scholarly journals Emergency trauma laparotomy and/or thoracotomy in the emergency department: risks and benefits

2019 ◽  
Vol 4 (1) ◽  
pp. e000269 ◽  
Author(s):  
Kaori Ito ◽  
Kahoko Nakazawa ◽  
Tsuyoshi Nagao ◽  
Hiroto Chiba ◽  
Yasufumi Miyake ◽  
...  
Keyword(s):  
Emergency Department ◽  
Injury Severity ◽  
Balloon Occlusion ◽  
Red Blood Cell Transfusion ◽  
Acute Care Surgery ◽  
Perioperative Outcomes ◽  
Emergency Laparotomy ◽  
Level Of Evidence ◽  
Anesthetic Care ◽  
Care Surgery

BackgroundIt is not mandatory for Japanese trauma centers to have an operating room (OR) and OR team available 24 hours a day/7 days a week. Therefore, emergency laparotomy/thoracotomy is performed in the emergency department (ED). The present study was conducted to assess the safety of this practice.MethodsThe data were reviewed from 88 patients who underwent emergency trauma laparotomy and/or thoracotomy performed by our acute care surgery group during the period from April 2013 to December 2017. Operation was performed in the ED for 43 of 88 patients (51%, ED group), and in the OR for 45 of 88 patients (49%, OR group). The perioperative outcomes of the two groups were compared.ResultsCompared with the OR group, the ED group had a higher Injury Severity Score (30±15 vs. 13±10, p<0.01), greater incidence of blunt trauma (74% (32/43) vs. 36% (16/45), p<0.01), larger volume of red blood cell transfusion (18±18 units vs. 5±10 units, p<0.01), higher incidence of new-onset shock after sedation among patients who received sedation in the ED (59% (17/29) vs. 25% (6/24), p<0.01), and higher in-hospital mortality rate (49% (21/43) vs. 0, p<0.01). All five patients who underwent laparotomy followed by thoracotomy died in the ED; none of these patients underwent preoperative placement of resuscitative endovascular balloon occlusion of the aorta (REBOA). Of the 21 patients in the ED group who died, 17 (81%) died immediately postoperatively; furthermore, 12 of the 22 patients who survived (55%) were not in shock prior to operation.DiscussionEmergency trauma laparotomy and/or thoracotomy outcomes were related to injury severity. The resources for trauma operations in the ED seemed suboptimal. The outcome of trauma operations may be improved by reviewing the protocols for anesthetic care, and by the usage of REBOA rather than aortic cross-clamping.Level of evidenceIV

Contemporary Utilization of Zone III REBOA for Temporary Control of Pelvic and Lower Junctional Hemorrhage Reliably Achieves Hemodynamic Stability in Severely Injured Patients

2019 ◽  
Vol 3 (2) ◽  
Author(s):  
Jason Pasley
Keyword(s):  
Vital Signs ◽  
Balloon Occlusion ◽  
Aortic Occlusion ◽  
Acute Care Surgery ◽  
Level Of Evidence ◽  
Systemic Complications ◽  
Occlusion Balloon ◽  
Valuable Adjunct ◽  
Care Surgery ◽  
Temporary Control

Background: Aortic occlusion is a valuable adjunct for management of traumatic pelvic and lower extremity junctional hemorrhage. Methods: The American Association for the Surgery of Trauma's Aortic Occlusion in Resuscitation for Trauma and Acute Care Surgery registry was reviewed for patients requiring Zone III resuscitative endovascular balloon occlusion of the aorta (REBOA) from eight verified trauma centers. After excluding patients in arrest, demographics, elements of treatment and outcomes were identified. Results: From Nov 2013 – Dec 2016, 30 patients had Zone III REBOA placed. Median age was 41.0 (IQR 38); median ISS 41.0 (IQR 12). Hypotension (SBP < 90mm Hg) was present on admission in 30.0% and tachycardia (HR > 100 bpm) in 66.7%. Before REBOA placement, vital signs changed in this cohort with hypotension in 83.3% and tachycardia noted in 90%. Median initial pH was 7.14 (IQR 0.22), and median admission lactate 9.9 mg/dL (IQR 5). Pelvic binders were utilized in 40%. Occlusion balloon devices included Coda™ (70%), ER-REBOA™ (13.3%), Reliant™ (10%).  After REBOA, hemodynamics improved in 96.7% and stability (BP consistently > 90 mm Hg) was achieved in 86.7%. Median duration of REBOA was 53.0 mins (IQR 112). Median PRBC and FFP requirements were 19.0 units (IQR (17) and 17.0 units (IQR 14), respectively. One amputation unrelated to REBOA utilization was required. Systemic complications included AKI (23.3%) and MODS (10%). REBOA specific complications included groin hematoma (3.3%) and distal thromboembolization (16.7%). Survival to discharge was 56.7%, with in-hospital deaths occurring in the ED 7.7%, OR 23.1%, ICU 69.2%. Conclusions: This review discusses the specifics of the contemporary use of Zone III REBOA placement as well as local and systemic complications for patients in extremis with pelvic/junctional hemorrhage. Further review is required determine optimal patient selection. Level of Evidence: Level IV Study Type: Therapeutic Key Words   Zone III REBOA, Pelvic Bleeding, Junctional Hemorrhage

Acute care surgery: the impact of an acute care surgery service on assessment, flow, and disposition in the emergency department

2012 ◽  
Vol 203 (5) ◽  
pp. 578-583 ◽  
Author(s):  
Chad G. Ball ◽  
Anthony R. MacLean ◽  
Elijah Dixon ◽  
May Lynn Quan ◽  
Lynn Nicholson ◽  
...  
Keyword(s):  
Emergency Department ◽  
Acute Care ◽  
Acute Care Surgery ◽  
Care Surgery ◽  
The Impact

Validation of a Novel Clinical Criteria to Predict Candidacy for Aortic Occlusion: An Aortic Occlusion for Resuscitation in Trauma and Acute Care Surgery Study

2020 ◽  
Vol 86 (10) ◽  
pp. 1418-1423
Author(s):  
Reynold Henry ◽  
Kazuhide Matsushima ◽  
Rachel N. Henry ◽  
Gregory A. Magee ◽  
Christoper P. Foran ◽  
...  
Keyword(s):  
Acute Care ◽  
Vital Signs ◽  
Balloon Occlusion ◽  
Aortic Occlusion ◽  
Acute Care Surgery ◽  
Trauma Patients ◽  
Clinical Criteria ◽  
Resuscitative Thoracotomy ◽  
Control Procedures ◽  
Care Surgery

For trauma patients with noncompressible truncal hemorrhage (NCTH), aortic occlusion (AO) is attempted with either resuscitative thoracotomy (RT) or the resuscitative endovascular balloon occlusion of the aorta (REBOA). However, it is often challenging to identify the group of patients who would benefit from AO procedures. We hypothesized that patients who met simple clinical criteria would have better outcomes following AO procedures. This is a retrospective cohort study using the Aortic Occlusion for Resuscitation in Trauma and Acute Care Surgery database (November 2013-August 2019) which included patients who arrived with signs of life and underwent AO procedures (RT or zone 1 REBOA). Outcomes were compared between patients who met the criteria (admission vital signs: Glasgow Coma Scale (GCS) ≥9 and systolic blood pressure <90 mm Hg) and those who did not. Subgroup analyses were then conducted on patients who had a REBOA placed and those who underwent RT. A total of 998 patients met our inclusion criteria. Of those, a REBOA was placed in 364 patients (37%), while 634 (64%) underwent RT. The overall mortality rate in the criteria (+) group was significantly lower than that in the criteria (−) group (62 vs. 79%, P < .001). In patients who survived beyond the emergency department following AO procedures, those who met the criteria underwent hemorrhage control procedures more frequently (83% vs. 57%, P < .001). Our data suggest that simple clinical criteria could guide the provider for proceeding with AO in patients with suspected NCTH.

scholarly journals Emergency Laparotomy in the Critically Ill: Futility at the Bedside

2018 ◽  
Vol 2018 ◽  
pp. 1-6 ◽  
Author(s):  
Niels D. Martin ◽  
Sagar P. Patel ◽  
Kristen Chreiman ◽  
Jose L. Pascual ◽  
Benjamin Braslow ◽  
...  
Keyword(s):  
Mortality Rate ◽  
Critically Ill ◽  
High Mortality ◽  
Kidney Injury ◽  
Acute Care Surgery ◽  
Emergency Laparotomy ◽  
Abdominal Exploration ◽  
Lactate Levels ◽  
American Society ◽  
Care Surgery

Background. Critically ill patients are often evaluated for an intra-abdominal catastrophe. In the absence of a preoperative diagnosis, abdominal exploration may be offered despite desperate circumstances. We hypothesize that (1) abdominal exploration for such patients is associated with a high mortality and (2) commonly obtained physiologic measures at laparotomy anticipate mortality. Methods. All acute care surgery (ACS) patients undergoing emergency laparotomy at a quaternary referral center during a 3-year period were reviewed. Inclusion was defined by emergency laparotomy in the operating room (OR) in a patient with an American Society of Anesthesiologists (ASA) score ≥4 or bedside laparotomy in the ICU (BSL). Mortality was the primary endpoint and was stratified by demographics, admitting service, surgical findings, and physiology. Comparisons between OR and BSL were by Fisher’s exact and Mann–Whitney tests. Results. 144 patients underwent emergency laparotomy (45 BSL vs. 99 OR). Overall mortality was 55.6% (77.8% BSL vs. 45.5% OR; p<0.001). Mortality by admitting service was cardiac 71.4% (n=42), medical 70% (n=30), ACS 42% (n=50), and other 36.4% (n=22) services. Preoperative lactate levels were higher in nonsurvivors (2.7 vs. 8.5 mmol/L, p<0.001), as was vasopressor use (62.5% vs. 97.5%, p<0.001), acute kidney injury (51.6% vs. 72.5%, p<0.01), leukocytosis (53.1% vs. 71.3%, p<0.04), and anemia (45.3% vs. 71.3%, p<0.01). The presence of any identifiable abdominal pathology established a 90% mortality rate. Conclusions. The need for BSL portends an extremely high mortality rate and is likely useful in preintervention counselling. Emergency OR laparotomy leads to mortality in nearly half of such patients and is anticipatable based on concurrent abnormal physiology.

scholarly journals Development of an acute care surgery service in Rwanda

2019 ◽  
Vol 4 (1) ◽  
pp. e000332 ◽  
Author(s):  
Egide Abahuje ◽  
Isaie Sibomana ◽  
Elisee Rwagahirima ◽  
Christian Urimubabo ◽  
Robert Munyaneza ◽  
...  
Keyword(s):  
Hospital Stay ◽  
Acute Care ◽  
Epidemiologic Study ◽  
Length Of Hospital Stay ◽  
Acute Care Surgery ◽  
Level Of Evidence ◽  
Midline Laparotomy ◽  
Resource Setting ◽  
Care Surgery ◽  
The Impact

BackgroundAcute care surgery (ACS) encompasses trauma, critical care, and emergency general surgery. Due to high volumes of emergency surgery, an ACS service was developed at a referral hospital in Rwanda. The aim of this study was to evaluate the epidemiology of ACS and understand the impact of an ACS service on patient outcomes.MethodsThis is a retrospective observational study of ACS patients before and after introduction of an ACS service. χ2 test and Wilcoxon rank-sum test were used to describe the epidemiology and compare outcomes before (pre-ACS)) and after (post-ACS) implementation of the ACS service.ResultsData were available for 120 patients before ACS and 102 patients after ACS. Diagnoses included: intestinal obstruction (n=80, 36%), trauma (n=38, 17%), appendicitis (n=31, 14%), and soft tissue infection (n=17, 8%) with no difference between groups. The most common operation was midline laparotomy (n=138, 62%) with no difference between groups (p=0.910). High American Society of Anesthesiologists (ASA) score (ASA ≥3) (11% vs. 40%, p<0.001) was more common after ACS. There was no difference in intensive care unit admission (8% vs. 8%, p=0.894), unplanned reoperation (22% vs. 13%, p=0.082), or mortality (10% vs. 11%, p=0.848). The median length of hospital stay was longer (11 days vs. 7 days, p<0.001) before ACS.ConclusionsAn ACS service can be implemented in a low-resource setting. In Rwanda, ACS patients are young with few comorbidities, but high rates of mortality and morbidity. In spite of more patients who are critically ill in the post-ACS period, implementation of an ACS service resulted in decreased length of hospital stay with no difference in morbidity and mortality.Level of evidencePrognostic and epidemiologic study type, level III.

scholarly journals Acute Care Surgery Billing, Coding and Documentation Series Part 1: Basic Evaluation and Management (E/M), Emergency Department E/M, Prolonged Services, Adult Critical Care Documentation and Coding

2020 ◽  
Vol 5 (1) ◽  
pp. e000578
Author(s):  
Thomas Esposito ◽  
Robert Reed ◽  
Raeanna C Adams ◽  
Samir Fakhry ◽  
Dolores Carey ◽  
...  
Keyword(s):  
Complex System ◽  
Emergency Department ◽  
Critical Care ◽  
Acute Care ◽  
Acute Care Surgery ◽  
Formal Training ◽  
Experienced Surgeon ◽  
Care Surgery ◽  
Basic Evaluation

This series of reviews has been produced to assist both the experienced surgeon and coder, as well as those just starting practice that may have little formal training in this area. Understanding this complex system will allow the provider to work ‘smarter, not harder’ and garner the maximum compensation for their work. We hope we have been successful in achieving that goal and that this series will provide useful information and be worth the time invested in reading it by bringing tangible benefits to the efficiency of practice and its reimbursement.

scholarly journals Gender distribution and leadership trends in trauma surgery societies

2020 ◽  
Vol 5 (1) ◽  
pp. e000433
Author(s):  
Shannon Marie Foster ◽  
Jennifer Knight ◽  
Catherine Garrison Velopulos ◽  
Stephanie Bonne ◽  
D'Andrea Joseph ◽  
...  
Keyword(s):  
Critical Care ◽  
Gender Diversity ◽  
Trauma Surgery ◽  
Executive Leadership ◽  
Senior Author ◽  
Acute Care Surgery ◽  
Level Of Evidence ◽  
Gender Distribution ◽  
Surgical Critical Care ◽  
Care Surgery

IntroductionWomen are under-represented in the surgical disciplines and gender bias is believed to play a factor. We aimed to understand the gender distribution of membership, leadership opportunities, and scientific contributions to annual trauma professional meetings as a case study of gender issues in trauma surgery.MethodsRetrospective collection of membership, leadership, presentation and publication data from 2016 to 2018 Trauma/Acute Care Surgery/Surgical Critical Care (TACSCC) Annual Meetings. Gender was assigned based on self-identification in demographic information, established relationships, or public sources.ResultsWomen remain under-represented with only 28.1% of those ascertaining American Board of Surgery certification in critical care self-identifying as female. The proportion of female members in Eastern Association for the Surgery of Trauma (EAST) was comparable (29.4%), slightly lower for Western Trauma Association (WTA) (19.0%), and lowest for American Association for the Surgery of Trauma (AAST) (12.8%, p<0.05). In contrast, AAST had the highest proportion of female participants in executive leadership (AAST 32.5%, WTA 19.0%, EAST 18.8%) and WTA the highest for committee chairs (WTA 33.3%, AAST 27.8%, EAST 20.5%). AAST had the most significant increase in executive leadership during the last 3 years (AAST 28.6% to 41.6%). Invited lectureships, masters, panelists and senior author scientific contributions demonstrated the largest gap of academic representation of female TACSCC surgeons.ConclusionFewer women than men pursue careers in the trauma field. Continuing to provide mentorship, leadership, and scientific recognition will increase gender diversity in TACSCC. We must continue to promote, sponsor, recognize, invite, and elect ‘her’.Level of evidenceIII, Epidemiology.

scholarly journals P074: Improving urology care in the emergency department through implementation of an Acute Care Urology model

CJEM ◽  
2019 ◽  
Vol 21 (S1) ◽  
pp. S90
Author(s):  
A. Kirubarajan ◽  
R. Buckley ◽  
S. Khan ◽  
R. Richard ◽  
V. Stefanova ◽  
...  
Keyword(s):  
Emergency Department ◽  
Acute Care ◽  
Outpatient Care ◽  
Renal Colic ◽  
Interdisciplinary Collaboration ◽  
Wait Time ◽  
Acute Care Surgery ◽  
Post Intervention ◽  
Care Surgery

Introduction: Renal colic is one of the most common presentations to the emergency department (ED), and often requires complex interdisciplinary collaboration between emergency physicians and urology surgeons. Previous literature has shown that adoption of interdisciplinary rapid referral clinics can improve both timeliness of care and patient outcomes. However, these Acute Care Surgery models have not yet been commonly adopted for urology care in the ED. Methods: In July 2016, we adopted the intervention of an Acute Care Urology (ACU) model through the creation of a rapid referral clinic dedicated to ED patient referrals, the addition of an ACU surgeon, and enhanced use of daytime OR blocks. We conducted a manual chart review of 579 patients presenting to the ED with a complaint of renal colic. Patient data was collected in two separate time periods to analyze trends before implementation of the ACU model (pre-intervention, September - November 2015), to examine the model's impact (post-intervention, September - November 2016). Secondary methods of evaluation included a survey of 20 ED physicians to capture subjective feedback through Likert scale data. Results: Of the evaluated 579 patients with a complaint of renal colic,194 patients were discharged from ED with an diagnosis of obstructing kidney stone and were referred to urology for outpatient care. The ED-to-clinic time was significantly lower for those in the ACU model (p &lt;0.001). The mean time to clinic was 15.76 days (SD = 15.47, range 1-93) pre-intervention versus 4.17 days (SD = 2.33, range = 1-12) post-intervention. Furthermore, the ACU clinic allowed significantly more patients to be referred for outpatient care (p = 0.0004). There was also higher likelihood that patients would successfully obtain an appointment following referral (p = 0.0055). Decreasing trends were shown in mean ED wait time, in addition to time from assessment to procedure. Results of the qualitative survey were overwhelmingly positive. All 20 surveyed ED physicians were more confident that outpatients would be seen in a timely manner (85% strongly agree, 15% agree). Qualitative feedback included the belief that follow-up is more accessible, that ED physicians are less likely to page the on-call urologist, and that they are able to discharge patients sooner. Conclusion: The ACU model for patients with renal colic may be beneficial in reducing ED-to-clinic time, ensuring proper follow-up after ED diagnosis, and improving patient care within the ED.

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