Trauma centers and trauma surgeons: have we become too specialized?
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Forecasting↗
Biomedical subjects
J D Richardson
Publications and source records attributed to J D Richardson.
Painful nonunion of multiple rib fractures managed by operative stabilization.
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Bone Plates↗
Should trauma surgeons do general surgery?
OBJECTIVE: Many trauma centers have separated emergency and general surgery from trauma care. However, decreased trauma volume and more frequent nonoperative management may limit operative experience and the economic viability of the trauma service. Trauma surgeons at our Level I trauma center have long provided all emergency surgical care and elective surgery. We sought to determine the impact of this policy. METHODS: We reviewed all admissions to the trauma service from June of 1992 to July of 1998 and cross-referenced this with our trauma registry. The number of major and minor procedures performed was also determined, and we reviewed all operative procedures by the trauma service for June of 1996 to October of 1998. RESULTS: Total admissions by the trauma service averaged 3,003 patients/year (range, 2,798-3,198 patients). Nontrauma patients accounted for 34% of all trauma service admissions (range, 26-40%). During this time period, there was no change in volume of operative or intensive care unit procedures, whereas minor procedures recently decreased from a peak of 141/month to 50/month. This was largely due to decreased use of diagnostic peritoneal lavage (surgeon reimbursable) and an increased use of computed tomographic scan and ultrasound (not presently reimbursed) to evaluate blunt abdominal trauma. During the past 2 years, nontrauma cases accounted for 33% of all operative procedures by the trauma service. CONCLUSIONS: Maintenance of emergency and general surgical care by the trauma service has allowed us to buffer impact of variations in trauma volume and to maintain operative skills in an era of increased nonoperative management of many injuries.
Abdominal Injuries↗
Empyema and restrictive pleural processes after blunt trauma: an under-recognized cause of respiratory failure.
Respiratory failure is a common complication among patients sustaining major blunt trauma. This is usually due to the underlying pulmonary injury, pneumonia, or adult respiratory distress syndrome. However, we have frequently found these patients to actually have a pleural process as the cause of their respiratory failure. Our objective was to assess the frequency of empyema and restrictive pleural processes after blunt trauma and their contribution to respiratory failure. We retrospectively reviewed all blunt trauma patients over a 5-year period who required a thoracotomy and decortication for empyema. Twenty-eight patients with blunt trauma required a thoracotomy and decortication for empyema. The most common finding was infected, loculated hemothorax/effusion in 23 patients, whereas 5 had an associated pneumonia. Chest radiographs were nondiscriminating, whereas CT scans in 25 patients showed previously unrecognized fluid collections, air-fluid levels, or gas bubbles. Neither thoracentesis nor placement of additional chest tubes was helpful. Positive cultures were uncommon. Ventilator dependence was present preoperatively in 13 patients who were on the ventilator an average of 13 days preoperatively and only 5.8 days postoperatively. Several patients believed to have adult respiratory distress syndrome were weaned within 72 hours of operation. All patients were ultimately cured. Empyema is an under-recognized complication of blunt trauma and may contribute to respiratory failure and ventilator dependence. Although difficult to diagnose, empyema should be considered in blunt trauma patients with respiratory failure and an abnormal chest radiograph. CT aids in the diagnosis, and the results of surgical treatment are excellent.
Adult↗
Interventional techniques are useful adjuncts in nonoperative management of hepatic injuries.
BACKGROUND: Nonoperative management has become the standard of care for hemodynamically stable patients with complex liver trauma. The benefits of such treatment may be obviated, though, by complications such as arteriovenous fistulas, bile leaks, intrahepatic or perihepatic abscesses, and abnormal communications between the vascular system and the biliary tree (hemobilia and bilhemia). METHODS: We reviewed the hospital charts of 135 patients with blunt liver trauma who were treated nonoperatively between July 1995 and December 1997. RESULTS: Thirty-two patients (24%) developed complications that required additional interventional treatment. Procedures less invasive than celiotomy were often performed, including arteriography and selective embolization in 12 patients (37%), computed tomography-guided drainage of infected collections in 10 patients (31%), endoscopic retrograde cholangiopancreatography with endoscopic sphincterotomy and biliary endostenting in 8 patients (25%), and laparoscopy in 2 patients (7%). Overall, nonoperative interventional procedures were used successfully to treat these complications in 27 patients (85%). CONCLUSION: In hemodynamically stable patients with blunt liver trauma, nonoperative management is the current treatment of choice. In patients with severe liver injuries, however, complications are common. Most untoward outcomes can be successfully managed nonoperatively using alternative therapeutic options. Early use of these interventional procedures is advocated in the initial management of the complications of severe blunt liver trauma.
Abdominal Injuries↗
Delayed surgery and interventional procedures in complex liver injuries.
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Humans↗
Blunt carotid artery injuries: difficulties with the diagnosis prior to neurologic event.
OBJECTIVE: To evaluate the incidence, timing of diagnosis, clinical factors for adverse outcome, and role of anticoagulant, surgical therapy, or endovascular intervention for patients with blunt carotid artery injury (BCAI). METHODS: Retrospective review of the records of patients who sustained BCAI between 1987 and 1997. RESULTS: There were 18 men and 12 women, with an average age of 29 years. The diagnosis of BCAI was initially suspected in 15 patients after a major or new neurologic event, and in 15 patients after changes were shown by computed tomography. BCAI was confirmed by arteriography in 29 patients and by magnetic resonance angiography in 1 patient. Treatment consisted of antiplatelet therapy (n = 9), anticoagulation (n = 8), surgical repair (n = 6), observation (n = 4), and endovascular embolization (n = 3). With some type of treatment, 14 patients with no neurologic deficits remained stable; however, treatment improved the final neurologic outcome in 8 patients (20%). Three patients remained with severe deficits, and five patients died. CONCLUSION: The consequences of BCAI may be devastating. In our study, there were no reliable means to suspect this injury before neurologic symptoms or abnormalities show on computed tomographic scan. Although external signs are occasionally helpful, most patients have no pattern of injury to suggest BCAI. For patients whose findings after neurologic examination do not correlate with those on the computed tomographic scan, an immediate angiogram is indicated. Occasionally, a proximal injury can be surgically repaired, but in most patients, anticoagulation therapy appears to be the best treatment to avoid or improve neurologic deficits.
Adolescent↗
Descending thoracic aortobifemoral bypass: an alternative approach for difficult aortic revascularization.
Descending thoracic aortobifemoral bypass is an alternative inflow operation in cases in which standard aortobifemoral or axillobifemoral bypass is not an option. We performed descending thoracic aortobifemoral bypass for failed inflow operations in four patients, prior abdominal/pelvic radiation in two patients, poor quality distal aorta (extensive atherosclerotic disease or poor tissue quality) in two patients, and abdominal sepsis in two patients. Eight have had excellent results with patency at a mean follow-up of 38 months. There was no limb loss. One patient died of organ failure, and one patient with hypercoagulability developed a graft clot. A literature review disclosed that a descending thoracic aortobifemoral bypass was reported to have been performed in 203 patients, with most cases reported in the last decade. This procedure was the primary inflow operation in 42 per cent of cases. Indications for the operation included failed aortic grafts (38%), "hostile" abdomen (21%), infected aortic grafts (18%), and other (23%). The patency rate was 95 per cent at 6 months. Few long-term results are known, but the results appear to be durable. Descending thoracic aortobifemoral bypass is a useful operation in highly selected circumstances in which conventional methods of aortic reconstruction are not available.
Anastomosis, Surgical↗
The role of general surgery in the age of surgical specialization.
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Certification↗
Antihyperalgesic effects of spinal cannabinoids.
Cannabinoids have been widely reported to produce antinociception in models such as tail flick and hot plate. However, their role in modulating thermal hyperalgesia is unknown. The potency of some drugs, such as the opioids, increases during hyperalgesia. Thus, we evaluated whether there is a change in the effectiveness of intrathecal cannabinoids with hyperalgesia. Additionally, we evaluated whether cannabinoids could inhibit capsaicin-evoked neurosecretion from isolated rat spinal cord. Our results indicate that 1 fmol anandamide (i.t.) completely blocked carrageenan-induced thermal hyperalgesia. However, anandamide at doses as high as 100 pmol had no effect on thermal latencies in normal animals. Additionally, anandamide inhibited K+- as well as capsaicin-evoked immunoreactive calcitonin gene-related peptide release. Finally, cannabinoid receptors were identified in sensory neurons. Collectively, these results indicate that there is an increased effectiveness of modulation of thermal nociceptive thresholds by spinal cannabinoids during hyperalgesia. This antihyperalgesic effect may be the result of cannabinoid-induced inhibition of neurosecretion from certain primary afferent fibers.
Animals↗
Hypoactivity of the spinal cannabinoid system results in NMDA-dependent hyperalgesia.
Cannabinoids, such as Delta9-THC, are capable of inhibiting nociception, i.e., pain transmission, at least in part, by interacting with spinal Gi/Go-coupled cannabinoid receptors. What is not known, however, is the antinociceptive role of endogenous spinal cannabinoids. If endogenous cannabinoids modulate basal nociceptive thresholds, then alterations in this system could be involved in the etiology of certain pain states. In this report we provide evidence for tonic modulation of basal thermal nociceptive thresholds by the spinal cannabinoid system. Administration of oligonucleotides directed against CB1 cannabinoid receptor mRNA significantly reduced spinal cannabinoid binding sites and produced significant hyperalgesia when compared with a randomer oligonucleotide control. A second method used to reduce activity of the spinal cannabinoid receptor was intrathecal administration of the cannabinoid receptor antagonist SR 141716A. SR 141716A evoked thermal hyperalgesia with an ED50 of 0.0012 fmol. The SR 141716A-induced hyperalgesia was dose-dependently blocked by the administration of D-AP-5 or MK-801, two antagonists to the NMDA receptor. These results indicate that there is tonic activation of the spinal cannabinoid system under normal conditions. Furthermore, hypoactivity of the spinal cannabinoid system results in an NMDA-dependent hyperalgesia and thus may participate in the etiology of certain chronic pain states.
2-Amino-5-phosphonovalerate↗
Thoracoscopy in the management of posttraumatic persistent pneumothorax.
BACKGROUND: Persistent posttraumatic pneumothorax (PPP) is an uncommon complication of traumatic injuries of the chest, usually managed with suction drainage and involving prolonged hospital stays. This study was conducted to assess the advantages of using video-assisted thoracoscopic surgery (VATS) in the management of patients with PPP. STUDY DESIGN: Eleven patients with PPP underwent VATS for diagnosis and for definitive treatment. RESULTS: Before VATS was done, all patients had undergone multiple attempts to resolve the PPP; the hospital stay before VATS was 10 days (range, 4-14 days). In 10 patients, the cause of the PPP was identified and a segmental stapled resection was performed, with complete success in resolving the air leak and obtaining pleural synthesis. In another patient, the source of the air leak was not identified and a thoracoscopically assisted chemical pleurodesis was performed, with immediate cessation of the air leak. All chest tubes were removed within 48 hours of the procedure; 9 patients were discharged within 72 hours of VATS. Preoperative computed tomography of the chest was useful in 2 patients, but bronchoscopy did not disclose any major airway injury. CONCLUSIONS: Videothoracoscopy is an accurate, safe, and reliable alternative to an open thoracotomy in the management of patients with PPP. In the patients in whom the procedure was completed, excellent results were obtained and the hospital stay was reduced. We believe that VATS should be used earlier and more frequently after failure of conservative management in such patients.
Adult↗
Non-operative management of blunt hepatic trauma.
BACKGROUND: Non-operative management is currently considered the treatment of choice in over 50 per cent of adult patients with blunt liver injury. This report reviews the criteria for non-operative management and its potential downside. METHODS: English language publications were reviewed. RESULTS: Most reports from major trauma centres in the USA support the non-operative treatment of patients with blunt liver injury if well established criteria are met. Using such criteria, non-operative treatment is successful in 50-80 per cent of cases. Adjunctive radiological techniques may be helpful in managing some complications of non-operative treatment. CONCLUSION: Non-operative management is safe in haemodynamically stable patients with blunt liver injury. Computed tomography (CT) of the abdomen is extremely useful to document the extent of the damage and the presence of associated injuries, but it is not possible, based on CT alone, to predict failure; careful physiological monitoring in selected patients is indicated to avoid catastrophic complications.
Adult↗
Collis-Nissen gastroplasty for shortened esophagus: long-term evaluation.
OBJECTIVE: The authors studied the short- and long-term results of an esophageal lengthening procedure (Collis gastroplasty) combined with a Nissen fundoplication in the management of patients with shortened esophagus and stricture secondary to gastroesophageal reflux disease. Summary Background Data There are several options for managing a shortened esophagus. There have been few long-term series with analysis of results regarding a lengthening procedure combined with a total fundoplication. METHODS: A personal series of 52 patients was examined with complete follow-up available for an average of 7 years. RESULTS: There were no deaths, esophageal leaks, or esophageal complications in the early postoperative period. Control of reflux was excellent and all patients had their dysphagia improved. The majority of patients with preoperative strictures required at least one postoperative dilation, but in most the need for dilation was short term. CONCLUSIONS: The Collis-Nissen procedure is a safe and reasonable alternative in the small subset of patients with severe reflux disease causing a shortened esophagus and stricture.
Adolescent↗
Impact of trauma attending surgeon case volume on outcome: is more better?
OBJECTIVE: To examine the relationship between annual trauma volume per surgeon and years of attending experience with outcome in a Level I trauma center with a large panel of trauma attending surgeons. METHODS: The outcomes of trauma patients were examined in 1995 and 1996 in relationship to surgeon annual trauma volume and years of experience. Outcome variables studied included overall mortality, mortality stratified by Trauma and Injury Severity Score, mortality in patients with an Injury Severity Score greater than 15, and preventable or possibly preventable deaths. Morbidity outcomes examined were overall complication rate and length of stay per attending surgeon. Additionally, five difficult problems were evaluated for critical management decisions by the attending surgeons, and these outcomes were correlated to annual volume and experience. RESULTS: There was no difference in outcome in either morbidity or mortality that correlated with annual volume of patients treated or years of experience. Critical management errors occurred sporadically and were not related to volume or experience. CONCLUSIONS: Outcome after trauma seemed to be related to severity of injury rather than annual volume of cases per surgeon. Although our results may not be applicable to other institutions, they should urge caution in adopting and promulgating volume requirements for individual attending surgeons in trauma centers.
Emergencies↗
Alternatives in the management of penetrating injuries to the iliac vessels.
BACKGROUND: The high mortality and morbidity rates after iliac vessel injuries remain a challenging problem for trauma surgeons. Several controversial issues surround the management of iliac vessel injuries, including the value of abbreviated laparotomy, the role of extra-anatomic bypass reconstruction (EABR), the use of vascular prostheses in the presence of contamination, and the need and timing for fasciotomy. METHODS: Retrospective review of the records of patients who sustained an injury to the iliac vessel between 1987 and 1996. RESULTS: A total of 64 patients were treated, including 23 with isolated iliac vein injuries, 17 with arterial injuries, and 24 with combined arteriovenous injuries. Vascular prostheses were placed in 17 patients with arterial injuries, including 12 with associated intestinal wounds. Graft infection did not occur. Of the 24 patients with combined injuries, 11 underwent abbreviated laparotomy and 1 died. Five deaths, however, occurred in 13 patients in whom no attempts were made for damage control laparotomy. Significant differences between survivors and nonsurvivors included final arterial pH, final prothrombin time, length of hypotension, and number of transfusions. Arterial ligation with EABR was performed in five patients and failed in two. Deep venous thrombosis and pulmonary embolism occurred in four patients, in three of them after venous injuries were ligated. The overall mortality rate was 23%. CONCLUSION: Our findings show that (1) abbreviated laparotomy reduces mortality in iliac injuries; (2) EABR should be performed early after stabilization to prevent limb ischemia; (3) the use of vascular prostheses with associated intestinal injuries did not appear to increase the incidence of graft infection; and (4) after vein ligation, early fasciotomy and prophylaxis against extremity swelling, deep venous thrombosis, and pulmonary embolism should be considered.
Adolescent↗
Posttraumatic renovascular hypertension after occult renal injury.
OBJECTIVE: Hypertension secondary to renal injury is an unusual problem, but one that occurs with some frequency in an active trauma unit. The incidence and management of posttraumatic renovascular hypertension at our Level I trauma center was reviewed. METHODS: A retrospective review of a trauma database was performed on patients treated by our trauma service between 1977 and 1996. Seven patients were identified who developed arterial hypertension as a direct result of a renal injury. RESULTS: All of the patients sustained multiple injuries, with five requiring celiotomy to control bleeding. Renal injuries were occult, and there was no compelling reason to suspect injury to the kidney. No patient had a history of hypertension or elevated arterial pressure on admission; however, sustained arterial hypertension was noted within 2 weeks to 8 months of injury. Arteriography was positive in all seven patients, with findings that included lacerations of the main renal artery, its major branches, or intrarenal constriction of the renal artery (presumably from scarring). Renal-vein renin assays localized to the injured kidney in six patients. Treatment included nephrectomy in four cases, revascularization in one case, and medical management in two cases. All of the patients treated operatively had prompt relief of their hypertension. The two patients treated soley by medical therapy had prompt, durable control of their arterial pressure with a single medication. However, medical treatment had failed before operation in several of the patients. CONCLUSIONS: Because of the serious complications associated with undiagnosed hypertension, new-onset or sustained hypertension after major trauma should be evaluated with attention to a possible renal cause.
Adult↗
Current options in prosthetic vascular graft infection.
Debate continues over which procedure is the best treatment for prosthetic graft infections. We retrospectively reviewed the medical records at our institution for all vascular graft infections that occurred from 1985 to 1995 to evaluate their occurrence, treatment, and outcome. Twenty-four patients had prosthetic graft infections. The average patient age was 62 years, and 67 per cent of the patients studied were men. The initial operation was for treatment of occlusive disease in 92 per cent of the patients, and aortofemoral bypasses were the most common procedures performed (15 of 24 patients, 63%). The average interval from graft implantation to presentation of infection was 29 months. In lower-extremity bypasses, the site of infection was most commonly in the groin (87%). Gram-positive organisms, including coagulase-negative Staphylococcus (32%) and Staphylococcus aureus (28%), were the most frequently isolated bacteria. Thirty procedures were performed for management of the graft infections. Extra-anatomic bypass was associated with no recurrent graft infections. Graft preservation was successful in two cases of early S. aureus infection (less than 1 year after original procedure), and in situ graft replacement was successful in all four cases of late-appearing coagulase-negative Staphylococcus infection (more than 1 year after original procedure). Both treatments failed in all five cases of Gram-negative infection (P = 0.008 by Fisher's exact test). The overall mortality and amputation rates were 17 per cent and 21 per cent, respectively, without significant differences between the treatment modalities. Extra-anatomic bypass remains the best treatment for prosthetic graft infection. In situ replacement and graft preservation treatments should be selective and based on presentation of the infection and the type of pathogenic organism.
Amputation, Surgical↗