Mandibular Degloving: A Case Report and Literature Review.

BACKGROUND: Degloving injuries of the extremities are well documented; however, there are few reports of degloving injuries to the mandible. A literature review demonstrates several cases of mandibular degloving in pediatric patients. However, no isolated mandibular degloving injuries have been reported in adults. CASE REPORT: We report a case of a 21-year-old male who presented to the emergency department with facial trauma after a motorcycle accident. Initial examination of the head and neck showed ecchymosis and edema overlying the left periorbital area, eye closure secondary to periorbital edema, upper eyelid and lower eyelid superficial lacerations, as well as a left oral commissural and lower intraoral lacerations. Following completion of maxillofacial computed tomography after primary and secondary survey, the intraoral lesion was found to be a degloving injury of the mandible. This injury was irrigated with bacitracin and betadine before closure. It was ultimately closed in a layered fashion with deep layers reconstructing the sheared attachments of the overlying tissue to the periosteum, followed by gingivobuccal mucosal apposition superficially. WHY SHOULD AN EMERGENCY PHYSICIAN BE AWARE OF THIS?: Facial trauma is a common presentation in the emergency department. It is important that the emergency physician complete a thorough head and neck evaluation, including the oral mucosa and gingivobuccal sulcus, as mandibular degloving injuries may be occult. Without a high level of suspicion, such lesions may be missed, increasing the risk of subsequent infection and obligate healing by secondary intention leading to increased morbidity.

A Case Report of the Anesthetic Management of a Parturient With Congenital Hypofibrinogenemia and Complete Placenta Previa.

A multidisciplinary approach among the obstetric, hematological, pharmaceutical, nursing, and anesthetic team proved essential for the successful peripartum management of a gravida 3, para 2 female with a new diagnosis of congenital hypofibrinogenemia complicated by a complete placenta previa. The patient presented to labor and delivery triage with vaginal bleeding. This case report describes the management of this parturient and presents a review of the literature available for the anesthetic management of parturients with congenital hypofibrinogenemia.

Leveraging the Existing Anesthesia Information Management System to Improve Anesthesia Quality Assurance Outcome Reporting.

INTRODUCTION: Tracking measures of quality over time has been shown to improve care within institutions and across health systems. Perioperative quality assurance (QA) tracking by anesthesia departments in the Military Health System (MHS) has not used a uniform system integrated into the workflow of anesthesia providers. The purpose of this study was to demonstrate that the use of the embedded QA outcome reporting feature in the anesthesia information management system (AIMS) increased the rate of reporting compared to the current paper reporting system in a military anesthesia department. MATERIALS AND METHODS: An electronic outcome reporting mechanism embedded in the AIMS was activated as an alternative to paper QA outcome reporting. The proportion of anesthesia cases per month in a 12-month period with a reported QA outcome was compared to the previous year in which only the paper reporting system was used. The total number of cases in each time period with an outcome reported was compared using chi square for proportions, and systems were evaluated using the Statistical Process Control methodology. This project was evaluated and determined to be exempt from review by our institutional review board. RESULTS: There was a 389.8% increase in the number of cases with a QA outcome reported after the implementation of the outcome reporting function integrated into the AIMS (χ2 = 207.72; P <.001, Table I). Systems before and after the intervention were stable, and special cause variation was noted only at the point of implementation of the electronic reporting system. Anesthesia providers were surveyed and felt that the addition of QA reporting to the AIMS made QA reporting more likely. CONCLUSIONS: The use of an electronic QA outcome reporting method integrated into the AIMS dramatically increased the likelihood that a QA outcome would be reported. The decreased administrative burden of the integrated outcome reporting system was likely the primary reason for this increase. This study was limited by the fact that it was done in a single institution; however, the size and timing of the increase clearly indicate that the intervention was the reason for improved reporting. Electronic health record upgrades should consider incorporating QA reporting into the AIMS across the MHS. These measures could allow for system-wide improvement, evaluation, and evidence-based education on their own, but also by facilitating participation in the American Society of Anesthesiologists' Anesthesia Quality Institute's National Anesthesia Clinical Outcomes Registry. This report serves as a valuable example to institutions and perioperative leaders in the MHS of how to improve the robustness of perioperative QA reporting such that it could be used to validate and improve the value of care.

Head and neck surgical reconstruction in Operation Iraqi Freedom and Operation Enduring Freedom-Afghanistan: A systematic review.

Historically, head and neck injuries constituted 16 to 20% of all nonfatal combat injuries. However, advances in body and vehicle armor in the context of the use of ambushes and improvised explosive devices by enemy combatants have resulted in fewer fatalities from head and neck wounds, and thus the incidence of nonfatal head and neck injuries has risen to as high as 52%. Despite this increase, data regarding specific injury distributions, surgical cases, and approaches to repair are lacking in the current literature. We conducted a study to systematically review the current literature regarding head and neck injuries and reconstructions during Operation Iraqi Freedom and Operation Enduring Freedom-Afghanistan. We found 44 articles that met our inclusion criteria. These articles covered 17,461 head and neck wounds sustained by 12,105 patients. Superficial soft-tissue facial injuries were most common wounds (31.7% of cases), followed by wounds to the neck (25.2%) and midface (17.9%). The 44 articles listed 5,122 discrete surgical reports covering 5,758 procedures. Of these procedures, simple facial laceration repairs (25.2%) and ophthalmologic surgeries (12.1%) were the most common soft-tissue repairs, and mandibular reconstructions (11.3%) were the most common type of bony reconstruction. Major flap reconstructions for coverage were required in only 0.4% of procedures. This information will be valuable for educating those involved in otolaryngology training programs, as well as civilian otolaryngologists regarding the types of injury patterns they should expect to see and treat in the returning veteran population.

Teaching and learning of medical biochemistry according to clinical realities: A case study.

To foster medical students to become physicians who will be lifelong independent learners and critical thinkers with healthy skepticism and provide high-quality patient care guided by the best evidence, teaching of evidence-based medicine (EBM) has become an important component of medical education. Currently, the teaching and learning of biochemistry in medical schools incorporates its medical relevance and applications. However, to our knowledge there have been no reports on integrating EBM with teaching and learning medical biochemistry. Here, we present a case study to illustrate the significance of this approach. This case study was based on a biochemistry/nutrition question in a popular board review book about whether a homeless alcoholic man is at risk of developing a deficiency of vitamin E. The possible answers and explanation provided in the book raised a question about the correct answer, which provided us with an opportunity to adapt the philosophy and certain basic EBM principles to find evidence for the clinical applicability of a commonly taught biochemistry topic. The outcome of this case study not only taught us how to conduct an EBM exercise to answer a specific patient question, but also provided us with an opportunity for in-depth teaching and learning of the medical relevance of a specific biochemistry topic based on the best clinical evidence obtained from a systematic research of medical literature.