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Deep neck infection is a surgical emergency that can result in life threatening complications such as airway obstruction, aspiration, thrombosis of major vessels and mediastinitis by spread of infection along fascial planes. Although appropriate surgical intervention and prompt antibiotics are given, revision surgeries are often required. We report a patient with mediastinal abscess caused by a deep neck infection that was initially intractable with usual surgical drainage but was eventually successfully treated with the modified application of a vacuum-assisted closure (VAC) device (InfoV.A.C. Therapy Unit; Kinetic Concept Inc., USA). We inserted silastic drain tubes into paratracheal area. It was difficult to pack the VAC foams, so they were prone to fail, with complete debridement. With modified VAC therapy assisted by silastic drain tube, the deeply located mediastinal abscess that had been unresponsive to conventional surgical drainage was successfully treated.
Abscess* ; Airway Obstruction ; Anti-Bacterial Agents ; Debridement ; Drainage ; Emergencies ; Humans ; Mediastinitis ; Neck* ; Negative-Pressure Wound Therapy* ; Retropharyngeal Abscess ; Thrombosis

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Editorial.

Chi Min PARK

Journal of Acute Care Surgery.2017;7(1):1-1. doi:10.17479/jacs.2017.7.1.1

No abstract available.
Critical Care ; Hemodynamics

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Two Cases of Bronchial Injury in Patients with Blunt Chest Trauma.

Hong Joo SEO ; Kyung Hoon SUN ; Sun Pyo KIM

Journal of Acute Care Surgery.2017;7(1):39-43. doi:10.17479/jacs.2017.7.1.39

Traumatic bronchial injury (TBI) is rare and often fatal, usually a result of blunt or penetrating chest trauma. Clinical manifestations of TBI include pneumothorax, pneumomediastinum, subcutaneous emphysema and continuous air leakage despite thoracostomy with negative pressure. However, TBI is initially difficult to diagnose because its signs are similar to other chest traumas. Delayed diagnosis of TBI can result in sepsis, bronchial stenosis, hypoxic injury, and eventually can cause death. We experienced two patients with TBI, possibly a result of blunt chest trauma. We did not diagnose TBI in the emergency room because we did not suspect it. During surgery, we discovered right bronchial rupture, so performed end to end anastomosis of bronchus in two patients. This report discusses the rare occurrence of TBIs due to chest trauma; our aim is to increase awareness of this diagnosis in the trauma center.
Bronchi ; Constriction, Pathologic ; Delayed Diagnosis ; Diagnosis ; Emergency Service, Hospital ; Humans ; Mediastinal Emphysema ; Pneumothorax ; Rupture ; Sepsis ; Subcutaneous Emphysema ; Thoracic Injuries ; Thoracostomy ; Thorax* ; Trauma Centers

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Pneumoperitoneum from Subcutaneous Emphysema after Blunt Chest Injury.

Byung Hee KANG ; Jonghwan MOON

Journal of Acute Care Surgery.2017;7(1):30-33. doi:10.17479/jacs.2017.7.1.30

Pneumothorax and pneumomediastinum can cause pneumoperitoneum, which does not require surgery. There are unverified theories pertaining to how air passes through the diaphragm. We report a case of pneumoperitoneum caused by blunt chest injury that was successfully managed with conservative care. Although the pneumoperitoneum was caused by thoracic injury, we believe that the air did not pass through the diaphragm, but instead came from the abdominal wall, as in subcutaneous emphysema.
Abdominal Wall ; Diaphragm ; Mediastinal Emphysema ; Pneumoperitoneum* ; Pneumothorax ; Subcutaneous Emphysema* ; Thoracic Injuries* ; Thorax*

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Multi-Detector Computed Tomography Coronal View for Deciding Optimal Incision Site in Acute Appendicitis.

Jun Won SON ; Seong Beom OH ; Hyun Young CHO

Journal of Acute Care Surgery.2017;7(1):23-29. doi:10.17479/jacs.2017.7.1.23

PURPOSE: This study identifies the optimal incision site by describing the relationship between McBurney's point and the base of appendix using the coronal view of abdominal multi-detector computed tomography (MDCT) in patients with acute appendicitis. METHODS: We reviewed the records of 206 patients with positive MDCT findings who were histologically diagnosed with acute appendicitis after appendectomy between January 2014 and September 2015. The outer 1/3 point between two points, the umbilicus and the right anterior superior iliac spine, was marked as McBurney's point on the coronal view. The superoinferior, mediolateral and radial distances between the base of appendix and McBurney's point were measured and recorded. RESULTS: The average age was 35.1±20.3 years. There were 34 patients below the age of 15-years-old (children), and 172 patients over 15-years-old (adults). In 35.4% of patients, the base of appendix was located within a radius of 2 cm from the McBurney's point, in 39.8% it was within 2~4 cm, and in 24.8% was over 4 cm. The average center coordinate of the base of inflamed appendix in our patients is 9.32 mm, 8.31 mm and the distance between two points is 12.5 mm. CONCLUSION: The location of appendix has wide individual variability; therefore the McBurney's point has limitations as an anatomic landmark. If we choose to customize appendectomy incisions considering the base of appendix by using an abdominal MDCT coronal view, additional incision site extension can be reduced.
Anatomic Landmarks ; Appendectomy ; Appendicitis* ; Appendix ; Humans ; Radius ; Spine ; Umbilicus

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General Principles in Hemodynamic Monitoring.

Hye Youn KWON ; Ji Young JANG ; Keum Seok BAE ; Hongjin SHIM

Journal of Acute Care Surgery.2017;7(1):2-8. doi:10.17479/jacs.2017.7.1.2

Hemodynamic monitoring continuously checks hemodynamic variables for problems so that the clinician can treat them when a patient's vital signs are unstable. There are many different monitoring systems, and many new technologies were developed over the past three decades. It is challenging to understand the many monitoring system in the intensive care units, for example. However, all such monitoring systems are based on the general principle of monitoring oxygen transport to a peripheral organ. In this review, from conventional to recent principles, general concepts and paradigm shifts of hemodynamic monitoring will be discussed.
Hemodynamics* ; Intensive Care Units ; Oxygen ; Vital Signs

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Blood Transfusions for Emergency Laparotomies in General Surgery.

Vignesh NARASIMHAN ; Robert SPYCHAL ; Charles PILGRIM

Journal of Acute Care Surgery.2017;7(1):15-22. doi:10.17479/jacs.2017.7.1.15

PURPOSE: Decisions regarding perioperative blood transfusions are subject to clinical and laboratory factors. Blood transfusions are associated with increased risk of infection, sepsis, organ failure, and length of stay. Current guidelines on transfusions are based on elective settings. There is a paucity of data on blood transfusion use in emergency surgery. This study reviews the appropriateness of blood transfusions in patients undergoing emergency general surgical laparotomies. METHODS: Patients undergoing emergency general surgical laparotomies at Peninsula Health from January 2013 to May 2015 were reviewed. Hemoglobin (Hb) levels triggering transfusion and overall blood utilization were obtained. Transfusions were classified based on whether they were given pre-, intra- or postoperatively. Transfusions with Hb >80 g/L in the absence of bleeding or preoperative anemia were deemed ‘inappropriate’ as per Australian Blood Authority guidelines. RESULTS: Over the 29-month period, 368 patients underwent 398 emergency laparotomies. Blood transfusions were given to 102 patients (27.7%). These patients required 240 transfusion episodes. Patients were given a median of three units of blood. One hundred and sixty-six transfusions (69.2%) were postoperative. Forty-six transfusions (19.2%) were given with Hb >80 g/L in the absence of other indications, and were deemed inappropriate. Inappropriate transfusions occurred more frequently on the ward compared to ICU (p<0.05). Almost two thirds of inappropriate transfusions were given for Hb 80~85 g/L. CONCLUSION: Nearly one in five patients received an inappropriate transfusion. More judicious use of blood products in emergency patients is required, especially on surgical wards.
Anemia ; Blood Transfusion* ; Emergencies* ; Hemorrhage ; Humans ; Laparotomy* ; Length of Stay ; Postoperative Complications ; Sepsis

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Prevalence of Multidrug Resistant Organisms in Inter-Hospital Transferred Critically Ill Patients.

Changho HEO ; Dae Sang LEE ; Eunmi GIL ; Chi Min PARK

Journal of Acute Care Surgery.2017;7(1):9-14. doi:10.17479/jacs.2017.7.1.9

PURPOSE: To assess the prevalence of multidrug-resistant organisms (MDROs) in inter-hospital transferred critically ill patients. METHODS: This is a retrospective study. The study population comprised patients who were transferred from other hospitals or health care units into the medical or surgical intensive care unit of Samsung Medical Center from January 2012 to December 2014. We evaluated the acquisition of clinically significant MDROs including methicillin-resistant Staphylococcus aureus (MRSA), vancomycin-resistant Enterococci (VRE), extended-spectrum beta-lactamase (ESBL)-producing Gram-negative bacteria, and carbapenem- resistant Gram-negative bacteria (CRGNB). RESULTS: Three hundred and twenty-one patients were included in this study. One hundred and fifty-one patients (47.0%) had at least one species of MDRO, 21.5% in MRSA, 27.1% in VRE, 15.6% in CRGNB, and 3.7% in ESBL. The prevalence of MDROs was significantly higher in male (52.7%), patients with diabetes (61.6%), patients with combined infectious diseases (51.6%), and medical patients (49.3%). Patients with MRSA had significantly longer length of stay than the patients without MRSA. The patients with CRGNB had higher mortality than the patients without CRGNB. CONCLUSION: The prevalence of MDROs in inter-hospital transferred critically ill patients was very high. Patients with MDROs in this study had longer hospital stay and higher mortality. These patients require more attention for isolation and hygiene protocols, and antibiotic choices.
beta-Lactamases ; Communicable Diseases ; Critical Care ; Critical Illness* ; Delivery of Health Care ; Gram-Negative Bacteria ; Humans ; Hygiene ; Intensive Care Units ; Length of Stay ; Male ; Methicillin-Resistant Staphylococcus aureus ; Mortality ; Prevalence* ; Retrospective Studies ; Vancomycin-Resistant Enterococci

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