Michel Wagner

Venous Thromboembolic Disease in Trauma and Surveillance Ultrasonography

BACKGROUND The literature reports a wide variation in the incidence of venous thromboembolic (VTE) disease in trauma patients. The performance of routine surveillance venous duplex ultrasound of bilateral lower extremities is controversial. Furthermore, recent examinations of the national trauma databank registry have suggested that routine duplex surveillance is associated with higher deep venous thrombosis (DVT) detection rates. MATERIALS AND METHODS We examined the incidence and risk factors for VTE disease in 2827 trauma patients admitted over a 2-y period to a state-verified level I trauma center. Detailed chart review was carried out for patients with VTE disease. We then evaluated the effects of a routine bilateral lower extremity duplex surveillance guideline on VTE detection in the subset of injury patients admitted to the trauma service. RESULTS We found an approximately 2% incidence of venous thromboembolic disease in a mostly blunt trauma population. Amongst patients with VTE disease, the most common risk factors were obesity and significant head injury. We then evaluated the 998 patients with injury who were admitted to the trauma service 1 y before and after surveillance guideline implementation. Despite a nearly 5-fold increase in the number of duplex scans, with a substantial increase in cost, we found no significant difference in the incidence of DVT. CONCLUSIONS Our preliminary data argue against the use of routine duplex surveillance of lower extremities for DVT in trauma patients. A larger, prospective analysis is necessary to confirm these findings.

Evolution and Current Trends in the Management of Acute Appendicitis

The treatment of appendicitis has evolved since the first appendectomy in the eighteenth century. It seems to have come full circle with nonoperative management in the era before frequent surgical interventions, to open surgical interventions, minimally invasive interventions, and now back to a renewed interest in nonoperative management of acute appendicitis. Scoring systems to help refine the diagnosis of acute appendicitis and advances in medical imaging have also changed the management of this condition. Scientific investigations into the effects the microbiome of the appendix plays in this disease process are also being considered.

Massive intrapericardial and intrathoracic hemorrhage secondary to unusual injuries causing cardiopulmonary arrest

A 28-year-old man sustained multiple stab wounds. During transport by emergency medical services, the patient suffered cardiac arrest and required cardiopulmonary resuscitation (CPR). On arrival, he was ‘in extremis’. Vital signs: blood pressure 58/33 mm Hg; pulse 144 bpm; respiratory rate 33 bmp; and oxygen saturation 85%. He was immediately intubated. In the right femoral and subclavian veins 8.5 French catheters were placed. Fluid resuscitation was started using Lactated Ringers, 2 units of uncross-matched packed red blood cells (PRBCs) and 2 units of fresh frozen plasma (FFP). Physical examination revealed 6 non-bleeding stab wounds, 2–3 cm each, located 1 cm below the right midclavicular line; 1 cm lateral and below the left sternoclavicular junction; 1 cm below and 2 cm medial to the right scapula; 2 cm medial to the midborder of the left scapula; in the right abdominal flank, at the posterior axillary line, 3 cm above the right iliac crest; and a right anterior midthigh wound. The patient had decreased breath sounds in both hemithoracic cavities. Bilateral 36 French chest tubes were placed at the fifth intercostal spaces. The right-sided chest tube produced 500 mL of blood, the left produced 1 L. A focused assessment with sonography for trauma (FAST) scan revealed significant fluid in the pericardium. A chest X-ray (figure 1) revealed moderate hemothorax on …

Laparotomy: The conquering of the abdomen and the historical journey of pancreatic and duodenal injuries.

U other injuries described since ancient times, pancreatic and duodenal injuries are relative newcomers to the annals of surgical history; as a matter of fact, there are but very few well-documented historical accounts of these injuries. Unlike cardiac injuries described in the Iliad, pulmonary injuries documented by Galen on gladiators or esophageal injuries described in the Edwin Smith Surgical Papyrus; these injuries awaited their description until autopsy studies were performed. This was the case of the first description of a pancreatic injury by Travers (Fig. 1) in England; or until some type of surgical intervention upon the abdomen could be carried out, as in the case of the first description of a duodenal injury by Larrey (Fig. 2) in France. One of the greatest barriers to the identification of pancreaticoduodenal injuries remained the unexplored frontier of the abdominal cavity. The treatment of firearmwounds was first described in a textbook by Brunschwig who recommended cauterization of all war wounds based on Von Pfolspeundt’s doctrine. Brunschwig is also credited with the repair of a segment of wounded bowel, resulting from a military injury, by transection and insertion of a silver tube over which the transected ends of the small bowel were tied. Despite his recommendation of this method, no credencewas given to this method and thus, it was rarely practiced. Larrey (Fig. 2), in 1798, repaired a transected segment of ileum. Unfortunately, few advocates for the operative management of gunshot wounds emerged. Similarly, the insurmountable barrier of pain management had to be conquered before any laparotomy could proceed. It took the courage of Baudens, who first advocated digital exploration of penetrating abdominalwounds, to identify blood, gas, or fecal material and in 1836, performed the first exploratory laparotomies and enterorrhaphies on patients who sustained gunshot wounds of the abdomen during the French-Algerian war. Baudens’ first surgical intervention was unsuccessful; however, he did not desist, and subsequently performed a second intervention with a reported survivor. Afterward, he proposed bold operations for abdominal gunshot wounds. Baudens’ experience and advocacy of exploratory laparotomy unfortunately went unheeded and was forgotten. It was not until the US Civil War that this procedure was considered valuable in the management of abdominal trauma; however, it was rarely practiced. Penetrating abdominal wounds treated expectantly had an overall mortality of 87%. The modern history of abdominal wound management began with the South AfricanWar (1899Y1901). SirWilliamMcCormac (see Figure, Supplemental Digital Content 1, http://links.lww.com/TA/A739), an Irish surgeon who served as the chief consulting surgeon to the South African field force stated: ‘‘That in this war, a man wounded in the abdomen dies if he is operated upon, and remains alive if he is left in peace.’’ This remark set the policy for nonoperative management. Delays in treatment prompted by the great distances over which the battles were fought also militated in favor of nonintervention. McCormac’s aphorism condemning operative management had great impact on military surgeons in England and other countries. As it is usually the case, wartime knowledge is frequently forgotten, and its lessons must be relearned. Consequently, it took yet another surgical maverick to emerge and challenge McCormac’s aphorism. Vera Gedroits (see Figure, Supplemental Digital Content 2, http://links.lww.com/TA/A740), a Russian princess and a surgeon at a time in which female physicians were rare, was such a person. She was appointed as a Russian Red Cross surgeon during the Russo-Japanese War (1904Y1905) and deployed to the Siberian front where, first in tents smeared with mud in 1904 and subsequently in a railway car, she performed 183 laparotomies for penetrating abdominal wounds, selecting only patients who presented within three hours of injury. Mortality data are not available, however; her 57-page report led the Society of Russian Military Surgeons to adopt the policy of routine exploratory laparotomy for penetrating abdominal wounds. This knowledge was not disseminated during both the French War in Morocco (1907Y1908) and the Balkan Wars (1912Y1913); therefore, the policy of nonoperative management of abdominal wounds remained firmly entrenched. It was not until World War I that British and American surgeons became more aggressive and began to operate on soldiers who had sustained penetrating abdominal injuries. The first abdominal explorations performed during World War I were by Pedley at Antwerp and by Sir Henry S. Souttar SURGICAL HISTORY

257: TRAUMA PATIENTS HAVE BEEN EXPOSED TO INCREASING RADIATION DOSES OVER THE DECADE 2001–2010

patients transported by a specialized pediatric transport team at ACH and state EMS services. Final disposition, Emergency Department (ED) length of stay (LOS), hospital LOS, and time to the operating room (OR) were compared between group. Demographic characteristics and baseline clinical variables were assessed with two sample t-tests for continuous variables (with appropriate log transformations of the skewed variables) and Pearson test for categorical variables. Multivariate linear models using ordinary least squares was used to assess whether the differences in LOS between EMS and specialized teams remained significant after adjusting for age, gender, race and ISS. Results: There were significant differences between specialized transport team and EMS groups for demographic variables; in particular median age of the specialized team group was lower; [EMS team 10.4y (9.6 ± 5.6) vs. Specialized team 6.2y (7.4 ± 5.8) median (mean ± SD)] and ISS scores were lower in the specialized transport group. For outcome variables, un-adjusted differences in ED disposition were different, LOS was shorter, ED LOS was shorter, and the probability of survival was higher in patients transported by a specialized pediatric team. Multivariate analysis, adjusting for age and ISS revealed a significantly different ED LOS with patients transported by EMS teams spending an average of 0.67 (95% CI 0.65 to 0.68) hours longer in the ED. Conclusions: The age difference between groups was expected as specialized teams are more often called upon to transport younger patients. The difference in ED LOS [EMS Team 2.5 (3.2 ± 3.9) vs Specialized Team 2.3h (2.6 ± 2.2) P<0.001] suggests that improved care provided by specialized pediatric teams may result in enhanced resuscitation during transport, decreasing time spent in the ED. In turn, patients are transferred to ICUs or ORs more quickly, thus expediting appropriate ongoing care and rationing ED resources more efficiently. Future evaluations will determine if differences exist in subsets of trauma patients and if the number of interventions during transport differs among specialized pediatric teams versus EMS teams. Specialized pediatric transport teams may provide better care and shorten ED LOS in trauma patients transported to tertiary care children’s hospitals.

Two hospitals with 1 trauma system: a joint approach to the care of the injured patient

BACKGROUND Trauma centers are closing at an alarming rate, but the need for trauma care persists. This article shows the sustainability and feasibility of a joint trauma system whereby 2 university-affiliated hospitals function as a single trauma center system in a moderate-sized city. METHODS Since 1994, 3 days per week, trauma patients are transported by emergency medical services (EMS) to hospital A. The other 4 days they are transported to hospital B. Trauma registry data from 1994 to 2008 were analyzed. Cost data were also examined. RESULTS The joint system admitted 28,338 trauma patients. On each centers nontrauma days, trauma team activation was required infrequently. The 2 centers share costs; they perform joint outreach, educational training, and quality control. The joint trauma system has been sustained since 1994. CONCLUSIONS Two hospitals functioning as a single trauma center system is a viable model of care for injured patients in a moderate-sized city with mostly blunt trauma.