James R. Yon

Management of adult pancreatic injuries: A practice management guideline from the Eastern Association for the Surgery of Trauma.

BACKGROUND Traumatic injury to the pancreas is rare but is associated with significant morbidity and mortality, including fistula, sepsis, and death. There are currently no practice management guidelines for the medical and surgical management of traumatic pancreatic injuries. The overall objective of this article is to provide evidence-based recommendations for the physician who is presented with traumatic injury to the pancreas. METHODS The MEDLINE database using PubMed was searched to identify English language articles published from January 1965 to December 2014 regarding adult patients with pancreatic injuries. A systematic review of the literature was performed, and the Grading of Recommendations Assessment, Development and Evaluation framework was used to formulate evidence-based recommendations. RESULTS Three hundred nineteen articles were identified. Of these, 52 articles underwent full text review, and 37 were selected for guideline construction. CONCLUSION Patients with grade I/II injuries tend to have fewer complications; for these, we conditionally recommend nonoperative or nonresectional management. For grade III/IV injuries identified on computed tomography or at operation, we conditionally recommend pancreatic resection. We conditionally recommend against the routine use of octreotide for postoperative pancreatic fistula prophylaxis. No recommendations could be made regarding the following two topics: optimal surgical management of grade V injuries, and the need for routine splenectomy with distal pancreatectomy. LEVEL OF EVIDENCE Systematic review, level III.

Congenital bronchial artery-pulmonary artery fistula in an adult.

We report the case of a 21-year-old man who presented with a hilar mass and whose condition was diagnosed as a congenital anomalous communication between the bronchial and pulmonary artery. We review his lung vascular embryology and anatomy that led to this rare systemic to pulmonary arterial shunt, describe other etiologies that may lead to abnormal systemic artery to pulmonary artery communication, and briefly discuss treatment options.

Aortocaval fistula and celiac artery transection after gunshot wound.

A 22-year-old male patient presented after a single gunshot wound, overlying the lateral 10th rib. He was alert and responding to commands but was tachycardic and hypotensive. A central line was placed, and the patient was a transient responder to fluids and 2 U of un–cross-matched blood initially. The patient was dyspneic but had equal breath sounds. Chest radiograph revealed a right hemothorax with missile overlying the right lateral chest wall, concerning for a combination of transmediastinal and upper abdominal injury (Fig. 1). A right chest tube was placed with 700-mL initial output. Ultrasound of the heart was normal without pericardial fluid. The patient became hypotensive again with increasing upper abdominal pain, and our massive transfusion protocol was initiated. Because of increased work of

The “TRAUMA LIFE” initiative: The impact of a multidisciplinary checklist process on outcomes and communication in a Trauma Intensive Care Unit

BACKGROUNDnChecklists have been advocated to improve quality outcomes/communication in the critical care setting, but results have been mixed. A new checklist process, TRAUMA LIFE, was implemented in our Trauma Intensive Care Unit (TICU) to replace prior checklists. The purpose of this study was to evaluate the impact of the TRAUMA LIFE process implementation on quality metrics and on patient/family communication in the TICU.nnnMETHODSnTRAUMA LIFE was considered maturely implemented by 2016. Multiple quality metrics, including restraint order compliance, were compared between 2013 and 2016 (pre- and post-implementation). Compliance with the Family Message (FM), a part of the TRAUMA LIFE communication process, was analyzed in 2016.nnnRESULTSnImprovement was seen in CAUTI, VAE, and IUCU; CLABSI rates increased. Restraint order compliance increased significantly. FM delivery compliance was inconsistent; improvement was noted in concordance between update content and FM documented in Electronic Medical Record.nnnCONCLUSIONnImplementation of TRAUMA LIFE was well integrated into the rounding process and was associated with some improvement in quality metrics and communication. Additional evaluation is required to assess sustainability.

Delayed cerebrospinal fluid leak after penetrating cervical trauma

Stab wound injury to the cervical spinal cord is a rare occurrence and usually presents with immediate, disastrous, and permanent neurological consequences. Rarer, and potentially as severe, is the complication of a delayed cerebrospinal fluid leak following a stab wound to the cervical spine. In this case, magnetic resonance imaging demonstrates a cerebrospinal fluid leak that extends to the skin with injury to the posterior dura at the C1/C2 level. Epidemiology and management of penetrating cervical spinal cord injury and delayed cerebrospinal fluid leaks are discussed.

Marjolin's Ulcer in Chronic Hidradenitis Suppurativa: A Rare Complication of an Often Neglected Disease.

Hidradenitis suppurativa (HS) is a chronic, debilitating disease with definitive treatment consisting of wide surgical excision of all affected tissue. Originally described in burns, Marjolin’s ulcer (MU) has been described in a variety of wound types, including hidradenitis. HS patients often have long delays to diagnosis and management of their chronic wounds, leading to increased risk of MU. A retrospective review of our burn database was performed from 2008 to 2014. Seventy-two consecutive patients taken to the operating room for HS were retrospectively evaluated for demographic data, number of excisions, total area of excised skin, need for skin grafting, pathology results, and outcome. Fifty-eight percent of patients were male. Mean age was 36.88u2009±u200913.52 years. Mean size of excision was 743.71u2009±u2009774.75u2009cm2. Total number of operative procedures was 187, averaging 2.612 per patient, with 52% of patients undergoing skin grafting. Two patients had confirmed pathology of squamous cell carcinoma. Both were women with perineal HS and had metastatic disease on further workup. Both patients underwent chemotherapy and radiation with progression of their disease. The incidence of MU of 2.78% in this study is similar to the 2% incidence described historically in the burn population. All practitioners who treat HS patients should be aware of the devastating complication of MU arising in the chronic wound bed. We recommend that all excised tissue be sent to pathology for evaluation, and to consider early wide local excision of any chronically inflamed tissues to alleviate the risk of MU for this patient population.

Traumatic aorto-right ventricular fistula from stab wound

Penetrating cardiac injuries are commonly instantaneously lethal. However, numerous delayed manifestations of cardiac injury, including traumatic ventricular septal defect, ventricular aneurysms, right pulmonary artery to left atrial fistula, valvular regurgitation, and aorto-right ventricular fistula, are all described in the literature. Here, we present a case of aorto-right ventricular fistula following a stab wound to the chest. Epidemiology, diagnosis, imaging, and management of penetrating cardiac injury and intracardiac fistulas are discussed. Correspondence to: James R. Yon, MD, 1900 W. Polk St., Suite 1300 Chicago, IL 60612, USA; E-mail: jyon@cookcountyhhs.org