Pak Shan Leung

The predictive value of initial serum lactate in trauma patients.

ABSTRACT Trauma patients require early assessment of injury severity. Trauma scores, although well validated, can be unwieldy in the emergency clinical setting. We sought to evaluate the prognostic value of initial serum lactate (ISL) for mortality, operative intervention (OI), and intensive care unit admission (ICUA) in trauma patients. We conducted an institutional review board–approved retrospective study. We reviewed all trauma patients between January 2007 and June 2012 in our prospectively maintained database. We included only adults whose ISL had been drawn within the first 35 min after arrival. We included only those patients whose interval between injury and arrival was within 24 h. Survivors and nonsurvivors were compared using logistic regression, Mann-Whitney U, and chi-square tests. Discriminating ability of ISL for mortality was assessed with receiver operating characteristic analysis. Our secondary outcomes (ICUA and OI) were evaluated with logistic regression test and receiver operating characteristic analysis. A total of 1,941 patients were included. Overall mortality was 6.2%. Median ISL was 32 mg/dL (interquartile range, 17 – 62) for nonsurvivors versus 21 mg/dL (interquartile range, 14 – 32) for survivors (P < 0.001). In multivariate analysis, ISL was a significant covariate for mortality (P = 0.015). The odds ratio was 1.010 (95% confidence interval, 1.002 − 1.019). The area under the curve was 0.63. The ISL was a significant covariate for OI (P = 0.033). The ISL did not reach significance for ICUA. The ISL is an easily measured, rapid, and inexpensive test that can help to quickly stratify injury severity in trauma patients. We have found that ISL, when used in strictly selected patients, can predict OI and mortality.

Ruptured Dissecting Intramural Duodenal Hematoma Following Endoscopic Retrograde Cholangiopancreatography

A 34-year-old woman with schizophrenia developed abdominal pain. Ultrasound demonstrated cholelithiasis and a dilated biliary tree. The patient underwent endoscopic retrograde cholangiopancreatography (ERCP), sphincterotomy, and extraction of gallstones from the common bile duct. She developed post-procedure fever, tachycardia, and abdominal pain and was taken to the operating room for urgent cholecystectomy with intraoperative cholangiogram. At laparotomy, an intramural dissecting duodenal hematoma was discovered, which extended the length of the duodenum and ruptured. She underwent gastric pyloric exclusion, gastrojejunostomy, and healed uneventfully. ERCP is not without risks, and a degree of vigilance should be maintained in patients who develop new symptomatology following the procedure.

The impact of enoxaparin administration in relationship to hemorrhage in mild traumatic brain injury

BACKGROUND Venous thromboembolism prophylaxis in the general trauma population is well established. However, risk of increased intracranial hemorrhage in traumatic brain injury (TBI) population is of concern. The aim for this study is to identify a reproducible model of mild traumatic brain injury (mTBI), evaluated by clinical and histological markers and test the hypothesis that enoxaparin increases the risk of spontaneous brain hemorrhage. METHODS 40 male Sprague Dawley rats were randomly assigned to 5 groups: group 1 (sham) with no TBI along with 4 groups comparing mTBI with and without pharmacological intervention using enoxaparin at 24 h and 72 h respectively. Mild traumatic brain injury was induced using a weight drop apparatus, with a clinical endpoint of time to right (TTR), along with histological and spectrophotometer analysis for qualitative hemorrhage. RESULTS There is a statistically significant difference between group 1 (sham) and all other groups with a mean longer time to right of 64 s (p = 0.005) in the mTBI groups. There was a statistically significant difference between group 1 (sham) and all other groups with an increase of 6 g/dL hemoglobin (p < 0.001) in the mTBI groups with no difference in hemorrhage between groups that were treated with enoxaparin. CONCLUSION The weight drop apparatus is a reproducible model for mTBI that has correlations with clinical and qualitative data. This model was able to produce clinical signs of concussion, as reflected by longer TTR and increased hemoglobin in the mTBI groups. Upon further analysis, there wasno increase in hemorrhage in the pharmacological intervention groups with enoxaparin.

Abdominal compartment syndrome due to spontaneous rectus sheath hematoma with extension into the retroperitoneal space

Abstract Rectus sheath hematoma (RSH) is an increasingly common clinical condition in our hospitals due to the increasing use of anticoagulant therapies for various purposes among our patients. Treatment of spontaneous RSH is generally conservative. For continued bleeding, interventional radiologic identification and subsequent embolization is an effective option. Surgery usually involves significant morbidity and is considered a technique of last resort. In this case report, we describe the case of middle aged female who developed abdominal compartment syndrome (ACS) from a large RSH that had extended into the retroperitoneum. The patient underwent abdominal decompression with removal of the hematoma and subsequently fared very well. Patients with large RSHs extending into the retroperitoneum should undergo constant monitoring of their abdominal pressures for early detection and treatment of potentially deadly condition of ACS.

2005: DISSECTING INTRAMURAL DUODENAL HEMATOMA FOLLOWING ENDOSCOPIC RETROGRADE CHOLANGIOPANCREATOGRAPHY

Crit Care Med 2016 • Volume 44 • Number 12 (Suppl.) severe alkalosis with a serum chloride level of 64 mmol/L and bicarbonate elevated at 40 mmol/L. Fluid losses of 350–400 mL from the fistula was reported daily. The fluid was sent for electrolyte analysis; results showed a chloride level of 129 mmol/L and the bicarbonate level was below the limit of detection. She was treated with normal saline infusion and the metabolic alkalosis and electrolyte disturbance normalized. Surgical repair of the fistula was planned, however the patient was not stable for surgery. The patient continued to deteriorate and subsequently died from shock. Results: In this patient with duodenal enterocutaneous fistula we would anticipate a metabolic acidosis to develop from bicarbonate loss. However, this patient presented with severe metabolic alkalosis. We hypothesize that decreased stimulation of pancreatic exocrine function resulted in very minimal bicarbonate secretion and instead hydrogen and chloride ions were lost and metabolic alkalosis developed.

Delayed duodenal injury following abdominal gunshot wound

A29-year-old male who sustained two abdominal gunshot wounds became hemodynamically unstable in the traumabay and was thus taken immediately to the operating room for exploratory laparotomy. Massive hemoperitoneum was discovered upon abdominal entry. After packing four quadrants, controlling hemorrhagic vessels branching from the superior mesenteric artery and superior mesenteric vein, packing a large liver laceration, performing partial small bowel resection and right hemicolectomy, a Grade 3 laceration along the second portion of the duodenum was discovered and closed primarily (Fig. 1). With an open abdomen, the patient was stabilized in the surgical intensive care unit. Reexplorationwas performed on hospital day (HD) 3; transverse colectomy, reanastomosis of the small bowel, feeding jejunostomy, and end ileostomy were performed. The repaired duodenal injury was evaluated and appeared viable. The abdomen was not yet amenable to closure.On further exploration on HD5, a bilious fluid collectionwas discovered in the duodenal region. The distal second portion of the duodenum and the third and fourth portions of the duodenum were found to be necrotic secondary to complete devascularization (Fig. 2). The previously repaired site and the adjacent pancreas appeared to be unaffected. What Would You Do? A. Pancreaticoduodenectomy B. Resection of the affected duodenum with primary duodenojejunal anastomosis and placement of a transgastric jejunal feeding tube C. Duodenal diverticularization with pyloric exclusion, gastrojejunostomy, vagotomy, biliary drainage, and placement of feeding jejunostomy D. Resection of the affected duodenum with antrectomy, side gastrojejunostomy with vagotomy, biliary drainage, and placement of feeding jejunostomy Figure 1. Initial duodenal injury. Figure 2. Devascularization of D3 to D4. CHALLENGE OF ACS

1332: Pancreas-Sparing Duodenectomy Following Abdominal Gunshot Wound

Introduction: Classic surgical treatment of duodenal lesions, regardless of pancreatic involvement, has been pancreaticoduodenectomy (PD). Reasoning behind this en bloc resection is operative time and technical demand due to common blood supply and anatomic complexity of the pancreatico-duodenal reg