Community medical response to the Fairchild mass casualty event.

BACKGROUND: On June 20, 1994, a discharged serviceman with a psychiatric history opened fire with a MAC-90 assault rifle at Fairchild Air Force Base in Spokane, Washington. The attack killed 5 people and wounded 22. This report reviews the communication, triage, transport, injuries, and the community medical response to this mass casualty. METHODS: Data for the review were obtained from city-wide debriefing sessions, medical records, and evaluation forms from prehospital agencies. RESULTS: A total of 19 patients were triaged to four community hospitals, while 3 victims with comparatively minor injuries stayed at the Base hospital. All fatalities except a child in utero died at the scene. All victims surviving to hospital were discharged recovered from their injuries. Two patients were undertriaged, 1 of whom sustained a pelvic and buttock wound. CONCLUSIONS: Rapid triage was possible due to: (1) initial treatment by military medical personnel; (2) an established and practiced disaster plan; (3) the use of disaster packs and triage tags; (4) the immediate initiation of triage and transport; and (5) coordinated ground and air transport.

Ancrod versus heparin for anticoagulation during vascular surgical procedures.

PURPOSE: The purpose of this study was to compare the conduct and early results of infrainguinal vascular reconstructions with use of ancrod or heparin for anticoagulation. METHODS: To test the hypothesis that ancrod was an effective alternative to heparin, 28 patients requiring infrainguinal bypass surgery were randomized to receive heparin during operation or ancrod before operation over a period of 12 hours to deplete circulating fibrinogen (0.2 to 0.5 gm/L). RESULTS: No clotting of blood within the grafts or native vessels was noted during the conduct of the surgical procedures in either group. No excessive bleeding was detected during operation in either group. The operative procedure, complication rate, and hospital course were also indistinguishable; patency at 1 month was also equal. CONCLUSION: Fibrinogen depletion with ancrod provides anticoagulation for the conduct of infrainguinal vascular reconstructions that is as effective as heparin. When heparin is contraindicated ancrod is an effective and safe alternative.

Cadaveric organ donor availability: regional trauma center vs. community hospital.

Organ donor shortage is now the greatest limitation to the success of organ transplantation. To assess and compare the role of a regional trauma center in identifying and referring cadaveric organ donors to that of a community hospital, we retrospectively reviewed records of potential cadaveric organ donors during a comparable 5-year period in each. The trauma center (TC) contributed 44 donors, while the community hospital (CH) supplied seven. Five hundred sixty-five possible donors were not harvested at the TC, compared to 126 at the CH. While most "non-donors" from both institutions were not suitable candidates, 8% could have served as good organ donors. Inability to obtain consent was the major obstacle in obtaining good candidates (70% at CH, 83% at TC). Failure to recognize and refer possible donors occurred in 2% of the cases at CH, compared to 0.4% at the TC. We conclude that regional trauma centers can play an important role in alleviating organ donor shortage.

Critical care air transportation of the severely injured: does long distance transport adversely affect survival?

Civilian aeromedical transportation systems, both fixed and rotary wing, have proliferated since the middle 1970s. However, outcome data substantiating the benefit of these services have been slow in coming. From February 22, 1982, through March 5, 1984, Airlift Northwest transported 118 trauma patients (aged 15 years and older) an average distance of 340 miles (range, 100 to 800 miles) with fixed-wing aircraft. The in-hospital mortality for this group was 19% compared with 18% for a comparable group of trauma patients who were ground-transported from within the city limits of Seattle, Washington. The two groups did not differ significantly in age, Injury Severity Score, or Glasgow Coma Score. These results suggest that some part of the clinical benefit of a regional trauma center may be extended up to 800 miles with no increase in transport-related mortality.

Traumatic rupture of the thoracic aorta in the pediatric patient.

Traumatic rupture of the thoracic aorta is rare in pediatric patients. Proper management of this injury is essential and requires a systematic approach, similar to that used in adult patients. Preoperatively, the multiply injured child must have other injuries properly prioritized and addressed. Proper selection of graft size, expeditious intraoperative management, and careful postoperative management result in a minimal number of complications associated with this injury.

Hemodynamic effects of external cardiac massage in trauma shock.

The effectiveness of closed chest cardiopulmonary resuscitation (CCCPR) in maintaining cardiac output has been well studied in cardiac arrest. Trauma surgeons most often encounter shock secondary to hypovolemia or cardiac tamponade, and the effectiveness of CCCPR in that setting has not been established. To determine the hemodynamic effects of external massage in profound shock, hypotension was induced in baboons. Pressures obtained with external massage were compared to spontaneous intra-arterial pressures before compression. Although external massage increased systolic pressures in both tamponade and hypovolemia, diastolic pressures were consistently decreased. We conclude that CCCPR does not augment arterial pressure in the clinical situations associated with decreased LVEDV and is unlikely to provide organ perfusion for trauma victims.

Empyema thoracis in patients undergoing emergent closed tube thoracostomy for thoracic trauma.

The vast majority of thoracic trauma victims require only observation or tube thoracostomy for definitive treatment of their thoracic injury. Although tube thoracostomy is generally considered a limited intervention, 2 to 25 percent of patients who undergo this procedure develop infectious complications. To determine the incidence and risk factors for the development of empyema thoracis after tube thoracostomy, a retrospective study was undertaken. We found that the development of empyema thoracis was increased in patients whose pleural space was incompletely drained and whose thoracic catheters were in place for a prolonged period.

The sensitivity of vital signs in identifying major thoracoabdominal hemorrhage.

Prehospital and emergency room recordings of hemodynamic vital signs frequently play a major role in the evaluation and treatment of trauma victims. Guidelines for resuscitation and treatment are affected by absolute cutoffs in hemodynamic parameters. To determine the sensitivity of various strata of systolic blood pressure and heart rate in identifying patients with major thoracoabdominal hemorrhage, a 1-year retrospective review was conducted. A third of all patients presented to the emergency department with a normal blood pressure and over three-quarters attained a normal blood pressure during the emergency department evaluation. Although the sensitivity of vital signs in identifying this group of patients improved as the variance from normal increased, standard cutoffs were relatively insensitive. We conclude that normal postinjury vital signs do not predict the absence of potentially life-threatening hemorrhage and abnormal vital signs at any point after injury require investigation to rule out significant blood loss.

Risk factors for urethral injuries in men with traumatic pelvic fractures.

Urethral injuries are commonly associated with pelvic fractures. The prompt recognition and appropriate management of these injuries may significantly impact subsequent morbidity, yet few studies have addressed the identification of the risk factors for urethral injury in men with pelvic fractures. We reviewed retrospectively the records of 405 men with pelvic fractures seen at our medical center, including 21 (5 per cent) with urethral injuries. Of the 21 men 14 (67 per cent) had fractures involving a pubic ramus and a sacroiliac joint, and 12 (57 per cent) had no physical signs (blood at the urethral meatus, perineal hematoma or a high-riding prostate) that would suggest a urethral injury. The likelihood for the presence of physical signs is directly related to the interval since injury. We believe that men with the combination of rami fractures and sacroiliac disruption should undergo retrograde urethrograms before urethral instrumentation, and that physical signs are unreliable indications for urethral injuries, especially soon after the injury.

The medical and social impact of nonaccidental injury.

To determine the medical and economic impact of nonaccidental trauma at a regional trauma and emergency care facility, a prospective patient database was used to follow up all victims of intentional injury admitted during one year. Specific patient data were combined with financial data to determine the medical outcome, expenditure, and hospital reimbursement. We found that 17% of the 2451 trauma patients admitted to our facility were victims of nonaccidental injury. The majority of these patients were severely injured, with an average hospital stay of six days. Hospital charges averaged $13,000 per patient. Three fourths of these individuals required governmental funding for medical care. Six months after completion of the review, only two thirds of all expenditures had been reimbursed. These patients represent a high medical services use group and consume a disproportionately high percentage of medical resources.

Air transport following surgical stabilization: an extension of regionalized trauma care.

A 30-month retrospective review was performed of all trauma patients initially evaluated and operatively stabilized at Level III hospitals, with subsequent specialized air transport within 48 hours of injury to the regional Level I trauma center in Seattle. Nineteen patients were identified, with a mean ISS of 44 (range, 20-66). Mean transport time and distance were 2.4 hours and 456 miles, respectively. The estimated average ground transport time for the same patients was 23.8 hours. No deaths occurred during transport, and the overall survival rate was 58%. Transport charges averaged $4,162, which was 14% of the complete hospitalization cost. We conclude that: 1) patient survival after air transport was no different than that predicted for trauma victims with immediate access to a trauma center; 2) postoperative hemodynamic instability predicted a poor outcome; 3) the higher cost of air relative to ground transport is outweighed by significant time savings in these critically injured patients; and 4) air transport following operative stabilization represents an extension of regionalized trauma care to the isolated areas of Washington and Alaska.

Traumatic pneumoperitoneum following combined abdominal and thoracic injury.

Pneumoperitoneum following blunt abdominal trauma in the absence of other signs of severe intraabdominal injury is a rare finding. Although the vast majority of all cases of pneumoperitoneum are due to a ruptured intraabdominal hollow viscus, free abdominal air may result from significant barotrauma to the thorax. This type of secondary pneumoperitoneum can occur in the absence of chest x-ray evidence of a pneumothorax or pneumomediastinum. The complications associated with a missed visceral injury warrant an exploratory laparotomy, even if an extraabdominal source for the pneumoperitoneum is suspected.

Incidence and effect of hypothermia in seriously injured patients.

Hypothermia is a well recognized consequence of severe injury, even in temperate climates, and the physiologic consequences of hypothermia are known to be detrimental. To analyze the frequency and risk factors for hypothermia and its effect on patient outcome, we prospectively studied 94 intubated injured patients at a regional trauma center during a 16-month period. Esophageal temperature probes were placed in the field or ER and core temperatures (T) were followed for 24 hours or until rewarming. Patients were designated as normothermic (greater than 36 degrees C), mildly hypothermic (34 degrees C-36 degrees C) or severely hypothermic (less than 34 degrees C) based on initial T. The risk factors for hypothermia evaluated included age, severity and location of injuries, blood alcohol level, blood transfusion requirements, and time spent in the field, ER, or OR. The average initial T was 35 degrees C, with no seasonal variation. Injury severity and survival correlated with severe hypothermia. Normothermic patients had an average ISS of 28 with a 78% survival. Severely hypothermic patients had an average ISS of 36 with a 41% survival (p less than 0.05). Patient age strongly correlated with outcome although there was no relationship between age and initial temperature. Sixty-two per cent of patients tested were positive for blood alcohol, and one half were legally intoxicated (BAC greater than 100 mg%). However, no consistent correlation was found between alcohol intoxication and initial temperature or patient survival. Blood transfusion requirements paralleled injury severity and patients receiving greater than 10 unit transfusions had significantly lower core temperature (p less than 0.05). The average temperature change was positive in the ER, OR, and ICU with time to rewarming correlating with the aggressiveness of warming measures.(ABSTRACT TRUNCATED AT 250 WORDS)

Nonoperative observation therapy for splenic injuries: a safe therapeutic option?

Combining these reported and estimated incidences of mortality from overwhelming postsplenectomy infection, splenic salvage with nonoperative observation therapy and operative therapy, and the incidence of posttransfusion hepatitis and related mortality provides a conditional probability estimation of the risks of death with nonoperative observation therapy and operative therapy (Figure 4). The combined mortality rates for nonoperative observation and operative therapies are based on the following measured and estimated statistics: The post-transfusion hepatitis death rate per unit of blood transfused is 0.14 percent. Forty percent of children and 20 percent of adults who have successful nonoperative observation therapy receive an average of 2 units of blood. One hundred percent of children and adults in whom nonoperative observation therapy is unsuccessful receive an average of 4 units of blood. Twenty percent of children and adults who undergo operation initially receive an average of 2 units of blood. Ten percent of observed children require laparotomy and 75 percent of these patients then undergo splenectomy. Forty percent of adults who have nonoperative observation initially later require laparotomy, 93 percent of whom also require splenectomy. Ten percent of children and adults treated with initial operation later require splenectomy. Death from overwhelming postsplenectomy infection occurs in 0.026 percent of adults who undergo splenectomy and 0.052 percent of children who undergo splenectomy. Given these assumptions, the conditional probability of death in a child who initially undergoes nonoperative observation therapy is 0.17 percent compared with 0.06 percent for initial operative therapy. In adults, 0.26 percent of the observed patients die compared with 0.06 percent for those operated on initially. As stated, many of the percentages or probabilities listed are estimations based on the best available clinical data. The inability to establish a mortality rate from overwhelming postsplenectomy infection remotely resembling that reported for otherwise healthy patients required an unsubstantiated estimate. However, even when mortality rates from overwhelming postsplenectomy infection of 0.43 percent and 0.6 percent were substituted, early laparotomy still produced lower mortality rates. This continues to be true if one assumes that early laparotomy will result in 50 percent or even 100 percent of patients undergoing splenectomy, although in these cases the statistical differences would be less. We acknowledge that these statistics may exceed or underestimate the true risk of either treatment plan.(ABSTRACT TRUNCATED AT 400 WORDS)

An unusual complication of rubber band ligation of hemorrhoids.

Rubber band ligation of hemorrhoids has had a low incidence of complications until recently, when five deaths resulted from bacterial septicemia or toxemia. The case presented describes a severe soft-tissue infection following banding successfully treated with antibiotics, surgical debridement, and hyperbaric oxygen.

Hospital stay following biliary tract surgery. A comparison of two community hospitals.

An apparent difference in length of postoperative hospitalization following biliary tract surgery at two university-affiliated community hospitals led to a retrospective review of 200 consecutive patients at each hospital. Patient characteristics and surgical practices that potentially affected hospital stay were compared. A highly significant difference was identified in the length of hospitalization between the two institutions. Statistically significant differences in variables that seemed to affect length of stay included the use of nasogastric tubes and abdominal drains and the time interval to the institution of postoperative feedings. Cumulative hospitalization was 517 days shorter at one institution. This was accomplished despite a high percentage of emergent procedures and more frequent involvement of surgical residents. Since hospital stay accounts for the majority of expenditure for surgical treatment of biliary tract disease, shortening postoperative hospitalization can significantly reduce the overall costs.

The influence of ethanol intoxication on outcome of injured motorcyclists.

Previous reports have failed to demonstrate a statistically significant adverse effect of acute ethanol intoxication in the well-resuscitated trauma patient. In the present study the prevalence of acute alcohol intoxication and its effect on outcome was analyzed in a homogenous population of young, previously healthy motorcycle accident victims (N = 134). The incidence of intoxication was 25%. The intoxicated cyclists were at fault for the accident 50% more often than the nonintoxicated cyclists and were found to wear helmets one third as frequently. Furthermore, the protective effect of helmet use as seen in the nonintoxicated group was lost in the intoxicated group, who sustained head injuries twice as frequently. Only patients with critical head injuries died and, although the ISS levels of those dying were similar in the two groups, the mortality following the critical head injury was twice as high among intoxicated patients (80 vs. 43%). Overall, the intoxicated group had a fourfold increased mortality rate. Thus, although intoxicated motorcyclists comprised 25% of the total population, they represent a mere 9% of the helmet-wearing population, and, in contrast, 39% of the severely head-injured victims and a majority (57%) of the mortality rate.

The role of helmets in reducing head injuries from motorcycle accidents: a political or medical issue?

The cases of 311 motorcycle accident victims who were seen at a major trauma center over 17 months were reviewed. The types and severity of injuries were standardized according to the Injury Severity Score (ISS) for motor vehicle accidents. Victims were categorized into groups: helmet or no helmet and major, minor or no head injury. Major injury was defined as a 3 on the Abbreviated Injury Scale for "head" (loss of consciousness for at least 15 minutes with or without skull fracture and with or without neurological deficit). THE FOLLOWING CONCLUSIONS ARE DRAWN: (1) The death rate for those with and without helmets was not significantly different, (2) the victims of fatal accidents had identical total ISS scores regardless of the presence of helmets, (3) the chance of sustaining a severe head injury was significantly higher in the no helmet group and (4) the incidence of long-term neurological defect was three times greater in the no helmet group.