Sixty-four patients with traumatic brachial artery injuries were treated. Fifty had penetrating and 14 had blunt injuries. Associated extremity and torso injuries were common. Despite an excellent vascular patency rate of 97 percent, limb loss resulted from severe soft-tissue injury and functional disability occurred due to nerve injury.

Adolescent↗

PubMed1988

Chest tube irrigation for postinjury hypothermia.

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Animals↗

PubMed1988

Value of distal colon washout in civilian rectal trauma--reducing gut bacterial translocation.

Recent experience with civilian rectal trauma challenges the military dictum advocating routine distal colon washout. Opponents contend that septic morbidity is not influenced by perioperative removal of feces from the rectosigmoid region. In an effort to elucidate this issue, we reviewed 27 consecutive patients sustaining extraperitoneal rectal trauma over the past 5 years. One patient, exsanguinating from abdominal vascular injury, was excluded from further analysis. In the remaining 26 patients, rectal injury was due to gunshot wound in 16 (62%), pelvic fracture in 8 (31%), and stab wound in 2 (7%). The mean Revised Trauma Score was 6.9 +/- 0.4, Abdominal Trauma Index 20.9 +/- 8.1, and Injury Severity Score 28.6 +/- 11.0. Proximal colostomy was done in all patients and presacral drains were placed in 23 (88%). Broad-spectrum antibiotics were administered for a minimum of 5 days. Thirteen (50%) of the group underwent intraoperative washout of the distal rectosigmoid colon, dictated by attending surgeon's preference; the other half did not. These two groups were otherwise comparable with respect to injury mechanism, shock on arrival, rectal wound severity, associated injuries, and perioperative blood transfusions. Major complications were greater in the no-washout versus washout groups: pelvic abscess, 46% vs. 8%; rectal fistulae, 23% vs. 8%; and sepsis, 15% vs. 8%. The single death (4%) occurred in the no-washout group. Although based on a small group of patients, these trends imply that distal colon washout reduces septic morbidity following civilian rectal trauma.(ABSTRACT TRUNCATED AT 250 WORDS)

Adult↗

PubMed1988

The role of a regional trauma system in the management of a mass disaster: an analysis of the Keystone, Colorado, chairlift accident.

On December 14, 1985, the Teller chairlift at the Keystone, Colorado, ski area collapsed, throwing 60 of the 372 people aboard to the ground from heights up to 50 feet. Initial triage and management of the victims was carried out by the local ski patrol, the on-duty physician at the area's Snake River Health Services Clinic, and by volunteer physicians and nurses present at the scene. Thirty-three people required immediate evacuation to hospitals, most of them being transported 75 miles by helicopter air ambulance to level I and II trauma centers in the Denver metropolitan area. Eighteen of these air-evacuated patients were in serious or critical condition. Less seriously injured victims were treated at local medical facilities. The scene evacuation was carried out by helicopter and ground vehicles in accordance with an existing disaster plan coordinated by the Colorado Trauma Institute (CTI). The unique problems posed by a mass casualty incident in a remote mountain location are emphasized by this tragedy. Patient salvage due to the efficacy of a regionally organized trauma system is clearly demonstrated.

Adolescent↗

PubMed1988

Total enteral nutrition versus total parenteral nutrition after major torso injury: attenuation of hepatic protein reprioritization.

Reprioritization of hepatic protein synthesis, a process involving accelerated production of acute-phase proteins at the expense of constitutive proteins, accompanies major trauma. The impact of isocaloric, isonitrogenous total enteral nutrition (TEN) versus total parenteral nutrition (TPN) on hepatic reprioritization was investigated in a prospective, randomized trial. Of the 59 patients with an abdominal trauma index (ATI) greater than 15 but not more than 40, 45 evaluable patients were followed. Results from 36 (18 TEN, 18 TPN) evaluable patients revealed that mean serum levels of acute-phase proteins increased, whereas mean serum levels increased to a greater extent in the TPN group. The maximal increase from baseline for the acute-phase response in both groups occurred at postinjury day 5 and was significantly higher for alpha 1-antitrypsin (alpha 1AT, p = 0.03) and orosomucoid (p = 0.02) in the TPN group. Nonacute-phase proteins reached a nadir at day 10 in the TPN group and increased in the TEN group; significant differences between TEN and TPN groups appeared for albumin (p = 0.004) and retinol-binding protein (RBP, p = 0.03); alpha 2-macroglobulin (alpha 2M) approached significance at day 10 (p = 0.07). When change from baseline values was compared, day 10 increases in alpha 2M were significantly higher (p = 0.04) in the TEN group. These data suggest that postinjury TEN attenuates reprioritization of hepatic protein synthesis in patients sustaining major trauma.

Abdominal Injuries↗

PubMed1988

Mobilization of the spleen in splenic salvage.

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Humans↗

PubMed1988

Advances in oxygen monitoring of trauma patients.

Monitoring the critically injured patient is imperative, to assure adequate resuscitation from shock. Unfortunately, the commonly monitored variables correlate poorly with ultimate survival. As a result, therapy is inappropriately focused. Invasive monitoring (by way of a pulmonary artery catheter and arterial cannula) permit serial determinations of parameters pertaining to oxygen delivery as well as oxygen consumption. These are crucial in defining the shock state as well as the need for therapeutic intervention. Recent advances in mixed venous oximetry offer alternative means of assessing the adequacy of peripheral delivery of oxygen. With the advent of metabolic carts, it became feasible to measure respiratory gas exchange to determine oxygen consumption. Complexity, expense, and time clearly limit practical application of that technology to a small percentage of patients in the intensive care unit. Unfortunately, unrecognized hypoxemia remains a common problem. Advances in noninvasive monitoring offer alternative means to assess oxygenation. Pulse oximetry and transcutaneous oxygen monitoring are the state of the art. The pertinent devices are easy to use, portable, and accurate. Knowledge of their technical and physiologic limitations is needed to assure reliability. Their potential role extends beyond the intensive care unit setting, such as with prolonged radiologic evaluation or difficult transportation.

Blood Gas Monitoring, Transcutaneous↗

PubMed1987

Traumatic popliteal and trifurcation vascular injuries: determinants of functional limb salvage.

Forty-seven patients with 64 popliteal or trifurcation arterial injuries were analyzed to elucidate the influence of associated limb trauma on ultimate functional recovery. Nerve, bone, and soft tissue injuries appeared to be critical risk factors. Two or more risk factors were present in 60 percent of 30 blunt injuries, compared with 17 percent of 18 penetrating injuries. All limbs with less than two of these risk factors recovered to a functional state, whereas none of the limbs with all three risk factors had a good outcome, and 7 of 13 limbs (54 percent) were amputated. Vascular reconstruction was successful in 90 percent of the 48 limbs, and patency was 100 percent among the 27 limbs with less than two risk factors. Patients with all three risk factors should be considered for early amputation. We believe reports of peripheral vascular trauma must delineate associated limb injuries to facilitate analysis of patients stratified by relative risk.

Adolescent↗

PubMed1987

Selective management of blunt abdominal trauma in children--the triage role of peritoneal lavage.

The evolution of selective laparotomy in children sustaining blunt abdominal trauma has been highly controversial. This report describes our experience and policy change during this transitional period. Emergency laparotomies performed in the pediatric age group (less than 14 yr) between 1980 and 1984, based on peritoneal lavage, were reviewed. Of 16 such patients, six (37.5%) had injuries identified at laparotomy necessitating operation, (four greater than Grade III spleen, one hepatic vein, one small bowel). The remaining ten patients (67.5%) had injuries which probably could have been managed nonoperatively (eight less than or equal to Grade II spleen, two less than or equal to Grade II liver). We additionally reviewed 46 peritoneal lavages done in children during 1984, and noted a 100% sensitivity but 86% specificity when considering essential laparotomies. Based on these data, we established a selective management protocol and initiated a prospective study in January 1985. The protocol consisted of: 1) routine peritoneal lavage (DPL) in children at high risk for abdominal injury, 2) immediate laparotomy for DPL positive for blood in conjunction with hemodynamic instability, 3) selective laparotomy for DPL positive for blood in a stable child, additionally evaluated by abdominal CT scan (major mechanism) or liver/spleen scan (minor mechanism), and 4) mandatory laparotomy for DPL effluent positive by criteria other than blood. This policy reduced unnecessary laparotomy, otherwise warranted by DPL, to 18% (2/11); both patients had Grade II splenic injuries. Five children sustaining low-energy trauma were managed nonoperatively following peritoneal aspiration of gross blood with L-S scan confirming minor solid visceral injury.(ABSTRACT TRUNCATED AT 250 WORDS)

Abdominal Injuries↗

PubMed1987

Intraoperative hypogastric artery embolization for life-threatening pelvic hemorrhage: a preliminary report.

Percutaneous pelvic embolization has become a useful adjunct in the management of life-threatening hemorrhage from pelvic trauma. However, this approach may be preempted by the need for emergency laparotomy. The surgeon is then confronted with a hemodynamically unstable patient with an expanding hematoma in the face of other life-threatening injuries. Bilateral hypogastric artery ligation has failed in this scenario due to extensive collateralization of the pelvic circulation. We present our experience with intraoperative hypogastric artery embolization used in the management of four patients, and review the available literature on the subject.

Embolization, Therapeutic↗

PubMed1987

Venous bullet embolism: rationale for mandatory extraction.

Venous missile embolism is a rare complication of penetrating trauma which poses controversial management options. We report a case of hepatic vein bullet embolism treated by percutaneous transvenous basket relocation and extraction via femoral vein cutdown. A review of 102 reported bullet emboli since 1930 indicates that the morbidity of a retained projectile is substantial (25%), while removal using modern techniques has few complications. Salient features of early extraction include: 1) prevention of proximal migration, 2) transvenous relocation of the missile to an accessible vein, and 3) peripheral surgical removal. Delayed recognition of an asymptomatic bullet embolus demands further judgment in guiding selective operative removal. A management scheme based on time of recognition, patient status, and embolus characteristics is presented for this unusual problem.

Adult↗

PubMed1985

Nonresectional management of major hepatic trauma. An evolving concept.

Over a 6 year period, 319 acute liver injuries were identified at laparotomy. Fifty-three patients (17 percent) sustained major hepatic trauma that necessitated complex operative techniques: lobectomy in 21, segmentectomy in 6, selective hepatic artery ligation in 3, and temporary packing in 7. Throughout the study period, there has been a progressive shift to nonresectional therapy. Lobectomy for parenchymal injuries has continued to have a prohibitive mortality rate of 64 percent, whereas alternative procedures, such as hepatotomy, selective hepatic artery ligation, and packing, have had lower mortality rates from hemorrhage without an increase in delayed death from sepsis. Hepatotomy has also proved useful to gain access to retrohepatic vena caval tears. Our present experience supports the national trend of surgical restraint in the operative treatment of complex liver trauma and suggests that hepatic lobectomy is rarely justified.

Adolescent↗

PubMed1984

Risk of splenic salvage after trauma. Analysis of 200 adults.

This review was undertaken to analyze critically the complications resulting from operative splenic salvage. Over a 6 year period, 200 adults who sustained splenic trauma underwent laparotomy. The mechanism of injury was blunt in 138 patients (69 percent), a stab wound in 32 patients (16 percent), and a gunshot wound in 30 patients (15 percent). Splenorrhaphy was accomplished in 85 patients (42 percent). Methods of repair included cautery and hemostatic agents in 24 patients (28 percent), debridement and suturing in 42 patients (50 percent), and partial resection in 19 patients (22 percent). Six patients died, four from head trauma and two from multiple organ failure. Postoperative complications occurred in 14 patients. Four were intraabdominal. Three patients required reoperation for splenic hemorrhage; one (2 percent) after suture repair and two (11 percent) after partial resection. A left subphrenic abscess developed in another patient. Splenic reimplantation was performed in 43 patients (22 percent). Five deaths occurred. One was due to head trauma, three to multiple organ failure, and one to overwhelming pneumococcal infection. Eleven postoperative complications occurred, but none was related to splenic autotransplantation. Despite the enthusiasm for splenic salvage, the number of patients suitable for splenorrhaphy plateaued at 56 percent. Complications of splenorrhaphy are infrequent, and the risk increases with more complex salvage attempts. We believe that splenic reimplantation remains a safe procedure.

Accidents, Traffic↗

PubMed1983

Preoperative antibiotics for abdominal gunshot wounds. A prospective, randomized study.

In an effort to define the optimal preventive antibiotics for gunshot wounds to the abdomen, 100 consecutive patients were randomized while in the emergency department to receive either combination ampicillin, amikacin, and clindamycin, combination doxycycline and penicillin, or carbenicillin (Groups I, II, and III, respectively). Antibiotics were continued for 5 days in the presence of distal ileal or colonic injury. The study groups were comparable in age, sex, incidence of shock, degree of peritoneal contamination, and abdominal trauma index. The incidence of infection was not statistically different among the groups. Enterobacteriacea were the predominant offenders, although anaerobes were identified in all groups. The critical risk factor was distal ileal or colon injury. This study indicates that a regimen employing a single agent whose spectrum includes both aerobes and anaerobes is as effective as more expensive and potentially toxic multiagent regimens.

Abdominal Injuries↗