Red blood cell transfusion in surgery: an observational study of the trends in the USA from 2011 to 2016.

Guidelines recommend restrictive red blood cell transfusion strategies. We conducted an observational study to examine whether the rate of peri-operative red blood cell transfusion in the USA had declined during the period from 01 January 2011 to 31 December 2016. We included 4,273,168 patients from all surgical subspecialties. We examined parallel trends in rates of the following: pre-operative transfusion; prevalence of bleeding disorders and coagulopathy; and minimally invasive procedures. To account for changes in population and procedure characteristics, we performed multivariable logistic regression to assess whether the risk of receiving a transfusion had declined over the study period. Clinical outcomes included peri-operative myocardial infarction, stroke and all-cause mortality at 30 days. Peri-operative red blood cell transfusion rates declined from 37,040/441,255 (8.4%) in 2011 to 46,845/1,000,195 (4.6%) in 2016 (p < 0.001) across all subspecialties. Compared with 2011, the corresponding adjusted OR (95%CI) for red blood cell transfusion decreased gradually from 0.88 (0.86-0.90) in 2012 to 0.51 (0.50-0.51) in 2016 (p < 0.001). Pre-operative red blood cell transfusion rates and the prevalence of bleeding disorders decreased, whereas haematocrit levels and the proportion of minimally invasive procedures increased. Compared with 2011, the adjusted hazard ratios (95%CI) in 2012 and 2016 were 0.96 (0.90-1.02) and 1.05 (0.99-1.11) for myocardial infarction, 0.91 (0.83-0.99) and 0.99 (0.92-1.07) for stroke and 0.98 (0.94-1.02) and 0.99 (0.96-1.03) for all-cause mortality. Use of peri-operative red blood cell transfusion declined from 2011 to 2016. This was not associated with an increase in adverse clinical outcomes.

Frequency of cervical spine injuries in patients with midface fractures.

The aim of this retrospective cohort study was to determine the frequency and risk factors for cervical spine injury (CSI) in patients with midface fractures. Patients ≥18 years of age entered in the Massachusetts General Hospital Trauma Registry from 2007 to 2017 were identified. Those with a midface fracture, computed tomography and/or magnetic resonance imaging of the cervical spine, and complete medical records were included. There were 23,394 patients in the registry; 3950 (16.9%) had craniomaxillofacial fractures and 1822 (7.8%) had a CSI. Craniomaxillofacial fractures included fractures of the midface (n=2803, 71.0%), mandible (n=873, 22.1%), and midface plus mandible (n=274, 6.9%). The overall frequency of CSI in patients with midface fractures was 11.4% (350/3077). Patients with midface fractures had a higher risk for CSI compared to patients without a midface fracture (odds ratio 2.4, 95% confidence interval 2.1-2.4, P<0.001). In a multivariate model, nasal and orbital fractures, chest injuries, age, injury severity score, and motor vehicle crash or fall as the etiology were independent risk factors for CSI. Mortality was two times higher in subjects with CSI. Early and accurate diagnosis of CSI is a critical factor when planning the treatment of patients with these fractures.

Timing of major fracture care in polytrauma patients - An update on principles, parameters and strategies for 2020.

OBJECTIVES: Sustained changes in resuscitation and transfusion management have been observed since the turn of the millennium, along with an ongoing discussion of surgical management strategies. The aims of this study are threefold: a) to evaluate the objective changes in resuscitation and mass transfusion protocols undertaken in major level I trauma centers; b) to summarize the improvements in diagnostic options for early risk profiling in multiply injured patients and c) to assess the improvements in surgical treatment for acute major fractures in the multiply injured patient. METHODS: I. A systematic review of the literature (comprehensive search of the MEDLINE, Embase, PubMed, and Cochrane Central Register of Controlled Trials databases) and a concomitant data base (from a single Level I center) analysis were performed. Two authors independently extracted data using a pre-designed form. A pooled analysis was performed to determine the changes in the management of polytraumatized patients after the change of the millennium. II. A data base from a level I trauma center was utilized to test any effects of treatment changes on outcome. INCLUSION CRITERIA: adult patients, ISS > 16, admission < less than 24 h post trauma. Exclusion: Oncological diseases, genetic disorders that affect the musculoskeletal system. Parameters evaluated were mortality, ICU stay, ICU complications (Sepsis, Pneumonia, Multiple organ failure). RESULTS: I. From the electronic databases, 5141 articles were deemed to be relevant. 169 articles met the inclusion criteria and a manual review of reference lists of key articles identified an additional 22 articles. II. Out of 3668 patients, 2694 (73.4%) were male, the mean ISS was 28.2 (SD 15.1), mean NISS was 37.2 points (SD 17.4 points) and the average length of stay was 17.0 days (SD 18.7 days) with a mean length of ICU stay of 8.2 days (SD 10.5 days), and a mean ventilation time of 5.1 days (SD 8.1 days). Both surgical management and nonsurgical strategies have changed over time. Damage control resuscitation, dynamic analyses of coagulopathy and lactate clearance proved to sharpen the view of the worsening trauma patient and facilitated the prevention of further complications. The subsequent surgical care has become safer and more balanced, avoiding overzealous initial surgeries, while performing early fixation, when patients are physiologically stable or rapidly improving. Severe chest trauma and soft tissue injuries require further evaluation. CONCLUSIONS: Multiple changes in management (resuscitation, transfusion protocols and balanced surgical care) have taken place. Moreover, improvement in mortality rates and complications associated with several factors were also observed. These findings support the view that the management of polytrauma patients has been substantially improved over the past 3 decades.

Proceedings of resources for optimal care of acute care and emergency surgery consensus summit Donegal Ireland.

BACKGROUND: Opportunities to improve emergency surgery outcomes exist through guided better practice and reduced variability. Few attempts have been made to define optimal care in emergency surgery, and few clinically derived key performance indicators (KPIs) have been published. A summit was therefore convened to look at resources for optimal care of emergency surgery. The aim of the Donegal Summit was to set a platform in place to develop guidelines and KPIs in emergency surgery. METHODS: The project had multidisciplinary global involvement in producing consensus statements regarding emergency surgery care in key areas, and to assess feasibility of producing KPIs that could be used to monitor process and outcome of care in the future. RESULTS: Forty-four key opinion leaders in emergency surgery, across 7 disciplines from 17 countries, composed evidence-based position papers on 14 key areas of emergency surgery and 112 KPIs in 20 acute conditions or emergency systems. CONCLUSIONS: The summit was successful in achieving position papers and KPIs in emergency surgery. While position papers were limited by non-graded evidence and non-validated KPIs, the process set a foundation for the future advancement of emergency surgery.

2016 WSES guidelines on acute calculous cholecystitis.

Acute calculus cholecystitis is a very common disease with several area of uncertainty. The World Society of Emergency Surgery developed extensive guidelines in order to cover grey areas. The diagnostic criteria, the antimicrobial therapy, the evaluation of associated common bile duct stones, the identification of "high risk" patients, the surgical timing, the type of surgery, and the alternatives to surgery are discussed. Moreover the algorithm is proposed: as soon as diagnosis is made and after the evaluation of choledocholitiasis risk, laparoscopic cholecystectomy should be offered to all patients exception of those with high risk of morbidity or mortality. These Guidelines must be considered as an adjunctive tool for decision but they are not substitute of the clinical judgement for the individual patient.

Erratum to: 2016 WSES guidelines on acute calculous cholecystitis.

[This corrects the article DOI: 10.1186/s13017-016-0082-5.].

Sample entropy predicts lifesaving interventions in trauma patients with normal vital signs.

INTRODUCTION: Heart rate complexity, commonly described as a "new vital sign," has shown promise in predicting injury severity, but its use in clinical practice is not yet widely adopted. We previously demonstrated the ability of this noninvasive technology to predict lifesaving interventions (LSIs) in trauma patients. This study was conducted to prospectively evaluate the utility of real-time, automated, noninvasive, instantaneous sample entropy (SampEn) analysis to predict the need for an LSI in a trauma alert population presenting with normal vital signs. METHODS: Prospective enrollment of patients who met criteria for trauma team activation and presented with normal vital signs was conducted at a level I trauma center. High-fidelity electrocardiogram recording was used to calculate SampEn and SD of the normal-to-normal R-R interval (SDNN) continuously in real time for 2 hours with a portable, handheld device. Patients who received an LSI were compared to patients without any intervention (non-LSI). Multivariable analysis was performed to control for differences between the groups. Treating clinicians were blinded to results. RESULTS: Of 129 patients enrolled, 38 (29%) received 136 LSIs within 24 hours of hospital arrival. Initial systolic blood pressure was similar in both groups. Lifesaving intervention patients had a lower Glasgow Coma Scale. The mean SampEn on presentation was 0.7 (0.4-1.2) in the LSI group compared to 1.5 (1.1-2.0) in the non-LSI group (P < .0001). The area under the curve with initial SampEn alone was 0.73 (95% confidence interval [CI], 0.64-0.81) and increased to 0.93 (95% CI, 0.89-0.98) after adding sedation to the model. Sample entropy of less than 0.8 yields sensitivity, specificity, negative predictive value, and positive predictive value of 58%, 86%, 82%, and 65%, respectively, with an overall accuracy of 76% for predicting an LSI. SD of the normal-to-normal R-R interval had no predictive value. CONCLUSIONS: In trauma patients with normal presenting vital signs, decreased SampEn is an independent predictor of the need for LSI. Real-time SampEn analysis may be a useful adjunct to standard vital signs monitoring. Adoption of real-time, instantaneous SampEn monitoring for trauma patients, especially in resource-constrained environments, should be considered.

High-frequency percussive ventilation improves oxygenation in patients with ARDS.

STUDY OBJECTIVES: To evaluate changes in respiratory and hemodynamic function of patients with ARDS and requiring high-frequency percussive ventilation (HFPV) after failure of conventional ventilation (CV). DESIGN: Retrospective case series. SETTING: Surgical ICU (SICU) and medical ICU (MICU) of an academic county facility. MEASUREMENTS AND RESULTS: Thirty-two consecutive patients with ARDS (20 from SICU, 12 from MICU) who were unresponsive to at least 48 h of CV and were switched to HFPV were studied. Data on respiratory and hemodynamic parameters were collected during the 48 h preceding and the 48 h after institution of HFPV and compared. Between the period of CV and the period of HFPV, the ratio of PaO2 to the fraction of inspired oxygen (F(IO2)) increased ([mean+/-SE] 130+/-8 vs. 172+/-17; p = 0.027), peak inspiratory pressure (PIP) decreased (39.5+/-1.7 vs. 32.5+/-1.9 mm Hg; p = 0.002), and mean airway pressure(MAP) increased (19.2+/-1.2 vs. 27.5+/-1.4 mm Hg; p<0.001). The rate of change of PaO2/F(IO2) per hour was also significantly improved between the two periods. The same changes in PaO2/F(IO2), PIP, and MAP were observed when the last value recorded while the patients were on CV was compared with the first value recorded after 1 h of HFPV. This improvement was sustained but not amplified during the hours of HFPV. The patterns of improvement in these three parameters were similar in SICU and MICU patients as well as in volume-control and pressure-control patients. There were no changes in hemodynamic parameters. CONCLUSION: The HFPV improves oxygenation by increasing MAP and decreasing PIP. This improvement is achieved soon after institution of HFPV and is maintained without affecting hemodynamics.

Outcome prediction of emergency patients by noninvasive hemodynamic monitoring.

OBJECTIVES: We used noninvasive hemodynamic monitoring in the initial resuscitation beginning in the emergency department (ED) for the following reasons: (1) to describe early survivor and nonsurvivor patterns of emergency patients in terms of cardiac, pulmonary, and tissue perfusion deficiencies; (2) to measure quantitatively the net cumulative amount of deficit or excess of the monitored functions that correlate with survival or death; and (3) to explore the use of discriminant analysis to predict outcome and evaluate the biological significance of monitored deficits. METHODS: This is a descriptive study of the feasibility of noninvasive monitoring of patients with acute emergency conditions in the ED to evaluate and quantify hemodynamic deficits as early as possible. The noninvasive monitoring systems consisted of a bioimpedance method for estimating cardiac output together with pulse oximetry to reflect pulmonary function, transcutaneous oxygen tension to reflect tissue perfusion, and BP to reflect the overall circulatory status. These continuously monitored noninvasive measurements were used to prospectively evaluate circulatory patterns in 151 consecutively monitored severely injured patients beginning with admission to the ED in a university-run county hospital. The net cumulative deficit or excess of each monitored parameter was calculated as the cumulative difference from the normal value vs the time-integrated monitored curve for each patient. The deficits of cardiac, pulmonary, and tissue perfusion functions were analyzed in relation to outcome by discriminant analysis and were cross-validated. RESULTS: The mean (+/- SEM) net cumulative excesses (+) or deficits (-) from normal in surviving vs nonsurviving patients, respectively, were as follows: cardiac index (CI), +81 +/- 52 vs -232 +/- 138 L/m(2) (p = 0.037); arterial hemoglobin saturation, -1 +/- 0.3 vs -8 +/- 2.6%/h (p = 0.006); and tissue perfusion, +313 +/- 88 vs -793 +/- 175, mm Hg/h (p = 0.001). The cumulative mean arterial BP deficit for survivors was -10 +/- 13 mm Hg/h, and for nonsurvivors it was -57 +/- 24 mm Hg/h (p = 0.078). CONCLUSIONS: Noninvasive monitoring systems provided continuously monitored on-line displays of data in the early postadmission period from the ED to the operating room and to the ICU for early recognition of circulatory dysfunction in short-term emergency conditions. Survival was predicted by discriminant analysis models based on the quantitative assessment of the net cumulative deficits of CI, arterial hypoxemia, and tissue perfusion, which were significantly greater in the nonsurvivors.

Multicenter study of noninvasive monitoring systems as alternatives to invasive monitoring of acutely ill emergency patients.

BACKGROUND: Recent reports showed lack of effectiveness of pulmonary artery catheterization in critically ill medical patients and relatively late-stage surgical patients with organ failure. Since invasive monitoring requires critical care environments, the early hemodynamic patterns may have been missed. Ideally, early noninvasive hemodynamic monitoring systems, if reliable, could be used as the "front end" of invasive monitoring to supply more complete descriptions of circulatory pathophysiology. OBJECTIVES: To evaluate the accuracy and reliability of noninvasive hemodynamic monitoring consisting of a new bioimpedance method for estimating cardiac output combined with arterial BP, pulse oximetry, and transcutaneous PO2 and PCO2; we compared this system of noninvasive monitoring with simultaneous invasive measurements to evaluate circulatory deficiencies in acutely ill patients shortly after hospital admission where invasive monitoring was not readily available. We also preliminarily explored early differences in temporal hemodynamic patterns of survivors and nonsurvivors. DESIGN AND SETTING: Prospective comparison of simultaneous invasive and noninvasive measurements of circulatory function with retrospective analysis of data in university-run county hospitals, university hospitals and affiliated teaching hospitals, and a community private hospital. PATIENTS: We studied 680 patients, including 139 severely injured or hemorrhaging patients in the emergency department (ED), 129 medical (nontrauma) patients on admission to the ED, 274 high-risk surgical patients intraoperatively, and 138 patients recently admitted to the ICU. RESULTS: A new noninvasive impedance device provided cardiac output estimations under conditions in which invasive thermodilution measurements were not usually applied. There were 2,192 simultaneous bioimpedance and thermodilution cardiac index measurements; the correlation coefficient, r = 0.85, r2 = 0.73, p < 0.001. The precision and bias was -0.124+/-0.75 L/min/m2. Both invasive and noninvasive monitoring systems provide similar information and identified episodes of hypotension, low cardiac index, arterial hemoglobin desaturation, low transcutaneous O2, high transcutaneous CO2, and low oxygen consumption before and during initial resuscitation. The limitations of noninvasive systems were described. CONCLUSIONS: Noninvasive monitoring systems gave continuous displays of physiologic data that provided information allowing early recognition of low flow and poor tissue perfusion that were more pronounced in the nonsurvivors. Noninvasive systems may be acceptable alternatives where invasive monitoring is not available.

Early closure of colostomies in trauma patients--a prospective randomized trial.

BACKGROUND: Most traumatic colon injuries can be repaired primarily, but a colostomy may still be required for severe colonic or rectal injury. The current trend is to reverse the colostomy early, rather than to wait the traditional 3 months before closure. METHODS: Forty-nine patients with colostomies after abdominal trauma were entered into the study. All patients had undergone a contrast enema in the second postoperative week to assess distal colon healing. Patients were excluded from early closure for nonhealing of the bowel injury, unresolving wound sepsis, or an unstable condition. We then compared the outcome of the remaining 38 (77.6%) patients allocated to either an early or a late colostomy group in a controlled, prospective, randomized trial. RESULTS: We found no significant difference in morbidity between the two groups, with an overall complication rate of 26.3%. Technically the early closure of colostomies was far easier than late closure and required significantly less operating time (p = 0.036) and with less intraoperative blood loss (p = 0.020). The closure of end colostomies was more time consuming, both early (p < 0.001) and late (p < 0.001) and caused more bleeding (p < 0.001 and p < 0.001, respectively). Total hospitalization was marginally shorter overall for early closure, but late closure of end colostomies resulted in prolonged hospitalization (p = 0.023). CONCLUSIONS: The early closure of colostomies and the use of loop colostomies whenever possible are recommended as both safe and beneficial for patients with colonic injury after trauma. Contraindications for early closure include nonhealing distal bowel, persistent wound sepsis, or persistent postoperative instability.

Penetrating trauma to the heart: a relatively innocent injury.

BACKGROUND: The purpose of this study was to examine the mortality rate of penetrating cardiac trauma in a large urban hospital. METHODS: This was a retrospective study over a period of 5 years and 5 months of all patients admitted alive with a stab or a gunshot cardiac injury. RESULTS: There were 310 patients with a stab wound and 63 with a gunshot wound. The overall mortality rate was 19%. The mortality rates for the stab and the gunshot groups were 13% and 50.7%, respectively. In the 296 patients with a cardiac stab wound confined to a single chamber and with no other associated extracardiac injury the mortality rate was 8.5%. CONCLUSIONS: An isolated cardiac stab wound is a relatively innocent injury in a patient at a hospital accustomed to managing penetrating trauma expeditiously.

Gunshot injuries of the liver: the Baragwanath experience.

BACKGROUND: This study comprised 304 patients with gunshot injuries of the liver, many of which from high-velocity firearms. The purpose of this study is to evaluate our management policy in gunshot injuries of the liver in light of our recent wider experience. METHODS: All grade I and II injuries and most grade III injuries were managed by simple operative measures, without postoperative mortality directly related to the liver trauma. RESULTS: Grade III, IV, and V injuries had 8.5%, 52%, and 16% resectional debridement rates and 8.5%, 38%, and 84% perihepatic packing rates, respectively. In the resectional debridement group the postoperative mortality rate was 15% (half the deaths were directly caused by the hepatic injury). The postoperative mortality rate in the perihepatic packing group was 31.5% of which 45% of deaths were due to ongoing bleeding, 27.5% to sepsis, and 27.5% to associated trauma. The septic complications were less common when packs were removed early. CONCLUSIONS: We suggest that resectional debridement and perihepatic packing should be liberally applied in the most severe grade III, most grade IV, and grade V gunshot injuries of the liver and that perihepatic packing should be removed as early as the physiologic derangements are corrected. Our experience with grade VI injuries is very limited, and their management should be studied in larger series.

Penetrating injuries of the iliac arteries: a South African experience.

BACKGROUND: We did a retrospective study of 62 patients with penetrating injuries of the iliac arteries. METHODS: The cause of injury was gunshot wound in 85.5% and stabbing in 14.5%. The arterial repair was achieved by various means: lateral arteriorrhaphy, end-to-end anastomosis, and polytetrafluoroethylene interposition grafts. RESULTS: There was a 42% mortality rate from exsanguination or secondary coagulopathy directly related to the arterial injury. Persistent shock, resuscitative thoracotomy, free intraperitoneal hemorrhage, and the number of vascular injuries were directly related to mortality. CONCLUSIONS: A high index of suspicion, aggressive resuscitation, and prompt surgery are necessary to improve the chances of surviving this ominous injury.

The high morbidity of colostomy closure after trauma: further support for the primary repair of colon injuries.

BACKGROUND: We examined the recent experience of a large urban trauma center to identify overall morbidity and factors predictive of outcome in patients undergoing colostomy closure after trauma. METHODS: We did a retrospective analysis of 40 patients who underwent colostomy closure after trauma at our institution between January 1992 and August 1996. RESULTS: The mechanism of injury was a gunshot wound in 30 patients (75%), a motor vehicle accident in 6 (15%), a stab wound in 3 (7.5%), and a rectal foreign body in 1 (2.5%). Loop colostomies were performed in 28 patients (70%) and end colostomies were performed in 12 patients (30%). Mean time until colostomy closure was 8 months (range, 0.5 to 28 months). Five patients underwent same admission colostomy closure (SACC). Contrast enemas were performed in 36 patients and found to be abnormal in 2 (6%) patients who were found during planning for SACC to have leaks from rectal trauma at 12 and 19 days after injury. Sixteen complications occurred in 12 patients (30%). Intraoperative complications occurred in two patients (5%) who sustained small and large bowel enterotomies. There were 4 major complications (1 fecal fistula, 1 anastomotic stricture, and 2 small bowel obstructions) in 3 patients (7.5%) and 10 minor complications (25%), 7 prolonged ileus and 3 superficial wound infections. Morbidity was significantly higher for patients whose initial injury involved the colon (11 of 20; 55%) as compared with those whose injury involved the rectum (2 of 16; 12.5%). The demographic, injury, and operative characteristics in the 12 patients with complications and the 28 patients without complications were compared to identify predictors of morbidity. The presence of a colon injury (RR = 7.70; p = 0.009) was a statistically significant predictor of morbidity after colostomy closure. The presence of an initial rectal injury, in contrast, was a predictor of low morbidity after closure (RR = 0.22; p = 0.024). No statistically significant differences were found with respect to age, gender, mode of injury, colostomy type, type of repair, need for laparotomy, or right- versus left-sided colostomy. Clinical trends were noted in five groups in whom the relative risk was greater than 2.0: age older than 30 versus less than 30 years (RR = 2.71; p = 0.079), end versus loop colostomy (RR = 2.33; p = 0.130), operative time greater than 2 versus less than 2 hours RR = 2.80; p = 0.141), estimated blood loss greater than 150 versus less than 150 cc (RR = 2.77; p = 0.079), and right- versus left-sided colostomy (RR = 2.00; p = 0.211). Patients with complications had significantly longer mean operative times (3.84 versus 2.46 hours; p = 0.02), higher mean blood loss (468 versus 142 cc; p = 0.006), and longer mean time until closure (11.3 versus 6.33 months; p = 0.02). CONCLUSIONS: Colostomy closure after trauma remains associated with significant morbidity. The patients in whom a colon injury was the indication for initial colostomy experienced high morbidity (55%) after subsequent closure. Patients who had a colostomy for rectal injury had a low morbidity after closure (6.25%). Intraoperative difficulties (longer operative times, higher blood loss) and long delays until colostomy closure increase complication rates. Timely closure may improve outcome after operation for bowel continuity restoration. Morbidity associated with colostomy closure should be considered additional evidence for performing primary repair of colonic injuries. Because the morbidity of colostomy closure after rectal injuries is low, proximal colostomy for extraperitoneal rectal injuries should remain the treatment of choice.

Outcome of a strict policy on emergency department thoracotomies.

OBJECTIVE: To audit emergency department thoracotomies from January 1981 to May 1993. DESIGN: Retrospective analysis of case records. SETTING: A large (3000-bed) tertiary care academic hospital; the department of general surgery (including trauma) consists of 360 beds. PATIENTS: All patients who underwent a thoracotomy in the emergency department during the above period. INTERVENTION: An emergency department thoracotomy was performed on trauma patients with recordable vital signs and rapid deterioration and on patients with uncontrollable bleeding or profound hypotension not responsive to resuscitation. The procedure was performed either on the resuscitation trolley in the emergency department or in the adjacent operating room. MAIN OUTCOME MEASURES: Survival and subsequent neurological function after thoracotomy. RESULTS: There were 312 stab injuries, 358 gunshot injuries, and 176 blunt injuries. Survival occurred in 26 stab-wound cases (8.3%), in 16 gunshot cases (4.4%), and in one blunt injury case (0.6%). There was one patient with neurological impairment in each of the three injury groups. Those with penetrating chest injuries had the best survival rate (20%), and the survival rate for penetrating abdominal trauma was 6.8%. CONCLUSIONS: Emergency department thoracotomies have a definite role in the management of trauma patients. The best results are obtained in patients with penetrating chest injuries.

Penetrating injuries of the neck in patients in stable condition. Physical examination, angiography, or color flow Doppler imaging.

BACKGROUND: The initial assessment of penetrating injuries of the neck is controversial, with angiography remaining the gold standard for identifying vascular injuries. Recent reports suggest that physical examination might be an accurate way to evaluate these injuries. Color flow Doppler imaging has been used with promising results to assess extremity injuries, but the role of color flow Doppler imaging in neck injuries has not been studied. OBJECTIVE: To evaluate and compare the roles of physical examination, color flow Doppler imaging, and angiography in the identification and management of penetrating neck injuries. STUDY DESIGN: A prospective study of patients in stable condition with penetrating injuries of the neck. All study patients were examined according to a written clinical protocol and subsequently underwent angiography and color flow Doppler imaging. The sensitivity and specificity of physical examination and color flow Doppler imaging were compared with those of angiography. RESULTS: Eighty-two patients fulfilled the criteria for inclusion in the study. Angiography demonstrated vascular lesions in 11 patients (13.4%), but only two (2.4%) of them required treatment. Serious injuries were detected or suspected during physical examination, but six lesions not requiring treatment were missed. When injuries not requiring treatment were excluded, the sensitivity was 100% and the specificity was 91%. With color flow Doppler imaging, 10 of the 11 injuries were identified, for a sensitivity of 91% and a specificity of 98.6%. The sensitivity and specificity were 100% for clinically important lesions. CONCLUSION: The combination of a careful physical examination and color flow Doppler imaging provides a reliable way to assess penetrating neck trauma and may be a safe alternative to routine contrast angiography.

Abdominal computed tomography for the diagnosis of intra-abdominal sepsis in critically injured patients: fishing in murky waters.

HYPOTHESIS: Abdominal computed tomographic (ACT) scans are useful in the evaluation of sepsis of unknown origin in patients with major trauma. DESIGN: Prospective case series of consecutive patients. SETTING: Intensive care unit of level I academic trauma center. PATIENTS: Eighty-five critically injured patients admitted to the intensive care unit in 32 months (6% of all intensive care unit admissions) who developed sepsis of unknown origin. INTERVENTIONS: One hundred sixty-one ACT scans. MAIN OUTCOME MEASURES: Sensitivity and specificity of the ACT scans, number of patients subjected to changes in treatment following an ACT scan. RESULTS: Forty-nine patients (58%) had an intraabdominal focus of infection identified on ACT scan. Penetrating trauma and emergent laparotomy were the only independent factors associated with abnormal findings on ACT scan. The sensitivity and specificity of the test were 97.5% and 61.5%, respectively. Overall, 59 patients (69%) benefited from treatment changes after an ACT scan. CONCLUSION: Abdominal computed tomographic scans reliably identify intra-abdominal foci of infection in patients with major trauma evaluated for sepsis of unknown origin.

Lung-sparing surgery after penetrating trauma using tractotomy, partial lobectomy, and pneumonorrhaphy.

OBJECTIVE: To evaluate the role of lung-sparing surgical techniques in the surgical management of penetrating pulmonary injuries. DESIGN: Retrospective case series. SETTING: Academic level I trauma center. PATIENTS AND METHODS: Forty patients underwent thoracic surgery for penetrating lung injuries during a 63-month period from January 1993 to March 1997. Five (12.5%) underwent anatomical lobectomy, 3 (7.5%) pneumonorrhaphy, 9 (22.5%) stapled wedge resection, and 23 (57.5%) stapled tractotomy. In total, 34 patients (85%) were treated with stapling techniques (1 anatomical lobectomy, 1 pneumonorrhaphy, 9 stapled wedge resections, and 23 stapled tractotomies) and 35 (87.5%) underwent had lung-sparing surgery for trauma. RESULTS: Morbidity and mortality rates were 40% and 5%, respectively. Patients who underwent anatomical lobectomy required longer mechanical ventilatory support, intensive care unit stay, and hospital stay and had a higher morbidity rate compared with patients who underwent lung-sparing surgery for trauma but had central and extensive pulmonary injuries. Stapled tractotomy was efficient in controlling bleeding and bronchial leaks, but, in 3 patients, parts of the divided lung parenchyma were devascularized and had to be resected. CONCLUSIONS: Lung-sparing surgery for trauma with the use of staplers can be used in the majority of patients with penetrating pulmonary injuries requiring operation. Stapled tractotomy is a rapid and effective method for controlling hemorrhage and air leaks.