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Azurdia AR, Walters J, Mellon CR, Lettieri SC, Kopelman TR, Pieri P, Feiz-Erfan I. Airway risk associated with patients in halo fixation. Surg Neurol Int 2024; 15:104. [PMID: 38628525 PMCID: PMC11021081 DOI: 10.25259/sni_386_2023] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/04/2023] [Accepted: 12/30/2023] [Indexed: 04/19/2024] Open
Abstract
Background The halo fixation device introduces a significant obstacle for clinicians attempting to secure a definitive airway in trauma patients with cervical spine injuries. The authors sought to determine the airway-related mortality rate of adult trauma patients in halo fixation requiring endotracheal intubation. Methods This study was a retrospective chart review of patients identified between 2007 and 2012. Only adult trauma patients who were intubated while in halo fixation were included in the study. Results A total of 46 patients underwent 60 intubations while in halo. On five occasions, (8.3%) patients were unable to be intubated and required an emergent surgical airway. Two (4.4%) of the patients out of our study population died specifically due to airway complications. Elective intubations had a failure rate of 5.8% but had no related permanent morbidity or mortality. In contrast to that, 25% of non-elective intubations failed and resulted in the deaths of two patients. The association between mortality and non-elective intubations was statistically highly significant (P = 0.0003). Conclusion The failed intubation and airway-related mortality rates of patients in halo fixation were substantial in this study. This finding suggests that the halo device itself may present a major obstacle in airway management. Therefore, heightened vigilance is appropriate for intubations of patients in halo fixation.
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Affiliation(s)
- Adrienne R. Azurdia
- Department of Emergency Medicine, HonorHealth Osborn, Scottsdale, United States
| | - Jarvis Walters
- Department of Surgery, Division of Trauma, Valleywise Health Medical Center, Phoenix, United States
| | - Chris R. Mellon
- Department of Trauma Surgery and Surgical Critical Care, HonorHealth Osborn, Phoenix, United States
| | - Salvatore C. Lettieri
- Department of Surgery, Division of Plastic Surgery, Valleywise Health Medical Center, Phoenix, United States
| | - Tammy R. Kopelman
- Department of Surgery, Division of Trauma, Valleywise Health Medical Center, Phoenix, United States
| | - Paola Pieri
- Department of Surgery, Division of Trauma, Valleywise Health Medical Center, Phoenix, United States
| | - Iman Feiz-Erfan
- Department of Surgery, Division of Neurosurgery, Valleywise Health Medical Center, Phoenix, United States
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Kopelman TR, Jamshidi R, Pieri PG, Davis K, Bogert J, Vail SJ, Gridley D, Singer Pressman MA. Computed tomographic imaging in the pediatric patient with a seatbelt sign: still not good enough. J Pediatr Surg 2018; 53:357-361. [PMID: 29198896 DOI: 10.1016/j.jpedsurg.2017.10.003] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/04/2017] [Accepted: 10/04/2017] [Indexed: 10/18/2022]
Abstract
PURPOSE Considering the improvements in CT over the past decade, this study aimed to determine whether CT can diagnose HVI in pediatric trauma patients with seatbelt signs (SBS). METHODS We retrospectively identified pediatric patients with SBS who had abdominopelvic CT performed on initial evaluation over 5 1/2years. Abnormal CT was defined by identification of any intra-abdominal abnormality possibly related to trauma. RESULTS One hundred twenty patients met inclusion criteria. CT was abnormal in 38/120 (32%) patients: 34 scans had evidence of HVI and 6 showed solid organ injury (SOI). Of the 34 with suspicion for HVI, 15 (44%) had small amounts of isolated pelvic free fluid as the only abnormal CT finding; none required intervention. Ultimately, 16/120 (13%) patients suffered HVI and underwent celiotomy. Three patients initially had a normal CT but required celiotomy for clinical deterioration within 20h of presentation. False negative CT rate was 3.6%. The sensitivity, specificity and accuracy of CT to diagnose significant HVI in the presence of SBS were 81%, 80%, and 80%, respectively. CONCLUSIONS Despite improvements in CT, pediatric patients with SBS may have HVI not evident on initial CT confirming the need to observation for delayed manifestation of HVI. LEVEL OF EVIDENCE Level II Study of a Diagnostic Test.
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Affiliation(s)
- Tammy R Kopelman
- Division of Burns, Trauma, and Surgical Critical Care, and Department of Surgery, Maricopa Medical Center, 2601 E Roosevelt St, Phoenix, AZ 85008.
| | - Ramin Jamshidi
- Division of Burns, Trauma, and Surgical Critical Care, and Department of Surgery, Maricopa Medical Center, 2601 E Roosevelt St, Phoenix, AZ 85008.
| | - Paola G Pieri
- Division of Burns, Trauma, and Surgical Critical Care, and Department of Surgery, Maricopa Medical Center, 2601 E Roosevelt St, Phoenix, AZ 85008.
| | - Karole Davis
- Division of Burns, Trauma, and Surgical Critical Care, and Department of Surgery, Maricopa Medical Center, 2601 E Roosevelt St, Phoenix, AZ 85008.
| | - James Bogert
- Division of Burns, Trauma, and Surgical Critical Care, and Department of Surgery, Maricopa Medical Center, 2601 E Roosevelt St, Phoenix, AZ 85008.
| | - Sydney J Vail
- Division of Burns, Trauma, and Surgical Critical Care, and Department of Surgery, Maricopa Medical Center, 2601 E Roosevelt St, Phoenix, AZ 85008.
| | - Daniel Gridley
- Department of Radiology, Maricopa Medical Center, 2601 E Roosevelt St, Phoenix, AZ 85008.
| | - Melissa A Singer Pressman
- Division of Burns, Trauma, and Surgical Critical Care, and Department of Surgery, Maricopa Medical Center, 2601 E Roosevelt St, Phoenix, AZ 85008.
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Walters JW, Kopelman TR, Patel AA, O'Neill PJ, Hedayati P, Pieri PG, Vail SJ, Lettieri SC, Feiz-Erfan I. Closed therapy of thoracic and lumbar vertebral body fractures in trauma patients. Surg Neurol Int 2017; 8:283. [PMID: 29279800 PMCID: PMC5705931 DOI: 10.4103/sni.sni_336_17] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/10/2017] [Accepted: 10/03/2017] [Indexed: 11/04/2022] Open
Abstract
Background The failure rate for the closed/non-surgical treatment of thoracic and lumbar vertebral body fractures (TLVBF) in trauma patients has not been adequately evaluated utilizing computed tomography (CT) studies. Methods From 2007 to 2008, consecutive trauma patients, who met inclusion criteria, with a CT diagnosis of acute TLVBF undergoing closed treatment were assessed. The failure rates for closed therapy, at 3 months post-trauma, were defined by progressive deformity, vertebral body collapse, or symptomatic/asymptomatic pseudarthrosis. The Arbeitsgemeinschaft für Osteosynthesefragen (AO) classification was utilized to classify the fractures (groups A1 and non-A1 fractures) and were successively followed with CT studies. Results There were 54 patients with 91 fractures included in the study; 66 were A1 fractures, and 25 were non-A1 fractures. All had rigid bracing applied with flat and upright X-ray films performed to rule out instability. None had sustained spinal cord injuries. Thirteen patients (24%) failed closed therapy [e.g. 13 failed fractures (14%) out of 91 total fractures]. Five failed radiographically only (asymptomatic), and eight failed radiographically and clinically (symptomatic). A1 fractures had a 4.5% failure rate, while non-A1 fractures failed at a rate of 40%. Conclusion Failure of closed therapy for TLVBF in the trauma population is not insignificant. Non-A1 fractures had a much higher failure rate when compared to A1 fractures. We recommend close follow-up particularly of non-A1 fractures treated in closed fashion using successive CT studies.
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Affiliation(s)
- Jarvis W Walters
- Department of Surgery, The University of Arizona, College of Medicine Phoenix, Phoenix, Arizona Maricopa Medical Center, Phoenix, USA
| | - Tammy R Kopelman
- Division of Trauma, The University of Arizona, College of Medicine Phoenix, Phoenix, Arizona Maricopa Medical Center, Phoenix, USA
| | - Arpan A Patel
- The University of Arizona, College of Medicine Phoenix, Phoenix, Arizona, USA
| | - Patrick J O'Neill
- Division of Trauma, The University of Arizona, College of Medicine Phoenix, Phoenix, Arizona Maricopa Medical Center, Phoenix, USA
| | - Poya Hedayati
- Department of Radiology, The University of Arizona, College of Medicine Phoenix, Phoenix, Arizona Maricopa Medical Center, Phoenix, USA
| | - Paola G Pieri
- Division of Trauma, The University of Arizona, College of Medicine Phoenix, Phoenix, Arizona Maricopa Medical Center, Phoenix, USA
| | - Sydney J Vail
- Division of Trauma, The University of Arizona, College of Medicine Phoenix, Phoenix, Arizona Maricopa Medical Center, Phoenix, USA
| | - Salvatore C Lettieri
- Division of Plastic Surgery, The University of Arizona, College of Medicine Phoenix, Phoenix, Arizona Maricopa Medical Center, Phoenix, USA.,Division of Plastic Surgery, Mayo Clinic College of Medicine, Rochester, Minnesota, USA
| | - Iman Feiz-Erfan
- Division of Neurosurgery, The University of Arizona, College of Medicine Phoenix, Phoenix, Arizona Maricopa Medical Center, Phoenix, USA
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Kopelman TR, Walters JW, Bogert JN, Basharat U, Pieri PG, Davis KM, Quan AN, Vail SJ, Pressman MA. Goal directed enoxaparin dosing provides superior chemoprophylaxis against deep vein thrombosis. Injury 2017; 48:1088-1092. [PMID: 28108019 DOI: 10.1016/j.injury.2016.10.039] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/18/2016] [Revised: 10/18/2016] [Accepted: 10/28/2016] [Indexed: 02/02/2023]
Abstract
INTRODUCTION Optimal enoxaparin dosing for deep venous thrombosis (DVT) prophylaxis remains elusive. Prior research demonstrated that trauma patients at increased risk for DVT based upon Greenfield's risk assessment profile (RAP) have DVT rates of 10.8% despite prophylaxis. The aim of this study was to determine if goal directed prophylactic enoxaparin dosing to achieve anti-Xa levels of 0.3-0.5IU/ml would decrease DVT rates without increased complications. MATERIALS AND METHODS Retrospective review of trauma patients having received prophylactic enoxaparin and appropriately timed anti-Xa levels was performed. Dosage was adjusted to maintain an anti-Xa level of 0.3-0.5IU/ml. RAP was determined on each patient. A score of ≥5 was considered high risk for DVT. Sub-analysis was performed on patients who received duplex examinations subsequent to initiation of enoxaparin therapy to determine the incidence of DVT. RESULTS 306 patients met inclusion criteria. Goal anti-Xa levels were met initially in only 46% of patients despite dosing of >40mg twice daily in 81% of patients; however, with titration, goal anti-Xa levels were achieved in an additional 109 patients (36%). An average enoxaparin dosage of 0.55mg/kg twice daily was required for adequacy. Bleeding complications were identified in five patients (1.6%) with three requiring intervention. There were no documented episodes of HIT. Subsequent duplex data was available in 197 patients with 90% having a RAP score >5. Overall, five DVTs (2.5%) were identified and all occurred in the high-risk group. All patients were asymptomatic at the time of diagnosis. CONCLUSION An increased anti-Xa range of 0.3-0.5IU/ml was attainable but frequently required titration of enoxaparin dosage. This produced a lower rate of DVT than previously published without increased complications.
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Affiliation(s)
- Tammy R Kopelman
- Department of Surgery, Maricopa Medical Center, 2601 East Roosevelt, Phoenix, AZ 85008, United States.
| | - Jarvis W Walters
- Department of Surgery, Maricopa Medical Center, 2601 East Roosevelt, Phoenix, AZ 85008, United States.
| | - James N Bogert
- Department of Surgery, Maricopa Medical Center, 2601 East Roosevelt, Phoenix, AZ 85008, United States.
| | - Usmaan Basharat
- Department of Surgery, Maricopa Medical Center, 2601 East Roosevelt, Phoenix, AZ 85008, United States.
| | - Paola G Pieri
- Department of Surgery, Maricopa Medical Center, 2601 East Roosevelt, Phoenix, AZ 85008, United States.
| | - Karole M Davis
- Department of Surgery, Maricopa Medical Center, 2601 East Roosevelt, Phoenix, AZ 85008, United States.
| | - Asia N Quan
- Department of Surgery, Maricopa Medical Center, 2601 East Roosevelt, Phoenix, AZ 85008, United States.
| | - Sydney J Vail
- Department of Surgery, Maricopa Medical Center, 2601 East Roosevelt, Phoenix, AZ 85008, United States.
| | - Melissa A Pressman
- Department of Surgery, Maricopa Medical Center, 2601 East Roosevelt, Phoenix, AZ 85008, United States.
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5
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Davis J, Roh AT, Petterson MB, Kopelman TR, Matz SL, Gridley DG, Connell MJ. Computed tomography localization of the appendix in the pediatric population relative to the lumbar spine. Pediatr Radiol 2017; 47:301-305. [PMID: 28091700 DOI: 10.1007/s00247-016-3773-x] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/18/2016] [Revised: 11/16/2016] [Accepted: 12/22/2016] [Indexed: 10/20/2022]
Abstract
BACKGROUND Computed tomography (CT) is commonly used to evaluate suspected acute appendicitis. Although very effective, CT uses ionizing radiation, exposing patients to an increased risk of cancer. OBJECTIVE This study assessed the potential for decreasing the field of view of the CT (and therefore the dose to the patient) in the evaluation of suspected acute appendicitis in children. MATERIALS AND METHODS This study was a retrospective review of prospectively collected data from 212 consecutive patients who underwent CT for suspected acute appendicitis. The most superior aspect of the appendix with respect to vertebral bodies was recorded. Age, gender and diagnosis (negative, acute appendicitis or alternative diagnosis) were noted. RESULTS The appendix was visualized in 190 of 212 subjects (89.6%). Overall, all visualized appendixes were located at or below the level of L1. Sixty-three of the subjects (29.7%) were diagnosed with acute appendicitis via CT imaging. All appendixes in patients with acute appendicitis were located at or below the level of the L3 vertebral body, predominating at the level of L5. Six subjects (3.1%) received alternative diagnoses, including pneumonia, pyelonephritis, small bowel obstruction and infected urachal cyst. There were no differences in appendix location with regard to diagnosis, gender, or age (P=0.664, 0.748 and 0.705, respectively). CONCLUSION CT field of view may be decreased to the level of L1 or L3 superiorly, decreasing radiation dose without affecting the rate of appendix visualization.
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Affiliation(s)
- John Davis
- Maricopa Medical Center Department of Surgery, Maricopa Integrated Health System, 2601 E. Roosevelt St., Phoenix, AZ, 85008, USA.
| | - Albert T Roh
- Maricopa Medical Center Department of Radiology, Maricopa Integrated Health System, Phoenix, AZ, USA
| | | | - Tammy R Kopelman
- Maricopa Medical Center Department of Surgery, Maricopa Integrated Health System, 2601 E. Roosevelt St., Phoenix, AZ, 85008, USA
| | - Samantha L Matz
- Maricopa Medical Center Department of Radiology, Maricopa Integrated Health System, Phoenix, AZ, USA
| | - Daniel G Gridley
- Maricopa Medical Center Department of Radiology, Maricopa Integrated Health System, Phoenix, AZ, USA
| | - Mary J Connell
- Maricopa Medical Center Department of Radiology, Maricopa Integrated Health System, Phoenix, AZ, USA
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6
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Bogert JN, Davis KM, Kopelman TR, Vail SJ, Pieri PG, Matthews MR. Resuscitative endovascular balloon occlusion of the aorta with a low profile, wire free device: A game changer? Trauma Case Rep 2017; 7:11-14. [PMID: 30014026 PMCID: PMC6024155 DOI: 10.1016/j.tcr.2017.01.006] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 01/02/2017] [Indexed: 11/29/2022] Open
Abstract
A 24 year old male arrived to our hospital after a motor cycle crash with evidence of a traumatic brain injury and in hemorrhagic shock not responsive to volume administration. Resuscitative Endovascular Balloon Occlusion of the Aorta (REBOA) was performed in a timely fashion using a new, low profile, wire free device. This lead to rapid reversal of hypotension while his bleeding source was sought and controlled. Recently, REBOA has emerged as an adjunct in the hypotensive trauma patient with noncompressible torso hemorrhage. As first described, this procedure makes use of commonly available vascular surgery and endovascular products requiring large introducer sheaths (12–14 French) and long guidewires. Concerns regarding this technique center around the safety and feasibility of using such equipment in the emergency setting outside an angiography suite. This has likely limited widespread adoption of this technique. To address these concerns, newer products designed to be placed through a smaller sheath (7 French) and without the use of guidewires have been developed. Here we report on our first clinical use of such a device that we believe represents a significant advance in the care of the trauma patient.
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Affiliation(s)
- James N Bogert
- Division of Trauma/Critical Care, Department of Surgery, Maricopa Medical Center, 2601 E. Roosevelt St., Phoenix, AZ 85008, United States
| | - Karole M Davis
- Division of Trauma/Critical Care, Department of Surgery, Maricopa Medical Center, 2601 E. Roosevelt St., Phoenix, AZ 85008, United States
| | - Tammy R Kopelman
- Division of Trauma/Critical Care, Department of Surgery, Maricopa Medical Center, 2601 E. Roosevelt St., Phoenix, AZ 85008, United States
| | - Sydney J Vail
- Division of Trauma/Critical Care, Department of Surgery, Maricopa Medical Center, 2601 E. Roosevelt St., Phoenix, AZ 85008, United States
| | - Paola G Pieri
- Division of Trauma/Critical Care, Department of Surgery, Maricopa Medical Center, 2601 E. Roosevelt St., Phoenix, AZ 85008, United States
| | - Marc R Matthews
- Division of Trauma/Critical Care, Department of Surgery, Maricopa Medical Center, 2601 E. Roosevelt St., Phoenix, AZ 85008, United States
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7
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Winton LM, Ferguson EMN, Hsu CH, Agee N, Eubanks RD, O'Neill PJ, Goldberg RF, Kopelman TR, Nodora JN, Caruso DM, Komenaka IK. Does Self-Assessment Improve the Effectiveness of Grand Rounds Lectures in a Community-Based Teaching Hospital? J Surg Educ 2016; 73:968-973. [PMID: 27236365 DOI: 10.1016/j.jsurg.2016.04.014] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 02/26/2016] [Revised: 04/05/2016] [Accepted: 04/18/2016] [Indexed: 06/05/2023]
Abstract
OBJECTIVE To determine whether use of self-assessment (SA) questions affects the effectiveness of weekly didactic grand rounds presentations. DESIGN From 26 consecutive grand rounds presentations from August 2013 to April 2014, a 52-question multiple-choice test was administered based on 2 questions from each presentation. SETTING Community teaching institution. PARTICIPANTS General surgery residents, students, and attending physicians. RESULTS The test was administered to 66 participants. The mean score was 41.8%. There was no difference in test score based on experience with similar scores for junior residents, senior residents, and attending surgeons (43%, 46%, and 44%; p = 0.13). Most participants felt they would be most interested in presentations directly related to their surgical specialty. Participants, however, did not score differently on topics which were the focus of the program (40% vs. 42%; p = 0.85). Journal club presentations (39% vs. others 42%; p = 0.33) also did not affect the score. The Pearson correlation coefficient for attendance was 0.49 (p < 0.0001) demonstrated that attendance was very important. Participation in the weekly SA was significantly associated with improved score as those who participated in SA scored over 20% higher than those who did not (59% vs. 38%; p < 0.0001). Based on multiple linear regression for mean score, SA explained the variation in score more than attendance. CONCLUSIONS The current study found that without preparation approximately 40% of material presented is retained after 10 months. Participation in weekly SA significantly improved retention of information from grand rounds presentations.
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Affiliation(s)
- Lisa M Winton
- Department of Surgery, Maricopa Medical Center, Phoenix, Arizona
| | | | - Chiu-Hsieh Hsu
- Arizona Cancer Center, University of Arizona, Tucson, Arizona; Mel and Enid Zuckerman Arizona College of Public Health, Tucson, Arizona
| | - Neal Agee
- Department of Surgery, Maricopa Medical Center, Phoenix, Arizona
| | - Ryan D Eubanks
- Department of Surgery, Maricopa Medical Center, Phoenix, Arizona
| | | | - Ross F Goldberg
- Department of Surgery, Maricopa Medical Center, Phoenix, Arizona
| | - Tammy R Kopelman
- Department of Surgery, Maricopa Medical Center, Phoenix, Arizona
| | | | - Daniel M Caruso
- Department of Surgery, Maricopa Medical Center, Phoenix, Arizona
| | - Ian K Komenaka
- Department of Surgery, Maricopa Medical Center, Phoenix, Arizona; Arizona Cancer Center, University of Arizona, Tucson, Arizona.
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8
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Kopelman TR, O'Neill PJ, Pieri PG, Salomone JP, Hall ST, Quan A, Wells JR, Pressman MS. Alternative dosing of prophylactic enoxaparin in the trauma patient: is more the answer? Am J Surg 2013; 206:911-5; discussion 915-6. [DOI: 10.1016/j.amjsurg.2013.10.005] [Citation(s) in RCA: 39] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/20/2013] [Revised: 10/17/2013] [Accepted: 10/18/2013] [Indexed: 10/26/2022]
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9
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Saphier NB, Kopelman TR. Traumatic Abruptio Placenta Scale (TAPS): a proposed grading system of computed tomography evaluation of placental abruption in the trauma patient. Emerg Radiol 2013; 21:17-22. [DOI: 10.1007/s10140-013-1155-3] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/18/2013] [Accepted: 08/27/2013] [Indexed: 11/27/2022]
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10
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Kopelman TR, Leeds S, Berardoni NE, O'Neill PJ, Hedayati P, Vail SJ, Pieri PG, Feiz-Erfan I, Singer Pressman MA. Incidence of blunt cerebrovascular injury in low-risk cervical spine fractures. Am J Surg 2012; 202:684-8; discussion 688-9. [PMID: 22137135 DOI: 10.1016/j.amjsurg.2011.06.033] [Citation(s) in RCA: 20] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/18/2011] [Revised: 06/28/2011] [Accepted: 06/28/2011] [Indexed: 10/14/2022]
Abstract
BACKGROUND It has been suggested that specific cervical spine fractures (CSfx) (location at upper cervical spine [CS], subluxation, or involvement of the transverse foramen) are predictive of blunt cerebrovascular injury (BCVI). We sought to determine the incidence of BCVI with CSfx in the absence of high-risk injury patterns. METHODS We performed a retrospective study in patients with CSfx who underwent evaluation for BCVI. The presence of recognized CS risk factors for BCVI and other risk factors (Glasgow coma score ≤ 8, skull-based fracture, complex facial fractures, soft-tissue neck injury) were reviewed. Patients were divided into 2 groups based on the presence/absence of risk factors. RESULTS A total of 260 patients had CSfx. When screened for high-risk pattern of injury for BCVI, 168 patients were identified and 13 had a BCVI (8%). The remaining 92 patients had isolated low CSfx (C4-C7) without other risk factors for BCVI. In this group, 2 patients were diagnosed with BCVI (2%). Failure to screen all patients with CSfx would have missed 2 of 15 BCVIs (13%). CONCLUSIONS We propose that all CS fracture patterns warrant screening for BCVI.
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Affiliation(s)
- Tammy R Kopelman
- Division of Burns, Trauma, and Surgical Critical Care, Maricopa Medical Center, Phoenix, AZ 85008, USA.
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11
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Berardoni NE, Kopelman TR, O'Neill PJ, August DL, Vail SJ, Pieri PG, Pressman MAS. Use of computed tomography in the initial evaluation of anterior abdominal stab wounds. Am J Surg 2011; 202:690-5; discussion 695-6. [DOI: 10.1016/j.amjsurg.2011.06.032] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/19/2011] [Revised: 06/28/2011] [Accepted: 06/28/2011] [Indexed: 11/16/2022]
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12
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Hibbard ML, Kopelman TR, O'Neill PJ, Maly TJ, Matthews MR, Cox JC, Vail SJ, Quan AN, Drachman DA. Empiric, broad-spectrum antibiotic therapy with an aggressive de-escalation strategy does not induce gram-negative pathogen resistance in ventilator-associated pneumonia. Surg Infect (Larchmt) 2011; 11:427-32. [PMID: 20818984 DOI: 10.1089/sur.2009.046] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/25/2023] Open
Abstract
BACKGROUND Early, empiric, broad-spectrum antibiotics followed by de-escalation to pathogen-specific therapy is the standard of care for ventilator-associated pneumonia (VAP). In our surgical intensive care unit (SICU), imipenem-cilastatin (I-C) in combination with tobramycin (TOB) or levofloxacin (LEV) has been used until quantitative bronchoalveolar lavage results are finalized, at which time de-escalation occurs to pathogen-specific agents. With this practice, however, alterations in antimicrobial resistance remain a concern. Our hypothesis was that this strict regimen does not alter antimicrobial susceptibility of common gram-negative VAP pathogens in our SICU. METHODS After Institutional Review Board approval, a retrospective review of SICU-specific antibiograms was performed for the sensitivities of common gram-negative VAP pathogens. Time periods were defined as early (January-June 2005) and late (July-December 2006). Chart review of empiric and de-escalation antibiotic usage was obtained. Data were collated, and statistical significance was assessed with the chi-square test using the on-line Simple Interactive Statistical Analysis tool. RESULTS Imipenem-cilastatin was used 198 times for empiric VAP coverage (811 patient-days), whereas TOB and LEV were given a total of 149 (564 patient-days) and 61 (320 patient-days) times, respectively. Collectively, the susceptibility of gram-negative organisms to I-C did not change (early 91.4%; late 97%; p = 0.33). Individually, non-significant trends to greater sensitivity to I-C were noted for both Pseudomonas aeruginosa (early 85.7%; late 90.9%; p = 0.73) and Acinetobacter baumannii (early 80%; late 100%; p = 0.13). Further, both TOB (early 77.1%; late 70.0%; p = 0.49) and LEV (early 74.3%; late 70.0%; p = 0.67) were found to maintain their susceptibility profiles. The frequency of resistant gram-positive VAPs was unchanged during the study period. Our de-escalation compliance (by 96 h) was 78% for I-C, 77.2% for TOB, and 59% for LEV. When infections requiring I-C were removed from the analysis, de-escalation compliance was improved to 92%. CONCLUSIONS In our SICU, early, empiric broad-spectrum VAP therapy followed by de-escalation to pathogen-specific agents did not alter antimicrobial resistance and is a valid practice. Further, our compliance with de-escalation practices was higher than published rates.
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13
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Uecker NE, O'Neill PJ, Agee N, Kopelman TR. Post-traumatic Subserosal Small Bowel Herniation Leading to Obstruction in a Child with Acute Spinal Cord Injury. Eur J Trauma Emerg Surg 2009; 35:583-6. [PMID: 26815382 DOI: 10.1007/s00068-008-8155-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/18/2008] [Accepted: 12/06/2008] [Indexed: 12/01/2022]
Abstract
The presentation of small bowel injury from lap belt use varies substantially, ranging from gross hemodynamic instability to insidious physiologic deterioration to simple failure of improvement. Rarely does small bowel injury manifest as an obstruction. This paper describes one such occurrence; in this case, herniation of intact mucosa/submucosa through a serosal tear caused a high-grade small bowel obstruction in a pediatric patient with an acute spinal cord injury and a virgin abdomen.
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Affiliation(s)
- Nathaniel E Uecker
- Division of Burns, Trauma, and Surgical Critical Care, Department of Surgery, Maricopa Medical Center, AZ, Phoenix, USA
| | - Patrick J O'Neill
- Division of Burns, Trauma, and Surgical Critical Care, Department of Surgery, Maricopa Medical Center, AZ, Phoenix, USA. .,Division of Burns, Trauma, and Surgical Critical Care, Department of Surgery, Maricopa Medical Center, 2601 E. Roosevelt St., Phoenix, AZ, 85008, USA.
| | - Neal Agee
- Division of Burns, Trauma, and Surgical Critical Care, Department of Surgery, Maricopa Medical Center, AZ, Phoenix, USA
| | - Tammy R Kopelman
- Division of Burns, Trauma, and Surgical Critical Care, Department of Surgery, Maricopa Medical Center, AZ, Phoenix, USA
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14
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Kopelman TR, O'Neill PJ, Macias LH, Cox JC, Matthews MR, Drachman DA. The utility of diagnostic laparoscopy in the evaluation of anterior abdominal stab wounds. Am J Surg 2009; 196:871-7; discussion 877. [PMID: 19095102 DOI: 10.1016/j.amjsurg.2008.07.031] [Citation(s) in RCA: 14] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/03/2008] [Revised: 07/03/2008] [Accepted: 07/03/2008] [Indexed: 11/19/2022]
Abstract
BACKGROUND To assess if diagnostic laparoscopy (DL) is superior to nonoperative modes (serial abdominal examination with/without computed axial tomography [CAT] and diagnostic peritoneal lavage) in determining the need for therapeutic laparotomy (TL) after anterior abdominal stab wound (ASW). METHODS Retrospective review of ASW patients. Patients were divided into group A (DL/exploratory laparotomy) to identify peritoneal violation (PV) and group B (initial nonoperative modes). RESULTS Seventy-three patients met inclusion criteria. In group A (n = 38), 29 patients (76%) had PV by DL and underwent exploratory laparotomy. Only 10 (35%) underwent TL (sensitivity for PV = 100%; specificity and positive predictive value of PV in determining need for TL = 29% and 33%, respectively). In group B (n = 35), 7 patients (20%) underwent TL, yielding an improved specificity (96%) and positive predictive value (88%). CONCLUSIONS We find no role for DL in the evaluation of ASW patients solely to determine PV.
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Affiliation(s)
- Tammy R Kopelman
- Division of Burns, Trauma Surgery and Surgical Critical Care, Department of Surgery, Maricopa Medical Center, Phoenix, AZ 85008, USA.
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15
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O'Neill PJ, Lumpkin MF, Clapp B, Kopelman TR, Matthews MR, Cox JC, Caruso DM, Feiz-Erfan I. Significant pediatric morbidity and mortality from intracranial ballistic injuries caused by nonpowder gunshot wounds. A case series. Pediatr Neurosurg 2009; 45:205-9. [PMID: 19494565 DOI: 10.1159/000222671] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/08/2008] [Accepted: 02/06/2009] [Indexed: 11/19/2022]
Abstract
Nonpowder (ball-bearing and pellet) weapons derive their source of energy from compressed air or carbon dioxide. Such weapons are dangerous toys that cause serious injuries and even death to children and adolescents. A retrospective chart review study was undertaken to describe nonpowder gun injuries at a southwestern US urban level I adult and pediatric trauma center. Specific emphasis was placed on intracranial injuries. Over the past 6 years, a total of 29 pediatric and 7 adult patients were identified as having nonpowder firearm injuries. The patient population was overwhelmingly male (89.7%; mean age, 11 years). Overall, 17 out of 29 pediatric patients (56.8%) sustained serious injury. Nine patients (30.0%) required operation, 6 (20.7%) sustained significant morbidity, and there were 2 deaths (6.9%). Injuries to the brain, eye, head, and neck were the most common sites of injury (65.6%). Specific intracranial injuries in 3 pediatric patients are described that resulted in the death of 2 children. We suggest that age warning should be adjusted to 18 years or older for unsupervised use to be considered safe of these potentially lethal weapons.
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Affiliation(s)
- Patrick J O'Neill
- Division of Burns, Trauma, and Surgical Critical Care, Department of Surgery, Maricopa Medical Center, Phoenix, Ariz., USA
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16
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Patel AP, Lokey JS, Harris JB, Sticca RP, McGill ES, Arrillaga A, Miller RS, Kopelman TR. Current Management of Common Bile Duct Stones in a Teaching Community Hospital. Am Surg 2003. [DOI: 10.1177/000313480306900702] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
The advent of laparoscopic cholecystectomy (LC) has complicated management of common bile duct (CBD) stones. While LC is routine, laparoscopic CBD exploration (LCBDE) is not, and an algorithm to manage suspected choledocholithiasis has not been uniformly accepted. We evaluated current management of choledocholithiasis. Patients suspected of having CBD stones over a 2-year period were evaluated, and 42 studies in the literature were reviewed. Thirty-two patients were identified. Fourteen patients (44%) had LC with intraoperative cholangiogram (IOC) with no preoperative studies. IOC revealed CBD stones in nine (64%). Seven had CBD exploration (CBDE) at cholecystectomy, and two had postoperative endoscopic retrograde cholangiopancreatography (ERCP). CBDE was successful in five cases, and ERCP was successful in one. Eighteen patients (56%) underwent preoperative ERCP. Five (28%) had no CBD stones. ERCP removed stones in nine patients, and four had open CBDE after failed ERCP. Current literature supports LC with IOC without any preoperative studies. Laparoscopic CBDE is highly successful but depends on surgeon experience. Removing CBD stones with ERCP is also very successful but is associated with increased cost, hospital stay, and complications. We conclude that LC with IOC should be performed without preoperative ERCP when choledocholithiasis is suspected. If found, stones should be removed laparoscopically if possible.
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Affiliation(s)
- Ajay P. Patel
- From the Academic Department of Surgery, Greenville Hospital System, Greenville, South Carolina
| | - Jonathan S. Lokey
- From the Academic Department of Surgery, Greenville Hospital System, Greenville, South Carolina
| | - James B. Harris
- From the Academic Department of Surgery, Greenville Hospital System, Greenville, South Carolina
| | - Robert P. Sticca
- From the Academic Department of Surgery, Greenville Hospital System, Greenville, South Carolina
| | - Eric S. McGill
- From the Academic Department of Surgery, Greenville Hospital System, Greenville, South Carolina
| | - Abenamar Arrillaga
- From the Academic Department of Surgery, Greenville Hospital System, Greenville, South Carolina
| | - Richard S. Miller
- From the Academic Department of Surgery, Greenville Hospital System, Greenville, South Carolina
| | - Tammy R. Kopelman
- From the Academic Department of Surgery, Greenville Hospital System, Greenville, South Carolina
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Patel AP, Lokey JS, Harris JB, Sticca RP, McGill ES, Arrillaga A, Miller RS, Kopelman TR. Current management of common bile duct stones in a teaching community hospital. Am Surg 2003; 69:555-60; discussion 560-1. [PMID: 12889615] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/04/2023]
Abstract
The advent of laparoscopic cholecystectomy (LC) has complicated management of common bile duct (CBD) stones. While LC is routine, laparoscopic CBD exploration (LCBDE) is not, and an algorithm to manage suspected choledocholithiasis has not been uniformly accepted. We evaluated current management of choledocholithiasis. Patients suspected of having CBD stones over a 2-year period were evaluated, and 42 studies in the literature were reviewed. Thirty-two patients were identified. Fourteen patients (44%) had LC with intraoperative cholangiogram (IOC) with no preoperative studies. IOC revealed CBD stones in nine (64%). Seven had CBD exploration (CBDE) at cholecystectomy, and two had postoperative endoscopic retrograde cholangiopancreatography (ERCP). CBDE was successful in five cases, and ERCP was successful in one. Eighteen patients (56%) underwent preoperative ERCP. Five (28%) had no CBD stones. ERCP removed stones in nine patients, and four had open CBDE after failed ERCP. Current literature supports LC with IOC without any preoperative studies. Laparoscopic CBDE is highly successful but depends on surgeon experience. Removing CBD stones with ERCP is also very successful but is associated with increased cost, hospital stay, and complications. We conclude that LC with IOC should be performed without preoperative ERCP when choledocholithiasis is suspected. If found, stones should be removed laparoscopically if possible.
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Affiliation(s)
- Ajay P Patel
- Academic Department of Surgery, Greenville Hospital System, Greenville, South Carolina 29605, USA
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