Nicholas Namias

1,000 Consecutive Ultrasounds for Blunt Abdominal Trauma

Diagnostic peritoneal lavage (DPL) and computed tomography (CT) are the primary diagnostic modalities used in the evaluation of patients with suspected blunt abdominal trauma (BAT). DPL is fast and accurate but is associated with complications. CT is also accurate, yet requires stability and transportability of the patients. Ultrasound (US) has been suggested as an aid in evaluating BAT. We evaluated US in the initial assessment of BAT in 1000 patients. Patients were eligible for the study if they met specified trauma criteria and had suspected BAT. We then followed the outcome of the patients and their further work-up. US showed a sensitivity of 88%, a specificity of 99%, and an accuracy of 97% for detecting intraabdominal injuries. We conclude that emergency ultrasound may be used as the initial diagnostic modality for suspected blunt abdominal trauma.

Penetrating colon injuries requiring resection: Diversion or primary anastomosis? An AAST prospective multicenter study

BACKGROUND The management of colon injuries that require resection is an unresolved issue because the existing practices are derived mainly from class III evidence. Because of the inability of any single trauma center to accumulate enough cases for meaningful statistical analysis, a multicenter prospective study was performed to compare primary anastomosis with diversion and identify the risk factors for colon-related abdominal complications. METHODS This was a prospective study from 19 trauma centers and included patients with colon resection because of penetrating trauma, who survived at least 72 hours. Multivariate logistic regression analysis was used to compare outcomes in patients with primary anastomosis or diversion and identify independent risk factors for the development of abdominal complications. RESULTS Two hundred ninety-seven patients fulfilled the criteria for inclusion and analysis. Overall, 197 patients (66.3%) were managed by primary anastomosis and 100 (33.7%) by diversion. The overall colon-related mortality was 1.3% (four deaths in the diversion group, no deaths in the primary anastomosis group, p = 0.012). Colon-related abdominal complications occurred in 24% of all patients (primary repair, 22%; diversion, 27%; p = 0.373). Multivariate analysis including all potential risk factors with p values < 0.2 identified three independent risk factors for abdominal complications: severe fecal contamination, transfusion of > or = 4 units of blood within the first 24 hours, and single-agent antibiotic prophylaxis. The type of colon management was not found to be a risk factor. Comparison of primary anastomosis with diversion using multivariate analysis adjusting for the above three identified risk factors or the risk factors previously described in the literature (shock at admission, delay > 6 hours to operating room, penetrating abdominal trauma index > 25, severe fecal contamination, and transfusion of > 6 units blood) showed no statistically significant difference in outcome. Similarly, multivariate analysis and comparison of the two methods of colon management in high-risk patients showed no difference in outcome. CONCLUSION The surgical method of colon management after resection for penetrating trauma does not affect the incidence of abdominal complications, irrespective of associated risk factors. Severe fecal contamination, transfusion of > or = 4 units of blood within the first 24 hours, and single-agent antibiotic prophylaxis are independent risk factors for abdominal complications. In view of these findings, the reduced quality of life, and the need for a subsequent operation in colostomy patients, primary anastomosis should be considered in all such patients.

Trial of Short-Course Antimicrobial Therapy for Intraabdominal Infection

BACKGROUND The successful treatment of intraabdominal infection requires a combination of anatomical source control and antibiotics. The appropriate duration of antimicrobial therapy remains unclear. METHODS We randomly assigned 518 patients with complicated intraabdominal infection and adequate source control to receive antibiotics until 2 days after the resolution of fever, leukocytosis, and ileus, with a maximum of 10 days of therapy (control group), or to receive a fixed course of antibiotics (experimental group) for 4±1 calendar days. The primary outcome was a composite of surgical-site infection, recurrent intraabdominal infection, or death within 30 days after the index source-control procedure, according to treatment group. Secondary outcomes included the duration of therapy and rates of subsequent infections. RESULTS Surgical-site infection, recurrent intraabdominal infection, or death occurred in 56 of 257 patients in the experimental group (21.8%), as compared with 58 of 260 patients in the control group (22.3%) (absolute difference, -0.5 percentage point; 95% confidence interval [CI], -7.0 to 8.0; P=0.92). The median duration of antibiotic therapy was 4.0 days (interquartile range, 4.0 to 5.0) in the experimental group, as compared with 8.0 days (interquartile range, 5.0 to 10.0) in the control group (absolute difference, -4.0 days; 95% CI, -4.7 to -3.3; P<0.001). No significant between-group differences were found in the individual rates of the components of the primary outcome or in other secondary outcomes. CONCLUSIONS In patients with intraabdominal infections who had undergone an adequate source-control procedure, the outcomes after fixed-duration antibiotic therapy (approximately 4 days) were similar to those after a longer course of antibiotics (approximately 8 days) that extended until after the resolution of physiological abnormalities. (Funded by the National Institutes of Health; STOP-IT ClinicalTrials.gov number, NCT00657566.).

Rapid Detection of Traumatic Effusion Using Surgeon-Performed Ultrasonography

BACKGROUND In the injured patient, rapid assessment of the thorax can yield critical information for patient management and triage. OBJECTIVES The objectives of this prospective study were (1) to determine if experienced surgeon sonographers could successfully use a focused thoracic ultrasonographic examination to detect traumatic effusion, and (2) to compare the accuracy and efficiency of ultrasonography with supine portable chest radiography. METHODS Surgeon-sonographers performed thoracic ultrasonographic examinations on patients with blunt and penetrating torso injuries during the Advanced Trauma Life Support secondary survey. All patients also underwent portable chest radiography. Performance times for ultrasonography and chest radiography were recorded. Comparisons were made of the performance times and accuracy of both tests in detecting traumatic effusion. RESULTS In 360 patients, there were 40 effusions, 39 of which were detected by ultrasonography and 37 of which were detected by chest radiography. The 97.5% sensitivity and 99.7% specificity observed for thoracic ultrasonography were similar to the 92.5% sensitivity and 99.7% specificity for portable chest radiography. Performance time for ultrasonography was significantly faster than that for chest radiography (1.30 +/- 0.08 vs. 14.18 +/- 0.91 minutes, p < 0.0001). CONCLUSION Surgeons can accurately perform and interpret a focused thoracic ultrasonographic examination to detect traumatic effusion. Surgeon-performed thoracic ultrasonography is as accurate but is significantly faster than supine portable chest radiography for the detection of traumatic effusion.

Incidence and Susceptibility of Pathogenic Bacteria Vary between Intensive Care Units within a Single Hospital: Implications for Empiric Antibiotic Strategies

BACKGROUND The purpose of this study was to determine whether the incidence of recovery and patterns of antibiotic susceptibility of pathogenic bacteria vary between intensive care units (ICUs) in a single teaching hospital. METHODS Culture and susceptibility results were collected prospectively for a 3-month period (April through June 1999) in each of the surgical, trauma, and medical ICUs. The number of unique isolates and susceptibility patterns were determined. Susceptibility of isolates among ICUs was compared with chi2. RESULTS Statistically significant differences between ICUs in susceptibility to various antibiotics were found for Staphylococcus aureus, Enterococcus sp, Acinetobacter sp, Enterobacter sp, Klebsiella sp, and Pseudomonas sp. Notably, vancomycin-resistant Enterococcus was not seen in the medical ICU, whereas it was seen in both the surgical and trauma ICUs. Klebsiella spp resistant to ceftazidime were seen only in the trauma ICU. The aminoglycosides and quinolones had attenuated activity against Pseudomonas sp in the surgical ICU, whereas they remained highly effective in the trauma ICU. Cefazolin had no activity against the Enterobacter sp in either of the surgical ICUs, but was highly effective in the medical ICU. CONCLUSION Although the microbiologic results of this study should not be extrapolated to other institutions, the principle is of value. There is variability between ICUs in a single large teaching hospital in susceptibility of bacterial pathogens to various antibiotics. This may have implications in the design of empiric antibiotic strategies and the planning of the hospital formulary. Hospital wide or composite ICU antibiograms are inadequate for planning empiric therapy in the ICU.

Management of casualties from the bombing at the Centennial Olympics

BACKGROUND The explosion of a bomb 75 to 100 yards away from attendees at a concert who were in the process of being evacuated from Centennial Olympic Park at approximately 1:25 AM on July 27, 1996, resulted in a multiple-casualty event involving primarily four hospitals in proximity to the blast. The purpose of this study was to review triage and care of the victims, emphasizing those with significant injuries. METHODS Retrospective review of triage and care of injured patients. RESULTS Ninety-six of the 111 victims of the blast were triaged in the first half hour to four hospitals within 3 miles of the bombing. Only four minor operations were performed in 61 patients evaluated at community hospitals. Ten of 35 patients evaluated at the regional trauma center underwent emergency or urgent operations, and all who were seriously injured did well. CONCLUSIONS Although overtriage to the regional trauma center occurred, outcome was excellent in all seriously injured victims treated there.

Laparoscopic cholecystectomy in cirrhotic patients

BACKGROUND Reported mortality for open cholecystectomy in patients with cirrhosis ranges from 10% to 80%. Laparoscopic cholecystectomy has gained acceptance in the general population and has become the procedure of choice for symptomatic cholelithiasis. We reviewed our experience with the use of laparoscopic cholecystectomy in this group. STUDY DESIGN We did a retrospective review of the records of 25 consecutive laparoscopic choleoystectomy procedures performed on cirrhotic patients from May 1992 to July 1996. RESULTS There were no mortalities in our group. All procedures were completed laparoscopically. Mean length of stay was 1.7 days (range, 1 to 8 days). Morbidity consisted of wound hematomas, pneumonia, and ascites for a rate of 32%. Only patients with Childs Class A and Class B cirrhosis were operated on. CONCLUSIONS Laparoscopic cholecystectomy can be performed safely in cirrhotic patients with well compensated liver function.

Secondary ultrasound examination increases the sensitivity of the FAST exam in blunt trauma.

INTRODUCTION Approximately one third of stable patients with significant intra-abdominal injury do not have significant intraperitoneal blood evident on admission. We hypothesized that a delayed, repeat ultrasound study (Secondary Ultrasound--SUS) will reveal additional intra-abdominal injuries and hemoperitoneum. METHODS We performed a prospective observational study of trauma patients at our Level I trauma center from April 2003 to December 2003. Patients underwent an initial ultrasound (US), followed by a SUS examination within 24 hours of admission. Patients not eligible for a SUS because of early discharge, operative intervention or death were excluded. All US and SUS exams were performed and evaluated by surgical/emergency medicine house staff or surgical attendings. RESULTS Five hundred forty-seven patients had both an initial US and a SUS examination. The sensitivity of the initial US in this patient population was 31.1% and increased to 72.1% on SUS (p < 0.001) for intra-abdominal injury or intra-abdominal fluid. The specificity for the initial US was 99.8% and 99.8% for SUS. The negative predictive value was 92.0% for the initial US and increased to 96.6% for SUS (p = 0.002). The accuracy of the initial ultrasound was 92.1% and increased to 96.7% on the SUS (p < 0.002). No patient with a negative SUS after 4 hours developed clinically significant hemoperitoneum. CONCLUSION A secondary ultrasound of the abdomen significantly increases the sensitivity of ultrasound to detect intra-abdominal injury.

Hemoperitoneum score helps determine need for therapeutic laparotomy.

PURPOSE Sonography provides a fast, portable, and noninvasive method for patient assessment. However, the benefit of providing real-time ultrasound (US) imaging and fluid quantification shortly after patient arrival has not been explored. The objective of this study was to prospectively validate a US hemoperitoneum scoring system developed at our institution and determine whether sonography can predict a therapeutic operation. METHODS For 12 months, prospective data on all patients undergoing a trauma sonogram were recorded. All sonograms positive for free fluid were given a hemoperitoneum score. The US score was compared with initial systolic blood pressure and base deficit to assess the ability of sonography to predict a therapeutic laparotomy. RESULTS Forty of 46 patients (87%) with a US score > or = 3 required a therapeutic laparotomy. Forty-six of 54 patients with a US score < 3 (85%) did not need operative intervention. The sensitivity of sonography was 83% compared with 28% and 49% for systolic blood pressure and base deficit, respectively, in determining the need for therapeutic operation. CONCLUSION We conclude that the majority of patients with a score > or = 3 will need surgery. The US hemoperitoneum scoring system was a better predictor of a therapeutic laparotomy than initial blood pressure and/or base deficit.

Honey in the Management of Infections

BACKGROUND Honey, a natural product of bees of the genera Apis and Meliponinae, has been recognized for medicinal properties since antiquity. Honey has demonstrated antimicrobial properties. These effects are variably ascribed to the pH, hydrogen peroxide content, osmotic effect, and as yet unidentified compounds putatively described as inhibines. MATERIALS AND METHODS This review will explore the use of honey in necrotizing soft tissue infections, postsurgical wound infections, wounds other than postsurgical infections, Helicobacter pylori of the stomach and duodenum, and burns. Throughout, the in vitro evidence that exists and the explanations that can be offered for the purported benefits of honey will be reviewed. Most of the reports are either uncontrolled case series or in vitro observations. As such, detailed critique of statistical methods will not be undertaken. CONCLUSION The purpose of this paper is not to debunk honey therapy as a myth, but to stimulate thought among surgeons interested in surgical infection and perhaps serve as the nidus for future research. The use of honey should be considered when more conventional therapies have failed.