Comparison of Geriatric Trauma Outcomes When Admitted to a Medical or Surgical Service After a Fall.

BACKGROUND: Blunt trauma in the geriatric population is fraught with poor outcomes, with injury severity and comorbidities impacting morbidity and mortality. METHODS: We retrospectively reviewed 2172 patients aged ≥65 y who fell, requiring hospital admission between January 2012 and December 2016. There were 403 patients in the surgical arm (SA) and 1769 patients in the medical arm (MA). Ground-level falls were the only mechanism of injury included. We excluded all ICU admissions and deaths within 24 h. RESULTS: There were 5 deaths (1.24%) in the SA and 16 deaths (0.90%) in the MA (P = 0.57). The mean trauma injury severity score survival probability prediction in the SA was 96.9% versus 97.1% in the MA. MA patients had more comorbidities overall than SA patients. There was no difference in mortality between the SA and MA groups in multiple logistic regression models that accounted for trauma injury severity scores (TRISS) and comorbidities. Unadjusted hospital length of stay was 1 d shorter (median; 95% CI -1.4 to -0.6) in the SA and 0.5 d shorter (median; 95% CI -0.8 to -0.1) when adjusted for TRISS and comorbidities using multiple quantile regression. Finally, patients in the SA were 2.1 (95% CI 1.7 to 2.6) times more likely to be discharged home compared with patients in the MA, and this remained significant (OR 1.9; 95% CI 1.5 to 2.5) with simultaneous adjustment for TRISS and comorbidities using multiple logistic regression. CONCLUSIONS: Geriatric blunt trauma patients admitted to surgical services after mechanical falls have no difference in survival, a shorter median length of stay, and increased likelihood of being discharged home compared with patients admitted to medical services.

Acute Pancreatitis: Etiology, Pathology, Diagnosis, and Treatment.

Acute pancreatitis is a fascinating disease. In the United States, the two most common etiologies of acute pancreatitis are gallstones and excessive alcohol consumption. The diagnosis of acute pancreatitis is made with a combination of history, physical examination, computed tomography scan, and laboratory evaluation. Differentiating patients who will have a benign course of their pancreatitis from patients who will have severe pancreatitis is challenging to the clinician. C-reactive protein, pro-calcitonin, and the Bedside Index for Severity of Acute Pancreatitis appeared to be the best tools for the early and accurate diagnosis of severe pancreatitis. Early laparoscopic cholecystectomy is indicated for patients with mild gallstone pancreatitis. For patients who are going to have a prolonged hospitalization, enteral nutrition is preferred. Total parenteral nutrition should be reserved for patients who cannot tolerate enteral nutrition. Prophylactic antibiotics are not indicated for patients with pancreatic necrosis. Surgical intervention for infected pancreatic necrosis should be delayed as long as possible to improve patient outcomes.

Subclavian Vein Central Line Catheter Mistakenly Placed in the Aorta: A Case Report and How to Avoid Complications.

An 85-year-old female with multiple medical problems presented with a sigmoid volvulus. While in the ICU, the patient required a central line because of poor peripheral access. The central line was mistakenly placed in the aorta while attempting to use the subclavian approach. In this manuscript we discussed ways of reducing complications and successfully placing subclavian vein catheters.

Perforated Small Bowel Adenocarcinoma: An Interesting Presentation of a Rare Disease.

Primary small bowel adenocarcinoma (SBA) is a rare disease with no clear guidelines on screening, diagnosis, or treatment. It has been associated with hereditary cancer syndromes; however, most cases are sporadic and frequently associated with inflammatory bowel disease. We present the case of a 43-year-old male who presented with abdominal pain, nausea, and vomiting and was initially diagnosed with a Crohn's disease flare. He subsequently developed a small bowel perforation and was taken to the operating room for resection of the inflamed segment of the ileum; this was later found to be secondary to an obstructing small bowel adenocarcinoma. He developed an anastomotic leak, which mandated re-exploration and allowed for the completion of an oncologic resection. Small bowel adenocarcinoma is difficult to diagnose and treat due to the absence of clear guidelines and the lack of randomized controlled trials in the setting of a very low incidence.

Features on Computed Tomography That Correlate With Acute Appendicitis.

Background: The purpose of this study is to investigate the relevant findings in adult patients admitted to Cabell Huntington Hospital who were diagnosed with acute appendicitis. Methods: Patients who had the postoperative diagnosis of acute appendicitis and a preoperative computed tomography (CT) scan from January 2011 through December 2016 were included in this retrospective chart review. Results: There were 592 patients. A thick, edematous appendix was the most common CT finding in acute appendicitis. The average diameter was 12.6 mm. The wall thickness correlated to the diameter of the appendix (P < 0.001). For comparison, we reviewed the CT scans of 50 trauma patients who had normal abdominal CT scans. The average diameter of a normal appendix was 4.9 mm (SD 1.139) with a range of 4-7 mm. Interestingly, the admission white blood cell count (P = 0.0372) as well as the thickness of the appendix (P < 0.0001) were strongly associated with increased length of stay. Conclusions: An appendiceal diameter greater than 9 mm should be considered abnormal and associated with acute appendicitis. Appendiceal size, white blood cell count, and age correlate with length of stay. Early antibiotics and early surgical intervention may decrease length of stay.

Later Stage Disease and Earlier Onset of Rectal Cancer: Epidemiology and Outcomes Comparison of Rectal Cancer in a Rural Appalachian Area to State and National Rates.

Although the overall rate of colorectal cancer (CRC) has remained stable, studies have shown an increase in the rate of CRC in young patients (<50) nationwide. We hypothesize that the rectal cancer (RC) rate in young people has increased in rural Appalachia. The goal is to provide insight into the future of RC epidemiology in underserved populations. This Institutional Review Board-approved retrospective study evaluated RC patients diagnosed in 2003 to 2016, and compared the ratio of early-onset RC to the state and national ratios using West Virginia State Cancer Registry, North American Association of Central Cancer Registries (NAACCR) and Surveillance, Epidemiology, and End Results Program Database. Demographics include age, gender, ethnicity, and county. We also evaluated cancer stage, family history, and comorbidities, including body mass index, smoking, and alcohol history. The rate of early-onset RC in our area is 1.5 times higher than the national rates. In our population, 100 per cent of patients were white with an equal gender distribution. Young patients with RC were noted to be more overweight than national rates. Young RC patients are more likely to have a first- or second-degree relative with cancer diagnosis. Smoking was strongly associated with young RC. Compared with national statistics, a higher proportion of young patients had Stage 1 or 2 disease which correlated with better survival. The rate of early-onset RC in the Tristate Appalachian area in West Virginia is higher than the national rate with risk factors including white ethnicity, obesity, diabetes mellitus, smoking, family history, and history of pelvic surgeries. It warrants further investigation and discussion of current CRC screening guidelines that begin at age 50.

Severe pelvic fracture with profound hypotension: a case report and treatment algorithm.

Approximately 9% of all blunt trauma patients suffer pelvic fractures. These fractures can range from insignificant and requiring almost no therapy to massive destruction of the pelvic ring with associated with multisystem injury and life-threatening hypotension which mandates the attention of the trauma surgeon, the orthopedic surgeon, the interventional radiologists and possibly other subspecialists. We present a case of a patient who presented to the emergency room in extremis from massive bleeding from a complex pelvic fracture. The patient developed abdominal compartment syndrome. The patient was emergently taken to the operating room but we were unable to control his pelvic bleeding. We propose an algorithm which might be helpful in these critically ill patients.

Blunt aortic trauma in a patient with the Ehlers-Danlos syndrome type VI.

A 24-year-old male with the Ehlers-Danlos syndrome (EDS) type VI (ocular scoliotic) who was kicked in the abdomen presented to the emergency room (ER) with abdominal pain. He was found to have a blunt traumatic aortic injury. The patient was treated nonoperatively. He was stable and discharged home on the eighth day. The patient returned to the ER several days later hypotensive and tachycardic. The patient was taken immediately to the operating room, but vascular repair was not possible. The patient expired. We discuss the challenges of taking care of a patient with EDS and offer suggestions that might improve future patient's outcome.

Safe subclavian vein cannulation.

Physicians and other advanced medical personnel commonly perform subclavian vein cannulation. Success depends on adequate knowledge of the anatomy. With this knowledge subclavian vein cannulation can be performed with low complication rates. The manuscript reviews the anatomy and the literature of subclavian vein cannulation.

Insufficient length of pulmonary artery introducer in an obese patient.

A 38-year-old, morbidly obese woman underwent surgery for debridement of necrotizing fasciitis of the abdominal wall. A pulmonary artery catheter was placed because of increasing fluid requirements. Despite multiple debridements and fluid resuscitation, the patient exhibited severe systemic inflammatory response. It was discovered that fluid placed in the introducer had extravasated into the subcutaneous tissues. In this obese patient, the pulmonary artery introducer was too short.

Morbidity and mortality of children following motor vehicle crashes.

HYPOTHESIS: The use of passenger compartment safety measures has not led to decreases in pediatric morbidity or mortality in our population of patients. DESIGN: Retrospective review. SETTING: University, tertiary care, level I trauma center. PATIENTS: All patients admitted to the Trauma Center at Louisiana State University Health Science Center School of Medicine in Shreveport between July 1, 1991, and December 31, 2000, who were younger than 16 years and involved in a motor vehicle crash. MAIN OUTCOME MEASURES: Intensive care complications, postoperative complications, and mortality. RESULTS: We reviewed the experience of all pediatric patients involved in motor vehicle crashes and transported to the Trauma Center at Louisiana State University Health Science Center School of Medicine in Shreveport from July 1, 1991, through December 31, 2000. A total of 191 patients met these criteria. There were 8 deaths, and only 1 of these patients was restrained. There were significantly more injuries in those patients who died compared with those who survived (Modified Injury Severity Score, 29 vs 9; P<.001). We compared the use of restraints in our cohort with the use of restraints in the US pediatric population. Only 20% of our patients were restrained vs 68% of the general pediatric population. This difference was significant (P<.001, chi2) test). CONCLUSIONS: In our population of patients, death was a relatively infrequent occurrence. All patients who died presented in extremis. No patient died as the result of a complication. The rate of seat belt use in our population of patients was low. The exact reason for why we were unable to detect any survival benefit with seat belt use is unclear and demands further investigation.