Falls From Beds Among Elderly Outpatients: Injuries and Outcomes

Introduction Falls from beds (FFBs) among outpatient elderly individuals are a prevalent issue, particularly for those aged 65 and above. This presents a notable health challenge with consequences that extend beyond personal well-being, placing a considerable strain on healthcare systems. Fall-related injuries often result in reduced independence, increased morbidity, and, in severe instances, fatalities. It is crucial to address these outpatient falls to safeguard the health and independence of the elderly population. Methods This review presents data sourced from a trauma registry covering admissions from March 31, 2016, to December 27, 2021, at Desert Regional Medical Center, a Level 1 Trauma Center in Palm Springs, USA. Over this period, 3,148 patients sought emergency care following falls. The study specifically investigates cases following FFBs, revealing 164 admissions out of the total. Furthermore, it contrasts patient demographics, injury types, and outcomes with existing literature. Results This retrospective analysis found that, among the 164 patients admitted to the emergency department over a five-year and eight-month period due to FFBs, 143 were classified as elderly, aged 65 and above. The mean age of those admitted was 76, whereas those not admitted had a mean age of 71. A significant majority, 87%, were hospitalized; within this group, 16% required intensive care. Surgical intervention was necessary for 27 individuals, and there were three fatalities. Soft tissue hematomas were the most common injuries, representing 24% of injuries at admission, closely followed by upper extremity fractures at 21%. Over half of these patients could not return home post-hospitalization, with 41% being transferred to skilled nursing facilities (SNF). Conclusions As the aging population in the United States continues to grow, the incidence of falls is on the rise, resulting in injuries like fractures and head trauma. The objectives of this review are to provide an overview of the current literature on FFBs, as well as to emphasize the significant impact of such injuries on the elderly population. Additionally, it includes an analysis of a dataset detailing injuries resulting from bed-related falls, offering a comparison to existing research.

Branching Out: A Retrospective Review of Tree Fall-Related Trauma

Introduction Falls from trees (FFTs), although rare, represent a significant public health concern due to the severe consequences they can impose. Such incidents, while statistically uncommon across the wider population, have the potential to cause drastic, lasting alterations in patients' lives. The severity of these events is often substantial, highlighted by high Injury Severity Scores (ISSs) and prolonged hospital length of stay (LOS), which brings to light the urgent need for preventive strategies and heightened awareness. Our study aims to present a current epidemiological understanding of the patterns, nature, and severity of injuries caused by FFTs. Additionally, it provides an analysis and comparison of data obtained from a de-identified trauma database of patients presenting after FFTs. Methods This review presents data from a trauma registry system detailing trauma admissions from March 31, 2016, to December 27, 2021, at the Desert Regional Medical Center in Palm Springs, California, United States, a designated Level 1 trauma center. Throughout this period of nearly five years and eight months, a total of 3,148 patients were recorded to have visited the emergency department due to falls. Specifically, the study zeroes in on the subset of patients who were admitted after experiencing FFTs. From the comprehensive retrospective examination, it was noted that among the 3,148 fall incidents, there were 50 cases that involved FFTs. Results This retrospective analysis focused on 50 patients treated at the emergency department after FFTs, with a predominantly male demographic profile of 49 (98%) and an average age of 44 years. Hospitalization was required for the vast majority (44%), with approximately one-third necessitating ICU care. Surgical procedures were necessary for 35 (70%) of these cases. Upon discharge, 36 (72% of patients) were able to return home. Vertebral fractures were the most frequent injury, present in 24 (22% of admissions), followed closely by soft tissue injuries at 23 (21%). The mean ISS was 11, although those with extended hospital stays of over 10 days had higher ISS scores of 16, in contrast to an ISS of 10 for those with shorter stays. Conclusions FFTs constitute a lesser-known category of trauma-related injuries in the broader spectrum of fall-related incidents. Although relatively infrequent, these incidents result in significant injury burdens. The objective of this review is to compile and summarize the existing body of literature on FFTs. It involves an in-depth analysis of admission, discharge, and demographic data related to FFTs, highlighting the significant consequences associated with such accidents. Additionally, this review incorporates an analysis of a specialized dataset dedicated to injuries resulting from FFTs, facilitating a comparative assessment against current research in this field.

A Retrospective Study on the Outcomes of Injuries From Border Wall Falls

Objective Our retrospective cohort study focuses on the outcomes of injuries sustained from falls from the USA-Mexico border wall. The purpose of this study is to understand and predict the types of injuries that will be present in patients who fall from the border wall. This can further help trauma response teams to better predict and prepare for the care of these patients.  Methods  This retrospective cohort study included all patients that were admitted to Desert Regional Medical Center, a trauma I center, after a fall from the border wall that ranged from heights of 15 to 30 feet. The admissions occurred between March 2016 to December 2021.  Results  Of the 108 patients included, 38.2% (78) sustained at least one lower extremity injury, of which the most common was injury to the calcaneus bone. Additionally, there were several concomitant injuries, of which the combination of lower extremity and lumbar injury was found to be the most common (11.2%). The injury severity score (ISS) was found to not be statistically significant (ɑ=0.05) between groups of patients whose length of stay (LOS) in the hospital was greater than 10 days and less than 10 days. There was 1% fatality (1 of 108) and 92.5% required surgical intervention (100 of 108).  Conclusions Patients injured from border wall falls are more likely to sustain lower extremity injuries than injuries to other parts of the body. Additionally, patients with lower extremity injuries sustained lumbar spinal injuries concomitantly, which can be most likely attributed to the axial compression of the spine during these falls. Most of these injuries required surgery and hospital admissions to treat. Understanding the patterns of injury from border wall falls can further help trauma response teams treat patients with efficient management.

Time Delay in Motor Vehicle Accident Arrival: A Critical Analysis of Trauma Team Activation

Introduction This research aims to investigate the role of time since trauma (TST) in refining trauma team activation (TTA) criteria within a level I trauma center. We analyze the association between TST and post-emergency department (ED) disposition, proposing new insights for the enhancement of TTA criteria. Methods A retrospective analysis was conducted on a dataset comprising 3,693 patients presenting to a level I trauma center following motor vehicle accidents (MVAs) from 2016 to 2021. Data from a trauma registry, encompassing time of injury, time of ED arrival, TTA status, and post-ED disposition, were utilized. TST was calculated as the difference between the time of injury and the time of ED arrival. Patients that received TTA, full or partial, were categorized based on TST (less than one hour, one to two hours, and two or more hours). Statistical analyses, including chi-square tests, were performed using the Statistical Analysis System (SAS) (version 3.8, SAS Institute Inc., Cary, NC). Results Of the 1,261 patients meeting the criteria, 98.3% received TTA, with decreasing TTA rates observed with increasing TST (p = 0.0076). A significant association was found between TST and post-ED disposition for patients who received TTA (p = 0.0007). Compared to the other TST groups, a higher proportion of patients with a TST of two or more hours were admitted, sent to the intensive care unit (ICU), and sent to the operating room (OR).  Conclusion The study indicates a statistically significant relationship between TST and TTA rates, challenging our assumptions about the decreased need for TTA over time. While a longer TST was associated with a lower percentage of TTA, patients with a TST of two or more hours demonstrated increased rates of admission, ICU utilization, and surgical interventions. This suggests that TTA criteria may benefit from refinement to include patients with longer TST. Acknowledging study limitations, such as a small sample size and retrospective design, this research contributes valuable insights into potential considerations for optimizing trauma care protocols.

Outcomes of Surgical Rib Plating: A Case Series

Rib fractures are a common result of blunt thoracic trauma. Complications of rib fractures include pneumothorax, hemothorax, respiratory failure, and death. The conservative management of rib fractures has been the mainstay of care with surgical rib fixation as a secondary management only performed in complicated flail segments. The purpose of this retrospective study is to describe the outcomes of six patients who underwent surgical rib fixation following a traumatic injury at a Level 1 trauma center. All care for these cases was performed at Desert Regional Medical Center in Palm Springs, CA. On average, patients stayed 12.3 total days in the hospital and 4.6 in the intensive care unit. Out of the six patients, only one required prolonged respiratory support eventually resulting in respiratory failure and death. This retrospective study on surgical rib fixation highlights the importance of early surgical intervention and the need for more general and trauma surgeons to be familiar with the procedure itself.

Spontaneous Rupture of a Right Gonadal Artery Aneurysm: A Case Report

Gonadal artery aneurysm is a rare condition characterized by nonspecific presentation, typically manifesting as flank pain and formation of a retroperitoneal hematoma on imaging studies. Failure to recognize and treat this condition promptly can have serious consequences, as the presence of an aneurysm may lead to severe bleeding. Notably, most reported cases of gonadal artery aneurysms are not trauma-induced but rather spontaneous. In this case report, we describe the case of a previously healthy woman in her late 30s who presented to the emergency department with initial symptoms of flank pain and elevated white blood cell count. Subsequent imaging via computed tomography of the abdomen and pelvis revealed a significant hematoma surrounding the right kidney, indicative of a substantial hemorrhagic event. Angioembolization followed by endograft placement was performed on the patient, and she was expected to make a full recovery.

Falls From Heights: A Retrospective Review of Roof Fall-Related Trauma

Background Falls from roofs (FFRs), while constituting just a segment of all falls, pose a significant public health issue. They not only impact individuals in their daily lives but also pose an increased risk in the construction field. The consequences of these falls range broadly, from minor bruises to serious harm, potentially leading to chronic disability or fatality. For the general populace, such falls might happen during simple activities like maintenance, with outcomes varying from fractures to critical head or spinal injuries. In construction, where elevated work is the norm, the likelihood and potential severity of falls are significantly greater. Construction workers face the threat of falls regularly, with these mishaps often resulting in enduring disabilities that affect both life quality and work capability. Methodology This study presents data from a trauma registry system, covering trauma admissions from March 31, 2016, to December 27, 2021, at a level 1 trauma center (Desert Regional Medical Center, Palm Springs, CA). During this five-year and eight-month period, a total of 3,148 patients presented to the emergency department after a fall. This study focuses on patients admitted after an FFR. A retrospective analysis of this data showed that out of these 3,148 patients, 75 presented after an FFR. Results In this retrospective analysis of 75 patients presenting to the emergency department after an FFR, the patient profile was predominantly male (70, 93%), with an average age of 51 years. Hospitalization was required for the majority of the patients (70, 93%), with a third necessitating intensive care unit (ICU) care. The necessity for surgical procedures was high at 57 (76%). Upon discharge, 8 (11%) patients were moved to acute rehabilitation. Injuries to the extremities were most common, accounting for 21% (36) of cases, in contrast to facial injuries at 8% (15). Upper extremity fractures were the most prevalent presenting injury at 31% (50), while lower extremity fractures were the least at 6% (9). The overall Injury Severity Score (ISS) averaged 12, with patients having hospital length of stays (LOSs) over 10 days presenting higher ISS scores (18) compared to those with shorter stays (ISS of 11). There was no significant difference in ISS between patients aged 60 and above compared to younger patients. Conclusions FFRs represent a substantial cause of injury in both the construction industry and residential settings. This study aims to provide an overview and summary of the existing literature on FFRs, present effective fall prevention methods, and underscore the considerable consequences of such injuries on both construction workers and homeowners. Additionally, it includes an analysis of a dataset detailing injuries resulting from roof-related falls, offering a comparison to existing research.

Injury Patterns in Vehicle Crashes: The Significance of Occupant Seating Position

OBJECTIVES

 Investigating patterns among the outcomes of patients involved in motor vehicle accidents (MVAs) can provide information necessary to guide targeted interventions to improve road traffic safety. Our purpose is to identify any differences between passenger and driver injury severity and overall clinical course after MVAs.

METHODS

 We performed a retrospective review and analysis of 3,693 patients involved in MVAs from 2016 to 2021. We divided the data into two groups, drivers and passengers, and compared the Injury Severity Score (ISS), Revised Trauma Score (RTS) on admission, days in the Intensive Care Unit (ICU), length of hospital stay (LOS), post Emergency Department (ED) disposition, discharge (DC) disposition, and signs of life on arrival (SOLA) to the ED. We compared mean ISS, New Injury Severity Score (NISS), RTS, length in ICU and LOS using a student's T-test and SOLA, post-ED and DC disposition using Chi-square analysis.

RESULTS

 We did not find any statistically significant difference in ISS, RTS, days in ICU, LOS, or SOLA between the drivers and passengers. However, we did find a statistically significant difference in the post-ED (X2= 113.743, p=<0.0001) and DC disposition (X2=41.172, p=<0.0001) of drivers and passengers. After the ED and DC, more passengers were transferred to a higher level of care than expected, while the inverse was true for drivers. The number of drivers discharged to Skilled Nursing Facilities (SNFs) was also higher than expected, further contributing to the observed difference in DC disposition.  Conclusion: Our study found no statistically significant difference between driver and passenger injury severity, length of hospital stay, days in ICU, and SOLA after an MVA. The clinical courses of the two groups were found to be significantly different based on post-ED and DC disposition data. We identified limitations, such as a relatively small sample size and insufficient data on specific car seat locations for passengers, underscoring the need for a more nuanced exploration. Future research must broaden its scope to encompass diverse crash scenarios, vehicle design and safety technologies, seat belt dynamics, and age- and gender-specific vulnerabilities.

Azygos Vein Pseudoaneurysm After Trauma: A Case Report

High-speed motor vehicle collisions (MVCs) often result in severe musculoskeletal, neurological, and vascular injuries. Among these, azygos vein pseudoaneurysms (AVPs) are a rare and potentially life-threatening vascular complication. Our case study highlights an instance of an AVP arising from a high-velocity MVC, underscoring their critical significance in trauma scenarios. Additionally, this report delves into the complexities of managing AVPs, both traumatic and idiopathic, emphasizing the urgent need for intervention and the intricacies of their treatment.

Acquired Hemophilia A After Multiple Transfusions Following Trauma

Acquired hemophilia A (AHA) is a coagulative disorder that is caused by the presence of inhibitors of factor VIII (FVIII). The presence of coagulation factor inhibitors can lead to severe episodes of bleeding in patients with no previous history of bleeding conditions. We present the clinical case of a man with severe bleeding two weeks after falling from a bicycle. The patient denied any previous history of bleeding disorders. The case clinically presented with a large retroperitoneal hematoma and continued to show signs of active bleeding even after multiple transfusions were administered. Coagulation studies showed an elevated inhibitor titer of 24.4 BU/mL (normal range is below 5 BU/mL) and a reduced FVIII activity level of 2% (normal range is between 50% to 150%), providing evidence of AHA. Hemostatic and immunosuppressive agents were then administered to the patient, whose condition improved in response to the treatments.

Increased Mortality and Morbidity Due to the Increase in Border Wall Height

Objective Our retrospective cohort study focuses on the differences in the severity of injuries sustained from border wall falls before and after wall height increase. Severity of injuries is categorized by injury severity score (ISS), length of stay in the hospital (LOS), ventilation, intensive care unit (ICU), and surgery. The purpose of this study is to underline the medical consequences of extending the US-Mexico border wall. Specifically, we focused on the severity of injuries that are seen in trauma centers near the US-Mexico border. We propose that the rise in trauma cases from the border wall is associated with the extension of the border wall.  Methods  This IRB-approved, retrospective cohort study included all patients that were admitted to Desert Regional Medical Center, a level 1 trauma center in Palm Springs, California, United States. Patients were admitted between March 2016 and December 2021, after sustaining a fall from the border wall. The fall of the height ranged from 15 to 30 feet. Patients were assigned to pre-2020 or post-2020 subgroups, based on time of admission. The total number of admissions, ISS, LOS, surgeries, ventilation, and ICU services were compared.  Results  Injuries from border wall falls grew 1250% from 2016 to 2021 (4 vs 50 admissions). When comparing the two subgroups, hospital admissions (20 vs 84) and ISS (9 vs 15) have also risen dramatically. Of all the variables compared, the days spent in the ICU proved to be statistically significant at a p-value of 0.02. Although the remaining data was not statistically significant, there still remains a trend of increasing injuries that are also more severe in presentation, requiring more interventions.  Conclusions The increase in border height has led to a record-high number of admissions and severity of injuries. This study shows that increasing the border wall height has led to a public health crisis and underlines the profound impact that political decisions have in the medical field.

Laparoscopic Cholecystectomy in a Patient With Situs Inversus: A Case Report and Literature Review

Situs inversus (SI) is an autosomal recessive congenital abnormality in which there is a complete mirror reversal of visceral organs. In this article, we present the case of a 26-year-old male with a past medical history of suicidal ideations, gallstones, and SI who complained of left upper quadrant pain for two weeks. After admission for acute cholecystitis, he underwent a successful laparoscopic cholecystectomy without postoperative complications. Due to the anatomical deviation characteristic of SI, it can be challenging for surgeons to accurately diagnose and perform laparoscopic cholecystectomies. Careful consideration must be given when deciding to do a laparoscopic cholecystectomy, as the placement of not only the trocars and surgical instruments but also the position of the surgeon and assistants needs to be deliberated.

Management of a Flail Chest Caused by Multiple Costosternal Fractures: A Case Report

Costochondral separation is a rare consequence of blunt thoracic trauma and can lead to life-threatening complications such as a flail chest. The diagnosis of costochondral separation remains challenging due to the obscurity of the condition on chest radiographs. Surgical rib fixation is a viable treatment option and research regarding its effectiveness and long-term benefits is promising but still evolving. Here, we discuss a case of flail chest caused by multiple costosternal fractures definitively managed with surgical rib fixation.

Spontaneous Bladder Rupture After Binge Drinking

Spontaneous bladder rupture is a rare cause of the acute abdomen. Alcohol has been described as one of the most common causes of spontaneous bladder rupture. We present the case of a 42-year-old male who presented to our Level I Trauma Center complaining of abdominal pain and difficulty urinating after an evening of drinking. Initial workup revealed free air and fluid within the abdomen and a Foley catheter within the peritoneal cavity. He was taken to the operating room emergently for exploration and was found to have a bladder rupture that was repaired. Post-operatively he recovered without complication. The often missed or delayed diagnosis of spontaneous bladder ruptures can increase morbidity and mortality. It is important to keep spontaneous bladder rupture in the differential when evaluating a patient with abdominal pain.

Rare Escherichia coli Empyema Necessitating to Pelvic Retroperitoneum With Extension to the Groin

Empyema necessitans is a rare form of infection that spreads to the soft tissue of visceral organs. In the case of thoracic empyema, the infection can spread to the parietal pleura of the lungs. This can cause many complications as treatment is more complicated with the spread of this infection. Escherichia coli (E. coli) is a rare occurrence of this infection, and understanding its role in the community and the implications of its survival in extraintestinal environments can be beneficial for the treatment of these cases.

Management of Complex Duodenal Injuries After Penetrating Trauma

Penetrating injuries to the duodenum can present a complex case for trauma or acute care surgeons. The associated injuries and complications can have devastating results. This report presents the case of a 41-year-old male who presented with a gunshot wound to his abdomen and suffered a gastric injury, transverse colon injury, duodenal injury, renal injury, and pancreatic tail injury. In this case, the patient underwent a complex Roux-en-Y reconstruction. The patient had a good outcome and continues to recover at home.

Cognitive Bias in the Management of a Critically Ill 29-Year-Old Patient

Cognitive bias is a significant issue in the management of critically ill patients. Often patients cannot communicate due to illness or mechanical ventilation, making history-taking difficult. Here we present a case where cognitive bias led the clinical team to treat the wrong diagnosis until the patient was in extremis.  We present a 29-year-old otherwise healthy female who initially presented to an outside facility with severe abdominal pain and hypotension. Due to a history of medical abortion two weeks prior, the patient was initially diagnosed with sepsis due to retained products of conception. Following a dilation and curettage that revealed no retained POC and worsening of the patient's symptoms, the patient was transferred to our facility for higher care. Over five additional days, the patient had a significantly worsening clinical picture before new diagnoses such as abdominal compartment syndrome, necrotic bowel, and adverse effects from diet pill cleanse were considered and acted upon. The patient ultimately suffered abdominal and bilateral lower extremity compartment syndrome leading to colectomy and bilateral below-the-knee amputations. As clinicians, we must provide the best care possible and reduce patient suffering. Cognitive bias is something that all clinicians must be aware of and learn to manage. Failure to be aware of one's cognitive bias puts the patient at risk and can be harmful. This case illustrates just how detrimental cognitive bias and misdiagnoses can be.

Marijuana Screening and Trauma Outcomes

Objective

The objective of this study was to determine if positive marijuana toxicology screen is associated with worse outcomes following trauma.

Methods

A 3-year retrospective study was conducted on adult trauma patients using a Level II trauma registry. Patients were included if they had marijuana toxicology results available and were excluded if they tested positive for polysubstance. Endpoints of interest were mortality, injury severity score, length of stay (LOS), Glasgow coma Scale, and blood requirements.

Results

Three hundred and eighty-one patients met the criteria. There was no difference between the two groups with regard to mortality (1.63% vs. 3.05%, odds ratio [OR]: 0.52 [0.13-2.14]) or LOS (1 day vs. 1 day, P = 0.125), and P > 0.05 for all other metrics besides age (31.53 years vs. 50.20 years, P = 0). OR for suffering major trauma in patients <55 years was 2.26 (16.88% vs. 8.26%, OR: 2.26 [1.02-5.01]), and patients 55 years and older were more likely to present with lower blood pressure (129.12 mmHg vs. 140.85 mmHg, P = 0.002) and higher heart rate (95.25 bpm vs. 83.47 bpm, P = 0.026).

Conclusions

A positive screen for marijuana in the setting of a trauma is not associated with increased mortality or hospital LOS. These results warrant further investigation of the effects of marijuana on trauma outcomes.

Benchmarking blood sugar control in the small rural intensive care unit

Objective: We sought to determine a benchmark for our blood glucose monitoring and compare our data to published data.Methods: Natividad Medical Center is a 172-bed rural hospital located in Salinas, California.Point of care blood glucose (POC-BG) data was extracted from our EMR for all ICU patients greater than 18 years of age between January 2014 and May 2018. Patient day-weighted mean POC-BGs were calculated for each patient by calculating the average POC-BG per day for each patient. Proportion measurements for each of our measurements groups were recorded (>180 mg/dL, <70 mg/dL, >250 mg/dL and <50 mg/dL). Monthly averages were plotted for visual comparison. Benchmarks were calculated by using 2x Standard Deviation for each measurement group.Results: A total of 3164 patients were found with 21,006 POC-BG measurements. The average POC-BG was 136 mg/dL and median 119 mg/dL. Proportion measurements of monthly day-weighted mean POC-BGs ranged from 0-1.2%, 5.3-44.8%, 0-0.3% and 0.6-16.5%, respectively for less than 70 mg/dL, greater than 180 mg/dL, less than 50 mg/dL and greater than 250 mg/dL. A 2x Standard Deviation was used to calculate our benchmark cut offs which provides a 95% confidence interval and includes 97.5% when neglecting the lower range. Our calculated benchmark values are 1.2, 38.2, 0.19, and 13.1% respectively for measurement groups less than 70 mg/dL, greater than 180 mg/dL, less than 50 mg/dL and greater than 250 mg/dL.Conclusion: Here we present data from a small rural hospital in the Western United States. We calculated benchmarks that could be used to track our ongoing hyper/hypoglycemia improvement projects. We found that when compared to published data, our hyper/hypoglycemia data was comparable to national data.

Empiric Stress Dose Steroids in Trauma Patients: A Case Report of Hypopituitarism in Traumatic Hemorrhage

Trauma patients experience relative adrenal insufficiency or critical illness-related corticosteroid insufficiency (CIRCI) in majority of 60% of patients. It has been shown that both septic shock and trauma cause dysfunction of the hypothalamic–pituitary axis and, in some cases, structural damage to the adrenal glands themselves through hemorrhage or infarction. Empiric steroids are used commonly in patients with septic shock for patients who are refractory to fluids and vasopressors. Here, we present a unique case of a 40-year-old male with multisystem trauma who developed adrenal crisis treated by empiric stress-dose steroids. His history later revealed a history of hypopituitarism. Although data do not support the use of empiric steroids for trauma patients, this case illustrates an example where considering steroid use and keeping adrenal insufficiency and CIRCI in the differential can influence outcome.

Recreational Drugs and Outcomes in Trauma Patients

Objective:

The objective of the study is to determine if marijuana, methamphetamine, or cocaine is associated with worse outcomes following trauma.

Methods:

A retrospective cross-sectional study was conducted on 731 trauma patients. Data collected from Natividad Medical Center's trauma registry were used to analyze reports of adult patients from July 1, 2014, to July 1, 2017. Analyzed endpoints were mortality, rates of major trauma, mean Injury Severity Score (ISS), and length of stay (LOS).

Results:

Odds ratios for mortality contained null value in each group. Odds ratios for suffering major trauma for marijuana and amphetamines were 1.2 and 2.6, respectively. P values for ISS were >0.05 for each group. P values for LOS were >0.05 for marijuana and cocaine and 0.01 for amphetamines.

Conclusions:

A positive screen for marijuana, amphetamine, or cocaine is not associated with increased mortality for victims of trauma. Amphetamines are associated with higher rates of major trauma and longer LOS. Marijuana is associated with higher rates of major trauma. Cocaine is not associated with the likelihood of suffering major trauma or length of stay.

Effects of Body Mass Index on Outcome Measures of the Patients with Penetrating Injuries; A Single Center Experience

Objective:

To determine if there was any decrease in measures of injury severity or outcome with obese patients (body mass index greater than or equal to 30 kg/m2) as compared to non-obese patients (body mass index less than 30 kg/m2).

Methods:

We conducted a retrospective review of the trauma database maintained by Natividad Medical Center's Level 2-Trauma program. From July 1st, 2014 to July 1st, 2017 there were 371 cases of penetrating trauma in adults between the ages of 18-80 years old. Overall 311 patients had BMI data recorded. We divided these 311 patients into two groups: penetrating injury due to firearm (n= 198) and penetrating injury due to stabbing or piercing (n=113). We compared non-obese patients against obese patients for age, gender, Injury Severity Score (ISS), length of stay (LOS), Intensive Care Unit LOS, units of blood given, direct transfer from ED to operating room, and mortality.

Results:

A total of 311 patients were included in the study, 198 (63.6%) patients suffered from gunshot wounds and 113 (36.4) from stab or piercing wounds. The mean age was 33.6 ± 12.8 and there were 283 (91%) men among the victims. Overall 87 (28%) required emergent surgery and a 19 (6.1%) mortality rate was recorded. In the gunshot wound group there was no significant difference between non-obese and obese patients for age (p=0.400), gender (p=0.900), ISS (p=0.544), LOS (p=0.273), Intensive Care Unit LOS (p=0.729), units of blood given (p=0.300), or mortality (p=0.855). We found that in the stab or piercing group there was no significant difference between non-obese and obese patients for age (p=0.900), gender (p=0.900), ISS (p=0.580), LOS (p=0.839), Intensive Care Unit LOS (p=0.305), units of blood given (p=0.431), or mortality (p=0.321).

Conclusion:

Our findings indicate that in our patient population, there was no significant difference in markers of injury severity, morbidity, or mortality in adult non-obese patients as comparted with obese patients.  Furthermore, there was no significant difference between the two groups in operative rates, suggesting that obesity may not confer a protective effect in penetrating trauma.

Hemorrhagic Cholecystitis after Warfarin Use for Deep Vein Thrombosis

Hemorrhagic cholecystitis is an uncommon form of acute cholecystitis which can be rapidly fatal. It may be hard to detect as it frequently presents with symptoms found in other, more common diagnoses. We report the case of a 63 year old man recently started on anticoagulation for deep vein thrombosis who was found to have hemorrhagic cholecystitis.

Massive Blood Transfusions and Outcomes in Trauma Patients; An Intention to Treat Analysis

Objective:

To determine if there exists an upper limit for amount of blood transfused in trauma patients before it reaches a point of futility.

Methods:

A prospective cohort study was conducted on 131 patients who received massive blood transfusion (MBT), defined as 10 U or higher of PRBCs received in the initial 24 hours. Data collected from a Level II trauma center registry were used to analyze reports of adult patients from July 2014 to 2017. Cohorts were divided by amount of blood received - 0 to 9 U, 10-19 U, 20 to 29 U, 30-39 U, 40 U or higher - odds ratio for mortality and p-values for mean Injury Severity Score and overall hospital length of stay were calculated for each group.

Results:

Odds ratios for massive blood transfusion groups from 10 units to 39 units each contained the null value, while our 40 units and above group did not (OR 12.52, 95% CI 1.3-117.7).

Conclusion:

Although this study is limited by its sample size, these results suggests that 40 units of PRBCs may be a threshold at which survival rates begin to decrease significantly.

Recurrent left chest mass: a case report

Empyema necessitans is a rare complication of untreated pleural space infections. Untreated empyema that spontaneously burrows through the parietal pleura can present with a subcutaneous abscess. In the following case report, we present a 55 year old male who presented with an intermittent left chest mass later to be diagnosed as empyema necessitans. The patient suffered from a hemothorax treated by tube thoracostomy three years prior. The patient had been seen several times and no mass could be appreciated. The patient was diagnosed with empyema necessitans on computed tomography and treated with a left thoracotomy. Empyema necessitans can develop if pleural infections are left untreated. We present an unusual presentation of this rare complication. Empyema necessitans should be kept in the differential diagnosis of patients with left chest masses or abscesses.

Scapulothoracic dissociation: An emerging high-energy trauma in medical literature

Scapulothoracic dissociation (STD) is a devastating consequence of high-energy trauma sustained by the shoulder girdle that can easily result in rapid mortality. Since described by Oreck et al. in 1984, STD has been reported in a handful of journals and individual case series, though is still considered a rare occurrence in the context of shoulder injuries. In this report, we examine the case of a 25-year-old female involved in a high-speed rollover auto accident. Unique to this case was the discovery of a completely transected axillary artery and vein with intracorporeal bleeding and complete avulsion of the ipsilateral brachial plexus requiring immediate ligation of the vessels followed by interval above-elbow-amputation and later glenohumeral disarticulation.

Delayed presentation of sigmoid volvulus in a young woman

Volvulus is an unusual condition in Western countries, generally isolated to elderly patients with multiple comorbidities. This report describes an unusual case of a very large gangrenous sigmoid volvulus in a young, otherwise healthy 25-year-old female. A review of the diagnosis and management is subsequently described. Without a consideration of the atypical demographics for sigmoid volvulus, the case illustrates the potential morbidity due to a delayed diagnosis. Early identification and management are crucial in treating sigmoid volvulus before the appearance of gangrene and necrosis, thereby avoiding further complications and associated mortality.

Safety analysis of percutaneous dilational tracheostomies with bronchoscopy in the obese patient

OBJECTIVES/HYPOTHESIS

Since originally described in 1985 by Ciaglia, percutaneous dilational tracheostomy (PDT) has grown in popularity, and today is widely used for critically ill patients requiring long-term mechanical ventilation. Since the inception of PDT, obesity has been considered a relative contraindication to its use. The purpose of this study is to evaluate the risks of PDT in obese patients.

STUDY DESIGN

Retrospective review.

METHODS

A retrospective review was performed of prospectively collected data from 426 patients who underwent PDT at a single teaching institution from July 2003 to October 2009. The groups were separated into those who had a body mass index (BMI) of <30 or ≥30 kg/m(2) . The following variables were collected: blood loss at the time of procedure, difficulty in tracheotomy dilation and/or tracheostomy placement, presence of tracheal ring breaks, any bleeding episodes requiring treatment by surgery or blood transfusion, pre- and postprocedure pneumonia, and stoma infection requiring antibiotics. All tracheostomies were placed using the Ciaglia Blue Rhino Introducer Kit (Cook Medical Inc., Bloomington, IN). Statistical analysis was performed with nonparametric statistics using χ(2) testing with P < .05 as significant.

RESULTS

No statistically significant difference was found between the obese and nonobese groups for any of the variables studied. Similar results were found when BMI of 40 was used for grouping.

CONCLUSIONS

PDT can be performed safely in obese patients. There were no statistically significant differences in measured variables found between the two study groups. This study supports the use of intensive care unit bedside PDT in the obese population.

Sodium acetate infusion in critically ill trauma patients for hyperchloremic acidosis

Introduction

Sodium acetate has been shown to cause hemodynamic instability when used as a hemodialysis buffer. The pattern of hemodynamic response to injury will be evaluated between those who received sodium acetate and those who did not.

The primary purpose of the study is to analyze the effect of sodium acetate on hemodynamic parameters. Secondarily we looked at the effects on prevention and treatment of hyperchloremic metabolic acidosis.

Methods

The study arm was comprised of patients who had received sodium acetate infusions in place of normal saline between March 2005 and December 2009. A control arm was created based on matching three pre-treatment variables: injury severity score (ISS), pH (+/- 0.03) and base deficit (+/- 3). A retrospective chart review was performed for patients in both arms. Blood pressure, arterial blood gas data and chemistry values were recorded for the time points of -6, -1, 0, 1, 6, 12, 24, 48, and 72 hours from start of sodium acetate infusion. Patients were excluded based on the following criteria: patients who were given sodium bicarbonate within 48 hours of starting sodium acetate, those given sodium acetate as a bolus, non-trauma patients, burn patients, patients who expired within 24 hours of arrival to the ICU, patients diagnosed with rhabdomyolysis and patients whose medical record could not be obtained.

Results

A total of 78 patients were included in the study, 39 in the study arm and 39 in the control arm. There were no statistically significant drops in blood pressure within either group. The median pH between the two groups at the start of infusion was equal. Both groups trended towards normal pH with the study arm improving faster than the control arm. The median serum bicarbonate at start of sodium acetate infusion was 19 mmol/L and 20 mmol/L at time zero for the study and control arms respectively with both trending upward during the study period. Chloride trended up initially in both groups but the study arm began to correct sooner at 24 hours compared to 48 hours for the control arm.

Conclusion

We analyzed the use of sodium acetate as an alternative to normal saline or lactated ringers during resuscitation of critically ill trauma patients at a single center. Our data shows that the hemodynamic profile remained favorable, without evidence of instability at any point during the study period. Normalization of hyperchloremia and metabolic acidosis occurred faster in the patients who received sodium acetate.

Giant fibroadenoma in a 22 year old patient: case report and literature review

Giant fibroadenomas are a rare form of fibroadenoma that present as rapidly enlarging breast masses. They are typically greater than 5 cm or 500 grams in size and most frequently are seen in premenopausal Afro-Caribbean or East Asian females. This unique case report presents a 22-year-old female who presented with an enlarging breast mass measuring 23 × 28 cm. After core needle biopsy, the mass was diagnosed as a giant fibroadenoma and treated surgically with mastectomy. After a 5 year follow up she has not reported any signs of recurrence of the mass.