Bedside procedures. Solutions to the pitfalls of intrahospital transport.

The technology to perform diagnostic and therapeutic procedures at the bedside continues to advance. Because of documented hazards and the expense of intrahospital transport, the bedside is becoming an appealing site for procedures that are more commonly performed in radiologic, bronchoscopic, other procedural suites, and the operating room.

Bedside laparoscopy.

The improved technical sophistication of laparoscopy offers an attractive highly accurate diagnostic modality at the bedside for critically ill patients who are confined to the ICU and intensive monitoring unit and who are in need of timely abdominal evaluation. If the surgeon understands the physiologic effects of peritoneal insufflation and considers them during the procedure, the patient tolerates the procedure well. It is important to limit insufflation pressures and laparoscopy time. The author also recommends using the open Hasson technique. Its primary use is diagnostic in penetrating and blunt trauma and in the obscure abdomen. It has been successfully employed therapeutically for acalculous cholecystitis, abscess drainage, and correction of placement of gastrostomy tubes and peritoneal dialysis catheters. It helps avoid risky transport trips and negative or nontherapeutic laparotomy with its known associated risks.

Syncope as etiology of road crashes involving elderly drivers.

A significant number of elderly drivers present without discernible external cause for their road crash. We hypothesize that syncope may contribute to their crash etiology and prospectively evaluated drivers older than 60 years with unexplained crash, presenting to our trauma center during a 1-year period. Prehospital data and prior medical history were obtained on all, followed by a standard syncope work-up. Of 79 drivers ages 60-98, 58 (73%) were at fault in the crash. In 33 (57%), the crash etiology could not be determined. Thirteen had prior syncope history. Workup was negative in two patients, and six died or were transferred before evaluation. Twenty-five of 33 (76%) had positive workups for syncope: cardiac causes in 10; neurologic in seven; psychiatric in five, endocrine in two; one indeterminant. Ten of 18 who survived had license revocation for medical reasons. Syncopal episodes are a frequent contributor to unexplained crashes among elderly drivers and should be suspected whenever external causes are not apparent.

Morbidity of negative coeliotomy in trauma.

Exploratory coeliotomy is essential in the care of abdominal trauma, but negative operation has a reported morbidity rate as high as 18 per cent. Ancillary studies such as computerized tomography, diagnostic peritoneal lavage and abdominal ultrasound have improved both sensitivity and specificity of evaluation in blunt and penetrating trauma, thus decreasing the rate of negative coeliotomy. A retrospective study of 50 consecutive negative laparotomies (10.5 per cent of all trauma laparotomies) at our Trauma Center revealed a morbidity rate of 22 per cent and mortality of 6 per cent. Although the negative coeliotomy rate was lower for blunt than penetrating trauma, morbidity was significantly higher for blunt trauma. Extra-abdominal injury alone could not account for this difference. We conclude that negative coeliotomy in penetrating trauma does not carry excessive morbidity. Negative coeliotomy in blunt trauma is accompanied by high morbidity and mortality, so adjunct diagnostic procedures should be utilized in this population in an effort to minimize negative laparotomies.

Elderly drivers involved in road crashes: a profile.

The ability of elderly citizens to drive safely has been the subject of ongoing debate. To identify the type of elderly driver who becomes involved in an injury-producing road crash, we profiled all drivers over 39 years of age admitted to our Level I Trauma Center over a 1-year period. Data were prospectively collected and drivers age 40-59 years were compared with those over 60 years. Eighty-four drivers age > or = 60 and 130 drivers age 40-59 were studied. Of the 84 elderly drivers, 67 were deemed at fault. Twenty-four of those crashes were due to driving errors, 12 due to syncopes, and in 20 no crash cause was determined. Fifty-three of the 67 at fault drivers had significant underlying medical problems, compared to 9 of 17 deemed not at fault. Only four were legally intoxicated. Of the 130 drivers in the comparison group, only 19 had significant underlying medical problems; in three syncope was suspected; 18 were legally intoxicated. We conclude from our data that underlying medical disorders occur frequently in elderly drivers and may contribute to their incidence of road crashes.

Diagnosis of unsuspected facial fractures on routine head computerized tomographic scans in the unconscious multiply injured patient.

PURPOSE: This article assessed the value of routine head computerized axial tomographic (CT) scans for diagnosis of unsuspected facial fractures and its clinical implications in the multiply injured patient who is intubated, unconscious, or sedated at the time of initial assessment and requires a head CT scan to assess for brain injury. METHODS: At a level I trauma center from June 1, 1992 to June 1, 1993 all intubated blunt trauma patients who required routine CT scan evaluation at initial assessment were studied prospectively. Routine scanning started at the foramen magnum and included the maxilla. Patients who died within the first 24 hours were excluded. RESULTS: The study population included 116 patients (85 male, 21 female) aged 12 to 85 years (mean, 28 years) with injury severity scores ranging from 1 to 50 (mean, 23). The mechanism of injury was: motor vehicle accidents (n = 74), motorcycling (n = 5), pedestrians accidents (n = 13), falls (n = 10), bicycling (n = 5), assaults (n = 8), and boating accident (n = 1). There were 19 suspected facial fractures; 18 required surgical repair. There were 27 unsuspected facial fractures; 13 required surgical care. Three suspected fractures were ruled out. CONCLUSION: Routine head CT scans to assess for brain injury in the multiply injured patient are also very useful in the diagnosis of unsuspected facial fractures, almost half of which will require surgical intervention.

Colostomy in trauma surgery: friend or foe?

Twenty-five patients underwent a colostomy that came to closure. There were eight blunt, 15 penetrating and two impaling injuries. Colostomy-related complications occurred in four patients; two wound infections, one stoma prolapse, one loop obstruction. Closure was performed during a second hospital stay after a standard mechanical bowel preparation and enteral and parenteral broad-spectrum antibiotics perioperatively. The procedure performed by board certified/eligible surgeons, lasted an average of 2.5-3h. Incisional hernias occurred as the only complication in two patients. For certain injuries of the colon, rectum and perineum, diverting colostomy is still the procedure of choice. It can be performed without significant additional morbidity. Subsequent closure in experienced hands does not carry a significant complication rate.

Failure of the legal system to enforce drunk driving legislation effectively.

STUDY OBJECTIVE: To evaluate the investigation and prosecution of drunk drivers and identify reasons for system failure. DESIGN: Prospective data collection on all drivers with an elevated blood alcohol level who were treated at a Level I trauma center between January 1 and June 30, 1991. SETTING: Level I trauma center/university medical center serving a population of 1.8 million. INTERVENTIONS: Prospective data collection, interviewing ambulance squad members, investigating police, and results of prosecution. MEASUREMENTS AND MAIN RESULTS: Of 321 drivers, 78 had ethanol levels of more than 100 mg/dL; nine were between 50 and 100 mg/dL. All drivers had rapid transport to a trauma center for severe injury or high-risk injury mechanism. Police reports were accessible for 84 of 87 drivers; all drivers were believed to be at fault. The crashes resulted in five deaths and 74 other victims requiring hospitalization. Six of the intoxicated drivers died. Police requests for blood alcohol levels were made for 28 drivers, one of whom died. The remaining 59 drivers had no legal blood alcohol level drawn. Although the greater the distance from our center (more rural), the less likely were requests for ethanol levels, but there were many "no requests" from nearby cities. Of the 28 drivers on whom legal alcohol levels were drawn, eight escaped central registration with the highway safety commission, which records any and every traffic violation within New Jersey. Of the remaining 20, eight were not prosecuted (excluding one death), including one repeat offender. One committed a later "driving while intoxicated" offense and was then prosecuted. The remaining 11 were all convicted; five were repeat offenders. CONCLUSION: Reasonable cause is required for legal blood alcohol requests. Our data demonstrated that this is difficult when the driver is unavailable for questioning. However, once legal blood alcohol levels have been obtained, inadequate legal follow-up leads to nonprosecution. Once officially charged, conviction appears certain, but even this punishment and re-education fail to change behavior in many of these drivers.

Review article: venous thromboembolism in trauma patients.

The increased coagulability in multiple injured patients results in increased risk for deep venous thrombosis and pulmonary embolism. The authors discuss etiology, diagnosis, treatment, and prophylaxis of venous thromboembolism in trauma patients.

Blunt traumatic bladder rupture: the role of retrograde cystogram.

STUDY OBJECTIVE: We evaluated the importance of microscopic and gross hematuria and the role of retrograde cystography and computed tomography (CT) in the diagnosis of blunt traumatic bladder rupture. DESIGN: All cases at a Level I trauma center between January 1, 1986, and March 31, 1989, were reviewed retrospectively. SETTING: Level I trauma center, university hospital. TYPE OF PARTICIPANTS: All patients with acute blunt abdominal trauma admitted to this Level I trauma center. INTERVENTIONS: The patients' charts were reviewed with emphasis on mode of diagnosis, treatment, and outcome. MEASUREMENTS AND MAIN RESULTS: Twenty-one patients had bladder rupture. All 21 had hematuria with more than 50 RBCs/high-power field, 17 gross and four microscopic. Twenty patients underwent retrograde cystography, which accurately identified bladder rupture, and one was found at laparotomy for other injuries. Seven patients had CT of the abdomen and pelvis, which failed to demonstrate bladder rupture. There were no associated urethral injuries in any of the patients with bladder rupture. CONCLUSION: Significant (more than 50 RBCs/high-power field) hematuria is the principal indication for evaluation for blunt bladder injury, and retrograde cystography is the diagnostic procedure of choice. CT is neither sensitive nor specific enough as primary diagnostic modality.

The role of CT scan in evaluation for laparotomy in patients with stab wounds of the abdomen.

Not every patient with a penetrating stab wound of the abdomen requires laparotomy. This report evaluates use of computerized tomographic (CT) scan in assessment of stable asymptomatic patients, with penetrating abdominal stab wounds, as an indicator of the necessity of abdominal exploration. In a prospective study, 50 patients with abdominal stab wounds were treated successfully with observation only, after admission abdominal CT scan interpretation was negative for pathology in 45 patients. In the remaining five it was of such minor nature that conservative management was justified (Series I). Twenty-eight stable asymptomatic patients with penetrating stab wounds of the abdomen comparable to the ones in Series I had CT scan on admission, and then underwent exploratory laparotomy independent of their CT scan findings (Series II). Of these 28 patients, 22 had correct CT scan findings verified by laparotomy, three were false positive for intra-abdominal injury resulting in negative explorations, and three patients had such nonspecific findings as fluid or air in the abdomen incompatible with precise organ injury identification. Our study shows that CT scan in patients with abdominal stab wounds identifies solid organ injury with great specificity and sensitivity, evaluates the retroperitoneum well, and detects peritoneal penetration by demonstrating intraperitoneal fluid or air. CT scan was unreliable in detection of bowel injury and does not demonstrate diaphragmatic injuries.