Cocaine Use and Incarceration: A Rare Cause of Bowel Ischemia, Perforation, and Gastrointestinal Hemorrhage

Cocaine use is rising in persons ≥50 years old and in black and socioeconomically disadvantaged communities. Cocaine-induced bowel ischemia and gastrointestinal injury are deadly findings that have been previously described in the literature. In this report, we present a case of small bowel ischemia, perforation, and upper gastrointestinal hemorrhage co-occurring in a 62-year-old incarcerated male with a 15-year history of cocaine use. The patient presented from jail, peritonitic in septic shock, and was promptly taken for emergent surgical exploration. He was found to have massive fecal peritonitis secondary to full-thickness ischemia and perforation of the jejunum and ileum. Immediately postoperatively, the patient developed a large volume of hemorrhage from multiple gastric and duodenal ulcers refractory to endoscopic intervention, ultimately requiring emergent embolization of the gastroduodenal artery. His course was further complicated by severe septic shock with a blunted response to catecholamine vasopressors. Early recognition and aggressive treatment of the gastrointestinal complications and the unique critical care challenges associated with cocaine use facilitated this patient’s eventual full recovery.

514 The Outcomes of Tracheostomy on Burn Inhalation injuries

Introduction

Tracheostomy has been proposed for patients with expected prolonged intubation and it has been shown to be beneficial for trauma patients with severe brain injury; however, the benefit of performing tracheostomy on burn inhalation injuries has not been extensively investigated. Our study aims to determine the outcomes of performing tracheostomy on patients with burn inhalation injuries requiring mechanical ventilation.

Methods

Retrospective review of our institutional burn registry from 2011 to 2019. We compared the outcomes of all burn patients that met our inclusion criteria which included: adequate data recording of inhalation injury within the registry, ventilator support for at least 24 hours, and a TBSA burn injury of < 15%. We stratified the patients into two groups: tracheostomy (group 1) versus no tracheostomy (group 2). Outcome measures included: in-hospital mortality rate, hospital length of stay, ICU length of stay, ventilator days, and ventilator associated pneumonia (VAP). Chi-squared and t-test analyses were used with significance defined as p< 0.05.

Results

A total of 33 burn patients met our inclusion criteria. Group 1 consisted of 10 patients and group 2 consisted of 23 patients. There was no statistically significant difference between the two groups in terms of %TBSA (p =0.24, t-test). There was a significantly higher ICU length of stay at 23.8 days in group 1 compared to 3.16 days in group 2 (p=0.0001, χ2). There was a significantly higher hospital length of stay at 28.4 days in group 1 compared to 5.26 days in group 2 (p=0.0001, χ2). Ventilator days was also significantly higher in group 1 with 20.8 days compared to 2.5 days in group 2. There was no statistically significant difference between the two groups in terms of mortality, however, the incidence of VAP was significantly higher in group 1 than in group 2, with six cases compared to zero cases, respectively(p=0.0001, χ2).

Conclusions

The ideal timing and implementation of tracheostomy with inhalational injury has yet to be determined. In our study, tracheostomy was associated with much longer lengths of stay and pneumonia. The impact of the underlying lung injury, versus the tracheostomy itself on these observations, is unclear. The challenge of characterizing the severity of an inhalation injury based on early visual inspection remains.

Predictors of Mortality in Trauma Patients

The purpose of this study was to ascertain risk factors for death from trauma. The large cohort allows for simultaneous evaluation of known mortality risk factors along with controlling for factors to assess the influence of each independently. Individually, base deficit, temperature, hypotension, age, and injury severity have been shown to be associated with an increased risk of death. However, in the English literature, there is no data on the independent predictive power and interaction of these risk factors. A review of trauma registry parameters from 1995 to 2000 was used. Demographics, injury severity, physiological and hematological parameters, and time data were evaluated in a univariate analysis. Variables significantly associated with mortality were entered into a stepwise backward multiple logistic regression. There were 1276 deaths (8.9%) with 25 per cent of the deaths within 3 hours. The top four predictors of mortality in this group were partial thromboplastin time (OR 3.37, 95% CI: 2.51–4.52), positive head computed tomography result (OR, 2.47; 95% CI, 1.95–3.04), initial hemoglobin (OR, 1.69; 95% CI, 1.23–2.31), base deficit (OR, 1.62; 95% CI, 1.29–2.04), and trauma resuscitation bay systolic blood pressure (OR, 1.45; 95% CI, 1.11–1.88). We conclude that prognostic indicators of all-cause mortality after trauma, which remain independent in the presence of all other factors and are potentially treatable, included low hemoglobin, elevated prothrombin and partial thromboplastin time, low scene and trauma bay systolic pressure, and elevated base deficit. The independent indicators of mortality, which are untreatable, included head injury, increasing age, and Injury Severity Score.

Evaluating Blunt Abdominal Trauma with Sonography: A Cost Analysis

Ultrasonography (US) is becoming increasingly utilized in the United States for the evaluation of blunt abdominal trauma (BAT). The objective of this study was to assess the cost impact of utilizing US in the evaluation of patients with BAT in a major trauma center. All patients sustaining BAT during a 6-month period before US was used at our institution (Jan–Jun 1993) were compared to BAT patients from a recent period in which US has been utilized (Jan–Jun 1995). The numbers of US, computed tomography (CT), and diagnostic peritoneal lavage (DPL) were tabulated for each group. Financial cost for each of these procedures as determined by our finance department were as follows: US $96, CT $494, DPL $137. These numbers are representative of actual hospital expenditures exclusive of physician fees as calculated in 1994 U.S. dollars. Cost analysis was performed with t test and chi squared test, and significance was defined as P < 0.05. There were 890 BAT admissions in the 1993 study period and 1033 admissions in the 1995 study period. During the 1993 period, 642 procedures were performed on the 890 patients to evaluate the

abdomen: 0 US, 466 CT, and 176 DPL (see table). This compares to 801 procedures on the 1033 patients in 1995: 552 US, 228 CT, and 21 DPL. Total cost was $254,316 for the 1993 group and $168,501 for the 1995 group. Extrapolated to a 1-year period, a significant ( P < 0.05) cost savings of $171,630 would be realized. Cost per patient evaluated was significantly reduced from $285.75 in 1993 to $163.12 in 1995 ( P < 0.05). This represents a 43 per cent reduction in per patient expenditure for evaluating the abdomen. By effectively utilizing ultrasonography in the evaluation of patients with blunt abdominal trauma, a significant cost savings can be realized. This effect results chiefly from an eight-fold reduction in the use of DPL, and a two-fold reduction in the use of CT.

Blood Pressure Effects of Thoracic Gunshot Wounds: The Role of Bullet Image Diameter

Differences in handgun bullet diameter, expansion, and penetration (no exit) versus perforation (with exit) may be the cause of variable blood pressure effects after thoracopulmonary injury. Forty nonlethal isolated gunshot wounds of the thorax were evaluated excluding wounds of the heart, great vessels, and spinal cord. Chest radiographs were assessed for bullet base diameter, bullet expansion, and wound length. Large bullets were defined as having radiographic base images of 9 mm or more in diameter. Systolic blood pressures were compared between penetrating large and small bullet groups and with perforating wounds. Response times and demographics were compared. Wounds caused by large bullet penetration resulted in lower initial systolic blood pressures than wounds caused by small bullet penetration (98 vs 125 mm Hg, P < 0.05). The average age, transport time, and wound length were similar among the bullet groups. We conclude that penetrating thoracopulmonary wounds caused by large bullets resulted in lower initial systolic blood pressure.