Background: Heitzer and Duret described the surgical creation of colostomy in the 1700s, more than a century before the introduction of anesthesia. With the ever increasing degree of frailty in ...patients of advanced age who require surgical intervention, a simplified methodology for the creation of a colostomy based on their original reports is described and the advantages for use in high risk patients and the critical care setting is discussed. Methods: Eleven patients underwent simplified colostomy under local anesthesia, without complication. Results: All colostomies functioned normally within hours. There were no bleeding or infectious complications, nor peri-operative adverse events. Conclusions: Colostomy formation can be safely performed under local anesthesia when the patient is considered too high risk to undergo general anesthesia.
Adrenal gland injury due to gunshot Angara, Vivek; Digiacomo, Jody C.
Chinese journal of traumatology,
06/2020, Letnik:
23, Številka:
3
Journal Article
Recenzirano
Odprti dostop
Adrenal gland trauma is a rare phenomenon, due to the small size and retroperitoneal location of the organ. The majority of adrenal gland trauma is due to blunt force injury and is only rarely ...encountered due to the penetrating mechanisms. A 20-year-old male sustained a gunshot wound to the left abdomen. Upon exploration, he was found to have a through and through injury to the left adrenal gland, among other injuries. Injury to the adrenal gland due to penetrating trauma is exceptionally rare. The principles of management are to control bleeding from the gland with debridement and hemostasis rather than attempt to resect the entire organ. The management of a penetrating injury to the adrenal gland is straightforward and should not be a contributor to a patient's morbidity or mortality.
Contralateral pneumothorax after percutaneous central venous catheter placement has not been previously reported. Three patients who required intubation and mechanical ventilation for acute ...respiratory failure due to COVID-19 were identified with a new pneumothorax on routine post-placement chest roentgenogram on the side opposite the catheter placement. Retrospective review of charts, radiographs, and laboratory studies. No causative relationship was identified between the percutaneous placement of the central venous catheters and the subsequent pneumothoraces identified on the contralateral side, other than the presence of active COVID-19 viral pneumonia. The timing of the contralateral pneumothoraces were coincidental the placement of the central venous catheters. We believe these pneumothoraces were a consequence of the pulmonary pathology of the COVID-19 virus.
The use of intravenous (IV) acetaminophen (APAP) postoperatively in older adults may be a beneficial strategy. We implemented a multimodal pain management approach in our hospital in 2015, with IV ...APAP being the first-line therapy.
This was a retrospective, single-center, observational cohort study of polytrauma, orthopedic surgical patients aged ≥50 y. Patients admitted in 2017, postimplementation of pain protocol, were categorized as the exposed patients. Patients in the year 2014 served as the historical cohort. The two primary outcomes evaluated were postoperative opioid consumption in morphine milligram equivalents (MMEs) and patient pain scores.
In total, 121 eligible patients were identified for this study; 22 historical control patients and 99 exposed patients. We observed a significant reduction in postoperative opioid use up to 48 h postoperatively (20.9 ± 27 versus 4.3 ± 12.4 MME P < 0.05 at 24 h and 19.8 ± 31.2 versus 2.1 ± 11.3 MME P < 0.05 at 48 h, respectively). The mean opioid consumption remained significantly lower in patient subgroup of age ≥74 y with no difference in the mean pain scores (1.5 ± 1.5 versus 1.9 ± 1.6 P = 0.48 at 24 h and 1.5 ± 1.8 versus 2.0 ± 1.5 P = 0.21 at 48 h postoperatively in the historical versus exposed cohort, respectively). Exposed patients had a shorter hospital length of stay than control patients (5.0 3, 7 versus 6.5 5, 9.5 d; P = 0.01).
The use of multimodal pain management with IV APAP as first-line therapy was associated with reduced opioid use in the perioperative setting for older adults with polytrauma.
•Multimodal pain management strategy is preferred for perioperative pain.•Using intravenous acetaminophen is an effective strategy in older adults.•Intravenous acetaminophen can reduce opioid consumption.•Intravenous acetaminophen may be effective in reducing adverse events associated with opioid use.
OBJECTIVE:To assess the impact of preassigning a single bed in the surgical intensive care unit (SICU) for the next trauma admission.
BACKGROUND:Prolonged emergency department (ED) dwell time before ...admission to a critical care unit has an adverse effect on patient outcomes and is often due to the lack of an available bed in the intensive care unit (ICU).
METHODS:A “Bed Ahead” policy was instituted at an urban level 1 Trauma Public Safety Net Teaching Hospital to preassign 1 SICU bed for the next trauma patient who warrants a critical care admission. A retrospective review of all trauma patients admitted to the SICU before and after implementation of this policy was performed to assess the impact on ED dwell time, ICU and hospital lengths of stay, complications, and in-hospital mortality.
RESULTS:ED length of stay (ED-LOS); ICU length of stay (ICU-LOS); hospital length of stay (HLOS); complications; and in-hospital mortality were compared before (PRE) and after (POST)implementation of the Bed Ahead policy. Statistically significant improvements were seen in the POST period for ED-LOS, HLOS, complications, and in-hospital mortality.
CONCLUSIONS:Preassigning 1 ICU for the yet to arrive next injured patient decreases ED dwell times, complications, HLOS, and in-hospital mortality.
In the past, injuries to the adrenal glands due to blunt trauma were considered rare, and were reported to be associated with high Injury Severity Scores (ISSs) and high mortality. Recent reports ...have reported a much high incidence associated with lower ISS and lower mortality. The purpose of this study was to assess the incidence of adrenal gland injuries due to blunt trauma in a large state trauma registry and determine whether these injuries are associated with a higher ISS and increased risk for mortality. A retrospective review was performed on the New York State Trauma Registry comparing blunt injured adults with adrenal injuries to those who did not. Concurrent organ injuries, ISS, and inhospital mortality were compared. Three hundred thirty-nine patients with adrenal gland injuries were identified. Concurrent liver and kidney injuries were more prevalent in the adrenal injured group, and concurrent injuries to the small and large intestine and spleen were more prevalent in the nonadrenal injured group. There was no difference in ISS or mortality between the adrenal injured and nonadrenal injured populations. The results of this study are consistent with recent smaller studies which identified incidence rates which were higher than previously reported and that ISS and mortality risk were unchanged by the presence of blunt adrenal gland injuries. Adrenal gland injuries due to blunt trauma are not uncommon, with an incidence rate of 0.61 per cent. Adrenal gland injuries are not associated with higher ISS or an increased risk of mortality.
Increased life expectancy has resulted in more older patients at trauma centers. Traditional assessments of injuries alone may not be sufficient; age, comorbidities, and medications should be ...considered.
446 older trauma patients were analyzed in two groups, 45–65 years and <65, using Injury Severity Score (ISS), the Charlson Comorbidity Index (CCI), and Comorbidity-Polypharmacy Score (CPS).
CCI and CPS were associated with HLOS in patients <65. In patients aged 45–65, only CPS was associated with HLOS. CPS was inversely associated with in-hospital mortality in patients <65, but not patients aged 45–65. CCI score was not associated with in-hospital mortality in either group.
Increased CCI and CPS were associated with increased HLOS. In patients over 65, increased CPS was associated with decreased mortality. This could be due to return toward physiologic normalcy in treated patients not seen in their peers with undiagnosed or untreated comorbidities.
The newest CT scanners provide resolution comparable to MRIs leading many to question when and whether cervical spine MRIs are warranted.
An 8 year retrospective review identified 241 patients who ...underwent CT scan and MRI of the cervical spine. The initial clinical examination, cervical spine CT scan, and cervical spine MRI were compared to identify cervical spine injuries that would have been missed had the MRI not been performed.
The CT scans were normal in 153 patients, and abnormal in 88. Of the 88 abnormal CT scans, the MRIs were abnormal in 65, and normal in the other 23. The indications for MRI in patients with normal CT scans were neck pain, an abnormal neurologic examination, and/or altered mental status. Of the 13 patients with abnormal MRIs, none were pain free with a normal clinical examination.
In the absence of focal signs of neurologic injury, the cervical spine can be cleared without a clinical exam or MRI if the cervical CT scan does not demonstrate injury or abnormality.
•Current generation high resolution multidetector CT scanner images rival MRIs.•Cervical MRIs can identify ligamentous injury when a confrontational exam cannot be obtained.•A retrospective review of 241 patients who received cervical CT and MRI for trauma was performed.•In the absence of focal signs of neurologic injury, MRI is not needed if the cervical CT is normal.
Background
Hip fractures in patients 65 years and older are associated with significant morbidity and mortality. With the steady increase in the elderly population, we implemented an evidence-based ...clinical practice guideline for the management of hip fractures to optimize patient care and surgical outcomes.
Aims
To evaluate the effects of a multidisciplinary hip fracture care pathway on patient outcomes in the care of elderly patients.
Methods
A retrospective analysis of the differences in outcomes prior to (January–October 2014) and after (November 2014–April 2016) implementation of a hip fracture care pathway at a regional Level I trauma center was performed.
Results
There were 80 patients in the pre-pathway group and 191 patients in the post-pathway group with an average age of 83.18 ± 8.24 years. The analysis demonstrated that the post-pathway group had a lower incidence of in-hospital complications (9.95 vs 30.00%;
p
≤ 0.001), shorter emergency room length of stay (3.76 ± 2.43 vs 6.78 ± 2.88 h;
p
≤ 0.0001), and shorter overall hospital length of stay (5.03 ± 3.46 vs 7.44 ± 6.66 days;
p
= 0.0028). The in-hospital mortality rate was similar between groups (4.71 vs 6.25%;
p
= 0.6018).
Discussion
The development of a multidisciplinary approach to the care of elderly patients with hip fractures improved morbidity and showed a downward trend in mortality.
Conclusions
Elderly patients with hip fractures treated at our trauma center had improved clinical outcomes after the implementation of a multidisciplinary care pathway.
There are many infectious and inflammatory causes for elevated core-body temperatures, though they rarely pass 40 ℃ (104 ℉). The term “quad fever” is used for extreme hyperpyrexia in the setting of ...acute cervical spinal cord injuries (SCIs). The traditional methods of treating hyperpyrexia are often ineffective and reported morbidity and mortality rates approach 100%. This study aims to identify the incidence of elevated temperatures in SCIs at our institution and assess the effectiveness of using a non-invasive dry water temperature management system as a treatment modality with mortality.
A retrospective analysis of acute SCI patients requiring surgical intensive care unit admission who experienced fevers ≥ 40 ℃ (104 ℉) were compared to patients with maximum temperatures < 40 ℃. Patients ≥18 years old who sustained an acute traumatic SCI were included in this study. Patients who expired in the emergency department; had a SCI without radiologic abnormality; had neuropraxia; were admitted to any location other than the surgical intensive care unit; or had positive blood cultures were excluded. SAS 9.4 was used to conduct statistical analysis.
Over the 9-year study period, 35 patients were admitted to the surgical intensive care unit with a verified SCI. Seven patients experienced maximum temperatures of ≥ 40 ℃. Six of those patients were treated with the dry water temperature management system with an overall mortality of 57.1% in this subgroup. The mortality rate for the 28 patients who experienced a maximum temperature of ≤ 40 ℃ was 21.4% (p = 0.16).
The diagnosis of quad fever should be considered in patients with cervical SCI in the presence of hyperthermia. In this study, there was no significant difference in mortality between quad fever patients treated with a dry water temperature management system versus SCI patients without quad fever. The early use of a dry water temperature management system appears to decrease the mortality rate of quad fever.
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