Digital radiology in trauma using small-dose exposure.

The microdose radiology system produces a large-field examination within thirty seconds on a video monitor. This video image can be manipulated in the same manner as a computed tomography (CT) scan. The system was installed at the Maryland Institute for Emergency Services (MIEMS) to examine severely injured patients. No major abnormalities were overlooked during the examination of these patients. The microdose system is useful in providing extensive radiologic information immediately applicable to the care of massively traumatized patients.

Open diagnostic peritoneal lavage in blunt trauma victims.

Open diagnostic peritoneal lavage was 97.8 per cent accurate for diagnosis of intra-abdominal injury in 2,072 blunt trauma victims. The only significant injuries missed were in certain patients with a ruptured hemidiaphragm, renal trauma and extraperitoneal bladder rupture. However, these injuries were identified by other means. False-postive lavage results are generally a consequence of technical error and can be minimized by careful surgical technique. Hemoperitoneum must be explained for all patients to prevent needless morbidity and mortality. Only diagnostic tests of proved value in blunt abdominal trauma should be used and risk to the patient must be minimized. We currently rely upon diagnostic laparotomy to evaluate hemoperitoneum in patients with a weakly positive lavage result confirmed by a second infusion. With this policy, approximately one of every four to five laparotomies was for injuries not requiring surgical therapy; and, the over-all morbidity rate and mortality was 12 and 3.5 per cent, respectively, in this group. By using open diagnostic peritoneal lavage in essentially all blunt trauma victims, we have had no deaths from either unrecognized intra-abdominal injury or delayed treatment.

Management of lung contusion.

One hundred and thirty-two consecutive patients with lung contusion were admitted during the three-year period of 1972 through 1974. All were treated with early intubation and mechanical ventilation with positive and-expiratory pressure with the postulate that such management would minimize the progression of interstitial edema, and intra-alveolar hemorrhage. If progressive increase in the alveolar/arterial oxygen tension gradient was not observed over the ensuing 24 hours, and in the absence of other non-thoracic indications of continuance of mechanical ventilation, patients were extubated and removed from the ventilator. All other patients were further ventilated and followed by daily chest roentgenograms and blood gas studies. Mean ventilation time was 6.2 days. Progressive hypoxemia and deterioration of pulmonary function were not seen. The incidence of pneumonia and tension pneumothorax was low. Overall mortality was 10.6 per cent. The most common cause of death was brain death. No deaths were the result of hypoxemia.

Radiology and the massive trauma victim.

The radiologic protocol as presented above has evolved over a period of several years. It is currently is use, and with only rare exceptions, has been found to be completely adequate for the massively traumatized patient. Its most important aspect is that practically no time is expended in the radiologic assessment of the patient.

Transcatheter embolization of autologous clot in the management of bleeding associated with fractures of the pelvis.

Extraperitoneal hemorrhage, associated with a fracture of the pelvis, is a major cause of death in pedestrian accidents. Transfusion alone may be unsatisfactory. Direct control of bleeding may be required. Surgically, this may be technically difficult or inadequate. Transcatheter embolization of autologous clot was used to control hemorrhage in three patients with such a fracture. If laparotomy is required immediately, arteriography of the pelvic area may be done postoperatively, If laparotomy is not performed, arteriography may define pelvic bleeding sites. Transcatheter embolization of autologous clot controls hemorrhage from branches of the hypogastric artery.

Pitfalls of Swan-Ganz catheterization.

In 60 patients in whom Swan-Ganz catheters apparently had been positioned correctly, the balloon was visualized by inflation with radiopaque contrast medium. Sixteen were located peripherrally; in 15 of these 16, the balloon inflated eccentrically and in each of these instances, an accurate wedge pressure could not be obtained. One patient in this group had an episode of hemoptysis immediately prior to detection of the peripheral location and eccentric inflation of the balloon. The correct placement and safe use of the Swan-Ganz catheter demand that the catheter tip be located in a large pulmonary artery and that redundant loops of catheter be avoided to prevent subsequent peripheral migration. Identification of peripheral placement and eccentric inflation should be suspected if a pulmonary wedge pressure is obtained with a significantly smaller volume of air than the balloon capacity. The use of a continuous flush system will provide an additional alert by a steady rise in the pseudowedge pressure on attempted balloon inflation.

Ruptured thoracic aorta due to blunt trauma.

Thirty-six ruptured thoracic aortas have been diagnosed in a total of 3,500 patients seen at the Maryland Institute for Emergency Medicine in the past 5 years. To our knowledge, no ruptured thoracic aortas have gone undetected. A new method of performing portable chest radiography has been developed which we feel clarifies the diagnosis of mediastinal hematomas and which allows us to determine which patients will undergo aortography. The reported survival rate of 75% is felt to be due to the rapidity with which these patients are brought to the hospital and use of a carefully planned protocol which permits early diagnosis and treatment. These results are due to the combined efforts of the Maryland State Police Helicopter System, the traumatologists, anesthesiologists, nurses, paramedics, radiologists, and thoracic surgeons working together as a completely integrated team.

Combined thoracic aorta and right carotid artery angiography in trauma.

In the critically injured patient, time is of the essence; a method is described for performing a thoracic aortogram for possible ruptured aorta, followed by a right carotid cerebral angiogram as a screening procedure to rule out cerebral vascular shift, using the pigtail catheter.