Current status of initial antibiotic therapy and analysis of infections in patients with solitary abdominal trauma:a multicenter trial in Korea

Purpose@#Proper use of antibiotics during emergency abdominal surgery is essential in reducing the incidence of surgical site infection. However, no studies have investigated the type of antibiotics and duration of therapy in individuals with abdominal trauma in Korea. We aimed to investigate the status of initial antibiotic therapy in patients with solitary abdominal trauma. @*Methods@#From January 2015 to December 2015, we retrospectively analyzed the medical records of patients with solitary abdominal trauma from 17 institutions including regional trauma centers in South Korea. Both blunt and penetrating abdominal injuries were included. Time from arrival to initial antibiotic therapy, rate of antibiotic use upon injury mechanism, injured organ, type, and duration of antibiotic use, and postoperative infection were investigated. @*Results@#Data of the 311 patients were collected. The use of antibiotic was initiated in 96.4% of patients with penetrating injury and 79.7% with blunt injury. Initial antibiotics therapy was provided to 78.2% of patients with solid organ injury and 97.5% with hollow viscus injury. The mean day of using antibiotics was 6 days in solid organ injuries, 6.2 days in hollow viscus. Infection within 2 weeks of admission occurred in 36 cases. Infection was related to injury severity (Abbreviated Injury Scale of >3), hollow viscus injury, operation, open abdomen, colon perforation, and RBC transfusion. There was no infection in cases with laparoscopic operation. Duration of antibiotics did not affect the infection rate. @*Conclusion@#Antibiotics are used extensively (84.2%) and for long duration (6.2 days) in patients with abdominal injury in Korea.

Veno-Veno Extracorporeal Membrane Oxygenation in Post-Traumatic Acute Lung Injury

Patients with severe lung injury and hemorrhagic shock, may develop acute respiratory failure syndrome during resuscitation, and may require extracorporeal membrane oxygenation (ECMO) support to ensure adequate oxygenation to sustain life. In this case study, a 69 year-old female was hit by a motor vehicle whilst riding her bicycle. She was in a state of hemorrhagic shock due to polytrauma and was resuscitated with massive fluid transfusion during the initial management. After admission to the intensive care unit, she suffered from hypoxia which required mechanical ventilation using 100% oxygen. However, hypoxia did not improve, so she was placed on venoveno ECMO support after 4 days of intensive care treatment. Although trauma and bleeding are considered as relative contraindications for ECMO support, veno-veno ECMO allows for lung rest, and improvement of pulmonary function.

Veno-Veno Extracorporeal Membrane Oxygenation in Post-Traumatic Acute Lung Injury

Patients with severe lung injury and hemorrhagic shock, may develop acute respiratory failure syndrome during resuscitation, and may require extracorporeal membrane oxygenation (ECMO) support to ensure adequate oxygenation to sustain life. In this case study, a 69 year-old female was hit by a motor vehicle whilst riding her bicycle. She was in a state of hemorrhagic shock due to polytrauma and was resuscitated with massive fluid transfusion during the initial management. After admission to the intensive care unit, she suffered from hypoxia which required mechanical ventilation using 100% oxygen. However, hypoxia did not improve, so she was placed on venoveno ECMO support after 4 days of intensive care treatment. Although trauma and bleeding are considered as relative contraindications for ECMO support, veno-veno ECMO allows for lung rest, and improvement of pulmonary function.

Antibiotic use in patients with abdominal injuries: guideline by the Korean Society of Acute Care Surgery

PURPOSE: A task force appointed by the Korean Society of Acute Care Surgery reviewed previously published guidelines on antibiotic use in patients with abdominal injuries and adapted guidelines for Korea. METHODS: Four guidelines were assessed using the Appraisal of Guidelines for Research and Evaluation II instrument. Five topics were considered: indication for antibiotics, time until first antibiotic use, antibiotic therapy duration, appropriate antibiotics, and antibiotic use in abdominal trauma patients with hemorrhagic shock. RESULTS: Patients requiring surgery need preoperative prophylactic antibiotics. Patients who do not require surgery do not need antibiotics. Antibiotics should be administered as soon as possible after injury. In the absence of hollow viscus injury, no additional antibiotic doses are needed. If hollow viscus injury is repaired within 12 hours, antibiotics should be continued for ≤ 24 hours. If hollow viscus injury is repaired after 12 hours, antibiotics should be limited to 7 days. Antibiotics can be administered for ≥7 days if hollow viscus injury is incompletely repaired or clinical signs persist. Broad-spectrum aerobic and anaerobic coverage antibiotics are preferred as the initial antibiotics. Second-generation cephalosporins are the recommended initial antibiotics. Third-generation cephalosporins are alternative choices. For hemorrhagic shock, the antibiotic dose may be increased twofold or threefold and repeated after transfusion of every 10 units of blood until there is no further blood loss. CONCLUSION: Although this guideline was drafted through adaptation of other guidelines, it may be meaningful in that it provides a consensus on the use of antibiotics in abdominal trauma patients in Korea.

Chronic Traumatic Glass Foreign Body Removal from the Lung through a Direct Parenchymal Incision

Traumatic intrapulmonary glass foreign bodies that are missed on an initial examination can migrate and lead to severe complications. Here, we present a rare case of a traumatic intrapulmonary glass foreign body surgically removed by a direct pulmonary incision, which preserved the pulmonary parenchyma and avoided severe complications caused by migration.

The Benefits and Risks of Performing Incidental Appendectomy

Acute appendicitis is the most common indication for emergency abdominal surgery worldwide. The risks and benefits of incidental appendectomy during other operations have been debated for over a century. There is no right answer to the question of whether or not to perform incidental appendectomy. Although there are only a few indications where it is explicitly recommended such as in gynecological surgery, malrotation, and Ladd's procedure, incidental appendectomy is cost-effective in selected patient groups, especially in the young, without an increase in morbidity and mortality. In this review, the literature on incidental appendectomy was assessed from several perspectives.

Pneumatic Colorectal Injury Caused by High Pressure Compressed Air

The pneumatic colorectal injury caused by high pressure compressed air are rare and can be fatal. Herein, we present a case of 45-year-old male who developed sudden onset of severe abdominal pain after cleaning the dust on his pants with high pressure compressed air gun dust cleaner. Emergent exploratory laparotomy was done which findings are a huge rectal perforation with multiple serosal and subserosal tear in sigmoid to splenic flexure of colon. Anterior resection with left hemicolectomy, and temporary transverse colostomy was performed. Postoperative course was uneventful. Recently, prognosis is generally favorable because of prompt diagnosis and emergent surgical management.

Heterotopic Mesenteric Ossification Following Damage Control Surgery

No abstract available.

Right-sided diaphragmatic rupture in a poly traumatized patient

Traumatic diaphragmatic rupture (TDR) is uncommon, and may be associated with other severe life-threatening injuries after blunt trauma. Recently, we experienced a right-sided TDR patient with other multiple life-threatening injuries. A 59-year-old female inflicted with a right-sided TDR accompanied by herniated liver was treated with thoracoscopic exploration. We successfully managed associated life-threatening injuries such as traumatic brain injury and pelvic bone fractures with bleeding, simultaneously.

Experience of Penetrating Gunshot Wound on Head in Korea

Craniocerebral gunshot injuries (CGIs) are extremely seldom happened in Korea because possession of individual firearm is illegal. So, CGIs are rarely encountered by Korean neurosurgeons or Korean trauma surgeons, though in other developing countries or Unites states of America their cases are indefatigably increasing. Management goal should focus on early aggressive, vigorous resuscitation. The treatments consist of immediate life salvage through correction of coagulopathy, intracranial decompression, prevention of infection and preservation of nervous tissue. There have been few studies involving penetrating CGIs in Korea. Here we present a case of penetrating gunshot wound in Korea. We present a 58-year-old man who was unintentionally shot by his colleague with a shotgun. The patients underwent computed tomography (CT) for assessment of intracranial injury. The bullet passed through the left parietal bone and right lateral ventricle and exited through the posterior auricular right temporal bone. After CT scan, he arrested and the cardiopulmonary resuscitation was conducted immediately. But we were unable to resuscitate him. This case report underscores the importance of the initial clinical exam and CT studies along with adequate resuscitation to make the appropriate management decision. Physicians should be familiar with the various injury patterns and imaging findings which are poor prognostic indicators.

Adaptation of New Oral Anticoagulants for Warfarin Anticoagulated Patient with Traumatic Ongoing Hemorrhage

The traditional drug for anticoagulation in those with a high risk of thrombosis is a vitamin K antagonist, such as warfarin. On the other hand, this drug has several limitations and hemorrhagic complications. Recently, novel or non-vitamin K-dependent antagonist oral anticoagulants (NOACs) have been developed to solve these problems. This paper presents a case of adaptation of NOAC for a warfarin anticoagulated patient with traumatic ongoing hemorrhages with a discussion of the clinical implications of NOAC.

The Ability of the Acute Physiology and Chronic Health Evaluation (APACHE) IV Score to Predict Mortality in a Single Tertiary Hospital / 대한구급학회지

BACKGROUND: The Acute Physiology and Chronic Health Evaluation (APACHE) II model has been widely used in Korea. However, there have been few studies on the APACHE IV model in Korean intensive care units (ICUs). The aim of this study was to compare the ability of APACHE IV and APACHE II in predicting hospital mortality, and to investigate the ability of APACHE IV as a critical care triage criterion. METHODS: The study was designed as a prospective cohort study. Measurements of discrimination and calibration were performed using the area under the receiver operating characteristic curve (AUROC) and the Hosmer-Lemeshow goodness-of-fit test respectively. We also calculated the standardized mortality ratio (SMR). RESULTS: The APACHE IV score, the Charlson Comorbidity index (CCI) score, acute respiratory distress syndrome, and unplanned ICU admissions were independently associated with hospital mortality. The calibration, discrimination, and SMR of APACHE IV were good (H = 7.67, P = 0.465; C = 3.42, P = 0.905; AUROC = 0.759; SMR = 1.00). However, the explanatory power of an APACHE IV score >93 alone on hospital mortality was low at 44.1%. The explanatory power was increased to 53.8% when the hospital mortality was predicted using a model that considers APACHE IV >93 scores, medical admission, and risk factors for CCI >3 coincidentally. However, the discriminative ability of the prediction model was unsatisfactory (C index <0.70). CONCLUSIONS: The APACHE IV presented good discrimination, calibration, and SMR for hospital mortality.

Colorectal Perforation After Anorectal Manometry for Low Anterior Resection Syndrome

We experienced 3 cases of manometry-induced colon perforation. A 75-year-old man (case 1) underwent anorectal manometry (ARM) 3 years after radiotherapy for prostate cancer and a laparoscopic intersphincteric resection for rectal cancer. A 70-year-old man (case 2) underwent ARM 3 months after conventional neoadjuvant chemoradiotherapy and a laparoscopic low anterior resection for rectal cancer. A 78-year-old man (case 3) underwent ARM 2 months after a laparoscopic intersphincteric resection for rectal cancer. In all cases, a colon perforation with fecal peritonitis occurred. All were treated successfully using prompt and active operations and were discharged without any complications. ARM with a balloon, as a measure of rectal compliance, should be performed 2 months or longer after surgery. If a perforation occurs, prompt and active surgical intervention is necessary due to the high possibility of extensive fecal peritonitis.

The Ability of the Acute Physiology and Chronic Health Evaluation (APACHE) IV Score to Predict Mortality in a Single Tertiary Hospital / 대한중환자의학회지

BACKGROUND: The Acute Physiology and Chronic Health Evaluation (APACHE) II model has been widely used in Korea. However, there have been few studies on the APACHE IV model in Korean intensive care units (ICUs). The aim of this study was to compare the ability of APACHE IV and APACHE II in predicting hospital mortality, and to investigate the ability of APACHE IV as a critical care triage criterion. METHODS: The study was designed as a prospective cohort study. Measurements of discrimination and calibration were performed using the area under the receiver operating characteristic curve (AUROC) and the Hosmer-Lemeshow goodness-of-fit test respectively. We also calculated the standardized mortality ratio (SMR). RESULTS: The APACHE IV score, the Charlson Comorbidity index (CCI) score, acute respiratory distress syndrome, and unplanned ICU admissions were independently associated with hospital mortality. The calibration, discrimination, and SMR of APACHE IV were good (H = 7.67, P = 0.465; C = 3.42, P = 0.905; AUROC = 0.759; SMR = 1.00). However, the explanatory power of an APACHE IV score >93 alone on hospital mortality was low at 44.1%. The explanatory power was increased to 53.8% when the hospital mortality was predicted using a model that considers APACHE IV >93 scores, medical admission, and risk factors for CCI >3 coincidentally. However, the discriminative ability of the prediction model was unsatisfactory (C index <0.70). CONCLUSIONS: The APACHE IV presented good discrimination, calibration, and SMR for hospital mortality.

Appendiceal transection associated with seat belt restraint

The seat belt is designed for safety in a motor vehicle and should be worn to prevent severe injuries. But, the seat belt itself can be an injury factor in combination with deceleration forces applied to fixation points of mobile viscera. Here, we present a 23-year-man with traumatic transection of the appendix, highly mobile viscera, following seat belt injury.

Endovascular stent graft for traumatic splenic vein aneurysm via percutaneous transsplenic access

Traumatic splenic vein aneurysm (SVA) is an extremely rare entity. Traditionally, treatment varied from noninvasive followup to aneurysm excision with splenectomy. However, there has been no prior report of traumatic SVA treated with endovascular stent graft for SVA via percutaneous transsplenic access. Therefore, we report the case of a 56-year-old man successfully treated with endovascular stent graft for traumatic SVA via percutaneous transsplenic access.

Endovascular stent graft for traumatic splenic vein aneurysm via percutaneous transsplenic access

Traumatic splenic vein aneurysm (SVA) is an extremely rare entity. Traditionally, treatment varied from noninvasive followup to aneurysm excision with splenectomy. However, there has been no prior report of traumatic SVA treated with endovascular stent graft for SVA via percutaneous transsplenic access. Therefore, we report the case of a 56-year-old man successfully treated with endovascular stent graft for traumatic SVA via percutaneous transsplenic access.

Blunt Splenic Injury by Gunshot / 대한구급학회지

Trauma is frequently not purely penetrating or purely blunt. Such mixed trauma can result from the mechanism of injury. Recently, we encountered a patient who accidentally shot himself with a shotgun. He had a 15 x 8-cm-sized penetrating injury on left flank that did not penetrate into the peritoneal cavity and a blunt splenic injury with hemoperitoneum. Surgical and interventional treatments were performed for each injury. We present this case with a review of the related literature.

A Case of Neobladder Rupture Following Blunt Trauma

Bladder rupture following blunt trauma is rare, and no neobladder rupture following blunt trauma has yet been reported. We present a case of neobladder rupture following blunt trauma. The patient was a 65-year-old male patient who had been treated for bladder cancer via a radical cystectomy with an orthotopic ileal neobladder four years prior to this admission, and who was admitted to our emergency department due to multiple trauma after a 1.5 m fall. Primary repair was performed for the neobladder rupture.

Pancreaticopleural Fistula with Hemothorax

Pancreaticopleural fistula is an uncommon complication of chronic pancreatitis. We report a case of pancreaticopleural fistula that was presented with right-sided hemothorax. A 49-year-old male with a history of chronic alcoholism was presented with a month of dyspnea. A chest radiography showed a right-sided massive pleural effusion with old-blood-colored fluids and amylase levels of 1,020 IU/L. On the chest computerized tomography (CT), there was pleural effusion and a well-defined tract from the posterior mediastinum to the pseudocyst in the tail of the pancreas. Even with conservative treatment with closed thoracostomy, octreotide and gabexate mesilate, he developed hemothorax. Abdominal CT revealed an increase of the hemorrhagic pancreatic pseudocyst. Distal pancreatectomy with splenectomy and external drainage of the pancreaticopleural fistula on the posterior mediasternum were performed. The patient had an uneventful course and was discharged on the 27th postoperative day. Management of pancreaticopleural fistula is multimodal included medication, endoscopic stenting and surgery. Surgery in pancreaticopleural fistula might be beneficial in selective cases.