Use of cardiopulmonary bypass to salvage patients with multiple-chamber heart wounds

BACKGROUND

The need for cardiopulmonary bypass in the treatment of penetrating heart injuries is debated.

OBJECTIVES

To review our experience with penetrating heart injuries and determine the indications and outcome for cardiopulmonary bypass.

DESIGN

Retrospective review.

SETTING

A university-based, level I trauma center.

PATIENTS

All victims of penetrating heart injury presenting between July 1, 1989, and December 31, 1995.

METHODS

Medical records were reviewed for demographic and physiological data, operative findings, and outcome.

RESULTS

Overall survival for 106 patients with penetrating heart injury was 55%. In an effort to resuscitate the heart, 4 patients with unresponsive cardiogenic shock were placed on cardiopulmonary bypass; none survived. Of 30 patients with multiple-chamber injuries, 11 presented with signs of life and 7 survived. Cardiopulmonary bypass was essential to repair complex injuries in 2 of the 7 survivors.

CONCLUSION

Cardiopulmonary bypass was ineffective in salvaging patients with cardiogenic shock but was essential in some patients with complex multiple-chamber cardiac injuries that could not be exposed and repaired by other means.

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.

Chemokine inhibition in rat stab wound brain injury using antisense oligodeoxynucleotides

Traumatic injury to the central nervous system (CNS) results in the breakdown of the blood-brain barrier and recruitment of hematogenous cells at the site of injury. The role of chemokines in this process has been well recognized and they have been regarded as promising targets for development of anti-inflammatory therapies. The expression of monocyte chemoattractant protein (MCP-1), in particular, has been closely linked to macrophage infiltration following trauma in rat brain. In this study we determined whether inhibition of MCP-1 following stab wound injury would reduce macrophage infiltration. Stab wound injured Sprague-Dawley rats were infused with MCP-1 sense or antisense oligonucleotides using an Alzet miniosmotic pump (1 microl/h for 3 days). Three days following injury, widespread gliosis was observed in both groups of rats as judged by glial fibrillary acidic protein (GFAP) immunoreactivity. Immunohistochemistry showed significantly less staining for MCP-1 in antisense treated animals. In addition, the number of macrophages were reduced by 30% in the antisense compared to the sense treated animals (P < 0.05). These results demonstrate that modulation of MCP-1 expression in stab wound injury directly affects monocytic infiltration and provide a basis for MCP-1 inhibition as a therapeutic strategy for controlling inflammatory events of traumatic brain injury.

10 year experience of splenic injury: an increasing place for conservative management after blunt trauma

It has been suggested that over 30 per cent of splenic injuries are suitable for conservative management by non-operative treatment and splenorrhaphy; splenic conservation avoids the risk of overwhelming post-splenectomy infection. In this study, injuries of the spleen have been retrospectively analysed for a 10 year period. In the first 5 years the spleen was conserved in only 6/45 (15 per cent) of patients with blunt injury (three non-operative, three splenorrhaphy). In the second 5 years of the study, the spleen was conserved in significantly more patients with blunt trauma, 25 of 61 (41 per cent). This change has been a result of increased non-operative management which has been successful in the majority of cases (20/22). This has been associated with the increased use of abdominal ultrasound. The rate of splenorrhaphy has not changed significantly, five patients compared with three in the previous 5 years. Non-operative management may be increasingly appropriate as less severe splenic injuries are being detected with an increased use of ultrasound. Splenic injury is not a mandatory indication for laparotomy; non-operative management of splenic injuries should be considered in selected patients who are haemodynamically stable and can be closely monitored.

[Harpoons--toy, tool, weapon?]

The case of a 13-year-old boy injured by a Spanish souvenir harpoon is reported. Shooting experiments with the harpoon showed that serious injuries can be caused. The results are discussed and compared with the rare literature.

The use of hemorrhage occluder pins for controlling paravertebral intercostal artery bleeding: case report

OBJECTIVE

To describe a technique for arresting traumatic bleeding uncontrollable by conventional means.

METHODS AND RESULTS

Major intrathoracic bleeding was stopped in a 17-year-old boy who had been stabbed in his right chest by using a Hemorrhage Occluder Pin (Surgical Instruments Inc., Placetia, Calif).

CONCLUSIONS

The use of occluder pins to stop bleeding from intercostal arteries may be life-saving.

[Supraselective embolization of renal pseudoaneurysm caused by an abdominal stab wound]

OBJECTIVE

To report the results of conservative management of post-traumatic (abdominal stab wound) pseudoaneurysm with arteriovenous fistula in segmental artery of left kidney and secondary persistent hematuria in an HIV positive patient.

METHODS/RESULTS

A supraselective left renal arteriography revealed a pseudoaneurysm. We performed embolization of the aneurysmal artery with coils and fibrin particles. Resolution of the hematuria was immediately achieved with no side effects or significant complications.

CONCLUSIONS

In our view, supraselective embolization is the first option in the treatment of post-traumatic renal artery aneurysms due to its low morbidity and limited aggressiveness.

Are scene flights for penetrating trauma justified?

OBJECTIVE

To evaluate the medical efficacy of helicopter scene flights for patients with noncranial penetrating injuries.

DESIGN

A retrospective review of 122 consecutive victims of noncranial penetrating injuries evacuated by helicopter from the scene of injury to a level I trauma center. There were no medical criteria for accepting or rejecting a request for a scene flight by any public safety agency or emergency medical service (EMS). Flights were dispatched if the weather permitted and if a helicopter was available.

RESULTS

The majority of patients were critically wounded. Their average Revised Trauma Score was 10.6, and 15.6% of the patients died (19 of 122), including all 11 patients who required prehospital cardiopulmonary resuscitation. Helicopter transport from the scene did not hasten trauma center arrival for any of the 122 patients. Ninety-two of the first-responder EMS units (75.4%) were advanced life support units (ALS) with crews of paramedics. The remaining 30 (24.6%) first-responder EMS units were basic life support units (BLS) with crews of emergency medical technicians (EMTs). Six of 122 patients (4.9%) required medical interventions by the medical flight crews beyond the capabilities of the ground EMS personnel. Only 3 of the 92 patients (3.3%) treated by first-responding paramedics received medical interventions by the medical flight crews beyond those authorized for paramedics (one cricothyroidotomy and two needle thoracenteses). Two of the 30 patients (6.7%) treated by first-responding EMTs received medical interventions by the medical flight crews not authorized for the EMTs. The on-scene paramedics performed endotracheal intubation on 10 patients. However, because of subsequent clinical deterioration, the medical flight crews performed endotracheal intubations on nine additional patients. In addition, two patients intubated by the first-responding paramedics required reintubation by the medical flight crews.

CONCLUSIONS

Scene flights in this metropolitan area for patients who suffered noncranial penetrating injuries demonstrated that these flights were not medically efficacious. This conclusion rests on the findings that arrival at a trauma center was not hastened by scene flights and that only 4.9% of patients required prehospital care by the medical flight crew beyond the capabilities of the first-responding EMS personnel (2.5 and 6.7% for ALS and BLS responders, respectively). Based on this experience, we believe that in metropolitan areas, scene flights for victims of noncranial penetrating injuries should be restricted to critically injured patients likely to require prehospital care by the medical flight crew that is beyond the capabilities of the first responders or when the scene flight is likely to significantly hasten the arrival of the injured patient to an appropriate trauma center.

Delayed cardiac tamponade following a stab wound: a case report

Penetrating trauma is a frequent presentation to urban emergency departments (EDs). Pericardial effusion with cardiac tamponade is a possible complication of penetrating trauma to the chest, to the back, and to the upper abdomen. Even if patients are stable initially without signs or symptoms of cardiac tamponade, there can be delayed sequelae. Presented is a case of cardiac tamponade diagnosed 21 days after a stab wound to the epigastrium.

The management of stab wounds to the chest: sixteen years' experience

In a retrospective review of 16 years of admissions to a regional cardiothoracic unit, 76 patients were admitted with stab wounds to the chest. Of these wounds, 75% were managed conservatively with tube drainage and observation and 25% required surgical intervention. 5.2% were managed as emergency room thoracotomies, 15.8% as urgent procedures in the operating theatre and 4% as late procedures. The total mortality was 1.3% and was seen in the emergency room thoracotomy group (mortality 25%). The risk if sub-diaphragmatic injury in the presence of chest injury is highlighted.

Selective nonoperative management of abdominal stab wounds: prospective, randomized study

In a prospective, randomized trial the safety and cost-effectiveness of selective nonoperative management was compared to mandatory laparotomy in patients with abdominal stab wounds not requiring immediate laparotomy for hemodynamic instability, generalized peritonitis, or evisceration of abdominal contents. Fifty-one patients were randomly assigned to mandatory laparotomy or expectant nonoperative management and compared for early (<90 days) mortality and morbidity, length of hospital stay, and hospital costs. There was no early mortality. The morbidity rate was 19% following mandatory laparotomy and 8% after observation (p = 0.26). Four patients (17%) managed nonoperatively required delayed laparotomy. The hospital stay was shorter in the observation group (median 2 days versus 5 days;p = 0.002). About $2800 (US) was saved for every patient who underwent successful nonoperative management. It is concluded that selective nonoperative management of abdominal stab wounds, although resulting in delayed laparotomy in some patients, is safe and the preferred strategy for minimizing the days in hospital with concomitant savings in hospital costs. Mandatory laparotomy detects some unexpected organ injuries earlier and more accurately but results in a high nontherapeutic laparotomy rate and surgical management of minor injuries that in many cases could be managed nonoperatively.

Non-operative management of stab wounds to the abdomen with omental evisceration

A consecutive series of 14 patients with anterior abdominal stab wounds and omental evisceration treated at the Kingston Public Hospital Jamaica over a 3-year period is presented. During this period 223 patients with abdominal stab wounds were seen of which 66 had omental evisceration. Conservative surgical management was the approach followed in 14 patients who presented without signs of peritonitis. There were no late complications or missed visceral injuries necessitating laparotomy. Serial physical examination was the method used to select patients for conservative surgical management with the exclusion of patients with deteriorating clinical signs or peritonitis. Omental evisceration through an abdominal stab wound in a patient with stable clinical signs and without evidence of peritonitis is not an absolute indication for exploratory laparotomy.

Stab wounds in The Gambia

Over a 24-month period (January 1990 to December 1991) 337 cases of stab wounds were managed at the Royal Victoria Hospital, Banjul, The Gambia. All stabbing occurred in and around Banjul and victims were predominantly male (99.1%). Stabbed subjects were mostly involved in fights (98.2%). The mean age of the subjects was 27.6 +/- 10.5 years. 155 subjects (46%) required emergency room treatment only while 182 (54%) needed hospitalisation. Superficial lacerations predominated (94.3%) while other major complications included haemothorax/pneumothorax (2.4%), haemopericardium/pneumopericadium (0.3%), cardiac lacerations (0.6%), and haemoperitoneum (2.4%). Visceral injuries managed were: Heart lacerations (2%), Liver lacerations (1.2%), lung lacerations (2.4%), peritoneal lacerations (0.6%), gut perforation (0.6%) and pericardial complications of inadequate initial management. Anaesthetic techniques used for major procedures including Thoracotomies and Laparotomies were simple to ensure safety and assure quick post anaesthetic recovery. All patients had an uneventful recovery. In a situation of restricted medical facilities, we have recorded successful management outcomes without resorting to mandatory exploratory celiotomy and expensive diagnostic procedures.

Conservative management of penetrating and blunt Type III renal injuries

OBJECTIVE

To determine the optimal management, conservative or surgical, of patients with penetrating or blunt Type III renal injuries.

PATIENTS AND METHODS

This retrospective study comprised 122 patients with blunt abdominal or penetrating trauma with suspected significant renal injuries. Forty-five patients (32 penetrating and 13 blunt trauma) with Type III injury were identified. Of these patients, 28 (17 penetrating and 11 blunt trauma) had their renal injuries treated conservatively while 14 patients, all with penetrating injuries, underwent immediate surgical repair. Three patients died from multiple trauma shortly after arrival in the emergency room.

RESULTS

In the 42 surviving patients with Type III renal injuries, four required delayed intervention. These included two of those managed conservatively and two of the 14 who underwent initial surgical intervention. Three renal units were lost, all of which were in those treated surgically. Thus, of the 42 surviving patients with Type III renal trauma, 28 (67%) were successfully managed conservatively without renal loss.

CONCLUSION

This study suggests that Type III penetrating trauma may be successfully managed conservatively with a similar outcome to those patients with Type III blunt injuries. Initial surgical intervention may only be necessary in those with associated intra-abdominal injuries or haemodynamic instability.

Management options in vertebral artery injuries

The treatment of 22 patients with vertebral artery injuries was reviewed. Only four patients required an emergency operation. Most of the injuries (13 of 22) were successfully managed by observation. Five patients were managed by angiographic embolization which was successful in three. In three patients with an aneurysm and arteriovenous fistula, proximal embolization of the vascular lesion was not adequate and a suboccipital craniectomy was required for distal ligation. Most vertebral artery injuries can safely be managed without an operation, or by angiographic embolization. Surgical intervention should be reserved for patients with severe bleeding or where embolization has failed.

Thoracolumbar infections in penetrating injuries to the spine

A detailed review of the TJUH experience and the published literature on gunshot and stab wounds to the spine has been presented. The following statements are supported. (1) Military (high-velocity) gunshot wounds are distinct entities, and the management of these injuries cannot be carried over to civilian (low-velocity) handgun wounds. (2) Gunshot wounds with a resultant neurologic deficit are much more common than stab wounds and carry a worse prognosis. (3) Spinal infections are rare following a penetrating wound of the spine and a high index of suspicion is needed to detect them. (4) Extraspinal infections (septic complications) are much more common than spinal infections following a gunshot or stab wound to the spine. (5) Steroids are of no use in gunshot wounds to the spine. In fact, there was an increased incidence of spinal and extraspinal infections without a difference in neurologic outcome compared with those who did not receive steroids. (6) Spinal surgery is rarely indicated in the management of penetrating wounds of the spine. The recommendations for treatment at TJUH of victims of gunshot or stab wounds with a resultant neurologic deficit are as follows. (1) Spine surgery is indicated for progressive neurologic deficits and persistent cerebrospinal fluid leaks (particularly if meningitis is present), although these situations rarely occur. (2) Consider spine surgery for incomplete neurologic deficits with radiographic evidence of neural compression. Particularly in the cauda equina region, these surgeries may be technically demanding because of frequent dural violations and nerve root injuries/extrusions. These cases must be evaluated in an individual case-by-case manner. The neurologic outcomes of patients with incomplete neurologic deficits at TJUH who underwent acute spine surgery (usually for neural compression secondary to a bullet) were worse than the outcomes for the patients who did not have spine surgery. A selection bias against the patients undergoing spine surgery was likely present as these patients had evidence of ongoing neural compression. (3) A high index of suspicion is necessary to detect spinal and extraspinal infections. (4) Do not use glucorticoid steroids for gunshot wound victims. (5) Conservative (nonoperative) treatment with intravenous broad spectrum antibiotics and tetanus prophylaxis is the sole therapy indicated in the majority of patients who sustain a penetrating wound to the thoracic or lumbar spines.

Stab wounds in Bulawayo, Zimbabwe: a four year audit

Between January 1989 and December 1992 a total of 102 patients (88 pc male and 12 pc female) were treated for stab wounds at Mpilo Central Hospital, Bulawayo, Zimbabwe. The case records of these patients have been studied retrospectively. The mean age of the patients was 30 years (Standard Deviation 9). Most of the patients, 82 pc (82/102) were residents of the city of Bulawayo with only 18 pc (18/102) coming from rural areas. The mean delay in presentation was 12 hours (SD 11). A knife was the stabbing instrument in most cases (82 pc). Fights, 38 pc (26/68), domestic disputes, 26 pc (18/68) and robbery 21 pc (14/68) were the commonest motives for stabbing. In most cases stabbing occurred in a beer hall, 47 pc (26/55) and at home, 31 pc (17/55). The majority of stab wounds occurred in the chest, 51 pc followed by the abdomen, 31 pc. Of the patients with stab wounds of the chest 22 pc (14/65) required intercostal chest drains. Of the 39 patients with stab wounds of the abdomen 20 patients were subjected to laparotomy. No abnormality was found at operation in 50 pc (10/20) of cases. No major complications or mortality were recorded in this series. Based on the findings in this study, there is need for us to adopt a more conservative approach to the management of stab wounds, especially those involving the abdomen. This policy of "selective conservatism" should be based on a thorough physical examination and appropriate special investigations. Active surgical intervention should be reserved for specific indications.

Penetrating stab wounds of the chest--when should chest physiotherapy commence? A comparative study

In an effort to optimise the physiotherapy management of patients with penetrating stab wounds to the chest, 26 male patients, aged between 18 and 30 years, were randomised to one of two groups on admission to Hillbrow Hospital. The patients in group I received chest physiotherapy immediately after insertion of the intercostal drain, while patients in group II received chest physiotherapy 9-12 hours after insertion of the drain as is currently the normal hospital procedure. Mean duration of intercostal drainage in group I was 40 hours and that in group II 65.92 hours. Patients in group I had significantly shorter intercostal drainage times than patients in group II (P = 0.0001). Patients in group I had a mean hospital stay of 43.96 hours while patients in group II had a mean hospital stay of 77.53 hours (P = 0.0001). There was a significant difference in the duration of hospitalisation between the two groups, this being shorter in group I than in group II. The prevalence of spiking temperatures was also significantly lower in group I than in group II, since only 2 patients in group I but 8 patients in group II developed a spiking temperature (P = 0.0207). This study suggests that an aggressive approach of immediate chest physiotherapy in these patients has definite beneficial results.