Venous Thromboembolic Events in Adult Trauma Patients Receiving Balanced Hemostatic Resuscitation (BHR): An Analysis of Their Incidence, Predictors, and Associated Mortality Rates at a Level 1 Trauma Center.

Background and objective Studies assessing the incidence of venous thromboembolic (VTE) events in the setting of massive balanced transfusions and/or tranexamic acid (TXA) infusion have yielded varied outcomes. In light of this, we conducted this study to examine the incidence of VTEs in trauma patients requiring blood products, and to identify the risk factors for VTE and mortality in this population. Methods We performed a retrospective analysis of trauma patients admitted to our level 1 trauma center from January 2013 to September 2023. Clinical characteristics were compared between patients who developed VTE and those who did not. A regression analysis of potential variables associated with the development of VTEs and mortality was performed. Results Among 1305 patients (mean age: 42.4 ± 18.8 years) receiving blood products within the initial 24 hours, 4.3% (56 patients) developed a VTE. Patients with VTE experienced prolonged ICU and hospital stays and ventilation duration (p<0.001). They were also noted to have delayed initiation of VTE prophylaxis (104.2 vs. 50.3 hours, p<.001). Prolonged ventilation >7 days was the sole significant factor associated with VTE in multivariate regression analysis [odds ratio (OR): 6.2, p=0.004]. Early TXA administration (within four hours) showed a higher association with VTE than TXA within 24 hours (OR: 2.1, p=0.07 vs. OR 1.6, p=0.22). Massive transfusion was found to increase VTE risk (OR: 2.65, p<0.001). Severe head and neck (OR: 6.0, p=0.002) and chest (OR: 3.8, p=0.01) injuries were key predictors of mortality, while TXA was not significantly associated with mortality in the multivariate model. Conclusions Our study revealed an elevated risk of VTE in patients requiring massive transfusion protocol (MTP, ≥6 units). Early TXA administration was neither associated with increased VTE risk in MTP patients nor increased mortality risk. Strategies directed at reducing the risk of VTE in massively transfused patients while maintaining the survival benefits of balanced resuscitation and TXA need to be devised.

The Role of Neuropsychology in Traumatic Brain Injury: Comprehensive Literature Review.

Traumatic brain injury (TBI) is a major public health concern, often leading to significant behavioral and cognitive changes with subsequent impairment in daily functioning and personal interactions. The management of TBI involves a multidisciplinary approach. Neuropsychology has emerged as a critical discipline in assessing, diagnosing, treating, and rehabilitating individuals with TBI. Successful management also requires careful consideration of the patient's cognitive status. Therefore, clinicians must have a comprehensive understanding of the overall clinical picture of the patient at the cognitive and physical level. The primary aim of this research is to explore the role of neuropsychology in TBI management and rehabilitation thoroughly while providing an updated review of the literature. Various neuropsychological assessment tools used to evaluate cognitive functioning in individuals with TBI will be discussed in addition to their validity, reliability, and usefulness in identifying cognitive deficits and developing individualized treatment plans. The findings in this article will have significant implications on the clinical practice of neuropsychology in TBI patients, highlighting the importance of neuropsychological assessment in optimizing the management of this population. The need for increased awareness of neuropsychology among health care professionals, especially in the acute hospital setting, is growing along with the increase in diagnosis of TBI and its complications. Adequate understanding of the complex interplay between cognitive, emotional, and behavioral factors in TBI can inform the development of new interventions and treatment strategies, making it equally as important for patients and their families.

The role of trauma services in intentional self-harm at a regional level 1 trauma center.

INTRODUCTION: Suicide claims many lives globally, each year. For every person that dies by suicide, multitudes more attempt it. A national shortage of psychiatrists may prevent many individuals from receiving timely mental health care. For many individuals, the primary entry point into the healthcare system is through the emergency department. The trauma service frequently treats patients with severe self-inflicted injuries and for many this is not the first time. This represents an opportunity for intervention to disrupt the cycle and prevent future death. METHODS: We conducted a retrospective chart review of all patients with self-inflicted injuries, admitted to the trauma surgery service between 2012 and 2021. All patients above 10 years old were included. RESULTS: Four hundred forty-one patients were admitted due to self-injurious behavior in the period under study. The majority of patients (71.9%) had a pre-existing mental health disorder. Fifty six patients suffered fatal injuries; the majority were White (78.6%), males (80.3%), and were inflicted by gunshot (71.4%). Nearly one third of patients with self-inflicted injuries had a history of self-injurious behavior with the average number of attempts being 2.7 (SD: ±3.8). CONCLUSIONS: We need interdisciplinary and innovative solutions for this public health crisis. Perhaps telemedicine can be used to buttress the access to adequate mental health care. More research needs to be done to better identify the barriers individuals encounter in accessing mental health care, both pre- and post-crisis. The goal is that, by identifying the gaps, we can collaboratively bridge them to prevent a preventable death.

Extraocular sebaceous carcinoma of the chest wall: A case report.

INTRODUCTION: Sebaceous carcinoma is a rare malignancy that is most commonly found in the head and neck region, particularly in the periocular region. Extraocular lesions are rarer, however are thought to have a higher association with Muir-Torre Syndrome, a variant of Lynch Syndrome, that affects both sebaceous glands and visceral organs. CASE PRESENTATION: Our patient was a 54 year old male with a past medical history of hypertension, stroke, and vertigo who presented to the emergency department with paresthesias concerning for a transient ischemic attack in the setting of a hypertensive emergency. After admission, the patient reported an abscess on the chest that was present for four months prior. Subsequent physical exam incidentally revealed a fungating mass located on the chest wall. The mass was noted to have central ulceration and necrosis. CLINICAL DISCUSSION: CT scan of the chest with intravenous contrast revealed that the mass did not invade the chest wall, therefore a surgical excision was performed. A final diagnosis of sebaceous carcinoma was made after microscopic examination of the resected mass. Immunohistochemistry revealed loss of expression of mismatch repair genes. The patient was lost to follow-up before any additional work up could be performed. CONCLUSION: Extraocular sebaceous carcinomas should be tested using immunohistochemistry for loss of expression of mismatch repair genes. Patients with loss of expression should be risk stratified using the Mayo Muir-Torre risk score to determine if they should undergo germline genetic testing for Lynch Syndrome. Patients with issues in adherence represent a unique diagnostic challenge in potentially evolving diseases.

Frailty Screening in Geriatric Trauma: A Pilot Feasibility Study.

BACKGROUND: Frailty in older adult trauma patients is associated with increased complications and worsened outcomes. Frailty screening can help guide care. Yet, trauma center assessment of frailty is relatively new, can be challenging to implement, and is not yet standard practice. OBJECTIVES: The purpose of this pilot feasibility study is to assess the impact of implementing frailty screening for older adult trauma patients and to evaluate the effect of frailty screening on palliative care consultation, inhospital complications, hospital length of stay, and discharge disposition. METHODS: We conducted a 3-month (July 2019 to September 2019) prospective observational pilot feasibility study of geriatric trauma patients 65 years and older presenting to a Level I trauma center. The Trauma-Specific Frailty Index score was completed within 24 hr of patient admission. Inferential statistics were used to assess the relationships. RESULTS: Fifty subjects were included. Between frail and nonfrail patient groups, there was no significant correlation between mean Trauma-Specific Frailty Index score and palliative care consultation, χ2(1,N=50) = 2.32, p = .149; inpatient complications, χ2(1,N=50) = 0.000, p = 1.000; hospital length of stay, t(48) = 0.95, p = .345; or discharge disposition (receiver operating characteristic curve, p = .337). There was a significant negative relationship between Trauma-Specific Frailty Index Scores and Injury Severity Scores, t(15) = 2.33, p = .035. CONCLUSION: This pilot study demonstrates that frailty screening can be implemented to help guide older adult trauma care but is not without challenges. Barriers to frailty screening should be addressed to ensure trauma team engagement. Additional research with a larger sample size is warranted to explore the benefits of frailty screening in guiding care.

A case of giant necrotic spermatic cord lipoma found incidentally during recurrent inguinal hernia repair: A case report.

INTRODUCTION AND IMPORTANCE: The literature regarding size descriptions for spermatic cord lipomas is limited. The term "giant" is utilized loosely and seen on case reports for masses as small as 6 cm. Here we present a case of a giant left sided spermatic cord lipoma, found incidentally during a recurrent inguinal hernia repair, that measured 18 × 14 × 10 cm on final pathologic examination. CASE PRESENTATION: A 59 year old male, with a history of morbid obesity and surgical history of prior bilateral inguinal hernia repair, presented with recurrent left sided groin and scrotal bulging with associated discomfort several months after the initial hernia repair. Following imaging performed on preoperative work up, the patient was brought to the operating room for a robotic inguinal hernia repair. CLINICAL DISCUSSION: Preoperative physical examination was limited due to the patient's body habitus which precluded a definitive diagnosis of inguinal hernia based on physical examination. Computed tomography of the abdomen and pelvis was performed with findings consistent with bilateral recurrent inguinal hernias. A bilateral robotic inguinal hernia repair was attempted. The procedure was converted to open via a groin incision when an incidental 18 cm left sided spermatic cord lipoma was discovered. An orchiectomy was ultimately performed as the mass was intimately intertwined with the spermatic cord. CONCLUSION: In our case, the patient had a recurrent inguinal hernia and an incidental finding of an 18 cm spermatic cord lipoma which warranted a left orchiectomy followed by open inguinal hernia repair. We propose standardizing the term "giant" to include spermatic cord lipomas >15 cm.

Use of an Electronic Referral Application to Address Post-Injury Needs of Victims of Firearm Injury in a Hospital-Based Violence Intervention Program.

BACKGROUND: Wraparound referrals are a cornerstone of hospital-based violence intervention programs, which have proven to be an effective public health approach for mitigating violence and recidivism. We hypothesized that replacing a manual referral process with an electronic referral application would increase the number of generated referrals and improve compliance with follow-up visits. STUDY DESIGN: The population for this single center quantitative study was a convenience sample of firearm-injured patients. Data from 74 patients were collected using the electronic health record, the electronic referral application, and the trauma registry before and after the intervention. RESULTS: Post-implementation of the electronic referral application showed an increased number of generated referrals, increased emergency department and inpatient utilization of trauma recovery center services, and an increase in second follow-up visit compliance. CONCLUSION: This study demonstrated an increase in the number of referrals and greater likelihood of completion of post-injury follow-up visits after implementing the electronic referral system.

An in-depth look at ventilator-associated pneumonia in trauma patients and efforts to increase bundle compliance, education and documentation in a surgical trauma critical care unit.

BACKGROUND: Ventilator-associated pneumonia (VAP) is considered the most common hospital acquired infection seen in critical care settings and leading cause of death in Intensive Care Units (ICU). The objective of this study was to assess whether specimen collection impacted diagnosis and if implementation of a VAP bundle would decrease rates at our center. METHODS: This single center study design is a retrospective chart review from 2017 to 2020 utilizing the electronic medical record. A pre-/postintervention comparison was performed following implementation of a unit wide VAP bundle and nursing education. Descriptive statistics and continuous variables were analyzed with independent group t -tests, and categorical variables were analyzed with chi-squared tests. RESULTS: Ventilator-associated pneumonia rates decreased in the postimplementation time (20.8%, n = 74 vs 12.2%, n = 15; P = .03). There were no significant differences in the patient profile of those who acquired VAP (ie, males 79.7% vs 86.7%, blunt injuries 63.5% vs 86.7% and severity scores 24.8 vs 25.1, pre vs postimplementation, respectively, all P-values greater than .05). DISCUSSION/CONCLUSIONS: Reduction in VAP rates were achieved by implementing a standardized, evidence based, prevention protocol. Further research is warranted as studies have noted that patients requiring mechanical ventilation are at greater risk for VAP than other ICU patients due to the nature of their injuries and increased risk of prolonged mechanical ventilation ≥ 21 days.

The Presence of Nucleated Red Blood Cells as an Indicator for Increased Mortality and Morbidity in Burn Patients.

Nucleated red blood cells (NRBCs) have been studied in critically ill and injured patients as a predictor of increased in-hospital mortality and poor clinical outcomes. While prior studies have demonstrated the prognostic power of NRBCs in the critical patient, there has been a paucity of literature available describing their value as a prognostic indicator in the severely burned patient. This retrospective observational study was conducted from 2012 to 2017. Inclusion criteria for this study included all burn patients with total body surface area > 10% who were aged ≥ 15 years. Demographic and clinical data were collected from the electronic medical record system. Data analysis consisted of descriptive and comparative analysis using SPSS. Two hundred and nineteen patients (17.5%) met inclusion criteria with 51 (23.3%) patients positive for NRBCs. The presence of NRBCs had an increased mortality rate with an odds ratio of 6.0 (P = .001; 2.5, 14.5); was more likely to appear in older patients (P < .001); and was associated with increased hospital length of stay (P < .001), injury severity scores (P < .001), and complications. The presence of NRBCs even at the low concentrations reported in our study showed a 6-fold increase in the rate of mortality. With the current improvements in burn care leading to higher survival rates, the need to improve upon the numerous models that have been developed to predict mortality in severe burn patients is clear given the significantly increased risk of death that the presence of NRBCs portends.

Modification of Stryker T5TM and Stryker Flyte® Personal Protection Surgical Helmets to Function as Powered Air-Purifying Respirators.

Since the SARS-CoV-2 (COVID-19) outbreak, health-care workers (HCWs) have had to create personal protective equipment (PPE) due to the worldwide demand and thus ensuing shortage. To address the dearth of available PPE, HCWs have quickly explored options to repurpose in-hospital equipment to provide alternative PPE to caregivers. We report the modification of a Stryker T5TM and Stryker Flyte® personal protection surgical helmets as a powered air-purifying respirator.

A complex genitourinary injury following gunshot in a 12 Year old and systematic review.

We highlight the case of a 12 year old male who presented after sustaining a gunshot injury to the scrotum resulting in testicular, prostatic, and urethral transection in addition to pelvic fracture, extra peritoneal bladder injury, and transmural injury to recto sigmoid and ileum. The patient underwent a left orchiectomy, primary repair of the bladder and urethra, placement of universal plate on superior pubic rami, and segmental rectosigmoid and ileum resection. These findings illustrate the collaborative efforts of trauma surgery and urology to treat complex lower genitourinary (GU) injuries and how the direct prioritization of surgical efforts provides acceptable outcomes.

A Single Center Review of the Dangers of Recreational Fires in the Pediatric Population.

The increasing trend of admissions due to recreational fires prompted a 5-year review. The retrospective chart review of pediatric burn injuries from campfires or bonfires treated at a single medical center's burn unit. The study included children within the ages of 0 to 15 admitted or transferred from January 2012 to December 2016 with first, second, and/or third degree burns by bonfires. These patients accrued burns due to active fires as well as postfire ember contact. Two hundred-eighty nine (289) were pediatric admissions out of which 66 (22.8%) were pediatric admissions associated with recreational fires. The mean annual admission for campfire or bonfire burns was 13 ± .98. The mean age was 4 ± 2.47 years. Gender distribution revealed 21 female and 45 male pediatric patients under the age of 15. From the available data, 8 (12%) of these burns occurred at home in the backyard and 16 (24%) at a public camp or park. Injury mechanisms were more commonly a result of direct contact with hot coals and embers (65%). Falls into open flame accounted for 23% (n = 15) of injuries, and flash flames accounted for 12% of injuries (n = 8). The presence of supervision was unknown in 56%; however, lack of supervision was a factor in 14% of our study population. By gaining a better understanding of the type of injury, mechanism of injury, and the demographic of recreational fire burn victims, policy, and awareness campaigns were instituted in an effort to reduce the incidence of recreational fire burns.

Isolated right atrial rupture from blunt trauma: a case report with systematic review of a lethal injury.

BACKGROUND: Isolated right atrial rupture (IRAR) from blunt chest trauma is rare. There are no physical exam findings and non-invasive testing specific to the condition, which result in diagnostic delays and poor outcomes. We present a case of IRAR along with a systematic review of similar cases in the literature. CASE REPORT: A 23-year-old male presented following a motor vehicle accident (MVA). He was bradycardic and hypotensive during transportation; and required intubation. There were contusions along the right chest wall with clear breath sounds, and no jugular venous distension, muffled heart sounds. Hemodynamic status progressively worsened, ultimately leading to his death. However, no external sources of bleeding or evidence of cardiac tamponade was found. METHODS: A search of PubMed, Ovid, and the Cochrane Library using: (Blunt OR Blunt trauma) AND (Laceration OR Rupture OR Tear) AND (Right Atrium OR Right Atrial). Articles were included if they were original articles describing cases of IRAR. RESULTS: Forty-five reports comprising seventy-five (n = 75) cases of IRAR. CONCLUSION: IRAR most commonly occurs following MVAs as the result of blunt chest trauma. Rupture occurs at four distinct sites and is most commonly at the right atrial appendage. IRAR is a diagnostic challenge and requires a high index of suspicion, as patients' hemodynamics can rapidly deteriorate. The presentations vary depending on multiple factors including rupture size, pericardial integrity, and concomitant injuries. Cardiac tamponade may have a protective effect by prompting the search for a bleeding source. A pericardial window can be diagnostic and therapeutic in IRAR. Outcomes are favourable with timely recognition and prompt surgical intervention.

Endo GIA stapler malfunction in a small bowel loop resection.

Endovascular gastrointestinal anastomosis (Endo-GIA) staplers are widely used in various surgical procedures despite difficulties in operating them and associated mechanical failures. We present a case of a patient whose post-operative recovery was complicated by intraoperative Endo-GIA stapler failure, which is rarely reported in literature. Our report describes the behavior and consequences of surgical stapler failure so surgeons can anticipate challenges of newer surgical devices while maintaining optimal patient outcomes.

Traumatic arteriovenous fistula formation secondary to crush injury.

We describe a patient who suffered a crush injury after a motor vehicle accident leading to complex pelvic injuries complicated by an AV fistula. Traumatic arteriovenous (AV) fistulas from blunt, non-penetrating injuries are uncommon and rarely described in medical literature. A CT followed by pelvic angiogram performed by interventional radiology revealed a traumatic fistula which was then treated by embolization. Patient underwent exploratory laparotomy, craniotomy and open reduction internal fixation of pelvis and was stabilized prior to discharge to rehabilitation.

Management of chronic abdominal wall seroma with Doxycycline sclerotherapy using a Negative Pressure Wound Therapy System KCI-V.A.C.Ulta™-A case report.

INTRODUCTION: Seroma is a common and challenging post-operative complication that surgeons are often faced with after performing procedures in which tissue dead spaces have been created. The management strategies consist of non-operative management, percutaneous drainage, or surgical drainage. Our case report discusses the use of Doxycycline sclerotherapy in the successful resolution of a chronic abdominal wall seroma. PRESENTATION OF CASE: We present the case of a 50 year old patient with extensive history of multiple abdominal surgeries, including appendectomy, multiple hernia repairs with recurrent mesh replacement as a result of infection followed by post-operative formation of seroma after each repair. Recently, patient underwent panniculecotomy complicated by seroma that was successfully resolved with the use of doxycycline sclerotherapy. DISCUSSION: Sclerotherapy has been used previously in the surgical field such as thoracic surgery, as a successful use of sclerosants in chronic pleural effusions has been documented. Sclerosants range from talc, tetracycline antibiotics, ethanol, polidocanol, erythromycin, OK-432, fibrin glue, and povidone-iodine, and are largely safe and easily applicable. Doxycycline in particular can be a simple and effective method for resolution of chronic seroma. This case demonstrates the successful use of doxycycline in the resolution of a chronic abdominal wall seroma. CONCLUSION: Chronic and recurrent seroma after surgery can be difficult to deal with. Using sclerosants such as Doxycycline would be an effective solution to treat this chronic issue and to prevent its recurrence especially if it is used with a Negative Pressure Wound Therapy System.

Superficial femoral artery transection following penetrating trauma.

We describe a patient who sustained a penetrating injury to the posterior right lower extremity just above the popliteal region with transection of the superficial femoral artery (SFA) despite minimal evidence of active bleeding. An on-table angiogram identified flow in the SFA followed by the popliteal artery and into the trifurcation of the right lower extremity. Eventually, a second operation revealed transection followed by end-to-end anastomosis of SFA and stabilization of the patient. The findings of this case highlight the need for a high index of suspicion and persistent clinical investigation to identify vascular injuries in the absence of hard signs of vascular trauma.

Too Hot for Your Pocket! Burns From E-Cigarette Lithium Battery Explosions: A Case Series.

The use of electronic cigarettes (ECs) has been on the rise with increased number of battery explosions causing burns. This study is a retrospective review of patients who presented with burns caused by EC explosions.Here, we present a case series of eight patients sustaining burns from EC explosions, within a year, to elucidate the pattern of such burns and to provide a treatment guideline.All of them were males. Five patients had partial-thickness burns and three had full-thickness burns. TBSA ranged from 4 to 16% (burns to lower extremity [n = 7], hand [n =3], scrotum/penis [n =2], chest [n = 1]). None had inhalation injuries. Two patients (29%) required skin grafting. EC explosion is predominantly attributed to its lithium-ion battery. Several types of injuries can occur, including chemical and thermal burns, inhalation injuries, metal poisoning, etc. There are currently no specific guidelines on the management of burns due to lithium-ion battery exposure. Herein, we recommend the following: Initial assessment of injuries should accompany the Advanced Trauma Life Support guidelines; serum levels of lithium, cobalt, and manganese should be checked and elevated levels should be monitored; patients should be monitored for signs of metal toxicity; wound should be extensively debrided and irrigated to remove any residual materials; and litmus test should be performed to check for alkali pH prior to irrigation with water or other aqueous solutions.

Iatrogenic Major Venous Injury Is Associated with Increased Morbidity of Aortic Reconstruction.

BACKGROUND: Major venous injury during open aortic reconstruction though uncommon often result in sudden and massive blood loss resulting in increased morbidity and mortality. This study details the etiology, management, and outcome of such injuries. METHODS: A retrospective review of 945 patients (1981-2017) undergoing aortic reconstruction from 2 midsized (350 bed each) teaching hospitals was conducted. Seven hundred twenty-three patients (76.5%) underwent open abdominal aortic aneurysm (AAA) repair/iliac aneurysm repair, 222 patients (23.5%) underwent aortofemoral grafting (AFG). Patients sustaining major venous injury (sudden loss of more than 500 mL of blood) during major aortic reconstruction were studied. The number of units of packed red blood cells transfused, location of injured vessel, type of repair, postoperative morbidity, and mortality were collected in our vascular registry on a continuous basis. All patients identified with iliac vein/inferior vena cava/femoral vein injury had follow-up noninvasive venous examination of the lower extremities. RESULTS: Eighteen major venous injuries (1.9%) occurred during aortic reconstruction in 17 patients (1 patient had 2 major venous injuries): IVC (n = 4), iliac vein (n = 10), left renal vein (n = 4, this includes a posterior retroaortic renal vein injury n = 1). Of the 18 major venous injuries, 7 occurred during open AAA repair for ruptured AAA and another 9 occurred during repair of intact AAA (P = 0.001), 2 venous injuries occurred after AFG, and 1 after primary AFG (P = 0.05). Using multivariate regression analysis, periarterial inflammation had significant association with major venous injury (P < 0.001). The presence of associated iliac aneurysm with abdominal aortic aneurysm also increased the incidence of major venous injury during AAA surgery (P = 0.05). Two patients (11.8%) died, one from uncontrolled bleeding due to tear of right common iliac vein during ruptured AAA repair and second patient from disseminated intravascular complication following repair of ruptured AAA. Intraoperative transfusion requirements were 3-28 units, (median 8 units). Three of 9 (33%) surviving patients developed iliofemoral venous thrombosis following repair of iliac/femoral vein injury. CONCLUSIONS: Major venous injury during aortic reconstructions occurs more commonly during the repair of ruptured AAA and redo AFG. Following repair of iliac/femoral vein injury, surveillance for possible deep venous thrombosis by duplex imaging should be considered.

Bilateral recurrent pyosalpinx in a sexually inactive 12-year-old girl secondary to rare variant of Mullerian duct anomaly.

Pyosalpinx is a severe sequel of chronic pelvic inflammatory disease, whereby the fallopian tubes become filled with pus.1 2 Pyosalpinx often affects sexually active women and rarely is seen in celibate adolescent girls.3 We report a case of a 12-year-old girl with no prior sexual history who presented to our emergency department with complaints of severe right lower quadrant pain of 1-day duration. Ultrasonography and CT scan of the abdomen and pelvis revealed free fluid collections in the pelvis without visualisation of the appendix. A preoperative diagnosis of acute ruptured appendicitis was given and she was taken to the operating room. Peroperative findings included bilaterally distended, pus-filled pyosalpinges. A definitive diagnosis of bilateral pyosalpinx was then made. Two-week antibiotic therapy was successful but the patient returned with recurrent pyosalpinx and a pelvic abscess 9 weeks later.