Triage vital signs do not correlate with serum lactate or base deficit, and are less predictive of operative intervention in penetrating trauma patients: a prospective cohort study.

BACKGROUND: Triage vital signs are often used to help determine a trauma patient's haemodynamic status. Recent studies have demonstrated that these may not be very specific in determining major injury. The purpose of this study was to determine if there is any correlation between triage vital signs, base deficit (BD) and lactate, and to determine the odds of operative intervention in penetrating trauma patients. METHODS: A prospective observational cohort study was undertaken. Baseline vital signs, BD and lactate were recorded in all patients for whom the trauma team was activated. Pearson correlation and coefficient (ρ) were calculated. ORs were calculated. RESULTS: 75 patients were enrolled. Pearson correlations and coefficients calculated for lactate to systolic blood pressure were: -0.052 (ρ=0.0011, 95% CI -0.225 to 0.228); lactate and HR: 0.23 (ρ=0.0166, 95% CI -0.211 to 0.242); lactate and RR: 0.23 (ρ=0.054, 95% CI -0.174 to 0.277). BD to systolic blood pressure were: 0.003 (ρ=0.00001, 95% CI -0.229 to 0.224); BD and HR: -0.19 (ρ=0.038, 95% CI -0.399 to 0.038); BD and RR: -0.019 (ρ=0.0004, 95% CI -0.244 to 0.208). Odds of operative intervention were greater in patients with abnormally high lactate, OR 4.17 (95% CI 1.57 to 11), but not for BD, OR 2.53 (95% CI 0.99 to 6.45), or any of the vital signs. CONCLUSIONS: Triage vital signs have no correlation to lactate or BD levels in penetrating trauma patients. Odds of operative intervention are greater in patients with abnormally high serum lactate levels, but not in those with abnormal triage vital signs or BD.

Pseudoaneurysm of the Abdominal Aorta at the Celiac Trunk After Penetrating Trauma.

We report the case of a 33-year-old man who had received multiple gunshot wounds to the abdomen; consequently, he was diagnosed with a traumatic dissection of the abdominal aorta at the level of the superior mesenteric artery (SMA) extending to just below the renal arteries with a posterior pseudoaneurysm of the aorta. He had wounds in the right upper quadrant and in the left lower back. He demonstrated signs of peritonitis for which he was taken to the operating room for exploratory laparotomy. A right common iliac to SMA bypass with a 7-mm ringed polytetrafluoroethylene (PTFE) graft was created. The celiac trunk was then ligated, and through the right groin sheath, a thoracic endograft stent (Cook Medical, Bloomington, IN) was inserted at the level of the thoracic aorta with resolution of the blood flow to the aorta, visceral and iliac arteries, as well as retrograde flow into the bypass graft. The literature on traumatic abdominal aortic pseudoaneurysm was reviewed, and based on that, we believe this report describes a unique case of a traumatic aortic pseudoaneurysm at the level of the celiac trunk, as well as our operative approach.

Assessment of the Use of Pharmacologic Venous Thromboembolism Prophylaxis in Post-Traumatic Brain Injury Patients.

BACKGROUND: Traumatic brain injury (TBI) is an independent risk factor for venous thromboembolism (VTE). Prophylaxis (PPX) beyond 48 hours increases VTE risk 3- to 4-fold. Pharmacologic VTE PPX initiation is controversial due to potential bleeding complications. OBJECTIVE: To evaluate VTE PPX in patients with TBI for practice variation, efficacy, and safety. METHODS: Retrospective review from January 2013 to September 2016 in adults admitted to the intensive care unit with moderate to severe TBI. Demographics, time to stable computerized tomography scan, time to PPX initiation, PPX regimen, and incidences of VTE and adverse effects were collected. Data were analyzed via descriptive statistics, analysis of variance, and linear regression models. RESULTS: Of 96 patients included, 14.6% did not receive VTE PPX (G1), 7.3% initiated therapy within 0 to 24 hours (G2), 14.6% after 24 to 48 hours (G3), and 63.5% after 48 hours (G4). VTE occurred in 0% of G1 and G2, 28.6% of G3, and 8.2% of G4 patients (P = .038). Of 9 VTE cases, 8 received medical and 1 received trauma PPX dosing (P = .44). There were 3 major bleeds (P = .79) and 19 minor bleeds (P = .042). Of 14 fatalities, 42.9% were in G1, 0% in G2, 14.2% in G3, and 42.9% in G4 (P = .009). CONCLUSION: The majority of patients received delayed PPX, with no correlation between VTE incidence and PPX regimen. There was a significant difference in VTE incidence stratified by time to PPX. Further studies are required to determine optimal timing of PPX. Higher mortality rate was correlated with the lack of PPX. Increased minor bleeds occurred with earlier PPX initiation.

Laparoscopic exploration and lavage in penetrating abdominal stab wounds: a preliminary report.

BACKGROUND: To determine the role of a combined laparoscopic exploration and lavage (LELA) in abdominal stab wounds (ASW). We hypothesized that peritoneal penetration (PP) is not an indication for exploratory laparotomy (EL) if LELA is negative. METHODS: A prospective study (Jan 2002-Dec 2003) was carried at our Level I Trauma Center. Patients with anterior fascia penetration in wound exploration and with systolic blood pressure greater than 90 mmHg were included. Patients with back and flank injuries, evisceration and presentation after six hours were excluded. LELA was considered positive if red blood cell count was >5000 and white blood cell count was >150 in a lavage without the presence of bile, gross blood, food fibers or stool. RESULTS: Eighty-nine patients with anterior ASW (AASW) were included. Twenty-eight patients underwent laparoscopy to rule out PP. Seventeen patients had PP and 8 demonstrated injuries that required immediate exploratory laparotomy. The remaining 9 underwent LELA. Four patients had positive LELA that demonstrated injuries (sigmoid, right colon, and small bowel [n: 2]). Five patients had a negative LELA and avoided an unnecessary EL. CONCLUSION: LELA in AASW shows a promising role to rule out mainly hollow viscus injuries. This technique could decrease the number of non-therapeutic laparotomies, length of stay and hospital costs without increasing the incidence of missed abdominal injuries.

Surgical residents' interpretation of diagnostic radiologic imaging in the traumatically injured patient.

BACKGROUND: Senior surgical residents are of paramount importance in directing further therapeutic modalities based on their interpretation of critical diagnostic imaging. We propose that senior surgical residents are proficient with interpreting radiologic imaging studies in the trauma patient. METHODS: A prospective cohort study was performed comparing surgery resident interpretations of computed tomography (CT) scans of the head, maxillofacial bones, spine (cervical, thoracic, lumbar), chest, abdomen, pelvis, and chest X-rays versus final radiologists' reports at a Level II trauma center from September 2014 to May 2015. A Cohen κ coefficient and a statistical analysis of variance testing were used to make multiple comparisons of the data. RESULTS: There were 951 trauma alerts activated in the period stated. Of these, 860 met our age inclusion criteria (age, > 18 years). There were 204 images included with an overall accuracy of 81.3%. Residents were more than 70% successful interpreting seven of nine categories. They achieved an accuracy of 84.6%, 62.5%, and 75% in the cervical, thoracic, and lumbar spine categories, respectively. Forty-one of 50 CT scans of the head were interpreted correctly. Maxillofacial CT scans proved to be the weakest category, with only 50% read accurately. In regard to CT scans of the abdomen and pelvis, 80% proficiency was achieved. Abdominal x-rays were read correctly in all instances and chest x-rays 83.3%. On κ analysis, there was an overall moderate agreement between the two groups with K = 0.449, and an overall p less than 0.0005 (Table 1). A perfect agreement existed with abdominal x-rays. CONCLUSION: Senior surgical residents are capable of interpreting critical images obtained in the trauma setting. When discordance existed with attending radiologists' interpretation, it did not change the clinical outcome or result in any critically missed findings. LEVEL OF EVIDENCE: Therapeutic/Care Management study, Level IV.

Amyand's hernia presenting as an unusual inguinal mass: a case report.

Accounting for approximately 0.4-0.6% of all inguinal hernias, Amyand's hernia is a rare condition in which a vermiform appendix is found in an inguinal hernia sac. It is most commonly found in males and in the pediatric population. Since Claudius Amyand's first reported case in 1736, there have only been a total of 228 documented cases of the Amyand's hernia. Due to its rarity, the pathophysiology and risk factors of the condition are still unclear. Some theorize that it is secondary to a patent processus vaginalis or perhaps the presence of a fibrous band between the hernia sac and testes. Amyand's hernia usually presents as an incarcerated or strangulated hernia, but its presentation can be quite variable. We report an unusual case of an Amyand's hernia presenting as an enlarging painful mass on the right lateral edge of the mons pubis, resembling an abscess.

Appendicitis Presenting Concurrently with Cecal Arteriovenous Malformation in a Child.

Acute appendicitis is a commonly diagnosed surgical problem in the pediatric population. Arterio-venous malformations (AVM) of the colonic tract are rarely reported in the pediatric literature. A 13-year old boy who presented with acute appendicitis with concurrent cecal AVM is reported in whom appendectomy was done. Later on radiological investigations AVM was confirmed.

Nasal cannula end-tidal CO2 correlates with serum lactate levels and odds of operative intervention in penetrating trauma patients: a prospective cohort study.

BACKGROUND: Penetrating trauma patients in shock often require urgent operative intervention. Studies have demonstrated that variables obtained in the emergency department, such as lactate levels, can help the physician determine the presence of hemorrhagic shock, leading to more rapid intervention and improve prognosis in trauma patients. The purpose of the study is to determine if end-tidal (ET) CO2 correlates with serum lactate levels, a measure of tissue hypoxia and subsequently shock, in penetrating trauma patients. Secondarily, we sought to determine whether ET CO2 could be used to determine the patient's odds of requiring operative intervention. METHODS: A prospective observational cohort study was undertaken at an urban Level 1 trauma center. Baseline ET CO2 from nasal cannula and serum lactate level were recorded in all patients in whom the trauma team was activated. Outcomes defined were whether operative intervention was needed. Pearson correlation (R), correlation coefficient (r(2)), and odds ratio were calculated. RESULTS: One hundred five patients were enrolled. Pearson correlations and coefficients calculated for serum lactate level to ET CO2 were R = -0.86 (r(2) = 0.74, p < 0.0001). Of patients requiring operative intervention, 81.97% had abnormally low ET CO2 and 54.1% had abnormally high serum lactate levels. Odds ratios of patients needing an emergent operation with abnormally low ET CO2 was 20.4 (95% confidence interval, 7.47-55.96) and with abnormally high serum lactate levels was 4 (95% confidence interval, 1.68-5.93). CONCLUSION: ET CO2 has a strong inverse correlation to serum lactate levels. Abnormally low ET CO2 values were associated with greater increased odds compared with serum lactate levels of penetrating trauma patients requiring operative intervention. LEVEL OF EVIDENCE: Prognostic/diagnostic study, level I.

Violent and fatal youth trauma: is there a missed opportunity?

INTRODUCTION: Accidents and assaults (homicides) are the leading causes of death among the youth of the United States, accounting for 53.3% of deaths among children aged 1 to19 years. Victim recidivism, defined as repeated visits to the emergency department (ED) as a victim of violent trauma, is a significantly growing public health problem. As 5-year mortality rates for recidivism are as high as 20%, it is important to determine whether victims with a history of violent trauma are at increased risk for fatal outcome with their next trauma. We hypothesized that victims of violent trauma who have had 1 prior ED visit for violent trauma will have increased odds of fatal outcome. METHODS: A retrospective chart review was conducted for patients presenting with penetrating trauma to the ED from January 1, 1999 to December 31, 2009. All patients between the ages of 15 to 25 years who presented to the ED for any penetrating trauma were included. Patients with prior presentations for penetrating trauma were compared to those patients who were first-time presenters to determine the odds ratio of fatal outcome. RESULTS: Overall, 15,395 patients were treated for traumatic presentations. Of these, 1,044 met inclusion criteria. Demographically, 79.4% were Hispanic, 19.4% were African American, and 0.96% were Caucasian. The average age was 21 years, and 98% of the population was male. One hundred and forty-seven (14%) had prior presentations, and 897 (86%) did not. Forty of the 147 patients (27%) with prior presentations had a fatal outcome as compared to 29 patients of the 868 (3%) without prior presentations, with odds ratio of 10.8 (95% confidence interval, 6.4-18.1; Pearson χ(2), P < 0.001). The 5-year mortality rate for those patients with fatal outcomes was calculated at 16.5%. CONCLUSION: Patients who had prior ED visits for penetrating trauma were at greater risk for fatal outcomes compared to those with no prior visits. Therefore, trauma-related ED visits might offer an opportunity for education and intervention. This may help to prevent future fatalities.

Should an Allen test be performed before radial artery cannulation?

BACKGROUND: This study aims to determine the current status of the Allen test for assessing the circulation of the hand. METHODS: The Ovid electronic database was searched using multiple search terms and keywords. Bibliographies of pertinent articles were examined. Data involving results of Allen tests, criteria for abnormality and outcomes, specifically those related to adverse events, were extracted. RESULTS: The criteria for an abnormal Allen test are not agreed upon. The significance of an equivocal or abnormal test is unclear. The test is not accurate in predicting postcannulation hand ischemia. Results of the test suffer from poor interrater reliability. Most critically ill patients cannot cooperate for the performance of the test as described. CONCLUSIONS: Performance of an Allen test before radial artery cannulation should not be considered a "standard of care."