Mucormycosis in trauma patients.

Cutaneous mucormycosis is a rare but often fatal infection in trauma patients. We retrospectively reviewed a 9-year experience with mucormycosis among injured patients. Eleven patients had biopsy- or culture-proven mucormycosis. Nine patients were victims of blunt trauma, two patients had burns measuring greater than 50% TBSA. No patient was at increased risk because of underlying disease or immunosuppression prior to injury. All 11 patients had open wounds on admission. Four patients died of mucormycosis. All nonsurvivors had phycomycotic gangrenous cellulitis of the head, the trunk, or both. In contrast, survivors had involvement of only the extremities. Because of underlying disease, contaminating wounds, antibiotic use, or immunocompromise secondary to shock and sepsis, trauma patients are at risk of developing mucormycosis. To successfully treat mucormycosis, diagnosis must be prompt and accompanied by aggressive debridement and parenteral administration of amphotericin B.

The pharmacokinetics of prophylactic antibiotics in trauma.

Despite prophylactic antibiotic use in abdominal trauma patients, infection rates remain high. A previous study from our institution indicated that higher doses of prophylactic antibiotics in trauma patients could significantly reduce subsequent infection rates. To determine if this resulted from altered pharmacokinetic profiles, we performed individualized pharmacokinetic analysis of the prophylactic amikacin regimens given to 28 trauma patients undergoing laparotomy. Patients were prospectively randomized to receive a standard regimen of 11 mg/kg of amikacin every 12 hours or to have their regimens adjusted based upon pharmacokinetic analysis. Repeated pharmacokinetic analyses were performed daily for the three-day prophylactic regimen. There was a significant expansion in the apparent volume of distribution for amikacin that correlated with fluid resuscitation. This, along with increased elimination rates, helps to explain the failure to achieve adequate amikacin levels using standard regimens in trauma patients. Such underdosing may contribute to relatively high infection rates following major abdominal injury.

Posterior hip dislocation associated with acute traumatic injury of the thoracic aorta: a previously unrecognized injury complex.

Posterior hip dislocation associated with acute injury to the thoracic aorta is a previously unrecognized injury complex. This study reveals that 8% of patients with posterior hip dislocation have associated injury to the thoracic aorta because of abrupt deceleration injuries. This study defines the association of traumatic posterior hip dislocation and acute traumatic injury of the thoracic aorta, describes the mechanism of injury, and discusses the evaluation of a patient with a suspected acute traumatic aortic injury.

Pharmacokinetic monitoring of nephrotoxic antibiotics in surgical intensive care patients.

An assessment of the dosage regimens prescribed for potentially nephrotoxic antibiotics (amikacin, gentamicin, tobramycin, and vancomycin) was undertaken on surgical intensive care unit patients. In 166 patients, 224 series of blood antibiotic level determinations were obtained. Using individualized pharmacokinetic determinations, the regimens were revised as necessary to provide optimal blood levels. Because of variable volumes of distribution and elimination rates, dosing according to standard clinical guidelines produced significantly lower peaks than did pharmacokinetically determined regimens for gentamicin (p less than 0.005), tobramycin (p less than 0.0001), and vancomycin (p less than 0.05). Importantly, fewer patients achieved therapeutic levels with the original regimens than with the revised regimens for gentamicin (9% vs. 91%, p less than 0.0005), tobramycin (27% vs. 92%, p less than 0.0001), and vancomycin (30% vs. 69%, p less than 0.0001). Individualized pharmacokinetic analysis of potentially nephrotoxic antibiotics in critically ill patients is essential if therapeutic, non-toxic levels are to be maintained.

Prophylactic antibiotics in trauma: the hazards of underdosing.

Prophylactic antibiotic regimens in trauma patients may be significantly altered by large fluid shifts and hyperdynamic physiologic responses. We prospectively studied prophylactic amikacin and clindamycin in 150 abdominal trauma patients requiring laparotomy, analyzing the effects of duration of coverage, dosing interval, and dose. No difference in infection rates was noted when 72-hour coverage was compared with 24-hour coverage (19% vs. 21%). Clindamycin dosed at 1,200 mg every 12 hours achieved acceptable serum concentrations; infection rates were not significantly higher than seen with 600 mg every 6 hours (21% vs. 12%, p greater than 0.05). High-dose (11 mg/kg) amikacin reduced infection rates in patients with high blood loss (p less than 0.025), high Injury Severity Scores (p less than 0.025), and no colon penetration (p less than 0.005). These data suggest that high doses are more effective than long courses of antibiotics in reducing infections in trauma patients undergoing laparotomy.

Gallbladder response to enteral lipids in injured patients.

Severely injured patients are at risk for complications of gallbladder stasis in a spectrum from sludge formation and cystic duct occlusion by inspissation and, subsequently, acalculous cholecystitis. In a double-blind randomized trial, the effect of enteral lipids on the ability of the gallbladder to clear itself was tested. The gallbladder was assessed by ultrasonography for acute contractions, sludge and dilatation on days 1, 3, and 7 after injury. There were no significant differences between patients who received enteral lipids and controls. Both groups showed modest enlargement of the gallbladder and failure of contraction. In a population at risk for biliary stasis following severe trauma, standard enteral lipids did not elicit, acutely or chronically, an appropriate reflexive evacuation of the gallbladder.

Gastrointestinal disruption: the hazard of nonoperative management in adults with blunt abdominal injury.

The danger inherent to nonoperative management of patients with blunt abdominal injury is that gastrointestinal disruptions will escape timely diagnosis and repair. However, children with blunt abdominal injury have been successfully treated nonoperatively for more than a decade. It has been recently proposed, based upon small series, that adults can be managed nonoperatively in a manner similar to that for children. To assess the likely safety for nonoperative management of adults with blunt abdominal injury, we determined the frequency of blunt gastrointestinal disruption in adults, and reviewed the sensitivity of the diagnosis of gastrointestinal disruption by computed tomography. The salient statistically significant findings, based upon an analysis of 6,301 adults and 1,275 children admitted following blunt trauma, were that blunt abdominal injury, blunt gastrointestinal injury, and blunt gastrointestinal disruption are much more frequent in adults. Based upon these findings and the low sensitivity reported for the diagnosis of gastrointestinal disruption by computed tomography, we conclude that the nonoperative management of adults with blunt abdominal injury is as a matter of routine not justified.

The medical and economic impact of severely injured lower extremities.

Modern methods of open fracture management, skeletal fixation, and soft-tissue and bone reconstruction have dramatically improved the potential for limb salvage. The absence of adequate objective parameters on which to base the decision for salvage results in delayed amputations in many cases. The present study was undertaken to review the medical and economic impact of delayed versus primary amputations following severe open fractures of the tibia. From January 1980 to August 1986, 263 patients with grade III open tibia fractures were treated at a major trauma center: 43 ultimately had amputations. This group included 38 males and five females with an average age of 31 years (range, 15-73). All patients were taken to the operating suite for consideration of limb salvage procedures including debridement, fasciotomy, revascularization, or rigid fixation. The standard subjective criteria including color, consistency, bleeding, and contractility were used to determine muscle viability at the time of debridement. If substantial muscle mass was found to be nonviable then amputation was considered. Fourteen (32.6%) of the patients had primary amputations. They averaged 22.3 days hospitalization, 1.6 surgical procedures to the involved lower extremity, and $28,964 hospital costs (range, $5,344-$81,282). The 29 patients with delayed amputations had an average of 53.4 days hospitalization, 6.9 surgical procedures, and $53,462 hospital costs (range, $14,574-$102,434). Six (20.7%) of the delayed amputation patients developed sepsis secondary to their involved lower extremity and died; no patient in the primary amputation group developed sepsis or died.(ABSTRACT TRUNCATED AT 250 WORDS)