Current helmet and protective equipment usage among previously injured ATV and motorcycle riders.

Injury recidivism among trauma patients may be related to an individual pattern of high risk behaviors. The extent to which an injury episode modifies this behavior pattern is unknown. A self report, voluntary, anonymous, cross sectional survey was administered to motorcycle and all-terrain vehicle (ATV) riders at a popular recreation site. Data included demographics, injury history, and current usage of helmet and protective gear. Two hundred eighty surveys were completed. History of ATV/motorcycle related minor and major injury were reported by 21% and 9%, respectively. Persons with a history of minor ATV/motorcycle injury only were less likely to use a helmet or protective equipment (78% v 74%, p = 0.58 and 49% v 41%, p = 0.29). Persons with a history of any major ATV/motorcycle injury were also less likely to use a helmet or protective equipment (77% v 56%, p = 0.03 and 48% v 40%, p = 0.53). These findings suggest a pattern of persistent high risk behavior among previously injured persons.

Fatal blunt aortic injuries: a review of 242 autopsy cases.

OBJECTIVE: To characterize fatal blunt aortic injury (BAI). METHODS: A retrospective chart review of 242 cases of fatal BAI in patients who underwent an autopsy at our institution between 1984 and 1997 was performed. Comparisons were made for statistical differences using the z-test. RESULTS: Two hundred forty-two cases of fatal BAI were reviewed, making this the largest BAI autopsy study to date. Mechanisms of BAI included driver/passenger in motor vehicle crash (MVC) (68%), pedestrian versus MVC (17%), and motorcycle crash (8%). When comparing the mechanisms in the time period 1984 to 1988 to the time period 1989 to 1997, only the pedestrian versus MVC mechanism was significantly different (12% vs. 23%, p < 0.05). MVC direction of impact included head-on (45%), lateral (35%), and complex (20%). Two thirds of the victims sustained head injuries, rib fractures, and/or hepatic trauma. Only 58% of the victims had the classic isthmus laceration. There was one preventable death secondary to delay in diagnosis. CONCLUSION: BAI is not limited to frontal impact crashes; there should be a high index of suspicion of BAI in lateral impact crashes as well as pedestrian versus MVC mechanisms. Nonisthmus and complex aortic lacerations are common in fatal BAI. Finally, BAI is a highly lethal injury with few preventable deaths in this series.

Bactericidal/permeability-increasing protein (rBPI21) in patients with hemorrhage due to trauma: results of a multicenter phase II clinical trial. rBPI21 Acute Hemorrhagic Trauma Study Group.

BACKGROUND: Infection and organ failure are the most common causes of death or serious complication in trauma patients surviving initial resuscitation and operation. Of the many possible causes of these complications, bacterial translocation and release of harmful cytokines and oxygen free radicals may play an important role in the pathogenesis of the complications associated with traumatic hemorrhage. Recombinant human bactericidal/permeability-increasing protein (rBPI21) has antibacterial and antiendotoxin properties, reduces cytokine levels, and increases survival in animal models of hemorrhagic shock. The primary objective of this study was to evaluate the safety and efficacy of prophylactic rBPI21 infusion in patients with hemorrhage due to trauma. METHODS: This was a phase II, multicenter, randomized, double-blind, placebo-controlled trial. Patients who required at least 2 U of blood were randomized to receive rBPI21 (4 mg x kg(-1) x d(-1) for 2 consecutive days) or an equivalent volume of placebo by continuous infusion within 12 hours of injury. The primary efficacy end point was mortality or serious complication occurring during the first 15 days of the study. Safety was monitored clinically and by laboratory panels during the study period. RESULTS: A total of 401 patients were treated (202 in the rBPI21 group and 199 in the placebo group). The composite end point rate of mortality or serious complication through day 15 was 46% in the placebo group and 39% in the rBPI21 group (hazard ratio = 0.79; p = 0.13). Secondary analysis, which adjusted for age, mechanism of injury, Injury Severity Score (1990 version), and units of blood received before study drug infusion showed similar results (hazard ratio = 0.79; p = 0.14). The proportion of patients who developed at least one serious organ dysfunction was 22% in the placebo group and 16% in the rBPI21 group (hazard ratio = 0.71; p = 0.14). The proportion of patients who developed either pneumonia or acute respiratory distress syndrome was 32% in the placebo group and 22% in the rBPI21 group (hazard ratio = 0.66; post hocp = 0.03). The beneficial trends of rBPI21 were observed in both blunt and penetrating trauma and were generally observed across different age groups, Injury Severity Scores, and units of blood transfused. No treatment difference was observed in mortality or resource utilization in this phase II study. CONCLUSION: rBPI21 was well-tolerated and demonstrated a favorable trend in reducing the composite primary end point of mortality or serious complication through day 15, especially respiratory complications, in patients with hemorrhage due to trauma. A phase III study is currently in progress.

Meandering bullet in the pericardial sac: to remove or not to remove.

Patients with bullets in the pericardial sac without obvious myocardial injuries are rare, making it difficult to analyze the natural history and propose management approaches. We present the case of a meandering bullet in the pericardial sac and a review of the literature.

Primary repair of 58 consecutive penetrating injuries of the colon: should colostomy be abandoned?

Although primary repair of penetrating colon injuries in patients with low injury severity is now widely accepted, several "risk factors" continue to be viewed as relative contraindications to this method of management. The purpose of this study was to evaluate the septic complications and leak rate in a series of consecutive penetrating colon injuries managed exclusively with primary repair. The records of 58 consecutive patients with penetrating intra-abdominal colon injuries managed at an urban Level I trauma center from July 1991 to December 1995 were reviewed. Patients were stratified for injury severity using the Penetrating Abdominal Trauma Index (PATI), and the presence of "risk factors" and septic abdominal and wound complications were recorded. All 58 patients were managed with primary repair. There were 48 gunshot wounds (72%), 7 shotgun wounds (12%), and 9 stab wounds (16%) with a mean PATI of 26.7 +/- 15.2 standard deviation. Seven patients (12.1%) developed intra-abdominal abscess, and all were managed by CT-guided percutaneous drainage. Five patients (8.6%) developed bacteremia, and eight patients (13.8%) developed fascial dehiscence. Three patients (5.2%) underwent abdominal re-exploration in the postoperative period, but none of these was related to failure of the colonic repair. There were no clinically apparent leaks or fistulae and no deaths. The presence of "risk factors" appeared to identify more severely injured patients as indicated by a higher mean PATI score and a higher incidence of intra-abdominal abscess, when compared to patients in whom the "risk factor" was absent. Primary repair can safely be used for virtually all penetrating colon injuries, as clinical leaks are rare, even in patients with "risk factors". Intra-abdominal abscess and other septic complications are dependent on the overall severity of the intra-abdominal injuries and probably result from contamination occurring at the time of injury rather than from postoperative leak from the primary repair.

Epidural and intravenous bolus morphine for postoperative analgesia in infants.

PURPOSE: To compare two doses of bolus epidural morphine with bolus iv morphine for postoperative pain after abdominal or genitourinary surgery in infants. METHODS: Eighteen infants were randomly assigned to bolus epidural morphine (0.025 mg.kg-1 or 0.050 mg.kg-1) or bolus iv morphine (0.050-0.150 mg.kg-1). Postoperative pain was assessed and analgesia provided, using a modified infant pain scale. Monitoring included continuous ECG, pulse oximetry, impedance and nasal thermistor pneumography. The CO2 response curves and serum morphine concentrations were measured postoperatively. RESULTS: Postoperative analgesia was provided within five minutes by all treatment methods. Epidural groups required fewer morphine doses (3.8 +/- 0.8 for low dose [LE], 3.5 +/- 0.8 for high dose epidural [HE] vs. 6.7 +/- 1.6 for iv, P < 0.05) and less total morphine (0.11 +/- 0.04 mg.kg-1 for LE, 0.16 +/- 0.04 for HE vs 0.67 +/- 0.34 for iv, P < 0.05) on POD1. Dose changes were necessary in all groups for satisfactory pain scores. Pruritus, apnoea, and haemoglobin desaturation occurred in all groups. CO2 response curve slopes, similar preoperatively (range 36-41 ml.min-1.mmHg ETCO2-1.kg-1) were generally depressed (range, 16-27 ml.min-1.mmHg ETCO2-1.kg-1) on POD1. Serum morphine concentrations, negligible in LE (< 2 ng.ml-1), were similar in the HE and iv groups (peak 8.5 +/- 12.5 and 8.6 +/- 2.4 ng.ml-1, respectively). CONCLUSION: Epidural and iv morphine provide infants effective postoperative analgesia, although side effects are common. Epidural morphine gives satisfactory analgesia with fewer doses (less total morphine); epidural morphine 0.025 mg.kg-1 is appropriate initially. Infants receiving epidural or iv morphine analgesia postoperatively need close observation in hospital with continuous pulse oximetry.

Surgical cricothyroidotomy in trauma patients: analysis of its use by paramedics in the field.

OBJECTIVE: To analyze the indications for and the success rate, complications, and neurologic outcomes of surgical cricothyroidotomy when performed in the field by ambulance paramedics. METHODS: The ambulance and hospital records of all trauma patients on whom a surgical cricothyroidotomy was attempted in the field by ambulance paramedics over a 5-year period were reviewed. A telephone survey of survivors was used to assess long-term complications and neurologic outcome. RESULTS: Surgical cricothyroidotomy was attempted on 50 patients, or 9.8% of those requiring definitive airway control. The most common indications were clenched teeth, blood or vomit obscuring visualization of the upper airway, severe maxillofacial injuries, and inaccessibility because the patient was trapped. Airway establishment was successful in 47 patients (94%). Major complications occurred in 2 patients (4%), where inadvertent dislodgement of the tube developed, requiring replacement. No patient developed significant subglottic stenosis. Nineteen patients (38%) survived and no patient died because of an inadequate airway. Evaluation of neurologic outcome revealed 12 patients (63%) with no significant deficits, 3 (16%) with moderate disability, 2 (10%) with severe disability, and only 2 in a persistent vegetative state. CONCLUSIONS: Surgical cricothyroidotomy can be performed on the critically injured patient in the field by ambulance paramedics with a high success rate and a low complication rate. The use of surgical cricothyroidotomy should be included in airway protocols for well-trained, ambulance Advanced Life Support paramedics.

Penetrating chest trauma: should indications for emergency room thoracotomy be limited?

A total of 160 patients underwent emergency room thoracotomy (ERT) from January 1988 to June 1995. There were 142 male and 18 female patients with ages ranging from 15 months to 72 years old with a mean age of 31 years. Blunt trauma was the mechanism of injury in 11 patients; none of them survived, and they were excluded from further analysis. A total of 149 patients sustained penetrating trauma, 111 patients gunshot wounds, and 38 patients stab wounds. A total of four patients survived to discharge for an overall survival rate of 2.7 per cent. All four were victims of a stab wound and were neurologically intact at the time of discharge. Special interest was placed in classifying patients according to their physiologic status both at the scene and on arrival to the emergency department. Class I, patients with no signs of life; Class II, Agonal--patients in electromechanical dissociation/pulseless electrical activity with no palpable pulse or blood pressure; Class III, Profound Shock--patients with blood pressure less than 60 mm Hg; and Class IV, Mild Shock--patients with blood pressure between 60 and 90 mm Hg. 122 patients (89%) fitted the criteria for Scene Classes I and II. None of these patients improved or responded to prehospital resuscitation to be moved up to Emergency Department Classes III or IV, and all of them died. Of the four survivors, three were in Scene Class III and one was in Scene Class IV. This study confirms a previous report that, overall, ERT has a very low survival rate. ERT should be abandoned in patients sustaining blunt trauma, and should probably be limited to patients sustaining penetrating chest injuries who fall into the physiologic Classes III or IV at the scene.

Conversion of laparoscopic to open cholecystectomy. An analysis of risk factors.

BACKGROUND: Identifying patients who are at risk for conversion from laparoscopic (LC) to open cholecystectomy (OC) has proven to be difficult. The purpose of this review was to identify factors that may be predictive of cases which will require conversion to laparotomy for completion of cholecystectomy. METHODS: We reviewed 581 LCs initiated between July 1990 and August 1993 at a university medical center and recorded reasons for conversion to OC. Statistical analysis was then performed to identify factors predictive of increased risk for conversion. RESULTS: Of the 581 LC initiated, 45 (8%) required OC for completion. Reasons for conversion included technical and mandatory reasons and equipment failure. By multivariate analysis, statistically significant risk factors for conversion included increasing age, acute cholecystitis, a history of previous upper abdominal surgery, and being a patient at the Veterans Affairs Medical Center (VAMC). Factors not increasing risk of conversion included gender and operating surgeon. CONCLUSIONS: We conclude that no factor alone can reliably predict unsuccessful LC, but that combinations of increasing age, acute cholecystitis, previous upper abdominal surgery, and VAMC patient result in high conversion rates. Patients with the defined risk factors may be counseled on the increased likelihood of conversion. However, LC can be safely initiated for gallbladder removal with no excess morbidity or mortality should conversion be required.

Selective use of computed tomography and diagnostic peritoneal lavage in blunt abdominal trauma.

The purpose of this study was to attempt to identify those blunt trauma patients in whom expensive diagnostic studies such as computed tomography and diagnostic peritoneal lavage are unnecessary to exclude intra-abdominal injury. The medical records of 1096 blunt trauma patients evaluated at an urban level I trauma center were reviewed. Because of the urgent need to exclude intra-abdominal hemorrhage in patients with hypotension (blood pressure < 90 mm Hg), and the difficulty in obtaining reliable information from abdominal examination in patients with Glasgow Coma Scale scores < 11 or spinal cord injury, 140 patients meeting these criteria were reviewed but excluded from statistical analysis. Six groups of major associated injuries felt to be potential risk factors for the prediction of intra-abdominal injury were analyzed in the 956 remaining patients. Only two of these potential risk factors, namely chest injury (p = 0.0001) and gross hematuria (p = 0.0003) attained statistical significance. All of the 44 significant intra-abdominal injuries occurred in the group of 253 patients that had either an abnormal abdominal examination, one of the statistically significant risk factors, or both, for a sensitivity of 100%. Of the 703 patients with a normal abdominal examination and no risk factors, none had a significant abdominal injury, for a negative predictive value of 100%. This study suggests that patients with either an abnormal abdominal examination or one of the two statistically derived risk factors require adjunctive diagnostic evaluation with diagnostic peritoneal lavage or computed tomography scan to exclude intra-abdominal injury.(ABSTRACT TRUNCATED AT 250 WORDS)

Postoperative apnea, bradycardia, and oxygen desaturation in formerly premature infants: prospective comparison of spinal and general anesthesia.

Eighteen formerly premature infants scheduled for inguinal herniorrhaphy and who were less than 51 wk postconceptional age were assigned to either the general anesthesia group (GA: atropine, halothane, and nitrous oxide) or the spinal anesthesia group (SA: hyperbaric tetracaine). Twelve-hour, three-channel continuous recordings of respiratory rate (chest wall impedance), electrocardiogram (ECG), and hemoglobin O2 saturation (SpO2) were obtained preoperatively and after surgery. These were analyzed for short (11-15s) and long (> 15 s) apnea spells, periodic breathing, and episodes of hemoglobin oxygen desaturation and bradycardia. Infants in the GA group had lower postoperative minimum SpO2 (68.7% +/- 11.4%) and minimum heart rate (79 bpm +/- 19) than infants in the SA group (80.7% +/- 9.2%, and 109 bpm +/- 30, respectively; P < 0.05) and had lower postoperative minimum SpO2 and minimum heart rate than they had preoperatively (79.0% +/- 13.7%, and 93 bpm +/- 31, respectively; P < 0.05); pre- and postoperative studies in the SA group did not differ. There were no differences in the incidence of postoperative central apnea. We conclude that spinal anesthesia reduces postoperative hemoglobin oxygen desaturation and bradycardia in formerly premature infants undergoing inguinal herniorrhaphy.

Pre-existing liver disease in the trauma patient.

Interest in the importance of pre-existing disease as an outcome predictor in trauma patients has begun to receive attention only recently. Data relating specifically to pre-existing liver disease remains scant. With an overall prevalence of 0.5% among all trauma patients, pre-existing liver disease has been shown to increase mean duration of hospital stay by up to 36% and mortality by a factor of five (Table 9). This data appears to support the recommendation of the American College of Surgeons Committee on Trauma in their most recent bulletin, "Resources for the Optimal Care of the Injured Patient," that a history of cirrhosis in an injured patient should alert prehospital providers to contact medical control and consider transport to a trauma center. The majority of the data on the pathophysiologic and clinical responses and management of the patient with pre-existing liver disease have been extrapolated from literature on liver disease in the surgical patient and in sepsis. Few specific data on the management of the trauma patient with pre-existing liver disease and its effects on morbidity and mortality are available. We hope this review stimulates further research, particularly on the pathophysiologic and clinical responses to trauma exhibited by patients with liver disease.

Pain management for children following selective dorsal rhizotomy.

Selective dorsal rhizotomy (SDR) is a neurosurgical procedure used for treating lower extremity spasticity in patients with cerebral palsy. The purpose of this paper is to present a review of our institution's first three years' experience with postoperative pain and spasticity management in patients who have undergone SDR. The medical records of the 55 patients who had an SDR during the study period were reviewed. The basis of postoperative analgesia was morphine, with the majority of patients receiving continuous morphine infusions (20-40 micrograms.kg-1.hr-1 (n = 49), 60 micrograms.kg-1.hr-1 (n = 1)). Four patients used a patient-controlled delivery system. One patient had successful analgesia with epidural morphine. Ketorolac (1 mg.kg-1 i.v. loading dose followed by 0.5 mg.kg-1 i.v. every six hr for 48 hr) was used as an adjunct to morphine in six patients. For management of postoperative muscle spasm, an intravenous benzodiazepine was used (diazepam 0.1 mg.kg-1 (n = 2), or midazolam infusion 10-30 micrograms.kg-1.hr-1 (n = 51)). All patients were cared for on a ward where nurses were familiar with the use of continuous opioid and benzodiazepine infusions. All patients received continuous cardiorespiratory monitoring as well as frequent nursing assessment. There were no episodes of postoperative apnoea or excessive sedation. We have found the use of continuous infusions of morphine and midazolam, along with adjunct ketorolac, to be effective in treating postoperative pain and muscle spasms following SDR.

The use of an absorbable mesh wrap in the management of major liver injuries.

Uncontrollable hemorrhage remains the predominant cause of death in patients with complex liver injuries. In view of the recently reported success in control of hemorrhage from and salvage of the injured spleen and kidney with an absorbable mesh wrap, we have begun to use a similar technique in the management of major hepatic parenchymal injuries, as an alternative to suture hepatorrhaphy, lobar resection, and perihepatic packing. The technique of mesh-wrap hepatorrhaphy is described in detail. Our initial experience with four cases is reported, demonstrating the unique features of the mesh and the technical ease with which it can be applied. Advantages over conventional techniques are discussed. These include avoidance of reoperation for removal of perihepatic packing, avoidance of hepatic necrosis after wide suture hepatorrhaphy, and avoidance of the morbidity associated with lobar resections.

The dose response of caudal morphine in children.

The authors compared the duration of analgesia and the frequency of side effects of three doses of caudal epidural morphine in children aged 1.2-7.9 yr. Caudal catheters were inserted in 32 children, randomly assigned to receive 0.033 mg.kg-1, 0.067 mg.kg-1, or 0.10 mg.kg-1 of preservative-free morphine for analgesia after major surgical procedures below the diaphragm. The first dose of caudal morphine was mixed with 0.25 ml.kg-1 of 1% lidocaine to confirm correct caudal catheter placement. By assessment of periodic pain scores and the time intervals between administration of caudal morphine and the recurrence of pain, the authors found that the mean (+/- SD) duration of analgesia was significantly longer after 0.10 mg.kg-1 (13.3 +/- 4.7 h) than after either 0.033 mg.kg-1 or 0.067 mg.kg-1 (10.0 +/- 3.3 and 10.4 +/- 4.2 h, respectively) (P less than 0.02). The frequency of vomiting, pruritus, and urinary retention was similar in each group. Vomiting was less common in patients who had nasogastric drainage than in patients who were fed soon after surgery (P less than 0.05). Delayed respiratory depression occurred in one child after 0.10 mg.kg-1 of caudal morphine. Caudal morphine, 0.033-0.10 mg.kg-1, provided prolonged analgesia in children. The authors recommend 0.033 mg.kg-1 of caudal morphine as an initial dose for children.

Caudal morphine for postoperative analgesia in children: a comparison with caudal bupivacaine and intravenous morphine.

We compared the efficacy, duration, and side effects of preservative-free morphine injected into the caudal space in children, with caudal bupivacaine and with intravenous morphine administration for relief of postoperative pain. Forty-six children, ages 1-16 yr, were randomly assigned to receive intravenous morphine (control group), caudal bupivacaine (0.25%, 1 ml/kg), or caudal morphine (0.5 mg/ml, 0.1 mg/kg). In half the patients given caudal morphine, the morphine was mixed with a dose of lidocaine adequate to produce sacral analgesia, to confirm correct caudal injection of the morphine. Caudal injections were performed at the end of surgery. Time until the first required postoperative intravenous morphine dose was recorded for each patient. The duration of analgesia was significantly greater with caudal morphine (median 12 hr, P less than 0.02) than with caudal bupivacaine (median 5 hr), and both were greater than with intravenous morphine in control patients (median 45 min). Urinary retention, pruritus, and nausea appeared with slightly greater frequency in the caudal morphine group, but no delayed respiratory depression occurred. Caudal morphine (0.5 mg/ml, 0.1 mg/kg) provided 8-24 hr of analgesia in children without a significantly greater incidence of side effects than caudal bupivacaine or intravenous morphine.