Early tracheostomy in trauma patients.

A retrospective analysis of 118 trauma patients who underwent tracheostomy for airway and pulmonary management was undertaken. Timing of the procedure was defined as early (0-3 days), intermediate (4-7 days), and late (> 7 days). Head injury patients received tracheostomy early (p < 0.00003). Aspiration evaluated by modified bedside aspiration test was a frequent occurrence in all three groups with no difference in incidence (p < 0.34). Pneumonia was less frequent in the early group compared with the intermediate and late groups (p < 0.0034). The incidence of pneumonia in the early group was not different from that observed in early extubated patients (n = 282; p < 0.23). Our study suggests that early tracheostomy may decrease pulmonary septic complications in trauma patients. Although no change in length of stay can be attributed to the early performance of tracheostomy, preventing pneumonia in the intensive care unit setting with its resulting high expense is beneficial.

Delayed rupture of the spleen--myths, facts, and their importance: case reports and literature review.

Over a 1-year period, three patients were seen in our trauma service with delayed bleeding (> or = 7 days) from an initially inapparent splenic injury. This entity was defined as a late occurrence of signs and symptoms attributed to splenic injury not detected by diagnostic computed tomographic (CT) scanning during the initial examination. We believe that this represents an "injury in evolution" minor enough to go undetected on initial CT scans of the abdomen. A high index of suspicion and liberal utilization of imaging techniques are essential for the identification of delayed splenic rupture. Further multicenter studies are required to delineate the true incidence of its occurrence and its clinical significance. We conclude that "delayed rupture" of the spleen is a true clinical entity. The occurrence of a delayed rupture may prove hazardous to patients discharged early from the hospital after blunt abdominal injury. A classification system to assess this type of injury is suggested.

Blunt vascular injury associated with closed mid-shaft femur fracture: a plea for concern.

During a period of six years, 765 consecutive patients were treated by the trauma service at Allegheny General Hospital for closed mid-shaft femur fractures that were a component of their injury complex. Thirty-one patients underwent angiography of the involved extremity for indications including loss of pulses in eleven and large hematomas or deformities of the thigh in the remainder. Ten patients (1.3%) were found to have acute vascular injuries. In nine patients there was an intimal flap of the superficial femoral artery (SFA), and in one, a pseudoaneurysm. Two patients had injuries of the femoral nerve. Three patients had no other associated major injuries (Injury Severity Score range, 10-19). Twelve months after the initial injury, one patient developed an arteriovenous fistula of the SFA. Detailed, repeated physical examinations, early utilization of angiography, and intensive follow-up by the trauma surgeon or orthopedic surgeon of patients with closed mid-shaft femur fractures should lead to early recognition of this potentially serious association.

Acute mortality associated with injuries to the pelvic ring: the role of early patient mobilization and external fixation.

PURPOSE: To analyze the effect on mortality of a protocol for early mobilization with external fixation of patients with pelvic ring injuries. METHODS: From 1981 through 1988, 605 patients with pelvic ring fractures and dislocations were treated. In 1982, a protocol for early external fixation of hemodynamically unstable patients and those with structurally unstable pelvic fracture patterns to achieve early mobilization to an upright chest position was initiated. Mortality rates were compared between 1981 (pre-protocol), 1982 (transitional), and 1983 through 1988, after initiation of a protocol of care that included external fixation of the pelvic injury. No statistical changes occurred from 1983 through 1988. RESULTS: Mortality rates in pelvic ring injury patients fell from 26% in 1981, to 6% in 1983 through 1988 (p < 0.001), whereas during the study period the mean injury Severity Score (ISS), 23, did not change. The mortality rate of a group of consecutive patients with comparable ISSs, but without pelvic ring injuries did not change. The mortality rate in patients with systolic blood pressure < 100 mm Hg at admission fell from 41% in 1981 to 21% 1983 through 1988 (p = 0.0001). Mortality in patients with closed head injuries associated with pelvic ring injuries fell from 43% in 1981 to 7% from 1983 through 1988 (p = 0.0001). The proportion of patients undergoing external fixation rose from 3% in 1981 to 31% in 1983 through 1988 (p = 0.0001). CONCLUSIONS: An organized protocol including external fixation and early patient mobilization to an upright chest position reduced mortality associated with injuries of the pelvic ring. Orthopedic stabilization of major skeletal injuries should be viewed as part of patient resuscitation, not reconstruction.

Hypoxemia after blunt chest injury: right-to-left intracardiac shunt managed non-operatively.

A case of patent foramen ovale with right-to-left intracardiac shunt after blunt chest injury is presented. The association of pulmonary contusion, pulmonary hypertension, and patent foramen ovale in a previously healthy subject is discussed. In such a case reduction of the afterload on the right ventricle is the suggested modality of treatment for hypoxemia due to the right-to-left shunt.

Cystic artery pseudoaneurysm: a rare cause of hemobilia.

Gallstone-induced cystic artery pseudoaneurysm is a rarely encountered cause of hemobilia. A few reports have appeared in the radiologic literature. We report such a case as a reminder of its uncommon occurrence.

Acute obstructive jaundice in the multiple trauma patient.

The appearance of acute jaundice in the multiple trauma patient may result from obstruction of the common bile duct by clot. Management of this problem may be hindered by a delay in diagnosis, especially where alterations in pigment load and hepatic clearance may have produced the jaundice. A high index of suspicion combined with the judicious use of various noninvasive imaging modalities may be helpful in making the diagnosis. The progression of jaundice in a patient suspected of having acute obstructive hemobilia should prompt rapid operative intervention. At laparotomy, cholangiography or common bile duct exploration should be done. Persistent bleeding should be managed initially with angiographic localization and transcatheter embolization; its failure would necessitate surgical control of the source.

Clinical and pathologic features of primary gastric rhabdomyosarcoma.

The authors report a case of a collision tumor composed of a primary gastric rhabdomyosarcoma intermingled with an adjacent infiltrating gastric adenocarcinoma. Only eight cases of gastric rhabdomyosarcoma have been reported previously and little information is recorded about the behavior of this tumor. Gastric rhabdomyosarcoma has several distinctive clinical features. It is a highly aggressive tumor (median survival, 2.5 months) occurring in both children and adults and frequently presents as metastatic disease to lung or cervical lymph node. The initial diagnosis is often difficult to establish, especially on biopsy material. In several instances, the correct diagnosis was established only at autopsy. The authors' patient was correctly diagnosed during life and received considerable benefit from cyclophosphamide, doxorubicin, and vincristine (CAV) therapy and survived for 26 months after diagnosis. Two of the previously reported eight cases of primary gastric rhabdomyosarcoma and this case have adjacent admixed glandular gastric adenocarcinomas. Since three of the nine known cases of primary gastric rhabdomyosarcoma have an adjacent admixed gastric adenocarcinoma, there appears to be a greater than chance association between these two tumors.

A technique for evaluation of the injured extremity with single film exclusion arteriography.

Single film exclusion arteriography is a simple technique for accurate evaluation of the vascular integrity of the extremity that has been traumatized which takes only minutes to perform. The procedure can be used to detect or exclude a vascular injury when obvious clinical signs of vascular disruption are absent but the mechanism of injury is suspicious. It also eliminates the delay and danger of formal angiography in select critically injured patients. Single film exclusion arteriography is an important diagnostic tool which can accurately delineate the presence of vascular trauma necessitating operative repair.

Traumatic iliofemoral arterial injury: an association with high anterior acetabular fractures.

Two patients with documented anteroposterior compression injuries to the pelvis sustained concomitant injury to the iliofemoral artery and fracture of the acetabulum involving the high anterior column (the portion of the ilium forming the anterior component of the acetabulum). In a series of 800 major pelvic fractures similar arterial injuries have not occurred in association with other documented mechanisms. A high index of suspicion for iliofemoral artery injuries should be held by the clinician treating patients with acetabular fractures of the high anterior column sustained from anteroposterior compressive forces.

Thoracic spine injuries in victims of motorcycle accidents.

Spinal cord injury can be devastating. Cervical spine roentgenography has been recommended in all severe multisystem trauma patients but little attention has been given to the thoracic spine. In a series of 266 motorcycle accident victims, seen over a 42-month period, 13 cases of thoracic spine injury were identified. During this same time interval four cases of cervical spine injury were identified. Eleven of the 13 cases involved a catapulting ejection from the motorcycle and resultant axial loading to the thoracic spine. Thoracic spine injuries are more common in these patients and therefore the thoracic spine should be immobilized until full thoracic spine roentgenography can be carried out.

A bacteriologic study comparing closed suction and simple conduit drainage.

A simple experimental study was designed to determine if closed suction drainage reduces the migration of pathogenic bacteria along a drain tract. Sixty New Zealand rabbits, equally divided into three groups, were splenectomized through midline incisions. Group I served as the control group and received no drainage. Groups II and III had drainage of the splenic bed with simple latex conduit drains (Penrose drains) and closed suction drains (Jackson-Pratt drains), respectively. The skin near the drain exit site was inoculated with a Streptococcus organism. The animals were sacrificed after 72 hours, and intraperitoneal culture specimens were obtained. None of the control rabbits had positive cultures on intraperitoneal specimens. Eighteen of 20 rabbits (90 percent) in Group II (Penrose) had positive cultures on specimens from the splenic bed, whereas 75 percent had positive cultures on drain specimens. Only 4 of 20 (20 percent) of the Group III rabbits had positive cultures on the drain or splenic bed specimens. This difference was statistically significant by chi-square analysis (p less than 0.001). Retrograde migration of bacteria along a drain tract does occur with relatively high frequency with simple conduit drainage and is significantly less with closed suction drainage.