Narrow pulse pressure is independently associated with massive transfusion and emergent surgery in hemodynamically stable trauma patients.

INTRODUCTION: Narrow pulse pressure (PP) is a sign of Class-II hemorrhage, but its clinical relevance is unknown. We hypothesized narrow PP is related to significant transfusion and need for emergent surgery. METHODS: Hemodynamically stable (SBP >/ = 90 mmHg) trauma patients were retrospectively reviewed. Narrow PP patients (<40 mmHg) were compared to normal patients (>/ = 40 mmHg). Outcomes included need for significant transfusion (>/ = 10 units) and emergent cavitary surgery. RESULTS: From 18,978 hemodynamically stable trauma patients admitted, 13% had narrow PP. They statistically required more massive transfusion, emergent surgery, or both (p < 0.0001), as well as higher mortality, longer hospital stay, and ICU stay (p < 0.0001). After controlling for age, gender, injury, ISS and GCS, NPP was independently associated with both significant transfusion and emergent surgery. CONCLUSION: In hemodynamically stable trauma patients, narrow PP is independently associated with three-fold increase in significant transfusion need and two-fold increase in emergent surgery need. Early identification of these patients may lead to more accurate and optimal intervention.

This too shall pass: Standardized Gastrografin protocol for partial small bowel obstruction.

BACKGROUND: One of the most common reasons for admission to a surgical service is for a partial small bowel obstruction. There is considerable variation in management. Several studies suggest that the use of diatrizoate (Gastrografin), a hyperosmolar contrast agent, can be helpful as a diagnostic agent as well as possibly therapeutic, reducing the need for operative intervention. There is a paucity of data on the use of Gastrografin in the community setting. We hypothesized that this standardized algorithm of Gastrografin administration would decrease the need for surgery and shorten a patient's length of stay, even outside the confines of a regulated clinical trial. METHODS: We performed a retrospective review of all patients admitted to two major hospitals in our network with the diagnosis of partial small bowel obstruction. Patients were excluded if they were admitted within thirty days of bowel surgery or if they were <18 years of age. The primary variable for analysis was the subsets of patients who were placed on our protocol versus no protocol at the other hospital. The primary outcome was hospital length of stay. Secondary outcomes included rate of surgery during the same admission and readmission within 30 days of discharge. All analyses were performed using Fisher's Exact test of Mann-Whitney U Test, as appropriate. RESULTS: A total of 1302 patients with partial small bowel obstruction were identified (103 on-protocol and 1199 off-protocol at our sister hospital). On-protocol patients had a shorter duration of hospitalization (mean, 4.9 days vs. 6.0 days, p < 0.001), lower rates of surgery (2% vs. 16%, p < 0.001), and similar rates of readmission for the same diagnosis (8% and 5%, p = 0.26), compared to off-protocol patients at our sister institution. CONCLUSION: A protocol utilizing Gastrografin for the management of partial small bowel obstruction decreases the need for surgery and shortens a patient's length of stay in a diverse community setting.

Adenosine diphosphate platelet dysfunction on thromboelastogram is independently associated with increased morality in traumatic brain injury.

PURPOSE: The purpose of this study is to determine if adenosine diphosphate (ADP) platelet dysfunction on thromboelastogram (TEG) is associated with increased in-hospital mortality in patients with head trauma. The hypothesis is that ADP dysfunction is associated with increased mortality. METHODS: This retrospective review evaluated trauma patients admitted to a level 1 trauma center from February 2011 to October 2013 who received a TEG. Patients were included if the TEG was drawn within the first 24 h of admission and the head abbreviated injury score was greater than or equal to three. Patients were categorized as severe ADP dysfunction if the degree of ADP inhibition on TEG exceeded 60 %. RESULTS: A total of 90 patients were included (no ADP dysfunction n = 37; ADP dysfunction n = 53). Initial Glasgow Coma Scale [GCS (12 ± 4 vs. 11 ± 5; p = 0.26)] and use of pre-injury antiplatelet agents (30 vs. 28 %; p = 0.88) were similar. Patients with ADP dysfunction on TEG had a higher in-hospital mortality rate (8 vs. 32 %; p < 0.01). ADP dysfunction was independently associated with in-hospital mortality upon fixed logistic regression (OR 6.2; 95 % CI 1.2-33) while controlling for age, gender, hypotension, pre-injury antiplatelet agents, GCS and Injury Severity Score. CONCLUSION: ADP dysfunction on TEG is associated with increased mortality in patients with traumatic brain injury.

Road rash with a rotten odor.

As military physicians, our mission is to support the fighting force and keep our soldiers mission capable. One group of disorders that can quickly cripple a fighting force is disorders of the foot. A complete survey of dematologic conditions of the foot is quite extensive, but only one comes with its own distinctive odor. This foul rash is pitted keratolysis.

Variability of the midfacial muscles: analysis of 50 hemifacial cadaver dissections.

The region of the midface represents a challenging area to both reconstructive and aesthetic surgeons. An anatomic study was performed that attempted to identify patterns and variations of the muscular anatomy. The goals of this study were twofold: to identify patterns and variability of the midfacial muscles that might impact on reconstructive efforts and to attempt to correlate this anatomy with features of the overlying soft tissues, specifically the nasolabial crease. Fifty hemifacial cadaver dissections were performed. The information collected was assembled into a large data base, and statistical significance was analyzed using Fisher's exact probability test. Results demonstrated that, although a great degree of variability exists with respect to the midfacial muscles, seven distinct patterns of these muscles did emerge. The most common pattern was the presence of a levator alae nasi, levator labii superioris, and zygomaticus major, which occurred in 44 percent of specimens. Specimens that possessed a risorius, zygomaticus minor, or both, were relatively uncommon. The consistent presence of the levators suggests adding a superior vector to recreate a smile in facial reanimation surgery. Two important anatomic variations were noted. A bifid zygomaticus major was found to be present in 34 percent of individuals. Because the inferior bundle had a dermocutaneous insertion, this anomaly may represent the anatomic correlate of a cheek "dimple." A second anomaly noted was the lateral cheek crease, which appeared to be associated with a cutaneous attachment from the underlying platysma muscle. However, no correlation could be found for facial muscle pattern and the overlying nasolabial crease structure. This lack of correlation may indicate that the facial muscles alone do not dictate the structure of the nasolabial crease and that other dynamic factors are involved in determining this feature of the aging face.