The role of nephrectomy in the acutely injured.

HYPOTHESIS: The high mortality in patients who undergo nephrectomy after trauma is not secondary to the nephrectomy itself but is the consequence of a more severe constellation of injuries associated with renal injuries that require operative intervention. DESIGN: A retrospective review of all patients identified using International Classification of Diseases, Ninth Revision codes as having sustained renal injuries over a 62-month period. PATIENTS: Seventy-eight patients with renal injuries who underwent exploratory laparotomy were identified. METHODS: All medical records were reviewed for patient management, definitive care, and outcome. Based on outcome, patients were assigned to either the survivor or nonsurvivor group. For patients who underwent nephrectomy, intraoperative core temperature changes, estimated blood loss, and operative time were also reviewed. RESULTS: Seventy-eight patients with renal injuries who underwent exploratory laparotomy were identified. Twenty-nine patients underwent laparotomy with conservative management of the renal injury, of whom 5 (17.2%) died. Twelve patients had renal injuries repaired and all survived. Thirty-seven patients underwent nephrectomy, of whom 16 (43.2%) died. Compared with nephrectomy survivors, nephrectomy nonsurvivors had a significantly lower initial systolic blood pressure, higher Injury Severity Score, higher incidence of extra-abdominal injuries, shorter operative duration, and higher estimated operative blood loss. The nephrectomy survivors' core temperature increased a mean of 0.5 degrees C in the operating room, while the nephrectomy nonsurvivors' core temperature cooled a mean of 0.8 degrees C. CONCLUSIONS: Patients who undergo trauma nephrectomy tend to be severely injured and hemodynamically unstable and warrant nephrectomy as part of the damage control paradigm. That a high percentage of patients die after nephrectomy for trauma demonstrates the severity of the overall constellation of injury and is not a consequence of the nephrectomy itself.

Nonoperative management of solid abdominal organ injuries from blunt trauma: impact of neurologic impairment.

The role of nonoperative management of solid abdominal organ injury from blunt trauma in neurologically impaired patients has been questioned. A statewide trauma registry was reviewed from January 1993 through December 1995 for all adult (age >12 years) patients with blunt trauma and an abdominal solid organ injury (kidney, liver, or spleen) of Abbreviated Injury Scale score > or =2. Patients with initial hypotension (systolic blood pressure <90 mm Hg) were excluded. Patients were stratified by Glasgow Coma Score (GCS) into normal (GCS 15), mild to moderate (GCS 8-14), and severe (GCS < or =7) impairment groups. Management was either operative or nonoperative; failure of nonoperative management was defined as requiring laparotomy for intraabdominal injury more than 24 hours after admission. In the 3-year period 2327 patients sustained solid viscus injuries; 1561 of these patients were managed nonoperatively (66 per cent). The nonoperative approach was initiated less frequently in those patients with greater impairment in mental status: GCS 15, 71 per cent; GCS 8 to 14, 62 per cent; and GCS < or =7, 50 per cent. Mortality, hospital length of stay, and intensive care unit days were greater in operatively managed GCS 15 and 8 to 14 groups but were not different on the basis of management in the GCS < or =7 group. Failure of nonoperative management occurred in 94 patients (6%). There was no difference in the nonoperative failure rate between patients with normal mental status and those with mild to moderate or severe head injuries. Nonoperative management of neurologically impaired hemodynamically stable patients with blunt injuries of liver, spleen, or kidney is commonly practiced and is successful in more than 90 per cent of cases. No differences were noted in the rates of delayed laparotomy or survival between normal, mild to moderately head-injured, and severely head-injured patients.

Evolution in damage control for exsanguinating penetrating abdominal injury.

OBJECTIVE: Damage control (DC) has proven valuable in exsanguinated patients. The purpose of this study was to quantify and qualify the impact of current damage control principles applied in a penetrating abdominal injury (PAI) population. METHODS: Over a 3-year period (June 1997-May 2000), of 271 laparotomies for PAI, 24 patients underwent DC (8.9%). Demographics, injury grade, resuscitative and operative parameters, acid-base status, coagulation profiles, fluid/transfusion requirements, definitive repairs, abdominal closure, complications, and outcomes were reviewed. Data were compared with our DC experience a decade earlier. Fisher's exact test was used for comparisons. RESULTS: Overall survival improved for equivalent Injury Severity Score, Revised Trauma Score, TRISS, admission systolic blood pressure, operating room systolic blood pressure, and Penetrating Abdominal Trauma Index score. Solids (1.2 vs. 1.3), hollow organ (1.5 vs. 1.7), and major vascular injuries (0.5 vs. 0.8) per patient remain unchanged. Currently, there was less hypothermia with equivalent operating room times. In intensive care unit survivors, acid-base status was similar but coagulopathy and hypothermia were less severe. Definitive colon management has shifted from ostomies to anastomoses. Eventual fascial closure occurred in 14 of 19 (74%) compared with 12 of 14 (86%) in the historical group. There were three gastrointestinal fistulae (one pancreatic), one anastomotic leak, and three intra-abdominal abscesses. CONCLUSION: Continued application of DC principles has led to improved survival with PAI. Better control of temperature, experience with the open abdomen, and intensive care unit care may be causative.

Anaphylactic shock from a latex allergy in a patient with spinal trauma.

Allergy to latex is a condition that affects patients as well as health care workers. It is a spectrum of immunologic disorders that ranges from mild hypersensitivity to life-threatening anaphylaxis. Beginning in the early 1970s, the health care community has become more aware of this entity, leading to many improvements in the understanding, diagnosis and treatment of patients with latex allergy. Many hospitals have developed protocols and procedures for patients with latex sensitivity. However, some physicians remain unaware of the logistics of taking care of patients with this disorder. We present a case of a severe anaphylactic reaction to latex in a trauma patient with a spinal cord injury. The difficulty of treating the acutely injured patient with this disorder is illustrated. A list of equipment that may be included in a latex-free emergency kit is provided.

The injured elderly in the trauma intensive care unit.

The injured elderly patient in the ICU presents many challenges. Demographic changes in western society will dramatically increase the patient population in question, and new, older, subsets are growing. The association of severe injury, preinjury comorbidity, and the aging process narrows the ability of the patient to respond to the stress of injury. When compared with younger patients, the elderly have greater mortality, morbidity, and higher costs. Age alone, however, does not predict outcome. Although aggressive or maximally supportive care is advocated, controlled data supporting this approach are lacking. Significant economic, sociologic, and ethical issues confront the care providers in almost every case. Continued and heightened study of all aspects of our injured elders focusing on the determinants of outcome is required. A realistic appraisal of the limitations of care and a reassessment of the financial implications of providing extended care are critical to the continuing ability to respond to this growing need.

Predictors of psychological distress following serious injury.

Posttraumatic psychological distress was assessed in 109 survivors of serious physical injury during acute hospitalization and at 3 months postdischarge. Participants had an average of 4.4 injuries, with a mean injury severity score of 15.5, denoting moderate to severe injuries. Using the Impact of Event Scale (IES), the mean total IES score in-hospital was 22.5 and at 3 months postdischarge was 30.6. Approximately 32% of individuals experienced high levels of distress in-hospital, and this increased to 49% at 3 months postdischarge. The regression model that best explained the variance in posttraumatic psychological distress at 3 months postdischarge included greater psychological distress during hospitalization, a positive drug/alcohol screen on hospital admission, younger age, and the lack of anticipating problems returning to normal life activities. These findings suggest that factors present during acute hospitalization may be used to identify individuals at risk for increased psychological distress, several months following serious physical injury.

The geriatric puzzle. Assessment challenges of elderly trauma patients.

Assessing elderly patients is like putting together a jigsaw puzzle. In the case described, it's entirely possible that the patient stumbled and fell, bumping his head and bruising his chest. His confusion is probably secondary to dementia, and his vital signs indicate a lack of serious injury. However, it's just as likely that the patient is hypotensive and unable to mount a compensatory tachycardia, has an expanding subdural hematoma, multiple rib fractures with a hemothorax and a ruptured spleen. And it could be worse. His diabetes could be out of control. He could suffer from chronic congestive heart failure, and his living will could be sticking out of his pocket. As the elderly population increases in number, their medical and social issues grow as well. The onus is on us, as healthcare providers, to learn about the aging population and the special problems they present so that we can continue to improve the quality of care we deliver.

Journey towards recovery following physical trauma.

Journey towards recovery following physical trauma Convalescence and recovery following illness are of central importance to nursing. These themes have been explored increasingly in the literature. The focus, however, has been primarily on the process of integrating chronic illness into one's life. Recovery from physical injury is rarely addressed. A body of work focusing on physical trauma demonstrates that recovery is often not complete after injuries that have not been viewed as disabling. To illuminate understanding of recovery following physical trauma, the purpose of our 1997 study was to describe more thoroughly the nature of recovery. A total of 63 adults, in a convenience sample, who survived serious physical trauma, were interviewed 2.5 years after injury using an open-ended semistructured interview guide. Three themes were identified: event, fallout, and moving-on. These themes provided the organizing structure for exploring the journey to recovery. This journey, as disclosed by the seriously injured, does not necessarily correspond with the views of most trauma clinicians. Traumatic events create a line of demarcation, separating lives into before and after. The event becomes the starting point of a journey to resume one's life. The event itself is more than the trauma; it is the perceptual and contextual experience that needs to be incorporated into a person's essence. Fallout from the injury is multifaceted and includes physical, psychological, social, and spiritual dimensions. Moving-on in this journey is nonlinear as survivors recognize their lives are forever different. The survivors' accounts suggest that nurses should carefully consider the question, 'What is successful recovery?'

A multi-institutional study of factors associated with fetal death in injured pregnant patients.

HYPOTHESIS: Factors associated with fetal death in injured pregnant patients are related to increasing injury severity and abnormal maternal physiologic profile. DESIGN: A multi-institutional retrospective study of 13 level I and level II trauma centers from 1992 to 1996. MAIN OUTCOME MEASURE: Fetal survival. RESULTS: Of 27,715 female admissions, there were 372 injured pregnant patients (1.3%); 84% had blunt injuries and 16% had penetrating injuries. There were 14 maternal deaths (3.8%) and 35 fetal deaths (9.4%). The population suffering fetal death had higher injury severity scores (P<.001), lower Glascow Coma Scale scores (P<.001), and lower admitting maternal pH (P = .002). Most women who lost their fetus arrived in shock (P = .005) or had a fetal heart rate of less than 110 beats/min at some time during their hospitalization (P<.001). An Injury Severity Score greater than 25 was associated with a 50% incidence of fetal death. Placental abruption was the most frequent complication, occurring in 3.5% of patients and associated with 54% mortality. Cardiotrophic monitoring to detect potentially threatening fetal heart rates was performed on only 61% of pregnant women in their third trimester. Of these patients, 7 had abnormalities on cardiotrophic monitoring and underwent successful cesarean delivery. CONCLUSIONS: Fetal death was more likely with greater severity of injury. Cardiotrophic monitoring is underused in injured pregnant patients in their third trimester even after admission to major trauma centers. Increased use of cardiotrophic monitoring may decrease the mortality caused by placental abruption.

Gunshot wounds below the popliteal fossa: a contemporary review.

The management of extremity injuries above the knee has been well described, but the evaluation and treatment guidelines for penetrating injuries below the popliteal crease has received less attention. A 6-year retrospective review of 100 patients who sustained isolated below-knee gunshot wounds. Patients with proximal extremity, torso, or head wounds were excluded from review so that we could focus on principles of managing below-knee wounds. All patients were evaluated with complete physical examination, ankle-brachial index, and plain X-rays. One patient presented with hemodynamic instability. Twenty-four patients underwent arteriography based on physical examination, an ankle-brachial index less than 0.9, or both. Twenty-two vascular injuries were identified in 19 patients, and an additional injury was found in a patient who went directly to surgery for pulsatile bleeding. Six of these 22 vascular injuries required treatment for bleeding or arteriovenous fistula. Treatment was by embolization in 5 and surgical ligation in 1. Thirteen patients had compartment syndromes. Thirty-five patients had fractures, and ten (29%) of these had an associated vascular injury. Four patients had peroneal nerve injuries, and three of these had long term disability. No limb loss or death occurred. We conclude that patients with low-velocity below-knee gunshot wounds sustain fractures, vascular injuries, compartment syndromes, and nerve injuries, in decreasing order of frequency. Arteriography and embolization may be useful to control bleeding; vascular reconstruction was unnecessary in our experience, and limb loss did not occur.

Rapid sequence induction for intubation by an aeromedical transport team: a critical analysis.

Airway control is the initial priority in the management of the injured patient. The purpose of this investigation was to evaluate the experience of an aeromedical transport team in the utilization of rapid sequence induction (RSI) for endotracheal intubation in the prehospital setting. Records of a consecutive series of injured patients undergoing RSI between June 1988 and July 1992 by a university-based aeromedical transport team were reviewed for demographics, intubation mishaps, and pulmonary complications. The relationship between intubation mishaps and pulmonary complications was analyzed. Eighty-four patients were studied with a mean age of 30.8 +/- 15.3 years. The mean Revised Trauma Score was 11.3 +/- 2.4, and the mean Injury Severity Score (ISS) was 19.6 +/- 11.5. Intubation mishaps occurred in 15 patients (18%), and pulmonary complications developed in 22 (29%) of the 75 patients surviving longer than 24 hours. There was no relationship between intubation mishaps and pulmonary complications. Abbreviated Injury Scale (AIS) face score was significantly higher in patients with intubation mishaps, compared with patients without mishaps (1.1 +/- 1.2 and 0.5 +/- 0.9, respectively, P < .05, Wilcoxon rank-sum). ISS and AIS chest were higher in patients with pulmonary complications, compared with those without (25.7 +/- 12.6 and 17.4 +/- 10.3 and 2.2 +/- 1.8 and 1.0 +/- 1.5, ISS and AIS respectively; P < .05, Wilcoxon rank-sum). Eighty-one patients (96%) underwent successful RSI, 73 (87%) on the first attempt. Failure to intubate occurred in three patients (4%). Performed under strict protocol by appropriately trained aeromedical transport personnel, RSI is an effective means to facilitate endotracheal intubation in the injured patient requiring definitive airway control. Pulmonary complications were related to injury severity and not to intubation mishaps.

Determining anatomic injury with computed tomography in selected torso gunshot wounds.

BACKGROUND: Changes in the management of torso gunshot wounds (TGSWs) have evolved in recent years as a result of differences between military and civilian injuries and increasing interest in avoiding nontherapeutic invasive procedures. The objective of this study was to establish the utility and accuracy of computed tomography (CT) in the evaluation of selected patients with TGSWs. METHODS: Retrospective review for a 6-year period of patients who sustained TGSWs and underwent CT solely for the purpose of trajectory determination. Patients had complete physical examinations and plain radiographic evaluations by a dedicated group of in-house trauma surgeons. When trajectory was indeterminate after evaluation, CT was performed. In some cases, CT was used when trajectory was determined to be intracavitary but organ injury was believed to be unlikely or amenable to nonoperative management. RESULTS: Fifty TGSW patients underwent 52 computed tomographic scans. Abdominal/pelvic CT was performed in 37 patients, and thoracic CT was performed in 15 patients. All patients were stable and none sustained complications attributable to CT or delay in therapy. Twenty of 37 abdominal/pelvic computed tomographic scans excluded transabdominal or pelvic trajectory. Seventeen of 37 scans proved transabdominal or pelvic trajectory; nine laparotomies were performed, and eight patients were observed. Nine of 15 thoracic computed tomographic scans excluded transmediastinal trajectory. Six of 15 scans suggested vascular proximity and prompted further workup, which was positive in two cases. CONCLUSION: CT of selected TGSW patients is safe and may reduce the incidence of invasive diagnostic procedures. A prospective evaluation of CT for TGSW patients is warranted.

Penetrating chest injury: who warrants aggressive treatment?

To determine the degree of severity in penetrating chest injuries that predicts survival, we conducted a logistic regression analysis. All patients suffering penetrating chest injuries (n = 310) admitted to an urban level I teaching hospital in the USA between January 1993 and December 1994 were evaluated. The Injury Severity Score (ISS), Glasgow Coma Scale (GCS), Trauma Score (TS), and Revised Trauma Score were used to compare injury survivors with nonsurvivors. We used the trauma scores to create a logit to predict the outcome among 160 patients in 1993 and tested the validity of this logit in another 150 patients in 1994. With death = 0, survival = 1, the equation lnPd/Ps = b0 + b1 ISS + b2 GCS + b3 TS was obtained from logistic regression, where b0 was the constant of the equation and b1, b2, and b3 were the coefficients of ISS, GCS, and TS, respectively. A logit score greater than 0.5 was found to be predictive of death with a sensitivity of 80.0%, a specificity of 97.5%, and an accuracy of 94.0%. Aggressive resuscitation should be aimed at patients with a logit score greater than 0.5 to reduce mortality. This knowledge may aid in the management of patients with severe chest injuries.

The impact of true partnership between a university Level I trauma center and a community Level II trauma center on patient transfer practices.

OBJECTIVE: To examine the effect of a clinical and administrative partnership with an academic urban Level I trauma center on the patient transfer practices at a suburban/rural Level II center. METHODS: Data for 2 years before affiliation (PRE) abstracted from inpatient charts and the trauma registry were compared with that for 2 years after (POST). The following data were collected: number of, reason for, and destination and demographics of transfers. Chi(2) test and t test analyses were used; p < 0.05 defined significance; data are mean +/- SEM. RESULTS: Transfer rate increased from 4% PRE to 6.9% (p = 0.001) POST with no significant difference in age, Glasgow Coma Scale score, Injury Severity Score, or Revised Trauma Score. Repatriation occurred in 12.8% POST (none PRE). The current Level I facility accepted 1.8% of all transfers PRE and 36.4% POST (p = 0.0001). PRE/POST rates by reason are as follows: pediatric, 14.6%/9.0% (p = 0.04); intensive care unit, 0.4%/1.7% (p = 0.13); complex orthopedic, 100%/0% (p = 0.005); vascular, 50%/0% (p = 0.008); spinal cord injury, 100%/100%; and ophthalmologic, 0%/100% (p = 0.005). CONCLUSIONS: In this experience of Level I/II partnership (1) transfer patterns were altered, (2) select patient cohort transfers decreased (pediatric, complex orthopedic, vascular), whereas others increased (aortic work-up), and (3) repatriation rates were low.

A prospective study of predictors of disability at 3 months after non-central nervous system trauma.

OBJECTIVE: To delineate which injury-related, demographic, and psychosocial variables were predictive of severe disability (limitations in the performance of socially defined roles and tasks) at 3 months after discharge from acute hospitalization for non-central nervous system traumatic injury. PATIENTS AND METHODS: The study design was prospective, longitudinal, and correlational. The sample consisted of 109 injured patients at three urban trauma centers. Data were obtained from patient interview using the Sickness Impact Profile, the Impact of Event Scale, and the Social Support Questionnaire; injury-related data were obtained from the medical record and computerized trauma registries. RESULTS: The sample had a mean age of 37.4 +/- 16.8 years, a mean number of injuries per person of 4.4 +/- 2.8, and a mean Injury Severity Score of 15.5 +/- 9.9. Motor vehicle crashes (34.9%) and violent injuries (33%) were the predominant causes of injuries. Patients experienced severe levels of disability (Sickness Impact Profile, mean = 26.1) and moderate levels of psychological distress (Impact of Event Scale, mean = 30.6; intrusion mean = 14.6 and avoidance mean = 16.0). Three variables were predictive of severe disability at 3 months: high levels of intrusive thoughts (odds ratio, 2.9; 95% confidence interval, 1.1-7.7); injury with a maximal Abbreviated Injury Scale score in an extremity (odds ratio, 2.9; 95% confidence interval, 1.2-6.9); and having not graduated from high school (odds ratio, 3.4; 95% confidence interval, 1.2-10). CONCLUSION: Extremity injuries, lack of high school graduation, and high level of posttraumatic psychological distress with intrusive thoughts are risk factors for severe disability at 3 months after discharge from the hospital.

Solid viscus injury predicts major hollow viscus injury in blunt abdominal trauma.

BACKGROUND: As nonoperative management of blunt abdominal trauma has become more popular, reliable models for predicting the likelihood of concomitant hollow viscus injury in the hemodynamically stable patient with a solid viscus injury are increasingly important. METHODS: The Pennsylvania Trauma Systems Foundation registry was reviewed for the period from January 1992 to December 1995 for all adult (age > 12 years) patients with blunt trauma and an Abbreviated Injury Scale (AIS) score > or = 2 for a solid viscus (kidney, liver, pancreas, spleen). Patients with an initial systolic blood pressure < 90 mm Hg were excluded. Hollow viscus injuries included only lacerations or perforations of the gallbladder, gastrointestinal tract, or urinary tract. RESULTS: In the 4-year period, 3,089 patients sustained solid viscus injuries, 296 of whom had a hollow viscus injury (9.6%). The mean age was 35.6 years, mean Injury Severity Score was 22.2, and mean Revised Trauma Score was 7.3; 63.3% of the patients were male. A solitary solid viscus injury occurred in 2,437 patients (79%), 177 of whom (7.3%) had a hollow viscus injury. The frequency of hollow viscus injury increased with the number of solid organs injured: 15.4% of patients with two solid viscus injuries (n = 547) and 34.4% of patients with three solid viscus injuries (n = 96) suffered a concomitant hollow viscus injury (p < 0.001 vs. one organ). A hollow viscus injury was 2.3 times more likely for two solid viscus injuries and 6.7 times more likely for three solid viscus injuries compared with a solitary solid viscus injury. For solitary solid viscus injury, the frequency of hollow viscus injury varied little with increasing AIS score (AIS score 2, 6.6%; AIS score 3, 8.2%; AIS score 4, 9.2%; AIS score 5, 6.2%) (p = 0.27 between groups), suggesting that the incidence of hollow viscus injury is related more to the number of solid visceral injuries than the severity of individual organ injury. Also, when the sum of the AIS scores for solid viscus injuries was <6, the mean rate of hollow viscus injury was 7.8%. This increased to 22.8% when the sum of the AIS scores for solid viscus injury was > or =6 (p < 0.001). A pancreatic injury in combination with any other solid viscus injury had a rate of hollow viscus injury of >33%. CONCLUSION: A model of organ injury scaling predicted hollow viscus injury. Multiple solid viscus injuries, particularly pancreatic, or abdominal solid viscus injuries with an AIS score > or = 6, were predictive of hollow viscus injury. Identification of these injury patterns should prompt consideration for early operative intervention.

Barrier precautions in trauma resuscitation: real-time analysis utilizing videotape review.

Blood-borne pathogens threaten all individuals involved in emergency health care. Despite recommendations by the Centers for Disease Control and the American College of Emergency Physicians, documented compliance with universal precautions in trauma resuscitation has been poor. The purpose of this study was to determine the factors that predispose to noncompliance with barrier precautions at a level I trauma center. Videotapes of trauma resuscitations performed during 1 month (n = 66) were reviewed. Full compliance with barrier precautions was documented in 89.1% of health care workers. Of the noncompliant health care workers, 50.7% were emergency department personnel and 47.8% were first responders to the trauma resuscitation area. Barrier precaution compliance improved from 62.5% to 91.8% with prenotification of patient arrival. Immediate access to barrier equipment is essential for all potential in-hospital first responders. Prehospital communication systems should be optimized to ensure prenotification.