Pulmonary tractotomy versus lung resection: viable options in penetrating lung injury.

BACKGROUND: Emergency lung resection following penetrating chest trauma has been associated with mortality rates as high as 55-100%. Pulmonary tractotomy is advocated as a rapid alternative method of dealing with deep lobar injuries. We reviewed our experience with resection and tractotomy to determine whether method of management affects mortality or if patient presentation is more critical in determining outcome. METHODS: A retrospective review of all patients with chest injury seen at an urban Level I trauma center from 2/89-1/99 was performed. All patients undergoing parenchymal surgery were included. Records were abstracted for grade of injury, type of resection, presenting systolic blood pressure (SBP), temperature, Injury Severity Score (ISS), operative time, and estimated blood loss (EBL). Mortality and thoracic complications were compared between groups. RESULTS: Two hundred forty-six of 2736 patients with penetrating chest trauma underwent thoracotomy, with 70 (28%) requiring some form of lung resection. There were 11 (15.7%) deaths. Patients who died had lower SBP (53 +/- 32 mm Hg vs 77 +/- 28 mm Hg), lower temperature (32.5 degrees +/- 1.3 degrees C vs 34.3 degrees +/- 1.2 degrees C), higher ISS (33 +/- 13 vs 23 +/- 9), and greater EBL (9.8 +/- 4.3 liters vs 2.8 +/- 2.1 liters) compared with survivors (p < 0.05 for all). Mortality was also increased in the presence of cardiac injury (33% with vs 12% without) and the need for laparotomy (26% with vs 9% without) (p < 0.05 for all). Tractotomy was associated with an increased incidence of chest complications (67% vs 24%, p = 0.05) compared with lobectomy with no difference in presenting physiology, operative time, or mortality. CONCLUSION: Lung resection for penetrating injuries can be done safely with morbidity and mortality rates lower than previously reported. Patient outcome is related to severity of injury rather than type of resection. Tractotomy is associated with a higher incidence of infectious complications and is not associated with shortened operative times or survival.

The impact of pre-existing end-stage renal disease on survival in acutely injured trauma patients.

End-stage renal disease and associated dialysis procedures alter homeostatic mechanisms and adversely affect the respiratory, cardiac, and central nervous systems. Currently outcomes research in acutely injured trauma patients utilizes Trauma and Injury Severity Score methodology with the Injury Severity Score and Revised Trauma Score, which do not account for comorbidities. Literature has yet to emerge that analyzes the effects of end-stage renal disease on acutely injured trauma patients. A retrospective review at an urban Level I trauma center was performed of all end-stage renal disease patients' medical records who were admitted for acute traumatic injury from 1994 through 1997. The charts were abstracted for age, sex, race, method of dialysis, specific injury, need for operation, etiology of trauma, length of stay, disposition from hospital, morbidity, and mortality. The Injury Severity Score; probability of survival; and W, M, and Z statistics were then calculated. The data collected were then compared with the overall data for the trauma center including patients with and those without end-stage renal disease during this time period. Mortality for patients with end-stage renal disease after suffering an acute traumatic injury is 2.45 that of the general population. Increased mortality was most prevalent in operative patients and those with Injury Severity Score >15. The average length of stay in the hospital was 55.3 per cent longer for patients with end-stage renal disease. Pre-existing end-stage renal disease negatively impacts survival after traumatic injury. A prospective multicentered study comparing renal patients with nonrenal patients is warranted. This would confirm the need for databases to account for the increased morbidity and mortality associated with end-stage renal disease when calculating probability of survival values for acutely injured trauma patients. Similarly future studies analyzing the affects of other comorbidities such as diabetes, chronic obstructive pulmonary disease, and hypertension on acutely injured trauma patients would help develop a more accurate method of predicting outcomes.

Primary venorrhaphy for traumatic inferior vena cava injuries.

Primary venorrhaphy for traumatic inferior vena cava (IVC) injury has been criticized because of the potential for stenosis, thrombosis, and embolism. A retrospective study was performed to evaluate the morbidity and outcome of this method. Thirty-eight patients at our institution had traumatic injuries to the IVC between 1994 and 1999. Thirty (79%) were from firearms, five (13%) from stab wounds, and three (8%) from blunt trauma. Six patients died in the emergency department. The remaining 32 patients underwent exploratory celiotomy with 23 survivors and nine intraoperative deaths for a mortality rate of 28 per cent (nine of 32). Vascular control was achieved by manual compression in 44 per cent and by local clamping directly above and below the injury in 38 per cent. All repairs were by primary venorrhaphy, and no patient was treated with patch angioplasty or venous reconstruction. Three patients had caval ligation. Follow-up IVC imaging in 11 patients revealed that the IVC was patent in eight, narrowed in two, and thrombosed below the renal veins in one. One patient developed a pulmonary embolus. The vast majority of traumatic injuries to the IVC can be managed by direct compression or local clamping and primary venorrhaphy. Direct repairs are associated with a low thrombosis and embolic complication rate.

Physical examination plus chest radiography in penetrating periclavicular trauma: the appropriate trigger for angiography.

BACKGROUND: To determine the role of physical examination, chest radiography, and angiography in the management of periclavicular penetrating trauma. METHODS: A retrospective review of the last 100 patients who suffered periclavicular penetrating trauma was performed. Patients with hard signs of vascular injury went either directly to the operating room or first to the angiography suite depending on their hemodynamic stability. All others underwent angiography and subsequent intervention if needed. The results were examined to determine the role of arteriography in the absence of hard signs of vascular injury. RESULTS: Of the 100 patients in the study, there were 81 without hard signs of vascular injury. All underwent angiography, with 11 "occult" injuries discovered. Each of these patients exhibited some physical examination or chest radiographic finding that may have predicted the presence of vascular injury. Using clinical criteria, physical examination was found to have a sensitivity of 82%, a specificity of 91%, a positive predictive value of 60%, and a negative predictive value of 96%. When coupled with the chest radiographic findings, these numbers were 100%, 80%, 44%, and 100%, respectively. Using these criteria would have eliminated the need for angiography in 56 (69%) patients and would not have missed any injuries. CONCLUSIONS: In patients with periclavicular penetrating trauma, a normal physical examination and chest radiographic excludes vascular injury. Proximity alone does not warrant angiography, although the test may be useful for therapeutic interventions or to plan operative approaches. A prospective study is essential to validate these findings.

Retrograde jejunogastric intussusception.

Retrograde gastrointestinal intussusception is a rare entity, most commonly reported after gastric resection and gastrojejunostomy. Its occurrence in the absence of previous gastric resection is extremely unusual, with only four cases reported. All cases were associated with previously placed gastrostomy tubes and implicated these as the inciting factor. We present a fifth case and review the literature. The mechanism of this phenomenon is described and recommendations to prevent this potentially fatal complication are made.

Clearing the cervical spine in victims of blunt assault to the head and neck: what is necessary?

A number of guidelines have been proposed to aid in determining the need for radiologic evaluation of the cervical spine (c-spine) in victims of blunt trauma. Mechanism of injury has not been shown to be an independent predictor of injury or the lack thereof. The current study was undertaken to determine the incidence of clinically relevant c-spine injuries in patients who sustained a blunt assault to the head and neck. The trauma registry of an urban Level 1 trauma center was used to identify patients who suffered a blunt assault to the head and neck and were admitted to the hospital over a 30-month period. One hundred two patients were identified. Only 8 patients met criteria for clinical clearance of the c-spine. Eighty patients were unable to be evaluated because of head injury or intoxicants; 14 patients had neck pain on initial examination. These 94 patients underwent plain film examination of their c-spine. Twelve required CT scanning to supplement visualization. The possibility of ligamentous injury was investigated by MRI or flexion/extension radiographs in 26 patients. No clinically significant c-spine injuries were identified. Although many victims of a blunt assault to the head and neck region may have a decreased LOC or neck pain, the likelihood of a ligamentous injury is so low that plain-film X-ray evaluation of the c-spine is all that is necessary to rule out injury in this patient population.

Anterior mediastinal abscess after closed sternal fracture.

BACKGROUND: Although sternal fractures after blunt chest trauma are markers for significant impact, the fracture itself is generally not associated with any specific wound complications. Mediastinal abscess and sternal osteomyelitis rarely occur after blunt trauma or cardiopulmonary resuscitation. Management of such complications is difficult, and requires a spectrum of operative procedures that range from simple closure to muscle flap reconstruction. METHODS: The trauma registry of a Level I trauma center was used to identify patients suffering a sternal fracture between January of 1994 and August of 1997. Records were reviewed for the mechanism of injury, length of hospital stay, and posttraumatic mediastinal abscess. RESULTS: Twenty-six patients were identified with sternal fracture. No clinically significant cardiac or aortic complications were noted. Three patients, all with a history of intravenous drug abuse and requiring central venous access in the emergency room, developed methicillin resistant Staphylococcus aureus mediastinitis. Sternal re-wiring and placement of an irrigation system successfully treated all three patients. CONCLUSION: Posttraumatic mediastinal abscess is an uncommon complication of blunt trauma in general and sternal fracture in particular. It can be recognized by the development of sternal instability. Risk factors include the presence of hematoma, intravenous drug abuse, and source of staphylococcal infection. Treatment with early debridement and irrigation can avoid the need for muscle flap closure.

Hemodynamic effects of aortic occlusion during hemorrhagic shock and cardiac arrest.

OBJECTIVE: To determine the hemodynamic consequences of aortic occlusion during controlled hemorrhagic arrest. METHODS: Ten anesthetized, hemodynamically monitored swine were subjected to a 40 mL/kg hemorrhage over 10 minutes, followed by a 5-minute period of apnea. At this time (T15), they were randomized into an UP group (n = 5) in which the thoracic aorta was occluded or a DOWN group (n = 5) in which the aorta was not occluded. Simultaneously, volume resuscitation with shed blood plus 20 mL/kg of normal saline was performed over a 10-minute period. Cardiac massage was performed until return of spontaneous circulation (ROSC), which was defined as a sustained systolic blood pressure > 60 mm Hg. After 30 minutes of occlusion (T45), the aortic occlusion was released. Parameters measured include mixed venous and arterial blood gases, serum lactic acid levels, cardiac index, mean arterial pressure (MAP), mean pulmonary artery pressure (MPAP), coronary perfusion pressure (CoPP), and left ventricular stroke work index (LVSWI). Oxygen delivery index (DO2I) was measured using a pulmonary artery catheter, and oxygen consumption index (VO2I) was measured by direct calorimetry (Delta Trac metabolic monitor). RESULTS: Four animals in each group achieved ROSC after 3.0 +/- 1.8 and 2.2 +/- 1.8 minutes in the occluded and nonoccluded groups, respectively. During cardiac compressions and volume resuscitation, the CoPP, MAP, and MPAP were greater in the UP group, although the differences did not achieve statistical significance. After volume resuscitation was complete and during the period of aortic occlusion (T25-T45), the UP group had significantly greater MAP (mm Hg), with a difference of 42.5 +/- 20.75 mm Hg at T25 and 44.7 +/- 19 mm Hg at T35 (p < 0.03). Despite no difference in DO2I, VO2I (mL/min/kg) was significantly lower in the UP group than in the DOWN group, 4.28 +/- 0.48 versus 8.33 +/- 0.85 at T25 (p = 0.0002) and 4.62 +/- 0.9 versus 7.09 +/- 0.72 at T35 (p = 0.0005). After release of aortic occlusion at T45, the UP group had significantly lower CoPP (mm Hg) than the DOWN group (20.5 +/- 17.3 versus 66.5 +/- 28.2 at T45, p = 0.03). LVSWI (g/kg) was also lower in the UP than in the DOWN group (18.6 +/- 8.28 versus 36.5 +/- 10.2 at T60 [p = 0.031 and 23.6 +/- 6.48 versus 48.8 +/- 15.3 at T240 [p = 0.021). After release of the occlusion, there were trends toward increased acidosis and lactic acid levels in the UP group. CONCLUSIONS: Aortic occlusion in this controlled hemorrhagic arrest model does not result in improved salvage but is associated with impaired left ventricular function, systemic oxygen utilization, and coronary perfusion pressure in the postresuscitation period.

Pseudomembranous colitis with associated fulminant ileitis in the defunctionalized limb of a jejunal-ileal bypass. Report of a case.

Presented is what is believed to be the first reported case of a defunctionalized limb of small intestine serving as a reservoir for Clostridium difficile. Because of the altered intestinal continuity, the ensuing enteritis and colitis failed to respond to nonoperative management. Current treatment strategies are reviewed. Surgical intervention, including restoration of normal gastrointestinal continuity, should be considered early in the hospital course of this patient population.