Using Right-Sided Roll to Improve Reliability of Focused Assessment with Sonography in Trauma: An Eastern Association for the Surgery of Trauma Multicenter Prospective Study.

BACKGROUND: The Focused Assessment Sonography in Trauma (FAST) examination is the standard of care for detecting hemoperitoneum in hypotensive blunt trauma patients. A pilot study demonstrated earlier identification of intra-abdominal fluid via FAST after right-sided roll (FASTeR) when compared with the standard FAST. The purpose of this study was to evaluate this phenomenon prospectively in hypotensive blunt trauma patients. STUDY DESIGN: An Eastern Association for the Surgery of Trauma-approved multicenter prospective trial was performed June 2016 to October 2020 at 8 designated trauma centers. Hypotensive adult blunt trauma patients were included. A traditional FAST examination was performed. After this, the secondary survey logroll for back examination was standardized to the patient's right side. A repeat supine right upper quadrant ultrasound view was obtained. The presence or absence of hemoperitoneum was confirmed by CT scan or intraoperative findings. FAST and FASTeR were compared using receiver operating characteristics. The area under the curve was calculated. RESULTS: A total of 182 patients met inclusion criteria. A total of 65 patients (35.7%) had hemoperitoneum on CT scan or intraoperative findings. The sensitivity of FASTeR was 47.7%, and of FAST was 40.0% (p = 0.019). The receiver operating characteristics area under the curve of the FASTeR examination was 0.717 vs 0.687 for the FAST examination (p = 0.091). CONCLUSIONS: Addition of a right upper quadrant view after right-sided roll does improve the sensitivity of the FAST examination while maintaining the standard positive predictive value. We demonstrate a trend that does not reach statistical significance about the overall accuracy. This multicenter prospective trial was underpowered to reveal a statistically significant difference in the overall accuracy as measured by the receiver operating characteristics area under the curve.

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.

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.

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.

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.

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.

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.

Small-volume resuscitation with HBOC-201: effects on cardiovascular parameters and brain tissue oxygen tension in an out-of-hospital model of hemorrhage in swine.

OBJECTIVE: Hemoglobin-based oxygen carriers, such as HBOC-201, offer several potential advantages over conventional resuscitation solutions or banked blood in the acute treatment of hemorrhagic shock. While previous studies with some hemoglobin solutions revealed vasoactive effects resulting in decreased oxygen delivery, these investigations were performed without directly measuring vital tissue oxygenation. The authors tested the hypothesis that a small-volume bolus of HBOC-201 would improve and sustain brain tissue oxygen tension (PbrO(2)) without adverse effects on cardiovascular end-points, when used in an acute out-of-hospital hemorrhage model. METHODS: Male Yorkshire swine (n = 7) were hemorrhaged to a mean arterial pressure (MAP) of 40 mm Hg while monitoring standard hemodynamic parameters. In addition, Clark-type polarographic probes were directly inserted into brain tissue to measure PbrO(2). Following institution of high-flow oxygen (FiO(2) = 1.0), resuscitation was performed with a bolus infusion of HBOC-201 (6 mL/kg). Swine were observed for two hours. RESULTS: Cardiac output (CO), MAP, pulmonary artery diastolic pressure (PAD), and PbrO(2) all decreased significantly with hemorrhage (p < 0.05). Immediately following resuscitation with HBOC-201 (mean volume = 239 mL), MAP and CO were restored to 83% and 84% of baseline levels, respectively. PbrO(2) increased significantly after treatment with HBOC-201, surpassing baseline levels by 66%. PAD rose above baseline levels during observation, but this increase was not significantly different from baseline levels (24.0 mm +/- 4.1 vs. 22.7 mm +/- 7.4). CONCLUSIONS: Small-volume resuscitation with HBOC-201 rapidly restored hemodynamic parameters and PbrO(2) following severe hemorrhage without detrimental vasoactive effects and without compromise to directly monitored brain tissue oxygenation. The results of this preliminary study demonstrate that HBOC-201 could potentially improve current resuscitation measures and that further investigations with HBOC-201 are warranted.

Unique presentation of urachal cyst disease: incidental finding to complicated infection.

Urachal remnant disease is uncommon in adults and can present with symptoms ranging from drainage near the umbilicus to a severe abdominal infection. Most cases are referred for treatment once diagnosed either clinically or radiographically with ultrasound or computerized tomography. We present a unique case of an infected urachal cyst visualized on a series of CT scans in an adult patient with abdominal pain over a period of years.

Refractory chylothorax following a transhepatic gunshot wound to the abdomen requiring unorthodox surgical treatment.

An 18 year-old-male sustained a gunshot wound to the abdomen which required an uneventful hepatorrhaphy. He later returned with a large right effusion and was diagnosed with a chylothorax. The output was persistent despite conservative measures. Thoracotomy with attempted thoracic duct ligation was unsuccessful at decreasing the output. Re-exploration and ligation of the thoracic duct was required thru an abdominal approach.

Perinephric Capsular Haematoma Associated with Complicated Pyelonephritis in a Patient with HIV.

A 53 year-old-male patient presented with 24 hours of left flank pain. He was an undiagnosed HIV positive individual with no history of trauma. He was anaemic and in acute renal failure with a serum creatinine of 4.14 mg/dL. A CT scan demonstrated a left perinephric capsular haematoma with retroperitoneal stranding. Due to haemodynamic instability, the patient was taken to the operating room and a nephrectomy was performed. Post-operatively, the patient required temporary haemodialysis. Pathologic examination of the specimen demonstrated active infection with a haematoma surrounding a fistulous tract communicating with the capsular surface. Infection is a rare cause of non-traumatic capsular hematomas of the kidney.

Spontaneous kidney rupture with incidental renal cell cancer in patient with Castleman's disease.

A 65-year-old man with a history of Castleman's disease presented with abdominal and right flank pain. He denied any recent trauma. On admission, his hemoglobin was 7.0 g/dL, and the blood urea nitrogen and serum creatinine concentration was 30 and 1.62 mg/dL, respectively. Computed tomography of the patient's abdomen revealed a large right perinephric hematoma. The patient underwent emergency nephrectomy. Microscopic examination of the specimen revealed an incidental renal cell carcinoma.