Jeremy Juern

Slightly hypertonic saline and dextran-40 in resuscitation of methamphetamine burn patients.

The inherent danger of illegal manufacture of methamphetamine is explosion and fire with the “cookers” presenting to burn centers for treatment. Recent studies have shown that methamphetamine burn patients required resuscitation volumes two to three times that of the standard Parkland formula and experienced a higher mortality rate. The purpose of this study was to compare the fluid resuscitation requirements and other characteristics of our methamphetamine-positive burn patients with a control group of methamphetamine-negative burn patients. A retrospective study of burn patients with methamphetamine-positive urine toxicology screens was conducted from August 1996 to April 2005. The data collected were age, sex, %total body surface area (%TBSA) burn, urine toxicology screen result, length of stay (LOS), ventilator days, weight, urine output, and fluid requirement during the first 24 hours along with fluid type, survival, and hospital charges. Methamphetamine-positive patients were matched to controls for %TBSA, age, and sex. Eleven methamphetamine-positive burn patients were well matched with 11 methamphetamine-negative controls. There was no difference in intubation rate, ventilator days, LOS, and there were no deaths in either group. There was no statistical difference between the two groups for the ratio of the 24-hour fluid resuscitation requirement divided by the estimate from the Parkland formula. Hospital charges were similar for the two groups. The largest volume of fluid infused was lactated Ringers (LR) and the slightly hypertonic fluid combination of LR + 50 mEq sodium bicarbonate + 3.4 mmol potassium phosphate. Both groups also received a dextran-40 (Rheomacrodex) infusion. In contrast to previous studies, our experience with methamphetamine-positive burn patients shows that they did not have an increased initial fluid requirement, a longer LOS, more days on the ventilator, higher hospitalization charges nor an increased mortality rate. The only apparent difference between our study and others is in the method of resuscitation. The slightly hypertonic fluid combination of LR + 50 mEq sodium bicarbonate +3.4 mM potassium phosphate was used for resuscitation along with Rheomacrodex. Prospective trials should be conducted on this fluid resuscitation strategy to determine wider applicability for all large burn patients.

Base excess: a review.

T of pH, carbon dioxide, and oxygen in blood goes back hundreds of years. This scientific history involves distinguished names such as Boyle, Dalton, Avogadro, Arrhenius, Henderson, and Hasselbach. Following in the footsteps of these luminaries, Siggaard-Andersen and Astrup developed the term base excess (BE) to describe the metabolic component of an alkalosis or acidosis. Ever since then, physicians and physicians-in-training have been trying to understand BE.There is a paucity of literature, even in critical care textbooks, to explainBE to the eager learner. This reviewarticlewill explain what BE is, groups of patients where it has been studied, and finally explore the pitfalls and limitations of its use. The goal is to understand BE without having to be a clinical chemist.

Transanal wading pool suction-drain injury resulting in complete evisceration of the small intestine: case report and review of the literature

Suction evisceration from a pool drain is a rare injury. This child presented with what appeared to be isolated perineal trauma. Ultimately, the patient was found to have complete transanal small bowel evisceration. Reported herein are the specifics of this case, along with a review of the relevant literature relating to this case.

Clinical significance of computed tomography contrast extravasation in blunt trauma patients with a pelvic fracture.

INTRODUCTION Blunt pelvic fractures can be associated with major pelvic bleeding. The significance of contrast extravasation (CE) on computed tomography (CT) is debated. We sought to update our experience with CE on CT scan for the years 2009–2014 to determine the accuracy of CE in predicting the need for angioembolization. METHODS This is a retrospective review of the trauma registry and our electronic medical record from a Level I trauma center. Patients seen from July 1, 2009, to September 7, 2014, with blunt pelvic fractures and contrast-enhanced CT were included. Standard demographic, clinical, and injury data were obtained. Patient records were queried for CE, performance of angiography, and angioembolization. Positive patients were those where CE was associated with active bleeding requiring angioembolization. All other patients were considered negative. RESULTS There were 497 patients during the study time period with blunt pelvic fracture meeting inclusion criteria, and 75 patients (15%) had CE. Of those patients with CE, 30 patients (40%) underwent angiography, and 17 patients (23%) required angioembolization. The sensitivity, specificity, positive predictive value, and negative predictive value of CE on CT were 100%, 87.9%, 22.7%, and 100%, respectively. Two patients without CE underwent angiography but did not undergo embolization. Patients with CE had higher mortality (13 vs. 6%, p < 0.05) despite not having higher ISS scores. CONCLUSIONS This study reinforces that CE on CT pelvis with blunt trauma is common, but many patients will not require angioembolization. The negative predictive value of 100% should be reassuring to trauma surgeons such that if a modern CT scanner is used, and there is no CE seen on CT, then the pelvis will not be a source of hemorrhagic shock. All of these findings are likely due to both increased comfort with observing CEs and the increased sensitivity of modern CT scanners. LEVEL OF EVIDENCE Therapeutic/care management study, level IV.

Gastrostomy-Tube Exchange

This video demonstrates the technique for the removal and replacement of a balloon gastrostomy tube. The indications, contraindications, and potential complications are also reviewed.

Laparoscopic repair of a traumatic intrapericardial diaphragmatic hernia.

Introduction: Intrapericardial diaphragmatic hernia is a rare injury. We present a case of an intrapericardial diaphragmatic hernia from blunt trauma. In this report we will review the current literature and also describe the first report of a primary laparoscopic repair of the defect. Case Description: A 38-year-old unrestrained male passenger had blunt chest and abdominal trauma from a motor vehicle collision. Two months later, on a computed tomography scan, he was found to have an intrapericardial diaphragmatic hernia. The defect was repaired primarily through a laparoscopic approach. Discussion: Symptoms of intrapericardial diaphragmatic hernia are chest pain, upper abdominal pain, dysphagia, and dyspnea. Chest computed tomography is the most useful diagnostic test to define the defect. Even when the injury is diagnosed late, laparoscopy can be used for primary and patch repair.

Removing the Critically Ill Patient from Mechanical Ventilation

Weaning from mechanical ventilation is usually straightforward but is occasionally challenging. Sedation must be used at the appropriate times and with appropriate dosing. A protocol that calls for a daily sedation holiday with a spontaneous breathing trial decreases time on the ventilator. Early tracheostomy is beneficial in traumatic brain injury patients. Noninvasive ventilation is most useful in patients with baseline obstructive sleep apnea and chronic obstructive pulmonary disease.

Analysis of Academic Medical Center Graduate Medical Education Websites for Policies Regarding Restrictive Covenants in Non-ACGME Fellowships

BACKGROUND The topic of restrictive covenants in fellowships that are not approved by the Accreditation Council for Graduate Medical Education (ACGME) has not been studied. OBJECTIVE To investigate the presence of institutional polices at academic medical centers regarding restrictive covenants in non-ACGME fellowships. METHODS The graduate medical education (GME) office website of 132 academic medical centers was evaluated and searched for the following as of June 1, 2017: presence of any ACGME residency or fellowship, presence of any non-ACGME fellowship, presence of GME policies and procedures, presence of a restrictive covenant policy, and if that policy applies to non-ACGME fellowships. RESULTS A total of 96 academic medical centers had non-ACGME fellowships. Of these, 56 prohibit restrictive covenants in non-ACGME fellowships because of either their GME policy or state law. Seven academic medical centers have a GME policy that allows restrictive covenants in non-ACGME fellowships. Two academic medical centers clearly state that fellows in a certain subspecialty fellowship will be required to sign a restrictive covenant. CONCLUSIONS GME policies at academic medical centers that allow restrictive covenants in non-ACGME fellowships are very uncommon. The practice of having fellows sign a restrictive covenant in a non-ACGME fellowship is in conflict with an American Medical Association ethics statement, ACGME institutional requirement IV.L, and the rules of the San Francisco Match.

Carotid and Vertebral Injuries

Carotid and vertebral arterial injuries will continue to be a challenge for the trauma surgeon. Trauma to the carotid and vertebral arteries can be from either penetrating or blunt mechanisms. Penetrating injuries to the neck can result in not only arterial trauma but also aerodigestive injuries. Zone 2 of the neck is easily accessible, but carotid and other arterial injuries in zones 1 and 3 may require more challenging methods of exposure. Endovascular techniques may be crucial for control of these vessels in certain situations. Blunt cerebrovascular injuries (BCVIs) must be sought out using screening criteria when the physician has a high degree of suspicion. Antithrombotics and antiplatelet agents, including heparinoids, warfarin, and aspirin, are the cornerstone of treatment in order to prevent a cerebrovascular accident. Endovascular stent placement may be utilized for grade III injuries such as pseudoaneurysm.

The effect of suturing on force for dislodgement of tracheostomy tubes: medial versus lateral sutures.

U decannulation of a tracheostomy is a lifethreatening complication. Tube displacement occurs at a rate of 0% to 7% and is particularly problematic in the early postoperative period, generally described as the first 7 days to 14 days following tracheostomy placement. It is during this period that the tracheocutaneous tract is forming and reinsertion of an accidentally decannulated tube can be difficult and may result in the formation of a false passage and the need for orotracheal intubation. Factors associated with tube dislodgement include obesity, postoperative swelling, length of the tube, frequent patient repositioning, and method of securing the tube. Several methods are described for tube security including the use of ties or tapes around the neck and suturing the plastic flange to the neck in various manners. Some surgeons decline to place sutures on the flange to prevent a false appearance of a secure tracheostomy that is less prone to accidental decannulation. Another concern with a sutured tracheostomy tube is that dislodgement might occur with the tube being held in the subcutaneous tissue by the sutures, delaying recognition of accidental dislodgement. This could potentially occur with a tracheostomy tube that has been dislodged into the subcutaneous tissue but appears to remain tightly secured to the neck, thus delaying a diagnosis of decannulation. Suturing the flange of a tracheostomy to the neckdecreases the incidence of early decannulation in children. Because of the wide variation in techniques in securing a tracheostomy, we attempted to objectively determine what role suturing played in addition to the tracheostomy ties. In addition, we sought to determine if placing sutures at the lateral margin of the tracheostomy flange is different from placing them medially. We hypothesized that medially placed sutures require more force for the same excursion of the tracheostomy tube.