Seong K. Lee

The effect of age on functional outcome in mild traumatic brain injury: 6-month report of a prospective multicenter trial

OBJECTIVE Elderly patients (aged 60 years and older) have been demonstrated to have an increased mortality after isolated traumatic brain injury (TBI); however, the prognosis of those patients surviving their hospitalization is unknown. We hypothesized that surviving elderly patients would also have decreased functional outcome, and this study examined the functional outcome of patients with isolated TBI at discharge and at 6 months posthospitalization. METHODS This was a multicenter prospective study of all patients with isolated moderate to severe TBI defined as Head Abbreviated Injury Scale score of 3 with an Abbreviated Injury Scale score in any other body area of 1. Patients surviving to discharge gave their consent and were enrolled. Data collected included demographics, Glasgow Coma Scale (GCS) score at admission, and neurosurgical interventions. Outcome data included discharge disposition and Glasgow Outcome Scale score and modified Functional Independence Measure (FIM) score at discharge and at 6 months. RESULTS Two hundred thirty-five patients were enrolled, with 44 (19%) aged greater than or equal to 65 years. Mechanisms of injury were falls (34%), assaults (28%), motor vehicle collisions (14%), pedestrian (11%), and other (12%). Falls were more common in the older patients and assaults in the younger group. The mean admitting GCS score was 12.8 (95% confidence interval [CI], 12.4-13.3), with older patients having a higher mean GCS score, 14.1 (95% CI, 13.6-14.6) versus 12.5 (95% CI, 12.0-13.1; p = 0.03). There were no differences in the percentage of patients admitted to the intensive care unit or requiring neurosurgical intervention between younger and older patients. Because there were few elderly patients with low GCS scores who survived to discharge, outcome measures focused on those patients with GCS scores of 13 to 15. A greater percentage of elderly were discharged to rehabilitation (28% vs. 16%, p =0.08). The mean discharge FIM score was 10.4 (95% CI, 9.8-11.0) for the elderly versus 11.4 (95% CI, 11.1-11.7) for the young (p =0.001), with 68% elderly and 89% young discharged with total independent scores of 11 to 12. At 6 months, the difference narrowed, but the mean FIM score was still greater for the young group, 11.7 (95% CI, 11.6-11.9) versus 11.0 (95% CI, 10.6-11.4; p < 0.001). CONCLUSION Functional outcome after isolated mild TBI as measured by the Glasgow Outcome Scale and modified FIM is generally good to excellent for both elderly and younger patients. Older patients required more inpatient rehabilitation and lagged behind their younger counterparts but continued to recover and improve after discharge. Although there were statistically significant differences in the FIM score at both discharge and 6 months, the clinical importance of these small differences in the mean FIM score to the patients quality of life is less clear. Measurable improvement in functional status during the first 6 months after injury is observed in both groups. Aggressive management and care of older patients with TBI is warranted, and efforts should be made to decrease inpatient mortality. Continued follow-up is ongoing to determine whether these outcomes persist at 12 months.

Trauma assessment training with a patient simulator: a prospective, randomized study.

BACKGROUND Patient simulators are computer-controlled mannequins that may increase realism during trauma training by providing real-time changes in vital signs and physical findings during trauma scenarios. We hypothesized that trauma assessment training on a patient simulator would be as effective as training with a more traditional moulage patient/actor. METHODS This study was conducted during a surgery intern orientation at two academic trauma centers. Interns (n = 60) attended a basic trauma course, and were then randomized to trauma assessment practice sessions with either the patient simulator (n = 30) or a moulage patient (n = 30). After practice sessions, interns were randomized a second time to an individual trauma assessment test on either the simulator or the moulage patient. Two surgeon-judges rated each intern live and on video for completion of 50 predetermined assessment objectives (total score) divided into sections (primary and secondary survey, general performance, diagnostic studies/procedures, and plan) and the identification and management of an acute neurologic deterioration in the test patient (event score). Multiple linear regression with random student effects was used to estimate the independent effects of all study variables. RESULTS Within randomized groups, mean trauma assessment test scores for all simulator-trained interns were higher when compared with all moulage-trained interns (71 +/- 8 vs. 66 +/- 8, respectively; p = 0.02). Simulator training independently showed a small but statistically significant improvement in both the total score and the event score (+4.6 and +8.6, respectively; p < 0.05). CONCLUSION Use of a patient simulator to introduce trauma assessment training is feasible and compares favorably to training in a moulage setting. Continued research in this area of physician education is warranted.

Tissue oxygen monitoring during hemorrhagic shock and resuscitation: a comparison of lactated Ringer's solution, hypertonic saline dextran, and HBOC-201.

BACKGROUND The ideal resuscitation fluid for the trauma patient would be readily available to prehospital personnel, universally compatible, effective when given in small volumes, and capable of reversing tissue hypoxia in critical organ beds. Recently developed hemoglobin-based oxygen-carrying solutions possess many of these properties, but their ability to restore tissue oxygen after hemorrhagic shock has not been established. We postulated that a small-volume resuscitation with HBOC-201 (Biopure) would be more effective than either lactated Ringers (LR) solution or hypertonic saline dextran (HSD) in restoring baseline tissue oxygen tension levels in selected tissue beds after hemorrhagic shock. We further hypothesized that changes in tissue oxygen tension measurements in the deltoid muscle would reflect the changes seen in the liver and could thus be used as a monitor of splanchnic resuscitation. METHODS This study was a prospective, blinded, randomized resuscitation protocol using anesthetized swine (n = 30), and was modeled to approximate an urban prehospital clinical time course. After instrumentation and splenectomy, polarographic tissue oxygen probes were placed into the liver (liver PO2) and deltoid muscle (muscle PO2) for continuous tissue oxygen monitoring. Swine were hemorrhaged to a mean arterial pressure (MAP) of 40 mm Hg over 20 minutes, shock was maintained for another 20 minutes, and then 100% oxygen was administered. Animals were then randomized to receive one of three solutions: LR (12 mL/kg), HSD (4 mL/kg), or HBOC-201 (6 mL/kg). Physiologic variables were monitored continuously during all phases of the experiment and for 2 hours postresuscitation. RESULTS At a MAP of 40 mm Hg, tissue PO2 was 20 mm Hg or less in both the liver and muscle beds. There were no significant differences in measured liver or muscle PO2 values after resuscitation with any of the three solutions in this model of hemorrhagic shock. When comparing the hemodynamic effects of resuscitation, the cardiac output was increased from shock values in all three animal groups with resuscitation, but was significantly higher in the animals resuscitated with HSD. Similarly, MAP was increased by all solutions during resuscitation, but remained significantly below baseline except in the group of animals receiving HBOC-201 (p < 0.01). HBOC-201 was most effective in both restoring and sustaining MAP and systolic blood pressure. There was excellent correlation between liver and deltoid muscle tissue oxygen values (r = 0.8, p < 0.0001). CONCLUSION HBOC-201 can be administered safely in small doses and compared favorably to resuscitation with HSD and LR solution in this prehospital model of hemorrhagic shock. HBOC-201 is significantly more effective than HSD and LR solution in restoring MAP and systolic blood pressure to normal values. Deltoid muscle PO2 reflects liver PO2 and thus may serve as an index of the adequacy of resuscitation in critical tissue beds.

Unique Presentation of Urachal Cyst Disease: Incidental Finding to Complicated Infection

Urachal remnant disease is uncommon in adults and can present with symptoms ranging from drainage near the umbilicus to a severe abdominal infection. Most cases are referred for treatment once diagnosed either clinically or radiographically with ultrasound or computerized tomography. We present a unique case of an infected urachal cyst visualized on a series of CT scans in an adult patient with abdominal pain over a period of years.

Intraoperative rescue extracorporeal membrane oxygenation and damage control during repair of a traumatic aortic injury

Abstract A 21-year-old male involved in a motorcycle crash presented with abdominal hemorrhage and a widened mediastinum on chest radiograph. He required an initial exploratory laparotomy for mesenteric injuries. An aortic injury was confirmed on computed tomography imaging and he subsequently underwent attempted endovascular repair. During that procedure, the patient experienced massive thoracic hemorrhage with cardiac arrest and profound respiratory failure. Damage-control thoracic surgery and rescue extracorporeal membrane oxygenation were successfully utilized with a favorable outcome.

A unique case of venous air embolus with survival

Venous air embolus (VAE) occurs when gas, specifically atmospheric air, enters into the vascular system. Although rare, they can be fatal due to risk of cardiovascular collapse. In this report, we present a unique case of a 66-year-old female trauma patient with an inferior vena cava air embolism. An overview of the potential cause is presented, along with a review of the management of VAE.

Congenital Renal Fusion and Ectopia in the Trauma Patient

We present two separate cases of young male patients with congenital kidney anomalies (horseshoe and crossed fused renal ectopia) identified following blunt abdominal trauma. Despite being rare, ectopic and fusion anomalies of the kidneys are occasionally noted in a trauma patient during imaging or upon exploration of the abdomen. Incidental renal findings may influence the management of traumatic injuries to preserve and protect the patients renal function. Renal anomalies may be asymptomatic or present with hematuria, flank or abdominal pain, hypotension, or shock, even following minor blunt trauma or low velocity impact. It is important for the trauma clinician to recognize that this group of congenital anomalies may contribute to unusual symptoms such as gross hematuria after minor trauma, are readily identifiable during CT imaging, and may affect operative management. These patients should be informed of their anatomical findings and encouraged to return for long-term follow-up.

Traumatic Lung Herniation following Skateboard Fall

Lung herniation (LH) is a rare clinical entity involving the protrusion of lung outside the thoracic cage. It has a variety of etiologies and clinical presentations, making diagnosis difficult. We present a case of a 20-year-old male who reported pleuritic pain after falling from a skateboard. Evaluation through computed tomography (CT) scanning of the chest revealed an anterior lung hernia associated with rib fractures. This case emphasizes the need for clinicians to include lung herniation in the differential diagnosis of patients with trauma and inexplicable or persistent pulmonary issues.

Alligator wrestling: the ultimate wrestling match.

A 45-year-old man was admitted to our facility after sustaining a bite to the head while wrestling1 an 11-foot 260 lbs American Alligator (Alligator Mississippiensis) at a Seminole Indian Reservation in the Everglades National Park in Lake Placid Florida (Fig. 1). On initial evaluation in the trauma room, the patient was found to be hemodynamically stable and neurologically intact. Multiple bite marks to the scalp and a left temporal-parietal skull fracture were documented (Fig. 2). He was admitted for observation, and further treatment included irrigation and cleaning of his wounds, tetanus toxoid, and Zosyn (piperacillin and tazobactam). The rest of his hospital stay was uncomplicated. People learn to wrestle an alligator for survival, personal satisfaction, or showmanship realizing that wrestling an alligator can result in injury or death. It is a popular sport and has been a big part of the Seminole Indian culture. Initiated in the early 20th century by members of the Miccosukee and Seminole Tribes of Florida as a tourist attraction taking advantage of fears and myths about alligators—as well as the reality of their danger— alligator wrestling continues to withstand the test of time. At the turn of the 20th century, showing off alligators as road side attractions helped Native Americans generate revenue. For tribes such as the Seminole and Miccosukee, learning how to “handle” alligators is part of their existence. According to the clan leader of the Seminole tribe of South Florida, “alligator wrestling has immense growth potential as long as there’s always going to be a part of the population who will want to see blood sports.” And it does not get much bloodier than going toe to toe with a reptile that could tear a human limb from limb. American alligators are mostly found in the Southeastern United States, from Virginia and North Carolina south to Everglades National Park in Florida and west to the southern tip of Texas. On average, a large adult American alligator’s weight and length is 800 pounds (360 kg) and 12 feet. According to the Florida Fish and Wildlife Conservation Commission, the largest alligator ever recorded in Florida is a 14 feet 5/8 inches (4.28 m) male from Seminole County. Alligators have an average of 75–80 teeth. The power of an alligator when closing its jaws and its power to keep its jaws closed is enormous. With a quick snap, it can crush the bones of a full grown cow. It is known that a shark bites with 330 pounds of pressure, a lion with 940 pounds, and an alligator can bite with nearly 2,400 pounds of pressure. Alligators are capable of killing humans but are generally wary enough not to see them as potential prey. There were nine fatal alligator attacks in the United States throughout the 1970s, 1980s, and 1990s, but alligators killed 12 people from 2001 to 2007. In May 2006, alligators killed three Floridians in 4 days, two of them in the same day. Alligators inflict damage with their sharp, cone-shaped teeth and powerful jaws. Bites are characterized by puncture wounds and/or torn flesh and can result in serious injuries due to the risk of infection. Inadequate treatment or neglect of an alligator bite may result in a severe infection that could require the amputation of a limb due to gangrene. Aeromonas Hydrophilia, Enterobacter Agglomerans, Citrobacter Diversus, Proteus Vulgaris, and Pseudomonas Spp. are commonly isolated from alligator mouths. Therefore, antibiotic therapy of alligator bites should be directed at gram-negative species. An estimated 5 million American alligators are spread out across the southeastern United States. Roughly 1.25 million alligators live in the state of Florida. In 1967, the alligator was listed as an endangered species (under a law that preceded the Endangered Species Act of 1973), meaning it was considered in danger of extinction. In 1987, the Fish and Wildlife Service pronounced the American alligator fully recovered and consequently removed the animal from the list of endangered species. The Fish and Wildlife Service still regulates the legal trade in alligator skins and products made from them.

Lightning Burns and Electrical Trauma in a Couple Simultaneously Struck by Lightning

More people are struck and killed by lightning each year in Florida than any other state in the United States. This report discusses a couple that was simultaneously struck by lightning while walking arm-in-arm. Both patients presented with characteristic lightning burns and were admitted for hemodynamic monitoring, serum labs, and observation and were subsequently discharged home. Despite the superficial appearance of lightning burns, serious internal electrical injuries are common. Therefore, lightning strike victims should be admitted and evaluated for cardiac arrhythmias, renal injury, and neurological sequelae.