Acute Colonic Pseudo-obstruction: Colonoscopy Versus Neostigmine First?

INTRODUCTION: Neostigmine (NEO) and decompressive colonoscopy (COL) are two efficacious treatment modalities for acute colonic pseudo-obstruction (ACPO). We hypothesize that a COL first strategy is associated with better outcomes compared to a NEO first strategy. METHODS: A single-center retrospective analysis was performed from 2013 to 2020. Patients ≥18 y with a diagnosis of ACPO were included. The outcome was a composite measure of acute operative intervention, 30-day readmission with ACPO, and 30-day ACPO-related mortality. A P-value of ≤ 0.05 indicated statistical significance. RESULTS: Of 910 encounters in 849 patients, 50 (5.5%) episodes of ACPO in 39 patients were identified after exclusion of one patient with colon perforation on presentation. The median (interquartile range) age was 68 (62-84) y. NEO and COL were administered in 21 and 25 episodes, respectively. In 16 (32%) episodes, no NEO or COL was administered. When patients were given NEO first, COL or additional NEO was required in 12/18 (67%) compared with a COL first strategy where a second COL and/or NEO was given in 5/16 (32%) (P = 0.05). Both strategies had similar outcomes (NEO, 4/18 versus COL, 4/16, P = 0.85). Twenty-two (44%) episodes had an early intervention (≤48 h) with NEO and/or COL. There was no difference in outcome between those that received an early intervention and those who did not (5/22 versus 5/28, P = 0.71). CONCLUSIONS: For patients failing conservative measures, a COL first approach was associated with fewer subsequent interventions, but with similar composite outcomes compared to a NEO first approach. Early (≤48 h) intervention with NEO and/or COL was not associated with improved outcomes.

Nonoperative management of splenic injuries: significance of age.

BACKGROUND: In the nonoperative management (NOM) of blunt splenic injuries (BSI), the clinical relevance of age as a risk factor has not been well studied. METHODS: Using the 2011 National Trauma Data Bank data set, age was analyzed both as a continuous variable and a categorical variable (group 1 [13-54 y], group 2 [55-74 y], and group 3 [≥75 y]). BSI severity was stratified by abbreviated injury scale (AIS): group 1 (AIS ≤2), group 2 (AIS 3), and group 3 (AIS ≥4). A semiparametric proportional odds model was used to model NOM outcomes and effects due to age and BSI severity. RESULTS: Of 15,113 subjects, 15.3% failed NOM. The odds of failure increased by a factor of 1.014 for each year of age, or factor of 1.5 for groups 2 and 3 each. BSI severity groups 2 and 3 had increases in the odds of failure by factors of 3.9 and 13, respectively, compared with those of group 1. Most failures occurred by 48 h irrespective of age. The effect of age was most pronounced in age groups 2 and 3 with the most severe BSI, where a NOM failure rate of >50% was seen. Both age and failure of NOM were independent predictors of mortality. CONCLUSIONS: Age is associated with failure of NOM but its effect seems more clinically relevant only in high-grade BSI. Factors that could influence NOM success in elderly patients with high-grade injuries deserve further study.

Open Abdomen after Two Trauma Laparotomies: Do Diuretics Help?

Data are lacking regarding the use of diuretics in facilitating closure of the open abdomen (OA). For patients with an OA after 2 laparotomies, we hypothesized that diuretic use was associated with a higher rate of primary fascial closure than no diuretic use. A retrospective review of patients with trauma laparotomies over 7 years was performed. Primary fascial closure (PFC) was defined as apposition of fascial edges without interposition mesh. Of 321 patients, 30 (9%) remained with an OA after 2 laparotomies. Prior to the third laparotomy, median cumulative fluid balance was +12.6 L. Thirteen (43%) received diuretics. Primary fascial closure rates were similar for diuretic use vs no diuretic (38% vs 59%, P = .46). Primary fascial closure was not associated with age (P = .2), gender (P = 0.7), cumulative fluid balance (P = .3), or units of packed cells (P = .4). Diuretic use in trauma patients with an OA after 2 laparotomies was not associated with successful PFC.

External signs of trauma: A poor predictor of injury in found down and ground level falls.

BACKGROUND: The significance of external signs (EST) and signs or symptoms of trauma (SS) after ground level falls or found down (GLF/FD) is unclear. We hypothesized that EST and SS were associated with injury. METHODS: Patients with GLF/FD were retrospectively studied. SS was defined as having any EST, tenderness, or subjective complaint. Outcomes were any significant finding (SF) and Injury Severity Score (ISS) > 8. Diagnostic accuracy of EST and SS were assessed with positive and negative likelihood ratios (LR+, LR-). RESULTS: Of 578 patients, 66% and 95% had EST and SS respectively. For EST, LR+ and LR-were 1.14 and 0.76 (SF), and 1.21 and 0.64 (ISS>8). For SS, LR+ and LR-were 1.07 and 0.19 (SF), and 1.03 and 0.49 (ISS>8). CONCLUSION: EST lacked sufficient diagnostic accuracy for SF and ISS>8. Lack of SS was reasonably accurate in ruling out SF but not ISS>8. Triage utilizing EST alone for GLF/FD is not useful.

Is clinician assessment accurate or is routine pan-body CT needed in the stable intoxicated trauma patient?

BACKGROUND: We sought to determine if clinician suspicion of injury was useful in predicting injuries found on pan-body computed tomography (PBCT) in clinically intoxicated patients. METHODS: We prospectively enrolled awake, intoxicated patients with low-energy mechanism of injury. For each of four body regions (head/face, neck, thorax and abdomen/pelvis), clinician suspicion for injury was recorded as "low index" or "more than a low index". The reference standard was the presence of any pre-defined significant finding (SF) on CT. Sensitivity, specificity, positive (LR+) and negative (LR-) likelihood ratios were calculated. RESULTS: Enrollment of 103 patients was completed. Sensitivity, specificity, LR+ and LR-for clinician index of suspicion were: 56%, 68%, 1.75, 0.64 (head/face), 50%, 92%, 6.18, 0.54 (neck), 10%, 96%, 2.60, 0.94 (thorax) and 67%, 93%, 9.56, 0.36 (abdomen/pelvis). CONCLUSION: Clinician judgement was most useful to guide need for CT imaging in the neck and abdomen/pelvis. Routine PBCT may not be necessary. SUMMARY: For awake, stable intoxicated patients after falls and assaults, clinician index of suspicion was most useful to guide the need for CT imaging in the neck and abdomen/pelvis. Our findings support selective use of CT if the index of suspicion is low. Routine PBCT may not be necessary.