Microcirculatory norepinephrine constrictor response in hemorrhagic shock

Hemorrhagic shock is characterized by a phase of compensation that preserves central blood flow and intravascular pressure through an integrated vasoconstrictor response mediated by catecholamines, particularly norepinephrine (NE). The skeletal muscle microcirculation is important in this response. Decompensation occurs when arteriolar vasodilation occurs despite continued hypovolemia and high circulatory levels of NE. Using an isolated decerebrate rat cremaster muscle, we measured constrictor response to NE (10(-7)M tissue concentration) in compensated and decompensated shock. Our data indicate that larger arterioles (143 to 152 microns) show persistent constrictor response with lowered sensitivity to NE. Smaller arterioles (11 to 22 microns) and all venules dilate late in shock but retain constrictor responses to NE. Dilator responses contribute to decompensation in small arterioles and venules but not because of altered NE constrictor response.

Approaches to the management of shotgun injuries

Shotgun wounds present specific challenges for the surgeon. Multiple penetrating wounds frequently involve large anatomic areas with potential multi-system injury. Experience with 121 patients sustaining shotgun wounds over the 5-year period ending 31 December 1981 was reviewed to assess results and evaluate treatment protocols. Sixty-six patients had chest wounds with pleural penetration. Twenty-four wounds were minor and were observed. Each had less than five pellets penetrating the pleura. Twenty-two patients had close-range injuries. Fourteen of these required chest tube drainage alone and eight patients required thoracotomy for control of bleeding. Eleven patients died, six as a direct result of the chest injury. In 55 patients with abdominal-retroperitoneal wounds exploratory operations were done if more than four pellets were thought to be lodged intraperitoneally or if signs of peritonitis were present, while lesser wounds without peritoneal findings were observed. In the 15 patients who did not have exploratory operations, there were no deaths or major complications. Thirty-five patients had exploratory operations. Two patients had five intraperitoneal missiles and no clinical evidence of peritonitis but were found to have significant intestinal perforations. Four patients died. Eighty-three patients with extremity wounds were classified according to location of injury. Forty-five had upper extremity wounds, with nine vascular injuries. Two patients died and one limb was amputated because of soft tissue infection. Thirty-eight patients had lower extremity wounds. Five had major vascular injuries. Preoperative arteriography was obtained in 13 patients with extremity injuries; the results of one of these were falsely negative. There were no deaths or amputations.(ABSTRACT TRUNCATED AT 250 WORDS)

Effects of electrolyte or colloid infusion on the injured lung

Diffuse lung injury (acid aspiration) and a modest intravascular volume deficit (15% total blood volume) were produced in mongrel dogs. Replacement of lost volume was with shed blood plus an equal volume hydroxy ethyl starch (Group I) or shed blood plus balanced salt solution (3 ml/ml shed blood). Extravascular lung value (EVLW) measurements were used to quantitate edema formation and alveolar arterial oxygen gradient (A-a and O2) was monitored on a reflection of hypoxia. No significant differences were observed in A-a and O2 between groups despite a significantly larger amount of pulmonary edema in Group I (hydroxy ethyl starch).

Peritoneal lavage: a useful diagnostic adjunct for peritonitis

Diagnostic peritoneal lavage (DPL) was used to aid in the rapid diagnosis of peritonitis in 138 patients for whom standard diagnostic criteria were not applicable because the patients had altered sensorium, were elderly, or had multiple medical problems. There were abnormal results in 77 patients, and all but one patient had peritonitis. Sixty-five patients had lesions that could be cured only by operative means; 54% of this group of extremely ill patients survived. Of 61 patients with negative results of DPL, only one had intraperitoneal inflammation (acute cholecystitis), which occurred 4 days after DPL. We believe DPL is a useful procedure for the detection of peritonitis in a critically ill subset of patients for whom the standard diagnostic criteria were not available.

Reassessment of Graham-Steele closure in acute perforated peptic ulcer

We studied 67 patients who had operation for perforated peptic ulcer. Operative treatment included plication with omentum (Graham closure) in 27 patients, vagotomy and pyloroplasty in 32 patients, or vagotomy and antrectomy in eight patients, depending on antecedent ulcer history, degree of contamination, and general patient condition. Mortality was high with simple closure in patients with long-standing perforation or associated disease. Early complications associated with Graham closure included rebleeding, perforation, and obstruction. There were no deaths or major complications related to vagotomy and pyloroplasty. In selected patients, definitive operation is safe and produces excellent long-term results.

Erythrocyte sodium-potassium-stimulated adenosine triphosphatase activity is not related to obesity

Altered erythrocyte sodium potassium (Na,K)-stimulated adenosine triphosphatase (ATPase) activity has been cited as having pathophysiologic significance in morbidly obese man. Previous studies have failed to consider obese patients after weight loss and, therefore, did not clarify the role of ATPase deficiency as a cause or effect of the obese state. To define more completely the possible alteration of cellular thermogenesis in obesity, a study was made of three groups of people: (1) normal weight controls; (2) morbidly obese; and (3) formerly morbidly obese patients who had lost over 100 pounds after gastric bypass surgery. Erythrocyte ATPase activity was determined by use of an assay that coupled ATPase activity with NADH oxidation in the presence of excess pyruvate kinase, lactic dehydrogenase, and phosphoenolpyruvate. This coupled assay produced a continuous slope so that activity could be calculated from the initial, maximal, linear portion of the decay trace. Results did not demonstrate any statistically significant differences in Na,K-ATPase activity between groups by analysis of variance. A nonsignificant correlation of 0.086 was seen between obesity index and Na,K-ATPase activity. It is concluded that (1) erythrocyte Na,K-ATPase activity is similar in both normal and obese individuals, (2) erythrocyte Na,K-ATPase does not change with weight loss, and (3) therefore, disordered erythrocyte thermogenesis does not have a role in the development or maintenance of obesity.

Efficacy of aerosolized methylprednisolone in an animal model of aspiration pneumonitis

Methylprednisolone (MPSS, 30 mg/kg) was administered intrabronchially by nebulization 15 min after HCl aspiration in anesthetized dogs. Control animals (SALINE group) received saline nebulization without steroid. Hemodynamic and oxygenation variables were determined before and 1, 2 and 3 hr after aspiration. At autopsy, lungs were removed and desiccated for gravimetric determination of lung water. Three hr postaspiration, intrapulmonary shunting (Qsp/Qt) in the MPSS group was significantly lower (22 vs 41%) and arterial oxygen tension (PaO2) was higher (265 vs 122 torr) than in the SALINE group. Thus, direct application of this glucocorticoid to airway membranes following acid aspiration improved gas exchange without obvious benefit to edema formation or cardiac output.

Successful management of injuries to the extraperitoneal rectum

We reviewed the records of 32 patients having extraperitoneal rectal trauma in the six-year period ending December 31, 1981. There were 23 penetrating injuries and nine blunt injuries. All patients were resuscitated and examined digitally by sigmoidoscope. Complete diverting colostomy and washout evacuation of the defunctionalized rectal segment were performed routinely. Dilatation of the anal sphincter and lavage with two to three liters of dilute povidone-iodine solution permitted cleansing of the rectal segment of all particulate fecal material. Retrorectal suction drains were inserted in 30 patients; the two remaining patients required abdominoperineal resection and gauze packing of the pelvis for control of hemorrhage. The mortality rate due to rectal injury was 3 per cent. Complications occurred in 5 patients (16%).

Arterial injuries with lower extremity fracture

Review of the records of 41 patients with lower extremity fractures associated with major arterial injuries disclosed that femoral artery injuries were consistently repaired with excellent results and no amputations. Diagnostic delay contributed to an 18% amputation rate following popliteal artery disruption. When arteries distal to the popliteal trifurcation were completely disrupted, a 25% rate of long-term good results was obtained.

Selective management of flail chest and pulmonary contusion

Four hundred and twenty-seven patients with severe blunt chest trauma were treated resulting in (1) flail chest, (2) pulmonary contusions, (3) pneumothorax, (4) hemothorax, or (5) multiple rib fracture. The need for endotracheal intubation and mechanical ventilation was determined selectively by standard clinical criteria. Avoidance of fluid overload and vigorous pulmonary toilet was attempted in all patients. Three hundred and twenty-eight patients were treated by nonintubation; 318 patients (96.6%) had a successful outcome, while ten required intubation. Only one patient died. The 99 patients who required intubation and mechanical ventilation had a high mortality because of associated shock and head injury; however, the total mortality for the entire group of patients was 6.5%, with only 1.4% mortality caused by pulmonary injury. The incidence of pneumonia was high (51%), but there was only a 4% incidence of tracheostomy complications. Flail chest and pulmonary contusion without flail chest occurred in 95 and 135 patients, respectively. Half of the flail chest patients were intubated, but 69.5% were intubated less than three days. Twenty per cent of the patients with pulmonary contusion required mechanical ventilation, usually for less than three days. This study demonstrates that patients with severe blunt chest trauma can be managed safely by selective intubation and mechanical, ventilation and that the incidence of complications associated with controlled mechanical ventilation can be greatly reduced.

Open pelvic fractures

Open pelvic fracture is a devastating injury with a reported 50% mortality rate from massive bleeding and pelvic sepsis. Utilizing a graded approach to management of hemorrhage that included wound packing, anti-shock trousers, angiographic embolization, and hemipelvectomy, we controlled bleeding in all but one of the 35 patients in this series. Patients lost an average of 15 units of blood. The overall survival rate was 94.5% in this series, with one death each from hemorrhage and head injury. Prevention of invasive infection by a diverting colostomy in patients with buttock wounds or perineal wounds was stressed, while anterior soft-tissue wound were managed selectively. Debridement and frequent dressing changes under anesthesia were necessary to prevent and/or treat soft-tissue infection. Associated injuries occur commonly with genitourinary and peripheral nerve trauma and account for the majority of the long-term morbidity.

Resuscitation and transfer of trauma patients: a prospective study

Improved outcome for trauma patients is closely linked to adequate early resuscitation and timely transfer of selected patients to trauma treatment centers. To document adequacy of early care of patients transferred to a regional trauma center, we analyzed 100 consecutive patients transferred after early care in a licensed emergency department by a medical doctor. Patients were evaluated in four injury categories: 1) neurologic, 2) chest, 3) abdominal, and 4) orthopedic. Standards promulgated by the American College of Surgeons Committee on Trauma and the American College of Emergency Physicians were applied in each injury category, and percentage of noncompliance with these accepted standards was calculated. Dangerous levels of noncompliance with accepted standards of trauma care were documented. On the average, major departures from accepted standards of early care were found in more than 70% of cases, particularly in the potentially lethal areas of airway acquisition and volume replacement. Implications of these data and an evaluation of corrective measures are discussed.

Use of the rhomboid major muscle flap for esophageal repair

A 16-year-old boy sustained vehicular blunt trauma with delayed esophageal rupture that resulted in empyema and an esophagopleurocutaneous fistula. Diverting esophagostomy, gastrotomy, and transpyloric jejunostomy were performed, and these procedures permitted satisfactory nutritional support of the patient. Staged direct closure of the esophagus buttressed by a rhomboid muscle flap preserved normal esophageal function. Both clinical application and cadaver dissections have demonstrated that the rhomboid flap has an excellent blood supply and that it can be used to repair lesions on either side in the upper half of the esophagus. Because this flap is extrathoracic, it is not usually distorted by intrathoracic sepsis or previous thoracic incisions. The rhomboid major muscle flap is an excellent alternative to conventional autogenous grafts for esophageal repair.

Cervicomediastinal injuries following blunt trauma

Blunt injuries to aortic arch branches are encountered with increasing frequency. From 1976 to 1980 20 patients with 26 cervicomediastinal arterial injuries were treated. Physical findings varied depending on the vessel injured: all subclavian artery injuries had positive signs, one carotid artery injury had a bruit as the only finding, and injuries to the innominate artery had no positive physical findings. Angiographic examination was performed in all patients when findings suggested vascular injury or there was a high index of suspicion based on patient history, widened mediastinum, or first rib fracture. Vessels injured included the subclavian (13 instances), carotid (five instances), innominate (five instances) and vertebral (three instances). In injured vertebral arteries were ligated. Innominate artery wounds were reconstructed using Dacron grafts; the remainder were excised in the area of intimal damage with primary anastomosis or interposition of a saphenous vein graft. There were no deaths or major vascular complications. Three patients, each, have major upper extremity neurologic deficits due to brachial plexus stretch injuries.

Liver failure

Hepatic failure emerging in a patient after injury is generally manifested as cholestatic jaundice. It differs in several important respects from hepatic failure, as it is understood to present in alcoholic or posthepatitic patients. Sepsis is the etiology of the hepatic failure in the overwhelming majority of patients who die following posttraumatic organ failure. Therefore, aggressive attempts to localize and eradicate infected foci are the foundation of treatment. Exploratory laparotomy will be a necessary diagnostic and therapeutic maneuver in many of these patients and will yield a 50 per cent rate of improvement and survival of patients.

Management of transmediastinal gunshot wounds

Gunshot wounds that transverse the mediastinum are major management problems for two primary reasons: (1) multiple injuries to vital structures are common and (2) the operative approach to control hemorrhage may not afford the optimum exposure to repair the various injuries encountered. We devised a management plan whereby patients in hemodynamically unstable condition underwent immediate operation and patients in stable condition underwent a rapid work-up to evaluate the organs at risk for injury including angiography, esophagoscopy, esophagography, bronchoscopy, and pericardial exploratory surgery while under local anesthesia. A total of 76 patients were treated. Thirty-three patients in unstable condition underwent immediate thoracotomy for hemorrhage or shock or median sternotomy for cardiac tamponade. Multiple organs were injured (average 2.7) and the mortality rate was high (12 of 33) because of the severity of the injuries. Twenty-seven of 43 patients in stable condition required operation after the systematic evaluation disclosed injuries to the great vessels (11), esophagus (9), trachea and bronchi (6), and heart (6). Three patients died of delayed complications (6.9%). The 16 patients who were in stable conditions and had no demonstrable injury were closely followed without operation with one complication and one death from an associated abdominal injury. A management plan for this difficult subset of patients with penetrating thoracic trauma is detailed.

Management of necrotizing tracheostomy infections

Management of three patients with necrotizing tracheostomy infections resulting in tracheal dissolution was reviewed with respect to presentation, cause, and management. Loss of tracheal substance led to difficulty in ventilation because of a large air leak. The stomal area cavitated in two patients, denuding the right common carotid artery in one. Purulent peristomal drainage was present in all three patients. Common factors of possible etiologic significance included necrotizing polymicrobial gram-negative tracheobronchial infections caused by Pseudomonas, Enterobacter, and Klebsiella species. Also of possible importance were suture fixation of the appliance, history of neurologic injury, and closure of the incision. Immediate therapy consisted of oral intubation for ventilatory purposes and a regimen of hourly application of 1% neomycin dressings. Seven to 21 days were necessary to allow formation of sufficient granulation tissue to support replacement of the tracheostomy appliance for continued mechanical ventilation. Once spontaneous ventilation was possible, a Montgomery T-tube was inserted for long-term tracheal stenting prior to reconstruction. The two patients treated by tracheal stenting are long-term survivors. Avoidance of suture fixation of the appliance, aggressive treatment of bronchopulmonary infection, and adequate stomal toilet may help to avoid this devastating complication.

Total parathyroidectomy and parathyroid autotransplantation in patients with chronic renal failure

Sixteen patients with chronic renal failure underwent total parathyroidectomy and parathyroid autotransplantation into the muscle of the forearm. Pertinent preoperative medical history of these patients included renal osteodystrophy, metastatic vascular calcifications, intractable itching and uncontrollable hyperphosphatemia. Efforts to control preoperative serum calcium and elevated serum parathormone levels were unsuccessful. The mass of parathyroid tissue implanted, in most instances, was approximately half that used in other series. Postoperatively, all patients received vitamin D and calcium orally, which were gradually decreased. Fourteen of the 16 patients had relief of symptoms, and all had restoration of parathormone levels to normal or slightly above normal, although in two patients, partial excision of hyperfunctioning tissue from the forearm was subsequently required because of recurring symptoms of secondary hyperparathyroidism. All patients had evidence of functioning grafts six to 40 months postoperatively or until death, attributable to intercurrent causes. The success of total parathyroidectomy and parathyroid autotransplantation in patients with chronic renal failure and symptomatic secondary hyperparathyroidism makes this a viable approach to the disease in such patients.

Emergency abdominal wall reconstruction with polypropylene mesh: short-term benefits versus long-term complications

The acute replacement of full-thickness abdominal wall has been facilitated by polypropylene mesh (Marlex) (PPM), allowing debridement of nonviable tissue and restoration of abdominal wall integrity without tension. However, no substantial long-term follow-up has been reported on the definitive wound coverage after the use of PPM in open wounds. Since 1976, we have placed PPM in 31 patients; 25 for infectious complication, three for massive bowel distension preventing abdominal closure, and three for shotgun wounds with extensive tissue loss. In 29 of 31 patients, the mesh was placed in heavily contaminated wounds; extensive fasciitis was present in 23 patients and 21 had intra-abdominal abscesses. Following mesh placement, 23 reoperations were required for continuing complications. No patients eviscerated, despite these multiple procedures. Polypropylene mesh was highly effective in restoring abdominal wall continuity. Despite advantages when PPM was used, significant long-term problems developed. Seven patients died from their primary illness in the postoperative period. Nine wounds were closed by granulation and subsequent split-thickness skin grafts. All nine developed mesh extrusion and/or enteric fistulae. Nine wounds healed by secondary intention, six developed enteric fistulae or continuing mesh extrusion. Full-thickness flap coverage after granulation provided the best means of wound closure. Polypropylene mesh had significant early advantages for providing abdominal wall integrity even in the presence of severe infection. However, long-term problems were common when wounds were closed to skin grafts or secondary intention. If the mesh cannot be completely removed, strong consideration should be given to myocutaneous flaps for coverage after the primary illness has resolved.

Indomethacin pretreatment in continuous positive-pressure ventilation

The purpose of the study was to investigate the possible involvement of prostaglandins (PG) and thromboxanes (TX) in the cardiovascular and pulmonary changes associated with the use of continuous positive-pressure ventilation (CPPV). Indomethacin (IND), an inhibitor of PG cyclo-oxygenase, was used to block the synthesis and release of PG and TX in the lung after alveolar stretch with CPPV. Groups of dogs received CPPV (buffer group) or CPPV + IND 5 mg/kh iv (CPPV + IND). Pulmonary edema or alveolar hemorrhage was evident in 5 of 6 buffer animals. This damage was also manifested by a 50% decrease in lung compliance. However, IND appeared to block development of lung tissue damage in 5 of 6 CPPV + IND dogs and compliance remained normal. A 52% lowering of cardiac index (CI) in the buffer group paralleled a 71% reduction of left ventricular dP/dt max (first derivative of left ventricular pressure). Peak transmural right heart filling pressure decreased only 15%. in contrast, the 38% decrement of CI in the CPPV + IND animals was coupled with a 98% reduction in filling pressure, but only a 25% decrease in dP/dt max. CPPV-induced changes may have been related, in part, to the release of cytotoxic negative inotrope(s) from damaged alveolar membranes because IND pretreatment blocked this damage.