Search

Background The increased popularity of personal watercraft (PWC) has resulted in an increase in PWC-related injuries. In an effort to better understand the problem, a retrospective review of 37 victims of such injuries seen at a Level I trauma center and fatalities examined by the medical examiner were analyzed. Results Fourteen percent of the victims were passengers, two of whom were struck from behind, resulting in severe injuries. Twelve patients died of their injuries. For six victims, the cause of death was drowning; only one of these victims was wearing a personal flotation device. Two patients sustained transected aortas, 20% had brain injuries, 20% had spinal fractures, and 48% had skeletal and skull fractures. Abdominal organ injuries were present in only 13.5% of the victims, but they were significant, with liver, spleen, and kidney lacerations and aortic and renal artery injuries. Conclusion In this population of victims of PWC crashes meeting preestablished trauma criteria or on-scene deaths, injuries were significant. Many of the drowning deaths may have been prevented with the use of personal flotation devices. The potential for serious intra-abdominal injury must be recognized and dealt with appropriately.

Fungal arteritis of the Y graft used to revascularize the whole pancreas graft developed in 2 recipients of simultaneous pancreas-kidney transplant that were performed within 36 hr of each other. The vascular infection became manifest 6-7 days following transplantation. In both patients, the vasculitis culminated in an arterial rupture that required immediate operative intervention. This compromise of the Y grafts contributed to loss of both pancreatic grafts and necessitated vascular reconstruction to reperfuse the lower extremity. To date, both patients continue to experience normal kidney transplant function.

Venous thromboembolic event after traumatic brain injury represents a unique clinical challenge. Physicians must balance appropriate timing of chemoprophylaxis with risk of increased cerebral hemorrhage. Despite an increase in the literature since the 1990s, there are clear disparities in treatment strategies. This review discusses the prominent studies and subsequent findings regarding the topic with an attempt to establish recommendations using the existing evidence-based literature.

Objective The authors compare open and laparoscopic appendectomy in a randomized fashion with regard to length of operation, complications, hospital stay, and recovery time. Methods Adult patients (older than 14 years of age) with the diagnosis of acute appendicitis were randomized to either open or laparoscopic appendectomy over a 9-month period. All patients received preoperative antibiotics. The operative time was calculated as beginning with the incision and ending when the wound was fully closed. Patients that were converted from laparoscopic to open appendectomy were considered a separate group. Return to normal activity and work were determined by questioning during postoperative clinic, telephone, or mailed questionnaire. Results There was a total of 169 patients randomized, 88 to the open and 81 to the laparoscopic group. The groups were similar demographically. Of the 81 laparoscopic patients, 13 (16%) were converted to open. In the open group, 70 patients (79.5%) had acute appendicitis and 21 (23.9%) had perforative appendicitis. In the laparoscopic group, 62 patients (76.5%) had acute appendicitis and 10 (12.3%) had perforative appendicitis. There was no statistical difference in the return to activity or work between the laparoscopic and open groups. The operative time was significantly longer in the laparoscopic group (102.2 minutes vs. 81.7 minutes, p < 0.01). The hospital stay of 2.2 days in the laparoscopic group and 4.3 days in the open group was statistically different (p = 0.007). There was no difference in the hospital stay for those with acute appendicitis (1.89 days vs. 2.61 days, p = 0.067) compared with those with a normal appendix but with pelvic inflammatory disease (1.1 days vs. 2.3 days, p = 0.11). There was a significant difference in patients with perforative appendicitis (1.5 days vs. 9.5 days, p < 0.01). The hospital cost for patients having laparoscopic appendectomy was $6077 and for an open appendectomy $7227 (p = 0.164). There were no increased complications associated with the laparoscopic technique. Conclusion Laparoscopic appendectomy is comparable to open appendectomy with regard to complications, hospital stay, cost, return to activity, and return to work. There was a greater operative time involved with the laparoscopic technique. Laparoscopic appendectomy does not offer any significant benefit over the open approach for the routine patient with appendicitis.

Objective: To evaluate the morbidity and hospital stay resultant from negative exploratory laparotomy (NL) for abdominal gunshot wounds (ABGSWs) and the potential impact the use of diagnostic laparoscopy (DL) could have on these variables. Design: A retrospective study was conducted. Materials and Methods: The charts of all patients with ABGSWs over a 4-year period were reviewed. Data was collected on injuries, rate of NL, morbidity and hospital stay. This was compared to a subsequent group of patients with ABGSWs managed with a DL protocol. Measurements and Main Results: Over a 4-year period, 817 patients had exploratory laparotomy (EL) for ABGSWs. The NL rate was 12.4% (101 of 817); 69 of these patients had no associated injury or other procedures. They had a 22% morbidity and an average hospital stay of 5.1 days. Subsequently, 85 patients with ABGSWs underwent DL. This group was similar to the EL group and would have undergone EL prior to the introduction of DL at our institution. In this group, 34 patients had no associated injury or other procedures. They had a 3% morbidity, and their average hospital stay was 1.4 days. The morbidity and hospital stay were statistically significantly reduced (p

Objective: Prior to the devastating earthquake in Haiti, January 12, 2010, a group of Haitian physicians, leaders and members of Project Medishare for Haiti, a Nongovernmental Organization, had developed plans for a Trauma Critical Care Network for Haiti.Design: One year after the earthquake stands a 50-bed trauma critical care and rehab hospital that employs more than 165 Haitian doctors, nurses and allied healthcare professionals, and administrative and support staff in Port-Au-Prince. Hospital Bernard Mevs Project Medishare (HBMPM) has been operating with the following two primary goals: 1) to provide critical- care- and trauma-related medical and rehabilitation services and 2) to provide clinical education and training to Haitian healthcare professionals.1Results: These goals have been successfully accomplished, with more than 43,000 outpatients seen, 6,500 emergency room visits, and about 2,300 surgical procedures performed. Daily patient care has been managed by Haitian medical staff as well as more than 2,400 international volunteers including physicians, nurses, and allied healthcare professionals.With the continued assistance of weekly volunteers, many programs and services have been developed; however, many challenges remain.Conclusions: This article highlights the development and progress of HBMPM over the last year with emphasis on developing inpatient and outpatient services, which include surgical, clinical laboratory, wound care, radiology, rehabilitation, and prosthesis/orthotics programs. Some of the challenges faced and how they were managed will be discussed as well as future plans to conduct more training and education to increase the building of medical capacity for Haiti.

Background Recently, three patients with hemopericardium after severe chest trauma were successfully managed nonoperatively at our institution. This prompted the question whether these were rare or common events. Therefore, we reviewed our experience with similar injuries to test the hypothesis that trauma-induced hemopericardium mandates sternotomy. Method Records were retrospectively reviewed for all patients at a Level I trauma center (December 1996 to November 2011) who sustained chest trauma with pericardial window (PCW, n = 377) and/or median sternotomy (n = 110). Results Fifty-five (15%) patients with positive PCW proceeded to sternotomy. Penetrating injury was the dominant mechanism (n = 49, 89%). Nineteen (35%) were hypotensive on arrival or during initial resuscitation. Most received surgeon-performed focused cardiac ultrasound examinations (n = 43, 78%) with positive results (n = 25, 58%). Ventricular injuries were most common, with equivalent numbers occurring on the right (n = 16, 29%) and left (n = 15, 27%). Six (11%) with positive PCW had isolated pericardial lacerations, but 21 (38%) had no repairable cardiac or great vessel injury. Those with therapeutic versus nontherapeutic sternotomies were similar with respect to age, mechanisms of injury, injury severity scores, presenting laboratory values, resuscitation fluids, and vital signs. Multiple logistic regression revealed that penetrating trauma (odds ratio: 13.3) and hemodynamic instability (odds ratio: 7.8) were independent predictors of therapeutic sternotomy. Conclusion Hemopericardium per se may be overly sensitive for diagnosing cardiac or great vessel injuries after chest trauma. Some stable blunt or penetrating trauma patients without continuing intrapericardial bleeding had nontherapeutic sternotomies, suggesting that this intervention could be avoided in selected cases. Level of evidence Therapeutic study, level III.

Extremity vascular trauma is common in most urban trauma centers and controversy remains about the optimal management of arterial injuries. We examined the records of 188 patients who had lower extremity arterial trauma from September 1987 to April 1992 to help clarify these issues. There were 142 (75.5%) gunshot wounds, 18 (9.6%) stab wounds, 5 (2.7%) shotgun wounds, and 23 (12.2%) patients with blunt trauma. There were 43 (22.9%) associated venous injuries. There were 10 repair failures in the acute postoperative period. There were no repair failures for the iliac artery. Three failures involved the superficial femoral artery (SFA), six were popliteal, and one tibial. Vein and polytetrafluoroethylene (PTFE) grafts were used to repair the SFA with equal success. Repair of the popliteal artery with PTFE failed in four of five cases, while vein grafts failed in only 2 of 19 cases (p < 0.01). Graft failure was associated with blunt trauma in 8 of 23 patients (35%), and always resulted in amputation. Penetrating injuries accounted for only 2 of 165 (1.2%) failures and were successfully redone with no amputations. Venous injury was present in all SFA failures. Popliteal vein injury was present in two PTFE and two vein grafts that failed. There were no infections of vein or PTFE grafts. In conclusion, PTFE and vein have equal graft patency for the repair of the iliac and femoral arteries. However, the patency of PTFE was significantly worse in the popliteal location. Vein grafts should be used for repair of this vessel. Graft failure and amputation were more common with popliteal and tibial injuries from blunt mechanisms.(ABSTRACT TRUNCATED AT 250 WORDS)

We present a series in which videothoracoscopy was used to evaluate and manage patients after thoracic trauma. We used this technique in 11 patients with thoracic injuries. We describe 5 representative cases. It was used successfully in 10 of 11 patients. Indications included evaluation of ongoing hemothorax, evacuation of clotted hemothorax and empyema, and decortication for persistent airleak. Etiologies included blunt trauma, stab wounds, and gunshot wounds.

The Miller School of Medicine of the University of Miami and Project Medishare, an affiliated not-for-profit organization, provided a large-scale relief effort in Haiti after the earthquake of 12 January 2010. Their experience demonstrates that academic medical centers in proximity to natural disasters can help deliver effective medical care through a coordinated process involving mobilization of their own resources, establishment of focused management teams at home and on the ground with formal organizational oversight, and partnership with governmental and nongovernmental relief agencies. Proximity to the disaster area allows for prompt arrival of medical personnel and equipment. The recruitment and organized deployment of large numbers of local and national volunteers are indispensable parts of this effort. Multidisciplinary teams on short rotations can form the core of the medical response.

Decisions regarding choice of thromboprophylaxis in patients undergoing major orthopedic surgery are based on assessment of individual patient risk for thrombosis versus risk for bleeding. An international survey sought physician views on definitions and relative importance of different types of major bleeding. A random sample of physicians from five countries (100 physicians per country, mainly surgeons) completed an internet-based 13-question survey on perceptions, concerns, and relevance of bleeding associated with thromboprophylaxis in major orthopedic surgery. Over 80% of responders were concerned or very concerned about bleeding with >70% considering surgical-site bleeding as the most concerning, and relevant type and site for bleeding. Nearly 80% of responders considered surgical-site bleeding to increase patient length of hospital stay, and >70% noted that it complicates patient rehabilitation. After fatal bleeding, bleeding leading to re-operation was ranked as the most concerning type of major bleed. Less than half of responders reported closely reading the major-bleeding definitions in clinical study publications. Most responders favored anticoagulants that could offer a reduced bleeding risk and similar venous thromboembolism (VTE) prevention compared to current anticoagulants rather than a decrease in VTE and similar bleeding risk. There is a disconnect between the definitions of major bleeding that surgeons would apply to describe bleeding associated with VTE thromboprophylaxis, and those used in clinical studies reporting the safety profiles of newer anticoagulant agents. Misperceptions about the benefit-to-harm profiles of thromboprophylactic therapies may incorrectly inform treatment choices in patients at high risk for post-operative VTE.

Background We recently reported that a new dressing, the Modified Rapid Deployment Hemostat (MRDH) controlled bleeding in hypothermic coagulopathic swine after traumatic liver avulsion. The purpose of this study was to evaluate the MRDH in coagulopathic trauma patients undergoing abbreviated laparotomy. Methods A prospective, observational clinical trial of the MRDH dressing was performed at our Level One Trauma Center in patients with high-grade visceral injuries with coagulopathy who failed conventional therapy and required packing. Attending surgeons graded the injury and the adequacy of hemostasis following application of the dressing. Patients were followed until discharge or death. Results Ten patients were enrolled: nine severe hepatic injuries, and one major abdominal vascular injury. All patients were hypothermic, acidotic, and clinically coagulopathic. Intraoperative hemostasis was immediately obtained after MRDH placement in all cases except one. There was one death. Conclusion The Modified Rapid Deployment Hemostat terminates bleeding from severe visceral injuries in coagulopathic patients undergoing abbreviated laparotomy.

Bacterial resistance to antibiotics has become a serious problem in medicine. Particularly worrisome is the increasing incidence of multi-resistant organisms such as methicillin-resistant Staphylococcus aureus (MRSA) and vancomycin-resistant enterococci (VRE). Not surprisingly, in view of the high incidence of life-threatening infections and heavy antibiotic use, resistance has become very frequent and problematic in intensive care units. The standard approach for the treatment of MRSA is vancomycin or teicoplanin. Long-term therapeutic and unrestricted prophylactic use of vancomycin has given rise to VRE which in turn may lead to the emergence of vancomycin-resistant S. aureus (VRSA) through plasmid mediated transmission. In order to reduce the incidence of VRE and to avoid the emergence of VRSA, vancomycin use should be restricted and alternative antibiotic strategies should be developed. Using those antibiotics to which MRSA are still generally sensitive, perhaps in combination with new ones, such as, quinupristin/dalfopristin, should be entertained. We performed a retrospective review of the Gram-positive infections in our Level 1 Trauma Center Intensive Care Unit, and an analysis of the resistance patterns of the NMSA infections showed that additional resistance rarely develops within less than 5 days. We then designed a new strategy for the treatment of MRSA infections. This strategy consists of the sequential use of a range of antibiotics with activity against MRSA in short 5-7 day pulses until the full clinical course is completed. Studies validating the benefit of this approach are currently in preparation.

Lingual infarction, although a very rare entity has been reported in 16 cases since 1961. The goal of this article is to alert the physician to the symptoms of tongue claudication to prevent the morbid effects of tongue infarction and blindness due to cranial arteritis. A discussion of the disease and the differential diagnosis is included.

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 X 2 . 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.

Objective: To determine whether computed tomography (CT) is an accurate diagnostic modality for the triage of hemodynamically stable patients with gunshot wounds of the abdomen and flank. Methods: A chart review of 83 trauma patients for whom abdominal CT was used as initial screening. Results: In 53 patients, CT revealed no evidence of peritoneal penetration, and in 15 patients, there was evidence of either peritoneal penetration or liver injury. There were no false results in these patients. Among 15 patients with questionable peritoneal penetration, cavitary endoscopy was performed in 11 and exploratory laparotomy was performed in 3, and 1 patient was initially observed and subsequently underwent exploratory surgery for a missed colonic injury. Conclusion: In selected centers and in hemodynamically stable patients with abdominal and flank gunshot wounds, abdominal CT can be an effective and safe initial screening modality to document the presence or absence of peritoneal penetration and to manage nonoperatively stable patients with liver injuries. If there is any question of peritoneal penetration, cavitary endoscopy should be part of the protocol of nonoperative management.

Prolonged use of fibrinolytic agents post thrombectomy is limited by present techniques that require arterial puncture and indwelling arterial catheters. This limitation can be avoided by attaching a short segment of saphenous vein to the arteriotomy used for the thrombectomy and bringing this out to the skin as a “venostomy”; thus providing ready access to the vascular tree for arteriography, prolonged infusion of thrombolytic agents, or selective catheter placement. In delayed thrombectomies (Categories 2 & 3 as described by the Ad Hoc Committee on Reporting Standards, J Vasc Surg 1986;4:80-94), extending the use of these agents may represent the only hope for limb salvage. (Ann Vasc Surg 1997;11:546–549.)

Objective: To compare intraoperative findings and/or angiography with color-flow duplex scan. Design: This prospective double-blind study was performed on all stable patients with zone 1, 2, or 3 penetrating neck trauma. Results of angiographic or intraoperative findings were compared with the results of duplex ultrasonographic scans. Main Outcome Measures: Fifty-five patients were studied over a 2-year period in which the distribution of injuries included 23 stab wounds (42%), 30 gunshot wounds (54%), and 2 motor vehicular lacerations (4%). There were 42 patients (76%) with normal ultrasonographic results and 13 patients (24%) with abnormal ultrasonographic results. The true-negative rate was 100%; however, there were 2 false positives resulting in 100% sensitivity and 85% specificity. Conclusions: Duplex ultrasonography provides an excellent diagnostic modality with cost-saving, patient-friendly characteristics and a low rate of morbidity. It should be instituted as the primary diagnostic procedure of choice for penetrating neck trauma. Arch Surg. 1996;131:691-693

Several recent publications have suggested that emergency surgery in patients with acquired immunodeficiency syndrome (AIDS) is associated with extremely high morbidity and mortality.We reviewed the records of 21 patients with AIDS at the University of Miami/Jackson Memorial Medical Center in Miami, Florida, who underwent 24 emergency operations after sustaining penetrating traumaNineteen patients (90%) presented with gunshot wounds and 2 (10%) presented with stab wounds. Two patients underwent multiple surgical procedures to control hemorrhage from a complex liver injury and to drain a retained hemothorax, respectively. After surgery, patients were managed according to standard protocols, the same as those for non-AIDS patients. Wound infection was present in 4 patients (19%), and occurred only in patients with100 CD4+ cells/microL. Fifty-seven percent of patients had no prior knowledge of having AIDS or being seropositive for the human immunodeficiency virus. One patient died after surgery and 18 patients (86%) were still alive 6 months after discharge.As the AIDS epidemic grows, general surgeons will be treating an increasing number of these patients. A low morbidity and mortality can be obtained with standard surgical care and techniques. Complications are not uncommon and should be treated as in any other surgical patient, unless it is a terminal condition or that posture runs against the patient's stated views or advance directives.

Objective : The purpose of this study was to evaluate the sensitivity, specificity, and predictive value of diagnostic laparoscopy (DL) in a large group of stable patients with abdominal gunshot wounds (ABGSWs). Design : This study was a prospective case series developed by management protocol. Materials and Methods : In a 2 1/2-year period, DL was performed in 121 consecutive patients who were hemodynamically stable with ABGSWs and met protocol criteria. This represented 18% of all patients with ABGSWs seen in this period at the Ryder Trauma Center. The evaluation was conducted to determine peritoneal violation, the presence of intra-abdominal blood, and the need for exploration. Measurements and Main Results : There were 42 (35%) positive and 79 (65%) negative DLs. In patients with positive DL, 39 (92.8%) had exploratory laparotomy. In this group, 32 (82%) had therapeutic laparotomy, 6 (15.4%) had nontherapeutic laparotomy, and 1 (2.5%) had a negative laparotomy. In this patient, DL was felt to be inadequate by the attending surgeon, although no penetration or intraperitoneal blood were present, and a negative laparotomy was done. This represents a failure rate of 0.8%. There were 3 (7.2%) positive DLs, in whom laparotomy was not performed. These patients had isolated nonbleeding liver injuries, and nontherapeutic laparotomy was successfully avoided. The negative DL group was divided into 47 patients (60%) with isolated ABGSWs, and 32 patients (40%) with associated injuries, mostly orthopedic and thoracic. There were no false-negative DLs and no delayed laparotomies in these 121 patients. There was no mortality in this study group. The sensitivity for peritoneal penetration was 100%, and the specificity was 98.7%. The positive predictive value was 97.6%, and the negative predictive value was 100%. In deciding on need for laparotomy (i.e., injury requiring repair), DL had a positive predictive value of 82% ; more importantly, the negative predictive value was 100%. Conclusions : In stable patients with ABGSWs and questionable intra-abdominal injury, DL can be safely used. It is highly sensitive and specific. It can effectively reduce the incidence of negative and nontherapeutic laparotomies, and the overall morbidity and hospital stay in this group of patients.

On the evening of January 12, 2010, a few hours after the Haitian earthquake, the leaders of Project Medishare in Miami began contacting Haitian associates, faculty and staff of the Miller School of Medicine at the University of Miami, and owners of small private jets in southern Florida. Project Medishare is a nonprofit nongovernmental organization created in 1995. Given our geographic proximity to Haiti and our 15-year relationship with Haitian physicians through Project Medishare, we were able to offer emergency medical relief and provide medical staff within 20 hours after the earthquake. A five-person team of medical relief workers arrived . . .

Diagnosing appendicitis continues to be a difficult task for clinicians. The use of routine CT scan has been advocated to improve the accuracy of diagnosing appendicitis. When compared with the use of clinical examination alone, CT scan was not significantly different with regard to making the diagnosis of appendicitis in women of childbearing age. The use of computed tomography in making the diagnosis of appendicitis has become the current standard of practice in most emergency rooms. In women of childbearing age, with possible appendicitis, we prospectively compared clinical observation alone (OBS) to appendiceal CT scan with clinical observation (CT). Ninety women (OBS: 48, CT: 42) with questionable appendicitis and an Alvarado Score ranging from two to eight were prospectively randomized. A true positive study/exam resulted in a laparotomy that revealed a lesion requiring operation (confirmed by pathology). A true negative exam/study did not require operation. Hospital stay (OBS = 1.9 ± 1.6 vs CT = 1.3 ± 1.4 days) and charges (OBS = $9,459 ± 7,358 vs CT = $9,443 ± 8,773) were similar. The OBS group had an accuracy of 93 per cent, sensitivity of 100 per cent, and a specificity of 87.5 per cent. The CT group had an accuracy of 93 per cent, sensitivity of 89.5 per cent, and specificity of 95.6 per cent. Although this study is too small to statistically establish equivalence, the data suggest that a CT scan reliably identifies women who need an operation for appendicitis and seems to be as good as clinical examination.