Bradley J. Phillips

Anhydrous ammonia burns case report and review of the literature

Chemical burns are associated with significant morbidity, especially anhydrous ammonia burns. Anhydrous ammonia is a colorless, pungent gas that is stored and transported under pressure in liquid form. A 28 year-old patient suffered 45% total body surface area of second and third degree burns as well as inhalational injury from an anhydrous ammonia explosion. Along with fluid resuscitation, the patients body was scrubbed every 6 h with sterile water for the first 48 h to decrease the skin pH from 10 to 6-8. He subsequently underwent a total of seven wound debridements; initially with allograft and then autograft. On post burn day 45, he was discharged. The injuries associated with anhydrous ammonia burns are specific to the effects of ammonium hydroxide. Severity of symptoms and tissue damage produced is directly related to the concentration of hydroxyl ions. Liquefactive necrosis results in superficial to full-thickness tissue loss. The affinity of anhydrous ammonia and its byproducts for mucous membranes can result in hemoptysis, pharyngitis, pulmonary edema, and bronchiectasis. Ocular sequelae include iritis, glaucoma, cataracts, and retinal atrophy. The desirability of treating anhydrous ammonia burns immediately cannot be overemphasized. Clothing must be removed quickly, and irrigation with water initiated at the scene and continued for the first 24 h. Resuscitative measures should be started as well as early debridement of nonviable skin. Patients with significant facial or pharyngeal burns should be intubated, and the eyes irrigated until a conjunctivae sac pH below 8.5 is achieved. Although health care professionals need to be prepared to treat chemical burns, educating the public, especially those workers in the agricultural and industrial setting, should be the first line of prevention.

Penetrating Bihemispheric Traumatic Brain Injury: A Collective Review of Gunshot Wounds to the Head

BACKGROUND Head injuries that cross midline structures of the brain are bihemispheric. Other terms have been used to describe such injuries, but bihemispheric is the most accurate and should be standard nomenclature. Bihemispheric head injuries are associated with greater mortality and morbidity than other penetrating traumatic brain injuries (TBIs). Currently, there is a tendency to manage severe gunshot wounds (GSWs) to the head nonoperatively, despite reports of improved outcome in military patients treated aggressively. Thus, controversy exists in the management of civilian TBI. METHODS PubMed was searched for query terms, and PRISMA guidelines were used. Studies were selected by relevance and inclusion of data regarding etiology, diagnosis, and management of bihemispheric TBI. Case reports, studies not in English, and records lacking information on mechanism or bihemispheric injuries were excluded. RESULTS Thirteen studies were included and most contained level IV evidence. The mean mortality rate of all head GSWs was 62% in adults and 32% in children. Bihemispheric GSWs had greater mortality rates of 82% in adults and 60% in children. There was a larger proportion of self-inflicted injury in studies with greater rates of bihemispheric injuries. CONCLUSIONS Bihemispheric injuries have greater mortality rates than other penetrating TBI. Violation of midline brain structures such as the diencephalon and mesencephalon, increased rate of self-inflicted wounds, and lack of a standard management algorithm may increase the lethality of these injuries. Although bihemispheric injuries historically have been considered nonsalvageable, an aggressive surgical approach has been shown to improve outcomes, particularly in the military population.

Penetrating injuries to the duodenum: An analysis of 879 patients from the National Trauma Data Bank, 2010 to 2014

BACKGROUND Despite wide belief that the duodenal Organ Injury Scale has been validated, this has not been reported in the published literature. Based on clinical experience, we hypothesize that the American Association for Surgery of Trauma Organ Injury Scale (AAST-OIS) for duodenal injuries can independently predict mortality. Our objectives were threefold: (1) describe the national profile of penetrating duodenal injuries, (2) identify predictors of morbidity and mortality, and (3) validate the duodenum AAST-OIS as a statistically significant predictor of mortality. METHODS Using the Abbreviated Injury Scale 2005 and International Classification of Diseases—9th Rev.—Clinical Modification (ICD-9-CM) E-codes, we identified 879 penetrating duodenal trauma patients from the National Trauma Data Bank between 2010 and 2014. We controlled patient-level covariates of age, biological sex, systolic blood pressure (SBP), Glasgow Coma Scale (GCS) score, pulse, Injury Severity Score (ISS), and Organ Injury Scale (OIS) grade. We estimated multivariable generalized linear mixed models to account for the nesting of patients within trauma centers. RESULTS Our results indicated an overall mortality rate of 14.4%. Approximately 10% of patients died within 24 hours of admission, of whom 76% died in the first 6 hours. Patients averaged approximately five associated injuries, 45% of which involved the liver and colon. Statistically significant independent predictors of mortality were firearm mechanism, SBP, GCS, pulse, ISS, and AAST-OIS grade. Specifically, odds of death were decreased with 10 mm Hg higher admission SBP (13% decreased odds), one point higher GCS (14.4%), 10-beat lower pulse (8.2%), and 10-point lower ISS (51.0%). CONCLUSION This study is the first to report the national profile of penetrating duodenal injuries. Using the National Trauma Data Bank, we identified patterns of injury, predictors of outcome, and validated the AAST-OIS for duodenal injuries as a statistically significant predictor of morbidity and mortality. LEVEL OF EVIDENCE Epidemiologic/Prognostic, level IV.

Trauma to the Superior Mesenteric Artery and Superior Mesenteric Vein: A Narrative Review of Rare but Lethal Injuries

Mesenteric vessels, including the superior mesenteric artery (SMA) and vein (SMV), provide and drain the rich blood supply of the midgut and hindgut. SMA and SMV injuries are rare and often lethal. Clinical management of these injuries is not well established, but treatment options include operative, non-operative, and endovascular strategies. A narrative review of the literature was conducted using MEDLINE Complete-EBSCO. Relevant studies, specifically those focusing on diagnosis and management of SMA and SMV injuries, were selected. Only original reports and collected series were selected to prevent duplication of cases. A search of the literature for mesenteric arterial injuries yielded 87 studies. Vessel-specific breakdown of the studies yielded 40 with SMA injuries and 41 with SMV injuries. These searches were winnowed to 26 individual studies, which were included in this collective review. Limitations of this study are similar to all narrative literature reviews: the dependence on previously published research and availability of references as outlined in our methodology. Although historically rare, mesenteric vessel injuries are seen with increasing incidence and continue to present a challenge to trauma surgeons due to their daunting mortality rates. Currently, universal treatment guidelines do not exist, but the various options for their management have been extensively reviewed in the literature.

Damage Control Cardiothoracic Surgery

Although damage control as a surgical concept and/or technique has become part of the trauma surgeon’s armamentarium for the past 25 years, it is meritorious to review its origins and indications. The concept, as described, takes its origin from Stone’s [1] hallmark work describing the “bailout” approach in honor of World War II paratroopers. In his 1986 seminal paper [1], he recognized a physiological “cluster” of intraoperative signs, i.e., coagulopathy, prompting interruption of trauma surgical procedures after institution of hemorrhage containing measures and packing of the abdominal cavity. He then proposed returning patients to a critical care setting and correcting the coagulopathy of trauma to return to the operating room later for definitive surgery.

Trauma pneumonectomy: A narrative review

PURPOSE Thoracic injuries are common in both blunt and penetrating trauma. Most thoracic injuries are managed non-operatively, approximately 7-20% undergo thoracotomy. Of the injuries requiring thoracotomy, 1-6% ultimately require pulmonary resection. Wedge resection and lobectomies are well-studied in the literature; however, there is a paucity regarding reports on total pneumonectomy in the setting of trauma. Our objectives were to summarize the evidence supporting the role of trauma pneumonectomy (TP) in the current era and reiterate that despite the associated morbidity and mortality TP is justified in selective cases. METHODS A review of the worlds literature was conducted following standard guidelines. Inclusion criteria included those studies reviewing blunt and penetrating trauma to the lungs in adults (age greater than 15 year) that reported mortality rates and outcome measures. RESULTS The PubMed search yielded 713 studies. Of these, 14 studies included pertinent information on TP. Studies included in this review were published from 1985 to 2017 and involved patient data that was collected from 1972 to 2014. Mortality ranged from 50% to 100% (median 63%; mean 68%). CONCLUSION In the setting of severe thoracic trauma, pulmonary resection may be necessary. Less aggressive techniques are options in a stable patient; however, in the setting of ongoing hemorrhage, TP should be considered and expediently conducted. The role of damage control thoracic surgery and related techniques is vitally important in these patients to improve the significant mortality of trauma pneumonectomy.

Treatment of Methamphetamine withdrawal in trauma patients

Background: Methamphetamine use has increased in the United States over the past several decades. Similarly, an increasing number of trauma patients are testing positive for methamphetamine, which impacts hospital resources and length of stay, particularly in intensive care units. Treatment of methamphetamine-positive patients has not been well defined in the medical literature. Methods: A systematic literature search was conducted to identify a treatment algorithm and medications used in methamphetamine-intoxication and withdrawal. PRISMA guidelines were followed in the search and classification of the available literature. Inclusion criteria were defined as “any peer-reviewed study that reported results regarding the management and treatment of withdrawal from methamphetamine. All studies that were published in English were initially identified and screened for inclusion. However, due to the paucity of published reports on this subject, all sources were reviewed. Results: The literature search yielded 329 publications, of which 22 were included in this systematic literature review. A total of 12 randomized trials, 6 animal models and 1 consensus recommendation by the WHO met inclusion criteria. 3 other studies were used as additional reference and supportive evidence. A proposed treatment algorithm for managing methamphetamine withdrawal was not identified. A consensus regarding treatment of methamphetamine-positive patients does not currently exist in the literature. Few drugs have shown any clinical efficacy in managing methamphetamine-withdrawal. However, some drugs indicated potential benefits in animal models. Most prominently, n-acetylcysteine, bupropion, and dextroamphetamine, might be beneficial for use in the acute and long-term management of methamphetamine withdrawal. Limitations: The greatest limitation was the lack of available Level I, II, and III studies in the medical literature. Reports that are published include mostly subjective experiences. Conclusions: The current methamphetamine epidemic impacts medical care and resources at trauma centers in the United States. A consensus regarding treatment of methamphetamine-positive patients, including medicinal agents and timing of their administration is lacking. Additional studies are needed to identify an effective treatment algorithm. Correspondence to: Bradley J Phillips, Vice Chairman of Surgery – Surgical Research, Associate Professor of Surgery, Department of Surgery, Department of Clinical and Translational Science, Creighton University School of Medicine Creighton University Medical Center, 601 North 30th Street, Suite 3701, Omaha, NE 68131-2137, USA, Tel: 402-717-4909; Fax: 402-717-6068; E-mail: Bradley. Phillips@alegent.org

Laparotomy: The conquering of the abdomen and the historical journey of pancreatic and duodenal injuries.

U other injuries described since ancient times, pancreatic and duodenal injuries are relative newcomers to the annals of surgical history; as a matter of fact, there are but very few well-documented historical accounts of these injuries. Unlike cardiac injuries described in the Iliad, pulmonary injuries documented by Galen on gladiators or esophageal injuries described in the Edwin Smith Surgical Papyrus; these injuries awaited their description until autopsy studies were performed. This was the case of the first description of a pancreatic injury by Travers (Fig. 1) in England; or until some type of surgical intervention upon the abdomen could be carried out, as in the case of the first description of a duodenal injury by Larrey (Fig. 2) in France. One of the greatest barriers to the identification of pancreaticoduodenal injuries remained the unexplored frontier of the abdominal cavity. The treatment of firearmwounds was first described in a textbook by Brunschwig who recommended cauterization of all war wounds based on Von Pfolspeundt’s doctrine. Brunschwig is also credited with the repair of a segment of wounded bowel, resulting from a military injury, by transection and insertion of a silver tube over which the transected ends of the small bowel were tied. Despite his recommendation of this method, no credencewas given to this method and thus, it was rarely practiced. Larrey (Fig. 2), in 1798, repaired a transected segment of ileum. Unfortunately, few advocates for the operative management of gunshot wounds emerged. Similarly, the insurmountable barrier of pain management had to be conquered before any laparotomy could proceed. It took the courage of Baudens, who first advocated digital exploration of penetrating abdominalwounds, to identify blood, gas, or fecal material and in 1836, performed the first exploratory laparotomies and enterorrhaphies on patients who sustained gunshot wounds of the abdomen during the French-Algerian war. Baudens’ first surgical intervention was unsuccessful; however, he did not desist, and subsequently performed a second intervention with a reported survivor. Afterward, he proposed bold operations for abdominal gunshot wounds. Baudens’ experience and advocacy of exploratory laparotomy unfortunately went unheeded and was forgotten. It was not until the US Civil War that this procedure was considered valuable in the management of abdominal trauma; however, it was rarely practiced. Penetrating abdominal wounds treated expectantly had an overall mortality of 87%. The modern history of abdominal wound management began with the South AfricanWar (1899Y1901). SirWilliamMcCormac (see Figure, Supplemental Digital Content 1, http://links.lww.com/TA/A739), an Irish surgeon who served as the chief consulting surgeon to the South African field force stated: ‘‘That in this war, a man wounded in the abdomen dies if he is operated upon, and remains alive if he is left in peace.’’ This remark set the policy for nonoperative management. Delays in treatment prompted by the great distances over which the battles were fought also militated in favor of nonintervention. McCormac’s aphorism condemning operative management had great impact on military surgeons in England and other countries. As it is usually the case, wartime knowledge is frequently forgotten, and its lessons must be relearned. Consequently, it took yet another surgical maverick to emerge and challenge McCormac’s aphorism. Vera Gedroits (see Figure, Supplemental Digital Content 2, http://links.lww.com/TA/A740), a Russian princess and a surgeon at a time in which female physicians were rare, was such a person. She was appointed as a Russian Red Cross surgeon during the Russo-Japanese War (1904Y1905) and deployed to the Siberian front where, first in tents smeared with mud in 1904 and subsequently in a railway car, she performed 183 laparotomies for penetrating abdominal wounds, selecting only patients who presented within three hours of injury. Mortality data are not available, however; her 57-page report led the Society of Russian Military Surgeons to adopt the policy of routine exploratory laparotomy for penetrating abdominal wounds. This knowledge was not disseminated during both the French War in Morocco (1907Y1908) and the Balkan Wars (1912Y1913); therefore, the policy of nonoperative management of abdominal wounds remained firmly entrenched. It was not until World War I that British and American surgeons became more aggressive and began to operate on soldiers who had sustained penetrating abdominal injuries. The first abdominal explorations performed during World War I were by Pedley at Antwerp and by Sir Henry S. Souttar SURGICAL HISTORY

Development of a colocutaneous fistula in a patient with a large surface area burn

A 61 year old female sustained a large surface area burn, complicated by inhalation injury. One month before the incident, she had undergone a left hemicolectomy with colorectal anastomosis for diverticular disease. Due to the severity of her burns, multiple surgical debridement and skin grafting procedures were required, including a large fascial debridement of her flank and back. Her hospital course was complicated by recurrent episodes of pulmonary and systemic infection, as well as pre-existing malnutrition. Prior to her discharge to a rehabilitation center, stool began to drain from her left posterior flank. This complication represented a colonic fistula arising from the recent colon anastomosis. The fistula was managed nonoperatively and gradually closed. To our knowledge, this is the first report of a colocutaneous fistula spontaneously draining from the abdomen via the retroperitoneum in a burn victim, not related to direct thermal injury to the peritoneal cavity.