Faculty Bibliography

Mass casualty events particularly those requiring multiple simultaneous operating rooms are of increasing concern. Existing literature predominantly focuses on mass casualty care in the emergency department. Hospital disaster plans should include a component focused on preparing for multiple simultaneous operations. When developing this plan, representatives from all segments of the perioperative team should be included. The plan needs to address activation, communication, physical space, staffing, equipment, blood and medications, disposition offloading, special populations, and rehearsal.

BACKGROUND:Data access through smartphone applications (apps) has reframed procedure and policy in healthcare, but its impact in trauma remains unclear. Citizen is a free app that provides real-time alerts curated from 911 dispatch data. Our primary objective was to determine whether app alerts occurred earlier than recorded times for trauma team activation and emergency department arrival. METHODS:Trauma registry entries were extracted from a level one urban trauma center from January 1, 2018 to June 30, 2019 and compared with app metadata from the center catchment area. We matched entries to metadata according to description, date, time, and location then compared metadata timestamps to trauma team activation and emergency department arrival times. We computed percentage of time the app reported traumatic events earlier than trauma team activation or emergency department arrival along with exact binomial 95% confidence interval; median differences between times were presented along with interquartile ranges. RESULTS:Of 3,684 trauma registry entries, 209 (5.7%) matched app metadata. App alerts were earlier for 96.1% and 96.2% of trauma team activation and emergency department arrival times, respectively, with events reported median 36 (24-53, IQR) minutes earlier than trauma team activation and 32 (25-42, IQR) minutes earlier than emergency department arrival. Registry entries for younger males, motor vehicle-related injuries and penetrating traumas were more likely to match alerts (P < .0001). CONCLUSION/CONCLUSIONS:Apps like Citizen may provide earlier notification of traumatic events and therefore earlier mobilization of trauma service resources. Earlier notification may translate into improved patient outcomes. Additional studies into the benefit of apps for trauma care are warranted.

Introduction: Hernias involving the appendix are unusual and are often found during surgical exploration. Only approximately 1% of all hernias contain a portion of the vermiform appendix. The rarity of these hernias makes for a difficult discussion on standard of management. Case report: 33 year old male who presented to the ED with right lower quadrant abdominal pain for ten days, and a CT scan demonstrated acute perforated appendicitis. During diagnostic laparoscopy, the appendix was visualized herniating through a previously undescribed orifice in the lateral right iliac fossa. The orifice was lateral to the femoral triangle, in the so called ''triangle of pain,'' which is a ''V'' shaped area bounded by the iliopubic tract, testicular vessels, and peritoneal fold. Using laparoscopic technique, the appendix was reduced, and an endoscopic stapler was used to remove the appendix. The hernia was primarily repaired, and surgery was completed in the usual manner.
Discussion(s): The most commonly described hernia which contains the appendix is the Amyand hernia. This occurs when the appendix becomes trapped within an inguinal hernia sac. The incidence ranges from 0.19% to 1.7%. An Amyand hernia is three times more likely to be seen in childhood due to a persistently patent processus vaginalis. The next most commonly described is De Garengeot's hernia. This occurs when the appendix is trapped within a femoral hernia sac, and occurs in approximately 1% of all femoral hernia cases. It differs from the Amyand hernia in that it is more commonly found in females, and follows a bimodal age distribution. The mechanism by which appendicitis develops within hernias is not fully understood, and is extremely rare with rates ranging from 0.07-0.13%. In these instances, perforation only occurs in approximately 0.1% of the cases. When perforation does occur, there is increased mortality due to the spread of severe peritoneal sepsis. Therapeutic strategies for these hernias depend on the condition of the appendix. The Losanoff and Basson classification is a management strategy for dealing with Amyand hernias. The Rikki modification adds to this in dealing with incisional hernias. The general principle shared between the two is that for a non-inflamed appendix, the patient should have hernia repair without appendectomy. When an acutely inflamed appendix is encountered, appendectomy should be performed and the hernia should be primarily repaired. These principles should be applied to all hernias containing the appendix in order to avoid postoperative complications

Introduction: The focused assessment with sonography in trauma (FAST) exam provides a rapid bedside screening tool for intraperitoneal free fluid and solid organ injuries. Blood clots within an injured organ may have similar echogenicity to that of the parenchyma. The sensitivity for detection of solid organ injury is therefore more limited and ranges from 41-44%. Case Presentation: A 52-year-old male presented as a Level 2 Trauma notification after plywood fell onto him from fifteen feet. Upon presentation he was evaluated according to ATLS protocol. Secondary survey was significant for suprapubic tenderness and abrasions to bilateral hips. A FAST exam was performed, showing echogenic fluid filling the bladder. A foley catheter was placed and gross hematuria was noted. Xray in the trauma bay showed fractures of the left superior and inferior pubic rami. Subsequently a CT cystogram was performed which showed large clot within the bladder with small extraperitoneal extravasation. The injury was managed with transurethral foley and gentle irrigation.
Discussion(s): The bladder is well protected by the bony pelvis, making rupture relatively uncommon in blunt trauma. However, it remains an important injury to rule out because mortality rates can be be as high as 22%. Pelvic fracture with associated gross hematuria is an indication for immediate cystography. Blunt extraperitoneal bladder rupture should be treated conservatively, with nonoperative management having comparable outcomes to primary repair. Relative contraindications to conservative management of extraperitoneal bladder rupture include bone fragments protruding into the bladder, open pelvic fractures, and concomitant rectal injuries. The use of transurethral catheters are preferred over suprapubic catheters, resulting in fewer complications and fewer days of catheterization.
Conclusion(s): FAST exam is less sensitive for diagnosing solid organ injury and ranges from 41-44%. Hematuria and pelvic fractures are seen together in 90% of bladder ruptures. When both are present in blunt trauma, cystography should be performed. Extraperitoneal bladder injuries should be managed non operatively with drainage transurethral catheter alone. Intraperitoneal bladder injuries should be managed by primary repair with transurethral catheter or suprapubic tube drainage

The incidence of hypothyroidism presenting with sigmoid volvulus, a phenomenon known as myxedema pseudovolvulus, is exceedingly rare. A male in his late thirties presented to our institution with a chief complaint of abdominal pain. The patient underwent CT scan, which was consistent with massive colonic dilatation with sigmoid volvulus. He was taken to the operating room for exploration and was found to have sigmoid volvulus and underwent a segmental resection. Postoperatively, the patient was newly diagnosed with severe hypothyroidism.