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.

Insulin requirements in the intensive care unit in response to infection.

Infectious complications in the intensive care unit (ICU) are classically identified when an elevated temperature triggers obtaining cultures. Elevated temperature, however, is a nonspecific marker of infection and may occur well into the course of the infection. The goal of this study was to evaluate whether escalating insulin demands may serve as an earlier marker for infection. A retrospective review of a prospective database from a trauma ICU over a 6-month period was done for all patients who developed infection while in the ICU. All patients in the ICU are placed at admission on an intensive insulin protocol with target blood glucose levels between 80 and 110 mg/dL. Data were collected on infection, insulin needs, blood glucose levels, temperature, white blood cell count, and antibiotic use. Twenty-four infections were identified, with 16 pneumonias, four bloodstream infections, and four urinary tract infections. Twelve of the 24 patients had increasing insulin needs in the 3 days preceding their infection diagnosis, with nine of the 12 requiring continued escalation of insulin needs from preinfection Day 3 to 2 to 1 (D3, D2, D1). In five of the 12 patients, the escalation of insulin dose preceded the elevated temperature, and in three of the 12 patients, the escalation preceded elevation of the white blood cell count above 12. For all 24 patients, the average insulin dose increased steadily, from 1.8 U/hr on D3 preinfection to 2.5 U/hr D2 and 3.1 U/hr D1. Infection does seem to be preceded by escalating insulin demands in many patients. A prospective study to evaluate the value of increased insulin demand as a marker for developing infection is warranted.

Lung protective ventilation strategies: have we applied them in trauma patients at risk for acute lung injury and acute respiratory distress syndrome?

Lung protective ventilation strategies for patients with acute lung injury (ALI) and acute respiratory distress syndrome (ARDS) are well documented, and many medical centers fail to apply these strategies in ALI/ARDS. The objective of this study was to determine if we apply these strategies in trauma patients at risk for ALI/ARDS. We undertook a retrospective review of trauma patients mechanically ventilated for > or = 4 days with an ICD-9 for traumatic pneumothorax, hemothorax, lung contusion, and/or fractured ribs admitted from May 1, 1999 through April 30, 2000 (Group 1), the pre-ARDS Network study, and from May 1, 2003 through April 30, 2004 (Group 2), the post-ARDS Network study. Tidal volume (VT)/kg admission body weight, VT/kg ideal body weight (IBW), and plateau and peak pressures were analyzed with respect to mortality. VT/Kg admission body weight and IBW were significantly reduced when comparing Group 1 with Group 2 (9.27 to 8.03 and 11.67 to 10.04, respectively). VT/kg IBW was greater (P < 0.01) for patients who died in Group 1 (13.81) compared with patients who lived (10.29) or died (9.89) in Group 2. Peak and plateau pressures were greater (P < 0.01) in patients who died in Group 1 than patients who lived or died in Group 2. A strict ARDS Network ventilation strategy (VT < 6 mL/kg) is not followed, rather a low plateau/peak pressure strategy is used, which is a form of lung protective ventilation.

Early glucose normalization does not improve outcome in the critically ill trauma population.

Strict control of serum glucose in critically ill patients decreases morbidity and mortality. The objective of this study was to evaluate the effect of early normalization of glucose in our burn and trauma intensive care unit. From January 2002 to June 2005, 290 patients were admitted with serum glucose 150 mg/dL or greater and 319 patients with serum glucose less than 150 mg/dL. The patients with hyperglycemia were more severely injured and more often required operative intervention within the first 48 hours. The patients with hyperglycemia were at increased risk for infection and mortality. Of those 290 patients in the hyperglycemic cohort, 125 patients had early normalization of serum glucose, whereas 165 patients required more than 24 hours to normalize. The early normalization cohort was younger in mean age than the late group, but these 2 groups were similar in injury severity. Correspondingly, there was no difference in the rate of infection. Although hyperglycemia on admission appears to correlate with a worse outcome, early glucose normalization did not affect morbidity and mortality in our critically ill population.

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.

A simulation-based training system for surgical wound debridement.

A simulation-based training system for surgical wound debridement was developed and comprises a multimedia introduction, a surgical simulator (tutorial component), and an assessment component. The simulator includes two PCs, a haptic device, and mirrored display. Debridement is performed on a virtual leg model with a shallow laceration wound superimposed. Trainees are instructed to remove debris with forceps, scrub with a brush, and rinse with saline solution to maintain sterility. Research and development issues currently under investigation include tissue deformation models using mass-spring system and finite element methods; tissue cutting using a high-resolution volumetric mesh and dynamic topology; and accurate collision detection, cutting, and soft-body haptic rendering for two devices within the same haptic space.

Mass Casualty Incident Management Preparedness: A Survey of the American College of Surgeons Committee on Trauma.

Mass casualty incidents (MCIs) are events resulting in more injured patients than hospital systems can handle with standard protocols. Several studies have assessed hospital preparedness during MCIs. However, physicians and trauma surgeons need to be familiar with their hospital's MCI Plan. The purpose of this survey was to assess hospitals' and trauma surgeon's preparedness for MCIs. Online surveys were e-mailed to members of the American College of Surgeons committee on Trauma Ad Hoc Committee on Disaster and Mass Casualty Management before the March 2012 meeting. Eighty surveys were analyzed (of 258). About 76 per cent were American College of Surgeons Level I trauma centers, 18 per cent were Level II trauma centers. Fifty-seven per cent of Level I and 21 per cent of Level II trauma centers had experienced an MCI. A total of 98 per cent of respondents thought it was likely their hospital would see a future MCI. Severe weather storm was the most likely event (95%), followed by public transportation incident (86%), then explosion (85%). About 83 per cent of hospitals had mechanisms to request additional physician/surgeons, and 80 per cent reported plans for operative triage. The majority of trauma surgeons felt prepared for an MCI and believed an event was likely to occur in the future. The survey was limited by the highly select group of respondents and future surveys will be necessary.

Assessing surgical skill training under hazardous conditions in a virtual environment.

The present study examined the performance of a surgical procedure under simulated combat conditions. Eleven residents performed a cricothyroidotomy on a mannequin-based simulator in a fully immersive virtual environment running a combat simulation with a virtual sniper under both day and night time lighting conditions. The results showed that completion times improved between the first and second attempt and that differences between day and night time conditions were minimal. However, three participants were killed by the virtual sniper before completing the procedure. These results suggest that some participants' ability to allocate attention to the task and their surroundings was inappropriate even under simulated hazardous conditions. Further, this study shows that virtual environments offer the chance to study a wider variety of medical procedures performed under an unlimited number of conditions.

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.

Protocol-driven ventilator management in a trauma intensive care unit population.

HYPOTHESIS: The use of weaning and sedation protocols affects the intensive care unit (ICU) course of a trauma population. DESIGN: Nonrandomized before-after trial. SETTING: A level I trauma center. PATIENTS: Three hundred twenty-eight consecutive trauma patients receiving mechanical ventilation treated in the ICU between October 1, 1997, and November 1, 1999. INTERVENTION: Sedation and weaning protocols were used to treat patients receiving mechanical ventilation during the second year of this study. MAIN OUTCOME MEASURES: Self-extubation rates, ventilator days, number of ICU days, and charges. RESULTS: There were 168 patients in the preprotocol group (year 1: October 1, 1997, to October 31, 1998) and 160 patients in the postprotocol group (year 2: November 1, 1998, to November 30, 1999). The groups were similar in age (P =.68), Injury Severity Score (P =.06), and Glasgow Coma Scale score (P =.29). There were no differences in self-extubation rates (P =.57), ventilator days (P =.83), ventilator charges (P =.83), number of ICU days (P =.67), or ICU charges (P =.67) between the 2 groups. No statistical difference was identified in any of these categories when long-term ventilator patients (defined as ventilator length of stay > or =3 SDs above the mean) were excluded. CONCLUSIONS: Use of weaning and sedation protocols did not affect the measured outcomes in this study. These findings may reflect difficulties inherent in the protocols or with their utilization. Further subgroup analysis focusing on ventilator-associated pneumonias and mortality may demonstrate benefits not identified herein.

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.

Nonoperative trauma management: has the pendulum swung too far? The distinguished Dr. William Matory lecture.

Over the last decade, the role of nonoperative management has revolutionized the specialty of trauma. However, this management paradigm has generated substantial controversy in several areas, including penetrating neck and abdominal trauma. Evidence-based analysis will be the ultimate guideline to determine what is optimal management. To prevent the pendulum from swinging too far, there should always exist a high index of suspicion to possible complications associated with the nonoperative approach. Also, the specific choice of management should be institution- and resource dependent.

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.

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.

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.

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.

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.

Transitioning to thoracic endovascular repair: a single institution's analysis of the management of blunt aortic injury.

Over the past 15 years, there has been a rapid transformation in the way blunt aortic injuries (BAIs) are managed shifting from open thoracotomies to thoracic endovascular repairs (TEVAR). As a result of this change, we sought to describe our experience with open and endovascular repairs through a retrospective analysis of all trauma patients admitted with BAI to our Level I trauma center from 2002 to 2011. Demographic data, type of repair, complications, length of stay (LOS) data, and mortality were identified. No difference was noted in age, sex, Injury Severity Score, or Glasgow Coma Scale score between the two groups. There were also no differences in the number of acute complications or mortality. Intensive care unit (ICU) LOS was significantly shorter in the TEVAR group (20 vs 9 days, P < 0.05). Additionally, there was a trend toward shorter hospital LOS (28 vs 18 days, P = 0.07) and ventilator length of stay (12 vs 5 days, P = 0.171). In summary, endovascular repair of BAI is safe and has no increased rate of acute complications or mortality. ICU LOS is much shorter with TEVAR, and there was a trend toward shorter ventilator and hospital LOS, all of which may result in decreased cost. Still, more needs to be learned about potential long-term complications.