Emergency Department thoracotomy in children--a critical analysis.

Recent clinical reviews have helped to clarify the role of Emergency Department (E.D.) thoracotomy in critically injured adults. However, guidelines in the pediatric population remain ill defined. The purpose of this report is to examine the yield of E.D. thoracotomy in patients less than or equal to 18 years of age to allow for a more cost-effective application of this heroic measure. From an 11-year experience of 689 consecutive E.D. thoracotomies, 83 patients (12%) were less than or equal to 18 years old. Mechanism of injury was blunt trauma in 57%, gunshot wound in 30%, and stab wound in 13%. Mean age was 15 years and 71% were male. Survival by injury mechanism was 9% (1/11) for stab wound, 4% (1/25) for gunshot wound, and 2% (1/47) for blunt trauma. Sixty-nine patients presented to the E.D. without vital signs and only one, a 16-year-old with stab wounds to the chest and abdomen, survived. In contrast, two (14%) among 14 patients presenting with vital signs were salvaged. As in adults, outcome was largely determined by injury mechanism and physiologic status on E.D. presentation. Blunt trauma, the predominant mechanism of lethal injuries in children, had a dismal outcome, with only 2% salvage and no survivors when vital signs were absent. This study demonstrates a similar outcome for E.D. thoracotomy in children compared to adults, and supports a selective policy of liberal use in penetrating injury irrespective of physiologic status but limited in those arriving lifeless following blunt trauma.

The role of a regional trauma system in the management of a mass disaster: an analysis of the Keystone, Colorado, chairlift accident.

On December 14, 1985, the Teller chairlift at the Keystone, Colorado, ski area collapsed, throwing 60 of the 372 people aboard to the ground from heights up to 50 feet. Initial triage and management of the victims was carried out by the local ski patrol, the on-duty physician at the area's Snake River Health Services Clinic, and by volunteer physicians and nurses present at the scene. Thirty-three people required immediate evacuation to hospitals, most of them being transported 75 miles by helicopter air ambulance to level I and II trauma centers in the Denver metropolitan area. Eighteen of these air-evacuated patients were in serious or critical condition. Less seriously injured victims were treated at local medical facilities. The scene evacuation was carried out by helicopter and ground vehicles in accordance with an existing disaster plan coordinated by the Colorado Trauma Institute (CTI). The unique problems posed by a mass casualty incident in a remote mountain location are emphasized by this tragedy. Patient salvage due to the efficacy of a regionally organized trauma system is clearly demonstrated.

Hemorrhage associated with major pelvic fracture: a multispecialty challenge.

Definitive treatment of life-threatening hemorrhage associated with blunt pelvic fracture remains controversial. To elucidate this issue, we reviewed 538 consecutive patients admitted with acute pelvic fracture during a 5-year period. Injury mechanism was motor vehicular in 214 (40%), falls in 152 (28%), auto-pedestrian in 92 (17%), motorcycle in 46 (9%), crush in 26 (5%), and assault or skiing in eight (1%). Ninety-two (17%) of these patients required greater than 6 units of blood transfusion during the first postinjury day, and are the primary focus of this report. Twenty-five patients (28%) had unilateral anterior (Group I, n = 20) or posterior (Group II, n = 5) fractures. The remaining 67 patients (72%) had anterior and posterior element involvement on the same side (Group II, n = 38), bilaterally (Group IV, n = 14), or open perineal wounds (Group V, n = 15). The PASG was applied in 47 patients (51%), and controlled hemorrhage in 12 (71%) of the 17 in whom it was used alone to tamponade pelvic bleeding. Peritoneal lavage was performed in 73 patients (79%). Initial aspirate yielded gross blood in 32 patients; 27 (84%) of these required urgent laparotomy. External skeletal fixation was applied in 19 patients; bleeding was controlled in 18 (95%). Pelvic angiography identified active hemorrhage in three patients and selective embolization was successful in two. Sixty-eight (74%) of the high-risk patients survived. Thirteen (54%) of the 24 deaths were attributable to the pelvic trauma, ten were due to recalcitrant bleeding, and three to delayed sepsis.(ABSTRACT TRUNCATED AT 250 WORDS)

Hospital-based rotorcraft aeromedical emergency care services and trauma mortality: a multicenter study.

A group of 1,273 blunt trauma patients who were treated and transported from the site of injury by seven different hospital-based rotorcraft aeromedical emergency care services were studied using a methodology based on injury severity designed to predict the mortality of such patients. The methodology predicted that 241 patients should have died; 191 patients did die. This 21% reduction in expected mortality was highly significant (P less than .001). Each of the seven rotorcraft services had a reduction in predicted mortality. The reduction was statistically significant (P less than .05) in five of the seven aeromedical services, or 86% of the total patient cohort. Hospital-based rotorcraft aeromedical emergency care services may reduce the expected mortality of blunt trauma patients treated at the site of injury.

Thoracic and abdominal injuries in skiers: the role of air evacuation.

The increasing popularity of skiing as a recreational sport has resulted in a greater number of major thoracic and abdominal injuries. These injuries, unlike the more common orthopedic injuries, are often life threatening. This 8-year study reviews 44 thoracic and abdominal ski injuries managed at an urban trauma center since the inception of a helicopter air evacuation program with in-flight resuscitation capabilities. Twenty-five per cent of the injured had signs of hemorrhagic shock, and nearly 60% required a major operation. The injuries were caused by high-speed collisions with stationary objects or other skiers and by falls. Three were penetrating injuries. Organs injured were: heart, lung, kidney, spleen, liver, rectum and abdominal wall, and more than half were multiple injuries. Almost half had associated orthopedic trauma. Resuscitation was initiated on helicopter arrival in these seriously injured patients (78% of helicopter-transported patients came to operation), and apparently contributed to the low mortality of 4.5%.

Rationale for selective application of Emergency Department thoracotomy in trauma.

The indiscriminate application of thoracotomy in the resuscitation of trauma has recently been challenged. Since 1 May 1974 400 consecutive trauma patients have undergone resuscitative thoracotomy in our Emergency Departments (ED). The mechanism of injury was blunt in 195 (49%) patients, gunshot wound in 147 (37%), and stab wound in 58 (14%) Upon arrival in the ED, 352 (88%) patients had no obtainable blood pressure (BP), 334 (84%), fixed pupils, and 315 (798%) failed to exhibit agonal respirations or other waning signs of life. One hundred six (27%) patients reached the operating room and 28 (7%) survived to be admitted to the intensive care unit. Sixteen were eventually discharged from the hospital, but four of these survivors had sustained irreversible cerebral damage. Overall, 12 of 400 (3%) patients survived ED thoracotomy with intact neurologic function. Four factors appeared predictive of poor prognosis. There were no survivors with intact neurologic function among: 150 patients sustaining blunt trauma and arriving in the ED without signs of life (BP, pupil reactivity, respiratory effort); or 87 patients with penetrating torso injuries who had no signs of life at the scene. Following thoracotomy, in the absence of cardiac tamponade, there were no intact survivors of 124 patients without cardiac activity or of aortic occlusion. We believe the above factors should militate against initiating resuscitative thoracotomy in the ED or in deciding to continue heroic measures following thoracotomy.

Trauma operating room in conjunction with an air ambulance system: indications, interventions, and outcomes.

We report a retrospective study of 198 trauma patients brought directly to a trauma operating room by an air ambulance system. Despite rapid transport, expert prehospital resuscitation, and the capability of early surgical intervention, the overall mortality was high (57%). There was no significant salvage of patients arriving without pulse, blood pressure or cardiac activity. Optimal trauma care failed to show encouraging results in this preselected group of patients with predominantly blunt and multisystem injury. The justification and cost effectiveness of this system of trauma care is discussed.

Hemorrhagic necrosis of pheochromocytoma associated with phentolamine administration.

A case of ruptured pheochromocytoma is presented, the pathophysiology discussed, and the literature reviewed. Evidence is presented that the use of alpha-adrenergic blockade in general, and phentolamine in particular, may predispose to this complication. Twelve cases of massive hemorrhagic necrosis with or without rupture were found in the literature, including the present case. Six had no operation; one survived. Six had immediate operation; 4 survived. An additional case of hemorrhage into a small pheochromocytoma following phentolamine is presented. This tumor was neither ruptured nor massively necrotic, but the case supports the hypothesis that alpha-adrenergic blockade may cause hemorrhage within the pheochromocytoma.

A civilian air emergency service: a report of its development, technical aspects, and experience.

1) The development of Air Emergency Service sponsored by a private community hospital is described. 2) Helicopter evacuation of the seriously injured and critically ill in civilian life proved feasible if the community is willing to pay for the services rendered. 3) Two thousand six hundred fifty patients have been transported by helicopter (85%) or fixed-wing plane in 27 months. A minimum of 2,000 flights seems a certainty for 1975. 4) The types of patient, causes of death, and other medical aspects are discussed. 5) The helicopter must be considered as only one component in the E.M.S. System. It will be successful only with development of a complete program which includes: communications; cooperation of law enforcement agencies, fire districts, and rescue squads; integration with ground transportation; the inclusion of highly trained allied medical personnel, physicians, emergency departments and hospitals; and community education and acceptance.