From Admission to Discharge-A Total Friction Burn Review from a Single Institution.

While most friction burns are adequately managed in an outpatient setting, many may require hospital admission, operative excision, and extended care. To this day, there is a wide variance in friction burn management. Our goal is to review the etiology, management, and outcomes of such burns warranting hospitalization. We conducted a retrospective review of all friction burns admitted to a single, American Burn Association-verified burn center from January 1, 2016 to December 31, 2020. A total of 28 (34%) patients required surgery for their friction burns and 15 (18%) ultimately required a split-thickness skin graft. The mean number of operations was 2.4 (95% CI 1.6-3.1). Overall, the operative group was younger (29.9 vs 38.3 years, P = .026), more likely to have a concomitant traumatic brain injury (25% vs 7%, P = .027), and had a longer hospital length of stay (17.5 vs 3.9 days, P < .001). Both groups had a similar overall TBSA (8.5% vs 10.0%, P = .35), but the operative group had a larger surface area comprised of third-degree burns (3.05% vs 0.2%, P < .001). Overall, friction burns resulting in hospital admission are associated with high-energy traumatic mechanisms and concomitant injuries. Patients who need operative intervention for their burns typically require multiple procedures often culminating in a split-thickness skin graft. While non-operative management of friction burns with topical agents has been found to be successful, patients with higher injury severity scores should be monitored very closely as they may require surgical excision.

The Pearls and Pitfalls of a Migrating Bullet Embolus.

Venous bullet embolism is an exceedingly rare trauma diagnosis that presents diagnostic and therapeutic challenges. We present the case of a 32-year-old man who sustained multiple gunshot wounds with a venous bullet embolism to the right pulmonary artery. Imaging at first demonstrated a bullet lodged within the right lower lobe. The patient underwent multiple bronchoscopies and ultimately was found to have a bullet embolus in the right pulmonary artery. Repeat endovascular attempts failed at removal, and during a right thoracotomy, the bullet migrated to the left pulmonary artery. Coil embolization of the left lower lobe pulmonary artery was performed, and the patient was found to be asymptomatic at the 1-year follow-up. To our knowledge, this is the first case to demonstrate coil embolization of the pulmonary artery as a method of endovascular treatment for a venous bullet embolus. We present this case report to emphasize the difficulty in diagnosis, localization, and management of a migratory bullet within the pulmonary circulation.

Higher risk of auto versus pedestrian crashes in school-age children on school days.

BACKGROUND: This study examines the rates of pediatric auto versus pedestrian collision (APCs) and determined ages and periods of greatest risk. We hypothesized that the rate of APC in children would be higher on school days and in the timeframes correlating with travel to and from school. METHODS: Retrospective case-control study of APC on school and nonschool days for patients younger than 18 years at an urban Level II pediatric trauma center from January 2011 to November 2019. Frequency of APC by hour of the day was plotted overall, for school versus nonschool days and for age groups: 0 year to 4 years, 5 years to 9 years, 10 years to 13 years, and 14 years to 17 years. t Test was used with a p value less than 0.05, which was considered significant. RESULTS: There were 441 pediatric APC in the study period. Frequency of all APC was greater on school days (0.174 vs. 0.101; relative risk [RR], 1.72, p < 0.001), and APC with Injury Severity Score greater than 15 (0.039 vs. 0.024; p = 0.014; RR, 1.67; 95% confidence interval, 1.10-2.56). Comparing school day with nonschool day, the 0-year to 4-year group had no significant difference in APC frequency (0.021 vs. 0.014; p = 0.129), APC frequency was higher on school days in all other age groups: 5 years to 9 years (0.036 vs. 0.019; RR, 1.89; p = 0.0134), 10 years to 13 years (0.055 vs. 0.024; RR, 2.29; p < 0.001), and 14 years to 17 years (0.061 vs. 0.044; RR, 1.39; p = 0.045). The greatest increase in APC on school days was in the 10-year to 13-year age group. DISCUSSION: All school age children are at higher risk of APC on school days. The data support our hypothesis that children are at higher risk of APC during transit to and from school. The age 10-year to 13-year group had a 129% increase in APC frequency on school days. This age group should be a focus of injury prevention efforts. LEVEL OF EVIDENCE: Prognostic and Epidemiologic; Level IV.

Early Characteristics and Progression of Blunt Traumatic Aortic Injuries at a Single Level I Trauma Center.

OBJECTIVES: The most widely accepted grading system for blunt traumatic aortic injury (BTAI) by the Society of Vascular Surgery (SVS) recommends endovascular repair for grade 2 and greater. Non-operative management in grade 2 injuries has been shown to be reasonable in certain circumstances. The natural history of low-grade injuries (1, 2) when managed non-operatively is not well defined. METHODS: Utilizing our trauma registry, patients from 2013 to 2016 with blunt traumatic injury who underwent initial computed tomography were identified. Aortic pathology was graded and grouped by SVS classification. Clinical courses were reviewed for timing of interventions, repeat imaging, concurrent injuries, and outcomes. Analysis of variance and Chi-square tests of significance were utilized to compare between groups. RESULTS: Out of 10,178 patients, we identified 32 with BTAI (grade: 1 (n = 13), 2 (n = 5), 3 (n = 3), 4 (n = 11)). High-grade injuries (3, 4) resulted only from motor vehicle, motorcycle, and pedestrian mechanisms. Initially, 9 patients (28%) required intervention, 5 (16%) were treated non-operatively, and 18 (56%) underwent repeat imaging. On repeat imaging, injuries that did not resolve remained stable and no injuries were found to progress. Of these patients, 9 (50%) required delayed intervention and 9 (50%) successfully underwent non-operative management. Patients with low-grade injuries were more likely to have successful non-operative management than those with high-grade injuries (72% vs 7%; p < 0.01). CONCLUSIONS: While low-grade injuries generally have good outcomes, some ultimately do require delayed intervention, and short-term imaging is not reliable in identifying these cases.

Contemporary management of traumatic cervical and thoracic esophageal perforation: The results of an Eastern Association for the Surgery of Trauma multi-institutional study.

BACKGROUND: Traumatic esophageal perforation is rare and associated with significant morbidity and mortality. There is substantial variability in diagnosis and treatment. Esophageal stents have been increasingly used for nontraumatic perforation; however, stenting for traumatic perforation is not yet standard of care. The purpose of this study was to evaluate current management of traumatic esophageal perforation to assess the frequency of and complications associated with esophageal stenting. METHODS: This was an Eastern Association for the Surgery of Trauma multi-institutional retrospective study from 2011 to 2016 of patients with traumatic cervical or thoracic esophageal injury admitted to one of 11 participating trauma centers. Data were collected and sent to a single institution where it was analyzed. Patient demographics, injury characteristics, initial management, complications, and patient mortality were collected. Primary outcome was mortality; secondary outcomes were initial treatment, esophageal leak, and associated complications. RESULTS: Fifty-one patients were analyzed. Esophageal injuries were cervical in 69% and thoracic in 31%. Most patients were initially managed with operative primary repair (61%), followed by no intervention (19%), esophageal stenting (10%), and wide local drainage (10%). Compared with patients who underwent operative primary repair, patients managed with esophageal stenting had an increased rate of esophageal leak (22.6% vs. 80.0%, p = 0.02). Complication rates were higher in blunt compared with penetrating mechanisms (100% vs. 31.8%, p = 0.03) despite similar Injury Severity Score and neck/chest/abdomen Abbreviated Injury Scale. Overall mortality was 9.8% and did not vary based on location of injury, mechanism of injury, or initial management. CONCLUSION: Most patients with traumatic esophageal injuries still undergo operative primary repair; this is associated with lower rates of postoperative leaks as compared with esophageal stenting. Patients who have traumatic esophageal injury may be best managed by direct repair and not esophageal stenting, although further study is needed. LEVEL OF EVIDENCE: Therapeutic, level IV.

Efficacy and safety of transversus abdominis plane blocks versus thoracic epidural anesthesia in patients undergoing major abdominal oncologic resections: A prospective, randomized controlled trial.

BACKGROUND: The purpose of this study was to compare patient outcomes for thoracic epidural anesthesia (TEA) with transversus abdominis plane (TAP) blocks. METHODS: A prospective, randomized trial was performed for patients undergoing abdominal oncologic surgeries. RESULTS: There were 32 TAP and 35 TEA subjects. The TEA group demonstrated increased episodes of hypotension in the first 24 h (3 v 0.6, p = 0.02). There was no difference in 24-48 h fluid balance between the groups. Overall parenteral morphine equivalents of opioids administered for the TEA group were higher for each postoperative day (p < 0.05). The post-operative survey did not demonstrate any difference in subjective pain between the TAP and TEA groups (6 v 6 p = 0.35). There was no attributable morbidity associated with either technique. CONCLUSIONS: TAP block use was associated with lower parenteral morphine equivalent usage and decreased incidence of hypotension in the early post-operative period compared to TEA.

Resident impact on operative duration for elective general surgical procedures.

BACKGROUND: Resident involvement in operations increases operative duration. This study investigated resident impact on operative time for a single general surgeon in an outpatient surgical setting. METHODS: A retrospective review was performed of index general surgical operations meeting inclusion criteria. Operative duration, patient demographics, 30-day complication/readmission rates, and degree of resident involvement were collected. RESULTS: 625 cases were analyzed. Patient demographics were similar for all procedural comparison groups. Operative time increased with resident involvement for each operation-umbilical hernia repairs were associated with a 19% increase (22.3 ± 6.7 versus 26.5 ± 7.5 min, p = 0.002), laparoscopic cholecystectomies demonstrated a 15% increase (25.8 ± 8.7 versus 29.7 ± 10.2 min, p = 0.001), and laparoscopic inguinal hernia repairs demonstrated a 25% increase (32.1 ± 11.3 versus 40.2 ± 8.9 min, p < 0.001). CONCLUSIONS: Each surgeon must decide if the increase in operative duration caused by resident involvement is justified by the intangible benefits residents provide.

The impact of tree-stand falls on a Level 1 trauma center in West Michigan.

BACKGROUND: Falls from tree stands are common during the hunting season. We examined the impact of this injury mechanism on a Level 1 trauma center in West Michigan. METHODS: Retrospective cohort study examining tree-stand fall patients between 2001 and 2013. RESULTS: A total of 193 patients were included. Less than 3% of patients were wearing a harness. Falls from greater than 20 feet were associated with a higher injury severity score (P = .018). The injury severity score and Glasgow coma scale of the normal weight and overweight (OW) groups were the same. Overall 91.3% of normal weight patients were discharged home vs 63.5% of OW patients (P = .009). Median rehab stay was 12 days (3 to 92), and median charge was $24,048 (2,398 to 134,752). CONCLUSIONS: Tree-stand falls cause significant injury, especially from heights greater than 20 feet. OW patients more frequently require rehabilitation. The infrequent use of safety harnesses is alarming.

Is there truly an oncologic indication for interval appendectomy?

BACKGROUND: The rate of recurrent appendicitis is low following nonoperative management of complicated appendicitis. However, recent data suggest an increased rate of neoplasms in these cases. METHODS: The study was a retrospective review of patients with acute appendicitis at 2 university-affiliated community hospitals over a 12-year period. The primary outcome measure was the incidence of appendiceal neoplasm following interval appendectomy. RESULTS: Six thousand thirty-eight patients presented with acute appendicitis. Appendectomy was performed in 5,851 (97%) patients at the index admission. Of the 188 patients treated with initial nonoperative management, 89 (47%) underwent interval appendectomy. Appendiceal neoplasms were identified in 11 of the 89 (12%) patients. These included mucinous neoplasms (n = 6), carcinoid tumors (n = 4), and adenocarcinoma (n = 1). The rate of neoplasm in patients over age 40 was 16%. CONCLUSIONS: There is a significant rate of neoplasms identified in patient over age 40 undergoing interval appendectomy. This should be considered following nonoperative management of complicated appendicitis.

Utilization of a non-preserved cadaver to address deficiencies in technical skills during the third year of medical school: a cadaver model for teaching technical skills.

BACKGROUND: Emergency technical procedures performed by medical students have decreased in the last decade. An Emergency Surgical Skills Laboratory (ESSL) using a non-preserved cadaver was developed in response to address this deficiency. METHODS: A total of 232 students rotating through a 6-week surgery clerkship participated in the ESSL from 1 July 2008 to 1 July 2011. Two four-hour sessions using case-based trauma scenarios in the ESSL served as a model for procedural instruction. Skills taught included basic suturing, intubation, cricothyrotomy, chest tube placement, thoracentesis, venous access, central line, and radial arterial line placement. RESULTS: Students noted that technical proficiency in suturing was obtained during the ESSL sessions in comparison to the emergency department or operating room (p < 0.001) during the 6-week clerkship. During the 6-week rotation only 12 % of students participated in chest tube insertion, 5 % central venous line placement, and 14 % femoral vein blood draw. Finally, 90 % of respondents reported increased understanding and comfort in regard to trauma resuscitation following the ESSL. CONCLUSIONS: Technical procedural proficiency has become increasingly difficult to obtain in medical school due to multifactorial limitations. The ESSL provides an opportunity for developing technical skills needed for emergency situations not otherwise provided during the surgical clerkship.