Objective:To determine if there was any decrease in measures of injury severity or outcome with obese patients (body mass index greater than or equal to 30 kg/m2) as compared to non-obese patients (body mass index less than 30 kg/m2).Methods:We conducted a retrospective review of the trauma database maintained by Natividad Medical Center's Level 2-Trauma program. From July 1st, 2014 to July 1st, 2017 there were 371 cases of penetrating trauma in adults between the ages of 18-80 years old. Overall 311 patients had BMI data recorded. We divided these 311 patients into two groups: penetrating injury due to firearm (n= 198) and penetrating injury due to stabbing or piercing (n=113). We compared non-obese patients against obese patients for age, gender, Injury Severity Score (ISS), length of stay (LOS), Intensive Care Unit LOS, units of blood given, direct transfer from ED to operating room, and mortality. Results:A total of 311 patients were included in the study, 198 (63.6%) patients suffered from gunshot wounds and 113 (36.4) from stab or piercing wounds. The mean age was 33.6 ± 12.8 and there were 283 (91%) men among the victims. Overall 87 (28%) required emergent surgery and a 19 (6.1%) mortality rate was recorded. In the gunshot wound group there was no significant difference between non-obese and obese patients for age (p=0.400), gender (p=0.900), ISS (p=0.544), LOS (p=0.273), Intensive Care Unit LOS (p=0.729), units of blood given (p=0.300), or mortality (p=0.855). We found that in the stab or piercing group there was no significant difference between non-obese and obese patients for age (p=0.900), gender (p=0.900), ISS (p=0.580), LOS (p=0.839), Intensive Care Unit LOS (p=0.305), units of blood given (p=0.431), or mortality (p=0.321). Conclusion:Our findings indicate that in our patient population, there was no significant difference in markers of injury severity, morbidity, or mortality in adult non-obese patients as comparted with obese patients.  Furthermore, there was no significant difference between the two groups in operative rates, suggesting that obesity may not confer a protective effect in penetrating trauma.

Objective:To determine if there exists an upper limit for amount of blood transfused in trauma patients before it reaches a point of futility. Methods:A prospective cohort study was conducted on 131 patients who received massive blood transfusion (MBT), defined as 10 U or higher of PRBCs received in the initial 24 hours. Data collected from a Level II trauma center registry were used to analyze reports of adult patients from July 2014 to 2017. Cohorts were divided by amount of blood received - 0 to 9 U, 10-19 U, 20 to 29 U, 30-39 U, 40 U or higher - odds ratio for mortality and p-values for mean Injury Severity Score and overall hospital length of stay were calculated for each group. Results:Odds ratios for massive blood transfusion groups from 10 units to 39 units each contained the null value, while our 40 units and above group did not (OR 12.52, 95% CI 1.3-117.7). Conclusion: Although this study is limited by its sample size, these results suggests that 40 units of PRBCs may be a threshold at which survival rates begin to decrease significantly.

Bilateral abducens nerve palsy due to closed head trauma is exceedingly rare. We present the case of a 51-year-old woman with posttraumatic bilateral abducens nerve palsy and persistent deficits at 1-year follow-up. This case demonstrates a rare example of cranial nerve palsy in the setting of a closed head injury without intracranial pathology.

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This is the case of a 17-year-old male who was saved from a penetrating thoracic gunshot wound by the extra-thoracic segment of a Nuss bar, placed 7 months earlier for treatment of a pectus excavatum defect. We discuss the significance of non-penetrating thoracic trauma and the workup involved.tions in leads II, III, and aVF, with non-specific T wave inversion in V2. Two view chest radiographs demonstrated a single Nuss bar with bilateral stabilizing plates and no evidence of bullet fragments, rib fracture, pleural effusion, or pneumothorax ( Figure 1). Chest CT with contrast showed induration of subcutaneous fat inferior and lateral to the left nipple, just anterior to the Nuss bar, with no evidence of fracture, vessel injury, or other intrathoracic injury (Figure 2). Due to the wound location and depth, it was noted by radiology that the Nuss bar likely reflected the bullet, preventing penetrating thoracic injury.Due to concern for cardiac contusion, he was transferred to our trauma center. Echocardiogram demonstrated a structurally normal heart without wall motion abnormalities. Repeat EKG was unchanged and the patient was discharged after overnight observation. DiscussionIn our patient, there was clear evidence both by exam and on CT imaging (Figure 2) that the bullet struck the patient directly at the level of the extra-thoracic projection of the Nuss bar and was deflected. This is a fascinating case of bullet deflection by a metallic prosthesis but also a case that calls attention to the management and potential sequellae of non-penetrating gunshot wounds.The Nuss bar is used for the surgical correction of pectus excavatum defects for either cosmetic or functional purposes [1]. The U-shaped metal rod is often a 1-2 cm, flattened appliance that is threaded under the concavity of the sternum using an introducer to avoid both the pericardium and internal thoracic vessels [1,2].