Outcome after major renovascular injuries: a Western trauma association multicenter report.

BACKGROUND: Major renal vascular injuries are uncommon and are frequently associated with a poor outcome. In addition to renal dysfunction, posttraumatic renovascular hypertension may result, although the true incidence of this complication is unknown. The objective of this study was to describe the factors contributing to outcome after major renovascular trauma. We hypothesized that the highest percentage of renal salvage would be achieved by minimizing the time from injury to repair. METHODS: This was a retrospective chart review over a 16-year period conducted at six university trauma centers of patients with American Association for the Surgery of Trauma grade IV/V renal injuries surviving longer than 24 hours. Postinjury renal function with poor outcome was defined as renal failure requiring dialysis, serum creatinine greater than or equal to 2 mg/dL, renal scan showing less than 25% function of the injured kidney, postinjury hypertension requiring treatment, or delayed nephrectomy. Data collected for analysis included demographics, mechanism of injury, presence of shock, presence of hematuria, associated injuries, type of renal injury (major artery, renal vein, segmental artery), type of repair (primary vascular repair, revascularization, observation, nephrectomy), time from injury to definitive renal surgery, and type of surgeon performing the operation (urologist, vascular surgeon, trauma surgeon). RESULTS: Eighty-nine patients met inclusion criteria; 49% were injured from blunt mechanisms. Patients with blunt injuries were 2.29 times more likely to have a poor outcome compared with those with penetrating injuries. Similarly, the odds ratio of having a poor outcome with a grade V injury (n = 32) versus grade IV (n = 57) was 2.2 (p = 0.085). Arterial repairs had significantly worse outcomes than vein repairs (p = 0.005). Neither the time to definitive surgery nor the operating surgeon's specialty significantly affected outcome. Ten percent (nine patients) developed hypertension or renal failure postoperatively: three had immediate nephrectomies, four had arterial repairs with one intraoperative failure requiring nephrectomy, and two were observed. Of the 20 good outcomes for grade V injuries, 15 had immediate nephrectomy, 1 had a renal artery repair, 1 had a bypass graft, 1 underwent a partial nephrectomy, and 2 were observed. CONCLUSION: Factors associated with a poor outcome following renovascular injuries include blunt trauma, the presence of a grade V injury, and an attempted arterial repair. Patients with blunt major vascular injuries (grade V) are likely to have associated major parenchymal disruption, which contributes to the poor function of the revascularized kidney. These patients may be best served by immediate nephrectomy, provided that there is a functioning contralateral kidney.

Diagnosis, treatment, and outcome of blunt carotid arterial injuries.

BACKGROUND: Blunt carotid injuries are rare, and present late with devastating strokes. A sizeable single-institution descriptive report could help characterize the injury and its diagnosis and treatment. METHOD: We performed a retrospective review of blunt carotid artery injuries from May 1988 to December 1997 at a level I trauma center. Chart review consisted of demographics, mechanism of injury, associated injuries, diagnostic modalities, initial neurologic status, treatment, and outcome. Discharge outcome was classified as "good" (normal-mild deficit), "fair" (needing daily assistance), "poor" (institutionalized), or "dead." RESULTS: During the study period 16 patients sustained a carotid artery injury. Mean age was 35 years and 63% were female. Vehicular trauma was the most common mechanism of injury (81%), followed by assaults (13%). Dissection was the most common injury (75%), with one quarter having an associated pseudoaneurysm. Initial neurologic presentation was normal in 31% and Glasgow Coma Score was < 13 in 31% (including 13% in coma). Eventual hemispheric symptoms developed in 81%. Associated injuries were present in 94%, commonly head (44%) and chest (50%). Duplex ultrasound accurately identified the injury in all patients (5 of 5) when used. Anticoagulation (88%) had no complications. Observation and therapeutic embolization each resulted in 1 fatal stroke. A third patient, with worsening deficits on heparin, died after carotid ligation, for an overall mortality of 19%. There were no deaths in the 13 patients treated by anticoagulation alone. Six patients (38%) had a "good" neurologic outcome, five (31%) "fair," and two (13%) "poor." Initial neurologic presentation, associated injuries, and mechanism of injury did not appear to correlate with these outcome categories. CONCLUSIONS: These uncommon injuries should be suspected in the presence of head and/or chest injuries, basilar skull fracture, or coma (particularly if the computed tomography scan is unremarkable). Presentation may be varied, but most patients eventually develop hemispheric symptoms. Duplex ultrasound detects many of these injuries, but this does not demonstrate its utility as a screening tool. Anticoagulant therapy appears to be associated with a better outcome than expectant or occlusive therapy.

A practical approach to proteinuria.

Proteinuria is defined as urinary protein excretion exceeding 150 mg/day. It may result from nonpathological (posture, fever, exercise) or pathological (glomerular or tubular) processes. Glomerular proteinuria is an early sign of kidney disease and may also play a role in the progression of glomerular damage. Asymptomatic proteinuria is common; it may be transient or persistent. Transient proteinuria is a benign condition and requires no evaluation. Persistent proteinuria can be the first sign of kidney disease. Persistent proteinuria commonly results from disorders associated with increased glomerular permeability such as nephrotic syndrome, glomerulonephritis (e.g., post-infectious, membranous, membranoproliferative, lupus, IgA), and genetic defects (Alport syndrome, mesangial sclerosis). Tubular disorders should also be considered. Evaluation for the underlying cause is traditional. Whether the early detection and evaluation of proteinuria prevents progressive disease is unknown.

Guns in young hands: a survey of urban teenagers' attitudes and behaviors related to handgun violence.

OBJECTIVE: To determine the nature and causes of gun violence among urban young people. METHODS: We conducted a confidential survey of 1,219 7th and 10th graders in Boston and Milwaukee, regarding their attitudes and behaviors toward violence and handguns. RESULTS: Twenty-nine percent have had a member of their immediate family shot, 42% could get a gun if they wanted, 28% have handled a gun without adult knowledge or supervision, 17% have carried a concealed gun, and 3% reported bringing a gun to school in the past 30 days. Nine percent admitted smoking cigarettes in the past week, 11% admitted smoking marijuana. Twenty-five percent were attacked or threatened within the past year. Reasons for gun carrying were mostly related to perceived safety/threats/revenge (73%), followed by casual handling (17%), hunting (4%), being cool (3%), target practice (2%), and gangs (1%). The following factors were significantly correlated with gun handling by chi 2 analysis, at p < 0.001 (percentage of respondents admitting unsupervised gun handling shown in parentheses): male (39%) versus female (19%); 10th graders (35%) versus 7th graders (24%) seat-belt nonusers (35%) versus users (20%); students who state they have poor grades (39%) versus good grades (26%); cigarette smokers (61%) versus nonsmokers (25%); have a gun in the home (46%) versus no gun in the home (23%). Also strongly correlated in multivariate analysis were violence exposure, having been arrested, and beliefs that "gun carrying is a good idea," or that "only cowards back down from a fight." CONCLUSIONS: Handgun availability and use are high among urban youth; gun carrying is mostly related to safety concerns and easy access, rather than to hunting or sport. This may be a cause of high handgun injury rates in this group. Gun injury prevention programs must address youth safety concerns along with handgun availability.

Obturator hernia: current diagnosis and treatment.

BACKGROUND: Obturator hernia is a rare pelvic hernia for which both diagnosis and therapy are difficult. Because symptoms are nonspecific and specific physical findings are often obscure, diagnosis of obturator hernia is often delayed until laparotomy for bowel obstruction. Strangulation is frequent, and mortality remains high (25%). Primary closure of the hernia defect is difficult because adjacent tissues are not easily mobilized. Although a variety of techniques have been described, surgical repair has not been standardized. METHODS: We report a case of bilateral obturator hernia with incarceration in association with bilateral femoral hernia in which these problems were satisfactorily addressed. RESULTS: The hernias were diagnosed by computed tomography (CT) scan and repaired with synthetic mesh placed in the preperioneal space. This technique is well suited to unilateral and bilateral combinations of obturator, inguinal, and femoral hernias. CT scan in the work-up of severe gastrointestinal symptoms with weight loss may lead to a diagnosis of occult hernia, thereby allowing elective repair and, hopefully, a reduction in mortality risk. CONCLUSIONS: We recommend CT scan for suspected obturator hernia and preperitoneal mesh repair of noninfected cases.

Duration of antibiotic treatment in surgical infections of the abdomen. The role of shock.

Emergency laparotomy requiring perioperative antibiotics is often accompanied by shock. Whether the shock is the result of haemorrhage, sepsis, cardiac disease, or vasodilatation, it represents a profound metabolic alteration which impairs cellular metabolism, causes immunosuppression, and alters pharmacokinetics. These changes lead to an increased risk of infection, which can be overcome, at least in part, by increasing the dose and (probably) the duration of perioperative antibiotics.

Traumatic hypothermia is related to hypotension, not resuscitation.

STUDY OBJECTIVE: To determine whether posttraumatic hypothermia is associated with hemorrhage or with resuscitation. METHODS: We used a sequential hemorrhage-resuscitation rat model. Rats were subjected to hemorrhage (30 mL/kg), then 1 hour of shock, followed by 2:1 crystalloid/blood resuscitation (60 mL/kg) at ambient temperature. A control group underwent neither hemorrhage nor resuscitation. RESULTS: We recorded core temperature and blood pressure every 10 minutes. Temperature drop averaged 3.4 degrees C and was fastest during hypotensive shock. Rate of temperature change correlated with blood pressure (beta = .0102, P < .001), shock phase (beta = .4504, P = .041), and blood pressure during shock phase (beta = .0116, P < .001), but not with resuscitation phase or with duration of shock or resuscitation. Three of 14 rats died during shock, none during resuscitation. An increase in temperature was noted in 1 of 14 rats during shock and in 7 of 11 rats during resuscitation. CONCLUSION: Hemorrhage-associated hypothermia occurs during hypotensive shock, not during fluid resuscitation.

Soft tissue abscesses associated with parenteral drug abuse: presentation, microbiology, and treatment.

Abscess formation at the site of drug injection is the commonest infectious complication in drug addicts. This study characterizes the clinical presentation of the condition, its current microbiology, and treatment outcome. All patients presenting for treatment of soft tissue abscesses associated with parenteral drug abuse over a 21-month period were studied. Sixty-six patients with 70 subcutaneous abscesses after injection of cocaine (85%), heroin (5%), or unreported drugs (10%) were identified. Only 42% were febrile (T > 37.5 degrees C), 54 percent had leukocytosis, and 47 percent had wound fluctuance. Wound cultures (243 isolates in 57 patients) grew predominately anaerobes (143 isolates) and facultative gram-positive cocci (88 isolates). Twenty-six blood cultures were obtained, and five (19%) were positive, two with the same bacteria isolated from the wound. Of the patients tested, 29 percent were positive for hepatitis B surface antigen and 9 percent for HIV. Simple incision and drainage was effective in all cases. Classical signs and symptoms of infection and abscess formation may be absent in this patient population. Many of these patients carry other blood-borne infections which the health professional must guard against. Cocaine injection, and "mixed" aerobic-anaerobic infections predominated, in contrast to earlier reports, when narcotics and aerobes predominated. Simple incision and drainage is adequate treatment; antibiotics, when given, should cover gram-positive and anaerobic bacteria; gram-negative coverage is unnecessary.

Shock-associated right colon ischemia and necrosis.

Ischemic complications associated with hemorrhagic shock after blunt or penetrating trauma can result in acute renal, pulmonary, or hepatic failure. Less well described is the association between hemorrhagic shock and ischemic necrosis of the right colon, with only 14 cases reported in the literature. Herein, we report three previously healthy young trauma victims with shock-associated right colon necrosis. Each patient suffered a period of hypotension after injury. Diagnosis and operation took place within 2 days of initial injury in all three cases. In each patient, a right colectomy and primary anastomosis was performed without complication. Pathologic examination of the resected specimens showed ischemic necrosis, but no evidence of vascular thrombosis or embolic occlusion of the mesenteric vessels. The etiology of this type of ischemic colitis is not clear, but seems to represent a form of nonocclusive mesenteric ischemia. Knowledge of this disease process will lead to early recognition, prompt treatment, and a satisfactory outcome.

Response of type I membranoproliferative glomerulonephritis to pulse methylprednisolone and alternate-day prednisone therapy.

Sixteen children with biopsy-confirmed type I membranoproliferative glomerulonephritis (MPGN) were treated with six alternate-day intravenous pulses of methylprednisolone followed by single-dose alternate-day prednisone for 12-66 months (mean 37 months). The average length of follow-up was 52 months (range 12-127 months). Compared with pretreatment values, the frequency of hematuria (13/16 vs. 8/16, P < 0.05) and the levels of serum albumin (2.66 +/- 0.69 vs. 3.76 +/- 0.39 g/dl, P < 0.001), creatinine clearance (97 +/- 37 vs. 129 +/- 26 ml/min/1.73 m2, P < 0.001), and proteinuria (5.2 +/- 5.1 vs. 1.0 +/- 0.8 g/day, P < 0.001) were significantly improved after 3 months of therapy. Improvement has persisted through the end of the follow-up period. Repeat kidney biopsies showed a significant reduction in acute changes but an increase in chronic changes. Thirteen patients have been off therapy from 1 to 74 months (mean 20.8 months). Nine have a normal urinalysis, creatinine clearance, and protein excretion. The remainder have normal renal function but proteinuria ranging from 3.2 to 4.3 g/day. The data support the evidence of other investigators that corticosteroid therapy is beneficial in type I MPGN and suggest that initiation with pulse methylprednisolone may promote early stabilization of the disease.

Characteristics of trauma centers and trauma surgeons.

We surveyed directors of trauma at 408 trauma centers (as indicated by the state chairmen of the American College of Surgeons' Committee on Trauma [ACSCOT]). Of the 408 trauma directors 290 (71%) responded with information relative to their hospitals and the 1537 general surgeons taking trauma call. Altogether, 75% of the surgeons worked on an identified trauma service, 80% belonged to a cadre of surgeons identified as expert, 52% were viewed as full time, 25% provided in-house staff coverage, and 76% had completed an ATLS course. Six percent of the entire group were 60 to 73 years old and demonstrated a commitment to trauma equal to that of their younger cohorts. As a group, the older surgeons took less call, but when community or the institutional call needs were identified, the older surgeons met the challenge.

A burr-like device to facilitate temporary abdominal closure in planned multiple laparotomies.

OBJECTIVE: To describe and test a method for temporary closure of the abdomen. DESIGN: Open laboratory and clinical studies. SETTING: Department of Surgery, Medical College of Wisconsin, USA. SUBJECTS: 11 patients who underwent planned relaparotomy. MATERIAL: The burr consists of two adherent sheets of polyamide and polypropylene, which may be trimmed to accommodate any wound. One sheet consists of micro-mushrooms, the second of multiple slings. The two sheets stick to each other upon pressure and can easily be separated to open the wound. INTERVENTION: Planned relaparotomy or staged abdominal repair. OUTCOME MEASURES: Measurements of tensile strength and microbiological cultures. RESULTS: The shearing force required to separate the burr is 150 +/- 27 N/5 cm2 when gas sterilized and 77 +/- 11 N/5 cm2 when used in five subsequent laparotomies. No adverse microbiological effects were seen. CONCLUSION: The artificial burr can be used for temporary closure of the abdomen. It circumvents the problems that occur with zip fasteners, Marlex mesh, slide fasteners, and towel clips.

Role of plasminogen-activator inhibitor type 1 in the pathogenesis and outcome of the hemolytic uremic syndrome.

BACKGROUND: Deposition of fibrin in glomeruli and renal failure are characteristic features of the hemolytic uremic syndrome. An inhibitor of glomerular fibrinolysis has been detected in plasma from children with this disorder. In this study, we define the inhibitor and show that its plasma level is correlated with the outcome of the disease. METHODS AND RESULTS: Plasminogen-activator inhibitor type 1 (PAI-1) in plasma was measured with an assay employing a specific monoclonal antibody in 40 consecutive children hospitalized with the hemolytic uremic syndrome: 12 who recovered adequate renal function (serum creatinine, less than or equal to 2.0 mg per deciliter [177 mumol per liter]) without dialysis, 23 who recovered adequate renal function after peritoneal dialysis, and 5 who did not recover adequate renal function after undergoing dialysis. At presentation, plasma PAI-1 levels were higher in the patients with the hemolytic uremic syndrome than in nine children with other forms of acute renal failure. That the inhibitor was PAI-1 was indicated by the fact that it was a potent inhibitor of tissue plasminogen activator, was acid-resistant, and was not inhibited by denaturation (all unique traits of PAI-1) and that it was neutralized by an antibody specific for PAI-1. Multivariate discriminant-function analysis revealed that the duration of elevated PAI-1 activity was strongly correlated with the outcome of the disease (P less than 0.001). Peritoneal dialysis reduced plasma PAI-1 levels dramatically. CONCLUSIONS: Our studies suggest that PAI-1 is the circulating inhibitor of fibrinolysis in the hemolytic uremic syndrome. Normalization of plasma PAI-1 levels (e.g., by peritoneal dialysis) is correlated with improvement in renal function. However, the possibility that increased plasma levels of PAI-1 are either causes or effects of the hemolytic uremic syndrome is not unequivocally established by these studies.

Pitfalls in the use of color-flow duplex ultrasound for screening of suspected arterial injuries in penetrated extremities.

We compared color-flow duplex ultrasonographic scanning (CFD) to arteriography in 67 patients who sustained 75 penetrating injuries to the extremities without obvious arterial injury. There were 72 negative and three (4.0%) positive CFD studies and no failed attempts. With arteriography as the "gold standard," CFD had a specificity of 99% and a sensitivity of 50%, positive and negative predictive values of 66% and 97%, and an accuracy of 96%. Small pseudoaneurysms were missed in an axillary and an aberrant radial artery, and a genicular artery pseudoaneurysm was misread as originating from the popliteal artery. Cautious interpretation of negative studies appears warranted, particularly in the axilla and in bifurcated arteries. Extremity arteries should be completely imaged to rule out aberrant anatomy. Questionable studies should be confirmed arteriographically. With these caveats, color-flow duplex scanning may be useful for screening extremities with penetrating injuries thought to harbor occult arterial injuries.

Carcinoma of the sigmoid colon: an unusual cause of Fournier's gangrene.

We report a case of perforated adenocarcinoma of the sigmoid colon in an inguinal hernia presenting as Fournier's gangrene. Bowel perforation has been known to cause this disease but, to our knowledge, perforation in an inguinal hernia due to benign or malignant disease has not been reported elsewhere. Gastrointestinal tract perforation should be sought as a potential etiology in patients with necrotizing fasciitis of the genitalia. When such a perforation exists occult malignancy should be ruled out.

Comparison of three methods of rewarming from hypothermia: advantages of extracorporeal blood warming.

We developed a new technique, extracorporeal venovenous rewarming (EVR), to rewarm hypothermic patients in the intensive care unit or operating room. We compared this method with the active external (standard) techniques of warming blankets; heated ventilator circuits, intravenous fluids, and gastric and peritoneal lavage; and cardiopulmonary bypass. The EVR technique warmed patients' blood or additional blood products and crystalloids to 40 degrees C at 150-400 mL/min and allowed survival from a core temperature of 31.1 degrees C after massive injury. The EVR technique rewarming patients more rapidly than standard techniques and may be most appropriate in patients with multisystem trauma when rapid correction of hypothermia-related hypovolemia, coagulopathy, and arrhythmia is necessary. Cardiopulmonary bypass is required in severely hypothermic patients with cardiac arrest. Standard techniques can be used when these immediately life-threatening conditions are not present.

Prostaglandin inhibitors in the treatment of nephrotic syndrome.

The management of nephrotic syndrome resistant to corticosteroid and cytotoxic therapy is unclear. In such patients, prostaglandin inhibitors can reduce proteinuria. Mechanisms may include a reduction in transcapillary hydraulic pressure and a decrease in capillary wall permeability. The antiproteinuric effect of these agents is enhanced by volume depletion induced by sodium restriction and thiazide diuretics. Complications may include aggravation of edema, hemodynamic renal failure, hyperkalemia, and drug nephrotoxicity. Although a reduction in protein excretion may improve the clinical status of nephrotic patients, it is unclear whether such methods will improve renal survival.

Calculated empiric antimicrobial therapy for mixed surgical infections.

In acute life-threatening surgical infections requiring immediate institution of antimicrobial therapy before bacteriological results are available, antibiotic treatment must be empiric. For best efficacy a more sophisticated form of empiric therapy is offered, termed calculated antibiotic therapy (CAT). Calculated antibiotic therapy requires consideration of a) typical bacterial spectrum; b) bacterial pathogenicity and synergism; c) antibacterial concentrations at the site of infection; d) toxicity and adverse effects; e) interaction with immune response; and f) results of properly conducted trials. Intraabdominal infections are used as an example here to assess the efficacy of clinically used cephalosporins and penicillins for determination of calculated antibiotic therapy. CAT identifies Escherichia coli and Bacteroides fragilis as the most important pathogens for intraabdominal infections and determines the most effective antibiotics at the tissue breakpoint, which is defined as the minimal concentration maintained for more than 90% of the dosage interval period at the infected tissues. At the tissue breakpoint calculated antibiotic therapy identifies cefotaxime-generation cephalosporins to be fully (100%) active against the most important aerobic pathogen E. coli and metronidazole as fully active against the important obligate anaerobe B. fragilis. Calculated antibiotic therapy becomes relatively important, since impeccably controlled clinical therapeutic trials as a foundation for therapy are rarely published.

Temporary abdominal closure (TAC) for planned relaparotomy (etappenlavage) in trauma.

Planned relaparotomy (temporary abdominal closure) was studied prospectively in 20 trauma patients. Four died in the first 24 hours from hypothermia, coagulopathy, shock (three), and septic shock (one). The 16 survivors had a Velcro-like prosthetic placed to facilitate abdominal closure and re-entry. Prosthetic was necessary in eight because bowel edema precluded fascial closure, and useful for removal of packing (three) and for the management of peritonitis (five). The prosthetic did not open spontaneously, nor was it associated with evisceration or bowel fistula. Temporary abdominal closure (TAC) permitted reappraisal and staged repair of intra-abdominal pathology, including bowel resection and anastomosis. TAC identified 14 problems early: bleeding (five), bile leaks (two), GI complications (six), liver necrosis (one). Five patients developed superficial wound infections, and three went on to develop fascial necrosis.