Thoracoscopy in the evaluation and management of thoracic trauma.

Video-thoracoscopy was used to evaluate and manage patients after thoracic trauma. It was used in 29 patients. Indications included retained hemothorax in 16 patients, empyema in 11, evaluation for the source of thoracic bleeding in 1, and an airleak in 1. The mechanism of injury was blunt trauma in 8 cases, 10 with stab wounds, and 11 with gunshot wounds. In blunt trauma, thoracoscopy was carried out an average of 11.7 days post injury, chest tubes were removed after an average of 7 days post thoracoscopy, and discharge averaged 10.7 days after thoracoscopy. The failure rate was 12.5% with no mortality. In stab wounds, it was carried out an average of 8.8 days post injury, chest tube removal occurred after 6.1 days, and discharge averaged 7.8 days after thoracoscopy. The failure rate was 20% with no mortality. In gunshot wounds, it was carried out an average of 7.5 days after injury, chest tubes were removed after 9.9 days, and discharge averaged 16 days post thoracoscopy. The failure rate was 9% with a mortality of 9%. Overall, the failure rate for thoracoscopy was 13.8% (4/29). The mortality rate was 3.5% (1/29). It was successfully performed up to 30 days post injury. It proved to be effective in the management of empyema, evacuation of clotted hemothorax, and diagnosis of ongoing thoracic bleeding.

The role of liver transplantation in the subacute trauma patients.

Two case reports are presented involving complex liver traumas requiring the need for liver transplantation. Both of these patients were designated unsalvageable until the transplant team was consulted. It is imperative that surgeons involved with complex hepatic trauma not give up hope and include these patients as potential liver recipients when irreversible liver failure occurs.

The need for aggressive nutritional intervention in the injured patient: the development of a predictive model.

Early nutritional intervention has been advocated in trauma patients. We have developed a model to identify those patients who will most benefit from the invasive and costly measures that are required to provide injured patients with early enteral feedings. Four hundred forty-two patients admitted to a level I trauma center during a 2-month period were evaluated using 21 clinical variables. Time to tolerance of a regular diet was used as the dependent variable in a step-wise regression, and then the selected variables were used to build a classification and regression tree to predict tolerance of a regular diet within 5 days. Our findings demonstrate that intensive care unit disposition, Injury Severity Score, Abdominal Trauma Index, and the need for early surgical intervention are important predictors regarding the need for early nutritional intervention. When the model was applied to the study population, it had a sensitivity of 83%, a specificity of 84%, and an accuracy of 84%.