Duration of Antibiotic Prophylaxis for Ballistic Fractures to the Extremities.

BACKGROUND: In the U.S. there are thousands of ballistic firearm injuries to the extremities and subsequent infections, yearly. There is a lack of consensus regarding the ideal duration of antibiotic treatment to prevent infection of these wounds. Our study investigated infection rate among ballistic extremity fracture patients based on antibiotic prophylaxis duration, operative management, wound severity, and fracture location. MATERIALS AND METHODS: Retrospective chart review of ballistic extremity fracture patients from a single trauma center from 01/01/2010 to 12/31/2020. RESULTS: Of 1611 fracture cases screened, 193 met our inclusion criteria. Infection rate was significantly higher among patients who received antibiotic prophylaxis for ≥48 hours (19.4%) compared to those who received antibiotics for <48 hours (4.4%) (Chi2 = 9.89, P = .001). This trend continued among patients who underwent operative management (P < .001), patients with articular ballistic fractures (P = .014), patients with non-articular ballistic fractures (P = .03), and patients with ballistic fractures to the lower extremities (P = .003). There was no difference in the rate of infection between patients who received ≥48 hours or <48 hours of antibiotic prophylaxis among patients with Gustilo-Anderson grade I, grade II, or grade III injuries, patients with ballistic fracture to the upper extremities, and patients who did not undergo operative management. DISCUSSION: Across all analyses in the present study, there was not a single correlation between antibiotic prophylaxis duration for ≥48 hours and lower rates of subsequent infection. For patients with ballistic fractures to the extremities, prophylactic antibiotic administration for ≥48 hours is unwarranted.

Erector Spinae Plane Blocks for Traumatic Rib Fractures: A Prospective, Interventional Study.

BACKGROUND: Rib fractures are present in 10% of all trauma patients and 30% of patients with significant chest trauma. Pain from rib fractures results in decreased respiratory effort which can lead to atelectasis and potentially pneumonia and death. Pain control is therefore of utmost importance in preventing the complications of rib fractures by improving respiratory function. Erector spinae plane blocks (ESPB) have been effectively used in elective surgery with subjective and objective improvements in pain. MATERIALS AND METHODS: We sought to evaluate subjective pain and objective evaluation of respiratory effort by way of incentive spirometry levels after administration of an ESPB for patients with rib fractures. Our trauma service applied ESPB over 2 years in patients with rib fractures. Ultrasound guidance was used to administer 50cc of a long-acting local anesthetic at the transverse process underneath the erector spinae muscle group. Evaluation of pain scores and incentive spirometry levels were measured prior to and after the ESPB. RESULTS: In total, we obtained data from 45 patients. Mean pre-pain scores were 7.93 with post-pain scores of 4.47 (p < 0.001). Mean pre-block incentive spirometry volumes were 1160 cc with post-block IS of 1495cc (p 0.035). There were no associated complications. DISCUSSION: ESPBs are safe and significantly reduce pain scores and increased incentive spirometry volumes after administration. They are easy to perform and can be done by the trauma service, including trainees. ESPB has the potential to reduce pulmonary complications of rib fractures, as well as subjectively improving pain experienced by our trauma patients. Based on our results, we recommend this block as an adjunct to multimodal analgesia for patients with rib fractures.

Practice patterns after implementation of a selective spinal immobilization protocol in a regional trauma system.

BACKGROUND: Universal spinal immobilization has been the standard of prehospital trauma care since the 1960s. Selective immobilization has been shown to be safe and effective for emergency medical services use, but it is unclear whether such protocols reduce unnecessary and potentially harmful immobilization practices. This study evaluated the impact of a selective spinal immobilization protocol on practice patterns in a regional trauma system. METHODS: All encounters for traumatic injury in the Tidewater Emergency Medical Services region from 2010 to 2016 were extracted from the Virginia Pre-Hospital Information Bridge. An interrupted time series analysis was used to assess practice change after system-wide protocol implementation in 2013. Intravenous access was used as a nonequivalent outcome measure in the absence of an appropriate control group. RESULTS: A total of 63,981 encounters were analyzed. At baseline, 16.7% of patients underwent full immobilization. The preprotocol slope was slightly positive (0.2% per month; 95% confidence interval, 0.1-0.2%). Slope and level changes after protocol implementation did not differ from those observed for intravenous access (-0.4% vs. -0.4% per month [ p = 0.4917] and -1.6% vs. -1.1% [ p = 0.1202], respectively). Cervical spinal immobilization became more common over the postimplementation period (0.1% per month; 95% confidence interval, 0.1-0.1%). Rates of immobilization for isolated penetrating trauma remained unchanged. CONCLUSION: Implementation of a selective spinal immobilization protocol did not reduce prehospital immobilization rates in a regional trauma system. Given the entrenched nature of immobilization practices, more intensive education and training strategies are needed. Efforts should prioritize eliminating immobilization for isolated penetrating trauma given its association with increased mortality. LEVEL OF EVIDENCE: Therapeutic/Care Management; Level IV.

Differences in Outcome Between Open vs Laparoscopic Insertion of Ventriculoperitoneal Shunts.

BACKGROUND: Abdominal access during ventriculoperitoneal (VP) shunt insertion has historically been obtained by neurosurgeons via an open abdominal approach. With recent advances in laparoscopy, neurosurgeons frequently consult general surgery for aid during the procedure. The goal of this study is to identify if laparoscopic assistance improves the overall outcomes of the procedure. METHODS: This retrospective study included all patients who underwent open or laparoscopic VP shunt placement between September 2012 and August 2020 at our tertiary referral hospital. Patient demographics, comorbidities, prior history of abdominal surgery, open vs. laparoscopic insertion, operation time, and complications within 30 days were obtained. RESULTS: Neurosurgery placed 107 shunts using an open abdominal technique and general surgery placed 78 using laparoscopy. The average OR time in minutes was 75.5 minutes for the open cohort and 61.8 for the laparoscopic cohort (p = 0.006). In patients without a history of abdominal surgery, the average OR time in minutes was 79.4 in the open cohort and 57.1 in the laparoscopic cohort (p = 0.015). The postoperative shunt infection rate was 10.2% in the open group and 3.8% in the laparoscopic group (p = 0.077). DISCUSSION: Laparoscopic placement of VP shunts is a reasonable alternative to open placement and results in shorter OR times. There is also a trend toward few infections in the laparoscopic placement. There appears to be an advantage with a team approach and laparoscopic placement of the peritoneal portion of the shunt.

Torso Computed Tomography Can Be Bypassed after Thorough Trauma Bay Examination of Patients Who Fall from Standing.

Reliance on CT imaging in the evaluation of low-impact blunt trauma is a major source of radiation exposure, cost, and resource utilization. This study sought to determine if torso (chest and abdomen) CT could be avoided in patients with ground level falls. This was a retrospective chart review of patients admitted to the trauma service between January 2013 and April 2014. The mechanism of injury was ground level fall or fall from sitting. Patient demographics, physical examination (PE) findings, imaging results, length of stay, and complications were reviewed. History and physical data were based on chief resident or attending documentation. A significant thoracic injury was defined as a hemothorax, a pneumothorax, greater than three rib fractures, or aortic injury. A significant abdominal injury was defined as a solid organ injury, an intra-abdominal hematoma, a hollow viscus injury, aortic injury, or a urologic injury. The trauma service evaluated 156 patients. Nine patients were excluded for intubation or Glasgow Coma Scale (GCS) < 13. Of the 147 remaining, mean age was 69 years, mean GCS was 14.8. A chest CT was obtained in 111 (76%). Eight (7%) had a significant thoracic injury. All patients with significant thoracic injury had positive examination findings. No patient with a normal PE was found to have a significant thoracic injury (negative predictive value of 100%). An abdominal CT was obtained in 86 (59%). Five (6%) were found to have a significant abdominal injury. All patients who had a significant radiographic injury had an abnormal PE (negative predictive value of 100%). In conclusion, thorough history and physical in the trauma bay allow the clinician to obtain selective torso CT imaging. Routine torso CT warrants re-evaluation in low-impact injury mechanisms as there appears to be little benefit compared with the resource utilization and expense.

The trauma pan scan: what else do you find?

The objective of this study was to investigate the prevalence of incidental findings in pan-computed tomography (CT) scans of trauma patients and the communication of significant findings requiring follow-up to the patient. A retrospective chart review of adult trauma patients was performed during the period of January 1, 2011, to August 31, 2011. During that period, 990 patient charts were examined and 555 charts were selected based on the inclusion criteria of a pan-CT scan including the head, neck, abdomen/pelvis, and chest. Patient demographics such as age, gender, mechanism of injury, and Injury Severity Score were collected. Nontraumatic incidental findings were analyzed to establish the prevalence of incidental findings among trauma patients. Discharge summaries were also examined for follow-up instructions to determine the effectiveness of communication of the significant findings. Between the 555 pan-CT scans (1759 total scans), 1706 incidental findings were identified with an incidence of 3.1 incidental findings per patient and with the highest concentration of findings occurring in the abdomen/pelvis. The majority of findings were benign including simple renal cysts with a prevalence of 7.7 per cent. However, 282 significant findings were identified that were concerning for possible malignancy or those requiring further evaluation, the most common of which were lung nodules, which accounted for 21.6 per cent of significant findings. However, only 32.6 per cent of significant findings were documented as reported to the patient. With the use of pan scans on trauma patients, many incidental findings have been identified to the benefit of the patient. The majority of these are clinically insignificant; however, only 32.6 per cent of potentially significant findings were communicated to the patient. The advantage of early detection comes from proper communication and this study demonstrates that there could be improvement in conveying findings to the patient.

Procalcitonin elevation suggests a septic source.

Procalcitonin is used as a marker for sepsis but there is little known about the correlation of the procalcitonin elevation with the causative organism in sepsis. All patients aged 18 to 80 years who were admitted to the surgery service from June 2010 to May 2012 and who had a procalcitonin drawn were evaluated. Culture data were reviewed to determine the causative organism. Infections analyzed included pneumonia, urinary tract infection (UTI), bloodstream infection, and Clostridium difficile. Other parameters assessed included reason for admission, body mass index, pressor use, antibiotic duration, and disposition. Two hundred thirty-two patient records were reviewed. Patients without a known infection/source of sepsis had a mean procalcitonin of 3.95. Those with pneumonia had a procalcitonin of 20.59 (P = 0.03). Those with a UTI had a mean procalcitonin of 66.84 (P = 0.0005). Patients with a bloodstream infection had a mean procalcitonin of 33.30 (P = 0.003). Those with C. difficile had a procalcitonin of 47.20 (P = 0.004). When broken down by causative organisms, those with Gram-positive sepsis had a procalcitonin of 23.10 (P = 0.02) compared with those with Gram-negative sepsis at 32.75 (P = 0.02). Those with fungal infections had a procalcitonin of 42.90 (P = 0.001). These data suggest that procalcitonin elevation can help guide treatment by indicating likely causative organism and infection type. These data may provide a good marker for initiation of antifungal therapy.

Thoracic ultrasound can predict safe removal of thoracostomy tubes.

BACKGROUND: Chest x-rays (CXRs) have been the mainstay for the management of thoracostomy tubes (TTs), but reports that ultrasound (US) may be more sensitive for detection of pneumothorax (PTX) continue to increase. The objective of this study was to determine if US is safe and effective for the detection of PTX following TT removal. METHODS: This was a retrospectively reviewed, prospective process improvement project involving patients who had a TT managed by the surgical team. Bedside US was performed by experienced surgeon sonographers before and after TT removal. Initially, a CXR was obtained before and after TT removal, with sonographers blinded to CXR findings. Subsequently, routine CXR was no longer obtained, and TT removal was determined by US. RESULTS: One hundred twenty-nine TTs were placed during the study. Initially, water seal and postpull US were performed on 49 TTs, with 6 tubes having only postpull imaging. US was able to detect all significant PTXs seen on CXR but identified one false-positive. Subsequently, 74 TTs had US imaging on water seal and after pull. Water seal US allowed the safe removal of 70% of the TTs. Twenty patients had no slide on water seal US and required follow-up CXR. Most importantly, US had a 100% negative predictive value for PTX during TT removal. CONCLUSION: US is safe and effective for the rapid diagnosis of PTX. This has allowed the discontinuation of routine CXR for the evaluation of PTX during TT removal for patients with adequate lung slide seen on thoracic US lung windows. LEVEL OF EVIDENCE: Diagnostic test, level II. Therapeutic study, level IV.

Evaluation and management of small-bowel obstruction: an Eastern Association for the Surgery of Trauma practice management guideline.

BACKGROUND: Small-bowel obstruction (SBO) represents as many as 16% of surgical admissions and more than 300,000 operations annually in the United States. The optimal strategies for the diagnosis and management of SBO continue to evolve secondary to advances in imaging techniques, critical care, and surgical techniques. This updated systematic literature review was developed by the Eastern Association for the Surgery of Trauma to provide up-to-date evidence-based recommendations for SBO. METHODS: A search of the National Library of Medicine MEDLINE database was performed using PubMed interface for articles published from 2007 to 2011. RESULTS: The search identified 53 new articles that were then combined with the 131 studies previously reviewed by the 2007 guidelines. The updated guidelines were then presented at the 2012 annual EAST meeting. CONCLUSION: Level I evidence now exists to recommend the use of computed tomographic scan, especially multidetector computed tomography with multiplanar reconstructions, in the evaluation of patients with SBO because it can provide incremental clinically relevant information over plains films that may lead to changes in management. Patients with evidence of generalized peritonitis, other evidence of clinical deterioration, such as fever, leukocytosis, tachycardia, metabolic acidosis, and continuous pain, or patients with evidence of ischemia on imaging should undergo timely exploration. The remainder of patients can safely undergo initial nonoperative management for both partial and complete SBO. Water-soluble contrast studies should be considered in patients who do not clinically resolve after 48 to 72 hours for both diagnostic and potential therapeutic purposes. Laparoscopic treatment of SBO has been demonstrated to be a viable alternative to laparotomy in selected cases.

Screening human immunodeficiency virus-positive men for anal intraepithelial neoplasia.

Squamous cell carcinoma of the anus is rare, but more common in men with human immunodeficiency virus (HIV). We describe our findings in 50 biopsies done on 37 HIV-positive men over 5 years. The men were referred from our HIV clinic for abnormal cytology on anal pap or anal condyloma. Thirty-seven patients were referred from the HIV clinic for abnormal cytology on anal pap or the presence of anal condyloma. Biopsies were done in the operating room using acetic acid to visually localize areas of dysplasia. If no abnormalities were seen, biopsies were taken from each quadrant of the anus. A retrospective review was done for biopsy indication, pathology, recurrence, and correlation with anal pap results. On initial biopsy, anal condyloma conferred the presence of anal intraepithelial neoplasia (AIN) in 64.7 per cent (11 of 17), abnormal paps in 83.3 per cent (10 of 12), and both in 50 per cent (3 of 6). Patients with anal condyloma had AIN in an average of 2.5 quadrants whereas those with abnormal cytology had AIN in 2.3 quadrants. Thirty-four of 50 biopsies showed abnormalities (68%), with AIN present in 32 cases, one case of carcinoma in situ, and one case of invasive carcinoma. Aldara was used nine times with improvement in four cases. In HIV-positive men, the presence of condyloma warrants surgical biopsy. Performing anal cytology on patients with anal condyloma did not increase the rate of positive results. Patients with AIN often had disease in more than two quadrants, making surgical excision problematic.

The incidence of benign and malignant neoplasia presenting as acute appendicitis.

Acute appendicitis remains the most common surgical emergency encountered by the general surgeon. It is most often secondary to lymphoid hyperplasia, however it can also result from obstruction of the appendiceal lumen by a mass. We sought to review our experience with neoplasia presenting as appendicitis. We retrospectively reviewed all patients admitted with the diagnosis of appendicitis to our Acute Care Surgery Service from July 1, 2007 to June 30, 2009. Patient demographics, duration of symptoms, lab findings, computed tomography findings, and pathology were all analyzed. Over the 2-year period, 141 patients underwent urgent appendectomy. Ten patients (7.1%) were diagnosed with neoplasia on final pathology, including four women and six men with a mean age of 46.9 years and mean duration of symptoms of 12.6 days. Final pathology revealed four colonic adenocarcinoma; three mucinous tumors; one carcinoid; one endometrioma; and one patient had a combination of a mucinous cystadenoma, a carcinoid tumor, and endometriosis of the appendix. Six patients had concurrent appendicitis. Colonic and appendiceal neoplasia are not unusual etiologies of appendicitis. These patients tend to present at an older age and with longer duration of symptoms.

Corticosteroid use in the intensive care unit: at what cost?

HYPOTHESIS: Corticosteroid use has a significant effect on morbidity and mortality in the intensive care unit (ICU). DESIGN: Case-control study. SETTING: Burn-trauma ICU in a level 1 trauma center. PATIENTS: All patients who received corticosteroids while in the ICU from January 1, 2002, to December 31, 2003 (n = 100), matched by age and Injury Severity Score with a control group (n = 100). INTERVENTIONS: None. MAIN OUTCOME MEASURES: We considered the following 7 outcomes: pneumonia, bloodstream infection, urinary tract infection, other infections, ICU length of stay (LOS), ventilator LOS, and mortality. RESULTS: Cases and controls had similar APACHE II (Acute Physiology and Chronic Health Evaluation II) scores and medical history. In univariate analysis, the corticosteroid group had a significant increase in pneumonia (26% vs 12%; P<.01), bloodstream infection (19% vs 7%; P<.01), and urinary tract infection (17% vs 8%; P<.05). In multivariate models, corticosteroid use was associated with an increased rate of pneumonia (odds ratio [OR], 2.64; 95% confidence interval [CI], 1.21-5.75) and bloodstream infection (OR, 3.25; 95% CI, 1.26-8.37). There was a trend toward increased urinary tract infection (OR, 2.31; 95% CI, 0.94-5.69), other infections (OR, 2.57; 95% CI, 0.87-7.67), and mortality (OR, 1.89; 95% CI, 0.81-4.40). Patients in the ICU who received corticosteroids had a longer ICU LOS by 7 days (P<.01) and longer ventilator LOS by 5 days (P<.01). CONCLUSIONS: Corticosteroid use is associated with increased rate of infection, increased ICU and ventilator LOS, and a trend toward increased mortality. Caution must be taken to carefully consider the indications, risks, and benefits of corticosteroids when deciding on their use.

Duodenal ulceration into the cystic artery with resultant massive hemorrhage.

Anterior duodenal ulceration with erosion into the cystic artery is an extremely rare source of upper gastrointestinal hemorrhage. Interventions that have previously been reported include open exploration with cholecystectomy, open exploration while leaving the gallbladder in situ, and angiographic management. We report a case of massive upper gastrointestinal bleeding related to duodenal ulcer penetration of the cystic artery and discuss potential management strategies.