studies. METHODS: Charts of blunt trauma patients admitted from June 2000 to June 2001 were reviewed for demographics, Glascow Coma Scale (GCS), physical and radiological findings, and length of stay. RESULTS: Our study found that 38% of patients undergoing cranial CT scanning had a unexpected finding on body scans. Changes were made in 26% of the study group because results found on the adjuvant CTs. CONCLUSIONS: Additional body CTs add minimal cost to the care of trauma patients but can significantly change the management. We believe it is beneficial to perform routine body CT examinations when performing cranial imaging for blunt head injury.