Cadaveric Simulation in Rib Plating is Beneficial for Helping Surgical Trainees to Assimilate New Technologies.

PURPOSE: Rib fixation procedures are being performed more frequently as they have shown multiple advantages over traditional non-operative management in well-selected patients. We have developed a rib-fixation simulation on cadavers for use by surgical residents in attempt to improve their comfort, knowledge and ability to use this new technology. METHODS: Residents in years 3 through 5 of training attended a rib-fixation simulation course with cadavers. Trauma faculty and representatives of manufacturers of rib-fixation hardware participated. The simulation consisted of groups of residents reviewing anatomy and creating adequate exposure for the entire procedure. Each group created rib fractures in the cadaver, determined which materials were needed, and then performed the rib-fixation procedure. Following the simulation, we surveyed the residents to determine the impact of the structured cadaveric rib fixation-based course on their comfort level. The survey was performed using a four- and five-level Likert questionnaire. The results were analyzed using paired t-tests. RESULTS: Of the participating residents, 72% of residents had performed five or fewer rib-fixation procedures in their training in the first cohort, while in the cohort for the following year, 65% had performed 5-10 procedures. The simulation had a statistically significant benefit to the residents' comfort level with rib plating (2.5 versus 3.6, p-value: 0.003). The greatest impact on the comfort level was seen in year 3 of training (2 versus 4, p-value 0.02). One hundred percent of residents found that having faculty and representatives present for the simulation was very helpful. The survey demonstrated that most residents gained new knowledge regarding the anatomy and technical dissection. In 20 of 25 encounters, residents strongly agreed that this simulation was beneficial for their surgical education, when used in addition to real operative experience. Every resident reported that they would recommend the simulation to younger resident classes. CONCLUSION: Rib-fixation simulations on cadavers were beneficial for surgical residents' self-assessed comfort level. The simulation increased residents' knowledge, comfort, and ability to perform rib-fixation procedures. We have seen a significant increase in resident participation in these cases after simulation training. Based on these findings, we will continue to incorporate these simulations into our program's curriculum.

"Blunt adrenal injury does not affect outcomes in adult patients with isolated abdominal injury - A National Trauma Data Bank review®".

INTRODUCTION: Traumatic blunt adrenal injury (BAI) has been an area of debate, with conflicting data on its impact. BAI from blunt abdominal injury is challenging to diagnose early due to retroperitoneal gland location and minimal clinical signs. The incidence of BAI ranges from 0.03 % to 4.95 %, with an increasing trend attributed to advanced CT imaging. Conflicting data exists regarding BAI's implications on patient outcomes, necessitating a comprehensive evaluation. METHODS: A retrospective review of the National Trauma Data Bank (NTDB®) for 2017-2021 included a total of 352,654 patients with 337,628 polytrauma patients and 15,026 isolated abdominal trauma patients. Patients were categorized into those with and without adrenal injury. Demographic data and outcomes were compared using statistical tests, focusing on Injury Severity Scores (ISS), mortality, length of stay, and ventilation days. RESULTS: Polytrauma patients with BAI had increased mortality, longer ICU and hospital stays, and ventilation requirements when compared to polytrauma patients without BAI. However, when evaluating isolated abdominal trauma patients with BAI showed no significant differences when compared to isolated abdominal trauma without BAI in mortality or ICU LOS and a slight decrease in ICU admissions, hospital LOS, and ventilation requirement. DISCUSSION: The study indicates a significant association between BAI and increased trauma severity among polytrauma patients. Mortality, however, did not exhibit a consistent rise across all patients with adrenal injury, emphasizing that BAI may not independently influence outcomes. These findings align with the notion that adrenal injury is linked to the overall trauma burden rather than being a primary determinant of mortality.

A Call for Help: A Retrospective National Study of Self-Inflicted Trauma Among American Indians and Alaskan Natives.

Background Self-inflicted injury accounts for approximately 312,000 emergency department visits annually. American Indians/Alaskan Natives (AIAN) have significantly higher rates of suicide. The National Trauma Data Bank (NTDB) was analyzed for the incidence of self-inflicted trauma. Methods Data were obtained from the NTDB 2012-2017. Patients were selected using ICD codes for self-inflicted trauma. Categorical and continuous variables were tested for significance. Results AIAN patients accounted for 1,176 of the 78,668 patients. The AIAN patients were younger, had lower injury severity score (ISS) scores, were more female, utilized Medicaid more frequently, were more likely to present with a cut or piercing injury, and had higher rates of positive alcohol and drug tests. AIAN patients had shorter lengths of stay in the ICU and overall hospital stay. Conclusion Despite a higher rate of suicide completion, the AIAN population had lower rates of presentation to the hospital and lower ISS scores. AIAN patients were younger, had higher rates of drug use, and utilized cutting/stabbing. This discrepancy could indicate a physical manifestation of a "call for help".

Changes in Patterns of Trauma Injuries in the Dakotas Region During the COVID-19 Pandemic.

BACKGROUND: The aim of this study is to compare impact of COVID-19 on trauma volume and characteristics on a set of trauma centers with a rural catchment area. The COVID-19 pandemic has affected different parts of the country quite differently, both in case volume and in local responses. State-wide responses have varied considerably, including variations in local mask mandates, school closures, and social distancing measures. METHODS: This was a retrospective trauma registry review of patients who were admitted to three of the tertiary care trauma centers in North and South Dakota between 2014 through 2022. RESULTS: In the analysis of 36,397 patients, we found a significant increase in trauma patient volume during the COVID-19 pandemic, with an increased percentage of patients presenting with a mechanism of injury secondary to abuse or assault. This increase in patient volume continued to rise during 2021 and 2022. CONCLUSIONS: Our study demonstrates how the COVID-19 pandemic impacted trauma center admissions in the rural and frontier Midwest differently from more urban areas, and the importance of including a variety of settings in trauma research.

"Blunt adrenal injury does not affect outcomes in the pediatric population with isolated abdominal injury- a National Trauma Data Bank Review®."

BACKGROUND: The incidence of blunt abdominal injury (BAI) in the adult population has been estimated to be between 0.03% and 4.95%. However, the impact of BAI on the pediatric population remains unknown. METHODS: We conducted a retrospective review of National Trauma Data Bank datasets for the years 2017-2019. We included patients under the age of 18 who experienced blunt trauma and had suffered a blunt abdominal injury with an Abbreviated Injury Scale (AIS) severity score of 2 or higher. RESULTS: Out of the 8064 pediatric patients with isolated abdominal trauma, 134 patients also suffered from BAI. We found no difference in the outcomes of patients with blunt adrenal injury in terms of mortality, length of stay in the intensive care unit (ICU) and hospital, and the number of ventilator days. Within poly-trauma patients BAI was associated with worst patient outcomes. CONCLUSIONS: This study demonstrates that BAI has minimal clinical impact on patient outcomes in isolation. However it is associated with worst outcomes in poly trauma patients suggesting correlation with increased trauma burden. LEVEL OF EVIDENCE: III.

Ketamine in Trauma: A Literature Review and Administration Guidelines.

Ketamine is a phencyclidine (PCP) derivative, which primarily acts as a noncompetitive N-methyl-D-aspartate (NMDA) receptor antagonist. Ketamine serves as an analgesic and a dissociative sedative that produces potent analgesia, sedation, and amnesia while preserving spontaneous respiratory drive. It is rapidly gaining acceptance in the management of pain as multiple studies have demonstrated its reliable efficacy and a wide margin of safety. This article reviews some of these studies, the history of ketamine, and its pharmacological and pharmacokinetic properties. The article also discusses the use of ketamine in the trauma setting, including joint reductions, procedures, sedation, and pain control, as well as dosing recommendations.

Management of an Unexploded Intracorporeal Firework in a Low Resource Setting: Case Report and Tips.

Surgical removal of unexploded ordnance has been described in literature, usually in the context of the military. We describe a case of a 31-year-old gentleman who presented with a traumatic fireworks injury resulting in an unexploded three-inch aerial shell lodged in his left upper thigh. The sole regional Explosive Ordinance Disposal (EOD) expert was not available, so a local pyrotechnic engineer was contacted and he helped in identification of the firework. The firework was removed without the use of electrocautery, irrigation, or metal instrument contact after skin incision. The patient recovered well after prolonged wound healing. Creativity needs to be employed in low resource settings to identify all available resources that can impart knowledge when medical training is not enough. People with knowledge of explosives can be, as in our case, local pyrotechnics engineer or can be local cannon enthusiasts, veterans, or active military personnel at a nearby military base.

Surgical Management of an Intentionally Ingested Vape Device Chronically Impacted within the Duodenum of an Adult Male.

Most foreign body ingestion cases are accidental in the adult population. Intentional ingestion of foreign bodies in adults is typically associated with psychiatric disorders or developmental delay. In most cases, foreign bodies pass spontaneously through the gastrointestinal tract or can be managed endoscopically. Rarely, surgical intervention is indicated. We present a unique case of surgical management of an intentionally ingested vape device that was chronically impacted within the duodenum of an adult male present for six weeks before intervention without associated perforation. The foreign object was removed via exploratory laparotomy with duodenotomy and primary duodenorrhaphy with an uncomplicated postoperative course. There are only two previously reported cases of an ingested vape device. One was managed by observation, and the other was removed endoscopically. There are no previously reported cases of an ingested vape device that required surgical management.

A Case of Argatroban Refractory Heparin Induced Thrombocytopenia and Thrombosis.

Prophylaxis for deep vein thrombosis is a standard of care for most hospitalized patients. This is typically given in the form of chemical prophylaxis by either, unfractionated heparin or low molecular weight heparin. One complication of administration, besides bleeding, is heparin induced thrombocytopenia (HIT). Of patients receiving therapeutic anticoagulation with heparin an estimated, .5%-1% will go on to develop heparin induced thrombocytopenia.1 We will present a case of argatroban refractory HIT after a coronary artery bypass grafting resulting in a massive left ventricular thrombus and death. There is a paucity of literature on the topic of argatroban refractory HIT. When it is discussed, the persistent drop of platelets and ongoing thrombosis, despite argatroban therapy, appears to be the hallmark. The treatment being used in these rare cases is intravenous immunoglobulin. Our case sheds light on the existence of this entity and helps consolidate some literature on the topic.

Stapling Common Enterotomy Does Not Increase Leak Rates in Stapled Anastomoses.

BACKGROUND: Stapled vs handsewn methods of bowel anastomosis have been extensively studied, however, no study has compared the handsewn vs stapled technique of closing the common enterotomy. Anecdotal concerns of higher leak rates due to crossing staple lines has led some to prefer a handsewn technique for closing the common enterotomy. METHODS: Patients undergoing stapled side-to-side enteroenteric and enterocolonic anastomoses in both emergent and elective settings at 1 tertiary center from 2016 to 2020 were studied. 758 patients were included. They were divided into 2 cohorts: Stapled-Stapled (SS) and Stapled-Handsewn (SH) depending on the fashion in which their stapled common enterotomy was closed. Association of anastomotic leak rate overall, in the emergent vs elective setting, and within enteroenteric and enterocolonic anastomotic subgroups was evaluated with both univariate and multivariate analysis. Association with the closure technique, mortality and average operative time was also compared. RESULTS: Multivariate analysis overall leak rates (SS 5.9% vs SH 3.7%, P = .23) and enteroenteric leak rates (SS 2.9 vs SH 4.1, P = .52) were similar between cohorts. Operative times were significantly shorter in the SS cohort (SS 121.8 min vs SH 138.1 min, P = .049), with a difference of 16.3 min on average. No difference in mortality was seen. DISCUSSION: The SH and SS result in similar anastomotic leak rates overall, and the SS technique is significantly faster than the SH technique. We therefore consider the SS technique to be an acceptable, and in the emergent setting, potentially preferred method of anastomotic technique.

Unusual Manifestation of a Non-inflamed Appendiceal Fistula as a Necrotizing Soft Tissue Infection in the Setting of a Gigantic Ventral Hernia.

Necrotizing soft tissue infection (NSTI) is a rapidly progressive infection of the soft tissues that necessitates early identification and emergent aggressive surgical debridement due to its high mortality. NSTI most often results from the introduction of microbes through breaks in the skin. Unique sources, like appendiceal fistulae, can be etiologies of abdominal wall NSTIs. We present the case of a 46-year-old female with a past medical history of poorly controlled type II diabetes mellitus and ventral hernia who presented in septic shock with a necrotic wound in her abdominal wall. The wound was overlying a large ventral hernia and was consistent with NSTI. She was treated urgently with fluid resuscitation, antibiotic therapy, and surgical debridement of the wound. On repeat exploration, an appendiceal fistula was found protruding from the hernial sac. Open appendectomy and primary repair of the ventral hernia were performed. Principles of immediate intervention and repeat surgical debridement allowed control of the septic insult and definitive source control upon identification of an appendiceal fistula.

SUNBURN: a protocol for delivering bad news in trauma and acute care surgery.

INTRODUCTION: The delivery of bad news can be one of the most challenging tasks in surgery. There are numerous barriers specific to trauma and acute care surgery (TRACS) that make these conversations more difficult. Prior protocols have all been designed for oncology and primary care with poorer application to TRACS. The lack of guidance for leading these conversations in TRACS led us to develop the SUNBURN protocol. It draws elements from prior protocols and discards the irrelevant aspects and pays particular attention to the TRACS-specific concerns. SUNBURN PROTOCOL: Step 1: S-Set Up; Step 2: U-Understand Perceptions; Step 3: N-Notify ('Warning Shot'); Step 4: B-Brief Narrative and Break Bad News; Step 5: U-Understand Emotions; Step 6: R-Respond; Step 7: N-Next Steps. CONCLUSION: This protocol can provide a framework to help guide and ease the delivery of bad news in TRACS.

A Case of Idiopathic Recurrent Spontaneous Bladder Rupture.

BACKGROUND: A female patient presented four years following spontaneous bladder rupture with a recurrent spontaneous bladder rupture. Summary. Urinary bladder rupture is a condition usually caused by trauma or surgical instrumentation. Spontaneous bladder rupture is a much more uncommon condition and is associated with intoxication, radiation, stricture, or neurogenic bladder. We describe a case of a 40-year-old woman with a history of three caesarian sections with an idiopathic recurrent spontaneous bladder rupture. Originally, she presented with one day of worsening severe abdominal pain. CT showed possible ischemic bowel. She was taken to the operating room (OR) and found to have a bladder rupture. This was repaired, and she did well postoperatively. Four years later, she presented to the emergency department (ED) with one week of worsening abdominal pain that became severe acutely. Given that she had a similar issue four years prior the patient was suspicious, her bladder was again ruptured. CT cystogram showed contrast extravasation into the peritoneum. The patient was taken urgently to the operating room for an open repair of the bladder rupture. She did well following the procedure. CONCLUSION: Spontaneous bladder rupture is a surgical emergency and should be in the differential diagnosis of any patient with peritonitis with elevated creatinine and free intraperitoneal fluid. This diagnosis should especially be considered if the patient has a history pelvic radiation, neurogenic bladder, or intoxication. We submit that a history of multiple pelvic surgeries should be included in this list. CT cystogram is the diagnostic test of choice. Operative repair is generally the treatment for this condition.

Surgical Faculty Perception of Service-Based Advanced Practice Provider Impact: A Southwestern Surgical Congress Multicenter Survey.

BACKGROUND: A previous single-center survey of trauma and general surgery faculty demonstrated perceived positive impact of trauma and surgical subspecialty service-based advanced practice providers (SB APPs). The aim of this multicenter survey was to further validate these findings. METHODS: Faculty surgeons on teams that employ SB APPs at 8 academic centers completed an electronic survey querying perception about advanced practice provider (APP) competency and impact. RESULTS: Respondents agreed that SB APPs decrease workload (88%), length of stay (72%), contribute to continuity (92%), facilitate care coordination (87%), enhance patient satisfaction (88%), and contribute to best practice/safe patient care (83%). Fewer agreed that APPs contribute to resident education (50%) and quality improvement (QI)/research (36%). Although 93% acknowledged variability in the APP level of function, 91% reported trusting their clinical judgment. CONCLUSION: This study supports the perception that SB APPs have a positive impact on patient care and quality indicators. Areas for potential improvement include APP contribution to resident education and research/QI initiatives.

Clostridioides difficile Enteritis Induced Anastomotic Rupture: A Case Report and Literature Review.

Background. A 76-year-old male patient who suffered small bowel anastomotic dehiscence believed to be a complication provoked by Clostridioides difficile enteritis. Case Presentation. The patient was a 76-year-old male who underwent small bowel resection with primary anastomosis for a small bowel obstruction. On postoperative day #7, he rapidly decompensated and upon return to the operating room was found to have complete anastomotic dehiscence with copious enteric spillage. The presentation appeared as if the staple line had burst open. Enteric contents confirmed the diagnosis of Clostridioides difficile enteritis. Subsequent hospital course was complicated by ventilatory-dependent respiratory failure, hemodynamic instability, and persistent anemia secondary to gastric ulcer requiring endoscopic cauterization. After a prolonged hospital course, he eventually progressed and was transferred to a skilled nursing facility on hospital day #42. Discussion. Clostridioides difficile causes inflammation and copious large volume secretions that would theoretically increase intraluminal pressures creating an internal tension. This tension along with other factors from the infection itself would likely be inhibitory of anastomotic healing. Although it is rare, Clostridioides difficile enteritis is being reported with increasing frequency, and in the setting of recent small bowel anastomosis, it should be considered a possible risk factor for anastomotic leak.

Evaluation of negative pressure wound therapy to closed laparotomy incisions in acute care surgery.

BACKGROUND: Surgical site complications in the form of wound infections are a major burden to the healthcare system. Negative pressure wound therapy (NPWT) as delivered by a surgical incision management system (SIMS) is a novel approach to improve wound healing when applied to closed incisions. However, data is limited in its application to laparotomy incisions in the acute care surgery setting. METHODS: A retrospective case-control study was performed to evaluate the outcomes of SIMS with regard to surgical site infections in a series of 48 consecutive patients in which SIMS was applied to closed laparotomy incisions in the acute care surgery setting. RESULTS: 48 cases were matched with equivalent controls without significant differences between groups. Patients who received the SIMS had significantly lower rates of surgical site infection and readmission rates. CONCLUSIONS: Negative pressure surgical incision management systems may be a novel approach to reduce surgical site infections in acute care surgery.