Management of Venous and Arterial Bullet Emboli.

Gunshot wounds account for significant morbidity and mortality in the United States. A rare and potentially fatal complication of a gunshot wound is bullet embolus. Potential complications include distal limb ischemia, coronary infarct, renal infarction, stroke, pulmonary embolization, cardiac valvular injury, thrombophlebitis, and dysrhythmias. Overall, surgical embolectomy and endovascular retrieval are the preferred treatments for bullet emboli. We report one case of venous bullet embolus and one case of arterial bullet embolus, both of which were successfully treated with endovascular retrieval. A thorough physical exam and appropriate imaging are vital to prompt identification and treatment of bullet emboli, as the repercussions of missed injuries can be devastating.

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.

Outcomes of Trauma Patients with Flail Chest and Surgical Rib Stabilization.

The goal of this project was to describe the current practices of this institution and identify which patients benefit from surgical stabilization of rib fractures (SSRF). A total of 1429 trauma patients admitted to our Level 1 center with rib fractures between January 1, 2014 and June 22, 2020 were retrospectively reviewed. Flail chest was observed in 43 (3.01%) patients. Surgical stabilization of rib fractures was pursued in 27 of all patients (1.89%). Twenty-four flail chest patients required intubation (ETT). Nineteen were not intubated (NoET). Of the ETT group, 8 underwent SSRF and 16 did not. Those who had SSRF had a shorter ventilator Length of Stay (7.1 vs 15.7 d) and Intensive Care Unit Length of Stay (9.8 vs 11.9 d). Surgical stabilization of rib fractures has shown success in managing flail chest. In intubated patients with flail chest, fixation seems to decrease Intensive Care Unit stays and the duration of ventilation. We believe we need to perform SSRF on more patients with flail chest.

Bedside Incentive Spirometry Predicts Risk of Pulmonary Complication in Patients with Rib Fractures.

This retrospective chart review demonstrates the relationship between bedside incentive spirometry (ICS) volumes and risk of pulmonary complications. Two hundred patients admitted for rib fractures between April and October 2016 were reviewed. The inclusion criteria were age 18-98 years, diagnosis of rib or sternal fractures, and no procedures requiring postoperative intubation within 48 hours of admission. The exclusion criteria were intubation before arrival, unable to participate in ICS, or previous tracheostomy. ICS volumes recorded in daily progress notes were collected. Of 200 charts reviewed, 154 met the inclusion criteria. In all, 25 endured at least one pulmonary complication. The average ICS on admission was 1355 cc. Patients who did not experience a complication had significantly higher admission ICS volumes than those who did (1441 ± 660 cc vs 920 ± 451 cc, P = 0.0003). They also achieved higher volumes at discharge (1705 ± 662 cc vs 1211 ± 453 cc, P = 0.006). The groups had similar demographics. An admission ICS volume <1 L was associated with 3.3× relative risk of pulmonary complication. Lower volumes were also associated with discharge to nonhome locations. Bedside ICS is a useful tool to identify patients at risk of pulmonary complications from rib fractures. Patients with admission ICS volume <1 L carry a higher risk of complication.

Effect of Implementation of Intermittent Straight Catheter Protocol on Rate of Urinary Tract Infections in a Trauma Population.

Catheter-associated urinary tract infections (UTIs) are a significant negative outcome. There are previous studies showing advantages in removing Foleys early but no studies of the effect of using intermittent as opposed to Foley catheterization in a trauma population. This study evaluates the effectiveness of a straight catheter protocol implemented in February 2015. A retrospective chart review was performed on all patients admitted to the trauma service at a single institution who had a UTI one year before and one year after protocol implementation on February 18, 2015. The protocol involved removing Foley catheters early and using straight catheterization. Rates were compared with Fisher's exact test and continuous data were compared using student's t test. There were 1477 patients admitted to the trauma service in the control year and 1707 in the study year. The control year had a total of 43 patients with a UTI, 28 of these met inclusion criteria. The intervention year had a total of 35 patients with a UTI and 17 met inclusion criteria. The rate of patients having a UTI went from 0.019 to 0.010 (p = 0.035). In females this rate went from 0.033 to 0.009 (p = 0.007), whereas in males it went from 0.012 to 0.010 (p = 0.837). This study shows a statistically significant improvement in the rate of UTIs after implementing an intermittent catheterization protocol suggesting that this protocol could improve the rate of UTIs in other trauma centers. We use this for all trauma patients, and it is being looked at for use hospital-wide.

Initial Cholecystectomy with Cholangiography Decreases Length of Stay Compared to Preoperative MRCP or ERCP in the Management of Choledocholithiasis.

There are several treatments available for choledocholithiasis, but the optimal treatment is highly debated. Some advocate preoperative endoscopic retrograde cholangiopancreatography (ERCP) followed by laparoscopic cholecystectomy (LC) with cholangiography (IOC). Others advocate initial LC + IOC followed by common bile duct exploration or ERCP. The purpose of this study was to determine whether initial LC + IOC had a shorter length of stay (LOS) compared with preoperative magnetic resonance cholangiopancreatography (MRCP) or ERCP. Patients who underwent cholecystectomy between 2012 and 2013 at two institutions were reviewed. Patients were selected if they had suspected choledocholithiasis, indicated by dilated CBD and/or elevated bilirubin, or confirmed choledocholithiasis. They were excluded if they had pancreatitis or cholangitis. There were 126 patients with suspected choledocholithiasis in this study. Of these, 97 patients underwent initial LC ± IOC with an average LOS of 3.9 days. IOC was negative in 47.4 per cent patients, and they had a shorter LOS compared with positive IOC patients (2.93 vs 4.82, P < 0.001). Laparoscopic common bile duct exploration was successful in 64.7 per cent and had a shorter LOS compared with postoperative ERCP patients (P = 0.01). Preoperative MRCP was performed in 21 patients with an average LOS of 6.48 days. Preoperative ERCP was performed in eight patients with an average LOS of seven days. Initial LC+IOC is associated with a shorter LOS compared to preoperative MRCP or ERCP. It is recommended as the optimal treatment choice for suspected choledocholithiasis.

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.

Can routine trauma bay chest x-ray be bypassed with an extended focused assessment with sonography for trauma examination?

The objective of this study was to investigate the feasibility of using ultrasound (US) in place of portable chest x-ray (CXR) for the rapid detection of a traumatic pneumothorax (PTX) requiring urgent decompression in the trauma bay. All patients who presented as a trauma alert to a single institution from August 2011 to May 2012 underwent an extended focused assessment with sonography for trauma (FAST). The thoracic cavity was examined using four-view US imaging and were interpreted by a chief resident (Postgraduate Year 4) or attending staff. US results were compared with CXR and chest computed tomography (CT) scans, when obtained. The average age was 37.8 years and 68 per cent of the patients were male. Blunt injury occurred in 87 per cent and penetrating injury in 12 per cent of activations. US was able to predict the absence of PTX on CXR with a sensitivity of 93.8 per cent, specificity of 98 per cent, and a negative predictive value of 99.9 per cent compared with CXR. The only missed PTX seen on CXR was a small, low anterior, loculated PTX that was stable for transport to CT. The use of thoracic US during the FAST can rapidly and safely detect the absence of a clinically significant PTX. US can replace routine CXR obtained in the trauma bay and allow more rapid initiation of definitive imaging studies.

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.

Do postoperative antibiotics prevent abscess formation in complicated appendicitis?

Recent studies have shown that postoperative antibiotics in nonperforated appendicitis do not reduce infectious complications; however, there is no consensus on patients with complicated appendicitis. The aim of this study is to determine whether postoperative antibiotic administration in complicated appendicitis prevents intra-abdominal abscess formation. We conducted a retrospective chart review of all patients undergoing appendectomy from 2007 to 2012 at our institution. Patients with complicated appendicitis (perforated, gangrenous, or periappendiceal abscess) were identified and data collected including details of postoperative antibiotic administration and rates of postoperative abscess development. Of 444 charts reviewed, 52 patients were included. Forty-four patients received greater than 24 hours and eight patients received 24 hours or less of postoperative antibiotics. In those receiving greater than 24 hours of antibiotics, nine of 44 (20.5%) developed a postoperative abscess, and in those receiving 24 hours or less of antibiotics, two of eight (25.0%) developed a postoperative abscess (P = 1.0000). There is no significant difference in postoperative abscess development among those with complicated appendicitis who received greater than 24 hours of postoperative antibiotics compared with those who did not. Postoperative antibiotics may not provide an appreciable clinical benefit for preventing intra-abdominal abscesses; however, larger sample sizes and prospective studies are needed to confirm these findings.

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.

Withdrawal of care in a trauma intensive care unit: the impact on mortality rate.

Withdrawal of care has increased in recent years as the population older than 65 years of age has increased. We sought to investigate the impact of this decision on our mortality rate. We retrospectively reviewed a prospectively collected database to determine the percentage of cases in which care was actively withdrawn. Neurologic injury as the cause for withdrawal, age of the patient, number of days to death, number of cases thought to be treatment failures, and the reason for failure were analyzed. Between January 2008 and December 2012, there were 536 trauma service deaths; 158 (29.5%) had care withdrawn. These patients were 67 (± 18.5) years old and neurologic injury was responsible in 63 per cent (± 5.29%). Fifty-two per cent of the patients died by Day 3; 65 per cent by Day 5; and 74 per cent Day 7. A total of 22.7 per cent (± 7.9%) could be considered a treatment failure. Accounting for cases in which care was withdrawn for futility would decrease the overall mortality rate by approximately 23 per cent. Trauma center mortality calculation does not account for care withdrawn. Treating an active, aging population, with advance directives, requires methodologies that account for such decision-making when determining mortality rates.

Basic ultrasound training can replace chest radiography for safe tube thoracostomy removal.

An ultrasound (US) examination can be easily and rapidly performed at the bedside to aide in clinical decisions. Previously we demonstrated that US was safe and as effective as a chest x-ray (CXR) for removal of tube thoracostomy (TT) when performed by experienced sonographers. This study sought to examine if US was as safe and accurate for the evaluation of pneumothorax (PTX) associated with TT removal after basic US training. Patients included had TT managed by the surgical team between October 2012 and May 2013. Bedside US was performed by a variety of members of the trauma team before and after removal. All residents received, at minimum, a 1-hour formal training class in the use of ultrasound. Data were collected from the electronic medical records. We evaluated 61 TTs in 61 patients during the study period. Exclusion of 12 tubes occurred secondary to having incomplete imaging, charting, or death before having TT removed. Of the 49 remaining TT, all were managed with US imaging. Average age of the patients was 40 years and 30 (61%) were male. TT was placed for PTX in 37 (76%), hemothorax in seven (14%), hemopneumothorax in four (8%), or a pleural effusion in one (2%). Two post pull PTXs were correctly identified by residents using US. This was confirmed on CXR with appropriate changes made. US was able to successfully predict the safe TT removal and patient discharge at all residency levels after receiving a basic US training program.

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.