Prognostic factors in blunt chest trauma. Analysis of 652 cases.

All records of 652 patients treated for blunt chest trauma at Ullevål Hospital, Surgical Department 3, during the period 1973-1981 were analyzed for factors predictive of prognosis. Mortality for the whole group was 7.7%. Age, blood pressure on admission, the number of fractured ribs, the need for blood transfusions and the need for artificial ventilation were the most important predictors of prognosis. Mortality increased significantly when at least two extrathoracic injuries were present (22.6%). Intrathoracic injuries did not increase mortality in cases of isolated thoracic injuries. Combined thoraco-abdominal injuries carried a high mortality (25%), especially when the injury had resulted in rupture of the diaphragm (57.1%). There were no sex-related differences. The majority of the patients could be handled adequately with oxygen support, chest drainage, physiotherapy and pain relief. The incidence of bronchial infection, septicaemia and hypercoagulability was significantly higher for patients on ventilators than for patients breathing spontaneously. Mortality increased when septicaemia or bronchial infection was present (30.8 and 21.9%, respectively). The injury severity score (ISS) for the 50 patients who died in the hospital was similar to that of some other reports.

High-dose corticosteroids in thoracic trauma.

Experimental data show that lung injury may be prevented or reduced when steroids are administered early. It seems, however, difficult to reverse a lung injury which is already established. Accordingly, we have since 1976 administered high doses of methylprednisolone already on admission in patients with multiple rib fractures and/or flail chest (30 mg/kg i.v. X 3 at 8 hr intervals). A retrospective analysis of 143 patients with severe blunt chest trauma, most of whom were multitraumatized (72%) and many in shock (19%) revealed a significantly lower mortality for 44 steroid treated patients compared to 99 nonsteroid patients with similar injuries (9.1 vs 29.3%, p = 0.02). The incidence of bronchial infection and septicemia was not increased in steroid treated patients. There was also a lower incidence of multiple organ failure in the steroid treated group (4.5%) as compared to the control group (9.1%, n.s.). Hemodynamic and blood gas changes were examined in a prospective controlled study including 40 patients with multiple rib fractures and lung contusion. Pulmonary vascular resistance (PVR), which is a good parameter of injury severity, was reduced significantly in the steroid treated group. This led to a reduction in right heart work. The corticosteroid induced reduction in PVR was seen whether the patient was on a ventilator or breathed spontaneously. There were no significant differences in the a-v oxygen difference or in intrapulmonary shunting. Both the number of complications and the duration of artificial respiration were reduced in the steroid group.

Corticosteroids in the treatment of blunt injury of the chest.

In a prospective, controlled study, the effects of large doses of methylprednisolone sodium succinate (MP) were examined in patients subjected to severe blunt injury of the chest. Forty patients with multiple fractures of ribs were selected for the study. The majority of the patients had associated extrathoracic injuries. Chest X-ray films revealed changes characteristic of pulmonary contusion in all cases. Twenty patients were given MP 30 mg/kg body weight intravenously and were compared with 20 patients receiving no steroids, but who were otherwise treated identically. There were no differences between the two groups with respect to the A-VO2 difference and intrapulmonary shunting. However, the steroid treatment led to a significant reduction in pulmonary vascular resistance and to a reduction of the work of the right side of the heart. The number of complications and periods of artificial respiration were reduced in the steroid group. All patients survived.

Renal artery aneurysm. Ex vivo repair and autotransplantation.

Reconstructive surgery for renal artery aneurysm requires adequate exposure and meticulous dissection. We report 9 patients with 17 aneurysms undergoing ex vivo aneurysmectomy. The reconstructions included vessel plasties, vein and arterial interponates, followed by autotransplantations to the iliac fossae. All kidneys functioned spontaneously, and all survived. Observation times of up to 7 years have now elapsed. Microsurgery and modern preservation techniques in the extracorporeal setting have extended the borders of renal artery surgery.

Mechanisms of left ventricular filling during increased preload and inotropy.

To examine the factors contributing to left ventricular filling, experiments were performed in anesthetized, open-chest dogs with intact or mechanically constricted mitral ostium. Stroke volume was raised either by increasing left ventricular end-diastolic volume (preload) by blood volume expansion or by infusing isoproterenol, a beta-adrenergic agonist. In all experimental settings, stroke volume rose in proportion (r greater than 0.9) to the pressure time product (PTP = integral of the diastolic atrio-ventricular (A-V) pressure difference). During saline infusion atrial distention and contraction increased atrial pressure more than ventricular pressure whereas diastolic filling time (DFT) was not lengthened. Peak mitral and peak aortic flow rose almost equally. During isoproterenol infusion at constant heart rate (atrial pacing), the increase in PTP was mainly caused by a longer DFT. When heart rate was allowed to rise, DFT was reduced and the A-V pressure difference increased because of a greater reduction in ventricular than in atrial pressure in early diastole. Thus, the A-V pressure difference is generated in different ways by raising preload and inotropy with and without changes in heart rate.

Tracheo-oesophageal fistula caused by cuffed tracheal tubes.

Two patients with tracheo-oesophageal fistula following endotracheal intubation and tracheostomy are reported. In both cases the fistulas were related to inflammation of the cuffs distal to the tracheostomy. Two kinds of surgical treatment were performed: (1) Resection of 3 cm of the cervical trachea, closure of the oesophageal fistula opening with absorbable sutures and interposing a muscle flap of the left sternohyoid muscle. (2) No resection of the trachea. Direct closure of the fistula openings, and interposition with fixation to the trachea of a vascularized intercostal muscle flap via a right-sided thoracotomy. For optimal results of surgery, the pre-operative requirements should include control of septicaemia and gastrobronchial regurgitation, establishment of spontaneous ventilation and correction of malnutrition. For these purposes, the gastrostomy and transgastric jejunostomy regime was important in our patients. The simultaneous use of tracheal and oesophagus tubes is considered a risk factor in development of tracheobronchial fistulas.

Injures of the colon and rectum.

Experience gained in wartime surgery have made important contributions to the treatment of colon injuries. During World War I, when the method of treatment was primary closure, the mortality rate was 60-70%. In World War II, when, following the recommendation of Ogilvie (15), the preferred method of treatment was exteriorization or proxima colostomy, the mortality rate fell to 25-30%. Given such marked improvement it was inevitable that the practice of exteriorization would be applied to civilian life. In 1951 Woodhall and Ochsner (24) suggested a more selective approach to the treatment of large bowel injuries. Following their report other authors (5, 11, 12, 18) have reported favourable results with primary suture and resection of certain types of colon wounds. During hte last decade the mortality of ano-rectal injury has been further reduced mainly due to the use of a washout of the distal rectum, presacral drainage and proper use of antibiotics.

Thoracic injuries.

Establishment of adequate ventilation takes the absolute precedence over all other therapeutic measures. Chest trauma has, therefore, the highest priority in a patient with multiple injuries. Bleeding may also be a decisive component. Emergency treatment aims at reestablishing normal physiological functions. Concurrently, diagnostic measures are taken to assess the underlying pathoanatomical changes. Treatment of chest injuries is a team effort of surgical and anaesthetic staff.

Methylprednisolone in the treatment of lung contusion following blunt chest trauma.

The effects of large doses of methylprednisolone (MP) (30 mg per kg. b.w.) in patients with lung contusion following blunt chest trauma were studied in 10 patients selected at random and compared with 10 chest trauma patients receiving no steroids, but otherwise treated in the same way. All patients survived. Serious post-traumatic complications were reduced in the steroid group. All patients were followed with haemodynamic and metabolic observations for 6 weeks using Swan-Ganz flow directed thermodilution catheters. The most pronounced effect of MP was a significant reduction of pulmonary vascular resistance which may prevent right heart failure. The study demonstrates that MP should be given in sufficient doses in patients with respiratory insufficiency following blunt chest trauma.

Efficacy of steroids in the treatment of lung contusion.

Haemodynamic, metabolic and clinical data were recorded in patients suffering from lung contusion following blunt chest trauma. The effects of large doses of methylprednisolone (30 mg per kg b.w.) were studied in 10 patients selected at random, and compared with 10 patients receiving no steroids, but who otherwise were treated in the same way. Serious post-traumatic complications were reduced in the steroid group. The beneficial effect of the steroid treatment seemed to be associated with a significant reduction in pulmonary vascular resistance, which may lead to a better tissue perfusion and a reduction of right heart work.

Haemodynamic and metabolic consequences of lung contusion following blunt chest trauma.

Haemodynamic and metabolic pulmonary functional data were recorded in 18 patients suffering from lung contusion following blunt chest trauma. Similar qualitative results were obtained whether the patients were given oxygen via a mask (Group 1, 8 patients) or needed assisted ventilation (Group 2, 10 patients). Cardiac index rose 25% during the first five days and remained elevated for three to six weeks. Pulmonary vascular resistance (PVR) and intrapulmonary shunting were elevated on admission and showed peaks on the second and fifth days. After three weeks there was still a shunt fraction of 21%, while PVR had become normal. Bronchial infections, sepsis and hyper-coagulability occurred more frequently in the respirator-treated group. Hospitalization was in average more than three times longer for these patients. It is concluded that respirator treatment should be restricted to patients in urgent need of artificial ventilation. The haemodynamic and metabolic findings were well correlated to the delayed clinical recovery.

Arterio-venous fistula following partial gastrectomy.

Arteriovenous (A-V) fistula localized to the gastrocolic ligament and occlusin of the common hepatic artery are rare complications following surgery. One patient with both these abnormalities after gastric resection is reported. No sign of liver tissue necrosis was demonstrated, and the development of an A-V fistula to the portal vein system might have been beneficial for the oxygenation of the liver tissue. A-V fistulae of the intestinal vessels should be considered in patients with abdominal complaints following gastrointestinal surgery. Resection of the fistula is recommended because of the increased risk of rupture of these thin walled and dilated intestinal vessels.

Carcinoma arising in a lung cyst.

Only a few reports on carcinoma arising in lung cysts exist. The literature is reviewed and one new case added, demonstrating the importance of establishing an exact diagnosis by surgery.