Crisis under the radar: Illicit amphetamine use is reaching epidemic proportions and contributing to resource overutilization at a Level I trauma center.

INTRODUCTION: Trauma centers reported illicit amphetamine use in approximately 10% of trauma admissions in the previous decade. From experience at a trauma center located in a southwestern metropolis, our perception is that illicit amphetamine use is on the rise and that these patients utilize in-hospital resources beyond what would be expected for their injuries. The purposes of this study were to document the incidence of illicit amphetamine use among our trauma patients and to evaluate its impact on resource utilization. METHODS: We conducted a retrospective cohort study using 7 consecutive years of data (starting July 2010) from our institution's trauma registry. Toxicology screenings were used to categorize patients into one of three groups: illicit amphetamine, other drugs, or drug-free. Adjusted linear and logistic regression models were used to predict hospital cost, length of stay, intensive care unit admission, and ventilation between drug groups. Models were conducted with combined injury severity (Injury Severity Score [ISS]) and then repeated for ISS of less than 9, ISS 9 to 15, and ISS 16 or greater. RESULTS: Eight thousand five hundred eighty-nine patients were categorized into the following three toxicology groups: 1,255 (14.6%) illicit amphetamine, 2,214 (25.8%) other drugs, and 5,120 (59.6%) drug-free. Illicit amphetamine use increased threefold over the course of the study (from 7.85% to 25.0% of annual trauma admissions). Adjusted linear models demonstrated that illicit amphetamine among patients with ISS of less than 9 was associated with 4.6% increase in hospital cost (p = 0.019) and 7.4% increase in length of stay (p = 0.043). Logistic models revealed significantly increased odds of ventilation across all ISS groups and increased odds of intensive care unit admission when all ISS groups were combined (p = 0.001) and within the group with ISS of less than 9 (p = 0.002). CONCLUSIONS: Hospital resource utilization of amphetamine patients with minor injuries is significant. Trauma centers with similar epidemic growth in proportion of amphetamine patients face a potentially significant resource strain relative to other centers. LEVEL OF EVIDENCE: Prognostic/Epidemiological, level II; Therapeutic, level III.

Through-and-through gunshot wound to the esophagus at the thoracic inlet:a novel management approach.

A 42-year-old man presented to the emergency department with gunshot wound to left upper back over the scapula and palpable bullet over the right supraclavicular fossa. The patient had a left-sided needle thoracostomy in the field. He was tachypneic and tachycardiac but normortensive on arrival. Due to the patient being in respiratory distress, he was orotracheally intubated. On examination, he was found to have a moderate left pneumothorax with mild mediastinal shift. He had a left closed tube thoracostomy placed. CT angiography imaging of the neck and chest was then obtained, and pneumomediastinum associated with bony fragmentation of the anterior T1 and T2 vertebral bodies was observed. Additional findings included right internal jugular injury and right apical pulmonary hemorrhage. The patient subsequently underwent flexible tracheobronchoscopy and esophagoscopy in the endoscopy suite, where a through-and-through esophageal injury at 21 cm from the incisors was recognized (figure 1). There was erythema noted in the trachea at this level, but no evidence of transmural injury to the trachea. Figure 1Through-and-through gunshot wound to esophagus. Arrows denote areas of injury. WHAT WOULD YOU DO?: Commence 14-day course of broad spectrum antibiotics.Endoscopic stenting with video-assisted thorascopic surgery (VATS) washout.Local exploration with wide drain placement.Open esophagectomy with spit fistula.

Pneumatosis intestinalis in solid organ transplant recipients.

Pneumatosis intestinalis (PI) is an uncommon medical condition in which gas pockets form in the walls of the gastrointestinal tract. The mechanism by which this occurs is poorly understood; however, it is often seen as a sign of serious bowel ischemia, which is a surgical emergency. Since the early days of solid organ transplantation, PI has been described in recipients of kidney, liver, heart, and lung transplant. Despite the dangerous connotations often associated with PI, case reports dating as far back as the 1970s show that PI can be benign in solid organ transplant recipients. This is an important observation, as operative intervention in these patients carries greater risk than surgical procedures in the general population. The higher operative risks in the transplant population are partly due to their immunosuppressed status and poor wound healing. Furthermore, no clear consensus exists on the optimal management of PI. Various treatment strategies such as bowel rest, antibiotics, and parenteral feeding have been implemented with similar levels of success. With the increasing use of solid organ transplantation, PI is being recognized with increasing frequency. In this review, we provide a summary of the incidence, presentation, diagnosis, and management of PI, particularly as it affects recipients of solid organ transplantation.

A 54-Year-Old Man Presenting With an Abnormal Abdominal CT Scan 8 Months After Double Lung Transplant.

A 54-year-old man who had undergone bilateral sequential lung transplant for idiopathic pulmonary fibrosis was admitted to the hospital for further evaluation of an abnormal abdominal CT scan. Three months previously a gastrojejunostomy tube had been placed after he was found to have evidence of silent aspiration with oral intake. At a recent clinic visit, he denied abdominal pain or problems with the feeding tube. He described frequent diarrhea since placement of the feeding tube.