Update on trauma care in Canada. 4. Resuscitation through the three phases of hemorrhagic shock after trauma

There are three phases of acute hemorrhagic shock after trauma. In phase I (from injury to operation for control of bleeding) the patient suffers from low cardiac output, tachycardia, reduced organ perfusion, oliguria and decreased capillary hydrostatic pressure, which in turn reduces extravascular fluid loss. Contraction of the interstitial space matrix replenishes plasma volume. Optimal therapy includes blood and crystalloid replacement to restore plasma volume, red cell mass and interstitial fluid. Three litres of crystalloid are usually required for each litre of blood lost. After operation, a period of obligatory extravascular fluid sequestration occurs as the intracellular and interstitial spaces expand (phase II). Optimal replacement therapy during this phase maintains plasma volume. Replacement is provided according to the patient's vital signs, because extravascular fluid expansion cannot be influenced by therapeutic manipulation. Phase III is a mobilization and diuretic phase. During this phase systolic hypertension may occur, and the patient must be treated with restriction of fluid, diuresis and careful monitoring of the heart and lungs. Attempts to alter these physiologic responses with supplemental albumin have proved detrimental. The albumin causes salt and water retention in the nephron, leading to weight gain, higher central filing pressures and worsening pulmonary function, and a greater need for diuretic and inotropic therapy. Albumin therapy also induces relocation of non-albumin proteins into the interstitial space, leading to impaired immunocompetence and coagulation. Successful resuscitation is facilitated by adaptation to these physiologic responses of hemorrhagic shock rather than manipulation of them.

Management of close-range shotgun injuries to the chest by diaphragmatic transposition: case reports

A method of reconstructing the chest wall following close-range shotgun injuries is described. This technique requires detaching the diaphragm peripherally and suturing it above the chest wall defect, resulting in an intact chest cavity and an abdominal wall defect. This latter problem can then be addressed by a variety of standard methods. Two patients are presented with excellent long-term results of diaphragmatic transposition, which should be in the armamentarium of all surgeons who deal with trunk trauma.

The fate of 100 prolonged venous access devices

The fate of 100 prolonged venous access devices (PVAD) placed for chemotherapy (97) or antibiotics (3) during a three-month period was prospectively evaluated. The PVAD included 52 double lumen Hickman (DLH), 29 Infuse-a-port (IAP), and 19 single lumen Hickman (SLH) catheters using percutaneous puncture in 72 pts and venous cutdown in 28 patients. The Hickman catheter subcutaneous tunnel ranged from 4-20 cm with the cuff placed 0.5 to 10 cm from the exit site. Each patient was contacted at two-week intervals to determine the state of the catheter until removal or death. After a one-year follow-up period, 16 per cent of the PVAD remain in place. There were 37 deaths and 22 PVAD were removed after completion of treatment. Mechanical problems led to removal in 12 patients including venous thrombosis (4), poor placement (3), occlusion (3), and a leaking device (2). There were four catheters that "fell out" and nine (8 DLH, 1 SLH) were removed for infection; all 13 catheters were placed in a subcutaneous tunnel less than or equal to 6 cm with the cuff 0.5 cm from the exit site. This study is unique in its accurate determination of fate; 40 per cent of the patients would have been "lost to follow-up" had a retrospective chart review been used, as many patients died at home or had their PVAD removed elsewhere. Recommendations to increase catheter life/patient satisfaction include 1) IAP as the PVAD of choice, 2) SLH preferable to DLH and 3) placement of long Hickman catheter tunnels (greater than or equal to 10 cm) with cuff greater than or equal to 2 cm from exit site.

The effects of chemotherapy on murine wound healing and orocutaneous fistula closure

The effects of cisplatin and 5-fluorouracil on wound breaking strength and the rate of closure of an orocutaneous fistula were studied in 80 male rodents. Treatment rats received a total of 4.6 mg/kg cisplatin and 62 mg/kg 5-fluorouracil in six doses/12 days; control rats received 0.9 per cent saline. After treatment, 30 treatment and 30 control rats received a dorsal skin incision which was closed primarily. Wound breaking strength were tested at one, three and five weeks in ten rats from each group. An 8-mm orocutaneous fistula was made in the remaining ten treatment and ten control rats; the rate of closure was noted weekly. Cisplatin and 5-fluorouracil did not significantly impair wound breaking strength at one, three, or five weeks. The rate of closure of the orocutaneous fistula was not effected by cisplatin/5-fluorouracil. The chemotherapy caused severe facial cellulitis and death in four orocutaneous fistula rats. Combined chemotherapy with cisplatin and 5-fluorouracil should not interfere with planned surgical care of head and neck tumors. Concomitant antibiotic coverage, however, is advocated.

Postoperative complications of abdominal trauma

Postoperative complications following laparotomy for patients with abdominal trauma may be difficult to detect, particularly in those patients with multiple injuries. Such complications may lead to multiple organ system failure and death. Consequently, techniques for prevention of these postoperative complications, from resuscitation through operation, are emphasized. These techniques include means for detecting all abdominal injuries, management of the complicated wound, and evaluation and treatment of abdominal abscesses.

Second annual W.R. Ghent lecture on trauma. Abdominal organ injury: diagnosis, treatment and education

In this lecture the author reviews aspects of education in the care of traumatized patients, with particular attention to abdominal injuries. He notes the lack of education in this aspect of medical care during the medical school years and the variable quality of trauma care education during residency training. The author outlines an organized approach to the teaching of trauma care, focusing on cognitive, psychomotor and affective education and the establishment of a uniform core curriculum for residents with the ultimate goal of enhancing patient care.

Ostomy prolapse in paraplegic patients: etiology, prevention, and treatment

Colostomies are sometimes used to manage those SCI patients who have large pressure sores that are frequently soiled by stool. Seventeen such patients in an Acute Spinal Cord Injury Unit were reviewed to define the problem of ostomy prolapse in paraplegic patients. It was concluded that prolapse is more likely in those patients with an injury at or above the T-10 level. The two patients who had loop colostomies developed prolapse. Those ostomies that were end-sigmoid and exteriorized into an area where there was sensation and abdominal wall muscular integrity were the most successful.

Efficacy of liver wound healing by secondary intent

Nonoperative treatment of liver injury raises questions about liver wound healing (LWH) when the edges are not approximated by primary intent. The efficacy of LWH was studied in 18 dogs and 18 pigs with a total of 108 standard 6-cm injuries. The 36 injuries in six dogs and six pigs were compressed for hemostasis and then allowed to heal by second intent. LWH in these animals was compared to 36 liver wounds in six dogs and six pigs following primary closure (hepatorrhaphy) and 36 liver wounds after omental buttress plus hepatorrhaphy in six dogs and six pigs. Average wound breaking strength (WBS) of liver wounds was studied at 3 weeks (54 wounds) and 6 weeks (54 wounds) with a Chatillon tensiometer and microscopic analysis. The WBS of liver wounds was also compared to normal uninjured liver WBS. The porcine WBS at 3 weeks after healing by second intent (0.31 kg/cm2) was similar to the WBS at 3 weeks after healing by hepatorrhaphy (0.30 kg/cm2) and omental buttress (0.25 kg/cm2). Porcine WBS at 6 weeks after healing by second intent was significantly greater than WBS at 6 weeks after hepatorrhaphy or omental buttress. The canine WBS at 3 weeks after healing by second intent exceeded WBS at 3 weeks after hepatorrhaphy or omental buttress. Canine WBS at 6 weeks after healing by second intent exceeded WBS at 6 weeks after omental buttress and was similar to WBS at 6 weeks after hepatorrhaphy. WBS in all groups paralleled the extent of fibrosis seen on microscopic analysis.(ABSTRACT TRUNCATED AT 250 WORDS)

Serratia marcescens outbreak in a paediatric oncology unit traced to contaminated chlorhexidine

Over an 18-month period we encountered 12 episodes of Serratia marcescens bacteraemia in 10 patients in a paediatric oncology unit. These were associated with long-term indwelling Hickman intravenous catheters (right atrial) and caused three deaths. Seven of the patients had only mild pyrexial illnesses and made a complete recovery. The source was traced to contaminated aqueous chlorhexidine in a bedside container in which plastic clamps were stored. When this was rectified the outbreak ceased. The identity of the causal Serratia strains was confirmed by plasmid analysis and they showed multiple antibiotic resistance, including the aminoglycosides. The study illustrates the emergence of S. marcescens as an opportunistic pathogen and emphasises the dangers of Hickman-associated bacteraemia.

The effect of hemorrhagic shock on the clotting cascade in injured patients

The effects of injury with hemorrhagic shock on the clotting and fibrinolytic systems were studied serially in 22 patients receiving 21 +/- 13 transfusions and 1.26 +/- 0.58 L of fresh frozen plasma (FFP) during operation (OR). The PT, aPTT, thrombin time (TT), fibrinogen (FI), factors V (FV) and VIII (FVIII), fibrin(ogen) split products (FSP) and fibrin monomers were measured in OR and after OR at 6 and 15 hours, days 2 and 4, and at convalescence (25 days). The TT, PT, and aPTT were were prolonged in OR and reflected the low FI, FV, and FVIII, respectively. After OR, clotting times and factor levels returned toward normal. By day 4 and convalescence, FI, FV, and FVIII exceeded normal levels. FSP levels were normal in OR. After OR FSP rose progressively through day 4 when all patients had levels greater than 10 mcg/ml and most patients had levels above 40 mcg/ml. Fibrin monomers were absent until the 15-hour study after which a small number of patients had monomers through the convalescent study. The acute fall in clotting factors is likely due to increased hemostatic demands, plasma dilution from resuscitation, and extravascular relocation from shock-induced extravascular expansion. Later factor restoration likely reflects enhanced hepatic synthesis, factor half-life, capillary selectivity retaining large molecular weight factors, and intravascular relocation from abundant extravascular stores. Throughout this biphasic response, the clotting times reflect factor levels. Fibrinolysis contributes little to these changes.

Caustic injury of the upper gastrointestinal tract in adults: a clinical and endoscopic study

During the past 8 1/2 years, we have treated 34 adult patients admitted for ingestion of caustic materials. In 19 patients the injury was accidental, and in 15 patients ingestion was a suicide attempt. Ingested agents included hydrochloric acid in four patients, sulfuric acid in one patient, a strong alkali such as sodium hydroxide or Drano in 15 patients, liquid bleach in eight patients, detergents in four patients, and ammonia in two patients. Each patient underwent early fiberoptic endoscopic evaluation. The extent and severity of the injury varied according to the ingested agent. Seven patients who had second- or third-degree injury had surgery. One patient who ingested sulfuric acid required hemigastrectomy for pyloric stenosis. Two patients with Drano ingestion had necrosis of the stomach and required total gastrectomy. Five patients with strong alkali ingestion had esophageal strictures, and colonic interposition was performed on four of these patients. No patient who had ingested bleach, ammonia, or detergent required surgery. Panendoscopy after caustic ingestion can be performed safely and provides an accurate guide for therapy. The ingestion of strong acid or alkali may produce profound pathologic changes, which may require surgery for perforation or stricture. Bleach, detergent, and ammonia usually cause mild injuries that will respond with medical treatment.

Emergent endoscopic retrograde cholangiopancreatography. A highly specific test for acute pancreatic trauma

Emergent endoscopic retrograde cholangiopancreatography (ERCP) was assessed as the definitive diagnostic test for acute pancreatic injury in a 23-year-old male automobile driver who sustained blunt abdominal trauma. Despite the patient's quiet, tender abdomen, rising serum amylase level, and an abdominal computed tomographic scan demonstrating probable pancreatic transection, a nonoperative approach was successful when an emergency ERCP demonstrated normal ductal anatomy. This approach is advocated when the presence of a possible pancreatic injury is the only reason for a planned exploratory laparotomy.

Free water clearance after supplemental albumin resuscitation for shock

Previous studies have shown that albumin supplementation in the resuscitation of hypovolemic shock impairs sodium and water excretion and increases renal insufficiency by mechanisms not fully delineated. Free water clearance (CH2O) is a sensitive indicator of renal tubular function. This study further investigates the renal effects of albumin by analyzing CH2O in 94 patients who received an average of 14.5 transfusions for shock; 46 received 31 g of albumin during operation and up to 150 g/day postoperatively while 48 received only electrolyte solution. Patients treated with albumin had a significant decrease in sodium clearance (CNa) (1.4 vs. 2.4 ml/min); however, they were more likely to have an abnormal increased CH2O (greater than 0.25 ml/min) (41% vs. 19%) or near zero CH2O (+/- 0.25 ml/min) (11% vs. 8%) than a normal negative CH2O (less than -0.25 ml/min) (48% vs. 73%). Peritubular albumin concentration correlated inversely with sodium excretion (ENa) and plasma volume correlated positively with ENa, but neither correlated with CH2O. However, filtered Na+ load correlated positively with both CNa and ENa and inversely with CH2O. Therefore, the combination of decreased CNa and increased CH2O reflects 1) increased peritubular oncotic pressure leading to greatly increased Na+ and water reabsorption, 2) increased plasma volume leading to decreased reabsorption of both, and 3) decreased filtered Na+ load causing a selective increase in Na+ reabsorption. These changes are mediated through distal nephron sodium-potassium exchange and result in increased CH2O after albumin therapy.

Nutritional support: a prophylaxis against stress bleeding after spinal cord injury

The incidence of upper gastrointestinal (UGI) bleeding and the effect of nutritional support was studied retrospectively in 166 spinal cord injured patients. Sixty six patients included in group 1 were started on oral diet when 'clinically ready' which resulted in a haphazard manner for provision of nutrition. One hundred patients in group 2 were treated according to an organised nutrition protocol. The protocol initiates total parental nutrition (TPN) if the patient is not tolerating an oral diet by day 5. All group 2 patients met their total energy requirements (TER) within 48 hours after initiating caloric supplementation. The overall incidence of acute acid peptic ulceration leading to significant bleeding or perforation was 4%. Five of the 66 group 1 patients (7.5%) and 2 of the 100 group 2 patients (2%) developed acute ulcerations. While the exact mechanism remains unclear, this significant (p less than 0.05) reduction indicates that a nutritional regimen that meets a patients TER decreases the likelihood of acid peptic complications after spinal cord injury.

[Hemostatic effect of local intramural injection of dehydrated ethanol in the canine gastrointestinal tract]

The relative value of a subserosal injection of 98% ethanol (0.2 ml x 4) in controlling acute and chronic bleeding from serosal vessels was assessed in dogs. Blood flow was measured from gastric serosal vessels (average diameter 1.6 mm) severed immediately after, 24 hours after, and 48 hours after ethanol injection. Blood flow from severed colonic serosal vessels (averaging diameter 1.0 mm) was measured prior to and immediately after ethanol injection. The safety of ethanol injection was tested by endoscopically guided submucosal injection which were sequentially observed endoscopy at one hour, 24 hours, and weekly for weeks after injection. Ethanol injection had no effect on bleeding from larger gastric vessels unless the injection was made 24 or 48 hours prior to vessel severence. Ethanol injection was effective in reducing bleeding from the smaller colonic vessels when done immediately prior to vessel severence. Gastric submucosal injections led to ulcers which extended into the muscle layer at on week and healed completely by three weeks; none perforated or bleed. These data support the potential efficacy of therapeutic ethanol injection for the control of small vessel (1.0 mm diameter) bleeding and the potential prophylactic value against rebleeding from larger vessels. Further studies are needed to determine if these findings are organ related as opposed to being diameter specific.

Feeding jejunostomy in patients who are critically ill

Nutritional support of critically or chronically ill patients is essential. Enteral feeding is preferred and can be accomplished with a feeding jejunostomy tube in selected patients. Complications relative to tube type have been identified herein. Selection of a cuffed tube jejunostomy using a Tenckhoff catheter, placed by the method presented herein, is recommended to minimize the occurrence of these complications and to facilitate nutritional therapy.

Role of Fluosol-DA 20% in prehospital resuscitation

Fluosol-DA 20% (FDA-20) resuscitation has been proposed for prehospital therapy of hemorrhagic shock (HS). Acute HS (mean arterial pressure 60 mm Hg X 90 min, then 40 mm Hg X 30 min) in 24 splenectomized dogs was treated with 50 ml/kg of lactated Ringer's solution (RL) plus a volume equal to 105% of shed blood volume of FDA-20 (group 1), FDA-20 carrier Annex solution (group 2), or RL (group 3). Cardiopulmonary, hemopoietic, hemodynamic, and organ function parameters were measured preshock, at the end of shock, and at 30 and 60 min, and 24 h after resuscitation. FDA-20 produced effective volume expansion, oxygen delivery, and oxygen consumption. The FDA-20 appeared to affect organ function and cells adversely as reflected by a fall in red cell mass and platelet levels and by a rise in liver enzymes, BUN, and serum creatinine. Both the FDA-20 and Annex solution led to a reduction in serum proteins including serum albumin, serum globulin, immunoglobulin-G, and fibrinogen. These reductions are probably due to an oncotically driven factor which appears to maintain an optimal lymph to plasma oncotic ratio. The hydroxyethyl starch in the FDA-20 and the Annex solution, thus, would drive the plasma proteins into the interstitial space. The prolonged prothrombin times and the activated partial thromboplastin times after FDA-20 may be due, in part, to a reduction in the coagulation proteins, although these were not measured. Pending further studies designed to assess the effects of FDA-20 on possible cellular and multiple organ toxicity, clinical studies are premature and unwarranted.

Hemostatic effect of local intramural injection of dehydrated ethanol in the canine gastrointestinal tract

The relative value of a subserosal injection of 98% ethanol (0.2 ml x 4) in controlling acute and chronic bleeding from serosal vessels was assessed in 17 dogs. Blood flow was measured from gastric serosal vessels (average diameter, 1.6 mm) severed immediately after, 24 hours after, and 48 hours after ethanol injection. Blood flow from severed colonic serosal vessels (averaging diameter, 1.0 mm) was measured before and immediately after ethanol injection. The safety of ethanol injection was tested by endoscopically guided submucosal injections which were sequentially observed by endoscopy at 1 hour, 24 hours, and weekly for 4 weeks after injection. Ethanol injection had no effect on bleeding from larger gastric vessels unless the injection was made 24 or 48 hours prior to vessel severence. Ethanol injection was effective in reducing bleeding from the smaller colonic vessels when done immediately prior to vessel severence. Gastric submucosal injections led to ulcers which extended into the muscle layer at 1 week and were completely healed by 3 weeks; none perforated or bled. These data support the potential efficacy of therapeutic ethanol injection for the control of small vessel (1.0 mm in diameter) bleeding and the potential prophylactic value against rebleeding from larger vessels. Further studies are needed to determine whether these findings are organ related as opposed to being diameter specific.

Management of chylothorax after blunt chest trauma

Chylothorax following blunt chest trauma is rare; we found only 19 cases reported. We describe an unusual patient with chylothorax from closed chest injury. The diagnosis is made from thoracentesis or tube thoracostomy fluid. Thoracostomy in the definitive therapeutic modality. Nonoperative or, when necessary, operative treatment of chylothorax after blunt trauma can lead to a successful outcome in 90% of cases.

Pneumomediastinum on a surgical service

Mediastinal emphysema results from multiple etiologies and is associated with a variety of underlying disease entities. Twenty five patients with pneumomediastinum treated on a surgical service over a 6 year period were reviewed. The cause of the mediastinal emphysema was related to trauma in seven patients, attempted central venous access in four patients, cardiopulmonary resuscitation in four patients and some type of Valsalva maneuver in ten patients. Besides the mediastinal emphysema, air may dissect into the peritoneal cavity, the pericardium, and the subcutaneous tissues within the neck and chest wall. Treatment of the mediastinal emphysema, per se, is expectant; success or failure is determined by treatment of the associated underlying problems. Deaths occurred in three patients after cardiopulmonary resuscitation and in one patient after crushing chest injury. One patient with an associated hydrothorax was found to have a perforated distal esophagus which was treated by emergency fundoplication. When associated diseases are absent and there is no evidence of pleural effusion or hydrothorax, no special diagnostic tests are indicated. Sequential chest x-rays are used to follow the pneumomediastinum through resolution, which usually occurs within 72 hours.

The effects of Hespan on serum and lymphatic albumin, globulin, and coagulant protein

The effects of hydroxyethyl starch (Hespan) resuscitation on serum and lymphatic proteins following hemorrhagic shock were studied in 34 splenectomized dogs. Following shock, five randomly assigned treatment groups received the shed blood plus 50 mL/kg of salt solution (RL) or RL with varying concentrations (0.22-1.5 gm/kg) of Hespan. Each dog received 50 ml/kg/d of the test solution for three days after shock. Prothrombin time, partial thromboplastin time, thrombin time, total serum protein, albumin, globulin, and coagulant protein activity of fibrinogen, prothrombin, and factor VIII were measured before shock, at the end of shock, following resuscitation, and on day 3; thoracic duct lymph values were obtained on day 3. Hespan-supplemented resuscitation lowered all serum proteins including albumin, globulin and coagulant proteins; concomitantly, the lymph protein rose after Hespan resuscitation. This decrease in serum proteins and rise in lymph proteins parallels similar results after albumin resuscitation in man and animals and suggests that Hespan induces an oncotically controlled extravascular protein relocation. Further studies on the significance of these findings need to be conducted.

Regenerative responses to exchange perfusion

Isovolemic exchange perfusion of conscious normal and splenectomized rats to a Hct of +/- 3% with the perfluorocarbon based oxygen transport fluid, Fluosol-DA 20%, is characterized by: 1) a greater than projected depression of fibrinogen and the plasma globulins and 2) a rapid regeneration of these and certain other plasma proteins. Similar responses were observed in a study of PFC resuscitation of hemorrhagic shock in splenectomized dogs in which there was a selective depression of the platelets, the plasma globulins, IgG and fibrinogen. In the rats, the red cells and platelets required 14-21 days to return to control levels while the leukocytes returned to normal in 1-2 days. The globulins and fibrinogen exhibited a transient rebound response at 3 and 12 hours post exchange respectively with total protein levels restored to control levels at 48 hours. In the shock study, the leukocytes, which remained at control levels throughout the shock period and for 1 hour post resuscitation were 2.5x control levels at 24 hours. The platelets which were depressed to 20% of control levels following resuscitation remained depressed through the 24 hour time course of the study. Implicit in these results is the possibility that; A) thrombosis and B) immunosuppression may be caused by some component(s) of the perfusion/resuscitation fluid.

Relocation of nonalbumin proteins after albumin resuscitation

Prior work showed that albumin (5% A) resuscitation lowered serum globulins and coagulation protein activity levels compared to balanced electrolyte solution (BES) resuscitation. In this experiment, the effect of 1.25% A in BES (A-BES) on serum and lymphatic levels of nonalbumin proteins was studied in 20 splenectomized dogs subjected to reservoir shock and then treated with (a) BES or A-BES, (b) shed blood, and (c) autogenous bank blood. Serum levels of albumin, globulin, and coagulation protein activity were measured preshock, postshock, and daily for 3 days; skin lymph levels were measured on Day 3. Compared to BES, A-BES resuscitation significantly decreased serum globulins and coagulation protein activity of fibrinogen, Factor VIII, and antithrombin III. In contrast, skin lymph globulins and coagulation protein activity levels increased significantly with A-BES compared to BES resuscitation. These data suggest that the serum protein changes seen with albumin-supplemented resuscitation result from extravascular relocation of nonalbumin proteins, possibly, due to an oncotic homeostatic factor.

Wound healing of the injured spleen with and without splenorrhaphy

Splenic wound healing was studied following splenorrhaphy and observational therapy for both canine and porcine splenic injury. The splenorrhaphy group included four adult male dogs and two adult male pigs studied 3 weeks postinjury. The observational therapy group included three dogs and three pigs examined at 3 weeks and three dogs and two pigs examined 6 weeks postinjury. The wound breaking strength (WBS) 3 weeks after splenorrhaphy was significantly greater than WBS of normal splenic tissue (0.41 vs. 0.71 kg/cm2 in dogs; 0.22 vs. 0.35 kg/cm2 in pigs). WBS 3 weeks after observant therapy for splenic injury in dogs was significantly less than normal (0.66 vs. 0.37 kg/cm2). No WBS differences were seen 3 weeks after observant therapy in pigs nor 6 weeks after observant therapy in dogs or pigs. Prolonged convalescence following splenic injury treated by repair or by observation appears unwarranted.