Low Threshold for Laparoscopic Exploration in Dementia Patients With Unexplained Abdominal Pain and Risk Factors for Acute Mesenteric Ischemia.

Acute mesenteric ischemia (AMI) is associated with a high mortality and morbidity. There are limited studies on the presentation and management of elderly dementia patients with AMI. The following case of an 88-year-old female with dementia presenting with AMI highlights the challenges in the care of elderly dementia patients with AMI, the importance of identifying risk factors and hallmarks of acute mesenteric ischemia early in the clinical course, and suggests that aggressive workup with diagnostic laparoscopy is crucial to timely diagnosis and effective care.

Financial Toxicity in Emergency General Surgery: Novel Propensity-Matched Outcome Comparison.

BACKGROUND: Financial toxicity describes the harmful effect of individual treatment costs and fiscal burdens that have a compounding negative impact on outcomes in surgery. While this phenomenon has been widely studied in surgical oncology, the purpose of this study was to perform a novel exploration of the impact of financial toxicity in emergency general surgery (EGS) patients throughout the US. STUDY DESIGN: The Nationwide Readmissions Database for January and February 2018 was queried for all EGS patients aged 18 to 65 years. One-to-one propensity matching was performed with and without risk for financial toxicity. The primary outcome was mortality, and the secondary outcomes were venous thromboembolism (VTE), prolonged length of stay (LOS), and readmission within 30 days. RESULTS: There were 24,154 EGS patients propensity matched. The mortality rate was 0.2% (n = 39), and the rate of VTE was 0.5% (n = 113). With financial toxicity, there was no statistically significant difference for mortality (p = 0.08) or VTE (p = 0.30). The rate of prolonged LOS was 6.2% (n = 824), and the risk was increased with financial toxicity (risk ratio 1.24 [1.12 to 1.37]; p < 0.001). The readmission rate was 7.0% (n = 926), and the risk with financial toxicity was increased (risk ratio 1.21 [1.10 to 1.33]; p < 0.001). The mean count of comorbidities per patient per admission during readmission within 1 year with financial toxicity was 2.1 ± 1.9 versus 1.8 ± 1.7 without (p < 0.001). CONCLUSIONS: Despite little difference in the rate of mortality or VTE, EGS patients at risk for financial toxicity have an increased risk of readmission and longer LOS. Fewer comorbidities were identified at index admission than during readmission in patients at risk for financial toxicity. Future studies aimed at reducing this compounding effect of financial toxicity and identifying missed comorbidities have the potential to improve EGS outcomes.

Jejuno-jejunal intussusception secondary to recurrent/metastatic melanoma.

Intussusception is uncommon in adults, and usually secondary to a neoplasm. Small bowel obstruction (SBO) is prevalent in adults but rarely due to intussusception. A 55-year-old woman with history of melanoma (four years in remission) presented with abdominal pain and melena. Upper and lower endoscopy was normal. She developed bilious emesis and worsening pain, so she presented to the emergency department. CT abdomen/pelvis identified a SBO with transition point at a small bowel intussusception; she was taken to the operating room. A mid-jejunal intussusception was reduced revealing a mass; resection and primary anastomosis was performed. Final pathology demonstrated a 5.5 cm melanoma, likely metastatic. She required no additional therapy and remains in remission eighteen months later. Intussusception due to metastatic melanoma is rare but should be on the differential for patients with SBO and history of melanoma. Knowledge of this history should prompt consideration for oncologic resection to optimize outcome.

Cerebral Fat Embolism via a Patent Foramen Ovale.

Fat embolism syndrome (FES) is a multisystem process predominantly secondary to long bone/pelvic fractures and orthopedic procedures. A 19-year-old man presents after motor vehicle collision with trace right pneumothorax, right grade 3 kidney laceration, left pubic rami, and right femoral shaft fractures. Right femur closed reduction ensued and he underwent intramedullary nailing; his other injuries were managed nonoperatively. Upon awakening in recovery, he was newly aphasic. Despite negative repeat CT brain, he continued to worsen and became tachycardic and hypoxemic. MRI/MRA brain demonstrated innumerable bilateral frontal, parietal, and occipital acute ischemic infarcts in a starfield pattern. Echocardiogram revealed a PFO. With supportive care, he improved and was discharged with planned outpatient PFO closure. One month later, he had complete symptom resolution with return to neurologic baseline. FES is a potentially devastating condition which may include cerebral fat embolism (CFE) with outcomes varying widely from mortality to complete recovery.

Open thoracic window: a useful alternative for retained infected pleural collections in critically ill trauma patients.

Historically, tube thoracostomy, image-guided drainage, or an open thoracotomy has been indicated as the standard procedure for the management of patients with retained infected pleural collections (RIPC). These infections can be a debilitating and potentially lethal complication in already critically ill trauma patients. The purpose of this review was to evaluate the usefulness of an open thoracic window (OTW) as definitive therapy for the management of RIPC refractory to conventional therapies. The medical records of patients who underwent an OTW for RIPC were reviewed for the following: demographic data, primary diagnosis, clinical findings that explained the failure of the conventional management, bacteriology of the retained collection, and final outcome. Over a 3-year period, eight critically ill trauma patients who had sustained multiple system trauma and developed a RIPC were identified (six males and two females; average age, 47 years). Of the eight patients identified, six collections were in the right and two in the left pleural cavity. Staphylococcus aureus and Acinetobacter were the two most common bacterial isolates from these collections. All patients had undergone multiple and unsuccessful drainage attempts by thoracostomy tubes. Additionally, two of the patients also underwent image-guided drainage procedures, which proved to be unsuccessful. After creation of the OTW, all patients had complete resolution of the RIPC, and all were discharged alive from the hospital. During outpatient follow up, the OTW was found to have completely healed and required no further surgical intervention. The creation of long-term pleural drainage, with an OTW, facilitates and expedites the resolution of persistent infected pleural collections by providing more efficient surgical drainage and mechanical débridement. Our experience also shows this uncommon operation to be an effective alternative when conventional measures have failed.

Investigating Clinical and Cost Burdens of Law Enforcement-Related K9 Injuries: The Impact of "the Bite" on a Community Hospital.

The decision to introduce canines (K9s) to a law enforcement (LE) agency does not typically involve the evaluation of the fiscal or clinical impact on local hospitals. This study compared injury, cost, and care associated with K9s to a common nonlethal force method, the Thomas A Swift Electrical Rifle (TASER), to highlight the cost and resources required to treat both patient types. Patients treated for LE-related K9 and TASER injuries at a Level I community-based trauma center (2011-2016) were evaluated for level of care required (e.g., surgeon/specialist), clinical interventions, proxy medical costs, and length of stay (LOS). Nearly one-third of K9 patients required tertiary-level medical care. The cost of treating the K9-inflicted injuries (n = 75) was almost twice as costly as care for patients subdued with a TASER (n = 80); the K9 patients had significantly (one-tailed t tests) higher medical costs (P = 0.036), required more medical procedures (P = 0.014), and had longer LOS (P = 0.0046) than the TASER patients. Patients with K9 injuries had higher acuity and were significantly more expensive to treat with longer LOS than TASER injuries. LE agencies considering establishing and operating a K9 unit should initiate discussions with their local medical first responders and health-care facilities regarding the capabilities to treat severe K9 injuries to ensure adequate resource allocation.

Necrotizing Fasciitis Resulting from an Anastomotic Leak after Colorectal Resection.

One of the most feared complications in colorectal surgery is an anastomotic leak (AL) following a colorectal resection. While various recommendations have been proposed to prevent this potentially fatal complication, anastomotic leaks still occur. We present a case of an AL resulting in a complicated and fatal outcome. This case demonstrates the importance of high clinical suspicion, early recognition, and immediate management.

Advances and changes in the management of liver injuries.

Because of advances in noninvasive imaging techniques and a better understanding of the natural history of hepatic injuries; currently, most patients with complex liver injuries are treated in a nonoperative manner. Additionally, the availability of less invasive procedures has expanded dramatically the treatment options for these patients, optimizing the outcomes of initial nonoperative management. Even though nonoperative management has become the standard of care in patients with complex liver injuries in most trauma centers in the United States, surgeons should not hesitate to operate on a patient to control life-threatening hemorrhage.

Prevention of bile peritonitis by laparoscopic evacuation and lavage after nonoperative treatment of liver injuries.

One of the major lessons learned in the World War II experience with liver injuries was that bile peritonitis was a major factor in morbidity and mortality; the nearly uniform drainage of liver injuries in the subsequent operative era prevented this problem. In the era of nonoperative management, patients who do not require operative treatment for hemodynamic instability may develop large bile and/or blood collections that are often ignored or inadequately drained by percutaneous methods. These inadequately treated bile collections may cause systemic inflammatory response syndrome and/or respiratory distress. We present an experience with laparoscopic evacuation of major bile/blood collections that may prevent the inflammatory sequelae of bile peritonitis. Patients usually underwent operation between 3 and 5 days postinjury (range, 2-18) if CT demonstrated large fluid collections throughout the abdomen/pelvis not amenable to percutaneous drainage. Most patients had signs of systemic inflammatory response syndrome, respiratory compromise, or elevated bilirubin. The bile and retained hematoma was evacuated from around the liver and closed-suction drainage was placed. Twenty-eight patients underwent laparoscopic evacuation/lavage of bile collections (about 4% of total blunt liver injuries). The majority (75%) had Grade IV or V injury. The amount of evacuated fluid ranged from 300 to 3800 mL. Other adjunctive procedures (endoscopic retrograde pancreaticocholangiography, angiography, and laparotomy) were occasionally required. There were no complications related to the procedure. Most patients had a dramatic decline in tachycardia, temperature, white blood cell count, serum bilirubin, and pain. Respiratory failure also resolved in most patients. Large bile and/or blood accumulations are present in a subset of patients with severe liver injuries treated nonoperatively. Delayed laparoscopic evacuation of these collections prevents bile peritonitis and decreases inflammatory response and avoiding early operation, which has been implicated in increased death from hemorrhage.

Inclusion of the Acute Care Surgeon in the Difficult Airway Protocol: A Nine-Year Experience.

An emergency surgical airway is a lifesaving intervention required in the event of airway loss or respiratory failure when conventional endotracheal intubation cannot be performed. The Acute Care Surgery/Trauma Service is a critical component in the angioedema/difficult airway protocol at our institution. We conducted a retrospective review (2007-2016) to analyze the role our service has in managing patients requiring an emergency surgical airway. Cases were analyzed for preexisting conditions, hospital location of procedure, techniques, complications, and mortality. Our protocol involves early coordination between anesthesia and the Acute Care Surgery/Trauma Service for patients with a potentially difficult airway. If anesthesia is unable to intubate the patient, a surgical airway is performed. Patients are preemptively taken to the operating room (OR) if stable for transport. There were 43 surgical airways performed during the study period. All patients had a failed attempt with oral endotracheal intubation. The most common factors associated with these patients were history of tracheostomy, angioedema, or difficult anatomy. Nineteen (44%) of the surgical airways were performed in the OR. Three deaths (7%) occurred from cardiac or respiratory arrest despite the emergency procedure. No immediate deaths occurred in the patients taken to the OR. Early coordination in patients with a difficult airway is another hospital resource that the acute care surgeon can provide to improve patient outcomes.

Intraoperative rescue extracorporeal membrane oxygenation and damage control during repair of a traumatic aortic injury.

A 21-year-old male involved in a motorcycle crash presented with abdominal hemorrhage and a widened mediastinum on chest radiograph. He required an initial exploratory laparotomy for mesenteric injuries. An aortic injury was confirmed on computed tomography imaging and he subsequently underwent attempted endovascular repair. During that procedure, the patient experienced massive thoracic hemorrhage with cardiac arrest and profound respiratory failure. Damage-control thoracic surgery and rescue extracorporeal membrane oxygenation were successfully utilized with a favorable outcome.

Lightning Burns and Electrical Trauma in a Couple Simultaneously Struck by Lightning.

More people are struck and killed by lightning each year in Florida than any other state in the United States. This report discusses a couple that was simultaneously struck by lightning while walking arm-in-arm. Both patients presented with characteristic lightning burns and were admitted for hemodynamic monitoring, serum labs, and observation and were subsequently discharged home. Despite the superficial appearance of lightning burns, serious internal electrical injuries are common. Therefore, lightning strike victims should be admitted and evaluated for cardiac arrhythmias, renal injury, and neurological sequelae.

A unique case of popliteal artery transection after a motorcycle collision.

Popliteal artery injuries may have devastating consequences if not recognized in a timely fashion. The risk of delayed diagnosis of a vascular injury is particularly high in blunt trauma to the lower extremity. We present a case of popliteal artery injury that is unusual in two respects: severity (a complete transection in the setting of a blunt injury) and lack of clinical and radiographic signs of the commonly associated musculoskeletal injuries.

Traumatic Lung Herniation following Skateboard Fall.

Lung herniation (LH) is a rare clinical entity involving the protrusion of lung outside the thoracic cage. It has a variety of etiologies and clinical presentations, making diagnosis difficult. We present a case of a 20-year-old male who reported pleuritic pain after falling from a skateboard. Evaluation through computed tomography (CT) scanning of the chest revealed an anterior lung hernia associated with rib fractures. This case emphasizes the need for clinicians to include lung herniation in the differential diagnosis of patients with trauma and inexplicable or persistent pulmonary issues.

Acute Care/Trauma Surgeon's role in obstetrical/gynecologic emergencies (The OBCAT Alert).

BACKGROUND: Overwhelming hemorrhage or other intra-abdominal complications may be associated with obstetrical or gynecologic (OB/GYN) procedures and may require the surgical training of an Acute Care/Trauma Surgeon. The OB Critical Assessment Team (OBCAT Alert) was developed at our institution to facilitate a multidisciplinary response to complex OB/GYN cases. We sought to review and characterize the Acute Care/Trauma Surgeon's role in these cases. METHODS: We conducted a retrospective review of all emergency consults during an OB/GYN case at our institution from 2008 to 2015. An OBCAT is a hospital based alert system designed to immediately notify OB/GYN, anesthesiology, Acute Care/Trauma, the intensive care unit (ICU), and the blood bank of a potential emergency during an OB/GYN case. RESULTS: There were 7±3 OBCAT alerts/year. Seventeen patients required Acute Care/Trauma surgery intervention for hemorrhage. Thirteen patients required damage control packing during their hospitalization. Blood loss averaged 6.8±5.5 L and patients received a total of 21±14 units during deliveries with hemorrhage. There were 17 other surgical interventions not related to hemorrhage; seven of these cases were related to adhesions or intestinal injury. Seven additional cases required evaluation post routine OB/GYN procedure; the most common reason was for severe wound complications. There were three deaths during this study period. CONCLUSION: Emergency OB/GYN cases are associated with high morbidity and may require damage control or other surgical techniques in cases of overwhelming hemorrhage. Acute Care/Trauma Surgeons have a key role in the treatment of these complex cases.

Congenital Renal Fusion and Ectopia in the Trauma Patient.

We present two separate cases of young male patients with congenital kidney anomalies (horseshoe and crossed fused renal ectopia) identified following blunt abdominal trauma. Despite being rare, ectopic and fusion anomalies of the kidneys are occasionally noted in a trauma patient during imaging or upon exploration of the abdomen. Incidental renal findings may influence the management of traumatic injuries to preserve and protect the patient's renal function. Renal anomalies may be asymptomatic or present with hematuria, flank or abdominal pain, hypotension, or shock, even following minor blunt trauma or low velocity impact. It is important for the trauma clinician to recognize that this group of congenital anomalies may contribute to unusual symptoms such as gross hematuria after minor trauma, are readily identifiable during CT imaging, and may affect operative management. These patients should be informed of their anatomical findings and encouraged to return for long-term follow-up.

A unique case of venous air embolus with survival.

Venous air embolus (VAE) occurs when gas, specifically atmospheric air, enters into the vascular system. Although rare, they can be fatal due to risk of cardiovascular collapse. In this report, we present a unique case of a 66-year-old female trauma patient with an inferior vena cava air embolism. An overview of the potential cause is presented, along with a review of the management of VAE.

Thoracoscopy for the acutely injured patient.

Advances in video-surgery digital technology, new instruments, and advanced surgical techniques have increased the importance of video-assisted thoracoscopic surgery (VATS) in the diagnosis and treatment of the acutely injured patient. Currently, VATS offers a new approach in the diagnosis and treatment of many thoracic conditions previously treated only by standard thoracotomy. Available data suggest that when caring for trauma patients, results of VATS are comparable with open surgery. Furthermore, the recovery process clearly is expedited with this minimally invasive modality. It has been our experience during the last decade that VATS is a safe, reliable, and effective alternative to conventional open thoracic surgery.