Thomas W. Carver

Nodular fasciitis: a sarcomatous impersonator

Reports of nodular fasciitis among adults are common; however, this condition is relatively rare in the pediatric population. Its clinical and histologic characteristics are similar to malignancies such as sarcoma; thus, it is prudent for the clinician caring for children and adolescents to be aware of the possibility of its occurrence. Nodular fasciitis is a benign mesenchymal tumor. Often presenting as a rapidly enlarging soft tissue mass, clinically, it can easily be mistaken as a sarcoma or other malignancy during clinical evaluation. In addition, the pathologist may recognize its high cellularity, high mitotic index, and infiltrative borders, which, as a result, may lead to erroneous diagnosis as a malignancy. Although more frequently seen in adults, it does occur in the pediatric population and should be considered during evaluation and treatment of soft tissue masses in children and adolescents.

Vital capacity helps predict pulmonary complications after rib fractures.

BACKGROUND Traumatic rib fractures are associated with significant morbidity. Vital capacity (VC) assesses pulmonary function; however, limited data link VC to patient outcomes. Our objective was to determine if VC predicted complications and disposition in patients with rib fractures. METHODS This is a retrospective chart review of all patients with fractured ribs admitted to a Level 1 trauma center during a 4-year period. Patients were excluded if no VC was performed within 48 hours of admission. Data collected included demographics, hospital/intensive care unit length of stay, epidural, discharge to home versus extended care facility, mortality, chest Abbreviated Injury Scale (AIS) score, Injury Severity Score (ISS), number of rib fractures, hemothorax/pneumothorax, presence of pulmonary contusion, presence of chest tube, chronic obstructive pulmonary disease, and average daily VC (percentage of predicted). Pulmonary complication was defined as pneumonia, need for intubation, new home O2 requirement, readmission for pulmonary issue, or intensive care unit transfer. Statistical analysis was performed using &khgr;2 and multivariate logistic regression. RESULTS Of 801 patients with rib fractures, 683 had VC performed within 48 hours. Average age was 53 years, median ISS was 13 (interquartile range, 9–18), and median length of stay was 5 days. Most (72%) were discharged home, and 26% went to extended care facility. Ten percent developed a pulmonary complication, and there were nine deaths. Every 10% increase in VC was associated with 36% decrease in likelihood of pulmonary complication. Patients with a VC greater than 50% had a significantly lower association of pulmonary complication (p = 0.017), and a VC of less than 30% was independently associated with pulmonary complication (odds ratio, 2.36). CONCLUSION Patients with fractured ribs and VC of less than 30% have significant association for pulmonary complication. Higher VC is associated with lower likelihood of pulmonary complication. VC may help identify those at risk for complications after rib fractures, but a prospective study is necessary to confirm these findings. LEVEL OF EVIDENCE Prognostic/epidemiologic study, level IV.

The need for immediate computed tomography scan after emergency craniotomy for head injury.

BACKGROUND Patients who undergo emergency craniotomy for head injury require vigilant postoperative (postop) care to obtain the best possible outcome. Although repeat head computed tomography (CT) scans are a key component of the management of these patients, there is no consensus on the optimal timing of the initial postop CT. METHODS We conducted a retrospective registry-based review of the care of 199 consecutive trauma patients who underwent craniotomy for head injury at a Level I trauma center to evaluate the role of postop CT in their management. RESULTS One hundred and ninety-nine patients underwent 218 craniotomies for head injury during the 78-month study period. Mean age was 48 years and 73.9% were men. Overall survival was 71.4%. The primary indication for operation included subdural hematoma (SDH) in 136 (62.4%), epidural hematoma (EDH) in 32 (14.7%), intraparenchymal hemorrhage or contusion in 21 (9.6%), depressed skull fracture in 17 (7.8%), and other indications in 12 (5.5%). Postop CTs were obtained after 197 (90.4%) of the operations at a mean of 19.2 hours and revealed a variety of unexpected findings with clinical implications. The only variable statistically associated with unexpected findings was SDH as an indication for operation (p < 0.01). Fourteen (7.0%) patients required a second craniotomy in the 2 days after their initial operation. In six (3.0%) patients, postop CTs were obtained between 4.2 hours and 21.1 hours after initial craniotomy and an earlier postop CT would most likely have prevented a significant delay in operation. Findings in these six patients included recurrent SDH or EDH in two, new SDH or EDH in two, and intraparenchymal hemorrhage in two. Neither neurologic examination nor postop intracranial pressure monitoring reliably predicted the presence of new or recurrent hemorrhage or other significant findings. CONCLUSION Early, if not immediate, postop CT after emergency craniotomy for head trauma appears to be warranted. We found a significant incidence of unexpected findings on postop CT and encountered avoidable delays in treatment of new or recurrent findings.

Natural history of a postpull pneumothorax or effusion: observation is safe.

BACKGROUND Thoracostomy tube (TT) for drainage of hemopneumothorax is the most common intervention in thoracic trauma. Postpull pneumothorax or effusion (PPP/PPE) is common after removal of a TT. The natural history of PPP/PPE after discharge has not been described. This study evaluates the outcomes and management of PPP/PPE after discharge. METHODS Trauma patients with TT placed from July 1, 2008, to June 30, 2013, were identified from an administrative database and trauma registry. PPP/PPE was defined as the presence of air or fluid in the chest on a postpull imaging. The electronic medical record and final radiology interpretation were reviewed to confirm PPP/PPE during index admission and at discharge. Clinical follow-up and imaging were reviewed for the presence of persistent PPP/PPE. Interventions directed toward PPP/PPE and readmissions were recorded for patients with and without a PPP/PPE. Multivariate logistic regression was performed to identify factors for chest-related readmission. RESULTS Seven hundred ten patients surviving to discharge had a TT placed during the study time frame. Of the 151 patients (21.3%) with documented PPP/PPE on discharge, 115 patients had follow-up data available. Outpatient imaging was obtained in 35 patients, with persistent PPP/PPE noted in 16 patients (45.7%). Six patients (4%) with PPP/PPE at discharge required reintervention. Patients without documented PPP/PPE at discharge had a lower readmission rate (0.7% vs. 6.6%, p = 0.02). Multivariate logistic regression noted the presence of persistent PPP/PPE at follow-up (p = 0.001) to be associated with readmission. CONCLUSION PPP/PPE is a common occurrence following removal of a TT. While patients discharged with PPP/PPE have a statistically higher reintervention rate, the absolute value remains low. This should be considered when treating clinically stable, asymptomatic PPP/PPE. LEVEL OF EVIDENCE Epidemiologic study, level IV.

Non Transplant Surgical Considerations: Hepatic Surgery and Liver Trauma

Surgery represents one of the main options for the management of liver related conditions, including benign or malignant tumors, biliary abnormalities, and trauma. Liver resections are major operations and carried a significant mortality risk until recently. Within the last 30 years the results have significantly improved, with a post-operative mortality below 3% in specialized centers around the world. At the same time, surgery for liver trauma has become quite rare and the majority of patients are managed non-operatively. When an operation is necessary, most are treated with peri-hepatic packing and a staged operation. While there are significant differences between these two groups with liver disease, the complexity of their treatment results in their admission to the intensive care unit (ICU). Caring for postoperative liver patients or those with liver trauma requires a thorough understanding of each disease process, and almost every intensivist will encounter several of these patients throughout a career.

Morel-Lavallée Lesions

Purpose of ReviewThe Morel-Lavallée (ML) lesion is a traumatic, closed soft tissue degloving injury. They have an inconsistent presentation, and diagnosis is often delayed. This review describes the pathophysiology of this injury, emphasizes the clinical and radiographic presentation, and highlights current management strategies.Recent FindingsEarly studies reported ML lesions occur solely over the greater trochanter, and while this remains the most common site, ML lesions can occur throughout the body. Early operative debridement should be performed, as aspiration or observation has an unacceptably high failure rate. Sclerodesis is an option in chronic ML lesions. ML wounds can be closed unless active infection is present.SummaryML lesions are more frequently being recognized incidentally on imaging but are still under-diagnosed in trauma patients. The delay in diagnosis and unfamiliarity with treatment options can lead to poor outcomes and unnecessary complications.

Thoracic irrigation prevents retained hemothorax: A prospective propensity scored analysis

BACKGROUND Thoracic trauma resulting in hemothorax (HTx) is typically managed with thoracostomy tube (TT) placement; however, up to 20% of patients develop retained HTx which may necessitate further intervention for definitive management. Although optimal management of retained HTx has been extensively researched, little is known about prevention of this complication. We hypothesized that thoracic irrigation at the time of TT placement would significantly decrease the rate of retained HTx necessitating secondary intervention. METHODS A prospective, comparative study of patients with traumatic HTx who underwent bedside TT placement was conducted. The control group consisted of patients who underwent standard TT placement, whereas the irrigation group underwent standard TT placement with immediate irrigation using 1 L of warmed sterile 0.9% saline. Patients who underwent emergency thoracotomy, those with TTs removed within 24 hours, or those who died within 30 days of discharge were excluded. The primary end point was secondary intervention defined by additional TT placement or operative management for retained HTx. A propensity-matched analysis was performed with scores estimated using a logistic regression model based on age, sex, mechanism of injury, Abbreviated Injury Scale chest score, and TT size. RESULTS In over a 30-month period, a total of 296 patients underwent TT placement for the management of traumatic HTx. Patients were predominantly male (79.6%) at a median age of 40 years and were evenly split between blunt (48.8%) and penetrating (51.2%) mechanisms. Sixty (20%) patients underwent thoracic irrigation at time of initial TT placement. The secondary intervention rate was significantly lower within the study group (5.6% vs. 21.8%; OR, 0.16; p < 0.001). No significant differences in TT duration, ventilator days, or length of stay were noted between the irrigation and control cohort. CONCLUSION Thoracic irrigation at the time of initial TT placement for traumatic HTx significantly reduced the need for secondary intervention for retained HTx. LEVEL OF EVIDENCE Therapeutic Study, Level III.