Acute cardiogenic shock secondary to blunt traumatic aortic valve injury.

Background: Blunt cardiac injuries rarely result in aortic valve cusp rupture, leading to acute aortic insufficiency and cardiogenic shock. This rare clinical entity carries a high mortality rate if left undiagnosed and not managed surgically, with few patients surviving beyond 24 h. It presents a diagnostic challenge in the polytrauma patient in shock, with multiple possible and complementary etiologies. Case presentation: We present a 56-year-old male with persistent hypotension, a wide pulse pressure, and elevated serum troponin levels suggesting blunt cardiac injury after a motor vehicle accident. Transthoracic and transesophageal echocardiography revealed normal biventricular function but severe aortic insufficiency due to prolapse of the left coronary cusp.He was taken emergently to surgery, where aortic valve exploration revealed complete left coronary cusp avulsion from the aortic annulus with a mid-cusp tear, requiring aortic valve replacement with a bioprosthetic valve. Postoperative echocardiography showed normal biventricular function with a well-seated bioprosthetic aortic valve with no insufficiency. Conclusions: Traumatic aortic valve injury can lead to torn or prolapsed cusps causing acute aortic insufficiency leading to cardiogenic shock, but early recognition with appropriate and targeted diagnostic imaging is vital to prevent rapid patient deterioration and demise.

Technical Considerations in Laparoscopic-Assisted Endoscopic Retrograde Cholangiography.

The use of endoscopic retrograde cholangiography (ERCP) for diagnostic and therapeutic interventions on the pancreaticobiliary system has steadily increased, but the standard approach through the oropharynx is prohibited after Roux-en-Y (RYGB) gastric bypass surgery. Laparoscopic access to the gastric remnant allows for the completion of ERCP using the standard side-viewing duodenoscope to facilitate the completion of standard and advanced endoscopic maneuvers. Here, we describe our experience with the technical aspects of safe and effective performance of laparoscopic-assisted ERCP.

To Resect or Not to Resect: A Nationwide Comparison of Management of Sigmoid Volvulus.

INTRODUCTION: Despite the high recurrence rate of sigmoid volvulus, there is reluctance to perform a prophylactic colectomy in frail patients due to the operation's perceived risks. We used a nationally representative database to compare risk of recurrence in patients undergoing a prophylactic colectomy versus endoscopic detorsion alone. METHODS: We performed a retrospective cohort study using the National Readmission Database (2016-2019) including patients aged ≥18 y who had an emergent admission for sigmoid volvulus and underwent endoscopic detorsion on the day of admission. We performed a 1:1 propensity matching adjusting for patient demographics, frailty score comprising of 109 components, and hospital characteristics. Our primary outcome was readmission due to colonic volvulus and secondary outcomes included mortality, complications, length of stay (LOS), and costs during index admission and readmission. We performed a subgroup analysis in patients with Hospital Frailty Score >5. RESULTS: We included 2113 patients of which 1046 patients (49.5%) underwent a colectomy during the initial admission. In the matched population of 830 pairs, readmission due to colonic volvulus was significantly lower in patients undergoing endoscopy followed by colectomy than endoscopy alone. Patients undergoing a colectomy had higher gastric and renal complications, longer LOS, and higher costs but no difference in mortality. In the subgroup analysis of frail patients, readmission was significantly lower in patients with prophylactic colectomy with no significant difference in mortality in 439 matched patients. CONCLUSIONS: Prophylactic colectomy was associated with lower readmission, a higher rate of complications, increased LOS, and higher costs compared to sigmoid decompression alone.

Incidence of Endoscopic Retrograde Cholangiography after Subtotal Fenestrating and Reconstituting Cholecystectomy.

BACKGROUND: Laparoscopic subtotal cholecystectomy (SC) is used for the difficult cholecystectomy, but published experience with resource use for SC is limited. We hypothesized that the need for advanced resources are common after SC. STUDY DESIGN: This was a retrospective review of laparoscopic cholecystectomies between 2017 and 2021 at a large center. SC cases were identified using a medical record tool. Baseline characteristics were assessed with Student's t -test and chi-square test. Primary outcome was endoscopic retrograde cholangiography (ERC) within 60 days. Secondary outcomes were reconstituted SC on postoperative ERC and length of stay (LOS). Uni- and multivariable logistic regression were used for binary outcomes. Multiple linear regression was used for LOS. Covariates included were age, sex, BMI, and American Society of Anesthesiology class. RESULTS: A total of 1,222 laparoscopic cholecystectomies were performed between 2017 and 2021. Of these, 87 (7%) were SC. Male (p < 0.001) and older (p < 0.001) patients were more likely to undergo SC. Odds of postoperative ERC were higher in the SC group (odds ratio 9.79, 95% CI 5.90 to16.23, p < 0.001). There was no difference in preoperative ERC (17% vs 21%, p = 0.38). Reconstituting SC had lower odds of postoperative ERC (odds ratio 0.12, 95% CI 0.023 to 0.58, p = 0.009). LOS was 1.81 times higher in the SC group (p ≤ 0.001). Postoperative ERC was not associated with LOS (p = 0.24). CONCLUSIONS: We present one of the largest single-center series of SC. Patients who underwent SC are more likely to be male, older, have higher American Society of Anesthesiology class, and have increased LOS. SC should be performed when access to ERC and interventional radiology is available. In the absence of these adjuncts, reconstituting SC decreases the need for early ERC, but long-term outcomes are unknown.

The Importance of Early Femoral Access When REBOA Catheter Must Be Removed Prior to Hemorrhage Control.

Resuscitative endovascular balloon occlusion of the aorta (REBOA) is a tool for hemorrhage control. We describe a case where the REBOA Catheter needed to be removed prior to hemorrhage control. The patient is a 40-year-old man that presented following motor vehicle collision. A REBOA Catheter was placed via the right common femoral artery (CFA). CT scan demonstrated extravasation from the left inferior epigastric artery. The Interventional Radiology (IR) team would only be able to perform angioembolization via contralateral access where the REBOA Catheter was in place. Prior to removing the REBOA Catheter on the right, left CFA access was obtained in the event a new catheter needed to be deployed. Ultimately, IR performed angioembolization without a second REBOA Catheter. In gaining contralateral access prior to removing the REBOA Catheter, this case provides a strategy for expeditious replacement of REBOA Catheters in situations where the catheter interferes with hemorrhage control procedures.

The Cost of Poverty: The Relationship Between Insurance Status, Length of Stay, and Discharge Disposition in Trauma Patients.

INTRODUCTION: Insurance status (IS) is known to be associated with length of stay (LOS). The impact of IS on excess LOS (ELOS), days between medical readiness and discharge date, has not been explored. METHODS: We conducted a retrospective study of patients with pelvic fractures at a level I trauma center. Outcomes included ELOS (primary), discharge disposition (secondary), and ELOS-associated complications (secondary). RESULTS: 185 patients were included. Uninsured patients were the youngest and had the least baseline comorbidities (31.3 years (median), Charlson Comorbidity Index (CCI) .1) while publicly insured patients were the oldest and had the most baseline comorbidities (58.4 years (median), CCI 2.32). Excess LOS and associated complications did not differ among groups. After regression analysis, UIPs had longer LOS than PRPs (2.07 days, 95% CI .28-3.85). UIPs were recommended to go to inpatient rehabilitation 51.6% of the time but were discharged home 93.6% of the time; 81.0% of these changes were attributed to insufficient financial resources. CONCLUSIONS: Excess LOS and complications associated with ELOS were not associated with IS. Although UIPs were younger and had fewer baseline comorbidities, they had longer LOS after regression analysis. While discharge recommendations differed based on insurance status, UIPs had limited access to rehabilitation due to financial disparities. Despite initial treatment team recommendations, UIPs had to be sent home as their lack of insurance precluded inpatient rehabilitation placement.

A Daily Checklist Method Increases Documentation of Code Status in Trauma Patients.

OBJECTIVES: While insufficient code status documentation (CSD) is a longstanding challenge, all patients deserve the opportunity to participate in decision-making regarding code status, especially trauma patients with an unpredictable course. Prior interventions to increase CSD relied on reminder systems. We hypothesize that introducing a daily checklist will increase CSD for patients in the trauma ICU. METHODS: This quality improvement study examined the efficacy of a twice-daily checklist for improving CSD in trauma patients at a level I trauma center. A pre-intervention (PRE) and post-intervention (POST) daily census characterized the percentage of patients with CSD (primary outcome), time-to-code status (TTCS, secondary outcome) documentation, and information about patients who were discharged with no code status (DNCS, secondary outcome). RESULTS: Of 213 PRE and 207 POST, daily census CSD for all patients increased from a median of 50.0% PRE to 64.4% POST (P < .05). Time-to-code status was halved (PRE: 25.30 h, POST: 12.71 h, P < .05). Code status documentation within 12 h increased from 41.8% PRE to 60.9% POST (P < .05). Overall, the percentage of patients with CSD during their hospitalization increased 20% (PRE: 63.8%, POST: 83.6%, P < .05). Discharged with no code status patients decreased 20% (PRE: 35.2%, POST: 15.5%, P < .05). CONCLUSION: Including code status in a daily checklist involving key aspects of care for trauma patients is an effective method for improving code status documentation. Capturing code status for more patients in trauma allows us to provide patient-centered, goal-concordant care.

Computed tomography scanning is feasible in select patients with REBOA catheter deployment.

BACKGROUND: Rapidly localizing and controlling bleeding is central to treating hemorrhagic shock. While REBOA allows temporary control, identifying the source of bleeding remains challenging. CT imaging with REBOA in place may provide information to direct hemorrhage control. The purpose of this study is to provide a descriptive summary of data comparing patients who did and did not undergo CT scan following REBOA deployment. Our hypothesis was that performing CT scan after REBOA placement in select patients is safe and can guide management of hemorrhagic shock. METHODS: We queried the AAST AORTA registry for patients receiving REBOA at our level 1 trauma center from May 2017 to December 2021. Clinical data was obtained through the Trauma Registry of the American College of Surgeons (TRACS). Comparison groups were those who underwent CT scan after REBOA deployment versus those who did not undergo CT scan after REBOA deployment. The primary outcome was inhospital mortality, and secondary outcomes included hospital-, ICU-, and ventilator-free days. RESULTS: 61 patients underwent CT scan with REBOA in place; 25 patients proceeded directly to hemorrhage control. Patients with REBOA prior to CT were more likely to have blunt mechanism, higher ISS, pelvic bleeding, and zone 3 REBOA placement. Mortality was not significantly different (51 % vs. 64 %). Patients who underwent CT with REBOA were more likely to undergo hemorrhage control in interventional radiology (43 % vs. 0 %). There was no difference in hospital-, ICU-, and ventilator-free days. DISCUSSION: We demonstrate the feasibility of performing CT in select trauma patients who undergo REBOA. We describe a pathway to enable expeditious workup and management of these patients. Optimal hemorrhage control management is impacted by CT scans when it can be performed. It is important to note that this is a severely injured patient population, and mortality is high even when hemorrhage is controlled. LEVEL OF EVIDENCE: III.

Zonisamide: A Comprehensive, Updated Review for the Clinician.

Purpose of Review: Zonisamide (ZNS) was first approved in the United States in 2000 for the adjunctive treatment of patients aged 16 years or older with partial (focal) seizures. Although ZNS has been proven to treat multiple seizure types, it has been largely underutilized in US clinical practice. Recent Findings: Published literature demonstrated that antiseizure medications (ASMs) acting on Na+ and Ca2+ channels may add beneficial effects in many seizure types by reducing seizure frequency and leading to overall improvements. In addition, effects of ZNS may lead to clinical improvements in Parkinson disease, alcohol and sleep disorders, pain, and migraine. ZNS is available in multiple formulations and is a safe and effective, broad spectrum ASM. Summary: The purpose of this review was to provide an update to what is known about the efficacy of ZNS and where it shows benefits in the treatment of patients with epilepsy and other CNS disorders through its many unique mechanisms of action.