R. Stephen Smith

Traumatic rupture of the aorta: Still a lethal injury

A 10 year retrospective review of a community experience with blunt trauma of the aorta has been presented. We found that an overall mortality of 84 percent was associated with this injury. Fourteen patients reached the emergency department with stable vital signs. Of these patients, 10 underwent successful treatment (71 percent). Despite advances in many areas of trauma care, blunt trauma of the aorta remains a highly lethal injury. However, this review has demonstrated that with prompt diagnosis and treatment, a significant number of these patients can be salvaged. It is for this reason that we have adopted an aggressive approach toward victims of blunt trauma. We now proceed with diagnostic aortography in any patient who has undergone a significant deceleration injury.

Gasless laparoscopy and conventional instruments. The next phase of minimally invasive surgery.

OBJECTIVEnTo assess the capability of a retractor system that permits laparoscopic surgery without pneumoperitoneum and to determine if the system facilitates the use of conventional surgical instruments during minimally invasive surgery.nnnDESIGNnProspective evaluation and data collection with review.nnnSETTINGnUniversity-affiliated county hospital.nnnPATIENTSnTwenty-nine male and 29 female subjects evaluated prospectively via 27 trauma-related and 31 elective procedures.nnnMETHODSnFifty-eight laparoscopic procedures were performed between July 1992 and February 1993 with a system consisting of an intra-abdominal fan retractor and an electrically powered mechanical arm using conventional surgical and laparoscopic instruments.nnnRESULTSnGasless laparoscopy was used in the evaluation of 27 patients with abdominal trauma (11 gunshot wounds, 11 stab wounds, and five blunt injuries). The need for celiotomy was obviated in 20 (74%) of 27 cases. Three enterotomies, two diaphragmatic lacerations, and one gastric perforation were repaired with conventional instruments. Gasless laparoscopic techniques were also used in cholecystectomy (n = 26), diagnostic laparoscopy (n = 3), and appendectomy (n = 2). Exposure similar to that obtained by pneumoperitoneum was obtained in 30 (97%) of 31 cases. One major (trocar tip enterotomy) and two superficial wound infections occurred in this group. The ability to use conventional surgical instruments was advantageous in several cases.nnnCONCLUSIONSnComparable exposure was achieved in this cohort of patients with gasless laparoscopy. The use of conventional surgical instruments provides an advantage with this technique. Further improvements in abdominal wall lift systems and modification of existing surgical instruments may expand the role of gasless laparoscopy.

Preliminary report on videothoracoscopy in the evaluation and treatment of thoracic injury

A prospective trial of videothoracoscopy was conducted at an urban trauma center between February 1992 and February 1993 to determine the efficiency of this less invasive method of evaluation and treatment. Twenty-four consecutive patients with chest trauma (penetrating, n = 22; blunt, n = 2) were examined thoracoscopically for clotted hemothorax that otherwise would have been treated with thoracotomy (n = 9), suspected diaphragmatic injury (n = 10), and continued bleeding (n = 5). To ensure maximal exposure, general anesthesia with a double-lumen endotracheal tube was used in each patient. Clotted hemothorax was successfully evacuated in eight of nine patients (89%). Diaphragmatic laceration was suspected in 10 patients (2 abnormal chest radiographs, 8 proximity penetrating wounds) and confirmed thoracoscopically in 5. In four patients, diaphragmatic lacerations were successfully repaired with thoracoscopic techniques. Five patients underwent thoracoscopy for continued hemorrhage (greater than 1,500 mL per 24 hours) after tube thoracostomy. Intercostal artery injury was confirmed in all patients, and diathermy provided hemostasis in three patients without thoracotomy. No complications occurred. These data suggest the following: (1) Videothoracoscopy is an accurate, safe, and minimally invasive method for the assessment of diaphragmatic injuries, control of continued chest wall bleeding, and early evacuation of clotted hemothorax. (2) This technique should be used more frequently in patients with thoracic trauma. (3) Technical advances may expand the therapeutic role of thoracoscopy.

The evolution of an integrated ultrasound curriculum (iUSC) for medical students: 9-year experience

Interest in ultrasound education in medical schools has increased dramatically in recent years as reflected in a marked increase in publications on the topic and growing attendance at international meetings on ultrasound education. In 2006, the University of South Carolina School of Medicine introduced an integrated ultrasound curriculum (iUSC) across all years of medical school. That curriculum has evolved significantly over the 9xa0years. A review of the curriculum is presented, including curricular content, methods of delivery of the content, student assessment, and program assessment. Lessons learned in implementing and expanding an integrated ultrasound curriculum are also presented as are thoughts on future directions of undergraduate ultrasound education. Ultrasound has proven to be a valuable active learning tool that can serve as a platform for integrating the medical student curriculum across many disciplines and clinical settings. It is also well-suited for a competency-based model of medical education. Students learn ultrasound well and have embraced it as an important component of their education and future practice of medicine. An international consensus conference on ultrasound education is recommended to help define the essential elements of ultrasound education globally to ensure ultrasound is taught and ultimately practiced to its full potential. Ultrasound has the potential to fundamentally change how we teach and practice medicine to the benefit of learners and patients across the globe.

Complications of the Angelchik antireflux prosthesis: A community experience

The use of the Angelchik antireflux prosthesis has increased rapidly in our community since its introduction in 1979. Our experience with two patients who had serious complications associated with this prosthesis led us to review all 76 patients in our community who had undergone implantation of the device. Complications developed in 20 patients after placement of the prosthesis, and 12 of them required subsequent laparotomy for removal of the prosthesis. The complications observed were persistent dysphagia, late-onset dysphagia, transient dysphagia, persistent vomiting, esophageal obstruction, early gas bloat syndrome, gastric erosion, slippage of the prosthesis over the gastric fundus, disruption of the prosthesis, and migration of the prosthesis. Because of the frequency of potentially serious complications, we cannot recommend its use in the surgical treatment of esophageal reflux.

Starting the clock: defining nonoperative management of blunt splenic injury by time

BACKGROUNDnThere is no consensus when the designation of nonoperative management (NOM) for splenic injury (BSI) should start. We evaluated NOM success rates based on different time points after admission.nnnMETHODSnThe National Trauma Data Bank was evaluated for BSI for the year 2008. Observations were evaluated by facility, the time to splenectomy, and the volume of BSI admissions.nnnRESULTSnOf 15,732 BSIs identified, the overall splenectomy salvage rate was 81%. After the 5th hour, the NOM success rate was 95%. Multivariable analysis revealed that higher BSI grades, level 2 centers and community hospitals, and age ≥55 were associated with failed NOM.nnnCONCLUSIONSnThe grade of injury is an important predictor for failure of NOM. If a 5% failure rate is to be considered a benchmark, then the 5-hour time point after admission should be used for the calculation of NOM success rates.

A chest trauma scoring system to predict outcomes.

BACKGROUNDnRib fractures (RIBFX) are a common injury and are associated with substantial morbidity and mortality. Using a previously published RIBFX scoring system, we sought to validate the system by applying it to a larger patient population. We hypothesized that the RIBFX scoring system reliably predicts morbidity and mortality in patients with chest wall injury at the time of initial evaluation.nnnMETHODSnA 3-year, registry-based, retrospective study involving 1,361 trauma patients was performed. Patients were divided into two groups with a Chest Trauma Score (CTS)xa0<xa05 and ≥5 (nxa0=xa0724 and 637, respectively). Each cohort was analyzed for specific outcomes (mortality, pneumonia, acute respiratory failure). CTS was defined by age, severity of pulmonary contusion, number of RIBFX, and the presence of bilateral RIBFX with a maximum score of 12. Receiver operating characteristics were used to determine the use of CTS ≥5 cut point.nnnRESULTSnPatients with a CTS of 5 or more were (Pxa0≤xa0.05) older (61 vs 50xa0years), had greater Injury Severity Scores (21.6 vs 16.2), and had a greater prevalence of pneumonia (10.1 vs 3.5%), tracheostomy (7.4 vs 2.9%), and mortality (9.0 vs 2.2%). Patients with CTS ≥ 5 had nearly 4-fold increased odds of mortality (odds ratio 3.99, 95% confidence interval 1.92-8.31, Pxa0=xa0.001) compared with those who had CTSxa0<xa05.nnnCONCLUSIONnA CTS of at least 5 is associated with worse patient outcomes. Increased vigilance is needed with trauma patients who present with RIBFX and a CTS ≥ 5 at initial presentation. This simple RIBFX scoring system may improve early identification of vulnerable patients and expedite therapeutic interventions.

Disruptive technology in the treatment of thoracic trauma

The care of patients with thoracic injuries has undergone monumental change over the past 25 years. Advances in technology have driven improvements in care, with obvious benefits to patients. In many instances, new or disruptive technologies have unexpectedly displaced previously established standards for the diagnosis and treatment of these potentially devastating injuries. Examples of disruptive technology include the use of ultrasound technology for the diagnosis of cardiac tamponade and pneumothorax; thoracoscopic techniques instead of thoracotomy, pulmonary tractotomy, and stapled lung resection; endovascular repair of thoracic aortic injury; operative fixation of flail chest; and the enhanced availability of extracorporeal lung support for severe respiratory failure. Surgeons must be prepared to recognize the benefits, and limits, of novel technologies and incorporate these methods into day-to-day treatment protocols.

Risk of pulmonary embolism in trauma patients: Not all created equal

INTRODUCTIONnPatients with traumatic brain injury (TBI) are assumed to be at an increased risk for pulmonary embolism (PE). Delay in the initiation of chemoprophylaxis and prophylactic placement of inferior vena cava filters have been advocated by some because of concerns for increased intracranial hemorrhage in the presence of prophylactic anticoagulation. We hypothesized that patients with isolated TBI would not be at increased risk for the development of PE compared with the general trauma population.nnnMETHODSnPatients from the National Trauma Data Bank from the year 2008 were analyzed. Patient demographics, Injury Severity Score, and the prevalence of deep-vein thrombosis and PE were extracted. Studied injuries were assigned to six categories: thorax, abdominal solid organs, pelvic fracture, lower extremity fracture, spine fracture, and TBI.nnnRESULTSnOf a total of 627,775 injured patients, 2,182 (0.35%) had a documented PE. The prevalence of PE in patients with isolated TBI, lower extremity, pelvic fracture, liver and/or spleen, thorax, spine, multiple injuries, and none of the studied injuries were 0.25%, 0.36%, 0.35%, 0.37%, 0.52%, 0.37%, 1.1%, and 0.12%, respectively. Using an age-, sex- and race-adjusted multivariable logistic regression model and controlling for interaction between inferior vena cava filters and injury types, we found that isolated TBI was not associated with PE.nnnCONCLUSIONnIsolated TBI does not appear to be associated with an increased incidence of PE compared with other injuries. Patients with isolated TBI may not require early aggressive prophylaxis as is the standard for other high-risk groups.

Abdominal Ultrasound: Credentialing and Certification

The use of clinical ultrasound as a diagnostic tool by surgeons has rapidly increased over the past two decades. The use of ultrasound has found its way into essentially all of the surgical subspecialties. Ultrasound provides a real-time diagnostic modality that enhances the surgeon’s ability to make therapeutic decisions. Utilization of ultrasound during operative procedures is an extension and expansion of other diagnostic modalities, such as computed tomography. A number of studies have documented that surgeons can perform ultrasound with a high degree of sensitivity, specificity, and accuracy. Other papers have documented that the interpretation of specific ultrasound images by surgeons is equivalent to the high-quality interpretation provided by radiologists and other imaging specialists.