Surgical resident experience on most trauma services is heavily weighted to nonoperative management, with a relatively low number of procedures, little experience with DPL, and highly variable experience with ultrasound. These data have serious implications for resident training and recruitment into the specialty.

BACKGROUND:Blunt traumatic abdominal wall hernias (TAWH) occur in approximately 15,000 patients per year. Limited data are available to guide the timing of surgical intervention or the feasibility of nonoperative management. METHODS:A retrospective study of patients presenting with blunt TAWH from January 2012 through December 2018 was conducted. Patient demographic, surgical, and outcomes data were collected from 20 institutions through the Western Trauma Association Multicenter Trials Committee. RESULTS:Two hundred and eighty-one patients with TAWH were identified. One hundred and seventy-six (62.6%) patients underwent operative hernia repair, and 105 (37.4%) patients underwent nonoperative management. Of those undergoing surgical intervention, 157 (89.3%) were repaired during the index hospitalization, and 19 (10.7%) underwent delayed repair. Bowel injury was identified in 95 (33.8%) patients with the majority occurring with rectus and flank hernias (82.1%) as compared with lumbar hernias (15.8%). Overall hernia recurrence rate was 12.0% (n = 21). Nonoperative patients had a higher Injury Severity Score (24.4 vs. 19.4, p = 0.010), head Abbreviated Injury Scale score (1.1 vs. 0.6, p = 0.006), and mortality rate (11.4% vs. 4.0%, p = 0.031). Patients who underwent late repair had lower rates of primary fascial repair (46.4% vs. 77.1%, p = 0.012) and higher rates of mesh use (78.9% vs. 32.5%, p < 0.001).Recurrence rate was not statistically different between the late and early repair groups (15.8% vs. 11.5%, p = 0.869). CONCLUSION:This report is the largest series and first multicenter study to investigate TAWHs. Bowel injury was identified in over 30% of TAWH cases indicating a significant need for immediate laparotomy. In other cases, operative management may be deferred in specific patients with other life-threatening injuries, or in stable patients with concern for bowel injury. Hernia recurrence was not different between the late and early repair groups.

Prognostic/Epidemiologic, level III.

The aim of this study was to evaluate the impact of prehospital antiplatelet and/or anticoagulant (APAC) use on treatment and outcomes in patients with severe blunt chest injury. Patients with three or more rib fractures and a hospital length of stay (LOS) > three days admitted from 2014 to 2015 were included. Demographics, mortality, complications, injuries, hospital and ICU LOS, use of blood products, and thoracostomy were studied. Of 383 patients, 27.4 per cent were on APAC medication. Patients on APAC were older ( P < 0.0001), had higher Glasgow Coma Score ( P < 0.0001), and had lower Injury Severity Score ( P < 0.0001) and total number of fractures ( P = 0.0013) than the non-APAC group. APAC was not a predictor of mortality with or without age adjustment. In multiple linear regressions, APAC did not predict an increased LOS. APAC patients did not demonstrate an increase in admission diagnosis or complication of hemothorax, blood transfusions, tube thoracostomy, tracheostomy, LOS, or mortality rates. Similar findings are present in the subgroup of patients studied with high kinetic energy mechanism of injury. Our study does not support the perceived morbidity of APAC therapy in patients with severe blunt chest injury.

No abstract

With quality and public reporting of increasing importance, benchmarks are anticipated to grow in relevance. We studied cholecystectomy in a practice in an urban tertiary care hospital. A total of 1083 cholecystectomies were performed in 2008 and 2009. Laparoscopic cholecystectomy was performed in 97.8 per cent of patients with a 2.2 per cent conversion rate. A planned open procedure was performed in only 2.2 per cent of patients. Approximately half of procedures were urgent and performed during an acute hospitalization. Most patients (74%) were female and most patients were overweight or obese (64.8%). Ages into the tenth decade of life were represented. Comorbidities included hypertension, 28.7 per cent; coronary disease, 15.6 per cent; diabetes mellitus, 13.4 per cent; gastroesophageal reflux disease, 10.7 per cent; and asthma, 5.5 per cent. Of female patients, 98 (12.2%) were postpartum and five (0.6%) were pregnant. Of 137 patients without gallstones, 59.1 per cent had biliary dyskinesia and 27 per cent had acalculous cholecystitis. Preoperative magnetic resonance cholangiopancreatography and endoscopic retrograde cholangiopancreatography (ERCP) were performed in most patients with suspected choledocholithiasis. Intraoperative cholangiograms were performed in 6.9 per cent of patients, 3.3 per cent for abnormal liver function studies. Postoperative ERCP was used in most patients with positive intraoperative cholangiograms. All-cause mortality was 0.8 per cent and attributable mortality was 0.2 per cent. Complications occurred in 7.5 per cent of patients, including retained common bile duct stones in 1.1 per cent, bile duct leak in 0.3 per cent, and common bile duct injury in 0.1 per cent.

BACKGROUND End-tidal carbon dioxide (ETCO2) is routinely used during elective surgery to monitor ventilation. The role of ETCO2 monitoring in emergent trauma operations is poorly understood. We hypothesized that ETCO2 values underestimate plasma carbon dioxide (pCO2) values during resuscitation for hemorrhagic shock. METHODS Multicenter trial was performed analyzing the correlation between ETCO2 and pCO2 levels. RESULTS Two hundred fifty-six patients resulted in 587 matched pairs of ETCO2 and pCO2. Correlation between these two values was very poor with an R 2 of 0.04. 40.2% of patients presented to the operating room acidotic and hypercarbic with a pH less than 7.30 and a pCO2 greater than 45 mm Hg. Correlation was worse in patients that were either acidotic or hypercarbic. Forty-five percent of patients have a difference greater than 10 mm Hg between ETCO2 and pCO2. A pH less than 7.30 was predictive of an ETCO2 to pCO2 difference greater than 10 mm Hg. A difference greater than 10 mm Hg was predictive of mortality independent of confounders. CONCLUSION Nearly one half (45%) of patients were found to have an ETCO2 level greater than 10 mm Hg discordant from their PCO2 level. Reliance on the discordant values may have contributed to the 40% of patients in the operating room that were both acidotic and hypercarbic. Early blood gas analysis is warranted, and a lower early goal of ETCO2 should be considered. LEVEL OF EVIDENCE Therapeutic, level IV.