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1.
J Trauma Acute Care Surg ; 92(5): 792-799, 2022 05 01.
Artigo em Inglês | MEDLINE | ID: mdl-35045059

RESUMO

BACKGROUND: Direct to operating room resuscitation (DOR) is used by some trauma centers for severely injured trauma patients as an approach to minimize time to hemorrhage control. It is unknown whether this strategy results in favorable outcomes. We hypothesized that utilization of an emergency department operating room (EDOR) for resuscitation of patients with abdominal trauma at an urban Level I trauma center would be associated with decreased time to laparotomy and improved outcomes. METHODS: We included patients 15 years or older with abdominal trauma who underwent emergent laparotomy within 120 minutes of arrival both at our institution and within a National Trauma Data Bank sample between 2007 to 2019 and 2013 to 2016, respectively. Our institutional sample was matched 1:1 to an American College of Surgeons National Trauma Databank sample using propensity score matching based on age, sex, mechanism of injury, and abdominal Abbreviated Injury Scale score. The primary outcome was time to laparotomy incision. Secondary outcomes included blood transfusion requirement, intensive care unit (ICU) length of stay (LOS), ventilator days, hospital LOS, and in-hospital mortality. RESULTS: Two hundred forty patients were included (120 institutional, 120 national). Both samples were well balanced, and 83.3% sustained penetrating trauma. There were 84.2% young adults between the ages of 15 and 47, 91.7% were male, 47.5% Black/African American, with a median Injury Severity Score of 14 (interquartile range [IQR], 8-29), Glasgow Coma Scale score of 15 (IQR, 13-15), 71.7% had an systolic blood pressure of >90 mm Hg, and had a shock index of 0.9 (IQR, 0.7-1.1) which did not differ between groups (p > 0.05). Treatment in the EDOR was associated with decreased time to incision (25.5 minutes vs. 40 minutes; p ≤ 0.001), ICU LOS (1 vs. 3.1 days; p < 0.001), transfusion requirement within 24 hours (3 units vs. 5.8 units packed red blood cells; p = 0.025), hospital LOS (5 days vs. 8.5 days, p = 0.014), and ventilator days (1 day vs. 2 days; p ≤ 0.001). There were no significant differences in in-hospital mortality (22.5% vs. 15.0%; p = 0.14) or outcome-free days (4.9 days vs. 4.5 days, p = 0.55). CONCLUSION: The use of an EDOR is associated with decreased time to hemorrhage control as evidenced by the decreased time to incision, blood transfusion requirement, ICU LOS, hospital LOS, and ventilator days. These findings support DOR for patients sustaining operative abdominal trauma. LEVEL OF EVIDENCE: Therapeutic/Care Management, Level III.


Assuntos
Traumatismos Abdominais , Traumatismos Abdominais/diagnóstico , Traumatismos Abdominais/cirurgia , Adolescente , Feminino , Humanos , Escala de Gravidade do Ferimento , Laparotomia , Tempo de Internação , Masculino , Centros de Traumatologia , Adulto Jovem
4.
Am Surg ; 86(2): 104-109, 2020 Feb 01.
Artigo em Inglês | MEDLINE | ID: mdl-32167051

RESUMO

Deep vein thrombosis (DVT) is linked to reimbursements and publicly reported metrics. Some hospitals discourage venous duplex ultrasound (VDUS) screening in asymptomatic trauma patients because they often find higher rates of DVT. We aim to evaluate the association between lower extremity (LE) VDUS screening and pulmonary embolism (PE) in trauma patients. Trauma patients admitted to an urban Level-1 trauma center between 2010 and 2015 were retrospectively analyzed. We characterized the association of asymptomatic LE VDUSs with PE, upper extremity DVT, proximal LE DVT, and distal LE DVT by univariate and multivariable logistic regression controlling for confounders. Of the 3959 trauma patients included in our study-after adjusting for covariates related to patient demographics, injury, and procedures-there was a significantly lower likelihood of PE in screened patients (odds ratio (OR) = 0.02, P < 0.001) and a higher rate of distal LE DVT (OR 11.1, P = 0.004). Screening was not associated with higher rates of proximal LE DVT after adjustment for covariates (OR = 1.8, P = 0.193). PE was associated with patient transfer status, pelvis fracture, and spinal procedures in unscreened patients. After adjusting for covariates, we have shown that LE VDUS asymptomatic screening is associated with lower rates of PE in trauma patients and not associated with higher rates of proximal LE DVT. Our detailed institutional review of a large cohort of trauma patients over five years provides support for ongoing asymptomatic screening and better characterizes venous thromboembolism outcomes than similarly sized purely administrative data reviews. As a retrospective cohort study with a large sample size, no loss to follow-up, and a population with low heterogeneity, this study should be considered as level III evidence for care management.


Assuntos
Doenças Assintomáticas , Embolia Pulmonar/diagnóstico por imagem , Tromboembolia Venosa/diagnóstico por imagem , Trombose Venosa/diagnóstico por imagem , Ferimentos e Lesões/complicações , Feminino , Humanos , Tempo de Internação , Modelos Logísticos , Extremidade Inferior/irrigação sanguínea , Extremidade Inferior/diagnóstico por imagem , Masculino , Razão de Chances , Embolia Pulmonar/complicações , Embolia Pulmonar/epidemiologia , Estudos Retrospectivos , Fatores de Risco , Fatores de Tempo , Ultrassonografia Doppler Dupla/estatística & dados numéricos , Tromboembolia Venosa/complicações , Trombose Venosa/complicações
5.
Am J Surg ; 219(1): 43-48, 2020 01.
Artigo em Inglês | MEDLINE | ID: mdl-31030991

RESUMO

BACKGROUND: Our institution amended its trauma activation criteria to require a Level II activation for patients ≥65 years old on antithrombotic medication presenting with suspected head trauma. METHODS: Our institutional trauma registry was queried for geriatric patients on antithrombotic medication in the year before and after this criteria change. Demographics, presentation metrics, level of activation, and outcomes were compared between groups. RESULTS: After policy change, a greater proportion of patients received a trauma activation (19.9 vs. 74.9%, P < 0.001) and a greater proportion of these patients were discharged directly home without injury (4.3 vs. 44%, P < 0.001). However, a smaller proportion of patients with a critical Emergency Department disposition or traumatic intracranial hemorrhage failed to receive a trauma activation (65.1 vs. 23.5%, P < 0.001; 70.7% vs. 27.3%, P < 0.001). There was no change in mortality (4.3 vs. 2.0%, P = 0.21). CONCLUSIONS: Implementing new criteria increased overtriage, decreased undertriage, and had little effect on mortality.


Assuntos
Fibrinolíticos/uso terapêutico , Avaliação Geriátrica , Triagem/estatística & dados numéricos , Triagem/normas , Ferimentos e Lesões , Idoso , Idoso de 80 Anos ou mais , Feminino , Humanos , Masculino , Estudos Retrospectivos , Ferimentos e Lesões/terapia
6.
J Trauma Acute Care Surg ; 85(4): 741-746, 2018 Oct.
Artigo em Inglês | MEDLINE | ID: mdl-30059459

RESUMO

BACKGROUND: Cervical spine injuries (CSIs) can have major effects on the respiratory system and carry a high incidence of pulmonary complications. Respiratory failure can be due to spinal cord injuries, concomitant facial fractures or chest injury, airway obstruction, or cognitive impairments. Early tracheostomy (ET) is often indicated in patients with CSI. However, in patients with anterior cervical fusion (ACF), concerns about cross-contamination often delay tracheostomy placement. This study aimed to demonstrate the safety of ET within 4 days of ACF. METHODS: Retrospective chart review was performed for all trauma patients admitted to our institution between 2001 and 2015 with diagnosis of CSI who required both ACF and tracheostomy, with or without posterior cervical fusion, during the same hospitalization. Thirty-nine study patients with ET (within 4 days of ACF) were compared with 59 control patients with late tracheostomy (5-21 days after ACF). Univariate and logistic regression analyses were performed to compare risk of wound infection, length of intensive care unit and hospital stay, and mortality between both groups during initial hospitalization. RESULTS: There was no difference in age, sex, preexisting pulmonary or cardiac conditions, Glasgow Coma Scale score, Injury Severity Score, Chest Abbreviated Injury Scale score, American Spinal Injury Association score, cervical spinal cord injury levels, and tracheostomy technique between both groups. There was no statistically significant difference in surgical site infection between both groups. There were no cases of cervical fusion wound infection in the ET group (0%), but there were five cases (8.47%) in the late tracheostomy group (p = 0.15). Four involved the posterior cervical fusion wound, and one involved the ACF wound. There was no statistically significant difference in intensive care unit stay (p = 0.09), hospital stay (p = 0.09), or mortality (p = 0.06) between groups. CONCLUSION: Early tracheostomy within 4 days of ACF is safe without increased risk of infection compared with late tracheostomy. LEVEL OF EVIDENCE: Evidence, level III.


Assuntos
Traumatismos da Medula Espinal/cirurgia , Fusão Vertebral/efeitos adversos , Infecção da Ferida Cirúrgica/etiologia , Traqueostomia/efeitos adversos , Adolescente , Adulto , Idoso , Idoso de 80 Anos ou mais , Vértebras Cervicais , Feminino , Humanos , Unidades de Terapia Intensiva , Tempo de Internação , Masculino , Pessoa de Meia-Idade , Estudos Retrospectivos , Taxa de Sobrevida , Fatores de Tempo , Adulto Jovem
8.
Adv Med Educ Pract ; 6: 339-46, 2015.
Artigo em Inglês | MEDLINE | ID: mdl-25995656

RESUMO

Medical resident education in the United States has been a matter of national priority for decades, exemplified initially through the Liaison Committee for Graduate Medical Education and then superseded by the Accreditation Council for Graduate Medical Education. A recent Special Report in the New England Journal of Medicine, however, has described resident educational programs to date as prescriptive, noting an absence of innovation in education. Current aims of contemporary medical resident education are thus being directed at ensuring quality in learning as well as in patient care. Achievement and work-motivation theories attempt to explain people's choice, performance, and persistence in tasks. Expectancy Theory as one such theory was reviewed in detail, appearing particularly applicable to surgical residency training. Correlations between Expectancy Theory as a work-motivation theory and residency education were explored. Understanding achievement and work-motivation theories affords an opportunity to gain insight into resident motivation in training. The application of Expectancy Theory in particular provides an innovative perspective into residency education. Afforded are opportunities to promote the development of programmatic methods facilitating surgical resident motivation in education.

9.
J Trauma ; 71(2): 380-5; discussion 385-6, 2011 Aug.
Artigo em Inglês | MEDLINE | ID: mdl-21825942

RESUMO

BACKGROUND: Acute cervical spinal cord injury (cSCI) is associated with significant morbidity and mortality. Vertebral level and American Spinal Injury Association (ASIA) score influence both hospital course and ultimate outcome. While controlling for these variables, we describe the effect of age on cSCI-related pneumonia and mortality. METHODS: All patients treated at our regional spinal cord injury center with an acute cSCI during a 5-year period (2005-2009) were reviewed retrospectively. Patient demographics, injury level, ASIA score, length of stay (LOS), radiologic, laboratory, and microbiology data were reviewed. Pneumonia was defined as an infiltrate on chest X-ray along with two of the following: leukocytosis, fever greater than 101°F, or positive bronchial alveolar lavage cultures; all occurring within the same 24-hour period. RESULTS: There were 244 cSCI during the study period. In-hospital mortality was significantly higher for those older than 75 years (40.5% vs. 4.0%, p < 0.0001). Pneumonia rates were not significantly different between age groups. In all age groups, high ASIA scores (A and B) were associated with increased pneumonia (61.9% vs. 17.4%, p < 0.0001) and mortality (16.7% vs. 3.5%, p = 0.002). Similarly, patients with higher cervical injury levels (C4 and above) had a higher incidence of pneumonia (39.5% vs. 25.9%, p < 0.05) and a trend toward higher mortality. CONCLUSIONS: Age was associated with an increase in mortality among patients with an acute cSCI. Injury level and ASIA score contributed significantly to overall pneumonia rate and mortality at all ages; however, pneumonia did not correlate directly with mortality in this population. Other factors play a role in the mortality associated with geriatric spinal cord-injured patients, including end-of-life decision making; these need to be investigated further in future studies.


Assuntos
Pneumonia/epidemiologia , Traumatismos da Medula Espinal/epidemiologia , Adolescente , Adulto , Fatores Etários , Idoso , Idoso de 80 Anos ou mais , Vértebras Cervicais , Comorbidade , Feminino , Mortalidade Hospitalar , Humanos , Tempo de Internação , Masculino , Pessoa de Meia-Idade , Estudos Retrospectivos , Traumatismos da Medula Espinal/complicações , Traumatismos da Medula Espinal/mortalidade , Adulto Jovem
10.
J Surg Res ; 163(2): 323-6, 2010 Oct.
Artigo em Inglês | MEDLINE | ID: mdl-20537353

RESUMO

BACKGROUND: Roadside pedestrian injuries represent a significant portion of trauma team activations, especially at urban trauma centers. Patient demographics and severity of injury vary greatly in this patient population. Herein, we hypothesize that injury patterns may be predictable, especially with respect to age. MATERIALS AND METHODS: All patients with roadside pedestrian injuries evaluated at our urban, level one trauma center from January 2006 through December 2008 were retrospectively reviewed. Data were collected from the institutional trauma registry. Age was used as an independent variable and compared with injury type, substance abuse, discharge setting, and mortality. RESULTS: There were 226 roadside pedestrian injuries during the study period. Patients were divided into groups according to age, under 20 y, 21-40 y, 41-65 y, and over 65 y. Head injuries were more prevalent in patients over age 65, 30.4% versus 14.0% (P = 0.05). There was a trend for increasing alcohol use in the younger population. The likelihood of discharge to a rehab facility increased with age, 0%, 11.8%, 38.2%, 50.0%, respectively (P < 0.001). Mortality was significantly higher in patients older than 65 y, 15.2% versus 3.3% (P = 0.049). CONCLUSIONS: Roadside pedestrian injuries have predictable injury patterns based on age. Older patients are more likely to have a head injury, longer length of stay, need for a rehab stay, and have a higher mortality. Further studies are needed to correlate precise injuries with collision mechanism and evaluate specific risk factors in this high risk population.


Assuntos
Acidentes de Trânsito/estatística & dados numéricos , Ferimentos e Lesões/epidemiologia , Acidentes de Trânsito/mortalidade , Adulto , Fatores Etários , Idoso , Consumo de Bebidas Alcoólicas/epidemiologia , Traumatismos Craniocerebrais/epidemiologia , Feminino , Humanos , Masculino , Pessoa de Meia-Idade , Fatores de Risco , População Urbana , Ferimentos e Lesões/mortalidade
11.
Surg Laparosc Endosc Percutan Tech ; 17(6): 554-5, 2007 Dec.
Artigo em Inglês | MEDLINE | ID: mdl-18097323

RESUMO

Minimally invasive techniques have been accepted as safe and reliable in the work-up of patients with lymphoproliferative disorders. As the oncologic indications of laparoscopy expand, many authors have raised concerns regarding the occurrence of port site metastases after minimally invasive procedures for a multiform array of neoplastic diseases. A review of the existing literature demonstrates no mention of port site occurrence following staging laparoscopy for malignant hematologic disorders. We report the first case of port site metastasis after diagnostic laparoscopy in a patient with large B-cell lymphoma. As these procedures become more common, we may be exposed to the increasing numbers of patients with this clinical presentation. A clear knowledge of the technical steps to minimize risk of port site metastasis is mandatory for any advanced laparoscopic surgeon.


Assuntos
Laparoscopia/efeitos adversos , Linfoma Difuso de Grandes Células B/patologia , Inoculação de Neoplasia , Neoplasias Cutâneas/secundário , Parede Abdominal , Humanos , Masculino , Pessoa de Meia-Idade , Estadiamento de Neoplasias
12.
Vasc Endovascular Surg ; 36(3): 219-22, 2002.
Artigo em Inglês | MEDLINE | ID: mdl-12075388

RESUMO

Endograft repair has rapidly become an alternative to conventional open repair of abdominal aortic aneurysms. Various trials continue to show decreased morbidity when compared to open repair. However, as with any new procedure, complications specifically related to this technique are being described. Herein, we report a case of an isolated ischemic jejunal stricture presenting as a small-bowel obstruction secondary to cholesterol emboli following endograft repair of an abdominal aortic aneurysms.


Assuntos
Aneurisma da Aorta Abdominal/cirurgia , Implante de Prótese Vascular/efeitos adversos , Jejuno/irrigação sanguínea , Idoso , Constrição Patológica , Embolia de Colesterol/complicações , Humanos , Obstrução Intestinal/diagnóstico , Obstrução Intestinal/etiologia , Masculino
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