Operative Management and Outcome of Idiopathic Rectal Necrosis in an Octogenarian.

Idiopathic acute rectal necrosis (IARN) is a rare condition due to a robust rectal blood supply. This report describes an 83-year-old man presenting with septic shock due to distal sigmoid and complete rectal necrosis with perforation. He underwent emergent exploratory laparotomy, sigmoid and proximal rectum resection, and end sigmoid colostomy creation with delayed distal rectal evaluation. Bedside proctoscopy revealed pale, viable-appearing distal rectal mucosa on postoperative day 3. The patient had a protracted, complicated hospital stay but required no further operative intervention. Subsequent colostomy reversal was done 8 months postoperatively, and the patient did well and has been discharged with normal gastrointestinal function. Our successful conservative operative management of IARN deviates from previously described management in the literature which is emergent abdominoperineal resection. This conservative surgical strategy appears to have contributed to the patient's positive outcomes, highlighting the importance of considering a similar approach for future IARN cases.

Assessing Futile Trauma Transfers in Rural Appalachia Following a Regional Health Care System Consolidation.

This study sought to define and analyze rates of futile trauma transfers (FTTs) after the consolidation of two rural level 1 trauma centers into one. Data was extracted from the regional trauma registry for a period of 5 years (2017-2022) for all trauma patients transferred into our level 1 trauma center (n = 3369). An FTT was defined as a transfer that (1) received no major interventions and (2) died or was discharged to a hospice facility within 72 hours. Out of the 3369 transfer patients analyzed during the 33-month pre-consolidation and 33-month post-consolidation periods, 34 patients met the criteria of an FTT within the transfer-to-discharge window. The pre-consolidation category contained 12, and the post-consolidation category contained 22. Chi-square analysis indicated no significant difference in FTT rate between categories. Furthermore, the post-consolidation FTT rate of 1.1% remained consistent with the estimated national average of 1.5%.

Application of the Geriatric Trauma Outcome Score in a Rural Setting.

OBJECTIVE: To retrospectively apply the Geriatric Trauma Outcome (GTO) score to the patient population of a rural South Central Appalachian level 1 trauma center and identify the potential utility of the GTO score in guiding goals of care discussions. METHODS: Trauma registry data was extracted for 5,627 patients aged 65+ from 2017 to 2021. GTO score was calculated for each patient. Descriptive statistics were calculated for age, Injury Severity Score (ISS), GTO score, receipt of red blood cells, discharge status, and code status. A simple logistic regression model was used to determine the relationship between GTO score and discharge status. The probability of mortality was then calculated using GTO score, and the distribution of code status among patients with ≤50, 51-75%, and >75% probability of mortality was examined. RESULTS: For every 10-point increase in GTO score, odds of mortality increased by 79% (OR = 1.79; P < .001). Patients had an estimated 50% probability of mortality with a GTO score of 156, 75% with 174, and 99% with a score of 234, respectively. Seventeen patients had a GTO score associated with >75% probability of mortality. Of those 17 patients, four retained a full code status. CONCLUSIONS: Our analysis demonstrates that the GTO score is a validated measure in a rural setting and can be an easily calculated metric to help determine a geriatric patient's probability of mortality following a trauma. The results of our study also found that GTO score can be used to inform goals of care discussions with patients.

Antithrombotics in the Fall Patient: Appropriateness and Risk-Benefit Analysis.

Falls are the leading cause of hospitalizations following trauma nationwide, resulting in over 3 million admissions in 2020. This population is typically aged, and many are prescribed antithrombotic (AT) therapy. In this prospective study, we aimed to analyze fall history while assessing appropriateness of AT regimen relative to fall risk. Patients presenting following ground level fall (GLF) and meeting inclusion criteria during the study period were enrolled. Primary outcome was the relationship between AT therapy necessity (CHA2DS2-VASc) and fall risk (Morse Fall Risk). The cohort of 30 patients had an average age of 77. CHA2DS2-VASc and Morse Fall Risk showed a moderate-positive correlation (r = 0.47; P = 0.012); however, 17% of patients categorized as high fall risk had a <5% 1-year risk of VTE. This study demonstrates that risks of hemorrhage may outweigh thromboembolism prophylaxis in a significant number of patients and sheds light on the astonishing fall volume in this population.

Sunken Skin Flap Syndrome: Neurological Dysfunction After Decompressive Craniectomy.

Sunken Skin Flap Syndrome (or Syndrome of the Trephined) following a head trauma is rare, but most often results from complications after decompressive craniectomy. This syndrome is most often characterized by neurological dysfunction that improves with cranioplasty. Early diagnosis and treatment are critically important to long term neurological improvement. This is a case report of a 49-year-old male who fell down a flight of stairs and was found unresponsive. Initial imaging revealed extensive head trauma. Neurosurgery performed an emergency decompressive craniectomy, but his post-operative course was complicated by the development of sunken flap syndrome one month after his initial surgery, diagnosed by an acute neurological decline and emergent CT imaging. A review of the literature indicates that this is a rarely documented finding, and this case report discusses the critical components of diagnosis and treatment of this unusual and potentially lethal condition.

Lower Extremity Sandblast Injury: A Rarely Seen Injury Mechanism in the Civilian Population.

Blast injuries are both complex and rare in the civilian population. This combination can often lead to missed opportunities for early, effective intervention. This is a case report of a 31-year-old male who suffered a lower extremity blast injury while using an industrial sandblaster. This blast injury presented as a closed degloving, or Morel-Lavallee lesion, which can easily be mistreated and lead to infection and further disability. Following assessment, identification, and confirmation of the Morel-Lavallee lesion via radiographic imaging, this patient underwent debridement surgery, wound vac therapy, and antibiotic treatment before being discharged home with no major physiologic or neurologic deficits. The purpose of this report is to highlight the importance of assessing for closed degloving injuries when presented with blast injury traumas in the civilian trauma setting, and outlines the process utilized for assessment and treatment.

Antibiotic prophylaxis for tube thoracostomy placement in trauma: a practice management guideline from the Eastern Association for the Surgery of Trauma.

Background: Antibiotic prophylaxis is routinely administered for most operative procedures, but their utility for certain bedside procedures remains controversial. We performed a systematic review and meta-analysis and developed evidence-based recommendations on whether trauma patients receiving tube thoracostomy (TT) for traumatic hemothorax or pneumothorax should receive antibiotic prophylaxis. Methods: Published literature was searched through MEDLINE (via PubMed), Embase (via Elsevier), Cochrane Central Register of Controlled Trials (via Wiley), Web of Science and ClinicalTrials.gov databases by a professional librarian. The date ranges for our literature search were January 1900 to March 2020. A systematic review and meta-analysis of currently available evidence were performed using the Grading of Recommendations Assessment, Development and Evaluation methodology. Results: Fourteen relevant studies were identified and analyzed. All but one were prospective, with eight being prospective randomized control studies. Antibiotic prophylaxis protocols ranged from a single dose at insertion to 48 hours post-TT removal. The pooled data showed that patients who received antibiotic prophylaxis were significantly less likely to develop empyema (OR 0.47, 95% CI 0.25 to 0.86, p=0.01). The benefit was greater in patients with penetrating injuries (penetrating OR 0.25, 95% CI 0.10 to 0.59, p=0.002, vs blunt OR 0.25, 95% CI 0.06 to 1.12, p=0.07). Administration of antibiotic prophylaxis did not significantly affect pneumonia incidence or mortality. Discussion: In adult trauma patients who require TT insertion, we conditionally recommend antibiotic prophylaxis be given at the time of insertion to reduce incidence of empyema. PROSPERO registration number: CRD42018088759.

Pediatric trauma patients are more likely to be discharged from the emergency department after arrival by helicopter emergency medical services.

BACKGROUND: Despite faster transport times, concern about the safety of medical helicopters has led to scrutiny in the national media. Few criteria exist for the use of helicopter emergency medical services (HEMS). This study evaluated if pediatric trauma patients transported by HEMS from the injury scene were more likely to be discharged from the emergency department and more likely to be less severely injured based on Injury Severity Score (ISS) compared with adult patients. METHODS: Retrospective data were obtained from the trauma registry at our Level I trauma center between July 1, 2005, and June 30, 2009. Trauma patients arriving by HEMS from the injury scene were included. χ(2) was used to compare the discharge rate and the ISS (divided into 0-15 and 16-75) of the adult and pediatric populations. Pediatric patients were those younger than 16 years. RESULTS: A total of 2,897 trauma patients were transported by HEMS. A total of 247 (9%) were pediatric patients, and 2,650 (91%) were adults. Among the pediatric patients, 23% were discharged, and 77% were admitted. Of the adult patients, discharge occurred in 16%, and 84% were admitted. Comparison of the discharge rate between pediatric and adult patients revealed a significantly higher proportion of discharge among the pediatric patients (p < 0.01). Among the pediatric patients, 72% had an ISS of 0 to 15, and 28% had an ISS of 16 to 75. Among the adult patients, 55% had an ISS of 0 to 15, and 45% had an ISS of 16 to 75. Comparison of these groups revealed a statistically significantly lower ISS in the pediatric group (p < 0.01). CONCLUSION: Consistent with a lower severity of injury, pediatric trauma patients transported by HEMS were more likely to be discharged directly from the emergency department when compared with adult patients. LEVEL OF EVIDENCE: Epidemiologic study, level III.

The Eastern Association of the Surgery of Trauma approach to practice management guideline development using Grading of Recommendations, Assessment, Development, and Evaluation (GRADE) methodology.

The Eastern Association for the Surgery of Trauma (EAST) is a leader in evidence-based medicine and the development of practice management guidelines (PMGs) in trauma and acute care surgery. The previous primer describing EAST's approach for assessing the quality of available evidence and making recommendations for developing PMGs was published in 2000. Since that time, many new systems have been developed in an attempt to overcome previous shortcomings and to devise a methodologically rigorous and transparent approach to the assessment of quality of evidence and development of guidelines. One of these is the Grading of Recommendations, Assessment, Development, and Evaluation (GRADE) system. The membership of EAST has determined that the GRADE methodology will be the system used in all future EAST PMGs. The purpose of this article was thus to describe the GRADE methodology.

Presumptive antibiotic use in tube thoracostomy for traumatic hemopneumothorax: an Eastern Association for the Surgery of Trauma practice management guideline.

BACKGROUND: Antibiotic use in injured patients requiring tube thoracostomy (TT) to reduce the incidence of empyema and pneumonia remains a controversial practice. In 1998, the Eastern Association for the Surgery of Trauma (EAST) developed and published practice management guidelines for the use of presumptive antibiotics in TT for patients who sustained a traumatic hemopneumothorax. The Practice Management Guidelines Committee of EAST has updated the 1998 guidelines to reflect current literature and practice. METHODS: A systematic literature review was performed to include prospective and retrospective studies from 1997 to 2011, excluding those studies published in the previous guideline. Case reports, letters to the editor, and review articles were excluded. Ten acute care surgeons and one statistician/epidemiologist reviewed the articles under consideration, and the EAST primer was used to grade the evidence. RESULTS: Of the 98 articles identified, seven were selected as meeting criteria for review. Two questions regarding presumptive antibiotic use in TT for traumatic hemopneumothorax were addressed: (1) Do presumptive antibiotics reduce the incidence of empyema or pneumonia? And if true, (2) What is the optimal duration of antibiotic prophylaxis? CONCLUSION: Routine presumptive antibiotic use to reduce the incidence of empyema and pneumonia in TT for traumatic hemopneumothorax is controversial; however, there is insufficient published evidence to support any recommendation either for or against this practice.

Are general surgeons behind the curve when it comes to disaster preparedness training? A survey of general surgery and emergency medicine trainees in the United States by the Eastern Association for the Surgery for Trauma Committee on Disaster Preparedness.

PURPOSE: We think that general surgeons are underprepared to respond to mass casualty disasters. Preparedness education is required in emergency medicine (EM) residencies, yet such requirements are not mandated for general surgery (GS) training programs. We hypothesize that EM residents receive more training, consider themselves better prepared, and are more comfortable responding to disaster events than are GS residents. METHODS: From February to May 2009, the Eastern Association for the Surgery of Trauma-Committee on Disaster Preparedness conducted a Web-based survey cataloging training and preparedness levels in both GS and EM residents. Approximately 3000 surveys were sent. Chi-squared, logistic regression, and basic statistical analyses were performed with SAS. RESULTS: Eight hindered forty-eight responses were obtained, GS residents represented 60.6% of respondents with 39% EM residents, and four residents did not respond with their specialty (0.4%). We found significant disparities in formal training, perceived preparedness, and comfort levels between resident groups. Experience in real-life disaster response had a significant positive effect on comfort level in all injury categories in both groups (odds ratio, 1.3-4.3, p < 0.005). CONCLUSION: This survey confirms that EM residents have more disaster-related training than GS residents. The data suggest that for both groups, comfort and confidence in treating victims were not associated with training but seemed related to previous real-life disaster experience. Given wide variations in the relationship between training and comfort levels and the constraints imposed by the 80-hour workweek, it is critical that we identify and implement the most effective means of training for all residents.