Vacuum-assisted wound closure provides early fascial reapproximation in trauma patients with open abdomens.

BACKGROUND: Damage control and decompressive laparotomies salvage severely injured patients who would have previously died. Unfortunately, many of these patients develop open abdomens. A variety of management strategies exist. The end result in many cases, however, is a large ventral hernia that requires a complex repair 6 to 12 months after discharge. We instituted vacuum-assisted wound closure (VAWC) to achieve early fascial closure and eliminate the need for delayed procedures. METHODS: For 12 months ending June 2000, 14 of 698 trauma intensive care unit admissions developed open abdomens and were managed with VAWC dressing. This was changed every 48 hours in the operating room with serial fascial approximation until complete closure. RESULTS: Fascial closure was achieved in 13 patients (92%) in 9.9 +/- 1.9 days, and 2.8 +/- 0.6 VAWC dressing changes were performed. There were 2 wound infections, no eviscerations, and no enteric fistulas. CONCLUSIONS: Use of VAWC can safely achieve early fascial closure in more than 90% of trauma patients with open abdomens.

Age should not be a consideration for nonoperative management of blunt splenic injury.

BACKGROUND: Operative management of blunt splenic injury is recommended for adults > or = 55 years. Because this is not our practice, we did a retrospective review to compare outcomes of patients > or = 55 years old versus patients < 55 years old. METHODS: During a 5-year period ending in July of 1998, 461 patients (3%) admitted to our Level I trauma center had a blunt splenic injury. Eighty-six patients (19%) died within 24 hours of massive injuries, leaving 375 patients for evaluation. Data were obtained from our trauma registry and medical records. RESULTS: A total of 29 patients (8%) were > or = 55 years old (mean age, 67 +/- 2 years; mean injury severity score [ISS] 25 +/- 2). Of these, 18 patients (62%) underwent nonoperative management (NOM). A total of 346 patients (92%) were < 55 years old (mean age, 28 +/- 0.6; mean ISS, 20 +/- 1). Of these, 198 patients (57%) underwent NOM. The failure rate was not different between the two age groups (17% vs. 14%). However, the ISS and mortality rate were significantly higher in the older age group that failed (ISS, 29.3 +/- 2.6 vs. 19.5 +/- 2.1; mortality: 67% vs. 4%). None of the deaths could be attributed to splenic injury. CONCLUSION: Adults > or = 55 years old with blunt splenic injury are successfully treated by NOM. Although older adults had significantly greater injuries, they had similar failure rates of NOM when compared with younger adults. Older adults had significantly higher mortality, but this was not a result of their splenic injury. Therefore, age should not be a criteria for NOM of blunt splenic injury.

Blunt versus penetrating subclavian artery injury: presentation, injury pattern, and outcome.

BACKGROUND: Subclavian artery (SCA) injuries are rare vascular injuries and may be difficult to manage. The majority of SCA injuries are secondary to penetrating trauma. The purpose of this report is to examine the injury patterns, diagnostic and therapeutic approaches, and outcome of patients with blunt and penetrating SCA injuries. METHODS: Retrospective review RESULTS: Fifty-six patients sustained SCA injuries (25 blunt, 31 penetrating). SCA injury location was evenly distributed between the proximal, middle, and distal SCA after penetrating trauma; proximal injuries were rare (2 of 25) with blunt mechanisms. A radial arterial pulse deficit was present in only 3 of 25 blunt injuries and 9 of 31 penetrating injuries. Complications occurred more commonly in both groups of patients with initial systolic blood pressures less than 90 mm Hg. Survival was 76% in blunt and 81% in penetrating groups; limb salvage was similar (92% in blunt and 97% in penetrating groups). Complete brachial plexus injuries were more common with blunt injuries. CONCLUSION: SCA injuries are rare vascular injuries with an associated high morbidity and mortality, regardless of mechanism. Blunt mechanisms result in more middle and distal injuries and more frequent complete brachial plexus injuries. Complications are related to the hemodynamic status of the patient upon presentation, and not to mechanism of injury.

Delayed diagnosis of blunt duodenal injury: an avoidable complication.

BACKGROUND: There is controversy about the impact on morbidity from delayed diagnoses of blunt hollow viscus injuries. A recent study suggested that the increased morbidity was primarily from delayed diagnosis of blunt duodenal injury (BDI). STUDY DESIGN: We studied the medical records from a 10-year period from June 1987 to June 1997 examining the data on 22,163 cases of blunt trauma. We assessed the incidence and consequences of delayed diagnoses of BDI, and identified preoperative factors associated with these delayed diagnoses. RESULTS: Thirty-five patients (0.2%) were identified in the retrospective study of the records from 22,163 blunt trauma patients to have sustained BDI. Of these, 25 patients (71%) were male. Ages ranged from 1 to 58 years (mean 18.8 years), and the predominant mechanism was motor vehicle accident in 18 patients (51%). Seven patients (20%) (group I) had a diagnostic delay of > 6 hours; 28 patients (80%) (group II) were diagnosed in < 6 hours. Six of the seven group I patients (86%) were evaluated initially with CT scans, and five (83%) showed findings suggestive of BDI. Among the 28 group II patients, 14 (50%) underwent initial diagnostic peritoneal lavage (DPL), and 14 (50%) had a CT scan. In seven of the group II patients (50%) who were initially evaluated by CT scan, there were findings suggestive of BDI. Diagnostic peritoneal lavage was initially equivocal (red blood cell count=5,000 to 100,000) in the remaining one group I patient compared with three of the group II patients who had DPL. Deterioration found on physical examinations prompted followup CT scans in 6 group I patients (86%), and the scans were diagnostic for BDI in all cases. CONCLUSIONS: Blunt duodenal injury is an uncommon entity. Despite the presence of suggestive CT and DPL findings, the diagnosis was delayed in 20% of the 35 patients whose records were examined in the study; this delayed diagnosis was associated with increased abdominal complications. Patients with persistent abdominal complaints and equivocal CT or DPL findings should undergo laparotomy or repeat CT scan evaluations.

Hollow visceral injury and blunt trauma.

BACKGROUND: The incidence of hollow viscus injury (HVI) after blunt trauma (BT) is variable, and differences between children and adults have not been well described. The purpose of this study is to determine the age-group-related incidence and characteristics of BT-associated HVI as well as the clinical markers and consequences of delayed diagnosis. METHODS: A 9-year trauma registry review of all patients with HVI. RESULTS: A large sample of patients (19,621) with BT were evaluated (2,550 < or = 14 years old; 17,070 > 14 years old). One hundred thirty-nine of 17,070 (0.8%) adults had HVI compared with 27 of 2,550 (1%) children. HVI occurred more frequently in the duodenum in children (11 of 27) compared with adults (17 of 139) (p < 0.05). Among patients with abdominal wall ecchymosis, 13.5% of children had HVI compared with 10.6% of adults. Delays in diagnosis of HVI occurred in 9 of 27 children compared with 10 of 139 adults (p < 0.0 5). Delayed diagnosis was associated with increased abdominal septic complications in both children (4 of 9) and adults (2 of 10) compared with diagnosis at presentation (p < 0.05). CONCLUSION: HVI occurs with a similar low frequency in both children and adults. Duodenal injuries are more common in pediatric BT patients. Abdominal wall ecchymosis is associated with increased HVI but is less predictive of HVI than previously described. Contrary to previous reports, delays in diagnosis are associated with increased morbidity.

Delayed complications of nonoperative management of blunt adult splenic trauma.

OBJECTIVE: To determine the incidence and type of delayed complications from nonoperative management of adult splenic injury. DESIGN: Retrospective medical record review. SETTING: University teaching hospital, level I trauma center. PATIENTS: Two hundred eighty patients were admitted to the adult trauma service with blunt splenic injury during a 4-year period. Men constituted 66% of the population. The mean (+/-SEM) age was 32.2+/-1.0 years and the mean (+/-SEM) Injury Severity Score was 22.8+/-0.9. Fifty-nine patients (21%) died of multiple injuries within 48 hours and were eliminated from the study. One hundred thirty-four patients (48%) were treated operatively within the first 48 hours after injury and 87 patients (31%) were managed nonoperatively. MAIN OUTCOME MEASURES: We reviewed the number of units of blood transfused, intensive care unit length of stay, overall length of stay, outcome, and complications occurring more than 48 hours after injury directly attributable to the splenic injury. RESULTS: Patients managed nonoperatively had a significantly lower Injury Severity Score (P<.05) than patients treated operatively. Length of stay was significantly decreased in both the number of intensive care unit days as well as total length of stay (P<.05). The number of units of blood transfused was also significantly decreased in patients managed nonoperatively (P<.05). Seven patients (8%) managed nonoperatively developed delayed complications requiring intervention. Five patients had overt bleeding that occurred at 4 days (3 patients), 6 days (1 patient), and 8 days (1 patient) after injury. Three patients underwent splenectomy, 1 had a splenic artery pseudoaneurysm embolization, and 1 had 2 areas of bleeding embolization. Two patients developed splenic abscesses at approximately 1 month after injury; both were treated by splenectomy. CONCLUSION: Significant numbers of delayed splenic complications do occur with nonoperative management of splenic injuries and are potentially life-threatening.

Operative treatment of truncal vascular injuries in children and adolescents.

BACKGROUND/PURPOSE: Pediatric truncal vascular injuries are rare, but the reported mortality rate is high (35% to 55%), and similar to that in adults (50% to 65%). This report examines the demographics, mechanisms of injury, associated trauma, and results of treatment of pediatric patients with noniatrogenic truncal vascular injuries. METHODS: A retrospective review (1986 to 1996) of a pediatric (< or = 17 years old) trauma registry database was undertaken. Truncal vascular injuries included thoracic, abdominal, and neck wounds. RESULTS: Fifty-four truncal vascular injuries (28 abdominal, 15 thoracic, and 11 neck injuries) occurred in 37 patients (mean age, 14+/-3 years; range, 5 to 17 years); injury mechanism was penetrating in 65%. Concomitant injuries occurred with 100% of abdominal vascular injuries and multiple vascular injuries occurred in 47%. Except for aortic and one SMA injury requiring interposition grafts, these wounds were repaired primarily or by lateral venorrhaphy. Nonvascular complications occurred more frequently in patients with abdominal injuries who were hemodynamically unstable (systolic blood pressure [BPS] <90) on presentation (19 major complications in 11 patients versus one major complication in five patients). Thoracic injuries were primarily blunt rupture or penetrating injury to the thoracic aorta (nine patients). Thoracic aortic injuries were treated without bypass, using interposition grafts. In patients with thoracic aortic injuries, there were no instances of paraplegia related to spinal ischemia (clamp times, 24+/-4 min); paraplegia occurred in two patients with direct cord and aortic injuries. Concomitant injuries occurred with 83% of thoracic injuries and multiple vascular injuries occurred in 25%. All patients with thoracic vascular injuries presenting with BPS of less than 90 died (four patients), and all with BPS 90 or over survived (eight patients). There were 11 neck wounds in 9 patients requiring intervention, and 8 were penetrating. Overall survival was 81%; survival from abdominal vascular injuries was 94%, thoracic injuries 66%, and neck injuries 78%. CONCLUSIONS: Survival and subsequent complications are related primarily to hemodynamic status at the time of presentation, and not to body cavity or vessel injured. Primary anastomosis or repair is applicable to most nonaortic wounds. The mortality rate in pediatric abdominal vascular injuries may be lower than previously reported.

Noncorrelation between thoracic skeletal injuries and acute traumatic aortic tear.

It is generally accepted that the presence of thoracic skeletal injuries has a predictive value for acute traumatic aortic tear (ATAT). The purpose of this study is to objectively assess the validity of that premise. The initial chest radiographs of 548 patients who underwent aortic angiography for suspected ATAT were reviewed for thoracic skeletal injuries. The incidence of thoracic skeletal injuries was compared between patients with and without angiographically confirmed ATAT. Rib fracture is the only thoracic skeletal injury whose incidence is statistically significantly higher in patients with ATAT (36 of 62, 58.1%) than in those without (207 of 486, 42.6%) (p = 0.0209). The positive predictive value of rib fractures in evaluating ATAT, however, is 14.8%, a rate similar to the incidence of ATAT at most trauma centers, and the specificity is 57.4%. The second most common finding in patients with ATAT, the absence of thoracic skeletal injury, is not statistically significantly different between patients with ATAT (24 of 62, 38.7%) and those without (220 of 486, 45.3%) (p = 0.3279). We conclude that (1) there is no clinically relevant correlation between thoracic skeletal injuries and ATAT, and (2) selection of patients requiring thoracic aortography must be based on appropriate mechanism of injury and radiographic evidence of mediastinal hematoma.

Pulmonary contusion: are children different?

BACKGROUND: Pulmonary contusion (PC) is a common sequelae of blunt trauma in adults and children; previous reports suggest that children have more favorable outcomes because of differences in mechanisms of injury, associated injury, and physiologic response. Our objective was to determine whether children who sustain PC have different outcomes compared with similarly injured adults. STUDY DESIGN: Our Level I Trauma Registry was reviewed for a 4-year period and identified 251 consecutive patients who sustained PC. Their charts were reviewed retrospectively for demographics, injury mechanism, injury severity scores, associated injuries, and outcomes (measured by the need for intubation, ventilation days, pneumonia, acute respiratory distress syndrome, and death). Data are expressed as the mean +/- SEM. The Student's t-test was used to compare the groups. A p value less than 0.05 was considered significant. RESULTS: Of the study patients, 41 (16%) were children (ages 2-16, mean 10 years) and 210 (84%) were adults (ages 17-80, mean 34 years). The most common injury mechanisms in children were motor vehicle accidents (56%) and auto-pedestrian accidents (39%), but in adults, motor vehicle accidents (80%, p = 0.02) predominated. Injury severity score was not significantly different between groups (children, 26 +/- 2 and adults 25 +/- 1). Similarly, the incidence of associated injuries was not different between children and adults: head 78% versus 62%, abdomen 59% versus 43%, and skeletal fractures 41% versus 29%, respectively. Neither need for intubation, ventilator days, pneumonia, acute respiratory distress syndrome, or death differed significantly between groups. CONCLUSIONS: Although children and adults differ in regard to injury mechanism, their overall injury severity, associated injuries, and outcomes are quite similar. Thus, contrary to previous reports, children do not have a more favorable outcome after PC.

Effect of full-time, specialized physician supervision on the success of a large, urban emergency medical services system.

OBJECTIVES: Despite the universal proliferation of emergency medical services programs throughout the United States since 1970, only a few have ever documented a valid lifesaving effect, particularly in large, urban centers. The purpose of this study was to demonstrate the effect of specialized physician supervision on the effectiveness of an emergency medical services system. DESIGN: Prospective, cohort study. SETTING: Large, urban municipality (population 2 million). PATIENTS: Evaluation of victims of out-of-hospital sudden cardiac death cases, before (n = 152) and after (n = 200) the introduction of specialized physician supervision for the emergency medical services system. INTERVENTIONS: The hiring of a full-time, salaried emergency medical services system physician whose principal duties would be to provide intensive individualized training, direct operational supervision, and continuous system monitoring, including frequent on-scene oversight of emergency medical services personnel. MEASUREMENTS AND MAIN RESULTS: Comparison of existing hospital discharge rates for out-of-hospital sudden cardiac death cases to those rates achieved 5 yrs after recruitment of the specialized emergency medical services system physician. A dramatic increase in hospital discharge rates was demonstrated for sudden death patients presenting with ventricular fibrillation, from zero at year 0 (0 of 152 patients survived), to 21% (42 of 200 patients) by year 5 (p < .001). This result was achieved despite the fact that all other related factors (budget, paramedic numbers, response times) significantly worsened during the comparison periods. CONCLUSIONS: The introduction of the new factor into the emergency medical services system (specialized physician supervision) was associated with significantly improved patient outcome. In view of current suboptimal outcome statistics found in most municipal emergency medical services programs across the United States, future goals of medical community leaders should be directed at efforts to properly train, certify, and establish appropriate positions for physicians who specialize in emergency medical services system supervision.

Patterns of infection and mortality in thoracic trauma.

Tissue infection and systemic sepsis are common causes of morbidity and late mortality after major thoracic trauma. To seek causative mechanisms, prognostic indicators, and areas of possible improvement in therapy, we reviewed 310 consecutive adults admitted with major thoracic trauma. Of these, 56 (18%) died of massive injuries in the first 5 days; the remaining 254 were considered at risk for infectious complications. There were 21 late deaths in this group, and 15 (71%) were caused by systemic sepsis. Eighty-four patients (33%) developed thoracic infections, and 15 (6%) had significant nonthoracic infections. Markers of increased risk of infection included blunt injury, shock and unconsciousness on arrival, and splenectomy. Pulmonary infection was increased significantly following prolonged endotracheal intubation, but was virtually absent following tracheostomy. The risk of infection was increased significantly if prophylactic antibiotics were not used, but no definite correlation could be made to advanced age, pre-existent disease, nor post-traumatic malnutrition. Attention to some of these factors may decrease the risk of infection in thoracic trauma.

Urban helicopter response to the scene of injury.

Metropolitan Houston with a population of four million has the nation's poorest freeway system. Its two Level I trauma centers are adjacent within a centrally located freeway loop, therefore the city is ideally suited for a trauma scene helicopter transport service. During 1981 there were 577 flights to the scene of injury (blunt, 466; penetrating, 111). Flights were requested by 60 agencies (EMS, law enforcement, etc.). All flights were manned by a surgical resident and flight nurse. The flight distances ranged from 2 to 57 miles (average, 14.4). Three hundred six flights (53%) were within the city, including 59 (10.2%) within the freeway loop. In approximately one half of the flights, the initial responding EMS unit was a paramedic unit. The average time at the scene was 28 minutes. The overall mortality for trauma scene flights was 35.7% (206/577). Eighty-nine patients (15.1%) died at the scene and were not transported (initial median scene Trauma Score, 2). The mortality among transported patients was 24.0% (117/488). Twenty-nine patients died during attempted emergency-center resuscitation (initial median scene Trauma Score, 5). Eight-eight patients died after hospital admission (initial median scene Trauma Score, 10). Only 27 patients (5.5%) did not require hospitalization. Scene treatment (intubation, hyperventilation and, when appropriate, mannitol administration) was routinely initiated for patients with severe head injuries. Two hundred seventy-nine patients required cardiopulmonary resuscitation, tracheal intubation, chest-tube placement, or other invasive procedures. Based upon these resuscitative efforts and invasive procedures, a physician in attendance was deemed medically desirable for one half of the flights.(ABSTRACT TRUNCATED AT 250 WORDS)

Oral contraceptives, pregnancy, and focal nodular hyperplasia of the liver.

There is uncertainty regarding the role, if any, of oral contraceptive steroids in the development of focal nodular hyperplasia of the liver. In a 36-year-old woman, a large left hepatic lobe tumor developed that was detected after 11 years of using these drugs. The tumor regressed when administration of the drug was stopped but began to increase in size during a subsequent pregnancy. A left hepatic lobectomy during the second trimester disclosed focal nodular hyperplasia. Both contraceptive steroids and pregnancy, with high levels of endogenous sex steroids, favored tumor growth in this patient, suggesting that focal nodular hyperplasia can be steroid related.

Radionuclide diagnosis of diaphragmatic rupture with hepatic herniation.

Seven surgically proven cases of a traumatic rupture of the right hemidiaphragm with a hepatic herniation were preoperatively diagnosed by radionuclide liver-spleen imagings, and they were retrospectively analyzed. All injuries resulted from blunt traumatic injury including automobile accidents, and there were associated pelvic and rib fractures in five cases. All patients developed some degree of dyspnea in the relatively immediate phase. All chest radiographs showed an apparent elevation of right hemidiaphragm. Radionuclide liver-spleen imaging with 99mTc sulfur colloid characteristically demonstrated a distortion of liver configuration with superior and posterior displacement of the right lobe. Four patients had a large tear in the central tendon of the right hemidiaphragm, and none had a tear in the anterior part or in left lobe of the liver. The differential diagnosis of elevated right hemidiaphragm is briefly discussed. It is concluded that the correct preoperative diagnosis of the diaphragmatic rupture with liver hernia could be made with an awareness of this condition following trauma and radionuclide liver-spleen imaging.

Peritoneal lavage and angiography in the management of patients with pelvic fractures.

One hundred consecutive patients with pelvic fractures who had undergone peritoneal lavage and abdominal and pelvic angiography were retrospectively analyzed. Sixty-four patients with negative lavages were treated successfully without laparotomy despite a 20 percent incidence of subcapsular or intraparenchymal hematomas of the liver or spleen. Thirty percent of the patients with positive peritoneal lavages were successfully managed without laparotomy when abdominal angiography failed to identify a source of active bleeding. Abdominal angiography was 92 percent accurate in predicting the presence or absence of hemorrhage in 25 patients who underwent laparotomy. There were no false-positive angiograms. The overall false-negative rate was 2.12 percent. These occurred in two patients with torn mesenteric vessels. Pelvic angiography identified arterial pelvic bleeding in 18 percent of the patients. Eighty-four percent of patients with major pelvic bleeding had successful embolization with prompt cessation of arterial bleeding. We conclude that abdominal and pelvic angiography can be a useful adjunct to peritoneal lavage in detecting intraperitoneal hemorrhage and can be of therapeutic value for arterial pelvic bleeding.

Factors affecting mortality in pelvic fractures.

Review of 100 consecutive patients with pelvic fractures admitted to a trauma service during an 11-month period was undertaken in order to define the factors which affected the mortality. Mortality was most significantly affected by severity of injury, presence of a head injury, admitting blood pressure, admitting hemoglobin level, and requirements for blood and blood products. Evaluation of anatomic configuration of fractures demonstrated that posterior fractures required larger amounts of blood and blood products, had a significantly decreased admitting blood pressure, and had a significantly higher mortality, despite there being no significant difference in injury severity between patients having anterior or posterior fractures.

Angiography and peritoneal lavage in blunt abdominal trauma.

Records of 123 consecutive patients who underwent abdominal angiography for blunt trauma were reviewed. Twenty-four patients underwent abdominal angiography on the basis of positive physical findings. Seven (29%) required intervention as determined by angiography and the diagnosis was confirmed. Ninety-nine patients had abdominal angiography in association with angiographic evaluation of the chest, pelvis, or extremities. In 14 (14%) the angiogram indicated the need for intervention. In 13 this diagnosis was confirmed at laparotomy. The fourteenth patient was embolized angiographically and did well. Fifty-four patients had peritoneal lavage in addition to their angiograms. Sixteen were positive and 38 were negative. In four patients the lavage was negative and the angiographic findings indicated need for intervention. Three of these four were confirmed at laparotomy and the fourth patient was embolized angiographically. Indications for abdominal angiography in blunt trauma are: 1) incidental to needed thoracic aortography; 2) incidental to angiography when done for pelvic fractures; 3) suspected intra-abdominal injuries when clinical and lavage data are not definitive.

A university-staffed, private hospital-based air transport service. The initial two-year experience.

During the first two years of a cooperative effort between the University of Texas Medical School at Houston and Hermann Hospital, Houston, a program designed to extend the emergency center to the patient by helicopter treated and moved 1,702 patients. A physician and flight nurse attended patients on each mission. Of all flights, 68.3% were because of major multiple trauma and 28.8% were to the scene of an accident. The magnitude of these injuries was reflected by a mortality of 11% at the scene of the accident and 7% in the emergency room of those transported. The primary purpose of the program is to minimize the time between the catastrophic event and the institution of appropriate medical therapy. Our experience with this program of early stabilization and rapid transport has led to the following observations: (1) single-organ injury is virtually nonexistent in the patient with multiple trauma; (2) clotting abnormalities, even disseminated intravascular coagulopathy, are seen regularly in patients with apparently isolated head injuries; and (3) patients with apparently isolated head injuries often have serious pulmonary function abnormalities.

Eosinophilic infiltration of the stomach.

An unusual case of eosinophilic infiltration of the proximal stomach with direct extension into the left hemidiaphragm, liver, and transverse colon is described. Because the lesion was unresectable, a trial of steroid therapy was begun, with an initially good clinical response. Subsequent extensive tumor necrosis and accompanying diaphragmatic perforation, autolysis of the left lower lung, and a chronic gastropleurocutaneous fistula led to death. This case underscores the aggressive nature which this "histologically benign" neoplasm can pursue.