Matthew Indeck

Blunt thoracic trauma. Analysis of 515 patients.

A retrospective analysis of 515 cases of blunt chest trauma is presented. The overall thoracic morbidity rate was 36% and mortality rate was 15.5%. Atelectasis was the most common complication. Severe chest trauma can be present in the absence of rib or other thoracic bony fractures. Emergency thoracotomies for resuscitation of the patient with blunt chest trauma with absent vital signs proved unsuccessful in 39 of 39 patients. A high index of suspicion for blunt chest injury occurring in blunt trauma, coupled with an aggressive diagnostic and therapeutic approach, remains the cornerstone of treatment to minimize the morbidity and mortality of such injuries.

Blunt Chest Trauma in the Elderly

Significant differences were identified between a group of elderly patients (65 years and older) and a nonelderly group both with blunt thoracic trauma. There was a lower incidence of elderly patients presenting in shock; however, cardiopulmonary arrest at arrival was more frequent in this group. Although the types of complications were similar in both populations, the morbidity and mortality rates were higher in the elderly. A high index of suspicion must be generated for an elderly patient who has sustained blunt chest trauma. An aggressive diagnostic and therapeutic approach may lead to a decrease in the high morbidity and mortality rates in the elderly.

Pelvic fractures in pregnancy: factors influencing maternal and fetal outcomes.

BACKGROUND The purpose of this study was to determine factors influencing maternal and fetal outcomes associated with pelvic fractures in pregnancy. METHODS A literature review of pelvic and acetabular fractures during pregnancy was performed, providing 101 cases for analysis (1 case report was included). Factors influencing maternal and fetal mortality were evaluated. RESULTS Pelvic and acetabular fractures during pregnancy were associated with a high maternal (9%) and a higher fetal (35%) mortality rate. Automobile-pedestrian collisions had a trend toward a higher maternal mortality rate, and vehicular collisions had a trend toward a higher fetal mortality rate, compared with falls. Injury severity influenced both maternal and fetal outcomes. Fracture classification (simple vs. complex), fracture type (acetabular vs. pelvic), the trimester of pregnancy, and the era of literature reviewed did not influence mortality rates. When considering potential causes of fetal death, direct trauma to the uterus, placenta, or fetus was not associated with a higher fetal mortality rate, compared with maternal hemorrhage. Pelvic and acetabular fracture surgery has rarely been reported in this patient population. CONCLUSION Pelvic and acetabular fractures in pregnancy continue to be associated with a high fetal mortality rate. Mechanism of injury and injury severity appeared to influence mortality rates, whereas the fracture classification, the fracture type, the trimester of pregnancy, and the era of literature reviewed did not.

Spontaneous splenic rupture complicating anticoagulant or thrombolytic therapy.

PURPOSE To characterize the clinical course and outcomes of reported cases of splenic hemorrhage during thrombolytic or anticoagulant therapy. METHODS The Medline, EMBASE (Excerpta Medica), BIOSIS, and SCISEARCH databases for English and foreign literature between 1966 and 1991 were searched. All reports of patients with documented splenic hemorrhage during anticoagulant therapy or thrombolytic therapy were reviewed. Foreign language manuscripts were translated into English. RESULTS Seventeen cases of splenic hemorrhage associated with anticoagulant or thrombolytic therapy were found. In one case, there was minor antecedent trauma; in the remaining cases, hemorrhage was spontaneous. Mortality overall was 24% and was more likely in patients with splenic hemorrhage after thrombolytic therapy (50%) than in patients receiving long-term anticoagulants (9%). Splenectomy was performed in 12 of 13 survivors. CONCLUSIONS Splenic hemorrhage associated with anticoagulant or thrombolytic therapy is a rare entity. It may be lethal, especially when associated with lytic therapy. Reversal of the anticoagulated or lytic state and emergent splenectomy are the treatment of choice. Splenic hemorrhage can mimic acute myocardial infarction and cardiogenic shock and must be considered when the condition of cardiac patients receiving lytic or anticoagulant drugs suddenly deteriorates.

Assessing the true risk of abdominal solid organ injury in hospitalized rib fracture patients.

BACKGROUND Despite the lack of evidence, traditional trauma teaching has suggested that low rib fractures increase the risk of abdominal solid organ injury (ASOI). This study was designed to assess if in fact this is true, and to try and define other factors that increased the risk of ASOI in rib fracture patients. METHODS The charts of 476 hospitalized rib fracture trauma patients were reviewed. Data were collected for age; sex; Injury Severity Score (ISS); rib fracture location; and the presence or absence of injuries to the abdominal organs, head, neck, face, thorax, great vessel, heart, thoracolumbar spine, pelvis, and extremities. RESULTS The probability of liver injury increased with the presence of any right-sided rib fracture, any low rib fracture, female gender, young age, and an elevated ISS. The probability of splenic injury increased with the presence of left-sided rib fractures only, any low rib fracture, young age, and an elevated ISS. CONCLUSION In hospitalized trauma patients, low rib fractures, right-sided rib fractures, female gender, young age, and an elevated ISS increased the probability of liver injury; and low rib fractures, left-sided only rib fractures, young age, and an elevated ISS increased the probability of splenic injury. Associated pelvic fractures and long bone fractures did not increase the likelihood of ASOI in this cohort.

Positive and Negative Volume-Outcome Relationships in the Geriatric Trauma Population

IMPORTANCE In trauma populations, improvements in outcome are documented in institutions with higher case volumes. However, it is not known whether improved outcomes are attributable to the case volume within specific higher-risk groups, such as the elderly, or to the case volume among all trauma patients treated by an institution. OBJECTIVE To test the hypothesis that outcomes of trauma care for geriatric patients are affected differently by the volume of geriatric cases and nongeriatric cases of an institution. DESIGN, SETTING, AND PARTICIPANTS This retrospective cohort study using a statewide trauma registry was set in state-designated levels 1 and 2 trauma centers in Pennsylvania. It included 39 431 eligible geriatric trauma patients (aged >65 years) in the Pennsylvania Trauma Outcomes Study. MAIN OUTCOMES AND MEASURES In-hospital mortality, major complications, and mortality after major complications (failure to rescue). RESULTS Between 2001 and 2010, 39 431 geriatric trauma patients and 105 046 nongeriatric patients were captured in a review of outcomes in 20 state-designated levels 1 and 2 trauma centers. Larger volumes of geriatric trauma patients were significantly associated with lower odds of in-hospital mortality, major complications, and failure to rescue. In contrast, larger nongeriatric trauma volumes were significantly associated with higher odds of major complications in geriatric patients. CONCLUSIONS AND RELEVANCE Higher rates of in-hospital mortality, major complications, and failure to rescue were associated with lower volumes of geriatric trauma care and paradoxically with higher volumes of trauma care for younger patients. These findings offer the possibility that outcomes might be improved with differentiated pathways of care for geriatric trauma patients.

Injury from silage wagon accident complicated by mucormycosis

Infection due to farm machinery injuries may be caused by microorganisms found in soil or decaying vegetable material. A case of injury due to entrapment of a young boy in a silage wagon is reported here. His injuries were complicated by infection with Aspergillus species, Absidia species, Rhizopus species (the latter two are members of the Mucorales order), and Pseudomonas maltophilia. Successful treatment of his infection followed aggressive surgical debridement of the anterior abdominal wall, amphotericin B, hyperbaric oxygen therapy, and surgical closure utilizing delayed placement of split-thickness skin grafts.

A retrospective study evaluating the use of Permacol surgical implant in incisional and ventral hernia repair

BACKGROUND The outcome of incisional and ventral hernia repair depends on surgical technique, patient, and material. Permacol™ surgical implant (crosslinked porcine collagen) has been used for over a decade; however, there are few data on outcomes. This study is the largest retrospective multinational study to date to evaluate outcomes with Permacol™ surgical implant in the repair of incisional and ventral hernias. METHODS Data were collected retrospectively on 343 patients treated for 213 incisional and 130 ventral hernias. Data evaluated included patient demographics, wound classification, surgical technique, morbidity, and recurrence rates. RESULTS Median follow-up time was 649 days (max: 2857), median age 57 years (range 23-91), and BMI 32 kg/m(2) (range 17.6-77.8). Two or more comorbidities were present in 70% of patients. Open surgery was performed in 220 (64%) patients. Permacol™ surgical implant was used as an underlay (250), sublay (39), onlay (37), or inlay (17). Surgical techniques included component separation (89; 25.9%), modified Stoppa technique (197; 57.4%), and Rives-Stoppa (17; 5.0%). CDC Surgical Wound Classification was Class I (190), Class II (103), Class III (28), and Class IV (22). Complications were seen in 40.5% (139) of the patients, with seroma (19%) and wound infection (15%) as the most common. Mesh removal occurred in 1 (0.3%) patient. Kaplan-Meier analysis demonstrated that the probabilities for hernia recurrence at one, two, and three years were 5.8%, 16.6%, and 31.0%, respectively. CONCLUSIONS Permacol™ surgical implant was shown to be safe with relatively low rates of hernia recurrence. CLINICAL TRIAL REGISTRATION NUMBER NCT01214252 (http://www.clinicaltrials.gov).

Tension pneumopericardium in blunt chest trauma.

Tension pneumopericardium is a rare complication of blunt chest trauma. We present two case reports of tension pneumopericardium, with clinical, hemodynamic, and radiographic evidence supporting the diagnosis. Although tension pneumopericardium is uncommon in blunt chest trauma, it should be considered in patients with pneumopericardium and hemodynamic instability.

Qualitative analysis of subcutaneous Lispro and regular insulin injections for stress hyperglycemia: A pilot numerical study

Increased glucose variability (GV) is an independent risk factor for mortality in the critically ill; unfortunately, the optimal insulin therapy that minimizes GV is not known. We simulate the glucose-insulin feedback system to study how stress hyperglycemia (SH) states, taken to be a non-uniform group of physiologic disorders with varying insulin resistance (IR) and similar levels of hyperglycemia, respond to the type and dose of subcutaneous (SQ) insulin. Two groups of 100 virtual patients are studied: those receiving and those not receiving continuous enteral feeds. Stress hyperglycemia was facilitated by doubling the gluconeogenesis rate and IR was stepwise varied from a borderline to a high value. Lispro and regular insulin were simulated with dosages that ranged from 0 to 6 units; the resulting GV was analyzed after each insulin injection. The numerical model used consists of a set of non-linear differential equations with two time delays and five adjustable parameters. The results show that regular insulin decreased GV in both patient groups and rarely caused hypoglycemia. With continuous enteral feeds and borderline to mild IR, Lispro showed minimal effect on GV; however, rebound hyperglycemia that increased GV occurred when the IR was moderate to high. Without a nutritional source, Lispro worsened GV through frequent hypoglycemia episodes as the injection dose increased. The inferior performance of Lispro is a result of its rapid absorption profile; half of its duration of action is similar to the glucose ultradian period. Clinical trials are needed to examine whether these numerical results represent the glucose-insulin dynamics that occur in intensive care units, and if such dynamics are present, their clinical effects should be evaluated.