Jimmy Windsor

Stab wounds to the back and flank in the hemodynamically stable patient: A decision algorithm based on contrast-enhanced computed tomography with colonic opacification

PURPOSE The authors wanted to determine whether contrast-enhanced computed tomography (CE-CT) with colonic opacification is an accurate tool to triage hemodynamically stable victims of stab wounds to the flank and back. PATIENTS AND METHODS One hundred forty-five consecutive patients were categorized as low-risk ( penetration superficial to the deep fascia) or high-risk (penetration beyond the deep fascia) based on CE-CT findings. RESULTS There were no significant differences in admission vital signs, Glasgow Coma Scale, or complete blood counts between low- and high-risk groups. None of the 92 low-risk patients required surgery or had sequelae. Six of the 53 high-risk patients underwent surgery, 2 based on initial CE-CT, 4 due to evolving clinical signs. The CE-CT correctly predicted surgical findings in all cases. CONCLUSIONS Hemodynamically stable patients with stab wounds to the back and/or flank can be successfully triaged based on CE-CT findings. Low-risk patients may be discharged immediately. High-risk patients may have a discharge decision implemented at 24 hours.

Re-engineering ventilatory support to decrease days and improve resource utilization.

OBJECTIVE The objective of this study was to describe the development of a cost-effective ventilatory strategy using a portable microprocessor-controlled respiratory monitor (Bicore CP-100; Allied Healthcare Products, Riverside, CA.) SUMMARY BACKGROUND DATA Until recently, clinicians have had to accept the uncertainties of clinical judgment, which unfortunately, often biased the patient to a prolonged ventilatory course to avoid extubation failures, necessitating reintubation. METHODS Over a 4-year period, the authors attempted to re-engineer the process of ventilatory support based on measured work of breathing (WOB), including physiologic (WOBPhys), imposed (WOBImp) and total (WOBTot). RESULTS The authors made 90 determinations of WOB in 31 patients. The coefficient of determination (i2) of WOBTot, with the breathing frequency was 0.35, with tidal volume was 0.10, and with the rapid shallow breathing index (f/V(tau)) was 0.23; therefore, the authors discarded them as reliable inferences. Of 27 patients ventilated for > 2 days with satisfactory blood gases, but with breathing frequency > 30 breaths/minute, 6 had WOBTot < 0.8 J/L and were extubated successfully. In 21 patients, WOBTot was elevated to 1.6 +/- 0.83 J/L, WOBImp was 1.1 +/- 0.64 J/L, approximately twice the WOBPhys (0.5 +/- 0.26 J/L), a normal value. Extubation was successful in 20 of those 21 patients. This approach was extended to the spontaneous breathing pre-extubation trial. In addition, the ventilator was adjusted so that the patient sustained a WOBTot of 0.6 to 1 J/L during the ventilatory support. This evolution was tracked for 18 months in a series of 838 trauma intensive care unit patients. Average duration of ventilation decreased from 8.2 to 4.2 days (49%; p < 0.01). This translated into approximately 2400 decreased ventilator days per year. CONCLUSION Objective measurement to guide the adequacy of ventilatory support and interpret apparent clinical weaning failures decreased total ventilatory time by 50%, permitting extubation in nearly 20% of patients previously considered failures.

Guided percutaneous drainage for posttraumatic empyema thoracis

BACKGROUND Guided percutaneous drainage (GPD) is used in the management of posttraumatic empyema thoracis; however, its equivalence to decortication has not been evaluated. METHODS We retrospectively reviewed the records of 12 patients who underwent GPD and nine who were treated with decortication. RESULTS No primarily GPD-managed empyemas necessitated a subsequent thoracotomy. The size and number of fibrinopurulent loculations treated by each technique were equivalent. Sterile purulent collections were found in 55.6% of decortication-treated patients and in 33% of patients who underwent GPD. Intrapleural analgesia was administered to 71.4% of decortication-treated patients and 28.6% of GPD-treated patients. Five patients undergoing decortication required intensive care unit monitoring after operation (average, 2.8 days), compared with no GPD-treated patients. The catheter was left in place at discharge in 41.6% of GPD-treated patients and was removed on an outpatient basis. CONCLUSIONS The efficacy of GPD in handling loculated pleural space infections equals that of decortication. An intensive care unit stay is avoided. The ability to discharge patients with external drainage catheters and the decreased requirement of pain control should reduce the number of inpatient hospital days. GPD is an effective first-line approach for posttraumatic empyema thoracis.

Perioperative management of acquired hemophilia a: a case report and review of literature.

Introduction: Acquired hemophilia A is a rare bleeding disorder with a high mortality rate. Diagnosis and treatment of this disorder can be very challenging to anesthesiologists because of lack of a personal or familial abnormal bleeding history. Case presentation: We report a 60-year-old woman who presented to the operating room for an urgent fasciotomy. She was initially diagnosed to have compartment syndrome of her left upper extremity secondary to an expanding hematoma after multiple unsuccessful venipuncture attempts. After surgical intervention, she developed recurrent intramuscular hematomas, became severely anemic, and required surgical re-exploration and multiple blood product transfusions. Ultimately, she was found to have an elevated activated partial thromboplastin time (aPTT), very low FVIII activity, and high FVIII inhibitor titers consistent with the diagnosis of acquired hemophilia A. Conclusions: Treatment strategies in acquired hemophilia are based on two major objectives. During the acute stage, effective control of bleeding is critical. The ultimate therapeutic goal during the subacute phase is the elimination of the inhibitors targeting factor VIII. Here, we present this case and will review current literature regarding therapeutic approaches to this rare condition in the operating room setting and postoperative course.