Failure rates of nonoperative management of low-grade splenic injuries with active extravasation: an Eastern Association for the Surgery of Trauma multicenter study

Objectives

There is little evidence guiding the management of grade I-II traumatic splenic injuries with contrast blush (CB). We aimed to analyze the failure rate of nonoperative management (NOM) of grade I-II splenic injuries with CB in hemodynamically stable patients.

Methods

A multicenter, retrospective cohort study examining all grade I-II splenic injuries with CB was performed at 21 institutions from January 1, 2014, to October 31, 2019. Patients >18 years old with grade I or II splenic injury due to blunt trauma with CB on CT were included. The primary outcome was the failure of NOM requiring angioembolization/operation. We determined the failure rate of NOM for grade I versus grade II splenic injuries. We then performed bivariate comparisons of patients who failed NOM with those who did not.

Results

A total of 145 patients were included. Median Injury Severity Score was 17. The combined rate of failure for grade I-II injuries was 20.0%. There was no statistical difference in failure of NOM between grade I and II injuries with CB (18.2% vs 21.1%, p>0.05). Patients who failed NOM had an increased median hospital length of stay (p=0.024) and increased need for blood transfusion (p=0.004) and massive transfusion (p=0.030). Five patients (3.4%) died and 96 (66.2%) were discharged home, with no differences between those who failed and those who did not fail NOM (both p>0.05).

Conclusion

NOM of grade I-II splenic injuries with CB fails in 20% of patients.

Level of evidence

IV.

Use of a Modified ABTHERA ADVANCE™ Open Abdomen Dressing with Intrathoracic Negative-Pressure Therapy for Temporary Chest Closure After Damage Control Thoracotomy

Case series

Patient: Male, 33-year-old • Male, 51-year-old

Final Diagnosis: Cardio thoracic trauma

Symptoms: Hemorrhagic shock

Medication: —

Clinical Procedure: Intrathoracic negative pressure therapy • thoracotomy

Specialty: Biotechnology • Cardiac Surgery • Critical Care Medicine • Surgery

An Eastern Association for the Surgery of Trauma multicenter trial examining prehospital procedures in penetrating trauma patients

BACKGROUND

Prehospital procedures (PHP) by emergency medical services (EMS) are performed regularly in penetrating trauma patients despite previous studies demonstrating no benefit. We sought to examine the influence of PHPs on outcomes in penetrating trauma patients in urban locations where transport to trauma center is not prolonged. We hypothesized that patients without PHPs would have better outcomes than those undergoing PHP.

METHODS

This was an Eastern Association for the Surgery of Trauma-sponsored, multicenter, prospective, observational trial of adults (18+ years) with penetrating trauma to the torso and/or proximal extremity presenting at 25 urban trauma centers. The impact of PHPs and transport mechanism on in-hospital mortality were examined.

RESULTS

Of 2,284 patients included, 1,386 (60.7%) underwent PHP. The patients were primarily Black (n = 1,527, 66.9%) males (n = 1,986, 87.5%) injured by gunshot wound (n = 1,510, 66.0%) with 34.1% (n = 726) having New Injury Severity Score of ≥16. A total of 1,427 patients (62.5%) were transported by Advanced Life Support EMS, 17.2% (n = 392) by private vehicle, 13.7% (n = 312) by police, and 6.7% (n = 153) by Basic Life Support EMS. Of the PHP patients, 69.1% received PHP on scene, 59.9% received PHP in route, and 29.0% received PHP both on scene and in route. Initial scene vitals differed between groups, but initial emergency department vitals did not. Receipt of ≥1 PHP increased mortality odds (odds ratio [OR], 1.36; 95% confidence interval [CI], 1.01-1.83; p = 0.04). Logistic regression showed increased mortality with each PHP, whether on scene or during transport. Subset analysis of specific PHP revealed that intubation (OR, 10.76; 95% CI, 4.02-28.78; p < 0.001), C-spine immobilization (OR, 5.80; 95% CI, 1.85-18.26; p < 0.01), and pleural decompression (OR, 3.70; 95% CI, 1.33-10.28; p = 0.01) had the highest odds of mortality after adjusting for multiple variables.

CONCLUSION

Prehospital procedures in penetrating trauma patients impart no survival advantage and may be harmful in urban settings, even when performed during transport. Therefore, PHP should be forgone in lieu of immediate transport to improve patient outcomes.

LEVEL OF EVIDENCE

Prognostic, level III.

Management of pediatric occult pneumothorax in blunt trauma: a subgroup analysis of the American Association for the Surgery of Trauma multicenter prospective observational study

BACKGROUND

Occult pneumothorax (OPTX) represents air within the pleural space not visible on conventional chest radiographs. Increased use of computed tomography has led to a rise in the detection of OPTX. Optimal management remains undefined.

METHODS

A pediatric subgroup analysis (age <18 years) from a multicenter, observational study evaluating OPTX management. Data analyzed were pneumothorax size, management outcome, and associated risk factors to characterize those that may be safely observed.

RESULTS

Fifty-two OPTX (7.3 ± 6.2 mm) in 51 patients were identified. None were greater than 27 mm; all those under 16.5 mm (n = 48) were successfully managed without intervention. Two patients underwent initial tube thoracostomy (one [21 mm] and the other with bilateral OPTX [24 mm, 27 mm]). Among patients under observation (n = 49), OPTX size progressed in 2; one (6.4mm) required no treatment, while one (16.5 mm) received elective intervention. Respiratory distress occurred in one patient (10.7 mm) who did not require tube thoracostomy. Nine received positive pressure ventilation; 8 did not have a tube thoracostomy. Twenty-four patients (51%) had one or more rib fractures; 3 required tube thoracostomy.

CONCLUSION

No pediatric OPTX initially observed developed a tension pneumothorax or adverse event related to observation. Pediatric patients with OPTX less than 16 mm may be safely observed. Neither the presence of rib fractures nor need for PPV alone necessitates intervention.

A multivariate logistic regression analysis of risk factors for blunt cerebrovascular injury

INTRODUCTION

The diagnosis of blunt cerebrovascular injuries (BCVI) has improved with widespread adaptation of screening protocols and more accurate multi-detector computed tomography (MDCT-A) angiography. The population at risk and for whom screening is indicated is still controversial. To help determine which blunt trauma patients would best benefit from screening we performed a comprehensive analysis of risk factors associated with BCVI.

METHODS

All patients with BCVI from June 12, 2000 (the date at which our institution began screening for these injuries) to June 30, 2009 were identified by the primary author (JDB) and recorded in a prospective database. Associated injuries were identified retrospectively by International Classification of Diseases, Ninth Revision (ICD-9) code and compared with similar patients without BCVI. Demographic information was also compared from data obtained from the trauma registry. Univariate analyses exploring associations between individual risk factors and BCVI were performed using Fisher's exact test for dichotomous variables and Student's t test for continuous variables. Additionally, relative risk (RR) was calculated for dichotomous variables to describe the strength of the relationship between the categorical risk factors and BCVI. Multivariate logistic regression models for BCVI, BCAI (blunt internal carotid artery injury), and BVAI (blunt vertebral artery injury) were developed to explore the relative contributions of the various risk factors.

RESULTS

One hundred two patients with BCVI were identified out of 9935 blunt trauma patients admitted during this time period (1.03% incidence). Fifty-nine patients (0.59% incidence) had a BVAI and 43 patients (0.43% incidence) had a BCAI. Univariate analysis found cervical spine fracture (CSI) (RR = 10.4), basilar skull fracture (RR = 3.60), and mandible fracture (RR = 2.51) to be most predictive of the presence of BCVI (P < .005). Independent predictors of BCVI on multivariate logistic regression were CSI (OR = 7.46), mandible fracture (OR = 2.59), basilar skull fracture (OR = 1.76), injury severity score (ISS) (OR = 1.05), and emergency department Glasgow Coma Scale (ED-GCS) (OR = 0.93): all P < .05.

CONCLUSIONS

Blunt trauma patients with a high risk mechanism and a low GCS, high injury severity score, mandible fracture, basilar skull fracture, or cervical spine injury are at high risk for BCVI should be screened with MDCT-A.

An evaluation of multidetector computed tomography in detecting pancreatic injury: results of a multicenter AAST study

BACKGROUND

Efforts to determine the suitability of low-grade pancreatic injuries for nonoperative management have been hindered by the inaccuracy of older computed tomography (CT) technology for detecting pancreatic injury (PI). This retrospective, multicenter American Association for the Surgery of Trauma-sponsored trial examined the sensitivity of newer 16- and 64-multidetector CT (MDCT) for detecting PI, and sensitivity/specificity for the identification of pancreatic ductal injury (PDI).

METHODS

Patients who received a preoperative 16- or 64-MDCT followed by laparotomy with a documented PI were enrolled. Preoperative MDCT scans were classified as indicating the presence (+) or absence (-) of PI and PDI. Operative notes were reviewed and all patients were confirmed as PI (+), and then classified as PDI (+) or (-). As all patients had PI, an analysis of PI specificity was not possible. PI patients formed the pool for further PDI analysis. As sensitivity and specificity data were available for PDI, multivariate logistic regression was performed for PDI patients using the presence or absence of agreement between CT and operative note findings as an independent variable. Covariates were age, gender, Injury Severity Score, mechanism of injury, presence of oral contrast, presence of other abdominal injuries, performance of the scan as part of a dedicated pancreas protocol, and image thickness < or =3 mm or > or =5 mm.

RESULTS

Twenty centers enrolled 206 PI patients, including 71 PDI (+) patients. Intravenous contrast was used in 203 studies; 69 studies used presence of oral contrast. Eight-nine percent were blunt mechanisms, and 96% were able to have their duct status operatively classified as PDI (+) or (-). The sensitivity of 16-MDCT for all PI was 60.1%, whereas 64-MDCT was 47.2%. For PDI, the sensitivities of 16- and 64-MDCT were 54.0% and 52.4%, respectively, with specificities of 94.8% for 16-MDCT scanners and 90.3% for 64-MDCT scanners. Logistic regression showed that no covariates were associated with an increased likelihood of detecting PDI for either 16- or 64-MDCT scanners. The area under the curve was 0.66 for the 16-MDCT PDI analysis and 0.77 for the 64-MDCT PDI analysis.

CONCLUSION

Sixteen and 64-MDCT have low sensitivity for detecting PI and PDI, while exhibiting a high specificity for PDI. Their use as decision-making tools for the nonoperative management of PI are, therefore, limited.

Off-Pump Coronary Artery Bypass is an Alternative to Conventional Cardiopulmonary Bypass When Repair of Traumatic Coronary Artery Injuries is Indicated

Coronary artery injuries after penetrating cardiac trauma are rare. The standard approach to these injuries has traditionally been coronary artery ligation. When cardiac perfusion is profoundly compromised, cardiopulmonary bypass has been used to facilitate revascularization, although with serious morbidity. We report a case of traumatic left anterior descending coronary artery transection repaired off-pump in a young stabbing victim. Penetrating traumatic cardiac injuries are highly lethal injuries. Cardiopulmonary bypass has been used for myocardial revascularization when cardiac perfusion is compromised, although with significant complications. Off-pump coronary artery bypass is a safe alternative in the traumatized patient.

Off-pump coronary artery bypass is an alternative to conventional cardiopulmonary bypass when repair of traumatic coronary artery injuries is indicated

Coronary artery injuries after penetrating cardiac trauma are rare. The standard approach to these injuries has traditionally been coronary artery ligation. When cardiac perfusion is profoundly compromised, cardiopulmonary bypass has been used to facilitate revascularization, although with serious morbidity. We report a case of traumatic left anterior descending coronary artery transection repaired off-pump in a young stabbing victim. Penetrating traumatic cardiac injuries are highly lethal injuries. Cardiopulmonary bypass has been used for myocardial revascularization when cardiac perfusion is compromised, although with significant complications. Off-pump coronary artery bypass is a safe alternative in the traumatized patient.

Sixteen-slice multi-detector computed tomographic angiography improves the accuracy of screening for blunt cerebrovascular injury

BACKGROUND

Blunt cerebrovascular injuries (BCVI) are rare but potentially devastating injuries, particularly if the diagnosis is delayed. Only four-vessel cerebral angiography (FVCA) has been shown to be adequately sensitive and specific as a screening tool for BCVI but is resource-intensive and invasive. Computed tomography (CT) angiography has emerged as a possible alternative, but its accuracy has been poor, particularly for low-grade injuries. Recent advances in CT technology, particularly the use of a multi-detector array for image acquisition should improve the accuracy of this technique. This study is the first reported experience of the role of the 16-slice multi- detector CT scanner in screening for BCVI.

METHODS

From January 2, 2003 to October 31, 2004, all patients who met predefined screening criteria were screened for blunt injury to the carotid (BCI) and vertebral (BVI) arteries with a 16-slice multi-detector CT scanner with angiographic reconstruction (CTA). If CTA was positive or equivocal for BCVI, FVCA was performed as a confirmatory test. If CTA was negative, no further diagnostic studies were performed.

RESULTS

There were 435 patients who met criteria and were screened with CTA. Of these, 25 injuries were identified in 24 patients for an incidence of BCVI of 1.2% (24/2023) among all blunt admissions (BTA) and 5.5% (24/435) among screened patients (SP). This was increased compared with the four-slice era (0.38% BTA, 2.4% SP, p<0.01). No patient with a negative CTA was subsequently identified as having, or developed neurologic symptoms attributable to a missed BCVI.

CONCLUSION

Sixteen-slice multi-detector CT angiography is an excellent tool to screen for BCVI and detects all clinically significant injuries. The detected incidence of BCVI increased more than threefold with the 16-slice scanner when compared with the four-slice scanner. This demonstrates a clear technological improvement in our ability to screen for these injuries.

Accelerated degradation of aldicarb and its metabolites in cotton field soils

The degradation of aldicarb, and the metabolites aldicarb sulfoxide and aldicarb sulfone, was evaluated in cotton field soils previously exposed to aldicarb. A loss of efficacy had been observed in two (LM and MS) of the three (CL) field soils as measured by R. reniformis population development and a lack of cotton yield response. Two soils were compared for the first test-one where aldicarb had been effective (CL) and the second where aldicarb had lost its efficacy (LM). The second test included all three soils: autoclaved, non-autoclaved and treated with aldicarb at 0.59 kg a.i./ha, or not treated with aldicarb. The degradation of aldicarb to aldicarb sulfoxide and then to aldicarb sulfone was measured using high-performance liquid chromatography (HPLC) in both tests. In test one, total degradation of aldicarb and its metabolites occurred within 12 days in the LM soil. Aldicarb sulfoxide and aldicarb sulfone were both present in the CL soil at the conclusion of the test at 42 days after aldicarb application. Autoclaving the LM and MS soils extended the persistence of the aldicarb metabolites as compared to the same soils not autoclaved. The rate of degradation was not changed when the CL natural soil was autoclaved. The accelerated degradation was due to more rapid degradation of aldicarb sulfoxide and appears to be biologically mediated.

Helical computed tomographic angiography: an excellent screening test for blunt cerebrovascular injury

BACKGROUND

Blunt cerebrovascular injury (BCVI) carries a high morbidity and mortality, especially when diagnosis is delayed. Recent studies have shown that increased recognition of these injuries is achieved with prompt screening, allowing for early treatment and better outcome. Controversy still exists, however, on the best screening test. This study was used to evaluate the role of helical computed tomographic angiography (CTA) of the carotid and vertebral arteries in the early screening of BCVI.

METHODS

All patients deemed at risk for BCVI underwent CTA within 24 hours of admission. Patients with a negative CTA test underwent no further radiologic evaluation of the cerebral vasculature. Those patients with positive or equivocal CTA results underwent four-vessel cerebral arteriography as a confirmatory test. Data were collected on the radiologic interpretation of all studies and patient clinical course.

RESULTS

Four hundred eighty-six patients fulfilled the criteria for screening and underwent CTA. Nineteen patients were diagnosed with 25 BCVIs during the period of study. There were 7 carotid injuries and 18 vertebral injuries. Eighteen of 19 patients with BCVI were screened with CTA. Seventeen patients were asymptomatic at the time of screening. Results of CTA for BCVI were as follows: sensitivity, 100%; specificity, 94.0%; prevalence (screened patients), 3.7%; positive predictive value, 37.5%; and negative predictive value, 100%. Except for one patient in whom the CTA was clearly misinterpreted by the radiologist, no patient with a negative CTA examination was subsequently found to have a missed injury.

CONCLUSION

CTA is an excellent test with which to screen for BCVI.

Erythromycin reduces delayed gastric emptying in critically ill trauma patients: a randomized, controlled trial

BACKGROUND

Early enteral feeding has been shown to be beneficial in improving outcome in critically injured trauma patients. Delayed gastric emptying occurs frequently in trauma patients, increasing the time to achieve nutritional goals, and limiting the benefit of early enteral feedings. Intravenous erythromycin is an effective agent for improving gastric motility in diabetics and postgastrectomy patients. The purpose of this study is to determine the effectiveness of erythromycin for improving gastric motility in critically injured trauma patients.

METHODS

All critically injured patients who received gastric feedings within 72 hours of admission were candidates for the study. Those patients who failed to tolerate feedings at 48 hours (gastric residual > 150 mL) were eligible for enrollment. Patients were prospectively assigned to two treatment groups by randomization to receive either erythromycin (ERY) or placebo (PLA). Treatment was continued in patients who tolerated gastric feedings until the feedings were no longer required. Patients with continued intolerance for 48 hours after randomization were considered failures of therapy and given metoclopramide.

RESULTS

Sixty-eight patients were enrolled and were well matched for age, sex, and Injury Severity Score. Mortality, intensive care unit length of stay, hospital length of stay, number of ventilator days, and rate of nosocomial infections were similar in each group. There was a significant difference between the ERY group and the PLA group in the amount of feedings tolerated at 48 hours (58% vs. 44%, p = 0.001). There was no difference in the amount of feedings tolerated (as a percentage of target goal volume) throughout the entire duration of the study (ERY [65% of target] vs. PLA [59%], p = 0.061). Overall success of therapy at 48 hours was 56% in the ERY group versus 39% in the PLA group, but this also did not reach statistical significance (p = 0.22).

CONCLUSION

Intravenous erythromycin improves gastric motility and enhances early nutritional intake in critically injured patients.

A prehospital glasgow coma scale score < or = 14 accurately predicts the need for full trauma team activation and patient hospitalization after motor vehicle collisions

BACKGROUND

Trauma team activation protocols should ideally minimize the undertriage of seriously injured patients and eliminate unnecessary activations for those patients that do not require hospitalization. This study examined which physiologic parameter(s) most reliably predicted the need for hospitalization after motor vehicle collisions (MVCs).

METHODS

A prehospital triage tool using standard physiologic parameters was developed and prospectively analyzed for reliability in predicting subsequent patient admission at a Level II trauma center after MVCs. Data were collected on 4,014 consecutive patients, 2,880 (72%) of whom had all of the physiologic parameters reported and recorded. Patients who arrived in extremis, who were dead on arrival, or who died shortly after arrival despite appropriate trauma team activation were ineligible for the study. Multivariate stepwise logistic regression analysis was used to determine which parameters were associated with hospital admission.

RESULTS

The Glasgow Coma Scale (GCS) score was the only prehospital physiologic parameter providing a clinically identifiable difference between those patients admitted (13 +/- 4) and those discharged to home (15 +/- 0.5) (mean + SD) (relative risk for hospitalization, 2.24; 95% confidence interval, 1.86-2.70 for GCS score < 14).

CONCLUSION

The prehospital GCS score is a reliable physiologic parameter for predicting hospital admission after MVC. When obvious indicators (hypoxemia, multiple long bone fractures, focal neurologic deficits) for trauma team activation are lacking, the prehospital GCS score may be used to reduce overtriage and undertriage rates.

Prospective evaluation of the safety of enoxaparin prophylaxis for venous thromboembolism in patients with intracranial hemorrhagic injuries

BACKGROUND

Patients with traumatic intracranial hemorrhagic injuries (IHIs) are at high risk for venous thromboembolism (VTE). The safety of early anticoagulation for IHI has not been established.

HYPOTHESIS

Enoxaparin can be safely administered to most patients with IHI for VTE prophylaxis.

SETTING

Level I trauma center.

DESIGN

Prospective, single-cohort, observational study.

PATIENTS AND METHODS

One hundred fifty (85%) of 177 patients with blunt IHI received enoxaparin beginning approximately 24 hours after hospital admission until discharge. Brain computed tomographic (CT) scans were performed at admission, 24 hours after admission, and at variable intervals thereafter based on clinical course. Patients were excluded for coagulopathy, heparin allergy, expected brain death or discharge within 48 hours, and age younger than 14 years. Complications of enoxaparin prophylaxis were defined as Marshall CT grade progression of IHI, expansion of an existing IHI, or development of a new hemorrhagic lesion on follow-up CT after beginning enoxaparin use.

RESULTS

Thirty-four patients (23%) had CT progression of IHI. Twenty-eight CT scans (19%) worsened before enoxaparin therapy and 6 (4%) worsened after beginning enoxaparin use. No differences between operative patient (2/24, 8%) and nonoperative patient (4/126, 3%) complications were identified (P =.23). Study group mortality was 7% (10/150). All 6 patients who developed progression of IHI after initiation of enoxaparin therapy survived hospitalization. A deep vein thrombosis was identified in 2 (2%) of 106 patients.

CONCLUSION

Enoxaparin can be safely used for VTE prophylaxis in trauma patients with IHI when started 24 hours after hospital admission or after craniotomy.

The high morbidity of blunt cerebrovascular injury in an unscreened population: more evidence of the need for mandatory screening protocols

BACKGROUND

Blunt cerebrovascular injuries are rare injuries causing substantial morbidity and mortality. The appropriate screening methods and treatment options for these injuries are controversial. We examined our experience with these injuries at a community Level I Trauma center over a 51 month period.

STUDY DESIGN

A retrospective review and analysis was done of all patients with the diagnosis of a blunt cerebrovascular injury during this period.

RESULTS

Fourteen patients had blunt carotid injury (0.40%) and three had blunt vertebral injury (0.09%) out of 3,480 total blunt admissions. The overall incidence of blunt cerebrovascular injury was 0.49%. The most common associated injuries were to the head (59%) and chest (47%) regions. The overall mortality rate was 59% (10 of 17), with death occurring in 8 of 14 (57%) blunt carotid injury patients and 2 of 3 (67%) blunt vertebral injury patients. Eight of ten (80%) deaths were directly attributable to the blunt cerebrovascular injury. Median time until diagnosis was 12.5 h (range 1-336 h) for the entire group and 19.5 h for nonsurvivors. Diagnosis was delayed > 24h in 7 patients and > 48h in 5 patients. All five patients whose diagnoses were delayed > 48 h developed complications, and four (80%) of these patients died.

CONCLUSIONS

Blunt cerebrovascular injury is uncommon, but lethal; particularly when the diagnosis is delayed. Aggressive screening protocols based on mechanism of injury, associated injuries, and physical findings are justified to minimize morbidity and mortality. Head and chest injuries may serve as markers for blunt cerebrovascular injury. Most deaths are directly attributable to the blunt cerebrovascular injury and not to associated injuries.

A potentially expanded role for enoxaparin in preventing venous thromboembolism in high risk blunt trauma patients

BACKGROUND

Venous thromboembolism (VTE) is a frequent and potentially life-threatening complication after trauma. The purpose of this study is to investigate the effectiveness of enoxaparin in preventing deep venous thrombosis (DVT) and pulmonary embolism (PE) after injury in patients who are at high risk for developing VTE.

STUDY DESIGN

A prospective single-cohort observational study was initiated for seriously injured blunt trauma patients admitted to a Level I trauma center during a 7-month period. Patients were eligible for the study if time hospitalized was > or = 72 hours, Injury Severity Score (ISS) was > or = 9, enoxaparin was started within 24 hours after admission, and one or more of the following high risk criteria were met: age > 50 years, ISS > or = 16, presence of a femoral vein catheter, Abbreviated Injury Score (AIS) > or = 3 for any body region, Glasgow Coma Scale (GCS) Score < or = 8, presence of major pelvic, femur, or tibia fracture, and presence of direct blunt mechanism venous injury. Patients with closed head injuries and nonoperatively treated solid abdominal organ injuries were also potential participants. The primary outcomes measured were thromboembolic events--either a documented lower extremity DVT by duplex color-flow doppler ultrasonography or a PE documented by rapid infusion CT pulmonary angiography or conventional pulmonary angiography.

RESULTS

There were 118 patients enrolled in the study. Two patients (2%) developed DVT, one of which was proximal to the calf (95% confidence interval, 0% to 6%). Two of 12 patients (17%) with splenic injuries who received enoxaparin failed initial nonoperative management. There were no other bleeding complications, and no clinical evidence or documented episodes of PE. One patient died from multiple system organ failure.

CONCLUSIONS

Enoxaparin is a practical and effective method for reducing the incidence of VTE in high risk, seriously injured patients. This study supports further investigation into the safety of enoxaparin prophylaxis in patients with closed head injuries and nonoperatively treated solid abdominal organ injuries.

Thoracic BB injuries in pediatric patients

Penetrating thoracic injury from BB shot remains an innocuous event in most patients, but factors including location, proximity, gun type, and patient weight may identify groups at risk. The following cases demonstrate morbidity and mortality in two patients, and this experience may suggest the need for reassessment of this injury.

Transesophageal echocardiography for diagnosing aortic injury: a case report and summary of current imaging techniques

Early diagnosis and rapid treatment of lethal aortic injuries associated with blunt trauma remain a challenge for trauma surgeons. The following case demonstrates the use of transesophageal echocardiography for definitive diagnosis of an aortic injury from blunt trauma. A summary of current diagnostic modalities is also presented.

Conservative treatment for adenocarcinoma of the pancreas

The records of 71 patients with the diagnosis of adenocarcinoma of the pancreas were reviewed. Seventeen patients were treated without surgery, 13 underwent exploratory laparotomy for diagnosis with no further palliative or curative operative procedure, six underwent pancreaticoduodenal resection, and 35 patients had a palliative gastric and/or biliary bypass procedure at initial operation. No preoperative signs or symptoms, routine laboratory tests, or radiologic evaluation were helpful as early diagnostic or prognostic indicators. Surgical mortality rates were not significantly different among the four groups; however, the survival time differences between the palliative group (4.8 mo) and the medically managed group (2.0 mo) was significant (p = 0.01 chi 2). Surgical morbidity did not differ significantly among the four groups of patients. The implications of these data in the treatment of patients with adenocarcinoma of the pancreas are discussed.

Defunctionalized jejunal limb for long-term access to the biliary tree

The morbidity associated with repeated operations for recurrent biliary disease is well recognized. It has been postulated that symptomatic relief could be provided nonoperatively using radiologic and endoscopic techniques via a defunctionalized jejunal limb brought out to the subcutaneous space at the time of choledochojejunostomy, and later reached by local cutdown. We have described the nonoperative management of multiple intrahepatic and common bile duct stones successfully removed via such a defunctionalized jejunal limb. Our results suggest that this technique can effectively allow nonoperative access to the biliary tree for treatment of recurrent biliary disease.

Prospective study of catheter-related infection during prolonged arterial catheterization

Ninety-six arterial catheters from 75 different anatomical sites in 56 surgical ICU patients were studied prospectively to determine the rate of catheter-related infection associated with prolonged arterial catheterization (defined as greater than 96 h). Every 96 h, all catheters were semiquantitatively (SQ) cultured and the percutaneous entry site was swab cultured. Sites were used indefinitely by exchanging the catheters over a guide-wire every 96 h as long as arterial monitoring was necessary and SQ cultures remained negative (less than or equal to 15 colonies). No sites used less than 96 h developed skin colonization, while 14/51 (27%) sites used greater than 96 h developed positive swab cultures. No SQ cultures were positive in sites with negative swab cultures (p less than .001). Catheter-related infection (a positive SQ culture) developed in 4/42 (9.5%) radial or femoral sites compared to 4/9 (44%) axillary sites used greater than 96 h (p less than .01). It is concluded that arterial catheter-related infection develops in less than 10% of radial or femoral sites used greater than 96 h, and 90% of radial and femoral sites may be used safely for prolonged periods if skin colonization at the percutaneous sites is controlled and SQ catheter cultures remain negative. Skin site swab cultures may be useful for determining when arterial catheters should be removed and SQ cultured.

Pancreatic pseudocyst with splenic involvement: an uncommon complication of pancreatitis

We have presented a case of chronic pancreatitis with pseudocyst involvement of the spleen complicated by splenic rupture. This complication is uncommon, only 19 cases having been reported. As illustrated by our case, there is a high risk of hemorrhage from a pseudocyst involving the spleen and pancreas. Immediate surgical intervention is therefore indicated. The treatment of choice is resection by splenectomy and distal pancreatectomy.

Accuracy and significance of fine-needle aspiration and frozen section in determining the extent of thyroid resection

The records of 46 patients were retrospectively reviewed to determine the accuracy and significance of fine-needle aspiration (FNA) and intraoperative frozen section (FS) in planning the extent of thyroid resection. For all 46 patients, both FNA and FS diagnoses were available for comparison with the final pathologic diagnosis. The sensitivity value for detection of malignancy by means of FNA was 90% compared with 60% by means of FS, although FS diagnoses were more specific (97%) than FNA diagnoses (56%). FNA diagnoses of benign conditions were correct in 20 of 21 (95%) patients. FS diagnoses of benign conditions were correct in 19 of these 21 patients (90%) but, more important, it did not alter the extent of resection or improve the accuracy of diagnosis. Five patients had findings at FNAs that were positive for malignancy. Frozen section confirmed this diagnosis in all five patients but, again, did not alter the extent of resection. Twenty patients had FNA findings that were "suspicious" for malignancy, with 12 of the tumors diagnosed as benign on FS and only one of four (25%) papillary carcinomas diagnosed as positive on FS. Only four of 20 (20%) FNA results that were "suspicious"--but not diagnosed as malignant--were confirmed as malignant on permanent section, whereas 70% of the FS diagnoses were correct in these 20 patients. Overall, only 16 of 46 (35%) FS diagnoses were helpful in determining the extent of thyroid resection. If a diagnosis of a benign or definitely malignant condition has been made by means of FNA preoperatively, FNA alone provides sufficient information for determining the extent of thyroid resection. Frozen section may be helpful if FNA results are suspicious, but it does not have sufficient sensitivity for determining the extent of resection, which should be deferred until permanent sections have been analyzed.

Necrotizing fasciitis from invasive Phycomycetes

Invasive phycomycotic fungal infections are life-threatening complications in patients with impaired immune response. A successful outcome usually depends on early aggressive treatment. Hyperbaric oxygen (HBO) therapy has been suggested as adjuvant therapy based on theoretical considerations and in vitro evidence of fungal growth retardation. A standard gas gangrene HBO protocol was used to treat a progressive necrotizing polymicrobial soft-tissue infection of the lower extremity in a patient with normal host defenses. Progression of the fungal infection was stopped only after radical surgical debridement. This Phycomycetes (Apophycomyces elegans) has not been previously reported as a pathogen in man.

Recurrent and chronic appendicitis

The records of 205 patients who underwent appendectomy were reviewed to determine the incidence of recurrent and chronic appendicitis. Twenty-one patients (10 per cent) met the criteria for diagnosis of recurrent appendicitis. Three patients (1.5 per cent) had a diagnosis of chronic appendicitis based upon clinical history and pathologic findings of lymphocytic or eosinophilic infiltration of the appendiceal wall. The diagnosis of recurrent or chronic appendicitis should be considered in patients presenting with recurrent pain of the right lower abdominal quadrant.

Continuous monitoring of mixed venous oxygen saturation during aortofemoral bypass grafting

Measurement of mixed venous oxygen saturation (SvO2) may be helpful in the care of critically ill patients. Serial determinations of SvO2 give an index of the relationship between oxygen delivery and tissue oxygen consumption. Continuous monitoring of SvO2 is now readily available with the Shaw Oximetrix pulmonary artery catheter (Oximetrix Inc., Mountain View, CA). This system has provided useful information in the high risk cardiac surgery patient. Continuous monitoring of mixed venous saturation may be helpful in high risk or critically ill general and peripheral vascular surgery patients both in the intensive care unit and in the operating room. The following clinical report is presented to illustrate the usefulness of continuous SvO2 monitoring in a high risk vascular surgery patient.

Acute respiratory failure: mortality associated with underlying disease

The hospital and ICU course of 98 patients who required mechanical ventilatory support longer than 72 h was reviewed to determine if mortality rates were influenced by admitting diagnosis. Patients with malignant diagnoses were compared to patients with nonmalignant diagnoses and to those admitted to the ICU after myocardial infarction or cardiorespiratory arrest. Although there was no significant intergroup difference in incidence of multiple organ system failure, age, and length of ICU and hospital stay, there was a much higher incidence of sepsis (p less than .05) and mortality (p less than .01) in the cancer group. Cancer patients and their families should be made aware of the extremely poor prognosis if prolonged acute respiratory failure develops.

The adult respiratory syndrome

The Adult Respiratory Distress Syndrome remains one of the most lethal complications in both surgical and medical intensive care units. Mortalities of 50 to 80 per cent are still reported in recent reviews. Many risk factors have been associated with an increased incidence of ARDS, but sepsis and direct pulmonary injury from aspiration, pulmonary contusion and near drowning are most commonly identified. Studies of physiopathologic factors of ARDS implicate granulocyte aggregation with the formation of oxygen free radicals and other cellular and chemical mediators. Pharmacologic agents and high frequency positive pressure ventilation are presently being investigated, but the accepted form of therapy combines increased inspired oxygen tensions, positive end expiratory pressure and some form of mechanical ventilation, if necessary.

Ventilatory support in patients with ARDS

Adult respiratory distress syndrome remains one of the most lethal conditions treated in surgical and medical intensive care units. Mortality rates of 50 per cent are still reported in recent reviews. Many risk factors are linked with an increased incidence of ARDS, but sepsis and direct pulmonary injury from aspiration, pulmonary contusion, and other forms of trauma are the most commonly associated risk factors. Studies implicate various cellular and chemical mediators associated with acute lung injury. Many pharmacologic agents and various forms of high-frequency ventilation are being studied for their effectiveness in treating ARDS. We consider that the standard treatment continues to be PEEP and mechanical ventilation to reverse hypoxemia linked with the pathophysiologic changes of ARDS. There are no prospective randomized studies comparing the various end points of therapy used clinically at present. We believe, however, that early intervention, with institution of ventilatory support as soon as signs of acute respiratory failure develop, may eliminate some deaths due to progressive hypoxemia leading to the full adult respiratory distress syndrome. Therapy should be started at this time and maintained while the etiologic factors are identified and treated. Minimal ventilatory support should be continued until the primary diseases have resolved and the multisystem impact of the critical illness has lessened. Weaning from inspiratory (IMV) support, manipulation of expiratory pressures (PEEP), and airway control should then be more easily accomplished and more successful in practice.

Abdominal CT scanning in critically ill surgical patients

Clinical parameters, intensive care unit (ICU) course, abdominal computed tomography (CT) scans, and the clinical decisions of 53 critically ill patients were reviewed to determine the influence of the CT scan. No scans were positive before the eighth day. Sensitivity was 48% and specificity, 64%. Seventeen (23%) scans of the 72 provided beneficial results: eight localized abscesses that were drained; nine were negative and not operated on. Five (7%) scans provided detrimental information: scan negative with abscess discovered or scan positive but negative laparotomy. Fifty (70%) scans were either of no help or not used in management. The mortality rate was 50% when CT led to an intervention, and 47% in the entire group. Hospital charges were +33,408. Personnel time and cost were 497 hours and +3658; of the total +37,066, 77% (+28,541) could be considered wasted. From these data, it was concluded that CT scans should be used to confirm abscesses, not to search for a source of sepsis.

A prospective randomized study of drained and undrained cholecystectomies

One hundred twenty-three patients undergoing elective cholecystectomy at USAF Medical Center Keesler were studied in a prospective randomized manner to determine the differences in morbidity and mortality following drained and undrained cholecystectomies. The groups were compared for differences in mortality, wound infection, postoperative fever, and length of hospitalization. One death occurred due to an unrelated cause in an undrained patient. Three per cent of the undrained group developed wound infections as compared to five per cent in the drained group. This was not statistically significant. A significant difference occurred in postoperative fever between the drained (58%) and undrained (30%) groups. Postoperative hospitalization was also significantly shorter in the undrained group. This study suggests that drainage following elective cholecystectomy is not only unnecessary, but may add to postoperative morbidity and length of hospitalization.

Hyperamylasemia due to poorly differentiated adenosquamous carcinoma of the ovary

In a patient with poorly differentiated ovarian carcinoma, the symptomatology was mistaken for acute pancreatitis. A review of the pertinent literature argues in favor of the early use of amylase isoenzymes in patients whose history, objective signs, and routine diagnostic studies fail to disclose pancreatic disease.