Notebook



3/21/16 Trauma Conference, Las Vegas

-whole body CT scanning may have increased survival in trauma pts.

 

 

Subclavian injury:

·       OR for hard signs (hemothorax, pulsetile bleeding, large hematoma, loss of pulse)

·       CTA for soft signs

Tx:

·       Clavicular incision: only incision needed for R or L

·       anterior scalene m overlies subclavian, phrenic n is on medial aspect of this (preserve)

·       can do delto pectoral extension

·       can do sternotomy extension= opens medial extension

·       just over clavicle, remove soft tissue attachments, remove clavicle from sternum with gigli saw (minimal functional deficit), or can just cut medial end and move.

·       PTFE often used

·       venous injury can be ligated

 

Concussion:

·       =occures immeditely, transient, causes disturbance of function but not structure, LOC not needed

·       there is no grading

·       SCAT3 is a cuncussion assessment tool

·       types of concussion: cognitive, vestibular, affective, somatic

Tx:

·       no return to play if symptomatic

·       gradual return

·       no brain rest

 

 

-vascular injuries below knee or shoulder should be repaired with venous grafts

 

Esophageal perforation

-eval with swallow study, CT, endoscopy

-explore cervical esophagus, even if only for drainage

-Criteria for nonop management of esophageal perforation:

Well contained/ localized

Contrast drains back into esophagus

Minimal sx, no sepsis

Cervical or thoracic esophagus

No maligancy

No distal esophageal obstruction

Detected early, or late with minimal sx

 

 

Aortic root injuries:

-R coronary comes off directly anterior

Blunt: usually need bypass, have time.

Access:

-midline, median sternotomy

 

Colonic Surgical Emergencies:

-primary anastamosis has ok outcome than for diverticulitis (MAY have improved morbidity/mortality over hartman's)

-Diverticulitis laparoscopic lavage has 2% conversion, 10% Morbidity. Not yet indicated for feculant or purulant peritonitis

 

 

Transition zone challenges:

Neck

·       -SCM incision initially

·       -Zone 3: detach scm, digastric, sternohyoid & styloid m devision

·       -beware of facial n posterior to mandible , inferior alveolar n anterior to mandible

·       -vertibral a travels in canal C6-C2

Thoracoabdominal

·       -suprahepatc vena cava can be accessed through central tendon via abdomen (like a pericardial window)

·       -diaphragm can be taken down radially laterally (preserves innervation of diaphram which comes centrally)

Popliteal

·       -usually accesed with incision parallel to sartorius m., divide gracilis, semimembranous, semitendinous, and medial head of gastrocnemius.

 

 

Residual Hemothorax:

·       = retained blood > 300-500ml (blunted costophrenic angle)

·       large size tube not found to help decrease

·       <300ml usually resorbed spontaneously

·       Large residual hemothorax can worsen resp function, risk empyema (27% incidence), entrap lung

·       Risk for empyema: no abx at time of insertion, penetrating trauma, duration of chest tube, multiple chest tubes.

Tx:

·       replace tubes (not recommended)

·       percutaneous drain: for encased collections

·       thrombolysis: TPA 25mg or Urokinas 100,000 U in 50ml NS via chest tube. Clamp. Walk for 4hrs. Unclamp. Repeat for 3d. After trauma, usually wait 3-5d; longer for head injury.

·       VATS- good for < 10d. lat decubitus; dbl lumen tube; two ports, 6th intercostal ant/post axillary lines; 3rd in mid axillary 4th intercostal

·       thoracotomy- for > 10d

 

Biliary Bailouts

·       Dome down is an option

·       subtotal cholecystectomy= GB drained, opened, evacuated, anterior wall excised, back wall may be left on; mucosa may be obliterated; cystic duct can be left open or closed with suture/endoloop/clips; drained.

o   For severe cholecystitis preventing safe dissection; cirrhosis (bleeding during dissection)

o   18% bile leak, usually resolves spontaneously; may need ERCP/stent; 2% need re-operation

·       Cholecystostomy hasn’t been shown to lower conversion rate of lap chole.; good for poor surgical candidates

 

Necrotizing pancreatits

·       Nasogastric feeds may be ok

·       Wait 5-7d before starting TPN (enteral better than tpN)

·       Infected pacreatic necrosis= Air in retroperitoneum, bacteria in necrotic fluid

o   Tx: abx, necrosectomy

o   Open: debride, can pack or drain.

o   Step up: IR drainage, if doesn't improve after a few days (try ~4wks from initial pancreatitis) --> do cutdown on drain, 10mm scope to access retroperitoneum, can debride with yankaur and ring forcepts; has lower DM, hernia, pancreatic insufficency, death.

 

Ostomies in obese pts

·       Preoperative stoma siting= 5cm of flat skin despite position changes; ostomy triangle is umbilius, ASUS, pubic symphisis

o   Obese pts may need higher on abdomen

o   Avoid prior radiation fields

·       Intraabdominal options

o   Clamp IMA to ensure blood flow is preserved

o   Don't dissect close to mesentary

o   Mobilize flexures

o   Make a large trephine (hole for bowel to go through ab wall)

o   Pseudo loop end colostomy

o   Pie crusting= cut mesentery perpendicular to vessel to gain length

·       Abdominal wall options:

o   Siting

o   Contouring, take subcutaneous fat

o   Can use Alexis Wound retractor to allow bowel to slide into site easier

 

 

3/22/16

 

EFAST (Extended focused assessment for trauma)

·       FAST (detects 200ml fluid, 80% sensitive, 100% specific for free fluid) + thoracic views

o   25-50% false negative for solid organ injury

o   Pediatric fast is < 50% sensitive

o   Doesn't eval retroperitoneum

·       Thoracic views detect pleura-pleura apposition and movement.

o   Comet tail= normal finding (no ptx)

o   HTX can be seen just above diaphram on liver/splene views

o   Pleura not moving with respiration (no moving comet tail) is ptx

 

IVC filters

·       TID heparin is comparable to lovenox for DVT prophylaxis

·       PE is #1 delayed death following trauma

·       Guidelines:

o   Known DVT/PE and can't anticoagulate

o   GCS < 8 tbi, spinal chord with plegia, complex pelvic/long bone -- little/no clinical evidence

o   PE while adequately anticoagulated

o   Too sick to tolerate a second PE

·       In general: Above knee DVT --> anticoagulate; if high risk/bleeding place a filter

·       About 20% PE's are actually primary pulmonary thrombosis

·       If unable to give DVT prophylaxis, can do surveillance US for DVT (weekly or biweekly)

·       Only 21% of retrievable filters are retrieved

·       Recommendations by Dr. Sise:

o   Filter for DVT/PE when can't anticoagulate

o   PE despite anticoagulation

o   Consider if unable to tolerate 2nd PE due to cardio/pulmonary instability

o   No role for SVC filters for upper extremity clot -- unless this caused a PE

o   No prophylactic IVC filter, do surveillance

 

Fibrinogen= Normal rxn to trauma is to increase; low (<230) in trauma is associated with bleeding and death. Early cryo may help, but doesn't effect mortality.

·       Should keep level > 200

 

 

Open Abdomen

·       Use: packing, bowel edema, ACS, sepsis/ischemic bowel

o   Diffuse non-surgical bleeding

o   hypothermia < 34C

o   acidosis < 7.3

o   volume overload > 7

o    bowel edema

·       Risk:

o   15% EC fistula

o   Protein loss

o   Hernia

·       Recommend:

o   Bowel anastamosed in 24hrs to prevent SBO

o   34% of pts are able to be closed 1st take back and can decrease infection/complications

o   Leaving abdomen open for sepsis has increased morbidity, fistulas, hernias, inflammatory response = don't do serial washouts for sepsis. Do re-exploration on demand.

o   Ischemic bowel only 20% need further resection for ischemia

 

TBI Management

·       ICP monitor does not effect outcome (NEJM Dec 27, 2012)

·       Decompressive craniectomy in diffuse TBI has worse outcome (NEJM 4/21/11)

·       Rescue craniectomy

o   Leaving bone flap off has complication of new surgery

o   Replacing bone flap has rick of inc ICP and needing removal

·       Targeted temperature measurement only indicated in neonates (hypothermia)

·       Mannitol v. HTS - no clear preference for eaither over the other

 

ABCDEF Initiative = ICU care

·       A= assess pain

o   Use scoring

o   Treat in 30min

o   Pain control before procedure/dressing change

·       B= spontaneous awake/breath trial

o   Decrease time in ICU, vent, mortality, delerium

o   Use RAS or SAS

o   Hold sedation until open eyes, squeeze, follow commands; then restart 50% of dose

·       C= choice of analgesia/sedation

o   Benzo's are bad

o   Analgesias first

o   Precedex has lower delerium than propofol lower than benzo

·       D= delerium assess

o   Can be hyper/hypo active or mixed

o   Delerium has 1% increased 1yr mortality for every day deleriuc

o   CAM-ICU is scoring system (poor for TBI)

o   Modifiable factors: sleep, choice of home meds, procedures, mobilization, pain

·       E= early mobility

o   Decreased incidence and duration of delerium

o   Avoid bedrest

·       F= family engagement

o   Presence in unit, in rounds (open ICU policy), shared decision making, ICU diaries

o   Decreases falls, agitation, cardiac complications

 

ECMO

·       Passive venous drainage, oxygenation, then pump blood back (to vein VV or artery VA, only VA is good for cardiac support as well)

·       Increased survival for H1N1 flu in 2009

·       40% survival in cardiac shock

·       Indications

o   Respiratory failure with > 50% expected mortality done within 7d

o   Failed Prone positioning, APRV, inhaled NO

·       1 additional survivor for 6 treated

 

Antibiotics in Acute Care Surgery

·       Intraabdoinal infection

o   No flouroquinolone for ecoli

o   Mefoxin for moderate perfoated

o   Primaxin, zosyn, cef/flag for severe infection, immunocompromised, extremes of age

·       Trauma laparotomy

o   Single dose broad spectrum (mefoxin, GN and anaerobe)

o   24hrs for hollow viscus injury

·       VAP

o   Late= after 4 d

o   Fluroquinolones are 100% penetration

o   B lactams low penetration

o   Ex: zosyn 1st, imipenem for escalation

o   7-10d duration

o   Use singe drug for single bug

o   CIPS: temp, wbc, trach secretio, oxygenation, cxr, tracheal aspirate cx

·       Cdiff

o   Most common healthcare infection

o   Metronidazle, vancomycin, fidoxamicin

o   Tx: Vanc 500mg/500cc q6hr per rectal lavage in addition to oral vanc and IV flag

 

Fluids in the ICU

·       Albumin may have increased mortality in TBI (SAFE trial), but is safe in sepsis

·       HES starches increase renal failure, not for acute resuscitation

·       Use lactate or base deficit, CVP 8-12, MAP > 65, SVO2 70%, UOP > 0.5 cc/kg/hr  as endpoints for resuscitation

 

Anticoagulation in TBI

·       Prophylaxis decreases DVT, not PE or death

·       Neurocritical Care Society guidelines:

o   Mechanical prophylaxis early

o   Add LMWH 24-48hrs if bleeding is stable on CT

·       Chemoprophylaxis and SCD reduce dvt risk

·       Chemo is better then mechanical prophylaxis

·       Lovenox is better than heparin to prevent DVT

·       Heparin can increase bleeding in the brain more

 

 

Lung Protection Strategies

·       Use PEEP/FiO2 table

·       Prone ventiolation trial 4-6hrs for ARDS (PF<200)

o   Works best in the first 5d

·       Ventilator strategies

·       NM blockade

o   Helps with pt-vent dissynchrony

o   Can have increased survival with PF<150

·       NO

o   Transient improvement in oxygenation

o   No survival advantage

·       Can trend SVO2 to identify limitation in oxygen delivery

o   Best ways to improve O2 delivery are Hb and CO

o   Increasing PaO2 only helps up to about 90% O2 sat

o   Ensure O2 demand is lessened (pain, sedation)

 

ICU nutrition

·       NPO better than TPN for normal Pt

·       TPN

o   Uses

·       Short gut

·       Preoperative malnourished pts without oral intake

·       Complicated or unusable GI tract (not open abdomen)

o   Complications:

·       Cholecystitis

·       Line complications

·       Liver dz

·       infection

·       Postpyloric feeds decrease PNA

 

 

 

TXA

·       Contraindicated with active clotting and acquired defective color vision

·       Must be given within 3 hrs of bleeding

 

 

Pain Control

·       Can judge opiod use with MME.

·       NSAIDS increase fracture non-union

·       Ketamine reduces pain severity, continuous or intermittent.

·       Alpha agonists (clonidine, Precedex) work

 

Addicted patient

·       Replacement therapy (methadone, buporphenone)

o   Can morphine titrate

o   Need to cover withdraw and pain control

o   Local/regional pain control, paracetamol

o   Careful with PCA

·       Drug addiction

o   Try to avoid opioids

·       1mg Oral morphine = 3mg IV morphine = 2mg oxycodone = 7.5mg hydromorphone = 1/6mg codein = 1/5mg tramadol

 

Cervical Spine imaging

·       Who to image (Nexus criteria):

o   Not alert

o   Intoxicated

o   Distracting injury

o   Midline c-spine tenderness

o   Neuro deficit

·       Unevaluable pt can consider remove collar based on CT alone (high NPV to exclude unstable injury)

·       Midline tenderness 100% sensitivity/specificity of CT (Jama 2014)

·       In adequate CT, can likely clear with CT unless there are neurodeficits

 

 

Death and dying in ICU

·       Advanced directive= written expression of how a pt would want to be treated in medical circumstances

·       DNR= MD order limiting medical treatment

o   Pts can suspend DNR perioperatively

·       Medical futility

o   Quantitative= when tx has minimal probability of success

o   Qualitative= perceived benefit is exceedingly poor

o   TX and CA has futility policy, MD can decide, must let family know, ethics, allow time to transfer

 

 

Delerium Tremens (DTs)

·       Mortality of 5-15%

·       15-30% of trauma pts go into alcohol withdraw

·       Older and higher BAL have higher risk of withdraw

·       Stages of AWS

o   1- 24hrs, anxiety, tachycardia, HTN

o   2- after 24hrs hallucinations, irritability

o   3- 3d, sz, hallucinations

o   4- 3-5d, adrenergic crisis, HTN, fever, cerebral edema (DTs)

·       Symptom triggered benzo tx is best; can use CIWA scale

·       Tx:

o   Benzo- 1st line

o   Precedex- adds alpha agonist

 

 

Hartford Consensus= group of experts on how to improve survival with active shooter

 

 

Brachial Plexus injuries

·       Erb’s palsy= C5,6, upper arm with waiters tip deformity

o   From overheas stretch

·       Klumpke’s palsy= C5-T, hand with claw hand

·       Penetrating injurà explore and repair

·       Blunt

o   Avulsion (no nerve root remaining)- can’t repair

o   Rupture- needs surgical repair

o   Axonotemesis- stretch injury, regenerates in 4-6wk

o   Neuropraxia- reverses rapidly

o   Dx:

§  Shoulder/arm film

§  CXR

§  Electrophysiology

§  MRI/CT myelogram to eval root avulsion

o   Tx:

§  OT, splints

§  Follow for 3mo

 

 

Pediatric Trauma

·       Airway

o   ETT size= (age+4)/4; nailbed width

o   Bradycardia with RSI= atropine 0.02mg/kg

o   Surgical airway= Avoid in kids due to subglottic stenosis

·       Breating

o   Similar to adults

o   Look at trachea on xray, more likely to shift in kids

·       Circulation

o   Blood volume of 80cc/kg

o   10cc/kg PRBC or FFP

o   20cc/kg crystalloid per ATLS

o   MTP started at 40cc/kg, hypotension

o   Use 1:1:1 ratio

o   Hyperkalemia is risk from blood through small IV’s

o   Bleeding in kids has higher mortality than in adults

 

 

Hernia Repair in contaminated field

·       30% laparotomies have incisional hernia

·       STITCH trial= Small biles 5mmx5mm with 2-0PDS reduce recurrence; excluded morbidly obese.

·       Lap v open repair

o   No clear defined difference

o   Lower wound infection

o   Increased enterotomies

o   Less hospital stay

o   Maybe < 3cm should not be lap, >10 should not be lap

·       PRIMA trial will address prophylactic mesh

 

 

Surgical Soul

·       Vascular structures

o   Deep= cava, kidney, IVC; Compress

o   Middle= mesenteric, portal; do double pringle

o   Superficial= pancreatico-duodenal arcade, need Kocher to find

o   Tx:

§  Wide kocher, Cattell Braasch, R kidney mobilization

§  Portal v- repair; ligate if dying and hepatic a intact

§  Hepatic a- repair

§  Bile duct- deal with later

§  SMV- transect head of pancreas

§  Proximal SMA- repair

§  SMV- repair, ligate in extremis

§  IVC- compress with sponge sticks; statinsky clamp, repair; ligate in extremis

§  Superficial vessels @ head of pancreas- ligate, pack

·       Pancreas

o   Consider bailout

o   Tx:

§  Drain!!

§  Whipple- only when injury already did the resection

·       Bile duct

o   Prijmary repair

o   Consider T-tube through a separate area

o   Can leave GB to leave as a conduit (roux limb)

·       Duodenum

o   Primary repair, tenuous suture line

o   Pyloric exclusion after repair (open antrum, oversew pyloris, loop gastro J)

 

 

Recurrant Adhesive Small bowel Obstruction

·       49% of sbo

·       5% of prior surgery will develop SBO due to adhesions

·       Recurrence rate increases after recurrence

·       Dx: Hx, px

o   SB > 3cm dilation

·       Tx:

o   Urgent surgery after resuscitation for complete SBO if no evidence of adhesions

o   Use lactate as an endpoint for resuscitation

o   Gastrograffin SBFT done after resuscitation and NG decompression

§  Reduces need for surgery

§  Reduces time for resolution

§  Reduce hospital stay

§  Failure of passage at 8hrs may need surgery; however, contrast in colon at 24hrs will likely resolve

o   PSBO resolves 55-75%

o   Complete SBO resolves ~35%

o   Fluorescein dye 1 ampule and Woods lamp to eval vascular compromise

·       Small bowel syndrome= <200cm SB

·       Hyaluronic acid/carboxymethylcellulose – reduces severity of obstruction

·       Icodextrin 4% irrigation solution reduces adhesions and SBO

 

 

 Unnecessary transfers

·       Inappropriate: closed distal radius, fami, closed anle, femur, tib/fib, clavicle, elbow dislocation, proximal humerus, felon, closed midshaft radius/ulna, closed metacarpal, femoral neck, intertrochanteric, patella, fibula, metatarsal

·       But accept.

 

Air ambulances

·       Has a role in long distance, hostile environment, difficult geography

·       No proven benefit for urban environment

 

 

EMTALA

·       Pt in emergency department must be evaluated and astabilized

·       On call physician availability

o   Each hospital must maintain community need on-call list

o   Coverage within reason depending on number of MDs

o   ER MD determins if on call MD must come in

o   Cannot refer to office unless it is in the hospital (rather than come in)

o   Simultaneous call is ok (unless critical access hospital)

o   Physician extender is ok unless ER MD says they want the MD

·       EMTALA does not apply to in-patients

·       EMTALA can get waived during certain emergency cirucmstances

 

 

Antibiotics Only for Acute Appendicitis

·       APPAC trial: RCT

o   Uncomplicated appendicitis

o   27% abx only failure rate over a 1yr

§  Still only7% complication versus 21% complication with immediate OR

o   Lower complications

o   Better pain and recovery

o   Protocol

§  3d IV abx (irtapenem)

§  OR group was open appy

·       NOTA study: prospective study

o   Brief course of abx

o   14% failure rate (66% still only managed with abx)

·       ABx only safe for kids as well

o   76% success at 1 yr (JAMA 2015)

·       10-20% complication rate with surgery

·       Choose surgery:

o   More certainty for future

o   High risk occupation or remote travel

·       Very low perforation rate from time of diagnosis

·       Protocol by Dr Martin:

o   Immunocompetent adult, no perforation, no abscess, no fecolith, no peritonitis, reliable pt

o   Initial IV abx

o   Can immediately convert to PO if tolerating PO

o   Admission if fever, worsening pain, abnormal vitals, not tolerating PO

o   F/u within 72hrs: pain, PO tolerance, bowel function, other complaints, vital signs

o   Appendectomy for worsening status, failure to improve, patient preference.

o   f/u imaging or endoscopy for suspicion of mass.

 

 

Organ donation

·       as of 2006, OPO (organ procurement organization) authorization on license is legally binding (Uniform Anatomical Gift Act)

·       Donation after circulatory death (DCD) starts ~1hr after pronounced death




5/1/17 TOPIC course


5/5/17 TMD Course Notes


9/13/17 AAST Notes

B-blocker in TBI

-propranolol at SICU admission decreases mortality without bradycardia

-no difference in hypotensive episodes

-labetalol IV 1mg q6hr (from separate study)

-length of stay is longer for Bblocker, may be due to survival

Timing of rib stabilization

-EAST conditionally recommends for flail chest

-Later= 3-7days to see if patient fails non-op tx

-early= 0-2 days based on clinical/radiographic features predicting failure--

Fail chest (>= 3 consecutive rib fractures with at least 2 fractures each), >= 3 severely fxr ribs (bicortical displacement), volume loss.

-early group has less prolonged mechanical ventilation, less pneumonia.

-other study reports contraindications as pulmonary contusion requiring mechanical ventilation, other injury requiring prolonged mechanical ventilation.

High Grade Renal Trauma

-Grade 3-5 is high grade

-60% nephrectomy rate for grade 5

-grade 5 nephrectomy rate has not dropped significantly over time

-penetrating injury has higher nephrectomy rate

Cribrari modification

-want < 35% overtriage, want < 5% undertriage

-Need for trauma intervention (NFTI) may be a better indicator of appropriate triage

-NFTI= PRBC in first 4 hrs, discharge from ed to OR in 90min, ED to IR, ICU stay > 3edays, placed on vent outside of procedural anesthesia.

-use NFTI to analize the level 1 overtriages and other undertriages.

Red book (resources for the optimal surgical care)

Stop The Bleed

-B-Con course

-texas is #1 in instructors and in classes.

-Blueprint from UPMC:

1) identify need (active shooter, mass casualty, MTA, industrial accidents, MVC)

2) expert consultation

3) find people who know people who can advance program further, can use high volume non-trauma centers. Include EMS/fire/police and educators/schools. Include active community groups

4) build team (steering commitee) from region. For subcommtties in education, law enforcement, and educations

5) fundraising: look at hospital outreach budget, hospital foundations, philanthropy

6) implementation: find passionate advocates (prior regional events, law enforecement, EMS liaison). Train-the-trainer is high yield. Advertise the effort, can use the media. Can use a county-by-county roll out using a hospital and EMS in each region. Can get police officer continuing education credit.

9-14-17

Sepsis and advanced age

-age is strong risk factor for adverse outcomes

-age >= 55 is advanced age

-aged have delayed immunorecovery, greater organ dysfunction, increased catabolism.

Emergency general surgery volume and hospital mortality

-7 procedures account for majority of inpatient mortality: colon rxcn, sb rsxn, choley, bleeding PUD, LOA, appy, laparotomy

-technical complications had no difference from low to high volume hospitals

-low volume had higher sepsis, pulmonary complications, in patient mortality

**Idea**

-look at mortality/hospital stay/narcotic usage with hip fxrs admitted prior to and after Emcare start

REBOA versus Resuscitative Thoracotomy

-overall, REBOA has 6% complication versus RT 4% complication

-REBOA seems to be used more in blunt injury

-REBOA had increased survival out of ER and survival to discharge

-47% or REBOA need femoral cutdown

-REBOA outcomes improved when used prior to arrest.

Timing of venousthromboprophylaxis in severe pelvic fracture

-PE can be thromboembolic or primary pulmonary thrombosis

-pelvic fractures have high risk of bleeding and risk of DVT

-Early VTEp after TBI gives lower dvt and pe

-LMWH ma have improved survival over UH

-early VTEp is <=48hrs after admission

-early VTEp gives lower mortality in pelvic fxrs and less VTE

Interrupted versus continuous closures of abdomen in emergency laparotomy

-Annals of Surgery 1983 with 571 randomized pts had no difference; multiple other studies showed no difference

-most of the studies were elective surgeries

-European Hernia Society guidelines: small bite, continuous, absorbable suture is the way to go; but cannot comment on emergency surgery

-Tolstrup showed decreased dehiscence with interrupted in emergency surgery

-Technique: 0 non-looped PDS, 1cm from edge and between stitches—why did the study use 1x1cm bites when 0.5x0.5cm gives less hernia.

-interrupted is slower, no statistical difference in outcomes (limited by followup and sample size).

EGS mortality in high quality trauma center

-looking at relationship between trauma mortality and EGS mortality

-EGS has 8x mortality compared to elective

-looked at facilities with 200EGS cases and > 400 trauma admissions

-7 procedures caccounted for 8% of all cases, complications, deaths, and cost

-hospitals with lower TQIP trauma mortality also have lower EGS mortality

ICU management of Geriatric TBI

ICP monitoring= give advanced warning

-CPP may need to be higher in older (>60yo)

-studies show dec mortality and inc mortality or no change survival with ICP

-BEST TRIP study (ICP v clinical/CT monitoring)= no change in outcome with monitoring

          -done outside US

          -ICP monitor gave more ‘efficient’ care with less interventions to dec ICP

-ACS TQIP and guidelines for management of severe TBI recommend ICP but don’t tell us who to place it in.

-Brain org= age>40, SBP<90 should have ICP monitor

Prognostic Models for Geriatric TBI

GTOS= specifically for geriatric trauma

-predicts in-hospital mortality

-requires ISS or AIS, not TBI specific

-GTOS II predicts disposition

Impact= predicts 6mo mortality and adverse outcome

-TBI specific

-overestimation of geriatric mortality

CRASH

-country specific

-TBI specific

-small overestimation of mortality

Palliative Care

-early provision of palliative care inc quality and length of life for life limiting conditions

-should not apply TQIP recommendation for not discussing prognosis in 1st 72hrs for geriatric TBI

-avoid #s in giving prognosis

-fluid situation

-address “palliative care bundle” daily

-Answer to pt/family Q’s: “it would surprise me if …” Ex ‘pt went home’

Helicopter versus ground transport

-helecopter advantages include speed, advanced capabilities, transfusions, airway management, experience.

-increased survival for abnormal RR (<10 or > 29), GCS < 14, hemo/pneumothorax even if helicopter transport takes longer than ground.

BIG= brain injury guidelines, modification below is being studied to minimize consults and resources

BIG-MaC 1= gcs 13-15, no focal neuro exam, no intoxication, no anticoagulation, no skull fracture, <4mm sdh, no edh, <4mm iph, <3 sulci and <1mm sah, no ivh

BIG-MaC 2= gcs 13-15, no focal neuro exam, yes intoxication, no anticoagulation, nondisplaced skull fracture, 4-7.9mm sdh, no edh, 4-7.9mm iph, single hemisphere or 1-3mm sah, no ivh

BIG-MaC 2= gcs any, yes focal neuro exam, yes intoxication, yes anticoagulation, displaced skull fracture, >8mm sdh, yes edh, >8mm or multiple iph, bi hemisphere or >3mm sah, yes ivh

Tx based on BIG-MaC score:

1-      No admission, 6hr ER observation, no repeat CT, no NSG consult,

2-   Hospital admission to floor, 24hr q8h observation, no repeat head CT, no NSG consult, GCS 15 for discharge

3-      Standard care

ICP monitoring

-67-55 yo may have increased mortality

-NTDB suggest < 45 yo have increased survival

-3rd brain trauma foundation guidelines state: ICP should be monitored in all salvageable patients with severe tbi (GCS 3-8) and abnormal CT scan

-4th edition state it only decreases in hospital and 2 wk mortality

Early Complications of Bariatric Surgery

Leaks

RYGB= from tension on anastomosis; w/in 7d of OR

          Dx: tachycardia > 120 à or

          -CT with 100cc contrast 60-80% sensitive

          -flouro gastrgraffin then thin barium

          -above tests look at GJ anastomosis only

          Tx: stable can be drained (95% close w/in 1mo); TPN, NPO

          -Unstable (HR >120) à OR

          -wide drain

          -repair leak if able (omental patch with interrupted sutures)

          -Gtube in remnant stomach

          -control sepsis

Sleve= more common, less blood supply, higher pressure; can be associated with twist/kink/stenosis; most @ angle of His

          Dx: tachy > 120; flouro

          Tx: drainage / repair for unstable

          -endoscopic stenting early can help with decreasing king (w/in 1 week)

Stenosis

RYGB

    Dx: inability to swallow, can’t pass EGD scope (<9mm)

    Tx: IVF, thiamine, neurology exam

    -goal 10-16mm anastomosis

    -only increase 2-3mm at a time

Sleve= may be twist/kink/stricture

    Dx: flouro & EGD may be negative

    Tx: stricture à balloon or surgical myotomy

    -Twist/Kink à conversion to RYGB or total gastrectomy

Bleeding

-EGD to dx and tx; could be GJ or JJ

Balloons are meant to come out after 6mo.


Late Complications of Bariatric Surgery

Band

-Obstruction= vomit, PO intolerance, severe GERD

          Dx: PA AXR (Phi Angle= spine to band angle nl 45-58degrees, 10:00 to 2:00)

          -slipped band= stomach slipped under band, phi angle > 60degrees, can result in ischemia

          Tx: deflate balloon (remove all fluid with 25g needle to port (max 4-13cc fluid)

          -band erosion= subtle pain, GERD, slow erosion, not emergent, can see infection;

          Tx: deflate balloon and endoscopic removal

          -emergent OR for unresolved pain, obstructive sx.

          -lesser curve of stomach is safe zone to cut band

Sleve= late complications are rare

RYGB  (common internal hernia, PUD/marginal ulcer, gallstone

-SBO= dilated gastric remnant needs OR, gtube

          -no blind NG tube

          -Start exploration @ terminal ileum to approach retrograde

          -close defect

-Marginal Ulcer= usually at GJ; epigastric pain

          -Risks are smoking, NSAID, pouch dilation

          -Emergent OR indications similar to PUD

                         -do graham patch or modified patch

                         -tx ulcer with PPI, stop smoking, stop NSAID; can address ulcer surgically later

-Biliary disease options include PTCD, CBDE, transgastric ERCP (put hole in gastric remnant, secure with stitch to hold through abdominal wall, place scope through abdomen)




Comments