Factors associated with pediatric trauma patients leaving against medical advice.

BACKGROUND: Discharge against medical advice (AMA) leads to worse patient outcomes, increased readmission rates, and higher cost. However, AMA discharge has received limited study, particularly in pediatric trauma patients. Our objective was to explore the risk factors associated with leaving AMA in pediatric trauma patients. METHODS: We performed a retrospective analysis on pediatric trauma patients from 2017 to 2019 using the National Trauma Data Bank. We examined patient characteristics including age (<18 years), race, sex, Glasgow Coma Scale, trauma type, primary payment methods, and Abbreviated Injury Scale. Multiple Logistic Regression models were utilized to determine characteristics associated with leaving AMA. RESULTS: Of the 224,196 pediatric patients included in the study, 238 left AMA (0.1%). Our study showed black pediatric trauma patients were more likely to leave AMA compared to nonblack patients (OR 1.987, 95% CI 1.501 to 2.631). Patients with self-pay coverage were more likely to leave AMA than those with other insurance coverages (OR 1.759, 95% CI 1.183 to 2.614). Blunt trauma patients were more likely to leave AMA than those with penetrating trauma (OR 1.683, 95% CI 1.216 to 2.330). Every one-year increase in age led to 15% increase in odds of AMA discharge (OR 1.150, 95% CI 1.115 to 1.186). Pediatric patients with severe abdominal injuries were less likely to leave AMA compared to those with mild abdominal injuries (OR 0.271, 95% CI 0.111 to 0.657). Patients with severe lower extremity injury were less likely to leave AMA compared to those with mild lower extremity injuries (OR 0.258, 95% CI 0.127 to 0.522). CONCLUSION: Race, insurance, injury type, and age play a role in AMA discharge of pediatric trauma patients. Black pediatric trauma patients have ∼ double the AMA discharge rate of nonblack patients. AMA discharge remains relevant, and addressing racial and socioeconomic factors provide opportunities for future interventions in pediatric trauma care. LEVEL OF EVIDENCE: III, retrospective study.

Contralateral diaphragmatic injury sustained from transhumeral amputation: an unusual case and brief literature review.

Right-sided diaphragmatic injury is an uncommon sequelae from blunt trauma and may be associated with other severe thoracoabdominal injuries. This injury can be easily missed on initial assessment and a high index of suspicion and clinical judgment is required. Recently, we treated a 25-year-old male inflicted with a right-sided diaphragmatic injury after a left-sided transhumeral amputation sustained from an overturned motor vehicle collision with thoracoscopic exploration and reapproximation.

A novel presentation of alcohol-induced gastric necrosis: a case report.

Acute gastric necrosis is a rare condition with unknown pathogenesis. Existing literature describes acute esophageal necrosis as a result of excessive alcohol use; however, it is more difficult to find literature on alcohol-induced gastric necrosis. This condition may present with epigastric tenderness, vomiting or diarrhea with findings of pneumoperitoneum, gastric pneumatosis and portal venous gas on computed tomography. These patients can have complications such as septic shock, peritonitis and death. In this case report, we discuss a patient with a history of alcohol abuse who presented with acute gastric necrosis. On endoscopy, this patient was found to have a black necrotic gastric fundus and unusual erythematous changes to the mucosa. Prior research has identified other findings of patchy or diffuse circumferential black pigmentation of esophageal mucosa in patients with alcohol-induced esophageal necrosis, otherwise known as black esophagus. This case report aims to describe this novel presentation of alcohol-induced gastric necrosis.

A rare anatomical variation complicating a diffuse abdominal pain presentation: A case report of colonic perforation in situs inversus totalis.

INTRODUCTION: Situs inversus totalis (SIT) is a rare anatomical variation of the thoracic and abdominal organs. It is a congenital anomaly with an incidence of 1:10,000 to 1:20,000. Patients with SIT do not have a decreased survival rate as compared to patients without SIT because SIT generally does not have a pathophysiologic significance. However, the anatomical variations in SIT can cause some challenges when assessing intraabdominal and intrathoracic symptoms or performing operations. CASE PRESENTATION: We report a case of a 93-year-old woman with a past medical history of hypertension, hyperlipidemia, atrial fibrillation, and situs inversus totalis who presented with diffuse abdominal pain for 4 days. Abdominal exam was significant for diffuse tenderness. Computed tomography (CT) imaging was significant for pneumoperitoneum. She emergently underwent an exploratory laparotomy, descending hemicolectomy and left in discontinuity with an open abdomen. On postoperative day 2 she underwent a stamm feeding gastrostomy tube, incisional hernia repair, and maturation of end colostomy. Her remaining hospital course was complicated by a pelvic collection, which was managed by a percutaneous guided drain placement. She was ultimately discharge to rehab on hospital day 15. DISCUSSION: SITS can present a particularly challenging situation to clinical diagnoses and surgical procedures. However, when identified, these patients should warrant special considerations prior to proceeding with surgical intervention. This includes radiologic imaging and proper planning prior to the operating room, when possible. CONCLUSION: We herein present a case of colonic perforation in a patient with situs inversus totalis. Proper planning, thorough imaging, and careful execution are necessary to ensure patient safety and care in patients with SIT. However, in the case of emergency this should not delay definitive management.

Outcomes of Extracorporeal Membrane Oxygenation in Acute Respiratory Distress Syndrome Following Traumatic Injury: A Propensity-Matched Analysis.

OBJECTIVES: The purpose of this study is to evaluate the overall occurrence of inhospital mortality in trauma patients who were placed on extracorporeal membrane oxygenation following the complication of the acute respiratory distress syndrome. DESIGN: Observational cohort study. SETTING: The data of all patients who were traumatically injured and developed the complication of acute respiratory distress syndrome were accessed from the Trauma Quality Improvement Program database from the calendar years of 2013 to 2016. PATIENTS: Patients 16 years old and less than 90 years old were included in the study. Variables included patient demography, Injury Severity Score, Glasgow Coma Scale score, Abbreviated Injury Scale score, and outcomes. INTERVENTIONS: Extracorporeal membrane oxygenation. MEASUREMENTS AND MAIN RESULTS: Propensity-matched analysis was performed between two groups: patients placed on extracorporeal membrane oxygenation and patients placed on conventional mode of ventilation. The primary outcome was inhospital mortality. Out of 6,121 patients who developed acute respiratory distress syndrome, 118 patients (1.93%) were placed on extracorporeal membrane oxygenation. The pair matched analysis showed significant difference between the two groups (extracorporeal membrane oxygenation vs conventional mode of ventilation) for overall inhospital mortality (35.6% vs 14.4%; p < 0.001). There were significant differences found between the two groups for the median hospital length of stay (41 [35-49] vs 27 [24-33]), ICU days (35 [30-41] vs 19 [17-24]), and ventilator days (30 [27-34] vs 15 [13-18]). All p values are less than 0.001. CONCLUSIONS: Approximately 2% of acute respiratory distress syndrome patients were placed on extracorporeal membrane oxygenation. The overall inhospital mortality remained high despite patients being placed on extracorporeal membrane oxygenation.

Posterior reversible encephalopathy syndrome in the setting of trauma: A case report.

Reports of posterior reversible encephalopathy syndrome (PRES) in the setting of trauma and acute care surgery are scarce. PRES presents rapidly with a variety of symptoms including headaches, visual disturbances, altered consciousness, and seizures. It is associated with acute hypertensive episodes. PRES is diagnosed with a specific neuroimaging pattern and a constellation of clinical symptoms. This case report presents two traumatically injured patients with one confirmed case of PRES and the other with a potential case of PRES. The diagnosis was made through neuroimaging showing patchy T2 and diffusion hyperintensity in the periphery of both occipital lobes and adjacent cerebellar hemispheres on MRI in one case. The other case highlights extensive stable white matter disease without evidence of acute infarct on MRI, as well as diminished attenuation within the cerebral white matter in the occipital lobes on CT scan. There was resolution of visual symptoms in one patient while the other patient's neurologic status did not allow for evaluation of symptom resolution. This report aims to emphasize the possibility of PRES in trauma patients with a specific pattern of neuroimaging and clinical symptoms, and to increase the index of suspicion in acute care providers.

Pentobarbital Induced Hypokalemia: A Worrying Sequela.

INTRODUCTION: Intracranial hypertension that is not responsive to other therapies can be managed through the use of a barbiturate induced coma. Although potentially effective, there are known complications associated with this treatment, and as such it is typically reserved for the most severe cases. One such sequela of barbiturate induced coma therapy is refractory hypokalemia and subsequent rebound hyperkalemia. PRESENTATION OF CASE: This case report discusses a patient who experienced hypokalemia during pentobarbital induced coma for unmanageable elevations in intracranial pressure and was treated conservatively to avoid rebound hyperkalemia depicting successful deployment of permissive hypokalemia. DISCUSSION: It is vital that clinicians understand the possible adverse effects associated with barbiturate induced coma therapy, and that a careful balance be struck between hypokalemia and potassium supplementation to avoid rebound hyperkalemia. CONCLUSION: Given that the risk of rebound hyperkalemia is of significant concern in patients who experience hypokalemia on barbiturate induced coma therapy, permissive hypokalemia can be a viable treatment option achieved by lowering the potassium replacement target threshold in such patients.

A comparison of open and endovascular treatment strategies for the management of splenic artery aneurysms.

Splenic artery aneurysms are rare with an incidence of less than 0.8%. Evidence to support an endovascular management strategy over open surgical repair for SAA is limited. We used the Nationwide Inpatient Sample to compare open to endovascular SAA repair by assessing postoperative outcomes, length of hospital stay, and mortality. Multivariate logistic regression analysis was done to determine predictors of postoperative complications. There were 2316 admissions with a diagnosis code for SAA [347 (14.9%) endovascular repair and 112 (4.8%) open surgery]. There was a statistically significant lower rate of cardiac (2.3% vs 6.9%, P = 0.05) and pulmonary (8.9% vs 16.1%, P = 0.05) complications for the endovascular repair group. The risk of surgical site infection was also lower (0.6% vs 5.1%, P = 0.01) in the endovascular group. Median in-hospital LOS was greater for open repairs (6 vs. 4 days, P = 0.01). There were no statistically significant differences across procedures for renal complications (8.9%, P = 0.88) or in-hospital mortality (3%, P = 0.99). Regression analysis established procedure type to be independent predictor of postoperative complications. Endovascular repair of SAA is therefore associated with a lower complication rate and less resource utilization but no difference in mortality peri-operatively. This may justify an endovascular first treatment strategy in the management of SAA.