Jasmeet S. Paul

Minimal aortic injury after blunt trauma: Selective nonoperative management is safe

BACKGROUND An increasing number of minimal aortic injuries (MAIs) are being identified with modern computed tomography (CT) imaging techniques. The optimal management and natural history of these injuries are unknown. We have adopted a policy of selective multidisciplinary nonoperative management of MAI. This study examines our experience with these patients from July 2004 to June 2009. METHODS Retrospective chart review of all blunt trauma patients who underwent chest CT angiography to evaluate for blunt aortic injury (BAI) was undertaken. All patients deemed to have a MAI were managed nonoperatively, and those with a severe aortic injury underwent repair. Data collected included age, mechanism of injury, Injury Severity Score, type and location of aortic injury, intensive care unit length of stay (LOS), overall LOS, ventilator days, disposition, and mortality. In addition, all BAIs were graded according to the Presley Trauma Center CT Grading System of Aortic Injury. RESULTS Forty-seven patients with BAI were identified. Thirty-two were classified as severe injuries, and 15 were considered MAI (32%). Nineteen underwent operative repair, 13 underwent endovascular stent graft repair, and 15 were managed nonoperatively. The average Injury Severity Score was 31 ± 10, and the average age was 44 ± 20 with no significant difference across treatment groups. There was no difference in overall or intensive care unit LOS. The nonoperative group had a shorter duration of ventilator days (1.1 vs. 4.28, p = 0.02). There were five deaths, none in the nonoperative group. None of these patients required subsequent intervention. All nonoperative patients had follow-up imaging at median of 4 days; on CT chest angiography, five injuries had resolved, eight had stable intimal flaps or pseudoaneurysm, and two had no detectable injury on subsequent aortogram. CONCLUSION Almost one-third of our BAI were safely managed nonoperatively. Patients with MAI should be considered for selective nonoperative management in a multidisciplinary approach with close radiographic follow-up. We recommend that patients with MAIs should be considered for selective nonoperative management.

Intraabdominal vascular injury: are we getting any better?

BACKGROUND Intraabdominal vascular injury (IAVI) as a result of penetrating and blunt trauma carries a high mortality rate. This study was performed to compare current mortality rates with a previously reported historic control. METHODS The experience at our institution from 1970 to 1981 was previously reported with an overall mortality rate of 32% in 112 patients with penetrating IAVI. In a retrospective analysis, this historic cohort was compared with 248 patients with penetrating and blunt IAVI during a 138-month interval ending in June 2007. RESULTS Overall mortality rate was 28.6%. The most commonly injured arteries were the iliac artery, aorta, and superior mesenteric artery. The most commonly injured veins were the inferior vena cava, iliac vein, and portal vein. Injury to the aorta, IVC, and portal vein had the highest mortality rates of 67.8%, 42.1%, and 66.6%, respectively. One hundred forty-four patients with one vessel injured had a mortality rate of 18.7%, whereas those with more than one vessel injured had a mortality rate of 48.7% (p < 0.001). A total of 46% of 117 patients in shock died compared with 9.6% of 104 patients not in shock (p < 0.001). Patients with a base deficit of less than -15 had a mortality rate of 72%, whereas those with a base deficit of 0 to -15 (p < 0.001) had a mortality rate of 18.9%. There was no difference in the overall mortality rate for penetrating trauma compared with the previous study. CONCLUSIONS Although over 20 years have passed, no significant changes have occurred in the mortality associated with IAVI. Patients presenting in shock with IAVI continue to have a high mortality rate.

Blunt abdominal aortic injury: A Western Trauma Association multicenter study

BACKGROUND Blunt abdominal aortic injury (BAAI) is a rare injury. The objective of the current study was to examine the presentation and management of BAAI at a multi-institutional level. METHODS The Western Trauma Association Multi-Center Trials conducted a study of BAAI from 1996 to 2011. Data collected included demographics, injury mechanism, associated injuries, interventions, and complications. RESULTS Of 392,315 blunt trauma patients, 113 (0.03%) presented with BAAI at 12 major trauma centers (67% male; median age, 38 years; range, 6–88; median Injury Severity Score [ISS], 34; range, 16–75). The leading cause of injury was motor vehicle collisions (60%). Hypotension was documented in 47% of the cases. The most commonly associated injuries were spine fractures (44%) and pneumothorax/hemothorax (42%). Solid organ, small bowel, and large bowel injuries occurred in 38%, 35%, and 28% respectively. BAAI presented as free aortic rupture (32%), pseudoaneurysm (16%), and injuries without aortic external contour abnormality on computed tomography such as large intimal flaps (34%) or intimal tears (18%). Open and endovascular repairs were undertaken as first-choice therapy in 43% and 15% of cases, respectively. Choice of management varied by type of BAAI: 89% of intimal tears were managed nonoperatively, and 96% of aortic ruptures were treated with open repair. Overall mortality was 39%, the majority (68%) occurring in the first 24 hours because of hemorrhage or cardiac arrest. The highest mortality was associated with Zone II aortic ruptures (92%). Follow-up was documented in 38% of live discharges. CONCLUSION This is the largest BAAI series reported to date. BAAI presents as a spectrum of injury ranging from minimal aortic injury to aortic rupture. Nonoperative management is successful in uncomplicated cases without external aortic contour abnormality on computed tomography. Highest mortality occurred in free aortic ruptures, suggesting that alternative measures of early noncompressible torso hemorrhage control are warranted. LEVEL OF EVIDENCE Epidemiologic study, level III; therapeutic study, level IV.

Vital capacity helps predict pulmonary complications after rib fractures.

BACKGROUND Traumatic rib fractures are associated with significant morbidity. Vital capacity (VC) assesses pulmonary function; however, limited data link VC to patient outcomes. Our objective was to determine if VC predicted complications and disposition in patients with rib fractures. METHODS This is a retrospective chart review of all patients with fractured ribs admitted to a Level 1 trauma center during a 4-year period. Patients were excluded if no VC was performed within 48 hours of admission. Data collected included demographics, hospital/intensive care unit length of stay, epidural, discharge to home versus extended care facility, mortality, chest Abbreviated Injury Scale (AIS) score, Injury Severity Score (ISS), number of rib fractures, hemothorax/pneumothorax, presence of pulmonary contusion, presence of chest tube, chronic obstructive pulmonary disease, and average daily VC (percentage of predicted). Pulmonary complication was defined as pneumonia, need for intubation, new home O2 requirement, readmission for pulmonary issue, or intensive care unit transfer. Statistical analysis was performed using &khgr;2 and multivariate logistic regression. RESULTS Of 801 patients with rib fractures, 683 had VC performed within 48 hours. Average age was 53 years, median ISS was 13 (interquartile range, 9–18), and median length of stay was 5 days. Most (72%) were discharged home, and 26% went to extended care facility. Ten percent developed a pulmonary complication, and there were nine deaths. Every 10% increase in VC was associated with 36% decrease in likelihood of pulmonary complication. Patients with a VC greater than 50% had a significantly lower association of pulmonary complication (p = 0.017), and a VC of less than 30% was independently associated with pulmonary complication (odds ratio, 2.36). CONCLUSION Patients with fractured ribs and VC of less than 30% have significant association for pulmonary complication. Higher VC is associated with lower likelihood of pulmonary complication. VC may help identify those at risk for complications after rib fractures, but a prospective study is necessary to confirm these findings. LEVEL OF EVIDENCE Prognostic/epidemiologic study, level IV.

A Case Study in Intra-abdominal Sepsis

Intra-abdominal infections are a common problem for the general surgeon and major sources of morbidity and mortality in the intensive care unit. Some of these patients present with peritonitis that can rapidly progress to septic shock. The basic principles of care include prompt resuscitation, antibiotics, and source control. This article will use a detailed case study to outline the management of a patient with severe intra-abdominal infection from diverticulitis from initial resuscitation to reconstruction. Components of the Surviving Sepsis Campaign as they pertain to surgical patients are discussed and updated, and the concept of damage control general surgery is applied.

Role of the Open Abdomen in Critically Ill Patients.

An open abdomen is common used in critically ill patients to temporize permanent abdominal closure. The most common reason for leaving the abdomen open by reopening a laparotomy, not closing, or creating a fresh laparotomy is the abdominal compartment syndrome. The open abdomen technique is also used in damage control operations and intra-abdominal sepsis. Negative pressure wound therapy may be associated with better outcomes than other temporary abdominal closure techniques. The open abdomen is associated with many early and late complications, including infections, gastrointestinal fistulas, and ventral hernias. Clinicians should be vigilant regarding the development of these complications.

Surgery Residency Curriculum Examination Scores Predict Future American Board of Surgery In-Training Examination Performance

IMPORTANCE A protected block curriculum (PBC) with postcurriculum examinations for all surgical residents has been provided to assure coverage of core curricular topics. Biannual assessment of resident competency will soon be required by the Next Accreditation System. OBJECTIVE To identify opportunities for early medical knowledge assessment and interventions, we examined whether performance in postcurriculum multiple-choice examinations (PCEs) is predictive of performance in the American Board of Surgery In-Training Examination (ABSITE) and clinical service competency assessments. DESIGN Retrospective single-institutional education research study. SETTING Academic general surgery residency program. PARTICIPANTS A total of 49 surgical residents. INTERVENTION Data for PGY1 and PGY2 residents participating in the 2008 to 2012 PBC are included. Each resident completed 6 PCEs during each year. MAIN OUTCOME MEASURES The results of 6 examinations were correlated to percentage-correct ABSITE scores and clinical assessments based on the 6 Accreditation Council for Graduate Medical Education core competencies. Individual ABSITE performance was compared between PGY1 and PGY2. Statistical analysis included multivariate linear regression and bivariate Pearson correlations. RESULTS A total of 49 residents completed the PGY1 PBC and 36 completed the PGY2 curriculum. Linear regression analysis of percentage-correct ABSITE and PCE scores demonstrated a statistically significant correlation between the PGY1 PCE 1 score and the subsequent PGY1 ABSITE score (p = 0.037, β = 0.299). Similarly, the PGY2 PCE 1 score predicted performance in the PGY2 ABSITE (p = 0.015, β = 0.383). The ABSITE scores correlated between PGY1 and PGY2 with statistical significance, r = 0.675, p = 0.001. Performance on the 6 Accreditation Council for Graduate Medical Education core competencies correlated between PGY1 and PGY2, r = 0.729, p = 0.001, but did not correlate with PCE scores during either years. CONCLUSIONS AND RELEVANCE Within a mature PBC, early performance in a PGY1 and PGY2 PCE is predictive of performance in the respective ABSITE. This information can be used for formative assessment and early remediation of residents who are predicted to be at risk for poor performance in the ABSITE.

Clinical utility of flat inferior vena cava by axial tomography in severely injured elderly patients.

BACKGROUND Flat inferior vena cava (IVC) has been associated with shock and mortality in young trauma patients (age < 55 years). Because of the greater possibility of nonhypovolemic shock in the elderly, we hypothesized that there would be no correlation between IVC ratio and the presence of shock. METHODS We conducted a retrospective cohort study of all severely injured (Injury Severity Score [ISS] ≥ 15), blunt trauma patients 55 years or older from April 2006 to April 2011. Only patients undergoing axial imaging of the IVC within 1 hour of arrival were considered. Anteroposterior and transverse diameter of the IVC were measured 2.5 mm above the renal veins. Transverse-to-anteroposterior IVC ratios of 2, 3, and 4 were analyzed. Hemodynamic (heart rate, blood pressure, systolic blood pressure, shock index, and adjusted shock index [ASI]) and laboratory (hemoglobin, HCO3, base excess) markers of shock were reviewed. Correlation among shock markers, IVC ratio, and death was analyzed using multivariate logistic regression. Relationship between shock and IVC ratio was analyzed using logistic regression and &khgr;2 where appropriate. RESULTS A total of 308 patients met the inclusion criteria during the study period. The IVC ratio was greater than 2, greater than 3, and greater than 4 in 180, 85, and 46 patients, respectively. The IVC ratio (analyzed continuously) correlated with mortality (p < 0.05). Ratios of greater than 3 and greater than 4 predicted a 2.0 and 2.2 times mortality increase (95% confidence interval, 1.00–5.00 and 1.00–4.95, respectively). IVC ratio did not correlate with shock (ASI > 50) for any of the ratios studied. CONCLUSION As in previous studies with younger injured patients, a flat IVC is predictive of increased mortality risk in the elderly. Presence of a shock state, as defined by ASI, is not correlated with a flat IVC. Moreover, almost one third of patients presenting in shock had a round IVC. This is consistent with our hypothesis that shock in the elderly trauma population may be multifactorial and the risk of nonhypovolemic shock must be considered. LEVEL OF EVIDENCE Diagnostic study, level IV.

Natural history of a postpull pneumothorax or effusion: observation is safe.

BACKGROUND Thoracostomy tube (TT) for drainage of hemopneumothorax is the most common intervention in thoracic trauma. Postpull pneumothorax or effusion (PPP/PPE) is common after removal of a TT. The natural history of PPP/PPE after discharge has not been described. This study evaluates the outcomes and management of PPP/PPE after discharge. METHODS Trauma patients with TT placed from July 1, 2008, to June 30, 2013, were identified from an administrative database and trauma registry. PPP/PPE was defined as the presence of air or fluid in the chest on a postpull imaging. The electronic medical record and final radiology interpretation were reviewed to confirm PPP/PPE during index admission and at discharge. Clinical follow-up and imaging were reviewed for the presence of persistent PPP/PPE. Interventions directed toward PPP/PPE and readmissions were recorded for patients with and without a PPP/PPE. Multivariate logistic regression was performed to identify factors for chest-related readmission. RESULTS Seven hundred ten patients surviving to discharge had a TT placed during the study time frame. Of the 151 patients (21.3%) with documented PPP/PPE on discharge, 115 patients had follow-up data available. Outpatient imaging was obtained in 35 patients, with persistent PPP/PPE noted in 16 patients (45.7%). Six patients (4%) with PPP/PPE at discharge required reintervention. Patients without documented PPP/PPE at discharge had a lower readmission rate (0.7% vs. 6.6%, p = 0.02). Multivariate logistic regression noted the presence of persistent PPP/PPE at follow-up (p = 0.001) to be associated with readmission. CONCLUSION PPP/PPE is a common occurrence following removal of a TT. While patients discharged with PPP/PPE have a statistically higher reintervention rate, the absolute value remains low. This should be considered when treating clinically stable, asymptomatic PPP/PPE. LEVEL OF EVIDENCE Epidemiologic study, level IV.

UNDETECTED PENETRATING BLADDER INJURIES PRESENTING AS A SPONTANEOUSLY EXPULSED BULLET DURING VOIDING: A RARE ENTITY AND REVIEW OF THE LITERATURE

BACKGROUND Patients presenting with a penetrating missile lodged in the pelvis are at risk for having a urinary tract injury. Once in the bladder, the missile can become impacted in the urethra, causing retention that requires extraction. Rarely, the missile can be expulsed spontaneously through the urethra. OBJECTIVES To describe the world literature regarding undetected penetrating bladder injuries presenting as spontaneously voided bullets and to contribute an additional case to the literature. CASE REPORT We present a case report of a 37-year-old man who sustained a gunshot wound to the right buttock, with an undetected urinary system injury and subsequent spontaneous voiding of a bullet. CONCLUSION There have been <10 cases reported in the literature of spontaneously expulsed bullets from the urethra, all of which were undetected injuries on initial presentation. Physicians should be aware of the potential for undetected urinary tract injuries in patients with penetrating missiles to the pelvis and understand the appropriate evaluation and management strategies for these injuries.