Emergent Operative Intervention Research Articles

Spontaneous Hemothorax from Pulmonary Intralobar Sequestration: A Case Report.

Pulmonary sequestration is a rarely reported phenomenon where aberrant lung tissue exists independently from the rest of the tracheobronchial network. Complications may include hemothorax; however, there is a paucity of descriptions of this condition in the literature. We describe a case of a pulmonary intralobar sequestration resulting in atraumatic tension hemothorax. A 73-year-old woman presented to our facility in extremis and with complaints of acute-onset flank pain. Her evaluation was notable for a large pulmonary sequestration with a presumed, moderate-sized effusion; however, initial review did not reveal an obvious underlying cause for her symptoms. Shortly after her arrival to the emergency department (ED) she experienced a cardiac arrest. On secondary review of her computed tomographic angiography, it was determined that what was previously thought to be a pleural effusion was a large hemothorax. Following this finding, a finger thoracostomy was performed, which resulted in the immediate evacuation of hemothorax. The thoracostomy was then converted into an ED thoracotomy to assess for active hemorrhage with brief return of spontaneous circulation. Prior to proceeding with emergent operative intervention, the patient's spouse requested that all further resuscitative efforts cease, and the patient was allowed to expire. In a review of the case, it was determined that the patient suffered from cardiac arrest due to a spontaneous hemothorax secondary to a large intralobar pulmonary sequestration. Pulmonary intralobar sequestration can result in spontaneous hemorrhage with fatal results. Early and correct interpretation of imaging and surgical intervention are crucial in ED management.

Standardized Gastrografin Protocol for Small Bowel Obstructions in Community Hospital Setting

Introduction: Small bowel obstructions (SBO) are diagnosed and treated variously. The purpose of this study is to determine whether the use of Gastrografin oral hyperosmolar contrast and serial abdominal X-rays will lead to a decreased length of stay, readmission rate, and need for surgical intervention versus current management of patients with SBO. Methods: A retrospective review of patients who presented to our hospital with the diagnosis of SBO over two years was performed. Patients were excluded if their clinical status led to emergent operative intervention, were admitted within 30 days of bowel surgery, or were <18 years old. The leading variable for analysis was patients undergoing Gastrografin protocol versus those that did not. The leading outcome was hospital length of stay. Secondary outcomes included number of CT scans during admission, progression to surgery and 30-day readmission rate. Analyses were performed using both unpaired T-tests and Chi-squared tests. Results: A total of 55 patients with a SBO that met study criteria were reviewed. Total patients who underwent Gastrografin protocol were 24 versus 31 who did not. Gastrografin protocol patients had a decreased length of stay (mean, 2.2 days vs 3.9 days, p=0.0048) and decreased number of CT scans during admission (mean, 1.0 scans vs 1.35 scans, p=0.0027) compared to non-protocol patients. Both Gastrografin protocol and non-protocol groups had similar progression to surgical intervention (4.2% vs 16.1%, p =0.158) and 30-day readmission rate (12.5% vs 16.1%, p=0.70). Conclusion: The Gastrografin protocol decreases length of stay and number of CT scans for patients admitted with SBO.

Identification of severely injured children at very low risk of emergent surgery: A national trauma registry study

ObjectiveThe number of pediatric trauma patients requiring surgical interventions has been steadily decreasing allowing for a judicious approach to immediately available resources. This study aimed to derive and validate a prediction rule that reliably identifies injured children who are at very low risk for requiring emergency surgery upon emergency department (ED) arrival. MethodsA retrospective cohort study of data included in the Israeli National Trauma Registry from January 1, 2011, through December 31, 2020, was conducted. We included children aged 0–14 years who presented to EDs from the scene of injury and were hospitalized. We excluded patients transferred between facilities or with isolated burns. The primary outcome was emergency operative intervention (EOI) performed within one hour of ED arrival. We tested mechanism, GCS, heart rate, and blood pressure as candidate predictors. We then randomized patients to two cohorts, derived and internally validated a prediction rule. ResultsDuring the study period, 83,859 children met enrollment criteria. The median age was 6 years (IQR 2–10) and 56,867 (67.8 %) were male; 75,450 (90.0 %) sustained blunt trauma. One hundred sixty-nine (0.20 %) children underwent EOI. In the derivation and validation cohorts, 34,138 (81.4 %) and 34,271 (81.7 %) patients, were classified as low risk based on blunt trauma mechanism, normal GCS (15), and low-risk heart rate (according to age). Of those, 8 (0.02 %) and 13 (0.04 %) required an EOI, respectively. In the validation cohort, the prediction rule for EOI had a sensitivity of 84 % (95 % CI 75–91), a specificity of 82 % (95 % CI 81–82), and a negative predictive value of 99.96 % (95 % CI 99.94–99.98). Among children with an Injury Severity Score>15, the sensitivity was 87 % (95 % CI 77–94), the specificity of 57 % (95 % CI 54–59), and the negative predictive value was 98.97 % (95 % CI 98.13–99.44). ConclusionsA limited set of physiologic parameters, readily available at hospital admission can effectively identify injured children at very low risk for emergent surgery. For these children, immediate deployment of surgical resources may not be necessary.

Chemotherapy-associated pneumoperitoneum in cancer patients: a scoping review.

The presence of air in the peritoneal cavity (pneumoperitoneum) is often secondary to perforated viscus. Emergent operative intervention is typically warranted in non-cancer patients. Cancer patients present a unique challenge as they have an increased risk of pneumoperitoneum due to local tumour invasion, radiation therapy, and frequent endoscopic procedures. There is a paucity of literature on the management of patients undergoing chemotherapy who present with pneumoperitoneum. The authors conducted a scoping review to identify and synthesize preliminary evidence on the presentation, management, and outcomes of this patient population. A scoping review of cases of pneumoperitoneum in cancer patients from 1990 to 2022 was conducted using the Arksey and O'Malley five-stage approach. Inclusion criteria were a known diagnosis of cancer, chemotherapy within 6 months of presentation, and imaging confirmation of pneumoperitoneum. The authors' exclusion criteria were cancer diagnosis at the time of presentation, perforation secondary to local cancer invasion, and last chemotherapy session greater than 6 months prior to presentation. Thirty-four cases (8 paediatric, 26 adults) were identified. The median time from the last chemotherapy treatment to presentation with pneumoperitoneum was 14 days. Twenty-one patients were managed operatively, and 13 were managed non-operatively. The most common source of perforation was multiple sites along the bowel. Thirty-day mortality was 33.3% for the operative cohort and 23.1% for the non-operative group. Pneumoperitoneum in cancer patients remains a highly morbid condition with a mortality rate of approximately 30%, regardless of the treatment approach. Non-operative management should be pursued whenever possible.

Pulse Pressure: A Predictor of Intervention in Blunt Abdominal Trauma.

Patients with life-threatening hemorrhages due to blunt torso trauma are at a particularly high risk of being underdiagnosed. The pulse pressure (PP) starts narrowing down before the traditional parameters start changing, making it a useful tool for assessing and planning early intervention. To assess the utility of low PP in predicting massive transfusion (MT) or operative intervention in patients with isolated blunt abdominal trauma. A total of 186 patients were included. The PP and mean arterial pressure (MAP) were calculated. Vitals, PP, and MAP were monitored every 15 min during the first 6 h, then every 30 min during the next 6 h, and afterward, every 4 h until discharge. A Chi-square test and an independent t-test (as appropriate) were applied to compare variables with PP at the time of presentation. Differences were considered statistically significant at p-value ≤ 0.05. A total of 55.9% of these patients had injuries due to road traffic accidents (RTA). Emergency operative intervention was provided to 26.3% of the patients. Death was 4.3%. MT was required by 26.3% of the patients. There was a statistically significant association between low PP and sex, length of stay, repeat extended focused assessment with sonography in trauma (eFAST), emergency operational intervention, outcome, MT, number of crystalloids consumed within the first four hours after presentation, injury severity score, systolic blood pressure (SBP), and pulse rate. The PP <30 mmHg was observed as a useful predictor for increased blood loss requiring blood transfusion or operative intervention.

Effect of 3% Hypertonic Saline Resuscitation on Lactate Clearance and Its Comparison With 0.9% Normal Saline in Traumatic Injury Patients: A Prospective Randomized Control Trial.

Fluid resuscitation with normal saline (NS) can aggravate lactate production. The objective of this study was to evaluate the efficacy of small-volume resuscitation using 3% hypertonic sodium chloride (HS) and its comparison with NS in trauma patients.The primary endpoint was an increase in lactate clearance after 1 hr of fluid resuscitation.The secondary endpoint was the incidence of hemodynamic stability, the volume of transfusion, correction of metabolic acidosis, and complications such as fluid overload and abnormal serum sodium levels. It was a prospective, randomized, single-blind study. The study was conducted on 60patients who arrived at the trauma center for emergency operative intervention. Inclusion criteria for patient selection were trauma victims of age more than 18 years and the requirement of emergency operative intervention for trauma except for traumatic brain injury. Patients were divided into two groups: Group HS (hypertonic saline) and Group NS (normal saline). Patients were resuscitated with either 3% HS (4ml/kg) or 0.9% NS (20ml/kg). The HS group had higher lactate clearance at 1 hour compared to the NS group, and this difference was statistically significant with a p-value of <0.001. When hemodynamic parameters were compared at 30 and 60 minutes after resuscitation, the HS group had a significantly lower heart rate (p<0.05 at 30 minutes and <0.001 at 60 minutes, respectively), a higher mean arterial pressure at 60 minutes (p<0.001), a higher pH at 60 minutes (p< 0.05), and a higher bicarbonate concentration at 60 minutes (p<0.05). The HS and NS groups had significant differences in serum sodium levels at 60 minutes (p<0.001). Resuscitation with 3% hypertonic saline improved lactate clearance. Lower volumes of fluid infusion for resuscitation achieved better hemodynamic stability and correction of metabolic acidosis in the hypertonic saline group. Our study shows that hypertonic saline can be a promising fluid for small-volume resuscitation in trauma patients with compensated mild to moderate shock.

Hepatic Arterioportal Fistula Following Liver Trauma: Case Series and Review of the Literature.

Hepatic arterioportal fistula (HAPF) is an uncommon complication of hepatic trauma, which can manifest with abdominal pain and the sequelae of portal hypertension months to years after injury. The purpose of this study is to present cases of HAPF from our busy urban trauma center and make recommendations for management. One hundred and twenty-seven patients with high-grade penetrating liver injuries (American Association for the Surgery of Trauma [AAST] - Grades IV-V) between January 2019 and October 2022 were retrospectively reviewed. Five patients were identified with an acute hepatic arterioportal fistula following abdominal trauma from our ACS-verified adult Level 1 trauma center. Institutional experience with overall surgical management is described and reviewed with the current literature. Four of our patients presented in hemorrhagic shock requiring emergent operative intervention. The first patient had postoperative angiography and coil embolization of the HAPF. Patients 2 through 4 underwent damage control laparotomy with temporary abdominal closure followed by postoperative transarterial embolization with gelatin sponge particles (Gelfoam) or combined Gelfoam/n-butyl cyanoacrylate. The final patient went directly for angiography and Gelfoam embolization after identification of the HAPF. All 5 patients had resolution of HAPF on follow-up imaging with continued post management for traumatic injuries. Hepatic arterioportal fistula can present as a complication of hepatic injury and manifest with significant hemodynamic aberrations. Although surgical intervention was required to achieve hemorrhage control in almost all cases, management of HAPF in the setting of high-grade liver injuries was achieved successfully with modern endovascular techniques. A multidisciplinary approach to such injuries is necessary to optimize care in the acute setting following traumatic injury.

The Impact of Protective Devices Across the Spectrum of Trauma Care and Across Racial Groupings.

Protective devices such as seat belts and helmets save lives. Most studies only address one aspect of the injury profile - compliance or mortality - not the entire spectrum of trauma care, and little attention is paid to racial differences in the use or impact of protective devices. Patients with blunt mechanisms where using protective devices would be expected were included and were divided into utilizing (P) vs not utilizing protection (Non-P). Chart review included demographics, injuries sustained, hemodynamics, and blood alcohol level. Outcomes included need for emergent operation, complications and death. Non-P patients were more likely male, presented at night and intoxicated. Highest risk behavior (intoxicated Non-P) presented at night (25.7% of nighttime presentations), and rarely during daytime (6.7% daytime presentations). Non-P were more likely hypotensive and sustain a traumatic brain injury. No race related differences were noted among young patients. Among older (>/=50years) patients, White patients were least likely Non-P and least likely presented at night. Non-P required more emergent operative intervention, ICU admission, and longer hospital stay. Overall, Non-P was associated with increased risk of death (OR = 1.6 (95% CI = 1.28 - 2.11). Given unique age and racial differences, we advocate for culturally and age specific public service campaigns.

Adding age-adjusted shock index to the American College of Surgeons' trauma team activation criteria to predict severe injury in children.

The American College of Surgeons (ACS) requires trauma centers to use six minimum criteria (ACS-6) for full trauma team activation. Our goal was to evaluate the effect of adding age-adjusted shock index (SI) to the ACS-6 for the prediction of severe injury among pediatric trauma patients with the hypothesis that SI would significantly improve sensitivity with an acceptable decrease in specificity. We performed a secondary analysis of prospectively collected EMS and trauma registry data from two urban pediatric trauma centers. Age-adjusted SI thresholds were calculated as heart rate divided by systolic blood pressure using 2020 Pediatric Advanced Life Support SI vital sign ranges and previously published Shock Index, Pediatric Adjusted (SIPA) thresholds. The primary outcome was a composite of emergency operative (within 1 hour of arrival) or emergency procedural intervention (EOPI) or Injury Severity Score (ISS) greater than 15. Sensitivities, specificities, and 95% CIs were calculated for the ACS-6 alone and in combination with age-adjusted SI. There were 8,078 patients included; 20% had an elevated age-adjusted SI and 17% met at least one ACS minimum criterion; 1% underwent EOPI; and 17% had ISS >15. Sensitivity and specificity of the ACS-6 for EOPI or ISS > 5 were 45% (95% confidence interval [CI], 41-50%) and 89% (95% CI, 81-96%). Inclusion of Pediatric Advanced Life Support-SI and SIPA resulted in sensitivities of 51% (95% CI, 47-56%) and 69% (95% CI, 65-72%), and specificities of 80% (95% CI, 71-89%) and 60% (95% CI, 53-68%), respectively. Similar trends were seen for each secondary outcome. In this cohort of pediatric trauma registry patients, the addition of SIPA to the ACS-6 for trauma team activation resulted in significantly increased sensitivity for EOPI or ISS greater than 15 but poor specificity. Future investigation should explore using age-adjusted shock index in a two-tiered trauma activation system, or in combination with novel triage criteria, in a population-based cohort. Diagnostic Tests or Criteria; Level II.

Does mortality after trauma team activation peak at shift change?

BackgroundPrior institutional data have demonstrated trauma mortality to be highest between 06:00–07:59 at our center, which is also when providers change shifts (07:00–07:30). The objective was definition of patient, provider, and systems variables associated with trauma mortality at shift change among patients arriving as trauma team activations (TTA). MethodsAll TTA patients at our ACS-verified Level I trauma center were included (01/2008–07/2019), excluding those with undocumented arrival time. Study groups were defined by arrival time: shift change (SC) (06:00–07:59) vs. non-shift change (NSC) (all other times). Univariable/multivariable analyses compared key variables. Propensity score analysis compared outcomes after matching. ResultsAfter exclusions, 6020 patients remained: 229 (4%) SC and 5791 (96%) NSC. SC mortality was 25% vs. 16% during NSC (p < 0.001). More SC patients arrived with SBP <90 (19% vs. 11%, p < 0.001) or GCS <9 (35% vs. 24%, p < 0.001). ISS was higher during SC (43[32–50] vs. 34[27–50], p < 0.001). Time to CT scan (36[23–66] vs. 38[23–61] minutes, p = 0.638) and emergent surgery (94[35–141] vs. 63[34–107] minutes, p = 0.071) were comparable. Older age (p < 0.001), SBP <90 (p < 0.001), GCS <9 (p < 0.001), need for emergent operative intervention (p = 0.044), and higher ISS (p < 0.001) were independently associated with mortality. After propensity score matching, mortality was no different between SC and NSC (p = 0.764). ConclusionsEarly morning is a low-volume, high-mortality time for TTAs. Increased mortality at shift change was independently associated with patient/injury factors but not provider/systems factors. Ensuring ample clinical resource allocation during this high acuity time may be prudent to streamline patient care at shift change.

Current Interventional Management of Acute Upper Gastrointestinal Bleeding

Upper gastrointestinal bleeding (UGIB), a common medical emergency, causes significant morbidity and mortality. Endoscopic evaluation and treatment remain the standard care in patients who can be hemodynamically stabilized. However, severe bleeding despite conservative medication treatment or medication combined with endoscopic intervention occurs in 5%-10% of patients, requiring interventional or surgical treatment. Endovascular embolization has emerged as an alternative to emergency operative intervention for high-risk patients with non-variceal UGIB and is now commonly considered the first-line therapy for refractory bleeding after endoscopic treatment. Child-Pugh class C or class B cirrhosis patients who have varicosity or active bleeding detected in endoscopy are at high risks for treatment failure, rebleeding, and death. A preemptive transjugular intrahepatic portosystemic shunt has been shown to reduce treatment failure and mortality significantly. Herein, we reviewed the current role of interventional treatment in the management of massive UGIB on the basis of years of clinical experience of the Department of Gastroenterology, West China Hospital, Sichuan University.

7. ‘INAPPROPRIATE’ EMERGENCY TRANSFERS FOR EVALUATION BY PLASTIC SURGERY

PURPOSE: So-called ‘inappropriate’ patient transfers in plastic surgery (PRS) are common and costly, yet lacking in any operational definitions. To address this, we investigated emergent, interfacility transfer requests for plastic surgery consultation at our institution in order to identify potential barriers and solutions for reducing rates of ‘inappropriate’ transfers. METHODS: We identified all transfer requests for PRS consultation at our institution over a one-year period and collected and analyzed relevant data. RESULTS: We identified 287 transfer requests, of which 239 (83.3%) were accepted by PRS. Transfer acceptance was significantly associated with the time of day (p=0.034), but not patient age, sex, insurance status, distance, injury mechanism, or region. Nearly 90% of transfers arrived via ambulance despite a median distance of 30.4 miles (range 1-293). 10.0% of transfers were taken for emergent operative intervention, whereas 68.1% underwent ED procedure only. This constituted definitive treatment (i.e. no subsequent outpatient or inpatient interventions) in 60.8% of cases, with low rates of return to the ED (6.3%) or complications (4.2%). 19.2% of transfers were discharged without a hospital admission or any interventions. Patients not accepted by PRS for transfer did not experience delays in-clinic follow-up (1.85 vs 4.7 days, p=0.680) or scheduling outpatient procedures (0.7 vs. 3.95 days, p=0.698). CONCLUSION: In this study, we utilize reproducible, objective, and evidence-based criteria to better characterize so-called ‘inappropriate’ patient transfer in PRS. Our findings represent a blueprint for identifying patients for whom emergent transfer for evaluation by a plastic surgeon may not increase the value of care.

Congestive heart failure and hypertension associated with Wilms tumor

Wilms tumor is the most common primary renal tumor in children. Wilms tumor has infrequently been reported to present associated with dilated cardiomyopathy and congestive heart failure. In prior case reports of Wilms tumor presenting with congestive heart failure, surgical intervention has taken place after stabilization of heart failure. Here we present the first reported case of a child with Wilms tumor associated with congestive heart failure, requiring emergent operative intervention due to tumor rupture and hemorrhage.

Colonic Perforation and Transstomal Evisceration of Small Bowel

The formation of an abdominal stoma is a commonly performed procedure in gastrointestinal surgery. Common complications include parastomal hernia, stomal necrosis, stomal prolapse, stenosis and secondary effects to surrounding skin. Transstomal evisceration is an extremely rare complication with only two previous reported cases. We present a unique case of transstomal evisceration of small bowel secondary to blunt force trauma. In addition, parastomal evisceration is also uncommon with only 15 reported cases. These conditions require emergent operative intervention due to the risk of ischemic injury to eviscerated contents. J Curr Surg. 2021;11(2):46-50 doi: https://doi.org/10.14740/jcs438

Pattern of illnesses presenting as acute abdomen: surgical study in 118 patients

Background: Acute abdomen is an important clinical entity and represents a symptom complex; of which, pain in the abdomen is a predominant feature. It is the result of some underlying condition and is a very common reason for patients reporting to emergency department. Pattern of illnesses presenting as ‘acute abdomen’ can vary from mild to life threatening in severity and management can similarly vary from just symptomatic relief to emergency operative intervention. It poses a significant challenge for the clinician since he is required to untangle the issue in a limited time frame and formulate a management plan. The aim of the study was finding the pattern of underlying conditions which had resulted in patients presenting with acute abdominal pain.Methods: A prospective observational study was carried out on 118 patients who reported with ‘acute abdomen’, from August 2015 to February 2017.Results: In this study, pattern of illnesses reflected that benign biliary disease was the commonest condition in the study population. This was followed by urolithiasis. An important observation was that ‘non-specific abdominal pain’ (NSAP) was the reason for acute abdomen in about 14% patients. Many other conditions like acute appendicitis, hollow viscus perforation, intestinal obstruction and pancreatitis presented with similar symptom complex in which abdominal pain was the main feature.Conclusions: At the end of the study, we had a better knowledge of the conditions presenting as acute abdomen in the source population and the same can be utilized for further research in the field of this important clinical entity.

Firearm-Related Injuries: A Single Center Experience

IntroductionFirearm-related injuries (FRI) are an important public health crisis in the US. There is relatively less city level data examining the injury-related trends in Tucson, Arizona. Our study aims to examine FRI, in Southern Arizona's only Level I trauma center. MethodsWe conducted a (2014-2019) review of our Level-I trauma center registry. We selected all patients who were evaluated for a FRI. We collected patient and center related variables. Our outcomes were the trends of FRI, injury-related characteristics, and mortality. Cochran–Armitage trend analysis was performed. ResultsA total of 1012 FRI patients were identified. The majority of patients were teenagers (32%) and young adults (30%), and 88% were male. Greater than 80% of patients belonged to the low/low-middle socioeconomic class, and 18.5% completed college. The most common firearm utilized was the handgun (45%). The prevalence of FRI increased significantly (2014:15%; 2019:21%; P< 0.01). The most common injury intention was assault (75%). The median ISS was 17(9-25) with most injuries sustained to the extremities (23%). Also, 25% required emergent operative intervention. There is a significant rise in the number of severely injured patients (ISS≥25) (2014:12.1%, 2019:20%; P< 0.01), self-inflicted injuries (2014:10%, 2019:17%; P < 0.01), unintentional injuries (2014:6%, 2019:12%; P< 0.01), and mortality (2014:11%; 2019:19%; P< 0.01). A high prevalence of substance abuse was noted (73% alcohol, 64% drugs). ConclusionsThe prevalence of FRI at our center has been rising over the past decade with a shift towards more severe injuries and higher mortality rates. Addressing these alarming changes requires targeted interventions on multiple frontiers.

730 An Atypical Presentation of a Hernia: Gastro-Inguinal Hernia

Abstract Acute presentation of an inguinal hernia is a common presentation to general surgery in the United Kingdom (UK). Rarely intra-abdominal organs, outside of small bowel and colon, can present within an inguinal hernia e.g., appendix or bladder. There has been limited publication involving an incarcerated hernia containing the stomach. We present the case of an 84-year-old male with a background of COPD and hypertension who presented to Accident &amp; Emergency with a three-day history of vomiting and diffuse abdominal pain. On examination, the patient had a distended abdomen with generalized peritonitis, and an irreducible non-tender inguinoscrotal hernia. A CT scan of the abdomen and pelvis demonstrated small bowel obstruction and gastric outlet obstruction secondary to a large incarcerated right inguinal hernia containing stomach. The patient rapidly deteriorated clinically, which led to a decision to palliate the patient. The patient died eight days after initial presentation. The cause of death was documented as likely perforated viscus in an inguino-scrotal hernia. This case illustrates the devastating prognosis of an acute presentation of an inguinal hernia containing the stomach. This should be considered a surgical emergency and immediate operative intervention should take place if the patient is clinically able to have surgery.

COVID-19: considerations for optimum surgical team protection before, during and after operation

&lt;p&gt;SARS CoV-2, the virus responsible for coronavirus disease 2019 (COVID-19), has caused a global pandemic. Surgeons’ obligation, as always, will be to provide timely, high-quality surgical care that achieves the best outcomes for patients. It is imperative to ensure the safety of health-care workers not only to safeguard continuous patient care but also to ensure they do not transmit the virus further. Viral particles have been found in nasal swabs, pharyngeal swabs, sputum, bronchial swabs, gastrointestinal tissue, blood, and stool.Surfaces in isolation rooms and even clinician shoe covers have tested positive as well. Some key considerations for protecting surgical teams; structure frequent communication before key events; assume the entire operation theater will be contaminated; choose personal protective equipment (PPE) effective against aerosolized particles; adapt surgical technique to reduce exposure risks; use a “buddy system” for donning and doffing; after operation/recovery; going home – what should be done to keep your family safe. Though careful planning and appropriate PPE are essential, the most effective way to prevent viral exposure is to avoid performing non-essential surgical procedures. Non-operative approaches may be a safe alternative to surgery for some patients. Many patients, however, will require emergency operative intervention.&lt;strong&gt;&lt;/strong&gt;&lt;/p&gt;

Damage Control Laparotomy with Appendectomy and Cesarean Section in the Setting of Perforated Appendicitis

Appendicitis is the most common general surgery problem in pregnant patients, but patients can present with vague symptoms making diagnosis difficult. Misdiagnosis and delayed diagnosis can lead to complications such as perforation, which can result in dire outcomes, including fetal and maternal demise. A high level of clinical suspicion should be maintained to identify the diagnosis and progress to operative intervention quickly. Here we present a case highlighting prompt recognition of perforated appendicitis leading to fetal and maternal distress with emergent operative intervention leading to good outcomes for both mother and baby.

Vague neck pain following a gastrointestinal procedure: a rare case presentation of vertebral osteomyelitis and cervical epidural abscess

Vertebral osteomyelitis (VO), spondylodiscitis, and spinal epidural abscesses (SEA) are infectious and inflammatory processes impacting the spine that cause major morbidity and mortality. They require prolonged hospital stays with expensive treatment regimens. Along with acute management, studies have provided evidence highlighting poor long-term outcomes. VO accounts for ~2% of all osteomyelitis. Recent data have illustrated an increase in incidence to 5.4 per 100,000 person years. The majority of patients that present with SEA and VO typically have some combination of back pain, fevers, and neurological deficits. A 55-year-old woman with known history of hypertension and hyperlipidemia, status-post endoscopic repair of a Zenker's Diverticulum 3 weeks prior, presented to our outpatient clinic with a 2-week history of axial cervical spine pain as well as left sided scapular and deltoid pain. Further questioning and exam revealed no neurologic deficits or fever. As pain persisted and she did not respond to treatment, further imaging was performed. She was found to have cervical discitis, osteomyelitis, and a cervical epidural abscess. Patients presenting with VO/SEA typically have spine pain with some other associated symptoms of spinal cord compression or fevers, making this a rare presentation. The urgency for discovery because of the need for emergent operative intervention is evident by the documented complications associated with a delay in diagnosis. This case report emphasizes the importance of always keeping VO/SEA on the differential for cervical spine pain even with lack of associated symptoms, in order to optimize patient care.