Recreational bicycling and injury to the external iliac artery.

Because the bony girdle of the pelvis protects the external iliac artery except where it enters the femoral canal, reports of blunt injury to this artery are rare. Emphasizing the importance of a thorough physical examination and judicious use of angiography, this case study discusses the diagnosis and treatment of an isolated external iliac artery injury rendered by a bicycle handlebar, a previously unreported cause of this type of injury.

Transection of the base of the tongue caused by penetrating injury.

Traumatic transection of the base of the tongue can be a life-threatening injury because of blood loss and airway obstruction. Airway control, hemostasis, and meticulous anatomic repair are necessary to prevent speech and airway dysfunction. Laryngeal injuries, when present, require these same principles.

Presacral drainage in penetrating extraperitoneal rectal injuries: is it necessary?

The objective was to evaluate the need for presacral drainage in low velocity penetrating rectal injury. Standard management of penetrating injuries to the extraperitoneal rectum from high velocity injury consists of debridement, diversion, drainage, and distal washout. A retrospective, descriptive review of penetrating rectal injury from 1983 to 1993 was undertaken. Independent variables included age, sex, injury severity score, mechanism of injury, caliber of weapon, associated injuries, pre-/intra-/postoperative antibiotics, length of stay, and presacral drainage. Dependent variables included wound infection and intra-abdominal abscess. Twenty-two consecutive patients met inclusion criteria. Mean injury severity score was 14.2 (SD +/- 2.3). Proximal colostomy was performed on 20; distal washout in 12 (60%). Eight (40%) of the 20 underwent presacral drainage; 12 (60%) did not. Use of presacral drainage was based on attending surgeon's preference. Groups were comparable regarding all independent variables. Routine use of presacral drainage in managing low velocity rectal wounds may not be necessary. Absence of drainage did not increase infectious complications.

Percutaneous endoscopic gastrostomy with T-bar fixation in children.

Percutaneous endoscopic gastrostomy (PEG) with the Ponsky "pull" technique has been the standard technique for pediatric gastrostomy tube placement since 1979. We evaluated safety and efficacy of PEG with the "push" technique and T-bar fixation. We reviewed PEGs performed in pediatric patients (< or = 17 years) over a 31-month period, excluding patients with previous abdominal surgery. We evaluated age, indications, location, time, and complications. Endoscopy was performed, the stomach insufflated, and the anterior abdominal wall transilluminated. T-bar fasteners were inserted percutaneously under endoscopic control. Fasteners were ejected from the needle tip with a stylet and secured. A 14 or 18 French gastrostomy tube was placed through the center of previously placed T-bar fasteners by using a modified Seldinger technique. Fifteen children (mean age, 9 years) underwent the procedure for the need for long-term enteral alimentation (severe closed head injury) (n = 7), for progressive neurologic dysfunction with feeding disorder (n = 7), or for failure to thrive (cystic fibrosis) (n = 1). No significant major postoperative complications occurred. The technique proved safe and effective for gastrostomy in children.

Prevention of pediatric mortality from trauma: are current measures adequate?

Trauma accounts for nearly half of pediatric deaths in the United States. We reviewed all pediatric trauma-related deaths that occurred over a 5-year period at two Georgia trauma centers to determine the number of trauma deaths in children, mechanism of injury, cause of death, and compliance with safety standards. Of the 69 fatalities, 31 were caused by motor vehicle accidents. Twenty-five of these victims (81%) were unrestrained; 17 were 4 years old or less, and only 1 of them was restrained in a car seat. Pedestrian versus vehicle accidents resulted in 19 deaths, 10 of the victims being 4 years old or less. Bicycle versus vehicle accidents resulted in 4 deaths, 2 of them due to closed head injury; none of the victims wore headgear. All-terrain vehicle accidents resulted in 2 deaths from massive head injury; neither victim wore a helmet. One death occurred from bicycle handlebar injury; 12 deaths resulted from causes other than vehicle accidents. Major causes of pediatric fatalities were motor vehicle accidents (45%), pedestrian-vehicle accidents (28%), and bicycle accidents (6%). This study indicates that when safety measures such as restraint systems, helmets, or proper supervision are ignored, children may die as a result of trauma.

Analysis of prehospital pediatric and adult intubation.

PURPOSE: Pediatric airway control, including endotracheal intubation (ETI), presents a clinical challenge in the prehospital setting. Endotracheal intubation is recommended for serious head injury (Glasgow Coma Scale score <=8). We evaluated the frequency of ETI in pediatric and adult patients with <=8 in the field, subsequently transported by a hospital-based, helicopter emergency medical service (HHEMS). METHODS: A retrospective, descriptive study of pediatric patients (<=14 years) and adult patients with GCS <=8 transported by HHEMS from January 1988 through March 1994 was conducted. Significance was determined by chi-square analysis. RESULTS: Inclusion criteria were met by 63 (15%) pediatric patients and 353 (85%) adults. Of the pediatric patients, 38 (60%) were intubated endotracheally; mean age was 7; mean injury severity score (ISS) was 28. Of adults, 267 (76%) were intubated endotracheally; mean age was 35; mean ISS was 33. A 16-percentage-point difference in frequency of successful ETI between groups was found to be significant (p <=0.01). Of 25 nonintubated pediatric (PED) patients, unsuccessful attempts were made on 20 (80%); 14 of 25 (56%) had significant head injuries evident on computerized tomography (CT) scan. Of 86 nonintubated adults, unsuccessful attempts were made on 29 (34%); 61 (71%) had significant head injuries. CONCLUSIONS: Pediatric coma patients were not intubated with the same frequency as adults. This discrepancy between groups was secondary to a higher failure rate in the pediatric group. Intubation was attempted in 92% of pediatric patients versus 84% of the adults. Unsuccessful intubation attempts in the pediatric group, 20 of 58 (34%), were compared with 29 of 296 (9.8%) in the adult group. Difficulty in pediatric airway control may require an increased level of training and experience.

Airway control in trauma patients with cervical spine fractures.

INTRODUCTION: Proper airway control in trauma patients who have sustained cervical spine fracture remains controversial. PURPOSE: This study was undertaken to survey the preferred methods of airway management in cervical spine fracture (CSF) patients, to evaluate the experience of handling such patients at a level-I trauma center, and to contrast the findings with recommendations of the American College of Surgeons Committee on Trauma. HYPOTHESIS: The methods used for control of the airway in patients with fractures of their cervical spine support the recommendation of the American College of Surgeons (ACS) Committee on Trauma. METHODS: The study consisted of two parts: 1) a survey; and 2) a retrospective study. Survey questionnaires were sent to 199 members of the Eastern Association for the Surgery of Trauma and to 161 anesthesiology training programs throughout the United States. Three resuscitation scenarios were posed: 1) Elective airway--CSF--breathing spontaneously, stable vital signs; 2) Urgent airway--CSF--breathing spontaneously, unstable vital signs; and 3) Emergent airway--CSF--apneic, unstable. In addition, a three-year retrospective study was conducted at a level-I trauma center to determine the method of airway control in patients with cervical spine fractures. RESULTS: Responses to the questionnaires were received from 101 trauma surgeons (TS) and 58 anesthesiologists (ANESTH). Respondents indicated their preference of airway methods: Elective airway: Nasotracheal intubation: TS 69%, ANESTH 53%. Orotracheal intubation: TS and ANESTH 27%. Surgical airway: TS 4%. Intubation with fiberoptic bronchoscope (FOB): ANESTH 20%. Urgent airway: Nasotracheal intubation: TS 48%, ANESTH 38%. Orotracheal intubation: TS 47%, ANESTH 45%. Surgical airway: TS 4%. FOB: ANESTH 16%. Emergent airway: Orotracheal intubation: TS 81%, ANESTH 78%. Surgical Airway: TS 19%, ANESTH 7%. FOB: ANESTH 15%. The retrospective review at the trauma center indicated that 102 patients with CSF were admitted; 62 required intubation: four (6%) on the scene, seven (11%) en route, five (8%) in the emergency department, 42 (67%) in the operating room, and four (6%) on the general surgery floor. Airway control methods used were nasotracheal: 14 (22%); orotracheal: 27 (43%); FOB: 17 (27%); tracheostomy: one (2%); unknown: three (4%). No progression of the neurological status resulted from intubation. CONCLUSION: The choice of airway control in the trauma patient with CSF differs between anesthesiologists and surgeons. However, the method selected does not have an adverse affect on neurological status as long as in-line stabilization is maintained. The methods available are safe, effective, and acceptable. The recommendations of the American College of Surgeons Committee on Trauma for airway control with suspected cervical spine injury are useful. The technique utilized is dependent upon the judgment and experience of the intubator.

Seroprevalence of human immunodeficiency virus in admitted trauma patients at a southeastern metropolitan/rural trauma center.

Human Immunodeficiency Virus (HIV) seropositivity was prospectively evaluated for trauma patients admitted to Memorial Medical Center between September 1989 and August 1990. Epidemiologic data, HIV risk factors, and opportunity for body fluid exposure were compiled for 520 admitted trauma patients 15 years of age or older who met inclusion criteria. Serum samples were obtained from initial laboratory tests. Patient identifiers were removed, and matching blinded numbers were placed on patient serum and data forms. Centers for Disease Control laboratories tested for HIV with the enzyme-linked immunosorbent assay method. The Epi-Info (Version 5.01, 1990) software package was used for statistical analysis of epidemiologic data. Results showed HIV seropositivity of admitted trauma patients to be 0.96 per cent (5/520). HIV seroprevalence among young black males from our urban area who were injured during violent aggression was 3.5 per cent. Management of 80 per cent of patients resulted in opportunity for body fluid exposure. Illicit drug use was reported by 15 per cent; 7.5 per cent gave a history of transfusion since 1977; 3 per cent identified high risk sexual partners; three patients reported homosexual activity. Two patients denied risk factors, but were HIV-seropositive. The results indicate that HIV exposure is a potential hazard to health care workers and that HIV risk factors alone are not reliable in identifying the HIV-positive patient.

Flight nurse interpretations of chest radiographs.

The authors conducted a study to determine whether basic instruction in reading chest radiographs could enable flight nurses to interpret radiographs accurately. Flight nurses were taught 10 trauma-related chest roentgenographic patterns. The chest radiographs of 40 transported trauma patients were chosen randomly over a 14-month period for interpretation by a flight nurse and a referring physician. Flight nurses correctly identified 47 out of 55 patterns (85%). Referring physicians correctly identified 37 out of 55 (67%). Flight nurses also correctly identified 13 patterns that the referring physicians missed. The results indicate that emergency radiologists can advance and improve the radiological aspects of emergent patient care by providing flight nurses with minimal training in interpreting radiographs. When a flight nurse and a physician in an outlying area--where trauma is less commonly encountered--work as a team, more accurate and earlier diagnoses can be made, and therapy can be instituted earlier.

A method for controlling bleeding from abdominal wall puncture site after laparoscopic surgery.

Bleeding from puncture sites can complicate laparoscopic procedures. Although it is usually self-limited, bleeding can persist into the postoperative course or obscure the field during the operative procedure. The following article describes a simple method for controlling this type of bleeding. To date, it has been used successfully on two separate occasions.

Effect of positive end-expiratory pressure on intra-abdominal pressure.

Massive elevation of intra-abdominal pressure (IAP) causes renal, cardiovascular, and respiratory dysfunction. Positive end-expiratory pressure (PEEP) markedly increases the detrimental effect of IAP on the cardiovascular system. The purpose of this study was to determine the effect of PEEP on IAP. In 15 patients requiring mechanical ventilation, IAP was measured, after 15-minute equilibration intervals, at PEEP levels of 0, 5, 10, and 15 cm H2O. Parametric analysis with multiple paired t tests and nonparametric analysis with Spearman's rho and Kendall's tau tests were used to determine correlation between PEEP and IAP. All patients were male. The mean age was 39 years (range, 18-77). Ten patients had just had laparotomy. No correlation was found between PEEP and IAP. We conclude that PEEP of 15 cm H2O or less has no effect on IAP, and we discuss the clinical implications.

Multipiece tire rim injuries.

Multipiece tire rims can explode during tire change, causing severe injury. Although more than 450 such accidents, with at least 80 deaths, have been recorded by the National Highway Traffic Safety Administration (NHTSA), we found no reports in the surgical literature on such injuries in the United States. This report describes experience with seven patients who sustained injuries in explosions of multipiece tire rims. All victims suffered massive maxillofacial trauma with associated ocular, cranial, intracranial, and extremity injuries. Two patients died, both because of intracerebral hemorrhage. One patient suffered serious long-term disability. All survivors required extensive reconstructive surgery. The design of the multipiece tire rim is inherently hazardous. Since many accidents of this type are not reported to the NHTSA, the incidence of such injuries may be significantly higher. An alternative, nonhazardous tire rim is available. Design modifications or a law restricting use of multipiece tire rims would prevent many accidents.

Evaluation of an end-tidal carbon dioxide detector in the aeromedical setting.

Endotracheal intubation is a lifesaving technique performed by flight crews often under difficult circumstances. Inadvertent unrecognized esophageal intubation is reported to occur up to 8% of the time. Recently a new disposable device has been developed to assist in determining proper endotracheal tube placement. The FEF end-tidal carbon dioxide detector (Fenem Co.) was evaluated in this study. From June 1989 to January 1990, all patients intubated or transported with endotracheal tubes in place by LifeStar, helicopter Emergency Medical Service, had the FEF detector positioned on the endotracheal tube. Flight crews continuously monitored changes in the indicator of the FEF during transport. On arrival to the emergency department, tube position was verified with direct laryngoscopy by an emergency department physician or trauma surgeon. Thirty-five patients were entered into the study. Thirty-four were identified by direct laryngoscopy as having proper placement of the their endotracheal tube and one was found to be intubated in the esophagus. The FEF device properly identified the single esophageal intubation and accurately identified proper position of the endotracheal tube in thirty-two patients. Of the three patients in cardiopulmonary arrest, the FEF device was accurate in detecting tube position in each case. The overall sensitivity of the FEF detector in this aeromedical setting was 94%. Specificity was calculated as 100%. The overall positive predictive value of the FEF detector was 100%. We therefore conclude that indication of a tracheal intubation by the FEF detector is reliable after six breaths in the aeromedical setting and advocate its use as an adjunct for monitoring tube position while in flight.