Management of traumatic lung injury: a Western Trauma Association Multicenter review.

BACKGROUND: Improved outcomes following lung injury have been reported using "lung sparing" techniques. METHODS: A retrospective multicenter 4-year review of patients who underwent lung resection following injury was performed. Resections were categorized as "minor" (suture, wedge resection, tractotomy) or "major" (lobectomy or pneumonectomy). Injury severity, Abbreviated Injury Scale (AIS) score, and outcome were recorded. RESULTS: One hundred forty-three patients (28 blunt, 115 penetrating) underwent lung resection after sustaining an injury. Minor resections were used in 75% of cases, in patients with less severe thoracic injury (chest AIS scores "minor" 3.8 +/- 0.9 vs. "major" 4.3 +/- 0.7, p = 0.02). Mortality increased with each step of increasing complexity of the surgical technique (RR, 1.8; CI, 1.4-2.2): suture alone, 9% mortality; tractotomy, 13%; wedge resection, 30%; lobectomy, 43%; and pneumonectomy, 50%. Regression analysis demonstrated that blunt mechanism, lower blood pressure at thoracotomy, and increasing amount of the lung resection were each independently associated with mortality. CONCLUSION: Blunt traumatic lung injury has higher mortality primarily due to associated extrathoracic injuries. Major resections are required more commonly than previously reported. While "minor" resections, if feasible, are associated with improved outcome, trauma surgeons should be facile in a wide range of technical procedures for the management of lung injuries.

Evaluating blunt abdominal trauma with sonography: a cost analysis.

Ultrasonography (US) is becoming increasingly utilized in the United States for the evaluation of blunt abdominal trauma (BAT). The objective of this study was to assess the cost impact of utilizing US in the evaluation of patients with BAT in a major trauma center. All patients sustaining BAT during a 6-month period before US was used at our institution (Jan-Jun 1993) were compared to BAT patients from a recent period in which US has been utilized (Jan-Jun 1995). The numbers of US, computed tomography (CT), and diagnostic peritoneal lavage (DPL) were tabulated for each group. Financial cost for each of these procedures as determined by our finance department were as follows: US $96, CT $494, DPL $137. These numbers are representative of actual hospital expenditures exclusive of physician fees as calculated in 1994 U.S. dollars. Cost analysis was performed with t test and chi squared test, and significance was defined as P < 0.05. There were 890 BAT admissions in the 1993 study period and 1033 admissions in the 1995 study period. During the 1993 period, 642 procedures were performed on the 890 patients to evaluate the abdomen: 0 US, 466 CT, and 176 DPL (see table) [table: see text]. This compares to 801 procedures on the 1,033 patients in 1995: 552 US, 228 CT, and 21 DPL. Total cost was $254,316 for the 1993 group and $168,501 for the 1995 group. Extrapolated to a 1-year period, a significant (P < 0.05) cost savings of $171,630 would be realized. Cost per patient evaluated was significantly reduced from $285.75 in 1993 to $163.12 in 1995 (P < 0.05). This represents a 43 per cent reduction in per patient expenditure for evaluating the abdomen. By effectively utilizing ultrasonography in the evaluation of patients with blunt abdominal trauma, a significant cost savings can be realized. This effect results chiefly from an eight-fold reduction in the use of DPL, and a two-fold reduction in the use of CT.

Timing of urgent thoracotomy for hemorrhage after trauma: a multicenter study.

HYPOTHESIS: It is possible to quantify an amount of thoracic hemorrhage, after blunt and penetrating injury, at which delay of thoracotomy is associated with increased mortality. DESIGN: A retrospective case series. SETTING: Five urban trauma centers. STUDY SELECTION: Patients undergoing urgent thoracotomy (within 48 hours of injury) for hemorrhage (excluding emergency department thoracotomy). DATA EXTRACTION: Respective registries identified patients who underwent urgent thoracotomy. Injury characteristics, initial and subsequent chest tube outputs, time before thoracotomy, and outcomes were evaluated. MAIN OUTCOME MEASURE: Death. RESULTS: One hundred fifty-seven patients (36 with blunt and 121 with penetrating injuries) underwent urgent thoracotomy for hemorrhage between January 1, 1995, and December 31, 1998. Mortality correlated with mean (+/- SD) Injury Severity Score (38 +/- 19 vs 22 +/- 12.6 for survivors; P<.01) and mechanism (24 [67%] for blunt vs 21 [17%] for penetrating injuries; P<.01). Mortality increased as total chest blood loss increased, with the risk for death at blood loss of 1500 mL being 3 times greater than at 500 mL. Blunt-injured patients waited a significantly longer time to thoracotomy than penetrating-injured patients (4.4 +/- 9.0 h vs 1.6 +/- 3.0 h; P =.02) and also had a greater total chest tube output before thoracotomy (2220 +/- 1235 mL vs 1438 +/- 747 mL; P =.001). CONCLUSIONS: The risk for death increases linearly with total chest hemorrhage after thoracic injury. Thoracotomy is indicated when total chest tube output exceeds 1500 mL within 24 hours, regardless of injury mechanism.

Efficacy of follow-up evaluation in penetrating thoracic injuries: 3- vs. 6-hour radiographs of the chest.

Pneumothorax (PTX) in patients with penetrating thoracic trauma is routinely ruled out with serial chest radiographs (CXRs). This study examined the efficacy of a shortened time period between initial and follow-up radiographs. Patients with penetrating torso injuries treated at a Level-1 trauma center received a CXR during their initial evaluation. If no pneumothorax or hemothorax was noted, and the patient did not require immediate admission to the Intensive Care Unit or operating room, a repeat chest film was taken at 3 and 6 h. Findings were treated as clinically indicated, and patients were discharged home if the last radiograph revealed no evidence of pathology. Over a 15-month period, 116 patients were evaluated for penetrating thoracic injuries (93 stabbings, 23 gunshot wounds) and had no pneumothorax detected on initial CXR. Two patients had pneumothorax detectable only by computed tomography. One patient had a normal initial CXR, but developed a PTX on the 3-h film, requiring tube thoracostomy. No patients developed a PTX on the 6-h study that was not present on the initial or 3-h CXR. In conclusion, extending the time between initial and final CXRs to 6 h in patients with penetrating thoracic trauma provided no additional information that was not available on the 3-h film.

Prospective randomized trial of two wound management strategies for dirty abdominal wounds.

OBJECTIVE: To determine the optimal method of wound closure for dirty abdominal wounds. SUMMARY BACKGROUND DATA: The rate of wound infection for dirty abdominal wounds is approximately 40%, but the optimal method of wound closure remains controversial. Three randomized studies comparing delayed primary closure (DPC) with primary closure (PC) have not conclusively shown any advantage of one method over the other in terms of wound infection. METHODS: Fifty-one patients with dirty abdominal wounds related to perforated appendicitis, other perforated viscus, traumatic injuries more than 4 hours old, or intraabdominal abscesses were enrolled. Patients were stratified by cause (appendicitis vs. all other causes) and prospectively randomized to one of two wound management strategies: E/DPC (wound packed with saline-soaked gauze, evaluated 3 days after surgery for closure the next day if appropriate) or PC. In the E/DPC group, wounds that were not pristine when examined on postoperative day 3 were not closed and daily dressing changes were instituted. Wounds were considered infected if purulence discharged from the wound, or possibly infected if signs of inflammation or a serous discharge developed. RESULTS: Two patients were withdrawn because they died less than 72 hours after surgery. The wound infection rate was greater in the PC group than in the E/DPC group. Lengths of hospital stay and hospital charges were similar between the two groups. CONCLUSION: A strategy of DPC for appropriate dirty abdominal wounds 4 days after surgery produced a decreased wound infection rate compared with PC without increasing the length of stay or cost.

Outcome after major renovascular injuries: a Western trauma association multicenter report.

BACKGROUND: Major renal vascular injuries are uncommon and are frequently associated with a poor outcome. In addition to renal dysfunction, posttraumatic renovascular hypertension may result, although the true incidence of this complication is unknown. The objective of this study was to describe the factors contributing to outcome after major renovascular trauma. We hypothesized that the highest percentage of renal salvage would be achieved by minimizing the time from injury to repair. METHODS: This was a retrospective chart review over a 16-year period conducted at six university trauma centers of patients with American Association for the Surgery of Trauma grade IV/V renal injuries surviving longer than 24 hours. Postinjury renal function with poor outcome was defined as renal failure requiring dialysis, serum creatinine greater than or equal to 2 mg/dL, renal scan showing less than 25% function of the injured kidney, postinjury hypertension requiring treatment, or delayed nephrectomy. Data collected for analysis included demographics, mechanism of injury, presence of shock, presence of hematuria, associated injuries, type of renal injury (major artery, renal vein, segmental artery), type of repair (primary vascular repair, revascularization, observation, nephrectomy), time from injury to definitive renal surgery, and type of surgeon performing the operation (urologist, vascular surgeon, trauma surgeon). RESULTS: Eighty-nine patients met inclusion criteria; 49% were injured from blunt mechanisms. Patients with blunt injuries were 2.29 times more likely to have a poor outcome compared with those with penetrating injuries. Similarly, the odds ratio of having a poor outcome with a grade V injury (n = 32) versus grade IV (n = 57) was 2.2 (p = 0.085). Arterial repairs had significantly worse outcomes than vein repairs (p = 0.005). Neither the time to definitive surgery nor the operating surgeon's specialty significantly affected outcome. Ten percent (nine patients) developed hypertension or renal failure postoperatively: three had immediate nephrectomies, four had arterial repairs with one intraoperative failure requiring nephrectomy, and two were observed. Of the 20 good outcomes for grade V injuries, 15 had immediate nephrectomy, 1 had a renal artery repair, 1 had a bypass graft, 1 underwent a partial nephrectomy, and 2 were observed. CONCLUSION: Factors associated with a poor outcome following renovascular injuries include blunt trauma, the presence of a grade V injury, and an attempted arterial repair. Patients with blunt major vascular injuries (grade V) are likely to have associated major parenchymal disruption, which contributes to the poor function of the revascularized kidney. These patients may be best served by immediate nephrectomy, provided that there is a functioning contralateral kidney.

Effect of a curfew law on juvenile trauma.

OBJECTIVE: As a method of crime reduction among teenagers, several cities, counties, and states across the country have enacted, or attempted to enact, curfew laws. A curfew law was successfully implemented in Dade County, Florida, in January of 1996. Although its efficacy for crime reduction has been questioned, its benefit for trauma prevention may be real. METHODS: Trauma registry data was collected retrospectively and prospectively from Dade County's Level I trauma center for all trauma victims 5 to 16 years of age. The time period spanned the 2 years before the institution of the curfew law (January 1, 1996) and the 2 years after. Total adult and pediatric trauma volumes during the 4-year period were used as comparisons, as well as juvenile traumas occurring during noncurfew hours. RESULTS: Total trauma volume did not change significantly across the 4-year period, nor did the volume among the curfew age group during noncurfew hours. The predominant mechanisms of injury during curfew hours were motor vehicle crashes and gunshots. Neither the patterns of mechanisms nor ages changed significantly during the precurfew and postcurfew eras. However, the volume of cases seen at the trauma center among the curfew age group was significantly lower with the curfew law in effect (mean, 7.0/month) than before it was in effect (mean, 9.5/month, p = 0.043). CONCLUSION: Although the overall trauma admissions and juvenile trauma admissions during the noncurfew hours remained relatively stable, juvenile trauma admissions during curfew hours dropped significantly in the 2 years after enforcement of the curfew law compared with the 2 years before the curfew law. This finding suggests that attempts to prevent late-night nonproductive street presence among teens can decrease the incidence of trauma occurrences.

Patterns of maxillofacial injuries in powered watercraft collisions.

Because of the widespread popularity of water sports, plastic and reconstructive surgeons can expect to manage an increasing number of injuries associated with these activities, particularly those related to powered watercraft vehicles. Although seat belts for motorists and helmets for motorcyclists may be efficacious, such devices currently do not serve a similar role in powered watercraft sports. In this study, a retrospective chart review of 194 consecutive patients who presented to the University of Miami/Jackson Memorial Hospital (Level I trauma center) as a result of powered watercraft collisions is presented. The purpose of this investigation was to assess the incidence, cause, demographics, and available management options for head and neck injuries secondary to powered watercraft. Identified were 194 patients who presented because of watersports-related injuries during the period January 1, 1991, through December 31, 1996. From this group, 81 patients (41.8 percent) sustained injuries directly attributable to powered watercraft collisions, including 41 personal watercraft collisions (50.6 percent), 39 boat collisions (48.1 percent), and 1 airboat collision (1.2 percent). The patient population, as expected, tended to be young and male with an average age of 29 years (range, 8 to 64 years old). Interestingly, 41 of the patients (50.6 percent) who presented to this trauma center as a result of powered watercraft collisions also sustained associated head and neck trauma. Of 74 injuries 24 were facial fractures (32.4 percent), 18 were facial lacerations (24.3 percent), 14 were closed head injuries (18.9 percent), 8 were skull fractures (10.8 percent), 4 were scalp lacerations (5.4 percent), 4 were C-spine fractures (5.4 percent), 1 was an ear laceration (1.4 percent), and 1 was a fatality (1.4 percent). Le Fort fractures were the most commonly identified facial fracture in this series. The number of these injuries seen in hospital emergency rooms will most likely increase in the future as the popularity of water-related recreational activities becomes even more widespread. Based on these findings, it is strongly recommended that future efforts be directed toward the prevention of these injuries through patient education and the eventual development of efficacious and safe protective equipment.

The role of computed tomography in selective management of gunshot wounds to the abdomen and flank.

OBJECTIVE: To determine whether computed tomography (CT) is an accurate diagnostic modality for the triage of hemodynamically stable patients with gunshot wounds of the abdomen and flank. METHODS: A chart review of 83 trauma patients for whom abdominal CT was used as initial screening. RESULTS: In 53 patients, CT revealed no evidence of peritoneal penetration, and in 15 patients, there was evidence of either peritoneal penetration or liver injury. There were no false results in these patients. Among 15 patients with questionable peritoneal penetration, cavitary endoscopy was performed in 11 and exploratory laparotomy was performed in 3, and 1 patient was initially observed and subsequently underwent exploratory surgery for a missed colonic injury. CONCLUSION: In selected centers and in hemodynamically stable patients with abdominal and flank gunshot wounds, abdominal CT can be an effective and safe initial screening modality to document the presence or absence of peritoneal penetration and to manage nonoperatively stable patients with liver injuries. If there is any question of peritoneal penetration, cavitary endoscopy should be part of the protocol of nonoperative management.

Immune responses of splenectomized trauma patients to the 23-valent pneumococcal polysaccharide vaccine at 1 versus 7 versus 14 days after splenectomy.

OBJECTIVES: Pneumococcal polysaccharide vaccine is given after emergency splenectomy for trauma to lessen the risk of overwhelming postsplenectomy sepsis. This study was undertaken to determine optimal timing of vaccine administration as determined by serum type-specific polysaccharide antibody concentration titer and functional activity of the resulting antibodies. METHODS: Fifty-nine consecutive patients undergoing splenectomy after trauma were randomized to receive pneumococcal vaccine postoperatively at 1, 7, or 14 days. Immunoglobulin G serum antibody concentrations against serogroup 4 and serotypes 6B, 19F, and 23F were measured before vaccination and 4 weeks postvaccination. Antibody concentrations were determined by enzyme-linked immunosorbent assay, and functional antibody by opsonophagocytosis. Results were compared with a normal adult control group (n = 12). RESULTS: Postvaccination enzyme-linked immunosorbent assay immunoglobulin G antibody concentrations for all serogroups and serotypes studied were not significantly different in splenectomized patients and control subjects. Postvaccination functional antibody activity was significantly reduced in early vaccination groups (serotype 6B excepted). However, with the exception of 19F, all titers for the 14-day group approached those of the control subjects (p > 0.05). Fold-increases of opsonophagocytic titers for serogroup 4 and serotypes 6B and 19F showed progressive increases with delay in vaccination. Except for serotype 23F, the number of postsplenectomy patients with opsonophagocytic titers <64 significantly decreased with a delay in vaccination (14 days). CONCLUSIONS: Postvaccination immunoglobulin G serum antibody concentrations were not significantly different from normal control subjects regardless of the time of vaccination (1, 7, or 14 days). Although concentrations approach normal, functional antibody activity was significantly lower. Better functional antibody responses against the serogroup and serotypes studied seemed to occur with delayed (14-day) vaccination.

Failure of splanchnic resuscitation in the acutely injured trauma patient correlates with multiple organ system failure and length of stay in the ICU.

INTRODUCTION: The purpose of our study was to evaluate the relationship between the state of splanchnic perfusion and morbidity and mortality in the hemodynamically unstable trauma patient acutely resuscitated in the ICU. METHODS: Gastric intramucosal pH (pHi) was monitored in a blinded fashion in 19 consecutive critically ill trauma patients with evidence of systemic hypoperfusion (arterial pH [pHa] <7.35, base excess >2.3 mmol/L, lactic acid >2.3 mEq/L) who received right heart catheters to guide resuscitation and subsequent hemodynamic monitoring. DESIGN: Prospective randomized consecutive series with retrospective analysis of data. SETTING: University hospital, surgical ICU. RESULTS: The mean values of APACHE II (acute physiology and chronic health evaluation) Injury Severity Score, pHa, arterial base excess, cardiac index, oxygen delivery index, and oxygen consumption index by 24 h were similar (Student's t test, p>0.1) between survivors and nonsurvivors and between those who developed at most a single (SOF) vs multiple organ system failure (MOSF). Supranormal oxygen delivery and utilization parameters were evenly distributed among survivors and nonsurvivors and patients with SOF and MOSF (chi2, p>0.5). Ten patients had a pHi <7.32 and nine patients had a pHi > or = 7.32 by 24 h. Fifty percent of patients with a pHi <7.32 died, compared with 11% of patients with a pH > or = 7.32 (chi2, p=0.07). Sixty percent of patients with a pHi <7.32 developed MOSF compared with 11% of patients with a pHi > or = 7.32 (chi2, p=0.03). The one patient who developed MOSF and died in the pHi > or = 7.32 cohort suffered from massive head trauma and had all futile medical interventions halted. No other patients who achieved a pH > or = 7.32 by hour 24 developed MOSF. Survivors with a pHi <7.32 at hour 24 had an increased ICU stay (pHi <7.32=46+/-15 days, pHi > or = 7.32=13+/-9 days; p<0.01). A pHi <7.32 carried a relative risk of 4.5 for death and 5.4 for the occurrence of MOSF. CONCLUSION: Attainment of a pHi > or = 7.32 at hour 24 carried a significantly reduced likelihood of MOSF. Being an inference of the state of regional perfusion, in a high-risk microvascular bed, gastric intraluminal tonometry should identify perfusion states of compensated or uncompensated shock during hemodynamic resuscitation of the critically ill injury patient. A low pHi appears to be a marker of postresuscitative morbidity and subsequent increased length of stay.

Personal watercraft crash injuries: an emerging problem.

BACKGROUND: The increased popularity of personal watercraft (PWC) has resulted in an increase in PWC-related injuries. In an effort to better understand the problem, a retrospective review of 37 victims of such injuries seen at a Level I trauma center and fatalities examined by the medical examiner were analyzed. RESULTS: Fourteen percent of the victims were passengers, two of whom were struck from behind, resulting in severe injuries. Twelve patients died of their injuries. For six victims, the cause of death was drowning; only one of these victims was wearing a personal flotation device. Two patients sustained transected aortas, 20% had brain injuries, 20% had spinal fractures, and 48% had skeletal and skull fractures. Abdominal organ injuries were present in only 13.5% of the victims, but they were significant, with liver, spleen, and kidney lacerations and aortic and renal artery injuries. CONCLUSION: In this population of victims of PWC crashes meeting preestablished trauma criteria or on-scene deaths, injuries were significant. Many of the drowning deaths may have been prevented with the use of personal flotation devices. The potential for serious intra-abdominal injury must be recognized and dealt with appropriately.

Management of paroxysmal atrioventricular nodal reentrant tachycardia in the critically ill surgical patient.

OBJECTIVES: Paroxysmal atrioventricular nodal reentrant tachycardia is an infrequently encountered supraventricular arrhythmia that continues to present difficult management problems in the critically ill surgical patient. The purpose of this study was to evaluate the efficacy of a new treatment algorithm involving the sequential administration of different classes of antiarrhythmic agents until conversion to sinus rhythm was achieved. DESIGN: Nonrandomized, consecutive, protocol-driven descriptive cohort. SETTING: University hospital surgical and trauma intensive care unit (ICU). PATIENTS: During an 11-month period, we prospectively evaluated all hemodynamically stable patients who sustained new-onset atrioventricular nodal reentrant tachycardia. INTERVENTIONS: Vagal maneuver, followed by the rapid, sequential infusion of antiarrhythmic agents (i.e., adenosine, verapamil, and esmolol, respectively) until the arrhythmia was terminated. MEASUREMENTS AND MAIN RESULTS: Twenty-seven patients (4% of all admissions) were evaluated, including 16 trauma patients (injury Severity Score of 20 +/- 8) and 11 general surgical patients (Acute Physiology and Chronic Health Evaluation II score of 17 +/- 7). Time from ICU admission to onset of atrioventricular nodal reentrant tachycardia was 4.5 +/- 5 days (median 2.5). Arrhythmia termination was achieved in all patients within minutes (mean 13 +/- 10 [SD]). Incremental sequential adenosine administration alone, however, was successful in affecting conversion to sinus rhythm in only 44% of initial episodes of atrioventricular nodal reentrant tachycardia (95% confidence interval 21% to 67%). A total of 14 (52%) patients developed 38 relapses of paroxysmal supraventricular tachycardia in the ICU after initial conversion to sinus rhythm. These relapses required additional antiarrhythmic therapy. Adenosine was only effective in 34% of the relapses (95% confidence interval 17% to 53%). Seven (50%) of these 14 patients developed multiple relapses. However, only two patients were receiving suppressive calcium-channel or beta-adrenergic receptor blockade at the time of relapse. CONCLUSIONS: The use of a multiagent algorithm was effective for the initial conversion of new-onset atrioventricular nodal reentrant tachycardia to sinus rhythm in critically ill surgical and trauma patients. This preliminary report suggests that adenosine has marginal efficacy in the critically ill surgical or trauma patient. Given the high frequency of relapses, regardless of the agents used to achieve initial control, suppression therapy for the arrhythmia during the period of maximal cardiovascular stress is essential.

Breathing measurement reduces false-negative classification of tachypneic preextubation trial failures.

OBJECTIVES: There is increased awareness of imposed work of breathing contributing to apparent ventilatory dependency. This study evaluates the impact of tachypnea as an indicator of ventilatory failure during a room air-5 cm H2O continuous positive airway pressure, spontaneous breathing, preextubation trial when associated with increased imposed work of breathing. DESIGN: Prospective, descriptive, 1-yr data collection. SETTING: University hospital trauma intensive care unit (ICU). PATIENTS: Mechanically ventilated trauma ICU patients surviving to discharge. INTERVENTION: Patients were weaned to minimal mechanical ventilator support and underwent a 20-min room air-continuous positive airway pressure preextubation trial (FIO2 = 0.21, continuous positive airway pressure = 5 cm H2O [0.5 kPa]). When passed (PaO2 >/= 55 torr [>/= 7.3 kPa], PaCO2 /= 7.35, respiratory rate 1.1 joule/L, imposed work of breathing was measured, and if residual "physiologic" work of breathing (patient work of breathing minus imposed work of breathing) was 30 breaths/min. Of these, 97 were successfully extubated despite tachypnea ranging from 32 to 56 breaths/min, when combined with either a patient work of breathing