Penetrating Injury to the Great Vessels: Case reviews and management approaches for West Indian Surgeons

Penetrating injury to the great vessels in the thorax is an increasingly common and alarming clinical scenario in the West Indies, and in Jamaica in particular. The management of these often life-threatening injuries involves careful surgical planning and prompt operation, with close adherence to the principles of adequate pre-operative stabilization and investigations, and intra-operative exposure and repair. While this may be more easily accomplished in tertiary care centres, the geographical realities of the West Indies require that every surgeon be familiar with these techniques. A report of the management of some recent cases is followed by a review of the subject and recommended treatment strategies are outlined.(AU)

Penetrating wounds to the torso: the University Hospital of the West Indies experience

OBJECTIVE: This study was done to determine the aetiology of penetrating torso injuries in patients presenting at the University Hospital of the West Indies (UHWI) as well as to document the organs frequently injured and to assess the outcome of these cases. DESIGN AND METHODS: Data were derived from the UHWI trauma registry. All patients presenting to the UHWI with penetrating torso injuries between January 1, 1998 and June 30, 1999 were studied. Biographic data, cause of injury, organs injured and procedures used in treatment were recorded. TRISS methodology was used to identify unexpected deaths. RESULTS: 1899 (42 percent) of the 4,496 admissions to the surgical services of the UHWI were due to trauma. Two hundred and twenty-nine (229) of these had torso injuries and 159 (8 percent) were due to penetrating injuries. Assaults accounted for 98 percent of cases. The male to female ratio was 7.4:1 and the mean age was 28 +or- 10 (SD) years. There were 92 (59 percent) stab wounds and 63 (41 percent) firearm injuries. Mean hospital stay was 8 +or- 15 (SD) days. Mortality rate was 10 percent. Small bowel (17), colon (15) and liver (15) were the abdominal organs most frequently injured. Pneumothorax or haemothorax was detected in 107 patients. All except 20 patients had a major surgical procedure done. There were seven non-therapeutic thoracotomies and 17 non-therapeutic laparotomies. Greater than 50 percent deaths were assessed as preventable. CONCLUSIONS: The wider use of imaging procedures in treatment protocols should reduce the number of non-therapeutic procedures. The preventable death rate may be decreased through training in ATLS protocols and improved equipment maintenance.(Au)

Penetrating injuries to the head and neck

A review of the incidence of penetrating injuries to the head and neck in Jamaica reveals an increase of almost 100 percent from 1974 to 1987 from a average of 57 cases per year in 1974 to 135 cases per year in 1997. In the USA from 1967 to 1983 (16 years) the increase was 48 percent with a projected 2 percent annual increase for industrialised cities: for example: 1. In 1975 there were 112 stab wounds and 98 gun shot wounds to the head and neck. 2. In 1976 there were 118 stab wounds and 121 gun shot wounds to the head and and neck. Penetrating injuries from firearms have risen steadily in Jamaica to equal those from stab wounds and this due to increase in the use of illegal weapons; for example: 1. In 1974 there were 17 stab wounds and 6 gun shot wounds to the head and neck. 2. In 1997 there were 27 stab wounds and 24 gun shot wounds to the head and neck. The typical victim of this injury is a male in his late teens to twenties and the left side of his head and neck is the most common site of injury. The type of object or weapon which inflicts the injury also affects the severity of the injury. Stab wounds cause fewer severe injuries than a machete chop, but with the introduction of firearms with muzzle velocities in the region of 760 metres per second, injury to both sides of the head and neck is possible with one missile. Management in Jamaica is based on selective exploration of these injuries. Our mortality rate of patients who reach the operating table alive does not exceed 1 percent.(AU)

Management of penetrating abdominal injuries

One hundred and twelve patients with penetrating abdominal injuries seen at the Kingston Public Hospital, Jamaica, over a twelve month period from January 1 to December 31, 1992 were reviewed. Seventy-five (67 percent) patients had stab wounds and thirty-seven (33 percent) sustained gunshot wounds. There were 10 deaths (27 percent) from gunshot wounds, and seven deaths (9 percent due to stab wounds. Using a protocol of selective conservatism for stab wounds, 41 (60 percent) were observed, 27 (40 percent) explored and 5 (12 percent) patients had negative laparotomy. The male to female ratio was 10: with 88 percent in the age group 16-35 years. A decision to perform laparotomy was used and is recommended (AU)

Penetrating abdominal injuries: the Jamaican experience - abstract

One hundred and twelve patients with penetrating abdominal injuries were reviewed at the Kingston Public Hospital, Jamaica, over a twelve month period from January 1, 1992 to December 31, 1992. This review included injuries resulting from stab wounds and gunshot wounds. Thirty-seven (33 percent) patients sustained gunshot wounds to the abdomen with 10 deaths, resulting in a mortality of 27 per cent. Seventy-five (67 percent) patients had stab wounds with 7 deaths, resulting in a mortality rate of 9 per cent. Patients with stab wounds were treated using a protocol of selective conservatism. Of the 68 surviving patients with stab injuries, 41 (60 percent) were observed and 27 (40 percent) explored, with negative laparotomy being performed in 5 (12 percent) patients. In both groups of patients with stab and gunshot injuries, there was a predominance of males, with a male to female ratio of 10 : 1, and with 88 per cent of the group between the ages of 16 and 35 years. A decision to perform laparotomy was based entirely on clinical assessment. No use was made of diagnostic peritoneal lavage, stabograms or local wound exploration. We conclude that few diagnostic procedures are necessary in patients with suspected abdominal injuries to determine whether penetration has taken place. The decision to perform exploratory surgery can be based exclusively on clinical criteria. Mandatory laparotomy for gunshot injuries with signs of peritonitis is recommended. Omental evisceration, or other signs of peritoneal penetration, do not warrant mandatory exploration in the absence of peritonitis (AU)

Splinter in the urine

A nine-year-old boy sustained a penetrating injury to the perineum. He later presented with urinary tract infections and a history of passing splinters in the urine. Investigation revealed a foreign body in the urinary bladder, and at suprapubic cystotomy splinters of wood and fragments of cloth were removed. (AU)

Penetrating injuries of the heart

This study represents a review of 33 patients seen at the Kingston Public Hospital, Jamaica, with penetrating cardiac injuries over a 7-year period from 1982 to 1989. Male patients between the ages of 12 and 30 years accounted for more than 80 per cent of cases. A history of syncope associated with haemodynamic instability were the predominant clinical features on presentation. The clinical triad of raised central venous pressure, muffled heart sounds, and low blood pressure levels was present in 33 per cent of the patients with cardiac tamponade. Pulsus paradoxus was not a significant diagnostic sign. Most of the injuries were stab wounds to the left anterior chest. The most commonly injured heart chamber was the right ventricle (48 per cent). Pericardiocentesis was no helpful in making the diagnosis and was only performed as a resuscitative measure in unstable patients prior to thoracotomy. Cardiorrhaphy was performed in the majority of patients through a left anterior lateral thoracotomy with median strnotomy being used only for suspected hilar injuries. A high index of suspicion in patients with penetrating thoracic trauma with expeditious thoracotomy will result in the greatest salvage rate (AU)

Penetrating injuries of the heart - abstract

This study represents a review of 33 patients seen at the Kingston Public Hospital, Jamaica, with penetrating cardiac injuries over a 7-year period from 1982 to 1989. Male patients between the ages of 12 and 30 years accounted for more than 80 per cent of cases. A history of syncope associated with haemodynamic instability were the predominant clinical features on presentation. The clinical triad of raised central venous pressure, muffled heart sounds, and low bloodpressure was present in 33 per cent of the patients with cardiac tamponade. Plus paradoxus was not a significant diagnostic sign. Most of the injuries were stab wounds to the left anterior of the chest. The most commonly injured heart chamber was the right ventricle (48 per cent). Pericardiocentesis was not helpful in making the diagnosis and was only performed as a resuscitative measure in unstable patients prior to thoracotomy. Cardiorrhaphy was performed in the majority of patients through a left anterior lateral thoracotomy with median sternotomy being used only for suspected hilar injuries. A high index of suspicion in patients with penetrating thoracic trauma with expeditious thoracotomy will result in the greatest salvage rate (AU)

Advances in the management of acute popliteal vascular blunt injuries

This report evaluates critical points in the managemant of 30 consecutive blunt traumatic popliteal vascular injuries. All arterial injuries were diagnosed both clinically and by Doppler and PVR examinations. Twenty-eight of the 30 arterial reconstructions required interposition bypass grafts, nine of which were PTFE and the remainder were autogenous saphenous veins. In 19 patients the distal anastomosis was made to the distal popliteal artery and in nine patients to the tibial-peroneal arteries. In ten patients in whom limb survival was threatened, the ischemic time was shortened by the use of temporary silastic shunt for rapid restoration of arterial flow. Nine patients had associated venous injuries which were repaired. Nine of the first 14 patients required fasciotomy but the last 16 patients were treated with hypertonic mannitol and only two of them required fasciotomy. There were no amputations, but in four limbs there were functional losses. In spite of the more extensive damage of blunt trauma, prompt and aggressive management aided by vascular laboratory tests, indewelling shunt, and hypertonic mannitol is rewarded with preservation of limbs following acute popliteal vascular injuries.(AU)

Delayed presentation of brain abscess following penetrating cranial wound

Two cases of brain abscess occurring several years after trivial head injury by a wooden object are presented. Attention is drawn to the high risk of late abscess formation in such cases, and the value of plain radiographs in detacting cases with penetration of the skull which are likely to develop neurological complications is emphasised (AU)

Intrapericardial heart and great vessel injuries

Eighteen patients with intrapericardial penetrating injuries of the heart or great vessels are reviewed, and the results compared with other published material. The majority presented with injuries of the left anterior chest wall and with clinical evidence of cardiac tamponade. Most of the injuries resulted from stab wounds, and there were two deaths which occurred in the immediate peri-operative period. The importance and clinical recognition of cardiac tamponade is stressed. Immediate thoracotomy and repair of the cardiac wound is advocated, and pericardiocentesis is recommended only as a temporary measure to allow transportation of the patient to definitive care. (AU)

Penetrating wounds of the thorax

A review of penetrating wounds of the chest seen at the University Hospital of the West Indies during the period January, 1974 to December, 1976, is presented. Haemothorax can be successfully treated by tube thoracostomy and underwater seal drainage. Emergency thoracotomy was necessary for bleeding in excess of 1,000 cc after tube thoracostomy, continued bleeding following tube thorascomy with associated signs of shock, a large entry wound, cardiac tamponade and associated inta-abdominal injury. All patients with cardiac tamponade who reached the hospital alive survived following thoracotomy and cardiorrhaphy (AU)

Penetrating wounds of the abdomen

The frequency of penetrating wounds seen in the University Hospital ofthe West Indies during a 3-year period, January, 1974, to December, 1976, is presented. Seventy-five patients had abdominal wounds. Abdominal stab wounds produced intra-abdominal damage in about half of the cases, but 77 percent of abdominal gunshot wounds resulted in visceral injuries. All gunshot wounds of the abdomen should be explored surgically but laparotomy should be performed selectively in patients with abdominal stab wounds (AU)

An unusual case of traumatic haemobilia

A case of traumatic haemobilia is presented. It is unusual in that it followed a minor penetrating injury with an ice pick, an instrument only slightly larger than a liver biopsy needle. Furthermore the precipitating cause for urgent surgery was an acute cholecystitis, rather than massive haemorrhage. Bleeding ceased after treatment for the infecting organisms, isolated from the gall bladder, following on cholecystectomy and biliary drainage (AU)