Cardiac injury remains a small percentage of trauma patients being received at trauma centers, despite a continual improvement in prehospital care and an unfortunate increase in penetrating trauma over the last few years. There are major differences between penetrating and blunt cardiac injury (BCI) in the presentation of the patient to the trauma bay, associated injuries, diagnostic methods, and therapeutic interventions. Depending on the mechanism of injury and management of these patients, low mortality is obtainable. There is clear evidence for those needing continuous monitoring when arrhythmia is present in the emergency room and/or cardiac enzymes are abnormal. For patients without these findings, there is no evidence for the need for continuous ECG monitoring. There are multiple approaches and techniques to treat a foreign body in the heart, depending on the characteristics of the impaled or retained object and the resources available at the hospital.
IntroductIonAmong nonpenetrating traumatic injuries, blunt thoracic aortic injury (BTAI) is the second most common cause of mortality, second to intracranial hemorrhage. 1 Chest X-ray (CXR) can screen for widened mediastinum, which may be a sign of aortic rupture or mediastinal hematoma. 2Although routinely used in severe trauma, mediastinal abnormalities on CXR are not sensitive and cannot serve as the sole screening criteria for BTAI.The use of computed tomography (CT) should be considered depending on CXR findings and mechanisms of injury in order to accurately diagnose BTAI. 3 If the patient is not stable, then the timing of CT depends on how the patient responds to damage control management.Once the BTAI is diagnosed, the timing and optimal repair in young patients remain in question.This is especially related to the precise anatomical location of the injury, the extent of the injury, and concurrent injuries.Here, we share a multitrauma case involving emergent extracorporeal membrane oxygenation (ECMO) and proximal descending thoracic aortic injury in a young male. case descrIptIonA 20-year-old male was found at the scene after a high-velocity motorcycle accident.The victim had a decreased level of consciousness and was suffering from abdominal to chest pain.After scoop-and-run to our trauma center, the patient arrived at our trauma bay with no external signs of bleeding, a patent airway, tachypnea what abrasions and contusions to anterior chest/torso, cool and clammy with weak and rapid central pulses, abdominal and chest tenderness, 1,
Dear Dr. William Schwab, Let me begin by saying we have never met. Maybe we have been in the same city, as I have passed through Philadelphia a few times over the last decade, or perhaps you have visited Israel and we have been within the same borders for a short amount of time. Nevertheless, you have made an impact on the teacher, mentor, and traumatologist I aim to be. I am writing to say thank you. Really, thank you from the bottom of my heart. Throughout my relatively short career as a surgeon, I have gotten to know and work with a handful of your former fellows. You know how it goes, you meet a colleague and begin talking about your backgrounds, where you trained, etc. I have done this hundreds of times, and every fellow who trained with you has said, “Dr. Schwab was a great person, and an outstanding mentor.” Of course there were synonyms for “great” and “outstanding” depending on the fellow, but there were always compliments. I never heard fellows talk about a mentor like that, with such consistency and admiration. Everyone mentioned what a wonderful human being you were, and how special a mentor. Human and mentor—these 2 aspects of who you are appeared to have left the biggest impression on them. They became competent, academic, and very good clinical traumatologists because of you and your team. Yet it is human and mentor carved on their core of personal and professional recall. I have recently taken my first position as a trauma unit director. I love what I do and am very passionate about it (an understatement, according to some). I sometimes come to a trauma case in the middle of the night, watch over the residents running the trauma code, hear and discuss their plan, and help them in any way necessary. Yet, as I play back the events the following day, there are always points when I could have taught a little something more; discussed an interesting and important point for longer; or made even more effort to teach something else that will help my residents, nurses, trauma team, and overall patient care. I am sure every attending feels like this sometimes—even you have I would imagine. When I am feeling scattered clouds of laziness approaching, or the hypothalamus battling for a few more minutes of sleep, I think about the effect you had on your fellows. I think about how their faces lit up (as much as emotion can show on the face of a surgeon) when they mentioned your name. This has been etched upon my core and provides the motivation to give as much as I can to our residents, fellows, nurses, nutritionists, social workers, physical therapists, students, and whomever else wants to learn at any hour of the day; to help, to be better, to be part of giving and caring for the trauma patients under our watch. In our profession, we see our patients’ fate change in the flash of a fall, accident, or act of violence. I do not know how we are able to separate our lives from work (which my therapist says needs to occur), and I hope our friends and families know who we are outside of what we do within the walls of the hospital. I want to thank you for the family you have created, the family you have mentored. And for showing me the positive and practical impact a true mentor, a true leader, a true human, can have on people. Maybe this letter is more a letter to myself, a reminder, a huge red light, a letter to state the (often overlooked) obvious—that mentorship is the key to training good, competent, humane surgeons. That this extra effort is what will create change, sustainability, and at the end of the pathway, is what will be remembered. That this is the type of person and surgeon I want to be. I am sure there are hundreds, if not thousands, of outstanding surgeon mentors in this world and they all deserve this letter, the appreciation, the thanks. But it is your name, Dr. Schwab, I have heard meeting after meeting. Thank you for being an inspiration and example to me, a stranger who is so far away. Acknowledgments: The author wishes to thank his mentors Dr. Rick Hodes, Dr. Marc de Moya, and Dr. Adan Rios.
A woman in her mid-30s presented to our 30-bed healthcare centre with extensive burns, hours after falling into a shallow pit of burning dried tea leaves. On arrival, there was no evidence of airway compromise. She was fully conscious but had signs of shock and hypovolemia. Forty-five per cent of the total body surface area was burned, including the face, neck, thorax, abdomen, upper limbs and thighs. The family refused referral to a burns centre and insisted on continuing treatment at our facility. Our hospital, not equipped to manage burns, was adapted to deliver effective, immediate care. After initial stabilisation, the patient was unwilling to remain hospitalised because of her husband's employment commitment. Subsequently, we were notified that the patient died within 1 month of discharge. This article highlights the importance of burns care facilities in rural India and the impact of a failure to access quality health on outcomes.
Proximal femoral fractures (PFFs) are a major medical event in an elderly's life. The extent of conservative treatment is poorly evaluated in Western health systems. This study retrospectively examines a national cohort of patients older than 65 years with PFFs treated by early surgery (ES) (<48h), delayed surgery (DS) (>48h), and conservative treatment (COT) over the past decade (2010 to 2019).The study cohort included 38,841 patients; 18.4% were 65 to 74 years, 41.1% were 75 to 84 years, and 40.5% were older than 85 years; 68.5% were female. ES rose from 68.4% in 2013 to 85% in 2017 ( P < 0.0001). COT dropped from 8.2% in 2010 to 5.2% in 2019 ( P < 0.0001). Level I trauma centers chose 2.3 times less COT (7.75% in 2010 decreased to 3.37% in 2019) while regional hospitals chose COT only 1.4 times less over the years ( P < 0.001). Hospitalization periods differed: 6.3 ± 0.6d for COT, 8.6 ± 0.3d for ES, and 12 ± 0.4d for DS ( P < 0.001), and the in-hospital mortality rates were 10.5%, 2%, and 3.6%, respectively ( P < 0.0001). One-year mortality rates decreased for ES only ( P < 0.001).ES rose from 58.1% in 2010 to 84.9% in 2019 ( P = 0.00002). COT is diminishing throughout the Israeli health system, from 8.2% in 2010 to 5.2% in 2019. Tertiary hospitals consistently practice less COT than regional hospitals ( P < 0.001), probably related to surgeons' and anesthetists' appraisal of the patient's medical status and demand. COT had the shortest hospitalization period but carried the highest in-hospital mortality rates (10.5%). The mild difference in out-of-hospital mortality between the COT and DS groups suggests similar patient characteristics that require additional investigation. In conclusion, more PFFs are treated within 48h with a reduced mortality rate, and the 1-year mortality has improved for ES only. Treatment preferences vary between tertiary and regional hospitals.
The amino acid sequence of a biologically active polypeptide isolated from calf thymus, termed thymosin alpha1, has been determined. Thymosin alpha1 is a heat stable, highly acidic molecule composed of 28 amino acid residues. This peptide is one of several present in thymosin fraction 5 that may participate in the regulation, differentiation and function of thymus-dependent lymphocytes (T cells). A nomenclature for the family of polypeptides present in thymosin fraction 5 is suggested.
