Pontine Tegmental Cap Dysplasia and Challenges in Facial Reconstructive Surgery.

Pontine tegmental cap dysplasia (PTCD) is a rare condition that affects the brain stem and multiple cranial nerves, which can result in bilateral facial palsies, hearing loss, bilateral trigeminal nerve dysfunction, oculomotor apraxia, feeding difficulties, seizures, hypotonia, and undeveloped speech. We document a case in which a patient with PTCD presents with a challenging lip deformity and requires multidisciplinary treatment to improve reconstructive surgical success and treatment outcomes. An extensive literature review was conducted. This report serves to increase awareness of PTCD and the need for multidisciplinary teams to participate in reconstruction of facial defects in a complex medical setting.

Angiographic delay: a viable alternative to surgical delay.

BACKGROUND: Selective embolization of the inferior epigastric arteries can serve as a method for transverse rectus abdominis musculocutaneous (TRAM) flap delay. The purpose of this study was to determine whether delay by selective arterial embolization is comparable to traditionally surgically delayed TRAM flaps as reported in the literature, in terms of skin and fat necrosis, and to examine whether certain risk factors play a role in TRAM flap fat necrosis despite angiographic delay. METHODS: Retrospective chart review was performed for 88 consecutive patients who underwent unilateral TRAM flap breast reconstruction after selective embolization of bilateral inferior epigastric arteries. RESULTS: Between 1997 and 2009, 88 pedicled TRAM flaps were performed for breast reconstruction in women with a mean age of 49.7 years. No patients had flap skin necrosis or total flap loss. In all, 13.6% patients had TRAM flap fat necrosis. Two patients in the TRAM fat necrosis group (16.7%) had a positive history of smoking, which was a statistically significant risk factor for necrosis (P = 0.048). CONCLUSIONS: Outcomes of pedicled TRAM flaps delayed by selective arterial embolization are comparable to historical controls of those delayed by traditional surgical means (ligation of artery and vein) and better than nondelayed flaps. Smoking remains a significant risk factor for TRAM flap fat necrosis despite the benefit of delay.

Significance of motor vehicle crashes and pelvic injury on fetal mortality: a five-year institutional review.

BACKGROUND: Motor vehicle crashes (MVC) are the leading cause of maternal injury during pregnancy. It is estimated that 1,300 to 13,000 fetal deaths/yr result from maternal MVC. METHODS: Pregnant women with injuries were identified by ICD-9 codes containing pregnancy and injury from hospital medical records and Trauma/ED registries. Records were reviewed for demographic data, fetal gestational age, mechanism of injury, injuries sustained, Glasgow Coma Score, loss of consciousness (LOC), Injury Severity Score (ISS), and maternal and fetal outcome. Fisher's exact test, t test, and logistic regression analysis were performed to analyze statistical analysis. RESULTS: From 2001 to 2005, 29,066 pregnant patients were seen at our institution. Five thousand two hundred forty-four of these patients visited the ED, and 294 of them reported injuries. One hundred forty-eight (50.3%) patients were involved in MVC. The average maternal age was 23.8 years. The mean gestational age was 20 weeks. The majority of patients were drivers (n=97, 70%) versus passengers (n=42, 30%), and 66% were restrained versus 34% unrestrained. There were no maternal deaths; however, seven mothers (4.7%) had poor fetal outcome (six fetal deaths and one hydrops fetalis). Increased maternal age, LOC, high ISS, and pelvic injury were risk factors for poor fetal outcome. Logistic regression revealed LOC and pelvic injury to be independent risk factors. CONCLUSIONS: Increased maternal age, LOC, and maternal pelvic fractures sustained during MVC contribute toward high ISS and significantly impacts fetal outcome. Despite fetal gestational age, aggressive radiographic pursuit of pelvic fractures may be warranted.

Predictors of fetal outcome in pregnant trauma patients: a five-year institutional review.

Injury Severity Score (ISS) and lactate are controversial in predicting fetal outcome. A retrospective review was conducted to determine whether ISS and lactate are valuable in predicting fetal survival in injured pregnant patients. Injured pregnant women were identified by ICD-9 codes from our Trauma Registry, Emergency Department Registry, and hospital medical records. Records were reviewed for demographic data, mechanism of injury, ISS, Glascow Coma Scale, lactate, vital signs, and maternal/fetal outcome. To determine statistical analysis, chi2 and t test analysis was performed. From 2001 to 2005, 294 women reported injuries. Most patients (51.7%) were discharged from the Emergency Department, yet 18 per cent were admitted to Trauma Surgery. The average maternal and gestational age was 23.4 years and 19.6 weeks, respectively. Seventy-two (33.3%) patients were in the first trimester. The majority of patients (88.1%) were involved in blunt trauma, and 10 (3.9%) had poor fetal outcome (nine fetal deaths and one hydrops fetalis). There were no maternal deaths. Maternal age, first trimester, elevated lactate, and high ISS were significant risk factors for poor fetal outcome (P = 0.044, P = 0.0173, P = 0.0001, and P = 0.0001, respectively). Specific parameters (ISS, lactate, maternal age, and gestational age) may be helpful in predicting poor fetal outcome and directing patient management.

Prospective evaluation of an extubation protocol in a trauma intensive care unit population.

Little data exists regarding extubation protocols in critically injured trauma patients. The objective of the current study was to prospectively examine the impact of implementing an extubation protocol on the outcomes of ventilated trauma patients in a surgical intensive care unit (STICU). Trauma patients admitted to the STICU over a 15-month period at a Level 1 trauma center were prospectively evaluated. The total period was divided into an education and institution period (April 2002-November 2003) and an evaluation period (December 2003-July 2003). Patient demographics, hospital course, complications, and outcomes from period I were compared with those obtained during period II. From April 8, 2002 through July 5, 2003, 69 patients intubated for greater than 24 hours were included in our analysis. Thirty-three were treated during period I and 36 were treated during period II. Both groups were well matched in terms of age, sex, Injury Severity Score, and chest Abbreviated Injury Score. Ventilation days significantly decreased from a mean of 16.3 to 8.2 days (P = 0.04). ICU length of stay also decreased, nearly meeting significance. A rigorously enforced extubation protocol significantly decreased ventilator days in STICU patients. Continued education of health care providers is key to the success of the protocol.

Diagnosis and treatment of uncommon wounds.

Uncommon wounds present unique challenges to plastic surgeons and other wound care providers in regard to their presentation, recognition, and ultimate treatment. This article presents an overview of diagnosis and actual case treatment of unusual wounds, a review of the literature, and case studies of interest. A systematic approach to diagnosis; careful review of history; and full understanding of topical, systemic, and surgical therapies is paramount to proper treatment recommendations, appropriate patient management, and successful wound-healing outcomes. The ability to identify and treat wounds caused by an unusual etiology or presentation is an important skill.

Trauma education and care in the jungle of Ecuador, where there is no advanced trauma life support.

BACKGROUND: The advanced trauma life support course is not available or affordable to rural areas in low-income countries. A trauma continuing education course was created to educate physicians of rural hospitals in the jungles of Ecuador. METHODS: A basic trauma care course was designed based on local resources and location of injury, including rudimentary health posts in the jungle, rural hospitals, and definitive referral centers. Course effectiveness was evaluated by a comparison of test scores before and after the course. A multiple choice questionnaire was given. Comparison to previous test scores was also performed. Paired Student's t test was used for statistical analysis. An objective structured clinical examination (OSCE), based on the course design, was administered. RESULTS: Twenty-six rural physicians participated in the course. Mean test scores significantly improved from pretest to post-test (72% to 79%; p = 0.032). Knowledge deficiencies in prehospital care, extremity injury care, and patient evaluation adjuncts significantly improved from 23% to 87%, 23% to 100%, and 31% to 100%, respectively. Test results after the course showed improvements in all major categories tested. Twelve of the 26 participants were repeat test takers from a course provided 2 years earlier. These participants showed improved pretest scores compared with their highest previous test score (76.8% versus 68.5%; p = 0.0496). Compared with first-time test takers, these participants showed improved pretest (76.8% versus 68.4%) as well as post-test (81% versus 76%) scores. Twenty-five of the 26 physicians participated in the OSCE, with a pass rate of 76%. The OSCE identified various strengths and deficiencies based on patient location and available resources. In rudimentary health posts, management was adequate for hemorrhage control (65%), immobilization (77%), and early transfer to rural hospitals (92%). Prehospital communication was inadequate (53%). Rural hospital management was adequate for primary evaluation (60%) and resuscitation (74%) but poor in secondary patient evaluation (53%), adjuncts (25%), and transfer to definitive referral centers (11%). OSCE scores differed from multiple choice questionnaire test results. DISCUSSION: Where there is no advanced trauma life support, a tailored trauma course and evaluation can be effective in educating local providers. A well-designed competency evaluation (multiple choice questionnaire and OSCE) is helpful in identifying deficient local aspects of trauma care. The course design and evaluation methods may serve as a model for continuing trauma care education in developing countries.