Anatomic Neuroimaging Characteristics of Posterior Fossa Type A Ependymoma Subgroups.

BACKGROUND AND PURPOSE: Posterior fossa type A (PFA) ependymomas have 2 molecular subgroups (PFA-1 and PFA-2) and 9 subtypes. Gene expression profiling suggests that PFA-1 and PFA-2 tumors have distinct developmental origins at different rostrocaudal levels of the brainstem. We, therefore, tested the hypothesis that PFA-1 and PFA-2 ependymomas have different anatomic MR imaging characteristics at presentation. MATERIALS AND METHODS: Two neuroradiologists reviewed the preoperative MR imaging examinations of 122 patients with PFA ependymomas and identified several anatomic characteristics, including extension through the fourth ventricular foramina and encasement of major arteries and tumor type (midfloor, roof, or lateral). Deoxyribonucleic acid methylation profiling assigned ependymomas to PFA-1 or PFA-2. Information on PFA subtype from an earlier study was also available for a subset of tumors. Associations between imaging variables and subgroup or subtype were evaluated. RESULTS: No anatomic imaging variable was significantly associated with the PFA subgroup, but 5 PFA-2c subtype ependymomas in the cohort had a more circumscribed appearance and showed less tendency to extend through the fourth ventricular foramina or encase blood vessels, compared with other PFA subtypes. CONCLUSIONS: PFA-1 and PFA-2 ependymomas did not have different anatomic MR imaging characteristics, and these results do not support the hypothesis that they have distinct anatomic origins. PFA-2c ependymomas appear to have a more anatomically circumscribed MR imaging appearance than the other PFA subtypes; however, this needs to be confirmed in a larger study.

Relative ADC and Location Differ between Posterior Fossa Pilocytic Astrocytomas with and without Gangliocytic Differentiation.

BACKGROUND AND PURPOSE: Pilocytic astrocytomas, the most common posterior fossa tumors in children, are characterized by KIAA1549-BRAF fusions and shows excellent 5-year survival rates. Pilocytic astrocytoma with gangliocytic differentiation, a recently defined pilocytic astrocytoma variant that includes glial and neuronal elements similar to a ganglioglioma, may be distinguished from a classic ganglioglioma by molecular, radiologic, and histopathologic features. This study investigated whether imaging could distinguish posterior fossa pilocytic astrocytoma with and without gangliocytic differentiation. MATERIALS AND METHODS: Preoperative MRIs (± CTs) of 41 children (age range, 7 months to 15 years; mean age, 7.3 ± 3.7 years; 58.5% male) with pilocytic astrocytoma with gangliocytic differentiation (n = 7) or pilocytic astrocytoma (n = 34) were evaluated; differences in tumor location, morphology, and minimum relative ADC between tumor types were compared (Wilcoxon rank sum test, Fisher exact test). Histopathology and BRAF fusion/mutation status were reviewed. Associations of progression-free survival with diagnosis, imaging features, and BRAF status were examined by Cox proportional hazards models. RESULTS: Pilocytic astrocytoma with gangliocytic differentiation appeared similar to pilocytic astrocytoma but had lower minimum relative ADC (mean, 1.01 ± 0.17 compared with 2.01 ± 0.38 for pilocytic astrocytoma; P = .0005) and was more commonly located within midline structures (P = .0034). BRAF status was similar for both groups. Non-total resection (hazard ratio, 52.64; P = .0002), pilocytic astrocytoma with gangliocytic differentiation diagnosis (hazard ratio, 4.66; P = .0104), and midline involvement (hazard ratio, 3.32; P = .0433) were associated with shorter progression-free survival. CONCLUSIONS: Minimum relative ADC and tumor location may be useful adjuncts to histopathology in differentiating pilocytic astrocytoma with gangliocytic differentiation from pilocytic astrocytoma. Shorter progression-free survival in pilocytic astrocytoma with gangliocytic differentiation is likely due to a propensity for involvement of midline structures and poor resectability.

Clinical, radiological, histological and molecular characteristics of paediatric epithelioid glioblastoma.

AIMS: A few case series in adults have described the characteristics of epithelioid glioblastoma (e-GB), one of the rarest variants of this cancer. We evaluated clinical, radiological, histological and molecular characteristics in the largest series to date of paediatric e-GB. METHODS: Review of clinical characteristics and therapy, imaging studies and histology was performed in patients younger than 22 years with e-GB seen at our institution over 15 years. Sequencing of hotspot mutations and fluorescence in situ hybridization of relevant genes were undertaken. RESULTS: Median age at diagnosis of six patients was 7.6 years. Tumours originated in the cerebral cortex (n = 2) or diencephalon (n = 4). Three patients presented with acute, massive haemorrhage and three had leptomeningeal dissemination at diagnosis. Paediatric e-GB had the typical histological characteristics seen in adult tumours. Universal immunoreactivity for INI1 and lack of diverse protein expression were seen in all cases. One tumour had a chromosome 22q loss. Three tumours (50%) harboured a BRAF: p.V600E. One thalamic tumour had an H3F3A p.K27M. All patients received radiation therapy with (n = 3) or without chemotherapy (n = 3). All patients experienced tumour progression with a median survival of 169 days. One patient with nonmetastatic disease had early leptomeningeal progression. Two patients had symptomatic tumour spread outside the central nervous system (CNS) through a ventriculoperitoneal shunt. One additional patient had widespread metastases outside the CNS identified at autopsy. CONCLUSIONS: Paediatric e-GBs are rare cancers with an aggressive behaviour that share histological and genetic characteristics with their adult counterparts. BRAF inhibition is a potential treatment for these tumours.

Incidence and survival of childhood Langerhans cell histiocytosis in Northwest England from 1954 to 1998.

BACKGROUND: Langerhans cell histiocytosis (LCH) is a rare proliferative disorder of pathological Langerhans cells, for which the aetiology and pathogenesis remain largely unknown. PROCEDURE: Information on the 101 children with LCH registered with the population-based Manchester Children's Tumour Registry (MCTR) between 1954 and 1998 was extracted from the records of the MCTR. This included age, sex, date of diagnosis, systems affected at diagnosis and follow-up. RESULTS: The overall incidence rate for LCH was 2.6 cases per million child years. In those under 1 year of age the incidence rate was 9.0 cases per million child years, compared to 0.7 cases per million in those aged 10-14 years (P < 0.0001 for age trend). There was no evidence of seasonal variation in presentation by month of birth or first symptom. Bone was the most common site of disease involvement (67% of cases), followed by skin (37%) and soft tissue (22%). The overall survival rate has improved over time, from 57% in 1954-1968 to 74% in 1985-1998. Ninety percent of deaths were due to disease progression, the remainder were due to complications of intensive therapy. The site of LCH lesions and extent of disease present at diagnosis strongly predicted survival outcome. Patients with initial liver involvement had a 5-year survival rate of 25% compared with 93% for those with bone lesions alone at diagnosis. CONCLUSIONS: Incidence rates varied significantly by age at diagnosis, and have been stable over time. Survival has improved considerably over time, but varies strongly by age and systems affected at diagnosis.

Penetrating trauma in patients older than 55 years: a case-control study.

BACKGROUND: Multiple studies have compared young and elderly blunt trauma patients, and concluded that, because elderly patients have outcomes similar to young patients, aggressive resuscitation should be offered regardless of age. Similar data on penetrating trauma patients are limited. STUDY DESIGN: In a retrospective review, 79 patients with penetrating injuries and age > or =55 were blindly matched for Injury Severity Score (ISS) and Abbreviated Injury Scores (AIS) with 79 penetrating trauma patients aged 15-35 years, who were admitted to the hospital over the same 4 year period (June 1994-June 1998). Mortality rates and length of stay in the intensive care unit (ICU) and the hospital were compared between the two groups. RESULTS: The average ISS for all patients was 12 (range 1-75) and identical for both groups. Both groups had similar injuries and were evaluated by an equal number and type of diagnostic studies. The mean ISS was not different between severely injured older and younger patients who required ICU admission or died. Among 32 nonsurvivors (18 older and 14 younger), older patients were more likely than younger patients to present with normal vital signs, although the comparison did not reach statistical significance (50% vs. 13%, P=0.25). There was a clinically significant trend for longer ICU (15+/-30 vs. 3+/-2 days, P=0.096) and hospital stay (10+/-18 vs. 6+/-8 days, P=0.08) among older patients, but mortality rates were similar (23% in older vs. 18% in younger, P=NS). Furthermore, these outcome parameters showed no difference when both groups were classified according to severity of injury or physiologic response. CONCLUSIONS: Following penetrating trauma, older patients arriving alive and admitted to the hospital are as likely to survive as younger patients who have injuries of similar severity, but at the expense of longer ICU and hospital stays.

Fetal death after trauma in pregnancy.

Trauma in pregnancy places the mother and fetus at risk. The objective of this study is to identify risk factors independently associated with acute termination of pregnancy and/or fetal mortality after trauma. The medical and trauma registry records of 80 injured pregnant patients were reviewed. Data were collected and then analyzed by univariate and multivariate analysis. Three patients died (3.7%), 23 had the pregnancy acutely terminated (30%), and 14 suffered fetal death (17.5%). The only independent risk factors for fetal mortality were an Injury Severity Score (ISS) > or =9 and a nonviable pregnancy (<23 weeks). The combination of both risk factors increased the likelihood of fetal mortality by fivefold over that of patients without either risk factor. Maternal hemodynamic parameters did not predict fetal loss. Two patients lost their fetuses despite insignificant trauma (ISS = 1) and normal hemodynamic parameters, whereas eight delivered normal babies despite major trauma (ISS > or = 16). Hemodynamic stability on admission does not predict fetal mortality. Although the presence of moderate to severe injuries (ISS > or = 9) increases the likelihood of fetal mortality, this complication may occur even with insignificant trauma. Close maternal and fetal monitoring is justified, regardless of maternal hemodynamic presentation or severity of injury.

Endpoints of resuscitation of critically injured patients: normal or supranormal? A prospective randomized trial.

OBJECTIVE: To evaluate the effect of early optimization in the survival of severely injured patients. SUMMARY BACKGROUND DATA: It is unclear whether supranormal ("optimal") hemodynamic values should serve as endpoints of resuscitation or simply as markers of the physiologic reserve of critically injured patients. The failure of optimization to produce improved survival in some randomized controlled trials may be associated with delays in starting the attempt to reach optimal goals. There are limited controlled data on trauma patients. METHODS: Seventy-five consecutive severely injured patients with shock resulting from bleeding and without major intracranial or spinal cord trauma were randomized to resuscitation, starting immediately after admission, to either normal values of systolic blood pressure, urine output, base deficit, hemoglobin, and cardiac index (control group, 35 patients) or optimal values (cardiac index >4.5 L/min/m2, ratio of transcutaneous oxygen tension to fractional inspired oxygen >200, oxygen delivery index >600 mL/min/m2, and oxygen consumption index >170 mL/min/m2; optimal group, 40 patients). Initial cardiac output monitoring was done noninvasively by bioimpedance and, subsequently, invasively by thermodilution. Crystalloids, colloids, blood, inotropes, and vasopressors were used by predetermined algorithms. RESULTS: Optimal values were reached intentionally by 70% of the optimal patients and spontaneously by 40% of the control patients. There was no difference in rates of death (15% optimal vs. 11% control), organ failure, sepsis, or the length of intensive care unit or hospital stay between the two groups. Patients from both groups who achieved optimal values had better outcomes than patients who did not. The death rate was 0% among patients who achieved optimal values compared with 30% among patients who did not. Age younger than 40 years was the only independent predictive factor of the ability to reach optimal values. CONCLUSIONS: Severely injured patients who can achieve optimal hemodynamic values are more likely to survive than those who cannot, regardless of the resuscitation technique. In this study, attempts at early optimization did not improve the outcome of the examined subgroup of severely injured patients.

Transcutaneous oxygen and CO2 as early warning of tissue hypoxia and hemodynamic shock in critically ill emergency patients.

BACKGROUND: Although cardiac and pulmonary function can be measured precisely, evaluation of tissue perfusion remains elusive because it usually is inferred from subjective symptoms and imprecise signs of shock. The latter are indirect criteria used to assess the overall circulatory status as well as tissue perfusion but are not direct quantitative measures of perfusion. However, noninvasive transcutaneous oxygen (PtcO2) and carbon dioxide (PtcCO2) tensions, which directly measure skin oxygenation and CO2 retention, may be used to objectively evaluate skin oxygenation and perfusion in emergency patients beginning with resuscitation immediately after hospital admission. OBJECTIVE: This study was a preliminary evaluation of tissue oxygenation and perfusion by objective PtcO2 and PtcCO2 patterns in severely injured surviving and nonsurviving patients; specifically, the aim was to describe time patterns that may be used as early warning signs of circulatory dysfunction and death. DESIGN: Prospective descriptive study of a consecutive series of severely injured emergency patients. SETTING: University-affiliated Level I trauma center and intensive care unit. PATIENTS AND METHODS: Forty-eight consecutive severely injured patients were prospectively monitored by PtcO2 and PtcCO2 sensors immediately after emergency admission. RESULTS: Compared with survivors, patients who died had significantly lower PtcO2 and higher PtcCO2 values beginning with the early stage of resuscitation. All patients who maintained PtcO2 >150 torr (19.99 kPa) throughout monitoring survived. Periods of PtcO2 <50 torr (6.66 kPa) for >60 mins or PtcCO2 >60 torr (8.00 kPa) for >30 mins were associated with 90% mortality and 100% morbidity. CONCLUSION: PtcO2 and PtcCO2 monitoring continuously evaluate tissue perfusion and serve as early warning in critically injured patients during resuscitation immediately after hospital admission.

Noninvasive hemodynamic monitoring for early warning of adult respiratory distress syndrome in trauma patients.

PURPOSE: Traditionally hemodynamic patterns after adult respiratory distress syndrome (ARDS) are described after appropriate diagnostic criteria have been met, but studies begun after the diagnosis of ARDS miss the antecedent circulatory influences that may contribute to its development. This study tests the hypothesis that noninvasive monitoring before the appearance of ARDS may reveal early circulatory deficiencies that lead to this disorder. The aims of this study are as follows: (1) to describe the time course of hemodynamic and tissue perfusion patterns in severely traumatized postoperative patients from the period immediately after admission and during surgical repair to the time that ARDS developed or to hospital discharge in patients who did not develop ARDS, (2) to compare the time course of these patterns in survivors and nonsurvivors of ARDS, and (3) to suggest that reduced flow and perfusion may be early warning signs of ARDS. Prospective descriptive study of severely injured trauma patients noninvasively monitored in the emergency department, operating room, and intensive care unit (ICU). Early hemodynamic pattems were described in the surviving and nonsurviving patients who subsequently developed ARDS. The study was performed in a University-affiliated Level I trauma center and ICU. PATIENTS AND METHODS: A consecutively monitored series of 60 severely injured patients were prospectively monitored by cardiac output, pulse oximetry (Sapo2), and transcutaneous O2 and co2 (Ptco2 and Ptc(co2)) sensors immediately after emergency admission. Twenty-nine patients developed ARDS in their ICU course, whereas 31 were discharged from the ICU and the hospital without developing ARDS. RESULTS: Patients who developed ARDS had significantly lower cardiac index and Ptco2 and higher Ptc(co2) values beginning with the early stage compared with those who did not develop ARDS. Nonsurvivors of ARDS had lower Ptco2 values than did the survivors. CONCLUSION: Early noninvasive monitoring in the emergency department, operating room, and ICU showed reduced cardiac and tissue perfusion functions in patients who subsequently developed ARDS. These patterns were more pronounced in the ARDS patients who died; these patterns may serve as early warning of ARDS.

High-frequency percussive ventilation improves oxygenation in patients with ARDS.

STUDY OBJECTIVES: To evaluate changes in respiratory and hemodynamic function of patients with ARDS and requiring high-frequency percussive ventilation (HFPV) after failure of conventional ventilation (CV). DESIGN: Retrospective case series. SETTING: Surgical ICU (SICU) and medical ICU (MICU) of an academic county facility. MEASUREMENTS AND RESULTS: Thirty-two consecutive patients with ARDS (20 from SICU, 12 from MICU) who were unresponsive to at least 48 h of CV and were switched to HFPV were studied. Data on respiratory and hemodynamic parameters were collected during the 48 h preceding and the 48 h after institution of HFPV and compared. Between the period of CV and the period of HFPV, the ratio of PaO2 to the fraction of inspired oxygen (F(IO2)) increased ([mean+/-SE] 130+/-8 vs. 172+/-17; p = 0.027), peak inspiratory pressure (PIP) decreased (39.5+/-1.7 vs. 32.5+/-1.9 mm Hg; p = 0.002), and mean airway pressure(MAP) increased (19.2+/-1.2 vs. 27.5+/-1.4 mm Hg; p<0.001). The rate of change of PaO2/F(IO2) per hour was also significantly improved between the two periods. The same changes in PaO2/F(IO2), PIP, and MAP were observed when the last value recorded while the patients were on CV was compared with the first value recorded after 1 h of HFPV. This improvement was sustained but not amplified during the hours of HFPV. The patterns of improvement in these three parameters were similar in SICU and MICU patients as well as in volume-control and pressure-control patients. There were no changes in hemodynamic parameters. CONCLUSION: The HFPV improves oxygenation by increasing MAP and decreasing PIP. This improvement is achieved soon after institution of HFPV and is maintained without affecting hemodynamics.

The "seat belt mark" sign: a call for increased vigilance among physicians treating victims of motor vehicle accidents.

The use of seat belts is shown to cause a specific pattern of internal injuries. Skin bruise corresponding to the site of the seat belt is known as the "seat belt mark" (SBM) sign and is associated with a high incidence of significant organ injuries. No study has yet defined the exact incidence of injuries requiring intervention at the presence of this sign. The objective of this study was to find the incidence of surgically correctable injuries in belted car occupants with a SBM sign and to define strategies of early detection and treatment of such injuries. The prospective study included consecutive patients involved in road traffic accidents who were admitted at an academic Level I trauma center. Of 650 car occupants, 410 (63%) were restrained and 77 (12%) had a SBM across the abdomen, chest or neck. The injuries of these 77 patients were compared with the injuries of belted patients without an SBM sign. Of patients with SBMs, 9 per cent had neck bruises, 32 per cent had chest bruises, 40 per cent had abdominal bruises, and 19 per cent had bruises in multiple sites. No significant neck injuries were detected. Three patients were found to have myocardial contusion, and 10 patients had intra-abdominal injuries (predominantly bowel and mesenteric lacerations) requiring laparotomy. There was a near 4-fold increase in thoracic trauma (22.5% versus 6%; P=0.01) and a near 8-fold increase in intra-abdominal trauma (23% versus 3%; P < 0.0001) between the groups of patients with and without SBMs. The presence of the SBM sign should alert the physician to the high likelihood of specific internal injuries. Routine laparotomy or mandatory evaluation by specific diagnostic tests is not justified; rather, a high index of suspicion with a low threshold for appropriate diagnostic evaluation and/or surgical exploration should be maintained for the optimal management of such patients.

Predicting the need for thoracoscopic evacuation of residual traumatic hemothorax: chest radiograph is insufficient.

BACKGROUND: The early removal of large residual posttraumatic hemothorax by videothoracoscopy is increasingly used to avoid the late sequelae of trapped lung and empyema. Plain chest radiography (CXR) is the tool most frequently used to select such cases for operation. Our recent experience has demonstrated that what appears to be a large retained hemothorax on CXR may turn out to be intrapulmonary or extrapleural conditions not amenable to thoracoscopic removal. Our objective was to evaluate the accuracy of CXR in detecting significant residual hemothorax and compare its clinical value to thoracic computed tomography (CT) when used to select patients for thoracoscopic evacuation. METHODS: All patients requiring tube thoracostomy for traumatic hemothorax were prospectively evaluated during a 22-month period (n = 703). Patients who, on the second day after admission, demonstrated opacification on CXR involving more than the costophrenic angle were evaluated by thoracic computed tomography for the presence of undrained fluid. Second-day CXR (CXR2) results were compared with the CT findings. Incorrect interpretation was defined as a difference of more than 300 mL between the two readings. All CXR2 and CT results were reviewed in the same fashion by a radiologist blinded to the surgeon's interpretations. Data on injury mechanism, hemodynamic status, laboratory values, interventions, and outcome were collected prospectively. RESULTS: Fifty-eight patients had clinically significant opacifications on CXR2. The surgeon's and radiologist's CXR2 interpretations were incorrect in 48 and 47% of the cases, respectively. The CT interpretations by the two specialists were in agreement in 97% of the cases. Management that would have been instituted on the basis of CXR2 findings was changed in 18 cases (31%). Twelve patients (21%) required early thoracoscopic evacuation of undrained collections. There was good correlation between the CT estimation and the thoracoscopically retrieved amount of blood. CONCLUSION: Although CXR is useful as a screening tool, it cannot be used to reliably select patients for surgical evacuation of retained traumatic hemothorax. Decision-making should be based on thoracic CT findings.

Inability of an aggressive policy of thromboprophylaxis to prevent deep venous thrombosis (DVT) in critically injured patients: are current methods of DVT prophylaxis insufficient?

BACKGROUND: Deep venous thrombosis (DVT) in severely injured patients is a life-threatening complication. Effective and safe thromboprophylaxis is highly desirable to prevent DVT. Low-dose heparin (LDH) and sequential compression device (SCDs) are the most frequently used methods. Inappropriate use of these methods because of the nature or site of critical injuries (eg, brain lesion, solid visceral or retroperitoneal hematoma, extremity fractures) may lead to failure of DVT prophylaxis. STUDY DESIGN: A prospective study was performed to evaluate the efficacy of a policy of aggressive use of LDH and SCDs in patients who are at very high risk for DVT. From January 1996 to August 1997, 200 critically injured patients were followed by weekly Doppler examinations to detect DVT at the proximal lower extremities. Only 3 patients did not receive any thromboprophylaxis. SCDs were applied in 97.5% and LDH was administered to 46% of the patients; 45% had both. RESULTS: DVT was found in 26 patients (13%). The majority (58%) developed DVT within the first 2 weeks, but new cases were found as late as 12 weeks after admission. The incidence of DVT was the same among patients who had SCDs only or a combination of LDH and SCDs. Mechanism of injury, type and number of operations, site of injury, Injury Severity Score, and the incidence of femoral lines were not different between patients with and without DVT. Differences were found in the severity of injury to the chest and the extremities and the need for high-level respiratory support. Patients with DVT had prolonged ICU and hospital stays (on average, 34 and 49 days, respectively) and a high mortality rate (31%). CONCLUSIONS: The incidence of DVT remains high among severely injured patients despite aggressive thromboprophylaxis. A combination of LDH and an SCD showed no advantage over SCD alone in decreasing DVT rates. Risk factors in this group of patients who are already at very high risk are hard to detect; Doppler examinations are justified for surveillance in all critically injured patients. Current methods of thromboprophylaxis seem to offer limited efficacy, and the search for more effective methods should continue.

Is there a limit to massive blood transfusion after severe trauma?

OBJECTIVE: To examine the hypothesis that the futility of short-term care for trauma patients requiring emergency operation can be determined based on the number of units of blood transfused and associated risk factors. DESIGN: A 4-year retrospective review of a cohort of critically injured patients who underwent an emergency operation. SETTING: A large-volume, academic level I, urban trauma center. PATIENTS: One hundred forty-one consecutive patients received massive blood transfusions of 20 U or more of blood during preoperative and intraoperative resuscitation (highest, 68 U). There were 43 survivors (30.5%) and 98 nonsurvivors (69.5%). MAIN OUTCOME MEASURES: Mortality. RESULTS: The number of blood units transfused did not differ between survivors and nonsurvivors (mean +/- SD, 31 +/- 11 vs 32 +/- 10; P = .52). Stepwise multiple regression analysis identified 3 independent variables associated with mortality: need for aortic clamping, intraoperative use of inotropes, and intraoperative time with a systolic blood pressure of 90 mm Hg or less. However, blood usage was not different among the subgroups of patients who had 1 or more of these risk factors. When patients were stratified according to the amount of massive blood transfusion (20-29, 30-39, 40-49, and 50-68 U), the incidence of risk factors was not different across the 4 subgroups. Survival in the presence of risk factors was not affected by the amount of blood transfused. CONCLUSIONS: Although mortality among critically injured patients requiring operation and massive blood transfusion can be correlated with independent risk factors, discontinuation of short-term care cannot be justified based on the need for massive blood transfusion of up to 68 units.

Lethal abdominal gunshot wounds at a level I trauma center: analysis of TRISS (Revised Trauma Score and Injury Severity Score) fallouts.

BACKGROUND: The TRISS methodology (composite index of the Revised Trauma Score and the Injury Severity Score) has become widely used by trauma centers to assess quality of care. The American College of Surgeons recommends including negative TRISS fallouts (fatally injured patients predicted to survive by the TRISS methodology) as a filter to select patients for peer review. The purpose of this study was to analyze the TRISS fallouts among patients with lethal abdominal gunshot wounds admitted to a level I trauma center. STUDY DESIGN: All patients categorized as TRISS fallouts admitted from January 1995 through December 1996 were analyzed. RESULTS: During the study period, 848 patients with abdominal gunshot wounds were admitted. Of the 108 patients with any sign of life on admission who subsequently died, 39 (36%) were TRISS fallouts. The patients were largely young (mean age, 29 years) and male (87%), received rapid transport (mean scene time, 11 minutes), and had an attending-led trauma-team response (<5 minutes, 87%). Major vascular (80%) and multiple intraabdominal injuries (90%) predominated. The mean Penetrating Abdominal Trauma Index was 40.3. The mean TRISS probability of survival was 89%. The peer-review process deemed the deaths to be nonpreventable in 38 patients (97%) and potentially preventable in one patient (3%). CONCLUSIONS: "TRISS fallouts" were predominantly patients who died despite receiving rapid prehospital transport, rapid senior-level trauma-team response, and surgical intervention for a serious complex of injuries. We conclude that without regional adjustment of coefficients used to predict the probability of survival, the TRISS methodology is of limited use in patients with abdominal gunshot wounds.

A selective approach to the management of gunshot wounds to the back.

BACKGROUND: Gunshot wounds to the back with retroperitoneal trajectories have been traditionally managed under the same guidelines as anterior gunshot wounds. Recent work has suggested that selective nonoperative management of anterior abdominal gunshot wounds is safe. The role of this policy in gunshot wounds to the back, where retroperitoneal organ injuries may be more difficult to detect clinically, has not been investigated. OBJECTIVE: To examine if selective nonoperative management based on clinical assessment is a safe alternative to mandatory exploration for gunshot wounds to the back. DESIGN: Prospective study. SETTING: Large-volume level-1 university affiliated trauma center. PATIENTS AND METHODS: Two hundred and three consecutive patients with gunshot wounds to the back were managed according to a protocol during a 12-month period. Patients with hemodynamic instability or peritonitis underwent urgent operation. The rest of the patients were observed with careful serial clinical examinations. RESULTS: Eleven patients underwent an emergency room thoracotomy and were excluded. Four more patients were operated upon, despite the absence of abdominal findings, because of associated spinal cord injuries (2 patients), inability to observe due to need for repair of an associated peripheral vascular injury (1 patient), and participation in another protocol of aggressive evaluation of asymptomatic patients with suspected diaphragmatic injuries (1 patient). Of the remaining 188 patients, 58 (31%) underwent laparotomy (56 therapeutic, 2 negative) and 130 (69%) were initially observed owing to negative clinical examination. Following the development of increasing abdominal tenderness, 4 of these 130 (3%) underwent delayed explorations, which were all nontherapeutic. The sensitivity and specificity of initial clinical examination in detecting significant intraabdominal injuries were 100% and 95%, respectively. CONCLUSIONS: Mandatory laparotomy is not necessary for gunshot wounds of the back. Clinical examination is a safe method of selecting patients for nonoperative management. An observation period of 24 hours is adequate for patients with no abdominal symptoms.

Radiographic cervical spine evaluation in the alert asymptomatic blunt trauma victim: much ado about nothing.

OBJECTIVE: To evaluate the hypothesis that alert nonintoxicated trauma patients with negative clinical examinations are at no risk of cervical spine injury and do not need any radiographic investigation. DESIGN: Prospective study. SETTING: A university-affiliated teaching county hospital. PATIENTS: Five hundred and forty-nine consecutive alert, oriented, and clinically nonintoxicated blunt trauma victims with no neck symptoms. RESULTS: All patients had negative clinical neck examinations. After radiographic assessment, no cervical spine injuries were identified. Less than half the patients could be evaluated adequately with the three standard initial views (anteroposterior, lateral, and odontoid). All the rest needed more radiographs and/or computed tomographic scans. A total of 2,27 cervical spine radiographs, 78 computed tomographic scans and magnetic resonance imagings were performed. Seventeen patients stayed one day in the hospital for no other reason but radiographic clearance of an asymptomatic neck. The total cost for x-rays and extra hospital days was $242,000. These patients stayed in the collar for an average of 3.3 hours (range, 0.5-72 hours). There was never an injury missed. CONCLUSIONS: Clinical examination alone can reliably assess all blunt trauma patients who are alert, nonintoxicated, and report no neck symptoms. In the absence of any palpation or motion neck tenderness during examination, the patient may be released from cervical spine precautions without any radiographic investigations.