Background The American Association for the Surgery of Trauma (AAST) has developed a grading system for emergency general surgery (EGS) conditions. We sought to validate the AAST EGS grades for patients undergoing urgent/emergent colorectal resection. Methods Patients enrolled in the “Eastern Association for the Surgery of Trauma Multicenter Colorectal Resection in EGS—to anastomose or not to anastomose” study undergoing urgent/emergent surgery for obstruction, ischemia, or diverticulitis were included. Baseline demographics, comorbidity severity as defined by Charlson comorbidity index (CCI), procedure type, and AAST grade were prospectively collected. Outcomes included length of stay (LOS) in-hospital mortality, and surgical complications (superficial/deep/organ-space surgical site infection, anastomotic leak, stoma complication, fascial dehiscence, and need for further intervention). Multivariable logistic regression models were used to describe outcomes and risk factors for surgical complication or mortality. Results There were 367 patients, with a mean (± SD) age of 62 ± 15 years. 39% were women. The median interquartile range (IQR) CCI was 4 (2-6). Overall, the pathologies encompassed the following AAST EGS grades: I (17, 5%), II (54, 15%), III (115, 31%), IV (95, 26%), and V (86, 23%). Management included laparoscopic (24, 7%), open (319, 87%), and laparoscopy converted to laparotomy (24, 6%). Higher AAST grade was associated with laparotomy (P = .01). The median LOS was 13 days (8-22). At least 1 surgical complication occurred in 33% of patients and the mortality rate was 14%. Development of at least 1 surgical complication, need for unplanned intervention, mortality, and increased LOS were associated with increasing AAST severity grade. On multivariable analysis, factors predictive of in-hospital mortality included AAST organ grade, CCI, and preoperative vasopressor use (odds ratio (OR) 1.9, 1.6, 3.1, respectively). The American Association for the Surgery of Trauma emergency general surgery grade was also associated with the development of at least 1 surgical complication (OR 2.5), while CCI, preoperative vasopressor use, respiratory failure, and pneumoperitoneum were not. Conclusion The American Association for the Surgery of Trauma emergency general surgery grading systems display construct validity for mortality and surgical complications after urgent/emergent colorectal resection. These results support incorporation of AAST EGS grades for quality benchmarking and surgical outcomes research.

La utilidad de la PET (Tomografía por emisión de positrones) en Oncología Clínica ha sido conocida desde hace más de 2 décadas, situándola como una técnica sensible para el diagnóstico y la estratificación pronostica de los pacientes oncológicos. La sensibilidad y especificidad de la PET frente a otros estudios de imagen han demostrado ser mayores. Por algunos años, se encontró una limitante por el alto costo de los equipos de los ciclotrones. Sin embargo, se da prioridad a la relación costo/beneficio que brinda esta técnica dada la información clínica obtenida gracias a ella. En este artículo se comentan los resultados observados al utilizarla en diversos tipos de cáncer, así como su eficacia en el estadíaje preoperatorio, la valoración de enfermedad residual, diagnóstico de recurrencias, seguimiento y estratificación pronostica del paciente con cáncer.

The American College of Surgeons Committee on Trauma requires that trauma centers with greater than 10 per cent injured patients admitted to non-trauma services (NTSs) have processes to review these for appropriateness of care. We previously described an algorithm to determine the appropriateness of NTS admissions. Our objective was to determine if the outcome and process of care was similar between TS- and NTS-admitted patients. We conducted a retrospective analysis of our trauma registry. NTS-appropriate patients by algorithm were included. Differences between patients admitted to a TS and an NTS were compared. Nine hundred forty-one patients met the algorithm criteria as appropriate for the NTS; 694 were admitted to TS and 247 to NTS. Contact with TS was the most common association with admission to TS. NTS patients were older and had similar Injury Severity Scores, and a similar proportion had three or greater pre-existing comorbidities. NTS-admitted patients had similar risk for mortality and complications, but longer length of stay, and were less likely to have a desirable discharge disposition. Minimally injured elderly patients constitute most of NTS and a large proportion of TS admissions. NTS admission seems appropriate with respect to mortality and complications. Differences in the care process may have accounted for longer length of stay and differences in disposition destination.

OBJECTIVE Evidence comparing stoma creation (STM) versus anastomosis after urgent or emergent colorectal resection is limited. This study examined outcomes after colorectal resection in emergency general surgery patients. METHODS This was an Eastern Association for the Surgery of Trauma-sponsored prospective observational multicenter study of patients undergoing urgent/emergent colorectal resection. Twenty-one centers enrolled patients for 11 months. Preoperative, intraoperative, and postoperative variables were recorded. χ2, Mann-Whitney U test, and multivariable logistic regression models were used to describe outcomes and risk factors for surgical complication/mortality. RESULTS A total of 439 patients were enrolled (ANST, 184; STM, 255). The median (interquartile range) age was 62 (53–71) years, and the median Charlson Comorbidity Index (CCI) was 4 (1–6). The most common indication for surgery was diverticulitis (28%). Stoma group was older (64 vs. 58 years, p < 0.001), had a higher CCI, and were more likely to be immunosuppressed. Preoperatively, STM patients were more likely to be intubated (57 vs. 15, p < 0.001), on vasopressors (61 vs. 13, p < 0.001), have pneumoperitoneum (131 vs. 41, p < 0.001) or fecal contamination (114 vs. 33, p < 0.001), and had a higher incidence of elevated lactate (149 vs. 67, p < 0.001). Overall mortality was 13%, which was higher in STM patients (18% vs. 8%, p = 0.02). Surgical complications were more common in STM patients (35% vs. 25%, p = 0.02). On multivariable analysis, management with an open abdomen, intraoperative blood transfusion, and larger hospital size were associated with development of a surgical complication, while CCI, preoperative vasopressor use, steroid use, open abdomen, and intraoperative blood transfusion were independently associated with mortality. CONCLUSION This study highlights a tendency to perform fecal diversion in patients who are acutely ill at presentation. There is a higher morbidity and mortality rate in STM patients. Independent predictors of mortality include CCI, preoperative vasopressor use, steroid use, open abdomen, and intraoperative blood transfusion. Following adjustment by clinical factors, method of colon management was not associated with surgical complications or mortality. LEVEL OF EVIDENCE Therapeutic study, level IV.

"Suicidal ingestion of household bleach resulting in total gastrectomy." Clinical Toxicology, 58(4), pp. 300–301

Taguchi, Jillian MD; Valenzuela, Julie MD; Fumanti, Brandon J. MD; Yelon, Jay DO, FACS; Szydziak, Lisa MS; Grossman, Michael D. MD, FACS Author Information

BACKGROUND Occupational exposure is an important consideration during emergency department thoracotomy (EDT). While human immunodeficiency virus/hepatitis prevalence in trauma patients (0–16.8%) and occupational exposure rates during operative trauma procedures (1.9–18.0%) have been reported, exposure risk during EDT is unknown. We hypothesized that occupational exposure risk during EDT would be greater than other operative trauma procedures. METHODS A prospective, observational study at 16 US trauma centers was performed (2015–2016). All bedside EDT resuscitation providers were surveyed with a standardized data collection tool and risk factors analyzed with respect to the primary end point, EDT occupational exposure (percutaneous injury, mucous membrane, open wound, or eye splash). Provider and patient variables and outcomes were evaluated with single and multivariable logistic regression analyses. RESULTS One thousand three hundred sixty participants (23% attending, 59% trainee, 11% nurse, 7% other) were surveyed after 305 EDTs (gunshot wound, 68%; prehospital cardiopulmonary resuscitation, 57%; emergency department signs of life, 37%), of which 15 patients survived (13 neurologically intact) their hospitalization. Overall, 22 occupational exposures were documented, resulting in an exposure rate of 7.2% (95% confidence interval [CI], 4.7–10.5%) per EDT and 1.6% (95% CI, 1.0–2.4%) per participant. No differences in trauma center level, number of participants, or hours worked were identified. Providers with exposures were primarily trainees (68%) with percutaneous injuries (86%) during the thoracotomy (73%). Full precautions were utilized in only 46% of exposed providers, while multiple variable logistic regression determined that each personal protective equipment item utilized during EDT correlated with a 34% decreased risk of occupational exposure (odds ratio, 0.66; 95% CI, 0.48–0.91; p = 0.010). CONCLUSIONS Our results suggest that the risk of occupational exposure should not deter providers from performing EDT. Despite the small risk of viral transmission, our data revealed practices that may place health care providers at unnecessary risk of occupational exposure. Regardless of the lifesaving nature of the procedure, improved universal precaution compliance with personal protective equipment is paramount and would further minimize occupational exposure risks during EDT. LEVEL OF EVIDENCE Therapeutic/care management study, level III.

Nontrauma service (NTS) admissions are an increasing problem as ground-level falls in elderly patients become more common. The admission and evaluation of trauma patients to nontrauma services in trauma centers seeking American College of Surgeons (ACS) verification, must follow the ACS mandates for performance improvement requiring some method of evaluating this population when admitted to services other than trauma, orthopedics, and neurosurgery. The purpose of this study and performance improvement project was to improve our process for the definition and evaluation of trauma patients who were being admitted to nontrauma services. We designed an algorithm to evaluate appropriateness of NTS admission and evaluated outcomes for NTS admissions utilizing that algorithm. We created a scoring algorithm and evaluated appropriateness of NTS admission over 2 years in a community-teaching ACS Level II trauma center. We reviewed trauma registry data using χ 2 and Fisher exact tests to determine differences in outcome for NTS versus trauma service (TS) admissions. From December 2014 to December 2016, NTS admission rate fell from maximum of 28% to 4% stabilizing between 8% and 10%. Mortality and overall complication rate between NTS and TS were similar ( p = .40 and .66, respectively), but length of stay was lower for TS admissions ( p < .0001). A scoring system of algorithm can be used to determine appropriateness of NTS admissions, and validity of the tool can be confirmed using registry-based outcome data for TS versus NTS admissions.

There are growing problems with the supply of trauma surgeons and/or willingness to participate in trauma care. Solutions proposed include the use of nonsurgeon providers and the development of an acute care surgery model to enhance the attractiveness of training in the field. We propose that immediate modification of clinical operations within trauma centers may address some of these problems and improve patient care and safety. The use of structured shift work models with efficient systems for communication and handoff may improve workforce utilization and vitality both in the near and far term. The following core competencies are addressed in this article: Interpersonal and communication skills, Practice-based learning and improvement, Professionalism, Systems-based practice. Republished with permission from: Grossman MD. Workforce, work hours, and workforce vitality: Toward new models of trauma coverage. OPUS 12 Scientist 2008;2(3):1-2.

STUDY OBJECTIVES:Ketamine and etomidate are used for procedural sedation (PS) to facilitate the performance of painful procedures. We hypothesized that ketamine produces adequate and comparable sedation conditions for dislocated large joint reduction when compared to etomidate and results in fewer adverse events. METHODS:This Institutional Review Board approved prospective trial compared a convenience sample of subjects, who were randomized to receive either ketamine or etomidate for PS to facilitate reduction of large joint dislocations. Following informed consent, subjects were assigned via a computer-generated algorithm to receive either etomidate (0.1 mg/kg) or ketamine (0.5 mg/kg) intravenously; if PS was not sufficient, subjects received repeat doses of etomidate or ketamine until adequate PS was achieved. The protocol's primary endpoint was a successful reduction of dislocated, large joints. Secondary endpoints included alteration in blood pressure, vomiting, recovery agitation, hypersalivation, laryngospasm, myoclonus, hypoxia, airway assistance with chin lift or jaw thrust, bag-valve-mask ventilation, endotracheal intubation, utilization of additional doses of ketamine or etomidate, and recovery time from sedation. RESULTS:Total enrollment was eighty subjects, 46 in the ketamine cohort and 34 in the etomidate cohort. The two PS groups were comparable in terms of gender, age, and weight. There was no significant difference in the primary endpoint of large joint dislocation reduction between the ketamine and etomidate cohorts (46/46, 100%; 32/34, 94.1%; P - 0.1). Shoulder, hip, and ankle joints account for the majority of joint reductions in this trial. Titration of PS was necessary for almost half of each cohort as evidenced by the utilization of additional dosages of the sedative agents: ketamine (22/46, 47.8%) and etomidate (14/34, 41.2%; P - 0.56). Among secondary outcome variables, significant differences between ketamine and etomidate cohorts were myoclonus (1/46, 2.2%, 15/33, 45.5%; P - 0.0001), assisted ventilation with airway manipulation (3/45, 6.7%; 9/33, 27.3%; P - 0.01), and pulsoximetry desaturation < 90% (0/46; 7/34, 20.6%; P - 0.002). There was no significant difference in recovery time from PS between the ketamine and etomidate cohorts (11 min vs. 10 min; P - 0.69). CONCLUSION:Ketamine produces PS conditions for successful large joint dislocation reduction that are adequate and comparable to etomidate. The increased likelihood of myoclonus, of the requirement for airway assistance, and of hypoxia observed with etomidate suggest potential benefits with the utilization of ketamine for PS for dislocated large joint reduction.

BACKGROUND: American College of Surgeons (ACS) verification is believed to provide benefits for trauma patients, but is associated with direct costs.STUDY DESIGN: We performed a 1-year retrospective review of the National Trauma Data Bank (NTDB) for 2012. Patients were separated into 3 age groups; Pediatric (PEDS), 0 to 14 years; adult, 15 to 65 years; and elderly (ELD), older than 65 years. We analyzed 2 injury severity cohorts, Injury Severity Score (ISS) 9 to 74 (ALL) and ISS 25 to 74 (MAJ). Multiple logistic regression to determine significance of ACS verification on mortality and major complications, controlling for age, ISS, shock, Glasgow Coma Scale, sex, age, comorbidities, and mechanism. Patients were excluded with an ISS <8 or equal to 75, dead on arrival, emergency department transfers, and burns.RESULTS: There were 392,997 patients: 262,644 in ACS centers and 130,353 in non-ACS centers. Distribution was: PEDS 3.8%, adults 64.5%, ELD 31.7%. For ALL adults, no differences were observed for primary outcome in ACS vs non-ACS centers (p = 0.128 and 0.061, for mortality and complications, respectively). For ALL PEDS and ELD, complications were more likely in non-ACS centers: (p = 0.003, odds ratio [OR] 2.61 [95% CI 1.36 to 5.0], and p < 0.0001, OR 3.17 [95% CI 2.21 to 4.56]). For MAJ trauma, death was more likely in adults in ACS vs non-ACS centers (p = 0.013, OR 0.82 [95% CI 0.71 to 0.96]). Complications for MAJ trauma were more likely in all age groups in non-ACS centers (adult: p = 0.028, OR 1.48 [95% CI 1.04 to 2.1]; ELD: p < 0.0001, OR 2.49 [95% CI 1.7 to 3.7]; PEDS: p < 0.0001, OR 4.29 [95% CI 2.13 to 8.69]). Length of stay was increased for all patients with complications (p < 0.0001).CONCLUSIONS: Measurable benefits in complications were observed in all age groups with MAJ trauma and in PEDS and ELD for ALL injury severity in ACS vs non-ACS trauma centers. (C) 2017 by the American College of Surgeons. Published by Elsevier Inc. All rights reserved.

Tisherman, Samuel A. MD, FACS, FCCMa,b,*; Alam, Hasan B. MD, FACSd; Chiu, William C. MD, FACSe; Emlet, Lillian L. MD, MSa,c; Grossman, Michael D. MD, FACSf; Luchette, Fred A. MD, MSc, FACSg; Marcolini, Evie G. MDh; Mayglothling, Julie A. MDi Author Information

Etomidate has been the preferred agent for intubating traumatically injured patients because of its lack of effect on hemodynamic parameters, whereas ketamine has been avoided over concerns that it causes increased intracranial pressure. This exploratory study examines if ketamine's efficacy and safety profile is similar to etomidate for rapid sequence intubation (RSI) of trauma patients. Consecutive intubated trauma patients (N = 100) were sedated with 1.5 mg/kg of ketamine prior to receiving succinylcholine for RSI. This group was compared to a sample of 100 controls intubated with etomidate taken from our trauma database. The primary endpoint was successful intubation. Secondary endpoints were change in blood pressure, heart rate and oxygen saturation, and occurrence of vomiting and aspiration. Compared to historical controls, there were no significant differences in rate of successful intubation (p =.68) or median number of intubation attempts (1 per group, p =.92). There were 6/200 (3%) unsuccessful intubations, 4 ketamine and 2 etomidate. For secondary outcomes, there was a statistically significant difference in post-intubation dBP with the ketamine cohort (94 mm Hg) v. the etomidate cohort (83 mm Hg; p =.002). The etomidate cohort had larger change in pulse (96 to 91) from pre to post-intubation compared to the ketamine cohort (100 to no change; p =.03). There were no significant differences between the ketamine and etomidate cohorts for other secondary outcomes of sBP, pulsox, vomiting, and aspiration (p > .05; Table). Ketamine appears comparable to etomidate for successful RSI in traumatically injured patients. Ketamine also provides appropriate intubating conditions without potentiating the risk of complications.TableRate of Successful IntubationsTotal (n)Successful Intubation# Intubation AttemptsMedian (IQR) Range (1-5)Ketamine10096 (96%)1Etomidate10098 (98%)1p-value.68.92Clinical VariablesKetamine (n = 100)Etomidate (n = 100)p valuePre RSI sBP156152.64Post RSI sBP159151.53Pre RSI dBP8486.94Post RSI dBP9483.02Pre RSI P10096.12Post RSI P10091.03Pre RSI POx9899.72Post RSI POx100100NAKetamine Frequency (%)Etomidate Frequency (%)Vomiting61.12Aspiration52.45 Open table in a new tab

Study Objectives: Ketamine and etomidate are used for procedural sedation to facilitate reduction of dislocated fractures and joints. We hypothesized that that ketamine produces adequate and equivalent conditions for reduction compared to etomidate and may result in fewer adverse effects. Methods: The study protocol was institutional review board approved. This was a randomized prospective trial utilizing a convenience sample of patients requiring procedural sedation for urgent reduction of orthopedic dislocations conducted in a community-teaching emergency department (ED). Patients who provide informed consent received either etomidate (0.1mg/kg) or ketamine (1.0mg/kg) according to a random number generator. Procedural sedation was administered according to a written procedural sedation protocol present in the ED and administered by ED nursing staff. The primary endpoint was successful reduction. Secondary endpoints included change in vital signs, vomiting, emergence reactions, hyper-salivation, laryngospasm and myoclonus. The need for intubation or airway assistance with bag-valve mask, chin lift, or jaw thrust was recorded as well. Additional doses of sedative and/or anesthetic agent as well as recovery time from sedation were recorded by nursing staff. Exclusion criteria included pregnancy, age <14, altered mental status, and patients with suspected cocaine abuse. Results: Results are displayed below. There were no significant differences in the primary endpoint of joint reduction. There was significant difference in the need for airway assistance as well an increased rate of myoclonus in the etomidate group, despite having a slightly shorter recovery time. All airway assists consisted of jaw thrust and chin lift or bag-valve mask; no intubations were required. Tabled 1 Conclusion: Ketamine produces procedural sedation conditions for successful joint dislocation reduction that are adequate and equivalent compared to etomidate. The significant reduction in myoclonus associated with ketamine use as well as increased requirement for airway assistance observed with etomidate suggest a potential advantage with the use of ketamine despite a slightly longer recovery time from procedural sedation.

Study Objectives: Ketamine produces dissociative anesthesia characterized by analgesia and amnesia with a safety profile appropriate for endotracheal intubation. Historically etomidate has been the preferred sedation agent for trauma bay intubations and ketamine has been avoided over concerns for causing increased intracranial pressure. Recent research has shown these concerns about ketamine to be overstated in original literature. This exploratory study seeks to determine whether ketamine provides equivalent conditions to etomidate for endotracheal intubation. The null hypothesis is that ketamine is comparable to etomidate as a single sedative agent for rapid sequence intubation. Methods: Traumatically injured patients requiring intubation were sedated with 1.5 mg/kg of ketamine prior to receiving succinylcholine for rapid sequence intubation (RSI). This group was compared to a randomly selected sample of 50 patients from historical controls intubated with etomidate. The primary endpoint was successful intubation (correct placement of endotracheal tube in 3 attempts or less). Secondary endpoints were changes in blood pressure, pulse rate and oxygen saturation before and after treatment with the sedating agent, as well as presence of vomiting and aspiration. Fisher's exact tests, mixed randomized-repeated measures analysis of variance and independent samples median tests were conducted as appropriate, with p < .05 denoting statistical significance for all outcomes. Results: Data were collected on 51 patients intubated with ketamine. When compared to historic controls there were no significant differences in successful intubation frequency, with a success rate of 94.1% in the ketamine group and 96% in the etomidate group (p=1.00) or median number of intubation attempts (1 and 1, p=0.48). No significant difference occurred for pre-post changes in sBP (p=0.39) or pulse (p=0.88), across both groups, or in the degree to which sBP (p=0.44) or pulse (p=0.84) changed from pre to post based on sedation group. Analysis of dBP and oxygenation changes was limited by skewed distributions, heterogeneity of variance and/or extreme outlier scores. No significant between-group differences were identified for dBP and oxygenation. No significant difference was found between groups in vomiting or aspiration (p=1.00). Conclusion: Based on current data, it appears that ketamine provides appropriate conditions to facilitate successful endotracheal intubation. These results should be interpreted cautiously given the sample size limitations and exploratory study design; however, there is no obvious evidence of harm in using ketamine.

Given the increasing number of operational nuclear reactors worldwide, combined with the continued use of radioactive materials in both healthcare and industry, the unlikely occurrence of a civilian nuclear incident poses a small but real danger. This article provides an overview of the most important historical, medical, and scientific aspects associated with the most notable nuclear incidents to date. We have discussed fundamental principles of radiation monitoring, triage considerations, and the short- and long-term management of radiation exposure victims. The provision and maintenance of adequate radiation safety among first responders and emergency personnel are emphasized. Finally, an outline is included of decontamination, therapeutic, and prophylactic considerations pertaining to exposure to various radioactive materials.

Grossman, Michael D. MD, FACS; Portner, Marc MD; Hoey, Brian A. MD, FACS; Schwab, William C. MD, FACS Author Information