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1.
Artigo em Inglês | MEDLINE | ID: mdl-32176167

RESUMO

BACKGROUND: Blunt cerebrovascular injuries (BCVIs) are associated with significant morbidity and mortality. This guideline evaluates several aspects of BCVI diagnosis and management including the role of screening protocols, criteria for screening cervical spine injuries, and the use of antithrombotic therapy and endovascular stents. METHODS: Using the Grading of Recommendations Assessment, Development and Evaluation (GRADE) methodology, a taskforce of the Practice Management Guidelines Committee of the Eastern Association for the Surgery of Trauma performed a systematic review and meta-analysis of currently available evidence. Four population, intervention, comparison, and outcome questions were developed to address diagnostic and therapeutic issues relevant to BCVI. RESULTS: A total of 98 articles were identified. Of these, 23 articles were selected to construct the guidelines. In these studies, the detection of BCVI increased with the use of a screening protocol vs. no screening protocol (OR 4.74, 95% CI 1.76-12.78; p = 0.002), as well as among patients with high-risk versus low-risk cervical spine injuries (OR 12.7, CI, 6.24-25.62; p = 0.003). The use of antithrombotic therapy vs. no antithrombotic therapy resulted in a decreased risk of stroke (OR 0.20, CI 0.06-0.65; p < 0.0001) and mortality (OR 0.17, CI 0.08-0.34; p < 0.0001). There was no significant difference in the risk of stroke among patients with Grade II or III injuries who underwent stenting as an adjunct to antithrombotic therapy vs. antithrombotic therapy alone (OR=1.63, CI=0.2-12.14; p = 0.63). CONCLUSIONS: We recommend using a screening protocol to identify patients at-risk for BCVI. Among patients with high-risk cervical spine injuries, we recommend screening CTA to detect BCVI. For patients with low-risk risk cervical injuries, we conditionally recommend performing a CTA to detect BCVI. We recommend the use of antithrombotic therapy in patients diagnosed with BCVI. Finally, we recommend against the routine use of endovascular stents as an adjunct to antithrombotic therapy in patients with Grade II or III BCVIs. LEVEL OF EVIDENCE: Systematic Review/Meta-analysis, level IIIStudy DesignDiagnostic test, therapeutic.

2.
Artigo em Inglês | MEDLINE | ID: mdl-32044870

RESUMO

BACKGROUND: Trauma is the leading cause of non-obstetric death during pregnancy and is associated with an increased risk of maternal and fetal mortality. In an effort to improve the delivery of care to pregnant trauma patients, we developed an institutional multidisciplinary quality initiative designed to improve response times of non-trauma specialists and ensure immediate availability of resources. We hypothesized that implementation of a Perinatal Emergency Response Team (PERT) would improve time to patient and fetal evaluation and monitoring by the Obstetrics (OB) team, and improve both maternal and fetal outcomes. METHODS: We performed a 6-year (2012-2018) retrospective cohort analysis of consecutive pregnant trauma patients presenting to our University-affiliated, Level I Trauma Center. Patients in the pre-PERT cohort (prior to April 2015) were compared to a post-PERT cohort. Variables analyzed included patient demographics, mechanism of injury, injury severity score (ISS), and level of trauma activation. The main outcome measure was time to OB evaluation. Secondary outcomes included time to cardiotocometry, and mortality. RESULTS: Of 92 pregnant trauma patients, there were 50 patients (54.3%) in the pre-PERT cohort and 42 (45.7%) in the post-PERT group. Blunt injuries predominated (98.9%), with the most common mechanism being motor vehicle collisions (76.1%), followed by assaults (13%), and falls (6.5%). The mean time to obstetrical evaluation was 44 minutes in the pre-PERT cohort compared to 14 minutes in the post-PERT cohort (p = 0.001). There was a significant decrease in Level I (highest acuity) trauma activations pre- and post-PERT (46% vs. 21%, p=0.01), and the time to cardiotocography was significantly decreased post-PERT implementation (72 vs. CONCLUSION: Implementation of a multidisciplinary perinatal emergency response team (PERT) improves time to evaluation by the obstetrics team and time to cardiotocometry in the pregnant trauma patient. LEVEL OF EVIDENCE: IV STUDY TYPE: Retrospective review.

3.
J Trauma Acute Care Surg ; 88(2): 320-329, 2020 Feb.
Artigo em Inglês | MEDLINE | ID: mdl-31688786

RESUMO

BACKGROUND: There has been an unprecedented increase in critical care research recently, and there is a need for an organized and systematic approach to surgical critical care research planning. The purpose of this article was to establish a surgical critical care research agenda via a systematic review of the literature and needs assessment. METHODS: A systematic review of the literature was performed to identify high-impact critical care articles since 1999 on the basis of citation data. Using a standardized data abstraction tool, surgical representation in the literature was analyzed. A needs assessment was performed using a modified Delphi approach in three rounds to obtain consensus among members of the Critical Care Committee of the American Association for the Surgery of Trauma (n = 30) regarding research priorities in surgical critical care. RESULTS: Of 1,019 articles screened, 645 underwent full-text review, and 276 articles were included in the final analysis. Surgical patients were identified in 177 studies (64.1%), whereas trauma patients were identified in 82 (31.7%). Key categories identified during the first round of the Delphi included end of life care, traumatic brain injury (TBI), delirium, post-intensive care syndrome (PICS), hemodynamic monitoring, and volume/fluid balance. During the second and third rounds, 10 topics were classified as high priority. The three highest ranked topics were: addressing goals of care in the acute care setting (4.44 ± 0.70); improving prognostic indicators in patients with severe TBI (4.38 ± 0.85); and interventions to mitigate PICS (4.22 ± 0.65). There was a strong positive correlation in ratings (Rs value = 0.90, p = 0.001) between rounds 2 and 3. CONCLUSION: The results of this study highlight the recent surgical critical care research literature and may serve as a platform for future research endeavors in surgical critical care.


Assuntos
Pesquisa Biomédica/métodos , Cuidados Críticos/métodos , Ferimentos e Lesões/cirurgia , Pesquisa Biomédica/normas , Cuidados Críticos/normas , Cirurgia Geral/métodos , Cirurgia Geral/normas , Humanos , Guias de Prática Clínica como Assunto , Lacunas da Prática Profissional , Projetos de Pesquisa/normas , Sociedades Médicas/normas
4.
Am J Surg ; 219(1): 71-74, 2020 Jan.
Artigo em Inglês | MEDLINE | ID: mdl-31128840

RESUMO

BACKGROUND: Following appendectomy, management is often guided by surgeon determination of whether the appendicitis is uncomplicated or complicated. Our objectives were to determine the incidence of discordance between intraoperative and pathological findings and determine effect on outcomes. METHODS: We performed a retrospective five-year cohort analysis of adults who underwent appendectomy for acute appendicitis. Outcomes examined were length of stay (LOS), return to ED, and 30-day readmission. We reported p-values from logistic regression. RESULTS: Of 1479 cases, 36.4% were labeled complicated appendicitis, among which, 58.2% were discordant. When intraoperative findings underestimated pathological findings, there was a decreased LOS (p < 0.001) compared to concordant diagnoses. There was no significant difference for readmission (p = 0.592) or ED (p = 0.857). CONCLUSION: Operative underestimation of appendicitis severity was associated with a shorter LOS. Discordance did not adversely affect hospital readmission or rate of return to ED. These findings suggest reliance on intraoperative findings is sufficient in guiding management. SUMMARY: We wanted determine the incidence of discordance between operative and pathological findings and determine effect on outcomes. Operative underestimation of appendicitis severity was associated with a shorter LOS. Discordance did not adversely affect hospital readmission or rate of return to ED. These findings suggest reliance on intraoperative findings is sufficient in guiding management.

5.
Neurosurgery ; 86(1): 19-29, 2020 01 01.
Artigo em Inglês | MEDLINE | ID: mdl-30476297

RESUMO

BACKGROUND: External ventricular drain (EVD) placement is essential for the management of many neurocritical care patients. However, ventriculostomy-related infection (VRI) is a serious complication, and there remains no well-established protocol guiding use of perioperative or extended antibiotic prophylaxis to minimize risk of VRI. OBJECTIVE: To analyze published evidence on the efficacy of extended prophylactic antimicrobial therapy and antibiotic-coated external ventricular drains (ac-EVDs) in reducing VRI incidence. METHODS: We searched PubMed for studies related to VRIs and antimicrobial prophylaxis. Eligible articles reported VRI incidence in control and treatment cohorts evaluating prophylaxis with either extended systemic antibiotics (> 24 hr) or ac-EVD. Risk ratios and VRI incidence were aggregated by prophylactic strategy, and pooled estimates were determined via random or mixed effects models. Study heterogeneity was quantified using I2 and Cochran's Q statistics. Rigorous assessment of study bias was performed, and PRISMA guidelines were followed throughout. RESULTS: Across 604 articles, 19 studies (3%) met eligibility criteria, reporting 5242 ventriculostomy outcomes. Extended IV and ac-EVD prophylaxis were associated with risk ratios of 0.36 [0.14, 0.93] and 0.39 [0.21, 0.73], respectively. Mixed effects analysis yielded expected VRI incidence of 13% to 38% with no prophylaxis, 7% to 18% with perioperative IV prophylaxis, 3% to 9% with either extended IV or ac-EVD prophylaxis as monotherapies, and as low as 0.8% to 2% with extended IV and ac-EVD dual prophylaxis. CONCLUSION: Management with both extended systemic antibiotics and ac-EVDs could lower VRI risk in ventriculostomy patients, but the impact on associated morbidity and mortality, healthcare costs, and length of stay remain unclear.

6.
Am Surg ; 85(10): 1139-1141, 2019 Oct 01.
Artigo em Inglês | MEDLINE | ID: mdl-31657310

RESUMO

Decisions regarding whether to close the skin in trauma patients with hollow viscus injuries (HVIs) are based on surgeon discretion and the perceived risk for an SSI. We hypothesized that leaving the skin open would result in fewer wound complications in patients with HVIs. We performed a retrospective analysis of all adult patients who underwent operative repair of an HVI. The main outcome measure was superficial or deep SSIs. Of 141 patients, 38 (27%) had HVIs. Twenty-six patients developed SSIs, of which 13 (50%) were superficial or deep SSIs. On adjusted analysis, only female gender (P = 0.03) and base deficit were associated (P = 0.001) with wound infections Open wound management was not associated with a decreased incidence of SSIs (P = 0.19) in patients with HVIs. Further research is required to determine optimal strategies for reducing wound complications in patients sustaining HVIs.


Assuntos
Traumatismos Abdominais/cirurgia , Técnicas de Fechamento de Ferimentos Abdominais/efeitos adversos , Procedimentos Cirúrgicos Dermatológicos/efeitos adversos , Infecção da Ferida Cirúrgica/epidemiologia , Ferida Cirúrgica/cirurgia , Técnicas de Fechamento de Ferimentos Abdominais/estatística & dados numéricos , Adulto , Antibioticoprofilaxia/estatística & dados numéricos , Procedimentos Cirúrgicos Dermatológicos/métodos , Duodeno/lesões , Feminino , Humanos , Intestino Delgado/lesões , Jejuno/lesões , Masculino , Estudos Retrospectivos , Pele , Estatísticas não Paramétricas , Estômago/lesões , Infecção da Ferida Cirúrgica/classificação , Infecção da Ferida Cirúrgica/etiologia , Infecção da Ferida Cirúrgica/prevenção & controle
7.
Am Surg ; 85(10): 1146-1149, 2019 Oct 01.
Artigo em Inglês | MEDLINE | ID: mdl-31657312

RESUMO

Cirrhosis is associated with adverse outcomes after emergency general surgery (EGS). The objective of this study was to determine the safety of laparoscopic cholecystectomy (LC) in EGS patients with cirrhosis. We performed a two-year retrospective cohort analysis of adult patients who underwent LC for symptomatic gallstones. The primary outcome was the incidence of intraoperative complications. Of 796 patients, 59 (7.4%) were cirrhotic, with a median model for end-stage liver disease (MELD) score of 15 (IQR, 7). On unadjusted analysis, patients with cirrhosis were older, more likely to be male (both P < 0.01), diabetic (P < 0.001), had a higher incidence of preadmission antithrombotic therapy use (P < 0.02), and experienced a longer time to surgery (3.2 vs 1.8 days, P < 0.001). Coarsened exact matching revealed no difference in intra- or postoperative complications between groups (P = 0.67). Operative duration was longer in patients with cirrhosis (162 vs 114 minutes, P = 0.001), who also had a nonsignificant increase in the rate of conversion to an open cholecystectomy (14% vs 4%, P = 0.07). The results of this study indicate that LC may be safely performed in EGS patients with cirrhosis.


Assuntos
Colecistectomia Laparoscópica/efeitos adversos , Tratamento de Emergência/efeitos adversos , Cálculos Biliares/cirurgia , Complicações Intraoperatórias/epidemiologia , Cirrose Hepática/complicações , Doença Aguda , Adulto , Fatores Etários , Ductos Biliares/lesões , Conversão para Cirurgia Aberta/estatística & dados numéricos , Tratamento de Emergência/métodos , Feminino , Fibrinolíticos/uso terapêutico , Cálculos Biliares/etiologia , Hemorragia/epidemiologia , Humanos , Incidência , Intestinos/lesões , Complicações Intraoperatórias/etiologia , Cirrose Hepática/epidemiologia , Masculino , Pessoa de Meia-Idade , Estudos Retrospectivos , Fatores de Risco , Segurança , Fatores Sexuais , Fatores de Tempo , Tempo para o Tratamento/estatística & dados numéricos
8.
Am Surg ; 85(10): 1175-1178, 2019 Oct 01.
Artigo em Inglês | MEDLINE | ID: mdl-31657319

RESUMO

Early surgical intervention decreases mortality in necrotizing soft tissue infections (NSTIs). Yet, a subset of patients will not have NSTIs (non-NSTIs) at the time of exploration. We hypothesized that NSTI and non-NSTI patients had similar causative organisms and that intraoperative wound cultures could help guide management. Culture results and outcomes were compared for all patients undergoing surgery for suspected NSTIs over a seven-year-period. Of 295 patients, 240 (81.4%) had NSTIs. Of the 55 non-NSTI patients (18.6%), 50 had cellulitis and 5 had abscesses. NSTI and non-NSTI patients had similar rates of bacteremia (20.4% vs 17.6%, P = 0.66), septic shock (15.9% vs 12.7%, P = 0.68), and mortality (10.4% vs 7.2%, P = 0.62). Wound cultures were collected more often in NSTI patients (229/240, 95.4%) than in non-NSTI patients (42/55, 76.4%, P < 0.01). Non-NSTI patients had positive deep wound cultures more than half of the time (23/42, 54.8%). The microbiologic profile was similar between groups, with Methicillin Resistant Staphylococcus aureus and Group A Streptococcus occurring with the same frequency. We advocate for deep wound cultures in all patients being evaluated operatively for NSTIs even if the exploration is considered negative because these patients have similar clinical characteristics and virulent microbiology, and culture results can help guide antimicrobial therapy.


Assuntos
Infecções dos Tecidos Moles/microbiologia , Infecções dos Tecidos Moles/cirurgia , Abscesso/epidemiologia , Abscesso/microbiologia , Adulto , Bacteriemia/epidemiologia , Técnicas Bacteriológicas , Celulite (Flegmão)/epidemiologia , Celulite (Flegmão)/microbiologia , Feminino , Mortalidade Hospitalar , Humanos , Masculino , Staphylococcus aureus Resistente à Meticilina/isolamento & purificação , Pessoa de Meia-Idade , Necrose/microbiologia , Estudos Retrospectivos , Choque Séptico/epidemiologia , Infecções dos Tecidos Moles/epidemiologia , Infecções dos Tecidos Moles/patologia , Streptococcus pyogenes/isolamento & purificação
9.
Am Surg ; 85(10): 1189-1193, 2019 Oct 01.
Artigo em Inglês | MEDLINE | ID: mdl-31657322

RESUMO

Paraesophageal hernia (PEH) repair is typically performed electively. Complex PEHs (obstructed or gangrenous) require more urgent repair and can have significant complications. Although elective repair is primarily laparoscopic, limited data are available on the use of laparoscopy for complex cases. Patients undergoing complex PEH repair were identified from the NSQIP database, and predictors of morbidity and mortality were compared for 2473 laparoscopic and 861 open repairs. Compared with the laparoscopic approach, emergent surgeries (36.7% vs 10.8%, P < 0.001) and preoperative sepsis (22.9% vs 7.4%, P < 0.001) were more common in the open group. Operative times were shorter for open repairs (152.6 vs 172.2 minutes, P = 0.03). However, open repair was associated with increased morbidity (28.2% vs 11%, P < 0.001) and mortality (5.2% vs 1.4%, P < 0.001), likely because of higher rates of preoperative comorbidities in the open group. On multivariable regression analysis, preoperative sepsis was associated with increased mortality and morbidity, whereas laparoscopic repair was associated with decreased morbidity. If laparoscopic repair can be safely completed, it is associated with decreased morbidity, despite longer operative times.


Assuntos
Doenças do Esôfago/cirurgia , Hérnia Hiatal/cirurgia , Herniorrafia/mortalidade , Laparoscopia/mortalidade , Idoso , Emergências/epidemiologia , Feminino , Herniorrafia/efeitos adversos , Herniorrafia/métodos , Humanos , Laparoscopia/efeitos adversos , Masculino , Morbidade , Duração da Cirurgia , Análise de Regressão , Sepse/epidemiologia
10.
Am J Surg ; 218(6): 1185-1188, 2019 12.
Artigo em Inglês | MEDLINE | ID: mdl-31551145

RESUMO

INTRODUCTION: The early identification of hemorrhagic shock may be challenging. The objective of this study was to examine the utility of a narrowed pulse pressure in identifying the need for emergent interventions following penetrating trauma. METHODS: In this 2.5-year retrospective study of adult patients with a penetrating mechanism, patients with a narrowed pulse pressure (<30 mmHg) were compared to those without. Main outcomes measures were the need for a massive transfusion or emergent operation. RESULTS: There were 957 patients, of which the majority were male (86%) and 55% presented with gunshot wounds. On multivariate analysis, a narrowed pulse pressure was associated with the need for massive transfusion (OR 3.74, 95% C.I. 1.8-7.7, p = 0.0003) and emergent surgery (OR 1.68, 95% C.I. 1.14-2.48, p = 0.009). CONCLUSIONS: A narrowed pulse pressure is associated with the presence of hemorrhagic shock and need for emergent interventions among patients with penetrating torso trauma.

11.
Am J Surg ; 218(6): 1079-1083, 2019 12.
Artigo em Inglês | MEDLINE | ID: mdl-31506167

RESUMO

BACKGROUND: The objective of this multi-center study was to examine the follow-up trends after emergency department (ED) discharge in a large and socioeconomically diverse patient population. METHODS: We performed a 3-year retrospective analysis of adult patients with acutely symptomatic hernias who were discharged from the EDs of five geographically diverse hospitals. RESULTS: Of 674 patients, 288 (43%) were evaluated in the clinic after discharge from the ED and 253 (37%) underwent repair. Follow-up was highest among those with insurance. A total of 119 patients (18%) returned to the ED for hernia-related complaints, of which 25 (21%) underwent urgent intervention. CONCLUSION: The plan of care for patients with acutely symptomatic hernias discharged from the ED depends on outpatient follow-up, but more than 50% of patients are lost to follow-up, and nearly 1 in 5 return to the ED. The uninsured are at particularly high risk.

12.
J Trauma Acute Care Surg ; 87(1): 117-124, 2019 Jul.
Artigo em Inglês | MEDLINE | ID: mdl-31260426

RESUMO

BACKGROUND: Hemodynamically unstable patients with severe pelvic fracture are a significant challenge to trauma surgeons and have high mortality. Significant variability across institutions in hemorrhage control adjuncts used to quell pelvic bleeding has been demonstrated. However, the effect of these methods on time to definitive bleeding control, type of resuscitation given, and outcomes remains unknown. We sought to elucidate those effects. METHODS: This was a multicenter retrospective review of severe pelvic fracture patients in shock between 2011 and 2016. Shock was defined as systolic blood pressure less than 90 mm Hg, heart rate greater than 120 beats per minute, or base deficit less than -5. Definitive bleeding control was defined as time to surgical control in the operating room or embolization by interventional radiology. Significance level was at p less than 0.05. RESULTS: A total of 279 severe pelvic fracture patients with shock on admission from 12 trauma centers were included. The cohort was primarily male (62%) with median (interquartile range) age of 40 years (28-54 years), Injury Severity Score of 38 (29-50), and Glasgow Coma Scale score of 13 (3-15). Overall mortality was 32%. The most common adjunct used was pelvic binder (50%) followed by no adjunct (30.5%); least common was resuscitative balloon occlusion of the aorta (REBOA) (2.5%). Preperitoneal packing alone and REBOA alone/with other adjunct(s) resulted in the fastest times to operating room/interventional radiology but also had the highest blood utilization and mortality rates. Resuscitative balloon occlusion of the aorta was most often used along with pelvic binder (6 of 13; 46%). CONCLUSION: Marked variation in management of severe pelvic fracture patients in shock indicates the need for a standardized approach to maximize outcomes and minimize transfusion requirements. The use of preperitoneal packing and/or REBOA yielded fastest times to definitive bleeding control. However, REBOA continues to be infrequently used. Future prospective analysis of this combination needs further validation in patients with severe pelvic hemorrhage. LEVEL OF EVIDENCE: Therapeutic study, level IV.


Assuntos
Fraturas Ósseas/complicações , Ossos Pélvicos/lesões , Choque Hemorrágico/terapia , Adulto , Feminino , Fraturas Ósseas/terapia , Técnicas Hemostáticas/estatística & dados numéricos , Humanos , Escala de Gravidade do Ferimento , Masculino , Pessoa de Meia-Idade , Estudos Retrospectivos , Choque Hemorrágico/etiologia , Centros de Traumatologia/estatística & dados numéricos , Resultado do Tratamento
13.
Trauma Surg Acute Care Open ; 4(1): e000264, 2019.
Artigo em Inglês | MEDLINE | ID: mdl-30899795

RESUMO

Background: Necrotizing soft tissue infections (NSTI) are aggressive infections associated with significant morbidity and mortality. Despite multiple predictive models for the identification of NSTI, a subset of patients will not have an NSTI at the time of surgical exploration. We hypothesized there is a subset of patients without NSTI who are clinically indistinguishable from those with NSTI. We aimed to characterize the differences between NSTI and non-NSTI patients and describe a negative exploration rate for this disease process. Methods: We conducted a retrospective review of adult patients undergoing surgical exploration for suspected NSTI at our county-funded, academic-affiliated medical center between 2008 and 2015. Patients were identified as having NSTI or not (non-NSTI) based on surgical findings at the initial operation. Pathology reports were reviewed to confirm diagnosis. The NSTI and non-NSTI patients were compared using χ2 test, Fisher's exact test, and Wilcoxon rank-sum test as appropriate. A p value <0.05 was considered significant. Results: Of 295 patients undergoing operation for suspected NSTI, 232 (79%) were diagnosed with NSTI at the initial operation and 63 (21%) were not. Of these 63 patients, 5 (7.9%) had an abscess and 58 (92%) had cellulitis resulting in a total of 237 patients (80%) with a surgical disease process. Patients with NSTI had higher white cell counts (18.5 vs. 14.9 k/mm3, p=0.02) and glucose levels (244 vs. 114 mg/dL, p<0.0001), but lower sodium values (130 vs. 134 mmol/L, p≤0.0001) and less violaceous skin changes (9.2% vs. 23.8%, p=0.004). Eight patients (14%) initially diagnosed with cellulitis had an NSTI diagnosed on return to the operating room for failure to improve. Conclusions: Clinical differences between NSTI and non-NSTI patients are subtle. We found a 20% negative exploration rate for suspected NSTI. Close postoperative attention to this cohort is warranted as a small subset may progress. Level of evidence: Retrospective cohort study, level III.

14.
J Am Coll Surg ; 229(2): 141-149, 2019 Aug.
Artigo em Inglês | MEDLINE | ID: mdl-30878583

RESUMO

BACKGROUND: Gunshot wound (GSW) injuries present a unique surgical challenge. This study explored the financial and clinical burdens of GSW patients across 2 Los Angeles County Level I trauma centers over the last 12 years, and compared them with other forms of interpersonal injury (OIPI). STUDY DESIGN: This was a retrospective study of patients presenting as those with GSW and OIPI (defined as combined stab wound or blunt assault), between January 1, 2006 and March 30, 2018, at LAC+USC Medical Center (LAC+USC) and Harbor UCLA Medical Center (HUCLA). Demographic and clinical variables were assessed for GSW patients and compared with victims of OIPI. RESULTS: There were 17,871 patients who met inclusion criteria. There was a significant difference in mortality for patients with GSW vs OIPI (11% vs 2%, p < 0.001). The odds ratio for GSW patients requiring operation was twice as high as those suffering OIPI (odds ratio [OR] 2.0, 95% CI 1.8 to 2.2). The odds ratio for GSW patients requiring ICU admission was 20% higher than that for OIPI patients (OR 1.23, 95% CI 1.11 to 1.36). Gunshot wound patients experienced a longer median length of stay vs OIPI patients (3 days vs 2 days, p < 0.001). The median hospital charge per admission for GSW was twice that of OIPI (GSW $12,612 vs OIPI $6,195; p < 0.001). CONCLUSIONS: When compared with OIPI, GSW patients arrived more severely injured and required more operations, more ICU admissions, and longer hospital stays. Patients with GSW incurred significantly higher hospital charges and had a significantly higher mortality rate. Gunshot wound injury is a unique public health concern requiring comprehensive, nation-wide, contemporary study.

15.
Ann Vasc Surg ; 57: 35-40, 2019 May.
Artigo em Inglês | MEDLINE | ID: mdl-30684614

RESUMO

BACKGROUND: Early identification of peripheral vascular injuries is crucial to prevent acute limb ischemia and amputation. We sought to identify predictors of vascular injury in patients with blunt lower extremity fractures. METHODS: A single institutional retrospective analysis of patients with blunt lower extremity fractures at a university-affiliated, county hospital over a 2-year period was performed. Patients with lower extremity vascular injury were compared to patients without lower extremity vascular injury. Multivariate logistic regression analysis was performed to identify independent predictors of vascular injury. RESULTS: Two hundred seventy-four patients were identified. The mean age was 37.2 ± 17.6 years, and 73.7% were male. The most common mechanisms were auto versus pedestrian/bicycle (44.2%) and motor vehicle accidents (27.7%). Twenty-two patients (8.0%) had vascular injuries, of which the most commonly injured arteries were the anterior tibial artery (8, 36.4%) and the posterior tibial artery (8, 36.4%). Patients with vascular injuries were more likely to have a tibia-fibula fracture (90.9% vs 52.4%, P < 0.01), an open fracture (63.6% vs 21.8%, P < 0.01), and a mid-shaft fracture (59.1% vs 19.4%, P < 0.01). Amputation was required in 3 patients (13.6%) with a vascular injury. On multivariate analysis, a tibia-fibula fracture (odds ratio [OR] = 5.48, 95% confidence interval [CI] = 1.15-26.1, P < 0.05), an open fracture (OR = 3.87, 95% CI = 1.37-11.0, P = 0.01), and mid-shaft fracture (OR = 2.91, 95% CI = 1.04-8.1, P < 0.05) were associated with the presence of a vascular injury. CONCLUSIONS: Open tibia-fibula fractures particularly those involving a mid-shaft location are independent predictors of vascular injuries in patients with blunt lower extremity fracture. These findings may help identify patients requiring diagnostic and surgical intervention.


Assuntos
Fíbula/lesões , Traumatismos da Perna/etiologia , Extremidade Inferior/irrigação sanguínea , Fraturas da Tíbia/etiologia , Lesões do Sistema Vascular/etiologia , Ferimentos não Penetrantes/etiologia , Adulto , Amputação , Feminino , Fíbula/diagnóstico por imagem , Fíbula/cirurgia , Fixação de Fratura , Humanos , Traumatismos da Perna/diagnóstico por imagem , Traumatismos da Perna/cirurgia , Salvamento de Membro , Masculino , Pessoa de Meia-Idade , Valor Preditivo dos Testes , Prognóstico , Estudos Retrospectivos , Medição de Risco , Fatores de Risco , Fraturas da Tíbia/diagnóstico por imagem , Fraturas da Tíbia/cirurgia , Procedimentos Cirúrgicos Vasculares , Lesões do Sistema Vascular/diagnóstico por imagem , Lesões do Sistema Vascular/cirurgia , Ferimentos não Penetrantes/diagnóstico por imagem , Ferimentos não Penetrantes/cirurgia , Adulto Jovem
18.
J Surg Educ ; 75(6): e91-e96, 2018 Nov.
Artigo em Inglês | MEDLINE | ID: mdl-30131281

RESUMO

OBJECTIVE: Identifying gaps in medical knowledge, patient management, and procedural competence is difficult early in surgical residency. We designed and implemented an end-of-year examination for our postgraduate year 1 residents, entitled Surgical Trainee Assessment of Readiness (STAR). Our objective in this study was to determine whether STAR scores correlated with other available indicators of resident performance, such as the American Board of Surgery in-training exam (ABSITE) and Milestone scores, and if they provided evidence of additional discriminatory value. STUDY DESIGN: Overall and component scores of the STAR exam were compared to the ABSITE and Milestone assessment scores for the 17 categorical residents that took the exam in 2016 and 2017. SETTING: Harbor-UCLA Medical Center, a university-affiliated academic medical center. PARTICIPANTS: Seventeen categorical general surgery residents. RESULTS: The STAR Total Test Score (ß = 2.77, p = 0.006) was an independent predictor of the ABSITE taken the same year, and components of the STAR were independent predictors of ABSITE taken the following year. The STAR Total Test Score was lowest in the 3 residents who had at least 1 low Milestone score assessed in the same year; and 2 of these 3 residents had at least 1 low Milestone score assigned the next year after STAR. Lastly, the Patient Care 1 and 2 Milestones assessed in the same year as STAR were uniformly scored as appropriate for level of training, yet the corresponding STAR component for those milestones demonstrated 3 residents as having deficiencies. CONCLUSIONS: We have created a multifaceted standardized STAR exam, which correlates with performance on the ABSITE and early milestone scores. It also appears to discriminate resident performance where milestone assessments do not. Further evaluation of the STAR exam with longer term follow-up is needed to confirm these initial findings.


Assuntos
Competência Clínica/normas , Cirurgia Geral/educação , Internato e Residência/normas , Fatores de Tempo , Apoio ao Desenvolvimento de Recursos Humanos , Estados Unidos
19.
J Trauma Acute Care Surg ; 85(1): 78-84, 2018 07.
Artigo em Inglês | MEDLINE | ID: mdl-29664893

RESUMO

BACKGROUND: Occupational exposure is an important consideration during emergency department thoracotomy (EDT). While human immunodeficiency virus/hepatitis prevalence in trauma patients (0-16.8%) and occupational exposure rates during operative trauma procedures (1.9-18.0%) have been reported, exposure risk during EDT is unknown. We hypothesized that occupational exposure risk during EDT would be greater than other operative trauma procedures. METHODS: A prospective, observational study at 16 US trauma centers was performed (2015-2016). All bedside EDT resuscitation providers were surveyed with a standardized data collection tool and risk factors analyzed with respect to the primary end point, EDT occupational exposure (percutaneous injury, mucous membrane, open wound, or eye splash). Provider and patient variables and outcomes were evaluated with single and multivariable logistic regression analyses. RESULTS: One thousand three hundred sixty participants (23% attending, 59% trainee, 11% nurse, 7% other) were surveyed after 305 EDTs (gunshot wound, 68%; prehospital cardiopulmonary resuscitation, 57%; emergency department signs of life, 37%), of which 15 patients survived (13 neurologically intact) their hospitalization. Overall, 22 occupational exposures were documented, resulting in an exposure rate of 7.2% (95% confidence interval [CI], 4.7-10.5%) per EDT and 1.6% (95% CI, 1.0-2.4%) per participant. No differences in trauma center level, number of participants, or hours worked were identified. Providers with exposures were primarily trainees (68%) with percutaneous injuries (86%) during the thoracotomy (73%). Full precautions were utilized in only 46% of exposed providers, while multiple variable logistic regression determined that each personal protective equipment item utilized during EDT correlated with a 34% decreased risk of occupational exposure (odds ratio, 0.66; 95% CI, 0.48-0.91; p = 0.010). CONCLUSIONS: Our results suggest that the risk of occupational exposure should not deter providers from performing EDT. Despite the small risk of viral transmission, our data revealed practices that may place health care providers at unnecessary risk of occupational exposure. Regardless of the lifesaving nature of the procedure, improved universal precaution compliance with personal protective equipment is paramount and would further minimize occupational exposure risks during EDT. LEVEL OF EVIDENCE: Therapeutic/care management study, level III.


Assuntos
Serviço Hospitalar de Emergência/estatística & dados numéricos , Exposição Ocupacional/estatística & dados numéricos , Toracotomia/efeitos adversos , Adulto , Feminino , Pessoal de Saúde/estatística & dados numéricos , Inquéritos Epidemiológicos , Humanos , Masculino , Estudos Prospectivos , Fatores de Risco , Toracotomia/estatística & dados numéricos , Centros de Traumatologia/estatística & dados numéricos , Estados Unidos
20.
J Trauma Acute Care Surg ; 85(1): 37-47, 2018 07.
Artigo em Inglês | MEDLINE | ID: mdl-29677083

RESUMO

BACKGROUND: We sought to determine the outcome of suicidal hanging and the impact of targeted temperature management (TTM) on hanging-induced cardiac arrest (CA) through an Eastern Association for the Surgery of Trauma (EAST) multicenter retrospective study. METHODS: We analyzed hanging patient data and TTM variables from January 1992 to December 2015. Cerebral performance category score of 1 or 2 was considered good neurologic outcome, while cerebral performance category score of 3 or 4 was considered poor outcome. Classification and Regression Trees recursive partitioning was used to develop multivariate predictive models for survival and neurologic outcome. RESULTS: A total of 692 hanging patients from 17 centers were analyzed for this study. Their overall survival rate was 77%, and the CA survival rate was 28.6%. The CA patients had significantly higher severity of illness and worse outcome than the non-CA patients. Of the 175 CA patients who survived to hospital admission, 81 patients (46.3%) received post-CA TTM. The unadjusted survival of TTM CA patients (24.7% vs 39.4%, p < 0.05) and good neurologic outcome (19.8% vs 37.2%, p < 0.05) were worse than non-TTM CA patients. However, when subgroup analyses were performed between those with an admission Glasgow Coma Scale score of 3 to 8, the differences between TTM and non-TTM CA survival (23.8% vs 30.0%, p = 0.37) and good neurologic outcome (18.8% vs 28.7%, p = 0.14) were not significant. Targeted temperature management implementation and post-CA management varied between the participating centers. Classification and Regression Trees models identified variables predictive of favorable and poor outcome for hanging and TTM patients with excellent accuracy. CONCLUSION: Cardiac arrest hanging patients had worse outcome than non-CA patients. Targeted temperature management CA patients had worse unadjusted survival and neurologic outcome than non-TTM patients. These findings may be explained by their higher severity of illness, variable TTM implementation, and differences in post-CA management. Future prospective studies are necessary to ascertain the effect of TTM on hanging outcome and to validate our Classification and Regression Trees models. LEVEL OF EVIDENCE: Therapeutic study, level IV; prognostic study, level III.


Assuntos
Parada Cardíaca Induzida/mortalidade , Hipotermia Induzida/métodos , Suicídio/estatística & dados numéricos , Adulto , Feminino , Parada Cardíaca Induzida/estatística & dados numéricos , Humanos , Masculino , Prognóstico , Estudos Retrospectivos , Fatores de Risco , Taxa de Sobrevida , Resultado do Tratamento , Adulto Jovem
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