Citations

Introduction: Scuba diving is a popular sport that carries risks unique to the underwater environment. Paediatric emergency department presentations for scuba diving injuries are incompletely characterised, particularly in comparison with adults. Methods: We retrospectively analysed scuba-related injuries recorded in the National Electronic Injury Surveillance System (NEISS) from 2005–2024. We estimated national paediatric emergency department presentations using NEISS weights and compared injury categories and hospitalisation rates between paediatric and adult patients. Results: We identified 68 paediatric cases, corresponding to an estimated 122 paediatric scuba-related emergency department presentations annually. Trauma was the most common injury category (41.2%), followed by otitis (17.6%) and ear, sinus, ocular, or dental barotrauma (16.2%). Hospitalisation was most common among patients with possible decompression sickness or arterial gas embolism (DCS/AGE) (42.9%) and drowning/aspiration (25.0%). Compared with adults, paediatric patients were less often hospitalised (10.3% vs 21.4%, P = 0.038), more likely to present with traumatic injuries (41.2% vs 26.1%, P = 0.010), and less likely to present with possible DCS/AGE (10.3% vs 25.0%, P = 0.006). Conclusions: Among patients presenting to United States emergency departments with scuba-related injuries, paediatric patients most commonly had trauma, otitis, or ear, sinus, ocular, or dental barotrauma. Paediatric divers were also less likely than adults to experience DCS/AGE injuries and were less likely than adults to require hospitalisation. Our data describes emergency department presentation patterns rather than overall injury risk among paediatric scuba divers.

Morel-Lavallee lesions (MLLs) are traumatic closed degloving injuries with operative intervention (OI), especially excisional debridement, remaining the mainstay of treatment. However, high-quality evidence describing operative techniques and outcomes remains limited. This study aimed to characterize current OI practices and associated outcomes, especially among patients undergoing excisional debridement, hypothesizing an increased risk of wound complications with this approach for MLLs. Methods This prospective (2021-2024), multicenter, observational study was conducted across 15 trauma centers and included patients diagnosed with MLL who underwent OI. The association between operative technique (eg, excisional debridement) and the primary outcome of wound complications was evaluated. Wound complications were defined as cellulitis, deep wound infection, skin necrosis, necrotizing soft tissue infection (NSTI), and/or organized hematoma. Results Of 88 MLL patients undergoing OI, 36 (40.9%) had excisional debridement, with 4 (11.1%) limited excision to skin, 20 (55.6%) extended to subcutaneous tissue, and 12 (33.3%) down to muscle. Excisional debridement had higher rates of skin necrosis (22.2% vs. 1.9%, P = .002). Although overall rates of wound complications were statistically similar between cohorts (33.3% vs. 17.3%, P = .098), univariate analysis demonstrated excisional debridement had increased risk of wound complications (OR 2.52, CI 1.07-5.97, P = .035). Conclusion This prospective multicenter study over three years demonstrated that a fifth of MLLs undergoing excisional debridement developed postoperative skin necrosis. Excisional debridement also had a more than two-fold increased risk of wound complications compared to other OIs. These findings underscore the importance of investigating alternative operative techniques, such as incision and drainage or minimally invasive debridement methods.

BACKGROUND: Morel-Lavallée lesions (MLLs) are closed degloving injuries that occur throughout the body and present treatment challenges due to their rarity and variability in management. We aimed to compare characteristics and outcomes for MLL patients undergoing early (less than 48 hours) vs late (more than 48 hours) surgical intervention, hypothesizing decreased length of stay (LOS) with early intervention. STUDY DESIGN: Fifteen centers participated in this prospective observational study, including all adult patients who sustained a MLL and underwent surgery. No patients were excluded. Bivariate comparisons for early vs late intervention cohorts were performed. RESULTS: Of 150 MLL patients, 101 (67.3%) underwent early intervention. Both cohorts had comparable ages, BMI, vitals, Charlson Comorbidity Index, and injury severity scores (all p > 0.05). However, early intervention patients more commonly had abdominal (37% vs 6.3%, p < 0.001) MLLs, whereas late intervention patients more often had hip (16.7% vs 3.0%, p = 0.01) and thigh (41.7% vs 22%, p = 0.03) MLLs. Early patients had shorter ICU LOS (2 vs 5, p = 0.003) but statistically similar hospital LOS (12 vs 20, p = 0.06). There was no difference in wound-related complications (19.8% vs 24.5%, p = 0.51) or mean number of additional surgeries (p = 0.41) between cohorts. CONCLUSIONS: Over two-thirds of MLL patients underwent early operation. These patients had decreased ICU LOS and a statistically similar albeit clinically shorter overall LOS, despite similar demographics, comorbidities, injury severity, and number of additional surgeries. Therefore, early operation appears beneficial and should be pursued in MLL patients when clinically indicated and feasible.

Background Costosternal cartilages and the costal margin, collectively termed costal cartilage, are hyaline cartilage connecting ribs to the sternum and to adjacent ribs, respectively. Presence of intact costal cartilage is essential for elasticity of the chest wall. Anecdotally, costal cartilage injuries are underdiagnosed on trauma CT scan in patients with rib fractures. Our aim was to determine a baseline frequency of acute costal cartilage injury among patients presenting with rib fractures. Methods We performed a retrospective cohort study of injured adult patients admitted to Level I/II trauma centers with rib fractures from January 2020 to July 2024. CT images obtained at admission were manually reviewed by chest wall surgeons for presence of costal cartilage injury. Concordance with the original radiology report was obtained. Multivariable regression was used to analyze factors associated with costal cartilage injury and missed cartilage fractures. Results 1441 patients were identified; 197 (14%) had a costal cartilage fracture. A plurality of injuries included falls (n=667, 46%). Median ISS (Injury Severity Score) was 13 (IQR: 9 to 21), median Abbreviated Injury Scale thorax score was 3 (IQR: 3 to 3), and median number of fractured ribs was 3 (IQR: 3 to 7). 294 (21%) patients had radiographic flail segments, and 136 (9%) had sternal fractures. 172 (87%) patients had a costal cartilage fracture missed on initial trauma chest CT. On multivariable analysis, ISS (adjusted OR (aOR) 1.02 (95% CI 1.01 to 1.04), radiographic flail segment (aOR 1.6 (95% CI 1.10 to 2.31)) and presence of sternal fracture (aOR 1.85 (95% CI 1.19 to 2.89)) were associated with costal cartilage fractures. Only the total number of rib fractures was associated with a missed costal cartilage fracture on univariate analysis (OR 1.17 (95% CI 1.01 to 1.36)). Conclusions Costal cartilage injuries are common and frequently are not identified during interpretation of the initial trauma CT. A higher index of suspicion is warranted for costal cartilage fractures among patients with greater injury burden, radiographic flail segment, and sternal fractures. Level of evidence Level III.

Introduction: Mass casualty incident (MCI) simulation scenarios are developed based on detailed review and planning by multidisciplinary trauma teams. This study aimed to assess the feasibility of using generative artificial intelligence (AI) in developing mass casualty trauma simulation scenarios. The study evaluated a range of mass casualty trauma simulation scenarios generated from a public generative artificial intelligence platform based on publicly available data with a validated objective simulation scoring tool. Methods: Using a large language model (LLM) platform (ChatGPT4, OpenAI, San Francisco, CA, USA), 10 complex MCI trauma simulation scenarios were generated based on publicly available US reported trauma data. Each scenario was evaluated by two Advanced Trauma Life Support (ATLS) certified raters based on the Simulation Scenario Evaluation Tool (SSET), a validated scoring tool out of 100 points. The tool scoring is based on learning objectives, tasks for performance, clinical progression, debriefing criteria, and resources. Two publicly available mass casualty trauma scenarios were similarly evaluated as controls. Revision and recommended feedback was provided for the scenarios, with review time recorded. Post-revision scenarios were evaluated. Interrater reliability was calculated based on Intraclass Correlation Coefficients (2, k) (ICCs). For the scenarios, scores and review times were reported as medians with interquartile range (IQR) as 25th and 75th percentiles. Results: Ten mass casualty trauma simulation scenarios were generated by an LLM, producing a total of 62 simulated patients. The initial LLM-generated scenarios demonstrated a median SSET score of 78.5 (IQR 74–82), substantially lower than the median score of 94 (IQR 93–95) observed in publicly available scenarios. The interrater reliability ICC for the LLM-generated scenarios was 0.965 and 1.00 for publicly available scenarios. Following secondary human revision and iterative refinement, the LLM-generated scenarios improved, achieving a median SSET score of 94 (IQR 93–96) with an interrater reliability ICC of 0.7425. Conclusions: The feasibility study suggests that a structured, collaborative workflow combining LLM-based generation with expert human review may enable a new approach to mass casualty trauma simulation scenario creation. LLMs hold promise as a scalable tool for the development of MCI training materials. However, consistent human oversight, quality assurance processes, and governance frameworks remain essential to ensure clinical accuracy, safety, and educational value.

ABSTRACTBackgroundWe aimed to determine the performance of postoperative computed tomography (CT) and upper gastrointestinal series (UGI) in patients who underwent surgery for a perforated peptic ulcer and to assess the yield of routine postoperative studies.MethodsRetrospective, single‐institution, chart‐review study of patients who underwent a repair of a perforated gastric or duodenal ulcer between August 2004 and September 2021 at Mayo Clinic, Rochester, Minnesota.ResultsWe identified a total of 240 patients, 28 (12%) were found to have leaks. When any of the four findings (extraluminal gas or fluid collection adjacent to the repair, worsening pneumoperitoneum, or enteral contrast extravasation) was present on postoperative CT scan (n = 116) it had sensitivity of 76% (95% CI 53%–90%), with a specificity of 90% (95% CI 84%–91%). Upper gastrointestinal series (UGI, n = 150) showed a sensitivity of 57% (95% CI 25%–84%) and a specificity of 99% (95% CI 96%–100%). UGI demonstrated higher specificity compared to CT (p < 0.01); there was no significant difference in sensitivity (p = 0.34). The findings from CT scans led to changes in management for a significantly greater number of patients compared to UGI (20% vs. 4%, p < 0.01). The diagnostic yield for leak identification was 3% for routine postoperative CT (n = 63) and 2% for routine UGI studies (n = 141).ConclusionsPostoperative CT is more likely to change management in patients who underwent repair of a perforated peptic ulcer compared to postoperative upper gastrointestinal series. The yield of routine postoperative studies is low, and their benefit is uncertain.

Abstract Internal herniation through the foramen of Winslow is one of the rarest types of hernia. As signs and symptoms can be quite generalized, prompt identification can prove difficult, leading to increased morbidity and mortality. The majority of reported cases of foramen of Winslow herniation result in obstruction of either the small or large bowel requiring operative intervention. As they are so rare, there is no established treatment algorithm for foramen of Winslow hernias. We present here a unique case of cecal herniation through the foramen of Winslow resulting in biliary compression and acute cholecystitis without bowel obstruction that was managed with laparoscopic cholecystectomy and right hemicolectomy.

Abstract Background Older adults presenting with trauma have worse outcomes than younger adults. Starting in 2016, we provided geriatrics consultation (GC) to older adults admitted to the trauma service. We aimed to analyze the impact of GC on patient outcomes. Methods We performed a retrospective pre–post study and year‐matched cohort study. We identified patients from the trauma registry at our level 1 trauma center. In the pre–post study, we compared patients who received GC (2016–2022) with controls (2011–2015). In the cohort study (2016–2022), we compared patients who received GC with controls. We matched for age, race, sex, and injury severity score (ISS) in both studies, as well as admission year in the cohort study. Outcome variables included mortality (in‐hospital, 30‐day, 90‐day), length of stay (LOS), discharge disposition, and hospital readmission rates (30‐day, 90‐day). Results We analyzed 1968 patients in the pre–post study and 2544 patients in the cohort study. Patients were similar in age, race, and sex. GC patients had a slightly higher ISS score and a higher rate of ICU stay. Delirium occurrence was lower among GC patients. GC patients had lower in‐hospital mortality compared to controls (pre–post OR 0.27, p < 0.001; cohort OR 0.31, p < 0.001) and increased LOS (6 days vs 4 days, p < 0.001; both studies). GC patients in the cohort study also had lower 30‐ and 90‐day mortality (OR 0.52 and 0.65, p < 0.01) and were less likely to return home (OR 0.81, p < 0.01); similar trends, though not statistically significant, were noted in the pre–post study. Lower readmission rates (statistically non‐significant) were noted in the GC group across both studies. Conclusions GC in older adults with trauma has proven benefit with reduced mortality and a trend toward lower readmission rates but was associated with increased LOS and higher rates of discharge to skilled facility.

Intussusception following Roux-en-Y gastric bypass is a rare, potentially life-threatening complication. Patients present with intermittent obstructive symptoms, and the diagnosis is made on imaging. Treatment is surgical considering the high likelihood of non-operative failure, strangulation, incarceration, perforation and concern for malignancy. We present the case of a woman in her 60s with a history of Roux-en-Y gastric bypass who presented with retrograde jejunojejunal intussusception at the distal Roux anastomosis. She proceeded to the operating room for complete anastomotic resection with reconstruction of three blind ends via two sequential isoperistaltic anastomoses. She progressed appropriately throughout her hospitalisation and was discharged on postoperative day 5 without recurrence. While intussusception in Roux-en-Y anatomy has been previously described, a literature review yielded sparse results in detailing its surgical correction. We highlight our unique surgical approach of jejunojejunal anastomotic resection with the creation of sequential isoperistaltic side-to-side anastomoses.