Splenectomy for trauma increases the rate of early postoperative infections.

Little is known what effect splenectomy for trauma has on early postoperative infectious complications. Our aim was to determine if splenectomy increases early postoperative infections in trauma patients undergoing laparotomy. We reviewed all trauma patients undergoing splenectomy from June 2002 through December 2004. Each splenectomy patient was matched to a unique trauma patient who underwent laparotomy without splenectomy based on age, gender, mechanism of injury, injury severity score, and presence of colon or other hollow visceral injury. Outcomes included infectious complications including pneumonia, urinary tract infection, bacteremia, and intra-abdominal abscess, as well as mortality. There were 98 splenectomy patients and 98 controls. The splenectomy patients had more overall infectious complications (45% vs 30%, P = 0.04) trended toward more urinary tract infections (12% vs 5%, P = 0.12), and more often had pneumonia (30% vs 14%, P = 0.02). Additionally, more splenectomy patients developed multiple infections (20% vs 7%, P = 0.01). There was no difference in mortality (11% vs 8%, P = 0.63). Splenectomy is associated with an increase in infectious complications after laparotomy for trauma. More specifically, splenectomy patients more often develop pneumonia and multiple infections. This increase in infections is not associated with increased mortality.

White blood cell and platelet counts can be used to differentiate between infection and the normal response after splenectomy for trauma: prospective validation.

BACKGROUND: Transient elevations of the serum white blood cell count (WBC) and platelet count (PC) are normal physiologic responses after splenectomy. The clinician is often challenged to identify an infection in a postsplenectomy patient with an elevated WBC. A previous retrospective study found that a WBC greater than 15 x 10/microL and a PC/WBC ratio < 20 on postoperative day 5, in addition to an Injury Severity Score > 16, were highly associated with infection and should not be considered as part of the physiologic response to splenectomy. The current study intends to prospectively validate the WBC and PC/WBC ratio on postoperative day 5 as markers of infection after splenectomy for trauma. METHODS: Consecutive trauma patients admitted to an urban, Level I trauma center who underwent splenectomy from June 2002 to December 2004 were collected prospectively. In addition to admission demographics, variables collected included daily WBC, PC, and PC/WBC ratio during the first 10 postoperative days. Outcome was the presence of infection. Patients with infection (infected group) were compared with those without infection (noninfected group). Injury Severity Score > 16, postoperative day 5 WBC > 15 x 10/microL, and PC/WBC ratio < 20 were investigated as risk factors for postsplenectomy infection. RESULTS: There were 96 trauma patients who underwent splenectomy during the study period, and 44 (46%) developed a postoperative infection. Infectious complications included pneumonia (n = 30 [31%]), followed by septicemia (n = 20 [21%]), urinary tract infection (n = 12 [13), abdominal abscess (n = 9 [9%]), and wound infection (n = 4 [4%]). Postoperative day 5 was the first day that infected patients had a higher WBC (16 +/- 6 x 10/microL vs. 14 +/- 4 x 10/microL, p = 0.03) and a lower PC/WBC ratio (15 +/- 9 vs. 24 +/- 12, p = 0.002) than noninfected patients. The presence of two or more risk factors for infection was associated with a 79% rate of infection, and no patient developed an infection if all three risk factors were absent. CONCLUSION: On postoperative day 5 after splenectomy for trauma, a WBC greater than 15 x 10/microL and a PC/WBC ratio less than 20 are reliable markers of infection.

Patterns of injury and functional outcome after hanging: analysis of the National Trauma Data Bank.

PURPOSE: Hanging has become the second most common method of attempted suicide among adolescents, but there is little relevant epidemiologic or outcome data in the trauma literature. Additionally, there are no studies examining the degree of functional disability among survivors of hanging injury. METHODS: The National Trauma Data Bank was queried for all patients with an E-code diagnosis of hanging injury. Demographic and injury pattern data were analyzed. Disability at discharge was assessed using the functional independence measure (FIM) scores for feeding, locomotion, and expression (range 1 = full disability to 4 = no disability). Univariate and multivariate analysis was performed to identify independent predictors of mortality and degree of functional disability at discharge. RESULTS: There were 655 patients identified (84% male) with a mean age of 30.3 years and mean injury severity score (ISS) of 9. There were 92 (14%) deaths in the emergency department (ED) and 119 (18%) deaths after admission, for an overall mortality rate of 33%. Excluding ED deaths, survivors had significantly higher Glasgow coma scores (GCS) at the scene (8 vs. 4) and in the ED (9 vs. 3), a lower ED base deficit (4 vs. 9), and lower ISS (6 vs. 15, all P < .01) compared with nonsurvivors. The strongest independent predictor of hospital mortality was ED GCS <15 (odds ratio 16.1, P < .01); the mortality rate was 1.5% for patients with an ED GCS of 15 versus 29% for any GCS <15. Of patients who survived to discharge (n = 277), 84% were functionally independent (total FIM = 12), and 10% had severe functional disabilities in feeding, expression, or locomotion (FIM <3). Patients with severe disability had a higher incidence of intracranial (38% vs. 19%) and chest injury (19% vs. 5%) but surprisingly demonstrated equivalent rates of vascular (0% vs. 2.6%) and spinal injury (11% vs. 12%) compared with those without severe disability. Independent predictors of functional outcome were ISS and ED GCS (both P < .01). There was no severe functional disability at discharge among patients with an ED GCS of 15 compared with a 15% severe disability rate if the ED GCS was <15. CONCLUSIONS: Hanging injuries are associated with a high overall mortality rate, with the admission GCS being the best independent predictor of outcome. However, the majority of survivors have little to no functional disability. The presence of severe disability at discharge is mainly attributed to intracranial and thoracic injury.

Does routine serial computed tomography of the head influence management of traumatic brain injury? A prospective evaluation.

BACKGROUND: Computed tomography (CT) of the head is the current standard for diagnosing intracranial pathology following blunt head trauma. It is common practice to repeat the head CT to evaluate any progression of injury. Recent retrospective reviews have challenged the need for serial head CT after traumatic brain injury (TBI). This study intends to prospectively examine the value of routine serial head CT after TBI. METHODS: Consecutive adult blunt trauma patients with an abnormal head CT admitted to an urban, Level I trauma center from January 2003 to September 2003 were prospectively studied. Variables collected included: initial head CT results, indication for repeat head CT (routine versus neurologic change), number and results of repeat head CT scans, and clinical interventions following repeat head CT. RESULTS: Over the 9-month period, there were 128 patients admitted with an abnormal head CT after sustaining blunt trauma. The 16 patients who died within 24 hours and the 12 patients who went directly to craniotomy were excluded. The remaining 100 patients make up the study population. Abnormal head CT findings were subarachnoid hemorrhage (47%), intraparenchymal hemorrhage (37%), subdural hematoma (28%), contusion (14%), epidural hematoma (11%), intraventricular hemorrhage (3%), and diffuse axonal injury (2%). Overall, 32 patients (32%) had only the admission head CT, while 68 patients (68%) underwent 90 repeat CT scans. Of the repeat head CT scans, 81 (90%) were performed on a routine basis without neurologic change. The remaining 9 (10%) were performed for a change in Glasgow Coma Scale (n = 5), change in intracranial pressure (n = 1), change in Glasgow Coma Scale and intracranial pressure (n = 1), change in pupil size (n = 1), or sudden appearance of a headache (n = 1). Three patients had their care altered after repeat head CT: two underwent craniotomy and one was started on barbiturate therapy. All three patients had their repeat head CT after neurologic change (decrease in Glasgow Coma Scale in 2 and increase in intracranial pressure in 1). CONCLUSIONS: Serial head CT is common after TBI. Most repeat head CT scans are performed on a routine basis without neurologic change. Few patients with TBI have their management altered after repeat head CT, and these patients have neurologic deterioration before the repeat head CT. The use of routine serial head CT in patients without neurologic deterioration is not supported by the findings of this study.

Abdominal approach to chronic diaphragmatic hernias: is it safe?

Standard teaching has been to approach chronic diaphragmatic hernias (CDH) via a thoracotomy. It has been our experience that CDH can be safely approached via an abdominal incision. The objective of this study was to evaluate the outcome of patients undergoing the transabdominal approach for repair of CDH and comparing the outcome with that of patients undergoing a transthoracic (TT) approach. This is a retrospective chart review and was performed of patients with CDH secondary to trauma. Patient demographics, presenting symptoms, operative approach, and complications were collected. Patients were stratified by the surgical approach, TA versus TT. The endpoints of analysis were need for second incision, intraoperative and postoperative complications (enterotomies, pneumonia), need for a chest tube, mechanical ventilation postoperatively, and ICU and hospital days. Twenty-eight patients with CDH repairs performed between Jan 1993 and Dec 2002 were identified. Nineteen patients were in the TA group, and nine were in the TT group. Patients in the TA group had a higher incidence of emergent surgery (68% vs 11%, P = 0.005) and had a lower incidence of postoperative pneumonia (0% vs 33%, P = 0.009). No case of enteric injury from lysis of adhesions in the chest was identified. The need for a second incision (11%), the mortality (11%), ICU stay, and hospital stay were the same between the two groups. It appears that repair of CDH can be performed safely through an abdominal approach.

Obesity is an independent risk factor of mortality in severely injured blunt trauma patients.

HYPOTHESIS: Obesity is associated with increased morbidity and mortality in critically injured blunt trauma patients. DESIGN: Case-control study of all critically injured blunt trauma patients between January 2002 and December 2002. SETTING: Academic level I trauma center at a county referral hospital. PATIENTS: Two hundred forty-two consecutive patients admitted to the intensive care unit following blunt trauma. Patients were divided into 2 groups by body mass index. The obese group was defined as having a body mass index of 30 kg/m2 or higher, and the nonobese group was defined as having a body mass index lower than 30 kg/m2. MAIN OUTCOME MEASURES: Univariate and multivariate analyses were performed to identify risk factors for mortality. Complications and length of stay were also evaluated. RESULTS: Of the 242 patients, 63 (26%) were obese, and 179 (74%) were nonobese. The obese and nonobese groups were similar with regard to age (mean +/- SD, 49 +/- 18 years vs 45 +/- 22 years), male sex (63% vs 72%), Glasgow Coma Scale score (mean +/- SD, 11 +/- 5 vs 11 +/- 5), and injury severity score (mean +/- SD, 21 +/- 13 vs 20 +/- 14). The obese group had a higher body mass index (mean +/- SD, 35 +/- 7 vs 24 +/- 3; P<.001). Mechanisms of injury and injury patterns were similar between groups. The obese group had a higher incidence of multiple organ failure (13% vs 3%; P =.02) and mortality (32% vs 16%; P=.008). Obesity was an independent predictor of mortality with an adjusted odds ratio of 5.7 (95% confidence interval, 1.9-19.6; P=.003). CONCLUSIONS: Critically injured obese trauma patients have similar demographics and injury patterns as nonobese patients. Obesity is an independent predictor of mortality following severe blunt trauma.

Fascial dehiscence after trauma laparotomy: a sign of intra-abdominal sepsis.

Fascial dehiscence (FD) after trauma laparotomy is associated with technical failure, wound sepsis, or intra-abdominal infection (IAI). The association of IAI with FD is inadequately evaluated. Knowing about its presence is essential to guide clinical diagnosis and management. Our objective was to identify the incidence and risk factors of IAI in patients with FD. We performed a medical record review of 55 trauma patients with FD. Patients with IAI were compared to patients without IAI and FD patients to all trauma laparotomy patients during the same period. Statistical significance was at P < 0.05. Thirty-nine (71%) FD patients had IAI, significantly higher than all trauma laparotomies (4.6%, P < 0.0001). Only 31 per cent of patients underwent laparotomy and drainage while 69 per cent received CT-guided percutaneous drainage followed by expectant management. Similarly, 33 per cent of the non-IAI group had operative management. No differences were found between the two groups in any of the examined factors. The majority of trauma patients with FD have IAI. No clinical or laboratory factors help identify FD patients likely to have IAI. Therefore, FD should be viewed as a sign of possible underlying IAI. Appropriate radiographic imaging or direct visualization of the entire abdominal cavity should be pursued before managing the dehisced fascia.