Source connectivity patterns in the default mode network differ between elderly golf-novices and non-golfers.

Learning to play golf has high demands on attention and therefore may counteract age-related changes of functional brain networks. This cross-sectional study compared source connectivity in the Default Mode Network (DMN) between elderly golf novices and non-golfers. Four-minute resting-state electroencephalography (128 channels) from 22 elderly people (mean age 67 ± 4.3 years, 55% females) were recorded after completing a 22-week golf learning program or after having continued with normal life. Source connectivity was assessed after co-registration of EEG data with native MRI within pre-defined portions of the DMN in the beta band (14-25 Hz). Non-golfers had significantly higher source connectivity values in the anterior DMN compared to non-golfers. Exploratory correlation analyses did not indicate an association to cognitive performance in either group. Inverse correlations between a marker of external attention with source connectivity of the anterior DMN may suggest a trend in the golf group only, but have to be replicated in future studies. Clinical relevance of these findings remains to be elucidated, but the observed difference in the anterior DMN may provide a starting point to further investigate if and how learning golf may have an impact on physiological age-related cognitive changes.

Patient volume per surgeon does not predict survival in adult level I trauma centers.

BACKGROUND: The 1999 American College of Surgeons resources for optimal care document added the requirement that Level I trauma centers admit over 240 patients with Injury Severity Score (ISS) > 15 per year or that trauma surgeons care for at least 35 patients per year. The purpose of this study was to test the hypothesis that high volume of patients with ISS > 15 per individual trauma surgeon is associated with improved outcome. METHODS: Data were obtained from the trauma registry of the five American College of Surgeons-verified adult Level I trauma centers in our mature trauma system between January 1, 1998, and March 31, 1999. Data abstracted included age, sex, Glasgow Coma Scale (GCS) score, intensive care unit length of stay, hospital length of stay, probability of survival (Ps), mechanism of injury, number of patients per each trauma surgeon and institution, and mortality. Multiple logistic regression was performed to select independent variables for modeling of survival. RESULTS: From the five Level I centers there were 11,932 trauma patients in this time interval; of these, 1,754 patients (14.7%) with ISS > 15 were identified and used for analysis. Patients with ISS > 15 varied from 173 to 625 per institution; trauma surgeons varied from 8 to 25 per institution; per-surgeon patient volume varied from 0.8 to 96 per year. Logistic regression analysis revealed that the best independent predictors of survival were Ps, GCS score, age, mechanism of injury, and institutional volume (p < 0.01). Age and institutional volume correlated negatively with survival. Analysis of per-surgeon patient caseload added no additional predictive value (p = 0.44). CONCLUSION: The significant independent predictors of survival in severely injured trauma patients are Ps, GCS score, age, mechanism of injury, and institutional volume. We found no statistically meaningful contribution to the prediction of survival on the basis of per-surgeon patient volume. Since this volume criterion for surgeon enpanelment and trauma center designation would not be expected to improve outcome, such a requirement should be justified by other measures or abandoned.

Primary aortoenteric fistula: computed tomographic diagnosis of an atypical presentation.

A primary aortoenteric fistula is a potentially devastating complication of untreated aortic aneurysmal disease. The clinical presentation can be confusing, leading to a delay in diagnosis. Computed tomography (CT) can greatly assist in establishing the diagnosis. An unusual case of a primary aortoenteric fistula with an atypical presentation is described. The patient presented with symptoms indicating an exacerbation of recurrent nephrolithiasis. No clinical history of an abdominal aortic aneurysm or previous history of gastrointestinal hemorrhage was reported. A CT scan demonstrated extravasation of arterial contrast into the duodenum. The aorta was repaired with an in-line prosthetic graft. A review of the literature regarding this rare entity and surgical options are presented.

Prehospital intubation in patients with severe head injury.

BACKGROUND: Prehospital intubation and airway control is routinely performed by paramedics in critically injured patients. Despite the advantages provided by this procedure, numerous potential risks exist when this is performed in the field. We reviewed the outcome of patients with severe head injury, to determine whether prehospital intubation is associated with an improved outcome. METHODS: A retrospective review of registry data of patients admitted to an urban trauma center with severe head injury (field Glasgow Coma Scale score of < or =8 and head Abbreviated Injury Scale score of > or =3) was performed. Patients were stratified by methods of airway control performed by prehospital personnel: not intubated, intubated, or unsuccessful intubation. Mortality was determined for each group. To control for significant variables between these populations, matching and multivariate analysis were performed. RESULTS: Patients requiring prehospital intubation or in whom intubation was attempted had an increased mortality (81% and 77%, respectively) when compared with nonintubated patients (43%). The mortality for patients who had prehospital intubation performed did not demonstrate an improved survival using matching. In fact, intubated patients had a significantly higher relative risk (RR) of mortality when compared with nonintubation (RR = 1.74,p < 0.001) and unsuccessful intubation patients (RR = 1.53, p = 0.008) CONCLUSION: For patients with severe head injury, prehospital intubation did not demonstrate an improvement in survival. Further prospective randomized trials are necessary to confirm these results.

Central venous injuries of the subclavian-jugular and innominate-caval confluences.

Injuries to the central venous system can result from penetrating trauma or iatrogenic causes. Injuries to major venous confluences can be particularly problematic, because the clavicle and sternum seriously limit exposure of the injury site. We report our institution's experience with central venous injuries of the subclavian-jugular and innominate-caval venous confluences. Significant injuries of the subclavian-jugular venous confluence frequently result from penetrating trauma, while injuries to the innominate-caval confluence are usually catheter-related. Median sternotomy provides adequate exposure of the innominate-caval confluence, while exposure of the subclavian-jugular venous confluence requires extension of the median sternotomy incision into the neck and resection of the clavicle. The literature is reviewed.

Pedestrian versus motor vehicle accidents: an analysis of 5,000 patients.

BACKGROUND: Pedestrian versus motor vehicle accidents are associated with substantial morbidity and mortality. Previous studies have examined pedestrian injury profiles on an individual hospital basis and have been limited by small patient populations. The objective of this study was to examine the demographics and injury profiles of pedestrian versus motor vehicle accidents in a large trauma system. STUDY DESIGN: Five thousand pedestrians injured by motor vehicles whose records were entered in a centralized county trauma database were reviewed retrospectively over 3 years. Patients were grouped by age: pediatric (less than 15 years), adult (15 to 65 years), and elderly (older than 65 years). The main outcome measures included mortality, hospital stay, ICU stay, Injury Severity Score, Glasgow Coma Scale, Revised Trauma Score, level of residual disability, and payer source. RESULTS: The pediatric group represented 38.1% of the study population, adults 53.9%, and the elderly 8.0%. Mortality was highest among the elderly (27.8%), followed by adults (8.1%) and children (3.1%). Overall, the pediatric group had the lowest Injury Severity Score (6.8 +/- 0.2, mean +/- SEM), the highest Revised Trauma Score (7.5 +/- 0.9), and the highest Glasgow Coma Scale (13.9+/-0.1). Hospital stay (4.9+/-0.2 days) and ICU stay (4.6 +/- 0.3 days) were also shortest in this age group. Among all patients, injuries included musculoskeletal (34.3%), head and neck (30.0%), external (24.4%), abdomen and pelvis (3.9%), chest (2.4%), spine (1.8%), and other (3.2%). Operations were required in 11%: orthopaedic (67%), thoracic (2%), abdominal (11%), neurosurgical or head (6%), and other (14%). At the time of discharge, 78% of patients had a temporary disability, 4% had a permanent handicap, and only 16% were functioning at preadmission capacity. Among those with identifiable payer sources, 45% were state or federal, 25% were cash or self-pay, 18% of patients belonged to an HMO or had a group carrier, and 12% were from other sources. CONCLUSIONS: This study contributes the largest database reported on motor vehicle versus pedestrian accidents and finds that these accidents are common in a large urban trauma system. Hospital stay, Injury Severity Score, Revised Trauma Score, Glasgow Coma Scale, and the mortality rate worsen with age. The high mortality rate among the elderly indicates the need for more aggressive and effective prevention efforts.

Hypothermia in trauma patients.

Hypothermia occurs commonly in severely injured patients and is associated with a high mortality rate. It perturbs the normal homeostatic response to injury and affects multiple organ systems and physiologic processes. In trauma patients, hypothermia-induced coagulopathy often leads to marked bleeding diathesis and frequently provides a challenge for the surgeon. Once hypothermia occurs, it is often difficult to correct. Efforts to prevent and treat hypothermia in trauma patients should be instituted in the field and continued as an integral part of the resuscitation process. Hospital personnel and physicians at various levels caring for trauma patients from the initial injury and thereafter should bear in mind that a patient's temperature is as important as any other vital sign. Appropriate measures for preventing and treating hypothermia should be instituted promptly and tended to with utmost vigilance.

Multiple organ failure: by the time you predict it, it's already there.

OBJECTIVE: Validate an at-risk population to study multiple organ failure and to determine the importance of organ dysfunction 24 hours after injury in determining the ultimate severity of multiple organ failure. METHODS: We evaluated 105 patients admitted to five academic trauma centers during a 1-year period who survived for more than 24 hours with Injury Severity Scores > or = 25 and who received 6 or more units of blood. Organ dysfunction was scored daily with a modified multiple organ failure scoring system made up of individual adult respiratory distress syndrome score, renal dysfunction, hepatic dysfunction, and cardiac dysfunction scores. Multiple organ failure (MOF) severity was quantitated using the maximum daily multiple organ failure score and the cumulative sum of daily multiple organ failure scores for the first 7 days (MOF 7) and 10 days (MOF 10). Independent variables included markers of tissue injury, shock, host factors, physiologic response, therapeutic factors, and organ dysfunction within the first 24 hours after admission. Data were subjected to a conditional stepwise multiple regression analysis, first excluding and then including 24-hour MOF as an independent variable. RESULTS: Of the 105 high-risk patients, 69 (66%) developed a maximum daily multiple organ failure score > or = 1; 50 (72%) did so on day 1 one and 60 (87%) did so by day 2. In multiple regression models, the multiple correlation coefficient increased from 0.537 to 0.720 when maximum MOF was the dependent variable, from 0.449 to 0.719 when maximum daily MOF was the dependent variable, from 0.519 to 0.812 when MOF 7 was the dependent variable, and from 0.514 to 0.759 when MOF 10 was the dependent variable. CONCLUSION: We have confirmed that the population of patients with Injury Severity Scores > or = 25 who received 6 or more units of blood represent a high-risk group for the development of multiple organ failure. Our data also indicate that multiple organ failure after trauma is established within 24 hours of injury in the majority of patients who develop it. It appears that multiple organ failure is already present at the time when most published models are trying to predict whether or not it will occur.

Penetrating injuries to the subclavian and axillary vessels.

BACKGROUND: Subclavian and axillary vascular injuries are notorious for their mortality and their difficult surgical exposure. In the present study we analyze our experience with 79 patients and describe the techniques used for surgical access to these vessels. STUDY DESIGN: Retrospective review of the medical records of all patients with penetrating injuries to the subclavian or axillary vessels who had been admitted to 2 Los Angeles trauma centers during a 4-year, 3-month period. RESULTS: Seventy-nine patients were admitted during the study period January 1993 to March 1997 (58 gunshot injuries, 21 other penetrating injuries). The artery was injured in 59 patients and the vein in 40 (20 patients had both arterial and venous injuries). Eighteen patients (23%) were admitted with no signs of life or were in extremis and underwent an emergency room thoracotomy without any survivors. Fifty-eight patients underwent exploration in the operating room, 1 patient with an arteriovenous subclavian fistula was successfully managed with a radiologically placed endovascular stent, and 2 patients with minimal subclavian artery injuries were managed nonoperatively. Overall mortality was 34.2%. Excluding the ER thoracotomies the overall mortality was 14.8%. The mortality for isolated arterial injuries was 20.5%, for isolated venous injuries 50%, and for both vessels 45.0%. The mortality in venous injuries was significantly higher than in arterial injuries (p < 0.05). The standard clavicular incision provided adequate exposure in 32 (50.0%) of the operating room cases. In the other 50% of operating room cases a combination of a clavicular incision with a median sternotomy or thoracotomy was necessary. Proximal subclavian injuries may be accessed through a clavicular incision combined with a median sternotomy irrespective of left or right site location. CONCLUSIONS: Subclavian and axillary vascular injuries remain lethal. A clavicular incision provides satisfactory surgical exposure in about half the patients. In patients with proximal injuries addition of a median sternotomy provides adequate surgical access in both right and left subclavian vessels.

Epidemiology of major trauma and trauma deaths in Los Angeles County.

BACKGROUND: Our objective was to study population-based trauma-related injuries and deaths in the county of Los Angeles and to identify trends and progress towards meeting the "Year 2000 National Health Objectives." STUDY DESIGN: We did a retrospective study for the year 1996. Data were obtained from the Trauma Registry of the Emergency Medical Services of the Department of Health Services, and the Coroner's Department of the County of Los Angeles. Traumatic injuries and deaths per 100,000 of the population were calculated according to mechanism, race, age, and gender. RESULTS: During 1996, there were 12,136 major trauma admissions in the 13 trauma centers in Los Angeles County. Another 1,929 victims died at the scene or were certified dead at nontrauma centers and were taken to the Coroner's Department (total 14,065 victims). The overall major injury rate was 151.0 per 100,000 population and the death rate was 30.9 per 100,000. The trauma death rate per 100,000 population was 56.4 for African-Americans, 33.5 for Hispanics, 26.3 for Caucasians, and 11.6 for Asians. Homicides were the leading cause of traumatic deaths (45.3%) followed by traffic accidents (31.9% of deaths). Firearms were responsible for 3,899 major injuries or deaths (41.7 per 100,000 population). The overall homicide rate per 100,000 population was 14.0, with a much higher rate for African-Americans (40.4 per 100,000) and Hispanics (18.7 per 100,000) than Caucasians (4.0 per 100,000) or Asians (3.4 per 100,000). African-American males were at very high risk for homicide (73.3 per 100,000), and in the age group 15 to 34 years, this problem reaches epidemic proportions (164.2 per 100,000). Traffic accidents accounted for 69.0 major injuries and 9.6 deaths per 100,000 people. Males were at significantly higher risk of dying in traffic accidents than females. People over 60 years of age were at significantly higher risk of traffic-accident death than younger people, for both passenger and pedestrian groups (p < 0.01). Firearm-related suicides were responsible for 4.6 deaths per 100,000 population. Caucasian males over 65 years were at much higher risk of suicide by penetrating trauma (29.5 per 100,000) than were Hispanics (6.3 per 100,000), Asians (5.4 per 100,000), or African-Americans (no deaths) in the same gender and age group. CONCLUSIONS: Trauma remains a major health problem in the county of Los Angeles. Despite the significant reduction of intentional trauma in 1996, it still exceeds national figures and is much higher than the targeted "Year 2000 National Health Objectives." Aggressive prevention strategies need to focus on the population groups at excessive risks of injury by assault, traffic accidents, and suicides.

Laparoscopic cholecystectomy facilitated by hydrodissection.

Hydrodissection has been used in the past in open cholecystectomy to facilitate dissection in difficult cases. Injection of 50 mL of saline, with a laparoscopic cyst aspiration needle during laparoscopic cholecystectomy between the gallbladder and the liver, causes an edematous area 1-1.5 cm thick between the gallbladder and the liver. This allows dissection to be carried out prograde and retrograde with less bleeding and a much smaller chance of gallbladder perforation and the escape of stones. One hundred and thirty-three laparoscopic cholecystectomies (LC) utilizing hydrodissection were compared to 48 historical controls (HC), comparing blood loss, stone spillage, and dissection time. Blood loss was on average less than 5 mL in the LC group and 56 mL in the HC. One case of minor biliary spillage occurred in the LC group and 11 gallbladder perforations in the HC group. Time taken for the dissection was 6.4 minutes for LC and 16 minutes for HC. Laparoscopic hydrodissection was accompanied by less bleeding, fewer incidents of gallbladder damage and stone spilling, and a much faster dissection time. It can also be performed prograde, which is helpful in liver cirrhosis.

Epidemiology of immediate and early trauma deaths at an urban Level I trauma center.

The objective of this study is to identify and differentiate the injury patterns and causes of death among patients who died within the 1st hour and those in the period between 1 and 48 hours after hospital admission. Information was collected from the 1994 to 1996 trauma data base at an urban Level I trauma center. The records of 155 trauma patients who died within the 1st hour (immediate trauma death, ITD) and between 1 and 48 hours (early trauma death, ETD) were examined retrospectively. Total and constituent Injury Severity Score (ISS), Trauma Score (TS), and Glasgow Coma Score were analyzed. ITDs constituted 49 per cent of all deaths within 48 hours. Blunt mechanisms accounted for 37 per cent of ITDs and 40 per cent of ETDs (not significant), whereas penetrating trauma accounted for 59 per cent of ITDs and 56 per cent of ETDs (not significant). Exsanguination most commonly caused death among ITDs (54%) and head injury (51%) among ETDs (P < 0.01). Patients who died within the 1st hour had higher ISS (42.6 +/- 23.2, P < 0.03), lower TS (1.7 +/- 1.9, P < 0.0001), and lower Glasgow Coma Score (3.1 +/- 1.1, P < 0.0001) than those who died after the 1st hour. Patients with ITD had a significantly worse chest ISS than those with ETD (47.4 +/- 28.6 vs 19.0 +/- 19.1, P < 0.0001). We conclude that 1) ITD is caused primarily by exsanguination, whereas ETD is largely due to the sequelae of severe neurologic injury; 2) ITD has a significantly lower TS and higher ISS than ETD; and 3) thoracic injuries are more severe among patients with ITDs than among those with ETDs. The severity of thoracic injury among ITDs suggests that rapid surgical intervention is critical during the resuscitation of these severely injured patients.

Perforated appendicitis: is it truly a surgical urgency?

Advanced perforated appendicitis with localized findings has classically been treated with either operative therapy or with percutaneous drainage. The role of nonoperative therapy followed by interval appendectomy (IA) remains controversial. We assessed the safety and efficacy of conservative management for perforated appendicitis in a 5-year review of patients treated conservatively for perforated appendicitis with localized abscess or phlegmon. Patients were treated initially with intravenous antibiotics, and CT-guided drainage was used only if the patient failed to improve after 48 to 72 hours. Patients still not improving underwent appendectomy. Patients responding to conservative therapy were recommended IA in 6 to 12 weeks. Sixty-six patients with 54 abscesses and 10 phlegmons were treated. Fifty-one patients (92%) improved without surgery. Only 58 per cent of the abscesses required percutaneous drainage. The mean length of stay for conservative therapy was 7.6 days. Forty-one patients underwent IA with a 10 per cent morbidity and a mean length of stay of 1.4 days. Conservative management of appendicitis with localized perforation or phlegmon is safe and effective. Percutaneous drainage is frequently not required. IA is associated with low morbidity without prolonged hospitalization.

Base of skull internal carotid and internal jugular gunshot wounds treated conservatively: inadequate treatment, or was well enough left alone?

Zone three carotid injuries present problems of access in emergency situations. Not only are the methods time consuming, but they also put certain structures in the neck at risk. A patient was treated at this institution with a large calibre gunshot injury of the right internal carotid and internal jugular vein. He was neurologically intact and his bleeding had been completely controlled. A decision was made to treat him conservatively and he recovered uneventfully with no neurological deficit and no further bleeding. Emergency exposure of the distal carotid artery involves dislocating the mandible, putting the facial nerve and parotid gland at risk of injury. Base of skull carotid injuries are best treated expectantly if there is no active bleeding or progressive neurological impairment. Careful follow-up is required to diagnose and treat carotid-jugular fistulas, false aneurysms and stenoses early.

Gunshot injuries of the lower oesophagus.

We present seven cases of lower oesophageal gunshot injury cared for by one surgeon. Diagnosis was made clinically, with the help of chest X-rays and with oesophagography and oesophagoscopy. Five were treated with wide debridement and resection of the distal esophagus and oesophago-gastric anastomosis with a Nissen wrap to protect the anastomosis. Two lesser injuries were treated by primary repair. The five treated with resection and oesophago-gastric anastomosis did not leak and the patients were discharged after oesophagography 10 days postoperatively. Primary repairs in two patients were complicated by oesophageal leaks, one subclinical and one with an empyema. The oesophageal blood supply is segmental in areas and variable in the distal part. Injury due to a bullet wound may cause more damage than is evident at surgery. Additional mobilization can further devascularize the distal oesophagus and lead to anastomotic leaks. We advocate wide debridement of oesophageal gunshot injuries and resection of the distal oesophagus. Continuity is restored with a primary oesophago-gastric anastomosis (double layer) with a fundoplication to protect the anastomosis.

Femoral hernia: the dire consequences of a missed diagnosis.

Femoral hernia has always presented more difficulty in diagnosis than other external abdominal hernias. The incidence of incarceration and strangulation is higher in our series than the published literature would suggest. A retrospective study was performed at our institution from February 1990 to June 1995. In that period, 22 patients were operated on for femoral hernia. There were 16 women and 6 men, average ages 51 and 48 years, respectively. The men weighed on average 209 lb, and the women, 154 lb. Three of our patients had elective repair of their hernias (16%); 19 were performed urgently or emergently (86%). Of the emergency repairs, 3 had strangulated small bowel requiring resection (16%), 1 had a strangulated vermiform appendix with abscess formation (5%), 3 had strangulated omentum requiring excision (16%), giving a total of 7 patients with strangulation and necrosis of the hernial contents (36%). The remainder had viable contents in the hernia sac. The time from the onset of symptoms to presentation at the hospital varied from 1 day to 3 years. The time from strangulation to presentation was between a few hours and 4 days. Surgery was performed on the day of admission (within 24 hours) on all but 2 of our patients. Procedures performed were McVay repair, 13; Bassini, 4; laparoscopic with Marlex mesh, 1 patient; drainage of a groin abscess in 2 patients with later repair; and on 2 patients the type of repair was not specified. One of the patients died. Postoperative wound infection occurred in 2 heavily contaminated patients, and 3 had pneumonia. Patients with no regular physician and no routine physical examinations are at higher risk for developing strangulation of femoral hernias. Emergency physicians and general practitioners are in the best position to diagnose these hernias early, when treatment can be elective.

Early computed tomography is rarely necessary in gallstone pancreatitis.

The role of early CT scanning in acute gallstone pancreatitis remains ill defined. The purpose of our study was to: 1) determine whether our previously identified admission prognostic factors for gallstone pancreatitis [white blood cell (WBC) count > or = 14.5 x 10(9)/L, blood urea nitrogen (BUN) > or = 12 mmol/L, Acute and Chronic Health Evaluation II score > or = 5, glucose > or = 150 mg/dL, and heart rate > or = 100 beats/min)] correlate with the severity of pancreatic inflammation on CT scan, and 2) to determine the utility of early CT scanning in the management of gallstone pancreatitis. Admission clinical and laboratory variables were collected prospectively. Early CT scan findings were graded using the Balthazar scoring system and subgrouped into mild-moderate (Balthazar grades A-C) or severe (grades D and E) by a radiologist blinded to the patients' clinical status. Ninety-seven patients underwent surgery during their initial hospitalization without preoperative CT scanning. Four had operative complications (4%). Forty-two patients underwent early CT scan (grade A, 19%; B, 5%; C, 21%; D, 10%; and E, 45%), but only four (all grade E) had surgery delayed because of necrotizing pancreatitis, abscess, or pseudocyst. All four had persistent abdominal pain. There was one (2.5%) operative complication in the CT group and no deaths. Admission WBC count > or = 14.5 x 10(9)/L and BUN > or = 12 mmol/L correlated with severe pancreatitis (grades D and E) on CT (P < .05). We conclude that in patients with gallstone pancreatitis, 1) admission WBC count > or = 14.5 x 10(9)/L and BUN > or = 12 mmol/L correlate with the severity of pancreatic inflammation on CT scan, and 2) CT scan findings rarely influence management decisions and CT is therefore unnecessary, except in the minority of patients with objective indications of severe or unresolving pancreatitis.

Noniatrogenic pediatric vascular trauma: a ten-year experience at a level I trauma center.

We retrospectively reviewed all pediatric patients (< 18 years old) who presented to a Level I trauma center from 1984 to 1994 with noniatrogenic vascular trauma. There were 48 patients (42 male and 6 female) ages 2 to 17 years. Mechanism of injury included gunshot wounds (34) stab wounds (10), and blunt trauma (4). The lower extremities were most commonly injured (31), followed by upper extremity (17), trunk (8), and neck (4). Twenty-one (44%) patients had associated nonvascular injuries (primarily orthopedic or peripheral nerve). Eighteen (37%) patients underwent preoperative angiography for suspected extremity (15) or carotid injuries (3). Twenty-nine patients went to surgery without angiography based on severe ischemia (11) or hemorrhage (18). Arterial injuries (45) were managed by interposition reverse saphenous vein graft (16), primary repair (15), ligation (5), or other operative (5) and nonoperative treatment (4). Venous injuries (15) were treated with primary repair (8), patch (3), ligation (3), and nonoperative management (1). Fasciotomy was performed in six (12%). There were three deaths (6%), all due to aortic and/or caval injuries. Limb salvage in survivors was 100 per cent. There were no complications from angiography. Postoperative duplex scans demonstrated patency in six of the seven patients studied with venous injuries. We conclude that 1) noniatrogenic pediatric vascular trauma is uncommon, and 2) using an aggressive approach to both the diagnosis and treatment of these injuries can achieve excellent limb salvage rates with a low morbidity and mortality.