Injury characteristics of the Pulse Nightclub shooting: Lessons for mass casualty incident preparation.

BACKGROUND: On the morning of June 12, 2016, an armed assailant entered the Pulse Nightclub in Orlando, Florida, and initiated an assault that killed 49 people and injured 53. The regional Level I trauma center and two community hospitals responded to this mass casualty incident. A detailed analysis was performed to guide hospitals who strive to prepare for future similar events. METHODS: A retrospective review of all victim charts and/or autopsy reports was performed to identify victim presentation patterns, injuries sustained, and surgical resources required. Patients were stratified into three groups: survivors who received care at the regional Level I trauma center, survivors who received care at one of two local community hospitals, and decedents. RESULTS: Of the 102 victims, 40 died at the scene and 9 died upon arrival to the Level I trauma center. The remaining 53 victims received definitive medical care and survived. Twenty-nine victims were admitted to the trauma center and five victims to a community hospital. The remaining 19 victims were treated and discharged that day. Decedents sustained significantly more bullet impacts than survivors (4 ± 3 vs. 2 ± 1; p = 0.008) and body regions injured (3 ± 1 vs. 2 ± 1; p = 0.0002). Gunshots to the head, chest, and abdominal body regions were significantly more common among decedents than survivors (p < 0.0001). Eighty-two percent of admitted patients required surgery in the first 24 hours. Essential resources in the first 24 hours included trauma surgeons, emergency room physicians, orthopedic/hand surgeons, anesthesiologists, vascular surgeons, interventional radiologists, intensivists, and hospitalists. CONCLUSION: Mass shooting events are associated with high mortality. Survivors commonly sustain multiple, life-threatening ballistic injuries requiring emergent surgery and extensive hospital resources. Given the increasing frequency of mass shootings, all hospitals must have a coordinated plan to respond to a mass casualty event. LEVEL OF EVIDENCE: Epidemiological Study, level V.

Cervical tracheal transection after scarf entanglement in a go-kart engine.

BACKGROUND: Tracheal disruption secondary to blunt force occurs infrequently. Most individuals suffering such an injury die before arriving at a hospital. Diagnosis for those who do present alive is often delayed, as signs and symptoms typically do not match the severity of injury. OBJECTIVE: The objectives of this case report are to present a unique mechanism for tracheal disruption and to discuss our management strategy. CASE REPORT: We describe an 18-year-old man who suffered tracheal disruption after entanglement of his scarf in a go-kart engine. His initial workup was conducted by emergency physicians and included computed tomographic evaluation of the neck. After diagnosis, the patient was transported to an operating suite. Awake tracheostomy was performed in this controlled environment to secure the airway, after which the trachea was repaired via primary anastomosis. CONCLUSIONS: Prompt recognition and appropriate intervention are critical in the care of patients with suspected tracheal transection to prevent mortality.

Advanced age may limit the survival benefit of open abdominal decompression.

Open abdominal decompression (OAD) and temporary abdominal closure (TAC) are widely performed for the treatment of intra-abdominal hypertension and/or abdominal compartment syndrome. During 2005 to 2009, 405 consecutive patients required OAD/TAC (trauma 68%, surgery 24%, medicine 5%, burn 3%). Overall patient survival to hospital discharge was 65 per cent regardless of age and was significantly decreased among patients older than 70 years of age (P < 0.0001). Survival by decade of life exceeded 50 per cent through the eighth decade but decreased to 19 per cent for the ninth decade (older than 80 years of age). Survival varied significantly by service (trauma 72%, surgical 56%, burns 55%, medical 33%) (P < 0.0001). Successful definitive fascial closure rates (range, 75 to 100%) were equivalent among all age groups (P = 0.78). Survival after OAD/TAC varies by decade of life and mechanism of injury/illness. Age alone should not negate the use of OAD/TAC. Reasonable survival rates may be expected for patients younger than 80 years of age.

Retrospective evaluation of residents' American Board of Surgery In-Service Training Examination (ABSITE) scores as a tool to evaluate changes made in a basic science curriculum.

OBJECTIVE: To evaluate the effectiveness of a new basic science curriculum at a university-affiliated general surgery residency program. DESIGN: A retrospective evaluation of general surgery residents' American Board of Surgery (ABS) In-Training Examination (ABSITE) scores before and after the implementation of a new basic science curriculum. SETTING: Not-for-profit tertiary referral center with a university-affiliated Accreditation Council for Graduate Medical Education (ACGME) accredited community general surgery residency program. PARTICIPANTS: Postgraduate year (PGY) 1 through 5 general surgical residents. RESULTS: The total questions answered correctly (percent correct) in the main 3 categories improved after implementation of the new curriculum for PGY 1 (total test: 70 +/- 7 vs 60 +/- 9, p < 0.05; clinical science: 71 +/- 10 vs 59 +/- 9, p < 0.05; and basic science: 69 +/- 7 vs 60 +/- 10, p = 0.0003) and for PGY 2 residents (total test: 74 +/- 5 vs 66 +/- 7, p < 0.05; clinical science: 74 +/- 7 vs 66 +/- 8, p = 0.003; and basic science: 74 +/- 5 vs 66 +/- 8, p < 0.05). With the exception of the percentage of clinical questions answered correctly for the PGY 4 level, there was no statistically significant worsening of scores in any other subcategories for any other PGY levels (3 through 5) after implementation of the new program. Before the institution of the new curriculum, 24% (26/110) of residents scored below the 35th percentile, and after the institution of the new curriculum, this number decreased to 12% (12/98), p = 0.006. The first-time passage rate on the ABS Qualifying Examination was unchanged in the period before and after the implementation of the new curriculum (89% vs 86%; p = 0.08). When comparing the bimonthly quizzes with the ABSITE, the correlation coefficient was 0.34. CONCLUSION: After the implementation of a new basic science curriculum organized and directed by the faculty, there were statistically significant improvements of PGY 1 and 2 residents' ABSITE scores.

Trauma laparotomy: evaluating the necessity of histological examination.

Trauma laparotomy is the most commonly performed procedure in the acute care setting. As current practice, removed specimens are sent for histological examination. A retrospective review of all trauma laparotomies with specimens removed and sent to pathology during a 12-month period was performed in a Level I trauma center. One hundred five procedures of 244 trauma laparotomies yielded specimens sent for examination. Eighty-six patients were male and 19 patients were female with an average age of 34 +/- 14 years. Fifty-six per cent of the injuries resulted from penetrating trauma and 44 per cent were from blunt trauma. Gunshot wound and motor vehicle crash were the most common penetrating and blunt injuries, respectively. One hundred thirteen specimens were sent to pathology. Forty-three per cent of the specimens were spleen, 24 per cent small bowel, 16 per cent large bowel, 4 per cent kidney, 2 per cent omentum, 3 per cent appendix, 3 per cent pancreas, and 1 per cent for gallbladder and lung. One hundred twelve of 113 grossly normal specimens had normal pathology. One grossly normal specimen exposed abnormal pathology revealing benign appendiceal mucocele. Therefore, 99.1 per cent of grossly normal specimens sent for histological examination after trauma laparotomy were normal. Based on our review, in select patients routine histological examination of tissues removed for traumatic injury is unnecessary.

One hundred consecutive splenectomies for trauma: is histologic evaluation really necessary?

Splenectomy remains the most commonly performed abdominal operation for trauma. Although the vast majority of these patients (pts) are young and healthy, histologic evaluation is still routinely performed. We propose that routine histologic sampling of an injured yet otherwise grossly normal spleen is unnecessary. A retrospective review of 100 consecutive pathologic specimens of pts undergoing splenectomy for trauma at a Level I trauma center was performed during a 25-month period. Data are reported as mean +/- SD. Average age was 34.4 +/- 15.1 years. There were 78 men and 22 women. Average injury severity score was 28.3 +/- 12.9. The most common mechanisms of injury were motor vehicle collisions (56%) and motorcycle collisions (15%). Average length of stay was 17.4 +/- 19 days. Microscopic pathologic findings returned as benign with no evidence for neoplasia in 99 of 100 specimens. Mean specimen weight was 184.6 +/- 188.7 g. Only one spleen, which appeared grossly abnormal and weighed 1,800 g, had abnormal histology demonstrating extramedullary hematopoiesis. This pt died before further workup. Our review suggests that the routine microscopic evaluation of spleens removed after traumatic injury, as is currently the standard of care at our institution, is unnecessary. Such examination should only be performed in cases of marked splenomegaly or in spleens that appear grossly abnormal.

Traumatic renal artery occlusion in a patient with a solitary kidney: case report of treatment with endovascular stent and review of the literature.

Renal artery occlusion after blunt trauma is a rare occurrence, and the optimal treatment for this condition has not been established. To our knowledge, endovascular repair for blunt renal artery occlusion in a solitary kidney has not been described in the literature. This case report describes a 42-year-old woman with a solitary left kidney presenting with total occlusion of the left renal artery after a significant crush injury. She was successfully treated by percutaneous placement of an endovascular stent. Postprocedure, the patient developed acute renal failure requiring temporary dialysis. At follow-up 4 months later, the patient has normal urinary output and a normal creatinine.

Nitrogen balance, protein loss, and the open abdomen.

OBJECTIVE: Goal-directed nutritional support is essential to improving morbidity and mortality. Open abdominal decompression is similarly crucial to the successful treatment of intra-abdominal hypertension and abdominal compartment syndrome. The open abdomen, however, places the patient at risk for potentially significant fluid, electrolyte, and presumably protein losses from the exposed viscera. Although nutritional protein assessments are frequently utilized to measure urinary nitrogen, these calculations do not consider the loss of protein from the open abdomen. We hypothesize that accurate assessment of nitrogen balance in the patient requiring an open abdomen must include either a measurement or estimation of abdominal fluid nitrogen loss. DESIGN: Prospective, observational cohort study. SETTING: Adult surgical/trauma intensive care unit of a level I trauma center. PATIENTS: Surgical/trauma patients requiring laparotomy. INTERVENTIONS: Serial 24-hr collections of urine and abdominal fluid protein were performed to characterize abdominal fluid protein loss and evaluate the clinical effect of accounting for abdominal fluid nitrogen as part of nitrogen balance calculations. MEASUREMENTS AND MAIN RESULTS: Nitrogen intake correlates with urinary nitrogen loss but not with abdominal fluid nitrogen loss. Abdominal fluid nitrogen loss is significant and remains relatively stable in the early postoperative period. Nutritional calculations that fail to account for abdominal fluid nitrogen loss significantly overestimate actual nitrogen balance by an average of 3.5 g/24 hrs. CONCLUSIONS: The open abdomen represents a significant source of protein/nitrogen loss in the critically ill. Failure to account for this loss in nutritional calculations may lead to underfeeding and inadequate nutritional support with a direct effect on patient outcome. Although direct measurement of abdominal fluid protein loss may be optimal, an estimate of 2 g of nitrogen per liter of abdominal fluid output should be included in the nitrogen balance calculations of any patient with an open abdomen.

Pancreaticoduodenectomy in a community general surgery residency program.

The morbidity and mortality of pancreaticoduodenectomy (PD) has been well documented. A retrospective review was performed to determine the morbidity and mortality of PD performed within the general surgery residency program of a tertiary community hospital. Patients undergoing PD for benign or malignant disease over a 6-year period were analyzed to determine overall mortality, major complication rate, and length of stay (LOS). Of 50 consecutive patients undergoing PD, overall mortality was 6 per cent, with a major complication rate of 52 per cent. Mean operative time was 333 +/- 68 minutes with an estimated blood loss of 459 +/- 301 mL. Mean hospital LOS was 21 +/- 13 days. Eighty-four per cent of patients with malignant disease had negative margins of resection. General surgery residents within a community residency program, with attending faculty supervision, can perform PD with mortality, morbidity, and LOS comparable with that reported in the university setting.

A planned complex suicide: need for a high index of suspicion.

Unusual ways of committing suicide are reported in the medico-legal literature, but few refer to the so-called "planned complex suicide" (PCS). PCS, also termed primary combined suicide, is defined as the combination of two or more methods of injury by the suicidal person to prevent failure of a single method of suicide alone. In contrast, in secondary or unplanned complex suicide, the victim uses the second method of suicide only after failure of the first method.2 Combinations of shooting, hanging, burning, and/or poisoning have been used as suicidal methods. Sometimes the double use of one method such as simultaneous gunshot wound from two firearms or ingestion of two different toxic substances has been reported. This gives the suicidal person a high degree of protection against failure of one of the methods, as both modes of injury are relatively certain. This case report demonstrates the importance of the treating physician maintaining a high index of suspicion for the possibility PCS with the aim of avoiding a misdiagnosis that may be fatal.