Trauma Activation and Substance Use in an Urban Trauma Center

Background: Alcohol and drug screens in trauma patients are endorsed by the American College of Surgeons Committee on Trauma. The objective was to determine the characteristics and frequency of alcohol and poly-drug combinations in patients triaged by Trauma Team Activation (TTA) codes. Methods: A retrospective study of a Level I hospital trauma registry was initiated with 14,972 patients of whom 7028 (47%) were Substance Users (SU). There were 10,369 TTA patients: 5396 (52%) were SU, and 4603 (31%) non-TTA patients, of whom 1632 (35.5%) were SU. Inclusion criteria were: age ≥14 years old, blood alcohol level and Urine Drug Screen (UDS) documentation, Injury Severity Score (ISS), TTA code, hospital charges and Length of Hospitalization (LOS). Statistical analyses were performed with one-way ANOVA, Maximum Likelihood chi squared, and Mann-Whitney U tests. Results: The median ISS was 5 for both groups. TTA patients were younger than non-TTA patients (median 33 years versus 41 years). Mortality was significantly higher for TTA (4.7%) than for non-TTA (0.7%) patients. From 2010-2013 to 2014-2018, all substance users had a significant decrease in alcohol only use (58.0% to 42.0%) with an increase in single drug (42.0% to 58.0%) and poly-drug use (36.9% to 63.1%), p < 0.0001. For all SU patients (TTA and non-TTA), the major single drugs used were opiates (19.9%), cannabinoids (THC) (15.2%), benzodiazepines (7.7%), amphetamines (6.6%), and cocaine (2.5%). The major poly-drugs were: opiates/THC (4.7%), opiates/benzodiazepines (4.6%), THC/amphetamines (3.1%), THC/benzodiazepines (2.2%). Conclusions: By trauma activation code designation, the TTA group had most of the positive alcohol and drug screens in this study. Since the change in mandated opioid prescription practices in 2014, this study showed increased poly-drug use (two to six-drug combinations) in urban trauma patients between 2014-2018. Opioids and cannabinoids continued to be the most frequently used drugs singly and in combinations.

Utilizing Instilling Negative Pressure Wound Therapy with Vashe Wound Solution for an Infected Sternal Dehiscence: A Case Report

Utilization of negative pressure wound therapy with instillation (NPWTi) for sternal dehiscence wounds secondary to sternal wound infection after surgery has become an accepted therapy. NPWTi accelerates wound healing through macrostrain, microstrain, and cyclic fluid instillation. Wounds benefit from additional superficial infection control with the removal of microorganisms, the release of proinflammatory mediators, stimulation of angiogenesis, as well as mechanical debridement. However, very few cases of utilizing NPWTi in the treatment of sternal wound infections have been reported in the literature. This case study describes the use of NPWTi with hypochlorous acid for the treatment of a sternal wound infection.

Troubleshooting a Difficult Trans-Tibial/Fibula Amputation: A Case Report

Necrotic feet secondary to vascular compromise in the diabetic patient may require an emergent guillotine amputation. Unrecognized, retained hardware in a distal ankle years after fracture repair may complicate the intraoperative guillotine amputation at the transtibial/fibula level. Troubleshooting such an unexpected surgical problem is not necessarily straightforward depending on the clinical situation. Presented is a case report where a patient with a necrotic burned foot failed to inform the burn team that he had implanted ankle hardware, prior to his surgical intervention. A successful amputation was completed after proceeding down a specific algorithm devised for such a scenario.

Complex Limb Salvage with Placental-Based Allografts: A Pilot Study

Background: Commercially available human placental amnion/chorion tissue allografts have been successfully used as protective treatment barriers for wounds and diabetic ulcers. Burn and traumatic limb injuries with exposed bone or tendon generally require surgical flaps or amputations for healing. The purpose of this study was to determine if dehydrated human amnion/ chorion membrane allografts (dHACM) with decellularized human collagen matrix (dHCM) could be used to salvage injured human extremities. Methods and Materials: dHACM/dHCM was topically applied to the wounds after debridement. Negative Pressure Wound Therapy (NPWT) was concurrently initiated, primarily to bolster the tissue with moisture and contamination control. Approximately every seven days, wounds were re-evaluated for granulation tissue growth response. As needed, patients received dHACM/ dHCM and NPWT in the outpatient or home care settings after discharge. Results: Fifteen males and two females (26 extremities) were treated for fourteen burn and three Necrotizing Soft Tissue Infections (NSTI) injuries. Closure was observed in patients after two to five dHACM/dHCM applications. The dHACM/dHCM treatment was initiated: (median) 17-days after injury;NPWT for 17-days;autograft or primary closure after 21-days;discharge 25-days after the first application. Conclusion: Treatment with human placental-derived allografts provided a protective covering that enabled the healing cascade to generate granulation tissue formation in extremity wounds with exposed tendon and/or bone. In select limb salvage cases, dHACM/dHCM treatment may be a promising alternative to amputations, tissue rearrangements, free tissue flaps or other techniques for resolution of extremity wounds with bone and tendon exposure.

Derivation of a Standardized Method to Identify the Anterior Compartment of the Lower Extremity Using Point-of-Care Ultrasonography

Introduction: Anterior compartment syndrome (ACS) of the lower extremity is a well-recognized surgical emergency. The anterior compartment is the most frequently missed of the four compartments during lower extremity fasciotomy. This study describes a novel approach that combines sonographic measurements and physical examination landmarks to accurately identify the anterior compartment. Materials and Methods: This study was conducted as a prospective anatomical study of 94 volunteers at a single institution. Physical exam and sonographic methods were utilized to derive measurements of the anterior compartment, followed by biometric and validation data. Results: Volunteers for the derivation and validation phases of study were similar regarding gender, height and weight, age, and BMI. The derivation set revealed the distance to the anterior compartment to be 2.77 cm (median 2.6 cm, range 1.5 - 5.4 cm) from the mid-axial line and resulted in identification of the anterior compartment 100% of the time (p < 0.001). Findings were reproducible in the internal validation set with 100% accuracy. Conclusion: The fascial planes of the anterior compartment can be identified with 100% accuracy when utilizing physical examination and sonographic methods. This can serve as a foundation for future studies evaluating ways to reduce of the number of missed anterior compartment fasciotomies in the setting of ACS.

Necrotizing Soft Tissue Infections of the Male and Female Breast: A Literature Review

Background: Within the spectrum of necrotizing soft tissue infections (NSTI), necrotizing fasciitis (NF) has been characterized by tissue and fascial necrosis with systemic toxicity. The objective was to determine and summarize the frequency and characteristics of breast NF and NSTI in the literature. Methods: Cases were obtained through PubMed, Google Scholar, Google, and from published article reference sections. One hundred twenty-three cases were gleaned from 96 articles that reported NF and NSTI of the breast (1924 through 2021). Results: NF was reported in 70 and NSTI in 53 cases (111 women and 12 men). Patients presented with swollen, painful breasts, erythema, bullae, crepitus, necrosis, gangrene, fever, tachycardia, and neutrophilia. Fifty-nine of 123 (48.4%) patients were septic on admission. The most frequent microorganisms were β hemolytic Group A Streptococcus, and Staphylococcus aureus. Treatment consisted of antibiotics, mastectomy and debridement with flaps, skin grafts or primary and secondary closure. Forty-four (63.0%) of the NF cases had chest wall involvement;of these, 18 (14.6%) involved the breast secondarily, P < 0.0001. There were twelve mortalities (9.8%): eleven (9.0%) with NF and one (0.8%) with NSTI, P = 0.007. Conclusions: Men and women with breast NF and NSTI presented with similar signs and symptoms and required the same emergent treatment as provided for NF and NSTI of the more common sites. As a time-sensitive disease, patients treated within 12 hours of admission had a better survival. Patients with NF were more likely to have sepsis on admission, a higher mortality, and fascial chest wall/muscle involvement than patients with NSTI.

Limb Salvage Using Human Placental Allografts: Adding to the Reconstructive Ladder Paradigm

Human placental allografts are the latest treatment modalities for diabetic ulcers, chronic wounds, limbs, and tendons for healing cascade and promoting granulation tissue coverage. Purion® processed dehydrated human amnion/chorion membrane allografts (dHACM), decellularized human collagen matrix (dHCM), dehydrated umbilical cord (dHUC) and micronized dehydrated human amnion/chorion membrane allografts (mdHACM) have been the newest modality used to salvage injured human extremities with tendon and bone exposure. A 53-year-old male was assaulted and sustained second and third degree burns to both legs. The left extremity had a 9.5% total body surface area (%TBSA) burned. The right extremity had a 5.5% TBSA and three exposed tendons (Achilles/flexor digitorum longus/tibialis anterior), muscles, talar and tibial bones. Bilateral extremity pedal pulses were present, and all toes had less than two second capillary refill. Sensation, motor, and strength were normal. During the 48-day-hospital stay, the patient had eight operations: tangential excisional debridements of necrotic tissue with weekly wound dressing applications of dHACM and dHCM, on both legs. In addition, dHUC was applied over the exposed tendons on weeks 2 - 5. The exposed tendons were injected with mdHACM on weeks 4 and 5. Negative pressure wound therapy was applied at 125 mmHg for fourteen days over the wound surfaces covered with a nonadherent dressing, 3% bismuth tribromophenate petrolatum dressing with a glycerol-hydroxyethyl cellulose lubricant. At discharge for rehabilitation, 90% of the split-thickness-skin-graft (STSG) was viable over the right ankle joint, tendons and bone. Use of human placental allografts prevented the need for myocutaneous flap coverage or amputation of the right foot.

Is the Critical Patient with a Septic Limb Too Sick for an Emergent Amputation? A Case Report Illustrating How to Perform a Bedside Physiologic Amputation

A physiologic amputation is an important option for the critically ill patient who has irreversible limb disease with necrotic wounds but who would have a low probability of surviving a standard open amputation, without effective preoperative resuscitation, antibiotics, and correction of metabolic derangements. An open amputation may be required secondary to vascular ischemic disease, necrotizing fasciitis, or thermal injury that has led to the critical and unstable condition. The physiologic amputation stabilizes the patient while preventing further metabolic deterioration. The cryoamputation is intended to rescue the patient’s life and is not meant for limb salvage. While physiologic amputation has been described for over a century, it is uncommonly performed. This case report describes a physiologic amputation in a step-by-step fashion for the surgeon attempting to save a critically ill patient’s life who might not otherwise survive an open amputation.

Enzalutamide Associated with Stevens-Johnson Syndrome/Toxic Epidermal Necrolysis (SJS/TEN) Overlap: A Case Report

Enzalutamide is a hormonal therapy that blocks the action of androgens, such as testosterone in the treatment of metastatic castration-resistant prostate cancer. Stevens-Johnson syndrome and toxic epidermal necrolysis (SJS/TEN) overlap and are part of an adverse drug reaction continuum of disease, in which there is a 10% - 30% involvement of the skin surface with mucositis, blisters, skin slough, and a macular rash. A 66-year-old male was treated with enzalutamide for metastatic prostate cancer and developed SJS/TEN overlap with 25% total body surface area skin involvement. The patient received a seven-day course of cyclosporine to which he responded by re-epithelialization but succumbed to multi-organ failure. While SJS/TEN has been reported with apalutamide, to our knowledge, this is the first case of SJS/TEN overlap with enzalutamide.