A method for management of extraperitoneal pelvic bleeding secondary to penetrating trauma.

Several techniques for the management of bleeding from extraperitoneal pelvic bullet tracks have been described in the literature. Some methods described include packing followed by direct control of the bleeding and use of thumbtacks. These methods often incur significant blood loss and prolonged operative times. We present our experience with an alternative method, which involves tamponade of the bleeding using a Foley catheter. This method has been used on 11 consecutive patients with successful control of life-threatening hemorrhage.

Colostomy in penetrating colon injury: is it necessary?

OBJECTIVE: To compare in a randomized prospective manner the complication rates associated with colostomy versus primary repair in penetrating colon injuries. METHODS: During a 38-month period, 114 patients with penetrating wounds of the colon were entered into a randomized prospective study at an urban Level I trauma center. The patients were randomized to a primary repair group or a diversion group. Randomization was completely independent of any risk factors, including number of abdominal organ systems injured, extent of fecal contamination, blood loss, presence of shock (systolic blood pressure < 80), time from injury to operation, and severity of colon injury. Five patients initially entered in the study died in the immediate postoperative period (< 24 hours) and were removed from the study because their deaths were unrelated to their colon injuries. RESULTS: A total of 109 patients were studied, of which 56 were randomized to primary repair and 53 to diversion (39 colostomies, 14 ileostomies). The average age for the primary repair group was 28.5 years and for the diversion group it was 26.8 years. The average Penetrating Abdominal Trauma Index for the primary repair group was 24.3 and for the diversion group it was 22.8. There were 11 (20%) septic-related complications in the primary group versus 13 (25%) in the diversion group. Complication rates in the presence of significant fecal contamination, shock, significant blood loss (> 1000 mL), more than two organ systems injured and extent of colon injury were all higher in the diversion group. There was one mortality in the diversion group and two in the primary repair group. CONCLUSIONS: The authors conclude that all penetrating colon injuries in the civilian population should be primarily repaired.

Colorectal trauma.

Surgical treatment of colon and rectal trauma continues to challenge physicians. Injuries to a colon or rectum filled with feces results in subsequent peritoneal contamination which will lead to severe septic complications unless dealt with promptly and correctly. The authors have reviewed the records of 242 patients with colon and rectal trauma operated on at the Cook County Trauma Unit from July 1, 1973 to December 31, 1983, to evaluate treatment results. The mechanism of trauma was penetrating in 233 of 242 patients. Most, if not all, colonic lesions were treated with either exteriorization, resection and no anastomosis, or closure and proximal colostomy. Mortality related to colonic injury was 2.5 percent. Morbidity related to colonic injury included wound infection, 6.3 percent; abscess, 2.5 percent; other, 3.3 percent. Despite the severity of the trauma, adherence to conservative principles of "no anastomosis" in the overwhelming majority of cases has resulted in low morbidity and mortality.

Head injury and hemorrhagic shock: studies of the blood brain barrier and intracranial pressure after resuscitation with normal saline solution, 3% saline solution, and dextran-40.

The effect of fluid resuscitation from hemorrhagic shock on cerebral edema, intracranial pressure (ICP), and blood brain barrier function was investigated in the presence of a simulated head injury. Beagle dogs were anesthetized and ICP was measured via a right subarachnoid bolt while a contralateral epidural balloon was inflated in the left hemicranium to mimic a closed head injury. Forty percent of the dogs' blood was shed and the shock state was maintained for 1 hour. Resuscitation was initiated with shed blood and a volume of either normal saline solution (NS, n = 5), 10% dextran-40 (D-40, n = 6), or hypertonic (3%) saline solution (HS, n = 6) equal to the amount of shed blood. Evans blue solution was infused intravenously, and intravascular volume was then maintained with normal saline solution. Control (n = 5) dogs did not undergo shock, but received equivalent volumes of normal saline solution and Evans blue solution. The dogs were killed after 2 hours of resuscitation, and the brains were removed, weighed, and fixed in formalin. The average intracranial pressure value after epidural balloon inflation was 18.6 +/- 0.80 mm Hg and decreased equally in all groups during the shock period, averaging 10.8 +/- 1.24 mm Hg at the end of the shock period. Fluid resuscitation markedly elevated ICP in the NS and D-40 groups, reaching maximal values of 46.6 +/- 12.11 mm Hg and 45.3 +/- 28.95 mm Hg, respectively. Maximal ICP values in control and HS groups measured 21.8 +/- 1.36 mm Hg and 15.8 +/- 2.04 mm Hg, respectively (p less than 0.25 for HS versus NS control). Wet brain weights were significantly less in the HS group compared with either NS or D-40 groups (p less than 0.05). Coronal sections of fixed HS brains showed deep cortical Evans blue staining on the side of balloon injury. Therefore, in the presence of an intracranial mass lesion, resuscitation with hypertonic (3%) saline solution is accompanied by lower ICP values and less cerebral edema than is isotonic saline or colloid resuscitation. Blood brain barrier function is not restored by hypertonic saline solution resuscitation.

The use of absorbable mesh in splenic trauma.

Previous reports from this hospital documented a splenic preservation rate of 50% (18/36) in adults after blunt and penetrating trauma. Recently (January through December 1984), use of an absorbable mesh helped to attain a 67% (22/33) salvage rate. The mesh is applied in such a fashion that it acts by tamponade. It proved useful in patients with bleeding from a large surface area or from deep parenchymal injuries, even those extending into the hilum. No deaths occurred in the splenic salvage patients. There was no difference in postoperative complications among the splenectomy, conventional splenorraphy, or mesh wrap splenorraphy groups. However, workup of persistent postoperative fevers in two splenic wrap patients revealed perisplenic fluid collections on CT scan. Aspiration yielded sterile fluid. Possible cause and effect relationship is being studied in the dog lab. We conclude that splenic wrapping is both a safe and efficacious method of splenic preservation.

Peritoneal lavage in penetrating thoraco-abdominal trauma.

Forty-five consecutive patients with penetrating thoraco-abdominal trauma underwent surgical exploration to evaluate the ability of peritoneal lavage to detect peritoneal penetration. Eight patients fulfilled standard criteria for operation and did not undergo lavage. The remaining 37 patients underwent diagnostic peritoneal lavage using a closed technique before exploratory laparotomy. Using 10,000 RBC/mm3 as our previously established criterion for peritoneal penetration, there were seven true positive, one false positive, 28 true negative, and one false negative lavage for an overall accuracy of 94.6% with 87.5% sensitivity and 96.6% specificity as determined by subsequent laparotomy. While 33% of this patient cohort were found to have significant injuries (four had isolated diaphragmatic injuries, all detected by peritoneal lavage), 67% were subjected to negative surgical exploration, as accurately predicted by peritoneal lavage. Negative laparotomy carried a 10.7% operative morbidity. Based on these data we advocate diagnostic peritoneal lavage in patients with thoraco-abdominal penetrating trauma who otherwise lack operative indications.

A new method of rapid fluid resuscitation during thoracotomy performed in the emergency room.

A new technique for inserting and securing large bore intravenous lines directly into the right atrium, to be used in patients requiring a thoracotomy in the emergency room, is described herein. A plastic clip is attached to the edge of the atrial appendage and holds a large catheter in place. We have used this new technique successfully at the Cook County Hospital Trauma Unit and have encountered no complications to date.

Resuscitation from hemorrhagic shock. Alterations of the intracranial pressure after normal saline, 3% saline and dextran-40.

Resuscitation from hemorrhagic shock by infusion of isotonic (normal) saline (NS) is accompanied by a transient elevation in intracranial pressure (ICP), although cerebral edema, as measured by brain weights at 24 hours, is prevented by adequate volume resuscitation. The transient increase in ICP is not observed during hypertonic saline (HS) resuscitation. The effect of colloid resuscitation on ICP is unknown. Beagles were anesthetized, intubated, and ventilated, maintaining pCO2 between 30-45 torr. Femoral artery, pulmonary artery, and urethral catheters were positioned. ICP was measured with a subarachnoid bolt. Forty per cent of the dog's blood volume was shed and the shock state maintained for 1 hour. Resuscitation was done with shed blood and a volume of either NS (n = 5), 3% HS (n = 5), or 10% dextran-40 (D-40, n = 5) equal to the amount of shed blood. Intravascular volume was then maintained with NS. ICP fell from baseline values (4.7 +/- 3.13 mmHg) during the shock state and increased greatly during initial fluid resuscitation in NS and D-40 groups, to 16.0 +/- 5.83 mmHg and 16.2 +/- 2.68 mmHg, respectively. ICP returned to baseline values of 3.0 +/- 1.73 mmHg in the HS group with initial resuscitation and remained at baseline values throughout resuscitation. NS and D-40 ICP were greater than HS ICP at 1 hour (p less than .001) and 2 hours (p less than .05) after resuscitation. These results demonstrate that NS or colloid resuscitation from hemorrhagic shock elevates ICP and that HS prevents elevated ICP.

Results of venous reconstruction after civilian vascular trauma.

The treatment of venous injuries remains controversial. In an attempt to evaluate the results of current management of venous injuries, we retrospectively reviewed our experience between 1979 and 1984. During this period 142 patients had sustained injuries to 158 veins in the neck (31 patients), abdomen (45 patients), upper extremity (20 patients), and lower extremity (62 patients). Overall, 90 venous injuries (61%) were repaired, including 83% of caval and iliac vein injuries and 90% of injuries to the common femoral, superficial femoral, and popliteal veins. There was no morbidity after repair of 73 major veins. Morbidity occurred in four of 11 patients after ligation of major veins (edema in two patients and above-knee amputation in two others). Both ligation (N = 51) and repair (N = 17) of lesser veins (jugular, brachial, profunda femoral, tibial, and minor abdominal veins) resulted in no morbidity. Overall mortality was 6% with all deaths occurring in patients with abdominal venous trauma. These data indicate that repair of venous injuries can be performed without morbidity and that minor veins can be ligated without adverse sequelae. However, in view of the morbidity associated with ligation of major veins, efforts to restore flow to these injured vessels appear appropriate unless contraindicated by life-threatening injury.

Fibronectin depletion and microaggregate clearance following trauma.

Ninety-seven traumatized patients had blood samples taken immediately upon admission before any resuscitation. Microaggregate (MA) formation was measured by the screen filtration pressure (SFP) technique. Plasma fibronectin levels (Fn) were measured by immunoturbimetric assay. An Injury Severity Score (ISS) was calculated for each patient. The results show a highly significant correlation between severity of trauma, amount of MA formation, and amount of Fn depletion. We conclude that the highly significant correlation between MA formation and Fn depletion following trauma suggests a role for the reticuloendothelial system (RES) in the clearance of MA that form following trauma. Further, enhancement of RES clearance of MA may be possible by purified Fn or cryoprecipitate administration early in the treatment of trauma patients, thereby preventing the adverse sequelae of end organ MA deposition.

Use of peritoneal lavage to evaluate abdominal penetration.

A retrospective study was undertaken to evaluate peritoneal lavage in detecting abdominal penetration. Two hundred thirty-five patients with thoracoabdominal, flank, or tangential abdominal gunshot wounds were lavaged. Of these patients, 44 (18.7%) had positive lavages, defined as red blood cell counts greater than 10,000 cells/mm3, white blood cell counts greater than 500 cells/mm3, or the presence of bile, feces, or vegetable matter. There were 13.6% false positives and 1.0% false negatives, with an overall accuracy of 96.6%. The results were unaffected by mechanism or site of injury. If the criteria were changed to include red blood cell counts greater than 100,000 cells/mm3, there would have been no false positives, but an unacceptably high 11.1% false negative rate. Therefore we conclude that peritoneal lavage can be a reliable indicator of abdominal penetration provided sufficiently sensitive criteria are used. These criteria should include red blood cell counts greater than 10,000 cells/mm3 instead of 100,000 cells/mm3.

Alterations of capillary flow during sepsis.

Normal red cells are flexible and can thus negotiate small capillaries with ease. Impaired red cell deformability (RCD) has been found in patients with uremia, peripheral vascular disease, and diabetes. This study was performed in order to determine if impaired RCD is present during sepsis. The RCD of citrated whole blood (WB) and citrated buffy coat-poor whole blood (BCP) from ten septic patients was compared to ten age-, sex-, and race-matched control patients. The samples were passed through polycarbonate 5 micron pore filters at -10 cm H2O pressure according to the technique of Reid. A red cell deformability index was calculated for each patient by multiplying the volume of blood flowing through the apparatus in a 1-minute period by the hematocrit. The results show very highly significant decreases of flow in both the WB and BCP blood in the septic group. Alterations in flow in the WB can be explained on the basis of changes in the buffy coat fraction and/or the red cell deformability. A decrease in flow in the BCP blood can be explained in terms of a diminished deformability of the red cells themselves. This increased rigidity of the red cells could, in part, explain the AV shunting and decreased microcirculatory flow seen in the septic state.